1. Traumatic Brain Injury Classification Israel national center for trauma and emergency medicine research Gertner Institute for Epidemiology and Health Policy Research Limor Aharonson-Daniel, PhD For International Collaborative Effort on Injury Statistics, Washington DC, September 7-8, 2006

2. In 1995, clinical case definition standardized It included any intracranial injury and any reported loss of consciousness or concussion. Guidelines for Surveillance of Central Nervous System Injury Thurman DJ, Sniezek JE, Jonson D, Greenspan A, Smith SM Atlanta: Centers for disease Control and Prevention, 1995).

3. The definition encompasses a wide range of conditions which are easily, and with clinical reasoning, classifiable into two very distinctive groups of patients Intracranial injury yes no LOC yes no duration < 1 hr 1-24 hr 24 hr+ unknown Fracture Internal Nerves concussion ICD-9-CM

4. Type 1 TBI: recorded evidence of an intracranial injury or a moderate or a prolonged loss of consciousness Shaken Infant Syndrome and injuries to the optic nerve pathways. Type 2 TBI: no recorded evidence of intracranial injury and a loc of less than one hour, a loc of unknown duration or an unspecified level of consciousness. Type 3 TBI: no evidence of intracranial injury and no loc. Barell matrix definitions

6. “We highly recommend the development of research guidelines to standardize definitional, case finding, and data reporting parameters to help establish a more precise description and hence utility of the epidemiology of TBI in Europe”. A systematic review of brain injury epidemiology in Europe F. Tagliaferri, C. Compagnone, M. Korsic, F. Servadei, and J. Kraus Acta Neurochir (Wien) (2005) Published online November 28, 2005 It was difficult to reach a consensus on all epidemiological findings across the 23 published European studies because of critical differences in methods employed across the reports.

7. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006. The ICD-9-CM codes for TBI included in the analysis differed slightly from those in the Barell Matrix, a recommended categorization of ICD-9-CM codes for nonfatal injuries. The inclusion of 959.01 (head injury, unspecified)…

8. Fracture of the vault or base of the skull 800.0–801.9 Other and unqualified multiple fractures of the skull 803.0–804.9 Intracranial injury, including concussion, contusion, laceration, and hemorrhage 850.0–854.1 Head injury, unspecified 959.01 ICD-9-CM codes for traumatic brain injury related ED visits (1995-2001) Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006. 995.55, 950(.1-.3)

9. Epidemiology of Emergency Department-Treated Traumatic Brain Injury in Minnesota Day H, Roesler J, Gaichas A, Kinde M, Accessed at http://www.mmaonline.net/Publications/MNMed2006/May/clinical-day.htm on aug 4 2006http://www.mmaonline.net/Publications/MNMed2006/May/clinical-day.htm

10. ‘skull fracture’ (800.0, 800.5, 801.0, 801.5, 803.0, 803.5, 804.0, 804.5), ‘concussion’ (850.0, 850.1, 850.5, 850.9), ‘intracranial injury of unspecified nature’ (854.0) and ‘head injury, unspecified’ (959.0). These codes are intended to identify TBI’s that approximate the mTBI clinical definition. They were recommended as the administrative case definition of mTBI for surveillance and research by the Centers for Disease Control and Prevention Mild Traumatic Brain Injury Work Group in October 2002. Mild traumatic brain injury in the United States, 1998–2000 BAZARIAN JJ, MCCLUNG J, SHAH MN, CHENG YT, FLESHER W & KRAUS J Brain Injury, February 2005; 19(2): 85–91 Includes cases where there is no intracranial injury even if there is an extended (>24h) LOC

11. Retrospective analysis of TBI data recorded in the Israel National Trauma Registry 1/1/1998-12/31/2005. Patients were included if they had isolated TBI. Population and methods A look at the data

12. AGE distribution by type of TBI 1998-2005, 7408 patients with isolated TBI

13. SEVERITY OF INJURY (ISS) 1998-2005, 7408 patients with isolated TBI

14. Type of TBI by injury severity Among all TBI (n=7408) Among ISS 16+ (n=3077)

15. Severity Indicators 1998-2005, 7408 patients with isolated TBI

16. Conclusion: Groups seem valid. Need to touch up definitions and finish the work begun a decade ago Implications for ICD-11?

17. Partners? NCIPC ANA Do we agree that it is our business to improve and disseminate a uniform / multi-leveled TBI definition?