Abstract
Introduction:
Traumatic brain injury (TBI) is a leading cause of disability and is associated with decreased survival. Although it is generally accepted that TBI increases risk of death in acute and postacute periods after injury, causes of premature death after TBI in the long term are less clear.
Methods:
A cohort sample of Olmsted County, Minnesota, residents with confirmed TBI from January 1987 through December 1999 was identified. Each case was assigned an age- and sex-matched non-TBI referent case, called regular referent. Confirmed TBI cases with simultaneous nonhead injuries were identified, labeled special cases. These were assigned 2 age- and sex-matched special referents with nonhead injuries of similar severity. Underlying causes of death in each case were categorized using death certificates, International Classification of Diseases, Ninth Revision, International Statistical Classification of Diseases, Tenth Revision, and manual health record review. Comparisons were made over the study period and among 6-month survivors.
Results:
Case–regular referent pairs (n=1,257) were identified over the study period, and 221 were special cases. In total, 237 deaths occurred among these pairs. A statistically significant difference was observed between total number of deaths among all cases (n=139, 11%) and regular referents (n=98, 8%) (P=.006) over the entire period. This outcome was not true for special cases (32/221, 14%) and special referents (61/441, 14%) (P=.81). A greater proportion of deaths by external cause than all other causes was observed in all cases (52/139, 37%) vs regular referents (3/98, 3%) and in special cases (13/32, 41%) vs special referents (5/61, 8%) (P<.001 for both). Among all case-referent pairs surviving 6 months, no difference was found between total number of deaths (P=.82). The underlying cause of death between these 2 groups was significantly different for external causes only (P<.01). For special cases surviving 6 months vs special referents, no difference was observed in total number of deaths (P=.24) or underlying causes of death (P=1.00) between groups.
Discussion/Conclusion:
This population-based case-matched referent study showed that increased risk of death after TBI existed only during the first 6 months after injury, and the difference was due to external causes.
Keywords: cause of death, life expectancy, long-term survival, mortality, traumatic brain injury
Introduction
Traumatic brain injury (TBI) is a leading cause of death and disability [1]. It is accepted that moderate to severe TBI increases risk of death acutely after injury [2–6]. Yet, an association between TBI and premature cause of death in the long term is not well understood. Investigators have reported specific causes of death after TBI in the long term. However, TBI cases were most commonly identified through use of hospital-based International Classification of Diseases (ICD) coding [7–13], and death rates were compared with the general population through use of standardized mortality ratios (SMRs) [9–12, 14–21]. These methods have well-recognized limitations, including underestimating TBI cases and not controlling for other traumatic injuries associated with the event that can affect mortality rate [18–23].
Understanding the relationships between TBI, death, and the underlying cause of death in the acute, postacute, and chronic phases after injury is essential for the development of preventive and clinical surveillance strategies to reduce TBI-associated death. The goals of the present analysis had 3 tiers. The study aimed to identify underlying causes of death in a population-based sample of patients with health-record–confirmed TBI and compare the underlying cause of death in the cases with their corresponding population-based referents. It studied the effect of nonhead trauma on causes of death by matching TBI patients experiencing nonhead trauma with referents experiencing nonhead trauma of the same severity. Further, the study aimed to determine whether cause of death differs between the postacute and chronic phases after injury; these categories were compared between study groups over the entire study period and among 6-month survivors.
Methods
This study was approved by Mayo Clinic and Olmsted Medical Center institutional review boards.
Rochester, Minnesota, county seat of Olmsted County (2018 census population, 156,277), is home to Mayo Clinic, a large private medical center. Comprehensive data about each patient at Mayo Clinic have been linked to a unique identification number since 1907. This linkage was developed into the Rochester Epidemiology Project (REP) in 1966 [24]. This health records linkage system is widely recognized as a powerful tool for population-based epidemiologic studies [25, 26], allowing for unique assessment of the natural history of TBI [27–31].
REP has data from more than 500,000 persons and includes all demographic information, surgical procedure codes, drug prescription, and diagnostic codes assigned at every medical contact for each person in this geographically defined region [32]. These data can be screened electronically with a coding system developed at Mayo Clinic for clinical purposes specifically, using 3 different systems and a modification of ICD, Eighth Revision, and ICD, Ninth Revision (ICD-9) [33], shown to have high sensitivity and specificity [25] (eAppendix).
TBI was defined as a “traumatically induced injury that contributed to the physiological disruption of brain function” [30, 31, 34, 35]. Each TBI event severity was categorized using the Mayo Classification System (Box) [36]. This classification system uses all health record data available, which creates an inclusive classification system superior to single clinical indicators of TBI severity (eg, loss of consciousness, initial Glasgow Coma Scale [GCS] score, length of posttraumatic amnesia) when applied to an epidemiologic cohort [35, 36]. TBI severity classification categories included definite (consistent with moderate-severe TBI), probable (consistent with mild TBI), or possible (consistent with concussive TBI) (Box).
Box. Mayo Clinic TBI Classification System.
1. Classify as definite (moderate-severe) TBI if ≥1 of the following criteria: |
a. Death due to TBI |
b. ≥30 min of loss of consciousness |
c. ≥24 h of anterograde posttraumatic amnesia |
d. Worst GCS score <13 in first 24 h after TBI (unless invalidated on review, including attributable to intoxication, sedation, or systemic shock) |
e. ≥1 of the following: |
i. Intracranial hemorrhage (eg, intracerebral hematoma, subdural hematoma, epidural hematoma, cerebral contusion, hemorrhagic contusion, subarachnoid hemorrhage) |
ii. TBI that penetrated dura mater |
iii. Brainstem injury |
2. If none of Criteria 1 applies, then classify as probable (mild) TBI if ≥1 of the following: |
a. <30 min of loss of consciousness |
b. <24 h of anterograde posttraumatic amnesia |
c. Depressed, basilar, or linear skull fracture with dura mater intact |
3. If neither Criteria 1 nor Criteria 2 applies, then classify as possible (symptomatic) TBI if ≥1 of the following: |
a. Blurred vision |
b. Confusion and mental status changes |
c. Dazed |
d. Dizziness |
e. Focal neurologic symptoms |
f. Headache |
g. Nausea |
Abbreviations: GCS, Glasgow Coma Scale; TBI, traumatic brain injury. Modified from Malec et al [36].
Case Identification
Methods for sample identification have been described previously [31, 34, 35]. A search of Olmsted County residents in the REP from January 1, 1985, through December 31, 1999, identified 46,114 cases with a TBI-related diagnostic code. Because of the labor-intensive effort involved in manually reviewing each case, a 20% random sample was initially selected. Time and budgetary constraints subsequently limited the cases to a 16% random sample, identifying 7,175 records. Trained nurse abstractors manually reviewed these records under the direction of a board-certified physiatrist (A.W.B.). Confirmed cases were defined as individuals without a documented history of prior TBI who had their first TBI event between January 1, 1985, and December 31, 1999. This abstraction confirmed 1,429 TBI cases. Information required to identify cases and their referents was available from January 1, 1987, limiting the sample to 1,257.
Selection of Referents
As described previously [31, 34, 35], TBI cases were matched to an individual of same sex and birth year (±1 year) seen by a REP clinician while an Olmsted County resident in the year (±1 year) of the case’s TBI. These were referred to as regular referents.
TBI cases associated with additional nonhead injuries were then identified among all cases, and the severity of those nonhead injuries was quantified with a Trauma Mortality Prediction Model [37]. These cases were referred to as special cases. Each of these cases was matched to 2 individuals of the same sex and birth year (±2 years) seen by a REP clinician while an Olmsted County resident in the year (±1 year) of the case’s TBI and had a traumatic injury of the same severity as their case’s, unassociated with head trauma, within a year of their case’s TBI. These referents were referred to as special referents. Of 1,257 TBI cases, 221 cases had TBI with other nonhead injuries and were categorized as special cases.
Underlying Cause of Death
The underlying cause of death was identified and was defined as the diagnosis of longest duration in the sequence of events leading to death. This compares with the immediate cause of death, or the final diagnosis that caused death. Underlying causes of death were categorized through extensive chart review using death certificates, ICD-9 and International Statistical Classification of Diseases, Tenth Revision (ICD-10), and manual review of specific factors of external causes of death (D.E. and A.W.B.).[38] All ICD-9 codes were converted to ICD-10 equivalents under the direction of a board-certified physiatrist (A.W.B.). Similarly, related ICD-10 categories were collapsed (Table 1).
Table 1.
Collapsed ICD-10 Categories
Letter category | Underlying cause of death category | Codes in regular case/referent | Codes in special case/referent |
---|---|---|---|
C, D | Neoplasms (malignant, in situ) | C | C, D |
F, G | Mental health/behavioral, nervous system | F, G | F, G |
I | Circulatory system | I | I |
J | Respiratory system | J | J |
S, T, V, W, X | External cause of injury (injury, poison, suicide, assault, exposure) | S, T, U, V, W, X | S, V, W, X |
A, B, E, K, M, N, Q, R | Other (infection, endocrine, digestive, musculoskeletal, genitourinary, congenital, signs/symptoms NOS) | A, B, E, K, M, N, Q, R | E, K, M, N, Q |
Abbreviations: ICD-10, International Statistical Classification of Diseases, Tenth Revision; NOS, not otherwise specified.
Statistical Analysis
Underlying cause of death categories were compared between 2 case and referent groups: all cases (regular and special) matched with all regular referents (not considering nonhead trauma), and special cases each matched with 2 special referents. This strategy enhanced the analytical power for the smaller special case sample.
To determine any difference between cause of death in the postacute and chronic phases after injury, the categories were compared between case and referent groups during the entire study period and among 6-month survivors.
Descriptive summaries were reported as mean (SD) for continuous variables and as frequency (percentage) for categorical variables. Comparisons of proportions between cases and referents were performed with Fisher exact test. All tests were 2 sided, and P<.05 was considered statistically significant. Analysis was performed with statistical software (SAS version 9.4; SAS Institute Inc).
Results
Case characteristics and the mechanism of TBI were tabulated for the sample (n=1,257 cases) and by age group (Table 2). The mean time to follow-up for cases was 10.5 years. In total, 237 deaths occurred over the study period for the 1,257 case-referent pairs when all cases were matched to all regular referents—139 among cases and 98 among referents (P=.006) (Table 3). Death occurred in 48% of cases after definite TBI, 10% after probable TBI, and 6% after possible TBI (Table 3). The underlying cause of death among cases was proportionally largest for external causes (52/139,37%) compared with 3 among matched referents (3/98, 3%) (P<.001) (Table 4). The number of deaths in the other collapsed categories for cases and referents were not significantly different.
Table 2.
All Case Cohort Characteristics
Cases, No. (%) |
||||
---|---|---|---|---|
Patient age, yb |
||||
Characteristica | Entire sample (N=1,257) | <16 (n=446) | 16–64 (n=698) | >64 (n=113) |
Male sex | 698 (56) | 286 (64) | 371 (54) | 41 (36) |
TBI classification | ||||
Definite | 105 (8) | 20 (5) | 58 (8) | 27 (24) |
Probable | 483 (38) | 153 (34) | 286 (41) | 44 (39) |
Possible | 669 (53) | 273 (61) | 354 (51) | 42 (37) |
Mechanism of injury | ||||
Fall | 352 (28) | 146 (33) | 123 (18) | 83 (73) |
Motor vehicle collision | 342 (27) | 27 (6) | 296 (42) | 19 (17) |
Sports or recreation | 310 (25) | 198 (44) | 111 (16) | 1 (1) |
Other | 97 (8) | 43 (10) | 49 (7) | 5 (4) |
Assault or gunshot | 82 (6) | 17 (4) | 63 (9) | 2 (2) |
Hit by object | 74 (6) | 15 (3) | 56 (8) | 3 (3) |
Abbreviation: TBI, traumatic brain injury.
Mean (SD) time to follow-up for cohort, 10.5 (5.98) years.
Mean (SD) age at injury for cohort, 27 (22.0) years.
Table 3.
Proportion of Deaths Among Cases and Their Regular Referents by Injury Severity Over the Entire Study Period
Injury severity | Cases, No. (%) (n=1,257) | Referents, No. (%) (n=1,257) |
---|---|---|
Definite | 50/105 (48) | 25/105 (24) |
Probable | 49/483 (10) | 42/483 (9) |
Possible | 40/669 (6) | 31/669 (5) |
Total | 139/1,257 (11) | 98/1,257 (8) |
Table 4.
Underlying Cause of Death Listed by Collapsed ICD-10 Categories for the 1,257 All Regular Case–Regular Referent Pairs Over Entire Study Period
Over study period, No. (%) | Among 6-mo survivors, No (%) | |||
---|---|---|---|---|
Collapsed ICD-10 category | All casesa | Regular referentsb | Regular cases | Regular referents |
Neoplasm | 16 (11) | 15 (15) | 14 (15) | 13 (14) |
Mental health/behavioral, nervous system | 12 (9) | 18 (19) | 12 (13) | 17 (18) |
Circulatory | 38 (27) | 32 (33) | 32 (34) | 30 (33) |
Respiratory | 5 (4) | 3 (3) | 4 (4) | 3 (3) |
External | 52 (37)c | 3 (3) | 15 (16)d | 3 (3) |
Other | 11 (8) | 11 (11) | 11 (12) | 10 (11) |
Unknown cause | 5 (4) | 16 (16) | 5 (5) | 16 (17) |
Total deaths | 139/1,257 (11)e | 98/1,257 (8) | 93/1,177 (8)f | 92/1,215 (8) |
Abbreviation: ICD-10, International Statistical Classification of Diseases, Tenth Revision.
Of the 1,257 cases, 80 had <6 months follow-up, with 46 deaths; for cases with ≥6 months follow-up (n=1,177), there were 93 deaths.
Of the 1,257 regular referents, there were 42 referents with <6 months follow-up, with 6 deaths; for the 1,215 regular referents with ≥6 months follow-up, there were 92 deaths (total, 98 referent deaths).
Difference in deaths by external cause vs all other causes for cases compared with referents, Fisher exact test, P<.001.
Difference in deaths by external causes vs all other causes for cases compared with referents, Fisher exact test, P<.01.
Difference in total deaths between all cases and regular referents, Fisher exact test, P=.006.
Difference in total deaths between regular cases and regular referents, Fisher exact test, P=.82.
Over the entire study period, a total of 93 deaths occurred among the 221 special cases (32/221, 14%) and the 441 matched special referents (61/441, 14%) (Table 5). (For 1 special case, only 1 referent could be identified.) No significant difference was observed in the proportion of total deaths in each sample (P=.81). However, the proportion of deaths due to external causes in the special cases (13/32, 41%) was significantly greater than for special referents (5/61, 8%) (P<.001). No significant difference was observed in the proportion of deaths for other causes.
Table 5.
Underlying Cause of Death Listed by Collapsed ICD-10 Categories for 221 Special Cases and 441 Matched Special Referentsa Over Study Period and Among 6-Month Survivors
Over study period, No. (%) |
Among 6-mo survivors, No. (%) |
|||
---|---|---|---|---|
Collapsed ICD-10 category | Special cases | Special referents | Special cases | Special referents |
Neoplasm | 4 (13) | 11 (18) | 3 (16) | 10 (18) |
Mental health/behavioral, nervous system | 2 (6) | 7 (11) | 2 (11) | 6 (11) |
Circulatory | 8 (25) | 19 (31) | 7 (37) | 14 (25) |
Respiratory | 1 (3) | 8 (13) | 1 (5) | 8 (14) |
External | 13 (41)b | 5 (8) | 2 (11)c | 5 (9) |
Other | 2 (6) | 5 (8) | 2 (11) | 5 (9) |
Unknown cause | 2 (6) | 6 (10) | 2 (11) | 8 (14) |
Total deaths | 32 (14)d | 61 (14) | 19 (9)e | 56 (13) |
Abbreviation: ICD-10, International Statistical Classification of Diseases, Tenth Revision.
Only 1 special referent was identified for 1 of the special cases.
Difference in deaths due to external causes vs all other causes for special cases compared with special referents, Fisher exact test, P<.001.
Difference in deaths due to external causes vs all other causes between special cases and special referents, Fisher exact test, P=1.00.
Difference in total deaths between special cases and special referents, Fisher exact test, P=.81.
Difference in total deaths between special cases and special referents, Fisher exact test, P=.24.
Within all case–regular referent pairs surviving 6 months, 185 deaths occurred, and no significant difference was observed between the numbers of death among cases and referents (P=.82) (Table 4). The proportion of underlying cause of death due to external causes among cases was significantly different than among referents (P<.01). Seventy-five deaths of 6-month survivors occurred among the 221 special cases and the 441 matched special referents (Table 5). No difference was detected in total deaths (P=.24) or in proportion of deaths due to external causes between special cases and referents (P=1.00) among 6-month survivors (Table 5).
Discussion
This population-based case-matched referent analysis of underlying cause of death after TBI showed that death due to external causes accounted for the greatest proportion of case deaths and was significantly greater than for matched referents. Further, when TBI cases whose injury included nonhead trauma were compared with referents having a similar severity of traumatic nonhead injury, the proportion of deaths due to external causes was significantly different from the referents only during the first 6 months after injury. Previous findings in this cohort have shown that the increased risk of death after TBI exists only in the first 6 months after injury [34].
In the context of the present analysis, it is reasonable to conclude that the external causes of death during the first 6 months after injury relate predominantly to the injuries associated with the traumatic event. The term external cause of death refers to the effect that comes from outside the body (eg, injury, poison, assault, exposure). Of all deaths from external causes across the case and referent groups, manual record review of death certificates and ICD coding of external cause of death found only 3 of the deaths attributable to factors not related to injury (eg, poison, overdose).
The population-based results reported herein are consistent with those reported by Selassie et al [10], that unintentional injury was the leading cause of death during the 15 months following discharge among patients hospitalized for TBI in South Carolina. A large national Swedish study also showed a preponderance of deaths due to external causes among 6-month survivors of TBI, particularly due to suicide, compared with both a population-based sample and sibling referents [8]. In a separate Swedish study of individuals hospitalized with severe TBI (GCS <8), a strong cause of death rate from external causes early after injury was found, but the rate did not differ from the general population after 1 year [39].
Among studies reporting cause of death in subgroups of individuals hospitalized for TBI and monitored over the longer term—with cases identified through hospital-determined ICD codes and deaths reported using SMRs—a large-scale nationally representative sample showed that external causes of death (18%) predominated after natural causes [11]. SMRs for suicide were 2.7 to 4.0, depending on the diagnosis group, and a suicide SMR for concussive injury was 3.02.
Ventura et al [12] analyzed a state-based trauma registry sample of patients hospitalized after TBI. Cases were identified with hospital-based ICD codes and death reported using SMR. They found that deaths within the first month after injury were caused by circulatory conditions and unknown causes, with TBI a contributing cause. Death due to mental health or behavioral disorders and nervous system diseases dominated this sample. Deaths due to external causes were the fifth highest SMR overall.
Studies showing statistically significant associations between TBI and cause of death differing from the findings reported herein likely relate to methodologic differences in case identification (manual review and abstraction vs administrative ICD coding by hospitals) and reference samples (population-based referents vs the general population). We have shown that only 40% of TBI cases in a population-based cohort confirmed by health record review were identified when only using ICD-9 coding recommended by the Centers for Disease Control and Prevention for identifying TBI [22]. Use of SMRs to compare the number of TBI-related deaths in a given sample may limit the accuracy of attributing deaths to TBI because the comparison group is not controlled for other contributors of death, such as other traumatic injuries associated with the event [23].
The strengths of this study include confirmation of TBI cases in a defined population through manual health record review, stratification of injury severity across its spectrum, comparison of cause of death in cases to population-based referents considering nonhead trauma, and determination of underlying cause of death through detailed manual review of death certificates and diagnostic coding. Consistent with other studies in this population, the incidence of TBI in the present cohort was dominated by probable and possible TBI, with definite injury occurring in 8% (105 cases) of the sample. This population-based cohort also confirmed the association between injury severity and death (Table 3). However, other studies using samples exclusive to moderate-severe TBI cases have found cause of death to be significantly higher not only for external causes but also for respiratory, circulatory, and nervous system disorders [40–43]. These differences in findings may relate to the small proportion of definite cases in our sample.
Limitations
This study has several limitations. The lack of statistical significance in the number of deaths, particularly among 6-month survivors in special cases and special referents, may be due to too few deaths, particularly of persons with definite TBI. Although the present analysis considered simultaneous nonhead injuries using 2 matched referents, other preexisting comorbidities of cases were not considered when selecting referents, potentially affecting results. In addition, the use of 2 regular referents for all cases would have strengthened the power of the study, considering the relatively few definite TBI cases.
The population of Olmsted County is predominantly White, with age and sex distribution similar to that for Minnesota, the Upper Midwest, and the US White population [24]. The applicability of this study’s findings to other community settings is limited because of the underrepresentation of persons of color and the distinctive medical care system of the region (ie, entire population served by primarily 2 group practices).
Finally, advances in the development of models of trauma care in the period since these data were acquired may potentially limit the relevance of these findings for current practice. However, there has been no consistent indication that mortality rate specifically after TBI has improved in recent decades, supporting the pertinence of these results [17, 44, 45].
Conclusion
Using the REP diagnostic record linkage resource to confirm cases and population-based matched referents, this study provides a distinctive report of the underlying cause of death after TBI over the full spectrum of age and injury severity, considering the influence of nonhead trauma for matched referents. Results show that in a population-based sample, TBI is associated with higher mortality rates during only the first 6 months after injury, and this increased risk of death is due to external causes. This in turn has implications for the long-term medical and rehabilitation treatment of individuals who survive the postacute phase after TBI as their health needs change with recovery and aging.
Acknowledgments
Statement of Ethics
This study was approved by Mayo Clinic and Olmsted Medical Center institutional review boards. All study participants provided authorization for their health data to be used for research purposes.
Funding Sources
This research was supported by Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS) and by the Mayo Clinic Center for Clinical and Translational Science, which is funded by the National Institutes of Health (NIH) Clinical and Translational Science Awards program. This project was made possible with use of the resources of REP, which is supported by the National Institute on Aging of the NIH under Award Number R01AG034676. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
Abbreviations
- GCS
Glasgow Coma Scale
- ICD
International Classification of Diseases
- ICD-9
International Classification of Diseases, Ninth Revision
- ICD-10
International Statistical Classification of Diseases, Tenth Revision
- REP
Rochester Epidemiology Project
- SMR
standardized mortality ratio
- TBI
traumatic brain injury
APPENDIX 1.
Mayo Adapted HICD-A codes
Mayo Adapted HICD-A | CODE DESCRIPTION |
---|---|
02985000 | PSYCHOSIS, ACUTE, WITH TRAUMA, BRAIN |
02985110 | PSYCHOSIS, ACUTE, WITH BRAIN TRAUMA |
02985120 | SYNDROME, AMNESTIC, TRAUMATIC (ACUTE) |
02995000 | PSYCHOSIS, CHRONIC, WITH BRAIN TRAUMA |
02995110 | PSYCHOSIS, CHRONIC, WITH TRAUMA, BRAIN |
03042000 | SYNDROME, ACUTE, BRAIN, WITH TRAUMA |
03042120 | SYNDROME, POST-CONTUSION, BRAIN NOS |
03042130 | SYNDROME, FRONTAL LOBE, POST-TRAUMA |
03052000 | SYNDROME, CHRONIC, BRAIN, WITH TRAUMA |
03052110 | SYNDROME, BRAIN, ORGANIC, CHRONIC, C BRAIN TRAUMA |
03052130 | SYNDROME, POST-CONTUSION, BRAIN CHRONIC |
04310000 | HEMORRHAGE, SUBDURAL, NOS |
04310110 | HEMORRHAGE, SUBDURAL, NOS |
04310111 | HEMATOMA, SUBDURAL, NOS |
04310120 | HEMATOMA, EPIDURAL, ACUTE |
04310130 | HEMATOMA, EPIDURAL, NOS |
04310131 | HEMATOMA, EXTRADURAL, NOS, SEE ALSO EPIDURAL |
04310140 | HEMATOMA, SUBDURAL, ACUTE |
04310150 | HEMATOMA, SUBDURAL, CHRONIC |
04311000 | HEMORRHAGE, SUBDURAL, WITH PARALYSIS |
04311110 | HEMORRHAGE, SUBDURAL, WITH PARALYSIS |
07610810 | DAMAGE, BRAIN, DUE TO BIRTH INJURY |
07610811 | INJURY, BIRTH, BRAIN |
07619510 | TRAUMA, BIRTH, NEC |
07700000 | COMA |
07700110 | COMATOSE |
07700111 | COMA, NOS |
07700112 | UNCONSCIOUS-SEE ALSO DISORDER |
07700120 | COMA, NOS, CAUSE SPECIFIED |
07700130 | COMA, SPINDLE |
07700140 | VEGETATIVE STATE (CNS) |
07707110 | AMNESIA, POST-TRAUMATIC |
07755110 | DISORDER, CONSCIOUSNESS, CAUSE SPECIFIED |
07920120 | HEADACHE, POST TRAUMA |
08000000 | FRACTURE, SKULL VAULT, CLOSED |
08000010 | FRACTURE, SKULL, VAULT |
08000020 | FRACTURE, SKULL, FRONTAL |
08000030 | FRACTURE, SKULL, VERTEX |
08000040 | FRACTURE, SKULL, PARIETAL |
08001000 | FRACTURE, SKULL VAULT, OPEN |
08001010 | FRACTURE, SKULL VAULT, OPEN |
08001020 | FRACTURE, SKULL, FRONTAL, OPEN |
08001030 | FRACTURE, SKULL, VERTEX, OPEN |
08001040 | FRACTURE, SKULL, PARIETAL, OPEN |
08009000 | FRACTURE, SKULL VAULT, LATE EFFECT |
08009010 | FRACTURE, SKULL VAULT, LATE EFFECT |
08009020 | FRACTURE, SKULL, FRONTAL, LATE EFFECT |
08009030 | FRACTURE, SKULL, VERTEX, LATE EFFECT |
08009040 | FRACTURE, SKULL, PARIETAL, LATE EFFECT |
08010000 | FRACTURE, SKULL BASE, CLOSED |
08010110 | FRACTURE, SKULL, ANTERIOR FOSSA |
08010120 | FRACTURE, SKULL, BASE |
08010130 | FRACTURE, SKULL, MIDDLE FOSSA |
08010140 | FRACTURE, SKULL, POSTERIOR FOSSA |
08010150 | FRACTURE, SKULL, OCCIPITAL |
08010160 | FRACTURE, SKULL, ANTRUM |
08010170 | FRACTURE, SKULL, ETHMOID |
08010180 | FRACTURE, SKULL, SPHENOID |
08010190 | FRACTURE, SKULL, TEMPORAL |
08010200 | FRACTURE, SINUS, CODE ALSO FRACTURE SKULL, PART SPECIFIED |
08010210 | FRACTURE, MALLEUS (EAR) |
08011000 | FRACTURE, SKULL BASE, OPEN |
08011110 | FRACTURE, SKULL, ANTERIOR FOSSA, OPEN |
08011120 | FRACTURE, SKULL, BASE, OPEN |
08011121 | FRACTURE, SKULL, OPEN |
08011130 | FRACTURE, SKULL, MIDDLE FOSSA, OPEN |
08011140 | FRACTURE, SKULL, POSTERIOR FOSSA, OPEN |
08011150 | FRACTURE, SKULL, OCCIPITAL, OPEN |
08011160 | FRACTURE, SKULL, ANTRUM, OPEN |
08011170 | FRACTURE, SKULL, ETHMOID, OPEN |
08011180 | FRACTURE, SKULL, SPHENOID, OPEN |
08011190 | FRACTURE, SKULL, TEMPORAL, OPEN |
08011210 | FRACTURE, MALLEUS, OPEN |
08019000 | FRACTURE, SKULL BASE, LATE EFFECT |
08019110 | FRACTURE, SKULL, ANTERIOR FOSSA, LATE EFFECT |
08019120 | FRACTURE, SKULL, BASE, LATE EFFECT |
08019130 | FRACTURE, SKULL, MIDDLE FOSSA, LATE EFFECT |
08019140 | FRACTURE, SKULL, POSTERIOR FOSSA, LATE EFFECT |
08019150 | FRACTURE, SKULL, OCCIPITAL, LATE EFFECT |
08019160 | FRACTURE, SKULL, ANTRUM, LATE EFFECT |
08019170 | FRACTURE, SKULL, ETHMOID, LATE EFFECT |
08019180 | FRACTURE, SKULL, SPHENOID, LATE EFFECT |
08019190 | FRACTURE, SKULL, TEMPORAL, LATE EFFECT |
08019210 | FRACTURE, MALLEUS, LATE EFFECT |
08019220 | FRACTURE, MALLEUS, OLD |
08020000 | FRACTURE, NASAL, CLOSED |
08020110 | FRACTURE, NOSE |
08021000 | FRACTURE, NASAL, OPEN |
08021110 | FRACTURE, NOSE, OPEN |
08022000 | FRACTURE, MANDIBLE, CLOSED |
08022110 | FRACTURE, JAW, LOWER |
08022111 | FRACTURE, MANDIBLE |
08022112 | FRACTURE, MAXILLA, INFERIOR, SEE ALSO FRACTURE, MANDIBLE |
08022210 | FRACTURE, JAW, NOS |
08023000 | FRACTURE, MANDIBLE, OPEN |
08023110 | FRACTURE, MANDIBLE, OPEN |
08023111 | FRACTURE, JAW, LOWER, OPEN |
08023210 | FRACTURE, JAW, NOS, OPEN |
08024000 | FRACTURE, FACIAL BONE, NEC, CLOSED |
08024110 | FRACTURE, PALATE |
08024120 | FRACTURE, ORBIT |
08024121 | FRACTURE, ORBIT, BLOWOUT |
08024130 | FRACTURE, JAW, UPPER |
08024131 | FRACTURE, MAXILLA |
08024132 | FRACTURE, MAXILLARY ANTRUM |
08024133 | FRACTURE, ANTRUM, MAXILLARY |
08024134 | FRACTURE, LA FORTE’S, SEE ALSO FRACTURE MAXILLA |
08024140 | FRACTURE, MALAR BONE |
08024150 | FRACTURE, FACE BONE |
08024151 | FRACTURE, FACIAL |
08024160 | FRACTURE, ZYGOMA |
08025000 | FRACTURE, FACIAL BONE, NEC, OPEN |
08025110 | FRACTURE, PALATE, OPEN |
08025120 | FRACTURE, ORBIT, OPEN |
08025130 | FRACTURE, JAW, UPPER, OPEN |
08025131 | FRACTURE, MAXILLA, OPEN |
08025132 | FRACTURE, MAXILLARY ANTRUM, OPEN |
08025140 | FRACTURE, MALAR BONE |
08025150 | FRACTURE, FACE BONE |
08025151 | FRACTURE, FACIAL |
08025160 | FRACTURE, ZYGOMA, OPEN |
08029000 | FRACTURE, FACIAL BONE, NEC, LATE EFFECT |
08029110 | FRACTURE, PALATE, LATE EFFECT |
08029120 | FRACTURE, ORBIT, LATE EFFECT |
08029130 | FRACTURE, JAW, UPPER, LATE EFFECT |
08029131 | FRACTURE, MAXILLA, LATE EFFECT |
08029132 | FRACTURE, MAXILLARY ANTRUM, LATE EFFECT |
08029141 | FRACTURE, MALAR BONE, LATE EFFECT |
08029151 | FRACTURE, FACIAL, LATE EFFECT |
08029152 | FRACTURE, FACE BONE, LATE EFFECT |
08029160 | FRACTURE, ZYGOMA, LATE EFFECT |
08029170 | FRACTURE, NOSE, LATE EFFECT |
08029180 | FRACTURE, MANDIBLE, LATE EFFECT |
08029181 | FRACTURE, JAW, LOWER, LATE EFFECT |
08029190 | FRACTURE, JAW, NOS, LATE EFFECT |
08029210 | FRACTURE, PALATE, OLD |
08029220 | FRACTURE, ORBIT, OLD |
08029230 | FRACTURE, MAXILLA, OLD |
08029231 | FRACTURE, JAW, UPPER, OLD |
08029240 | FRACTURE, MALAR BONE, OLD |
08029250 | FRACTURE, FACE BONE, OLD |
08029251 | FRACTURE, FACIAL, OLD |
08029260 | FRACTURE, ZYGOMA, OLD |
08029270 | FRACTURE, NOSE, OLD |
08029280 | FRACTURE, MANDIBLE, OLD |
08029281 | FRACTURE, JAW, LOWER, OLD |
08029290 | FRACTURE, JAW, NOS, OLD |
08030000 | FRACTURE, SKULL, NEC, CLOSED |
08030110 | FRACTURE, SKULL, NOS |
08031000 | FRACTURE, SKULL, NEC, OPEN |
08031110 | FRACTURE, SKULL, NOS, OPEN |
08039000 | FRACTURE, SKULL, LATE EFFECT |
08039110 | FRACTURE, SKULL, NOS, LATE EFFECT |
08039210 | FRACTURE, SKULL, OLD |
08500000 | CONCUSSION, CURRENT |
08500110 | CONCUSSION, NOS |
08500120 | CONCUSSION, BRAIN, WITHOUT SKULL FRACTURE |
08500130 | COMMOTIO CEREBRI (WITHOUT SKULL FRACTURE) |
08509000 | CONCUSSION, LATE EFFECT |
08509110 | ENCEPHALOPATHY, DUE TO TRAUMA |
08509111 | ENCEPHALOPATHY, POST-TRAUMATIC |
08509112 | PORENCEPHALY, POST-TRAUMATIC |
08509210 | CONCUSSION, LATE EFFECT |
08509211 | SYNDROME, CONCUSSION (LATE EFFECT) |
08510000 | LACERATION, OR CONTUSION, CEREBRAL |
08510110 | CONTUSION, BRAIN |
08510111 | CONTRA COUP (COUP CONTRA COUP) |
08510120 | LACERATION, TENTORIUM CEREBELLI |
08510121 | LACERATION, CORTEX, CEREBRAL |
08510122 | LACERATION, CEREBRAL |
08510123 | LACERATION, CEREBELLUM |
08510130 | COMPRESSION, BRAIN, DUE TO LACERATION OR CONTUSION |
08511000 | LACERATION, CEREBRAL, OPEN |
08511110 | WOUND, BULLET, INTRACRANIAL |
08511111 | WOUND, GUNSHOT, INTRACRANIAL |
08511120 | CONTUSION, BRAIN, WITH OPEN INTRACRANIAL WOUND |
08511121 | WOUND, OPEN, BRAIN |
08511122 | LACERATION, CEREBRAL, WITH OPEN INTRACRANIAL WOUND |
08519000 | LACERATION, CEREBRAL, LATE EFFECT |
08519110 | WOUND, OPEN, BRAIN, LATE EFFECT |
08519120 | CONTUSION, BRAIN, LATE EFFECT |
08519130 | LACERATION, CEREBRAL, LATE EFFECT |
08520000 | HEMORRHAGE, SUBARACHNOID, SUBDURAL OR EXTRADURAL |
08520110 | HEMATOMA, SUBARACHNOID, TRAUMATIC |
08520111 | HEMORRHAGE, SUBARACHNOID, TRAUMATIC |
08520120 | HEMATOMA, SUBDURAL, TRAUMATIC |
08520121 | HEMORRHAGE, SUBDURAL, TRAUMATIC |
08520122 | HEMATOMA, EPIDURAL, TRAUMATIC |
08521000 | HEMORRHAGE, SUBARACHNOIN, SUBDURAL OR EXTRADURAL, OPEN |
08521110 | HEMATOMA, SUBARACHNOID, TRAUMATIC |
08521111 | HEMORRHAGE, SUBARACHNOID, TRAUMATIC |
08521120 | HEMATOMA, SUBDURAL, TRAUMATIC |
08521121 | HEMORRHAGE, SUBDURAL, WITH OPEN INTRACRANIAL WOUND |
08529000 | HEMORRHAGE, SUBARACHNOID, SUBDURAL OR EXTRADURAL, LATE EFFECT |
08529110 | HEMORRHAGE, SUBARACHNOID, LATE EFFECT |
08529111 | HEMATOMA, SUBARACHNOID, LATE EFFECT, TRAUMATIC |
08529112 | HEMIPLEGIA, SUBARACHNOID, LATE EFFECT, HEMORRHAGE, TRAUMATIC |
08529120 | HEMORRHAGE, SUBDURAL, LATE EFFECT, TRAUMATIC |
08529121 | HEMATOMA, SUBDURAL, LATE EFFECT, TRAUMATIC |
08529122 | HEMIPLEGIA, SUBDURAL, LATE EFFECT, TRAUMATIC |
08529130 | HEMATOMA, EXTRADURAL, LATE EFFECT, TRAUMATIC |
08529131 | HEMORRHAGE, EXTRADURAL, LATE EFFECT, TRAUMATIC |
08529132 | HEMIPLEGIA, ALTERNANS FACIA, EXTRADURAL, LATE EFFECT, TRAUMATIC |
08530000 | HEMORRHAGE, INTRACRANIAL, NEC |
08530110 | COMPRESSION, BRAIN, DUE TO INJURY |
08530120 | HEMORRHAGE, BRAIN, TRAUMATIC |
08530121 | HEMIPLEGIA, BRAIN, TRAUMATIC |
08530122 | HEMATOMA, BRAIN, TRAUMATIC |
08531000 | HEMORRHAGE, INTRACRANIAL, NEC, OPEN |
08531110 | HEMIPLEGIA, BRAIN, WITH OPEN INTRACRANIAL WOUND |
08531111 | HEMORRHAGE, BRAIN, WITH OPEN INTRACRANIAL WOUND |
08531112 | HEMATOMA, BRAIN, WITH OPEN INTRACRANIAL WOUND |
08539000 | HEMORRHAGE, INTRACRANIAL, NEC, LATE EFFECT |
08539110 | HEMIPLEGIA, BRAIN, HEMORRHAGE, LATE EFFECT, TRAUMATIC |
08539111 | HEMORRHAGE, BRAIN, LATE EFFECT, TRAUMATIC |
08539112 | HEMATOMA, BRAIN, LATE EFFECT, TRAUMATIC |
08540000 | INJURY, INTRACRANIAL, NEC |
08540110 | INJURY, INTRACRANIAL, NOS |
08540210 | INJURY, HEAD, NEC, (INTRACRANIAL)–CHI |
08540220 | SYNDROME, HEAD, TRAUMATIC |
08540310 | CONCUSSION, OSSEOUS LABYRINTH |
08540311 | CONCUSSION, LABYRINTH |
08541000 | INJURY, INTRACRANIAL, NEC, OPEN |
08541110 | INJURY, HEAD, NEC, (INTRACRANIAL), WITH OPEN INTRACRANIAL WOUND |
08541120 | INJURY, INTRACRANIAL, WITH OPEN INTRACRANIAL WOUND |
08541210 | LACERATION, INTRACRANIAL |
08541220 | FOREIGN BODY, INTRACRANIAL |
08541230 | WOUND, OPEN, INTRACRANIAL |
08549000 | INJURY, INTRACRANIAL, NEC, LATE EFFECT |
08549110 | IRRITATION, BRAIN, BY SCAR TISSUE |
08549120 | EPILEPSY, TRAUMATIC |
08549130 | INJURY, HEAD, NEC, (INTRACRANIAL), LATE EFFECT |
08549131 | POSTURING, DECEREBRATE, POST-TRAUMATIC |
08549140 | INJURY, INTRACRANIAL, LATE EFFECT |
08690130 | CONCUSSION, BLAST |
08730000 | LACERATION, SCALP |
08730110 | WOUND, OPEN, HEAD |
08730120 | INJURY, SCALP, NOS |
08730130 | WOUND, OPEN, SCALP |
08730131 | LACERATION, SCALP |
08731000 | LACERATION, SCALP, COMPLICATED |
08731110 | WOUND, OPEN, HEAD, NEC, COMPLICATED |
08731111 | FOREIGN BODY, HEAD, NEC |
08731120 | INJURY, SCALP, COMPLICATED |
08731130 | WOUND, OPEN, SCALP, COMPLICATED |
08731140 | WOUND, OPEN, INFECTED, HEAD, CODE ALSO BY SITE, COMPLICATED |
08737140 | WOUND, OPEN, FOREHEAD |
08738140 | WOUND, OPEN, FOREHEAD, COMPLICATED |
09002210 | INJURY, HEAD, ARTERY, NEC |
09002220 | INJURY, HEAD, VEIN, NEC |
09002230 | ANEURYSM, HEAD, ARTERY, NEC, TRAUMATIC |
09003110 | INJURY, HEAD, ARTERY, NOS |
09003120 | INJURY, HEAD, VEIN, NOS |
09003130 | ANEURYSM, HEAD, ARTERY, NOS, TRAUMATIC |
09003132 | FISTULA, ARTERIOVENOUS, HEAD, TRAUMATIC |
09003141 | HEMATOMA, ARTERIAL, HEAD, CODE ALSO INJURY, VASCULAR BY SITE |
09100140 | INJURY, SCALP, SUPERFICIAL, NOS |
09100141 | INJURY, HEAD, SUPERFICIAL |
09101140 | INJURY, SCALP, SUPERFICIAL, INFECTED |
09198000 | INJURY, MULTIPLE, NOS |
09198110 | INJURY, MULTIPLE SITES, NEC |
09198111 | INJURY, NOS |
09198112 | TRAUMA, NOS, SEE ALSO INJURY BY SITE |
09198113 | AVULSION, NOS, SEE ALSO WOUND/INJURY TYPE SPECIFIED |
09198114 | SWELLING, TRAUMATIC-SEE ALSO INJURY BY SITE |
09198120 | INJURY, MULTIPLE SITES, NOS |
09198130 | HEMATOMA, SUBUNGUAL, NOS |
09199111 | SYNDROME, POST TRAUMATIC |
09200160 | CONTUSION, HEAD |
09200161 | HEMATOMA, HEAD |
09200162 | CONTUSION, FOREHEAD |
09200170 | CONTUSION, SCALP |
09200171 | CONTUSION, CAPITIS |
09200172 | HEMATOMA, SCALP |
09200180 | HEMATOMA, PERICRANIAL |
09209110 | HEMATOMA, PERICRANIAL, LATE EFFECT |
09209113 | HEMATOMA, CAPITIS, LATE EFFECT |
09209117 | HEMATOMA, SCALP, LATE EFFECT |
09250110 | HEMATOMA, SCALP, LATE EFFECT |
09250111 | CONTUSION, MULTIPLE SITES |
09250112 | ECCHYMOSIS, TRAUMATIC, NOS, SEE ALSO CONTUSION |
ICD-9-CM | CODE DESCRIPTION |
294.0 | AMNESTIC SYNDROME |
310.0 | FRONTAL LOBE SYNDROME |
310.2 | POSTCONCUSSION SYNDROME |
432 | OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE |
767.0 | SUBDURAL AND CEREBRAL HEMORRHAGE DUE TO BIRTH TRAUMA |
767.9 | UNSPECIFIED BIRTH TRAUMA |
780.0 | ALTERATION OF CONSCIOUSNESS |
800 | FRACTURE OF VAULT OF SKULL |
801 | FRACTURE OF BASE OF SKULL |
802 | FRACTURE OF FACE BONES |
803 | OTHER AND UNQUALIFIED SKULL FRACTURES |
804 | MULTIPLE FRACTURES INVOLVING SKULL OR FACE WITH OTHER BONES |
850 | CONCUSSION |
851 | CEREBRAL LACERATION AND CONTUSION |
852 | SUBARACHNOID, SUBDURAL, AND EXTRADURAL HEMORRHAGE, FOLLOWING INJURY |
853 | OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE FOLLOWING INJURY |
854 | INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE |
873.0 | OPEN WOUND OF SCALP, WITHOUT MENTION OF COMPLICATION |
873.1 | OPEN WOUND OF SCALP, COMPLICATED |
873.42 | OPEN WOUND OF FOREHEAD, UNCOMPLICATED |
873.52 | OPEN WOUND OF FOREHEAD, COMPLICATED |
873.8 | OTHER AND UNSPECIFIED OPEN WOUND OF HEAD WITHOUT MENTION OF COMPLICATION |
900.9 | INJURY TO UNSPECIFIED BLOOD VESSEL OF HEAD AND NECK |
905.0 | LATE EFFECT OF FRACTURE OF SKULL AND FACE BONES |
906.0 | LATE EFFECT OF OPEN WOUND OF HEAD, NECK, AND TRUNK |
906.3 | LATE EFFECT OF CONTUSION |
907.0 | LATE EFFECT OF INTRACRANIAL INJURY WITHOUT MENTION OF SKULL FRACTURE |
908.6 | LATE EFFECT OF CERTAIN COMPLICATIONS OF TRAUMA |
910.8 | OTHER AND UNSPECIFIED SUPERFICIAL INJURY OF FACE, NECK, AND SCALP W/O MENTION OF INFECTION |
910.9 | OTHER AND UNSPECIFIED SUPERFICIAL INJURY OF FACE, NECK, AND SCALP INFECTED |
920 | CONTUSION OF FACE, SCALP, AND NECK EXCEPT EYE(S) |
959.8 | OTHER AND UNSPECIFIED INJURY TO OTHER SPECIFIED SITES, INCLUDING MULTIPLE |
959.9 | OTHER AND UNSPECIFIED INJURY TO UNSPECIFIED SITE |
From Leibson CL, Brown AW, Hall Long K, et al. Medical care costs associated with traumatic brain injury over the full spectrum of disease: a controlled population-based study. J Neurotrauma. 2012;29(11):2038–2049.
APPENDIX 2.
Mayo traumatic brain injury (TBI) classification systema
A. Classify as Definite TBI if one or more of the following criteria apply: |
1. Death due to this TBI |
2. Loss of consciousness of 30 minutes or more |
3. Post-traumatic anterograde amnesia of 24 hours or more |
4. Worst Glasgow Coma Scale full score in first 24 hours <13 (unless invalidated upon review, eg, attributable to intoxication, sedation, systemic shock) |
5. One or more of the following present: |
• Intracerebral hematoma |
• Subdural hematoma |
• Epidural hematoma |
• Cerebral contusion |
• Hemorrhagic contusion |
• Penetrating TBI (dura penetrated) |
• Subarachnoid hemorrhage |
B. If none of Criteria A apply, classify as Probable TBI if one or more of the following criteria apply: |
1. Loss of consciousness of momentary to less than 30 minutes |
2. Post-traumatic anterograde amnesia of momentary to less than 24 hours |
3. Depressed, basilar or linear skull fracture (dura intact) |
C. If none of Criteria A or B apply, classify as Possible (Symptomatic) TBI if one or more of the following symptoms are present: |
• Blurred vision |
• Confusion (mental state changes) |
• Dazed |
• Dizziness |
• Focal neurologic symptoms |
• Headache |
• Nausea |
Adapted from Malec JF, Brown AW, Leibson CL, Flaada JT, Mandrekar JN, Diehl NN, Perkins PK. The Mayo classification system for traumatic brain injury severity. J Neurotrauma. 2007;24:1417–24.
Footnotes
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Contributor Information
Dmitry Esterov, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota.
Erica Bellamkonda, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota.
Jay Mandrekar, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; Department of Neurology, Mayo Clinic, Rochester, Minnesota.
Jeanine E. Ransom, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
Allen W. Brown, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota.
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