Coding for TBI

Theresa B. Lattimore

Traumatic Brain Injury with Skull International Classi fi cation of Diseases, Fracture Ninth Revision, Clinical Modi fi cation (ICD-9-CM ) Codes Used in Traumatic 800.00Ð800.09 Fracture of vault of skull, closed, Brain Injury without mention of intracranial injury 800.10Ð800.19 Fracture of vault of skull, closed, with Acute Injury Codes cerebral laceration and contusion 800.20Ð800.29 Fracture of vault of skull, closed, with subarachnoid, subdural, and extradural Note that codes in categories 800, 801, 803, 804, 851, hemorrhage 852, 853, and 854 require a fi fth digit as follows: 800.30Ð800.39 Fracture of vault of skull, closed, with 0. Unspeci fi ed state of consciousness other and unspeci fi ed intracranial 1. With no loss of consciousness hemorrhage 2. With brief [less than 1 h] loss of consciousness 800.40Ð800.49 Fracture of vault of skull, closed, with 3. With moderate [1Ð24 h] loss of consciousness intracranial injury of other and unspeci fi ed nature 4. With prolonged [more than 24 h] loss of con- 800.50Ð800.59 Fracture of vault of skull, open, sciousness and return to preexisting conscious without mention of intracranial injury level 800.60Ð800.69 Fracture of vault of skull, open, with 5. With prolonged [more than 24 h] loss of con- cerebral laceration and contusion sciousness without return to preexisting con- 800.70Ð800.79 Fracture of vault of skull, open, with scious level subarachnoid, subdural, and extradural hemorrhage Use fi fth-digit 5 to designate when a patient 800.80Ð800.89 Fracture of vault of skull, open, with is unconscious and dies before regaining con- other and unspeci fi ed intracranial sciousness, regardless of the duration of loss hemorrhage of consciousness 800.90Ð800.99 Fracture of vault of skull, open, with 6. With loss of consciousness of unspeci fi ed intracranial injury of other and unspeci fi ed nature duration 801.00Ð801.09 Fracture of base of skull, closed, 7. With , unspeci fi ed without mention of intracranial injury Note that these extenders do not apply to the 801.10Ð801.19 Fracture of base of skull, closed, with 850xx series or 802xx series codes. cerebral laceration and contusion 801.20Ð801.29 Fracture of base of skull, closed, with subarachnoid, subdural, and extradural  T. B. Lattimore , M.S.N., N.P.-C. ( ) hemorrhage Programs (M96) , Wounded, Ill, 801.30Ð801.39 Fracture of base of skull, closed, with & Injured (M96), & Injured Directorate, US Navy other and unspeci fi ed intracranial Bureau of Medicine and Surgery , Washington , DC , USA hemorrhage e-mail: [email protected]

J.W. Tsao (ed.), Traumatic Brain Injury: A Clinician’s Guide to Diagnosis, Management, and Rehabilitation, 325 DOI 10.1007/978-0-387-87887-4, © Springer Science+Business Media, LLC 2012 326 T.B. Lattimore

801.40Ð801.49 Fracture of base of skull, closed, with 804.20Ð804.29 Multiple fractures involving skull or intracranial injury of other and face with other bones, closed, with unspeci fi ed nature subarachnoid, subdural, and extradural 801.50Ð801.59 Fracture of base of skull, open, without hemorrhage mention of intracranial injury 804.30Ð804.39 Multiple fractures involving skull or 801.60Ð801.69 Fracture of base of skull, open, with face with other bones, closed, with cerebral laceration and contusion other and unspeci fi ed intracranial 801.70Ð801.79 Fracture of base of skull, open, with hemorrhage subarachnoid, subdural, and extradural 804.40Ð804.49 Multiple fractures involving skull or hemorrhage face with other bones, closed, with 801.80Ð801.89 Fracture of base of skull, open, with intracranial injury of other and other and unspeci fi ed intracranial unspeci fi ed nature hemorrhage 804.50Ð804.59 Multiple fractures involving skull or 801.90Ð801.99 Fracture of base of skull, open, with face with other bones, open, without intracranial injury of other and mention of intracranial injury unspeci fi ed nature 804.60Ð804.69 Multiple fractures involving skull or 802.0 Closed fracture of the nasal bones face with other bones, open, with cerebral laceration and contusion 802.1 Open fracture of the nasal bones 804.70Ð804.79 Multiple fractures involving skull or 802.20Ð802.29 Closed fracture of the mandible face with other bones, open, with 803.00Ð803.09 Other and unquali fi ed skull fractures, subarachnoid, subdural, and extradural closed, without mention of injury 804.80Ð804.89 Multiple fractures involving skull or 803.10Ð803.19 Other and unquali fi ed skull fractures, face with other bones, open, with other closed, with cerebral laceration and and unspeci fi ed intracranial contusion hemorrhage 803.20Ð803.29 Other and unquali fi ed skull fractures, 804.90Ð804.99 Multiple fractures involving skull or closed, with subarachnoid, subdural, face with other bones, open, with and extradural hemorrhage intracranial injury of other and 803.30Ð803.39 Other and unquali fi ed skull fractures, unspeci fi ed nature closed, with other and unspeci fi ed intracranial hemorrhage 803.40Ð803.49 Other and unquali fi ed skull fractures, closed, with intracranial injury of other Traumatic Brain Injury Without Skull and unspeci fi ed nature Fracture 803.50Ð803.59 Other and unquali fi ed skull fractures, open, without mention of intracranial 850.0 Concussion with no loss of injury consciousness 803.60Ð803.69 Other and unquali fi ed skull fractures, 850.11 Concussion with brief loss of open, with cerebral laceration and consciousness of 30 min or less contusion 850.12 Concussion with brief loss of 803.70Ð803.79 Other and unquali fi ed skull fractures, consciousness of 31Ð59 min open, with subarachnoid, subdural, and 850.2 Concussion with moderate loss of extradural hemorrhage consciousness (1Ð24 h) 803.80Ð803.89 Other and unquali fi ed skull fractures, 850.3 With prolonged loss of consciousness open, with other and unspeci fi ed (more than 24 h) and return to intracranial hemorrhage preexisting conscious level (complete 803.90Ð803.99 Other and unquali fi ed skull fractures, recovery) open, with intracranial injury of other 850.4 Concussion with prolonged loss of and unspeci fi ed nature consciousness without return to 804.00Ð804.09 Multiple fractures involving skull or preexisting conscious level face with other bones, closed, without 850.5 With loss of consciousness of mention of intracranial injury unspeci fi ed duration 804.10Ð804.19 Multiple fractures involving skull or 850.9 Concussion, unspeci fi ed face with other bones, closed, with 851.00Ð851.09 Cortex (cerebral) contusion without cerebral laceration and contusion mention of open intracranial wound Coding for TBI 327

851.10Ð851.19 Cortex (cerebral) contusion with open Manifestation Codes intracranial wound 851.20Ð851.29 Cortex (cerebral) laceration without Coding manifestation is encouraged since there mention of open intracranial wound is not one common presentation for traumatic 851.30Ð851.39 Cortex (cerebral) laceration with open intracranial wound brain injury (TBI). The “coma” codes from 780.0 851.40Ð851.49 Cerebellar or brain stem contusion to 780.93 may NOT be used with TBI. Likewise, without mention of open intracranial memory loss, 780.93, may NOT be used with wound TBI. The manifestation codes should be listed 851.50Ð851.59 Cerebellar or brain stem contusion with after the primary TBI code from the preceding open intracranial wound list during the acute hospitalization. 851.60Ð852.69 Cerebellar or brain stem laceration Following is a list of relatively new or little without mention of open intracranial wound known TBI code manifestations: 851.70Ð851.79 Cerebellar or brain stem laceration with open intracranial wound 310.0 Frontal lobe syndrome (due to ) 851.80Ð851.89 Other and unspeci fi ed cerebral 310.2 Postconcussion syndrome laceration and contusion, without 310.8 Other speci fi ed nonpsychotic mental mention of open intracranial wound disorders following organic brain damage 851.90Ð851.99 Other and unspeci fi ed cerebral Mild memory disturbance due to organic laceration and contusion, with open brain damage intracranial wound 339.20 Posttraumatic headache, unspeci fi ed 852.00Ð852.09 following 339.21 Acute posttraumatic headache injury without mention of open 339.22 Chronic posttraumatic headache intracranial wound 852.10Ð852.19 Subarachnoid hemorrhage following injury with open intracranial wound These codes are new and available for use 852.20Ð852.29 Subdural hemorrhage following injury beginning October 1, 2010 without mention of open intracranial wound 780.33 Posttraumatic seizures 852.30Ð852.39 Subdural hemorrhage following injury Note that this code is not to be used for with open intracranial wound posttraumatic epilepsy, where the appro- 852.40Ð852.49 Extradural hemorrhage following injury priate code from category 345.xx should without mention of open intracranial be used wound 799.50 Unspeci fi ed signs and symptoms involving 852.50Ð852.59 Extradural hemorrhage following injury cognition with open intracranial wound 799.51 Attention or concentration de fi cit 853.00Ð853.09 Other and unspeci fi ed intracranial 799.52 Cognitive communication de fi cit hemorrhage following injury, without 799.53 Visuospatial de fi cit mention of open intracranial wound (This is the default code for Traumatic 799.54 Psychomotor de fi cit cerebral hemorrhage ) 799.55 Frontal lobe and executive function de fi cit 853.10Ð853.19 Other and unspeci fi ed intracranial Note that the code 310.0 is to be used if the hemorrhage following injury, with open manifestation is due to brain damage intracranial wound 799.59 Other signs and symptoms involving 854.00Ð854.09 Intracranial injury of other and cognition unspeci fi ed nature without mention of open intracranial wound (This is the The 799-series codes (different from those default code for Traumatic brain injury mentioned above) allow providers to code emo- but other codes more accurately re fl ect the degree of injury ) tional/behavioral symptoms without using mental 854.10Ð854.19 Intracranial injury of other and health diagnosis codes. These codes do not replace unspecifi ed nature with open mental health diagnosis codes. Providers should intracranial wound use these codes when they observe the symptoms 959.01 Head injury, unspeci fi ed but a mental health diagnosis is not established. 328 T.B. Lattimore

While these codes are intended to be used for TBI Terrorism (GWOT). The military requires this symptoms, they are not limited to TBI. code with all TBI documentation. Since it is bro- 799.21: nervousness ken down by relation to GWOT and severity level 799.22: irritability it provides more signifi cant detail for surveillance 799.23: impulsiveness purposes. It may be of value in some cases to add 799.24: emotional lability the information to a list of diagnoses that a patient 799.25: demoralization and apathy has a history of TBI, and instances may occur 799.29: other signs and symptoms involving when no “late effect” is present; this information emotional state needs to be captured. In that case, use the code Other manifestations, such as paresis, speech and language disturbances, and sleep disorders, V15.52_0 Personal History of traumatic brain injury (TBI) not otherwise speci fi ed may be found in the ICD-9-CM index and are too V15.52_1 Personal History of TBI, Global War on numerous to list here. Terrorism (GWOT) Related, Unknown Severity Level V15.52_2 Personal History of TBI, GWOT Related, Late Effects of Traumatic Brain Injury Mild V15.52_3 Personal History of TBI, GWOT Related, Anytime after the acute phase, manifestations of Moderate TBI would be considered “late effects.” The fi rst- V15.52_4 Personal History of TBI, GWOT Related, listed code becomes the manifestation (late Severe effect), and the second code is a “late effect code” V15.52_5 Personal History of TBI, GWOT Related, Penetrating Intracranial Wound, No Level appropriate to the injury as listed below: of Severity Assigned V15.52_6 Personal History of TBI not GWOT 905.0 Late effect of fracture of skull and facial bones Related, Unknown Level of Severity Late effect injury classi fi able to 800Ð804 V15.52_7 Personal History of TBI not GWOT 907.0 Late effect of intracranial injury without Related, Mild mention of V15.52_8 Personal History of TBI not GWOT Late effect of injury classi fi able to 850Ð854 Related, Moderate V15.52_9 Personal History of TBI not GWOT Related, Severe Screening for Traumatic Brain Injury V15.52_A Personal History of TBI not GWOT Related, Penetrating Intracranial Wound, Especially in the military setting, patients may be No Level of Severity Assigned screened for possible TBI. The code to be used in V15.52_B Personal History of TBI, Unknown if GWOT Related, Unknown Severity Level this situation is V15.52_C Personal History of TBI, Unknown if GWOT Related, Mild V80.01 Screening for traumatic brain injury V15.52_D Personal History of TBI, Unknown if GWOT Related, Moderate The military currently uses this code to denote V15.52_E Personal History of TBI, Unknown if screening for TBI regardless of the outcome of GWOT Related, Severe the screening (concussion or no concussion). V15.52_F Personal History of TBI, Unknown if GWOT Related, Penetrating Intracranial Wound, No Level of Severity Assigned Personal History of Traumatic Brain These codes may not be a fi rst-listed diagnosis. Injury Related to the Global War on Terrorism Coding TBI in the Military Population This series of codes was developed for the mili- tary to assist in tracking TBI, particularly those The military has unique needs related to coding sustained in relation to the Global War on for TBI. The military has signifi cant instances of Coding for TBI 329

TBI in both combat and the daily life associated diagnosed . When used in combination with preparing for combat. As a result the mili- these codes, both military specifi c and others, tary has placed great emphasis on capturing help provide military leaders with a unique blend information through ICD-9 coding. In addition to of data on the current medical status as well as the typical TBI codes used in the civilian sector, operational impact of TBI in the combat the military has created a series of TBI history environment. codes that connect a patient to injury related to the Global War on Terrorism (GWOT). The mili- tary also encourages use of the External Injury Quick Guide to Coding in the Military Codes (E-codes) as appropriate. In particular the Population E979.2 (Terrorism Involving Other Explosions/ Fragments), code is used to document TBI related The encounters must be broken down to initial to Improvised Explosive Devices (IEDs). The visit and follow-up. At the initial visit, the fi rst military also uses Deployment Status Codes to code used will be the primary diagnostic code help determine if injury was related to combat (i.e., 8xx Series code). This is followed by the and where care took place. Speci fi cally V70.5_5 history of concussion code (V15.52_x). The third (During Deployment Encounter) and V70.5_6 position is for any relevant symptom codes. The (Post-deployment Encounter) can provide data fourth position is the deployment status code fol- on where the care of a combat-related injured lowed by the screening code or the E-code. The service member took place. The military relies TBI screening code can be at the end of the list. on the V80.01 (Screening for TBI) to capture On any follow-up visits the fi rst code will be the screenings regardless of the resulting diagnosis. symptom code. However, the history of TBI code This code is key to the military surveillance (V15.52_x) will be second. The deployment picture because it provides data on how many status code and late effect codes would be next. exposures to potentially concussive events each You do not recode the TBI diagnostic code, service member has in relation to the number of E-code or screening code at follow-up visits.

Code at initial Code for Code TYPE Details evaluation follow-up visit 1. TBI diagnostic ¥ 850.0 concussion without LOC YES (Code 1st) NO code ¥ 850.1 concussion with brief LOC ¥ 850.11 concussion with LOC £ 30 min 2. Personal ¥ V15.52_1 Injury related to Global War on YES (Code 2nd) YES (Code 2nd) history of TBI Terrorism, Unknown ¥ V15.52_2 Injury related to Global War on Terrorism, Mild 3. Symptom ¥ Common examples in TBI include: YES (Code 3rd) YES (Code 1st) codes Ð 784.0 Headache Ð 388.3 Tinnitus 4. Late effect ¥ 905.0 Late effect of intracranial injury with NO YES (Code 3rd) code skull or facial fracture ¥ 907.0 Late effect of intracranial injury w/o skull or facial fracture 5. Deployment ¥ V70.5_5 During deployment encounter YES (Code 4th) YES (Code 4th) status code 6. TBI screening ¥ V80.01 Special Screening for TBI Code If applicable (Code 5th) NO code 7. E-code ¥ E979.2 Terrorism Involving Other If applicable (Code 6th) NO Explosions/Fragments 330 T.B. Lattimore

critically ill, the correct codes are the critical care Current Procedural Terminology codes. These codes, CPT 99291 and 99292, use Coding for Traumatic Brain Injury time as the basis for setting level of service instead of bullet points. Current Procedural Terminology (CPT) coding New of fi ce patients often have concussion, does not depend on the diagnosis. It depends on and the level of Evaluation and Management the work performed in the service, and more (E/M) service depends on the severity of the pre- work is needed for more serious presenting senting problem and risk. For example, a level 3 problems. of fi ce new patient visit CPT 99203 would be a New patients with moderate to severe TBI are high school athlete presenting asymptomatic usually level 5 consultations CPT 99255 or level 4 days after a concussion, requesting permission 3 admissions CPT 99223 because of the altered to return to playing in the football team next mental state and risk of substantial morbidity. week. Symptomatic TBI patients usually require When managing the patient in the intensive a higher level of service when seen in the of fi ce. care unit, and when the patient is unstable and Index

A Attention Acceptance and commitment therapy (ACT) , goal-directed control 214, 263 goal attainment , 287–289 Acute stress disorder (ASD) , 113, 206, 216, pharmacotherapy , 289 234, 297 process training , 253 Aggression PTSD , 296 anger , 226–227 theory-driven cognitive intervention , 299–300 anticonvulsants , 228, 257 Automated Neuropsychological Assessment Metrics antipsychotics , 258 (ANAM) , 215 beta-blockers , 258 Brief Anger and Aggression Questionnaire , 227 buspirone and lithum , 258 B Buss Perry Aggression Scale , 226 Benign positional vertigo (BPV) , 140 cognitive behavioral therapy , 228 Bioactive scaffold , 323 co-occuring disorder , 227 Blast-induced neurotrauma (BINT) , 198–199 depression , 227 Blast-related concussion frequency of , 226 ASR , 114 impulsive , 228 blast-concussion vs. etiology , 105 levetiracetam , 258 blast exposure , 104 methylphenidate , 257 cognitive outcomes , 114 military and veteran personnel , 227 diagnosis neuropsychological assessment and functioning , AAN concussion grading criteria , 111 227–228 clinical signs , 110 Overt Aggression Scale , 226 consciousness vs. post-traumatic amnesia , 111 prevalence of , 226 CT , 109 Airway Pressure Release Ventilation (APRV), 77 DTI , 109–110 Alertness , 254–256, 281–282 MACE , 110 Amnesia , 235 MRI , 109 antegrade , 92 US Department of Defense , 110, 111 blast-related concussion , 108 diagnostic testing , 105 post-traumatic , 2, 19 IED , 104 retrograde , 93 Iraq and Afghanistan , 104 Revised Westmead Post-traumatic Amnesia Scale neurological sequelae , 103 (R-WPTAS) , 57 Operation Enduring Freedom , 104 Anticonvulsants , 83–84, 175, 257 Operation Iraqi Freedom , 104 Antiepileptic drug (AED) , 83–84 outcomes , 114 Antiepileptic prophylaxis , 176 pathology , 107–108 Anxiety pathophysiology prevalence of , 224 air- fi lled organs and air- fl uid interfaces , 106 risk , 225 barotraumas , 106 Arousal state , 281–282 blast wave , 106 ATLS secondary survey examination , 71, 72 CNS injury , 107

J.W. Tsao (ed.), Traumatic Brain Injury: A Clinician’s Guide to Diagnosis, Management, and Rehabilitation, 331 DOI 10.1007/978-0-387-87887-4, © Springer Science+Business Media, LLC 2012 332 Index

Blast-related concussion (cont.) C explosive blast , 105, 106 Case conceptualization , 216, 219 frequency stress wave , 106 Center for the Study of Traumatic Encephalopathy IED , 107 (CSTE) , 93 primary blast injury , 106 Cerebralspinal Fluid Leak (CSF) , 43 primary mechanism , 106 Cerebral swelling , 41–42 quaternary injury , 107 Chronic pain , 284 secondary/teritary injury , 107 Chronic traumatic encephalopathy (CTE) , 90, 93, 127 tympanic membrane , 106–107 Clinician Administered Posttraumatic Stress Disorder PCS , 114 Scale (CAPS) , 211–212 persistent symptoms , 114 Cognitive behavioral therapy (CBT) , 213, 216, 219 psychological symptoms , 104 Cognitive disorder PTSD , 105, 115 acetylcholinesterase inhibitors , 255 shell shock , 103, 104 amantadine , 255 soldiers , 103, 105 attention process training , 253 symptoms , 108–109 bromocriptine , 255 treatment cognitive behavioral therapy , 254 acute stress and mood disorders , 113 combined memantine therapy , 254 amitriptyline , 113 constraint-induced language therapy , 253–254 education , 112 functional language stimulation , 253 frequently provocative testing , 112 medication , 254 headache syndrome , 112–113 methylphenidate , 254–255 mild traumatic brain injury , 112 Cognitive neuroscience pharmacological , 113 alertness and arousal state , 281–282 post-concussive headaches , 113 cognitive dysfunction post-traumatic headaches , 112–113 chronic , 275 second impact syndrome , 112 contusions and hemorrhages , 275 sleep disturbances and hygiene , 113 emotion , 297 somatic symptoms , 112 frontal executive functions and memory , 275–276 tinnitus , 113 incidence , 274 tympanic membrane , 113 severity , 276 World War I , 104 spontaneous recovery , 276–277 World War II , 105 combined combat neurotrauma syndrome , 277 Blunt injury fatigue , 282–283 acute secondary injury intervention , 26, 42 agents vs. training , 279 cerebral swelling , 41–42 ancillary health factors vs. cognitive ischemia and infarction , 43 functioning , 279 blast-induced injury , 43–45 attention , 287–289 CSF , 43 behavioral approach , 278–279 hydrocephalus , 43 behavioral vs. biological modi fi cation , 280 primary extra-axial injury brain training games , 300 EDH ( see ) dysfunction sources , 277–278 IVH , 29–31 engagement , 279 pneumocephalus , 21, 22, 25 environment vs. patient , 279 SAH , 29, 31 external vs. internal tools , 279–280 SDH ( see ) goal-directed behavior , 277 primary intra-axial injury intervention goals , 278 cortical contusion , 33–35 learning and memory , 290 DAI ( see ) long-term health care , 302–303 encephalomalacia , 37 modi fi cations to , 297 ICH , 36–37 neural plasticity , 300 vascular injury outcomes , 279 arterial dissection , 37–38 pharmacotherapy , 280–281 arteriovenous fi stula , 39–41 potential target for , 290–291 pseudoaneurysm , 38–39 selection gateway , 300–302 Brain concussion , 1–2 systems of care , 303–304 Brief Anger and Aggression Questionnaire , 227 theory-driven cognitive intervention , 299–300 Brigade Combat Team , 184 vertical integration , 300 Buss Perry Aggression Scale , 226 medications , 281 Index 333

pain , 284 perforating missile injury , 21, 24 sleep , 283–284 pimary injury , 16 Cognitive processing therapy (CPT) , 212–213 secondary injury , 16 Cognitive training super fi cial missile injury , 20, 21 combat-related injury , 285 Diffuse axonal injury (DAI) , 4 executive control and memory , 285–286 acute , 33, 34 foundations for , 286–287 conventional imaging techniques , 32 goal-directed control corpus callosum , 32 attention , 287–289 dorsolateral quadrant , 32 brain states , 294–295 3D tractography , 33, 34 challenge the patient , 293 Grade III , 32, 34 emotion and cognition interaction , 295 Grade I/II , 32, 33 learning and memory , 290 obar white matter , 32 meta-cognitive strategy training , 294 shear hemorrhages , 32, 33 multiple goal-direction process , 292–293 shear-strain deformation , 30 target , 291–292 white matter fi bers , 30, 32 top-down modulatory process , 292 Diffuse vascular injury (DVI) , 4 transfer and generalization , 293–294 Diffusion tensor imaging (DTI) , 2, 109 learning goals , 284–285 Diffusion-weighted imaging (DWI) , 18–19 process-targeted method , 285 Dural arteriovenous fi stula (DAVF) , 40, 41 skill training , 285 Dysphagia , 252–253 CogSport™ , 53, 54 Common data elements (CDEs) , 3 Complementary and alternative medicine (CAM) , 214 E Concomitant symptom , 316 Epidural hematoma (EDH) Consent to Offer Neural Tissue of Athletes with acute , 22, 25 Concussive Trauma (C.O.N.T.A.C.T.) , 93 biconvex hyperdense collection , 22 Constraint-induced movement therapy (CIMT) , 248 de fi nition , 22 Conversion disorder , 260, 262 MR signal characteristics , 23 Co-occurring disorders. See Military health care; outer dural layer , 22, 24 Post-traumatic stress disorder (PTSD) skull fracture , 22 Current Procedural Terminology (CPT) , 331 subacute , 22, 25 Cyclosporin A (CsA) , 322–323 swirl sign , 23, 26 venous , 23, 26 Epileptogenesis , 177 D Epworth Sleepiness Scale (ESS) , 123, 124 Decompressive craniectomy (DC) , 81, 83 Erythropoietin (EPO) , 321 Defense and Veterans Brain Injury Center (DVBIC) , 184 Eugonadal sick syndrome , 197 Depression Event-related potentials (ERPs) , 318 aggression , 227 Excessive daytime sleepiness (EDS) , 120, 131 antidepressants , 256 Executive function apathy , 256 alertness and arousal , 281–282 cognitive and psychosocial functioning , 225 de fi cits , 286–287 cognitive behavioral therapy , 255–256 goal-directed control , 287–289 counseling , 255 return to work , 276 diagnosis , 225 Exposure therapy , 212 PCS , 259–263 Extraventricular drain (EVD) , 78 prevalence of , 224 risk factors , 225 suicide , 225–226 F treatment , 257 Fluid Attenuated Inversion Recovery (FLAIR) , 18 Diagnostic imaging Frontal lobes. See Executive function blunt injury (see Blunt injury) computed tomography , 16–18 conventional radiography , 16 G depressed missile injury , 21, 22 Gastric ulcer prophylaxis , 84 GCS , 16 Glasgow Coma Scale (GCS) , 2, 70, 214–215 intracranial structures , 16 Glasgow Traumatic Brain Bank , 316 MRI ( see Magnetic Resonance Imaging) Gradient-Recalled-Echo (GRE) T2*-weighted penetrating missile injury , 21, 23 imaging , 18 334 Index

H hypertonic saline , 79 Headache abortive medications hyperventilation , 80 analgesic products , 161 induced hypothermia , 80 headache relief , 159 internal jugular , 77 medication-overuse headache treatment , 160, 161 IVC , 78 midrin , 161 mannitol , 78–79 NSAIDs , 159–161 pharmacologic agents , 79–80 opioid medications , 161 treatment , 77–78 triptan class , 161 Intracranial hemorrhage (ICH) , 70 Headache prophylactic medication , 162 Intraventricular catheter (IVC) , 78 HeadMinder™ , 53 Intraventricular hemorrhage (IVH) , 29–31 Herniation syndromes , 72–73 Hormone replacement therapy (HRT) , 198 Hydrocephalus , 43 K Hyperbaric oxygen therapy (HBOT) , 215 Keane posttraumatic stress disorder scale , 212 Hyperprolactemia , 186, 197 Hypertonia , 247–248 Hypertonic saline (HTS) , 78 L Hypopituitarism , 186, 188–189 Loss of consciousness (LOC) Hypothalamic–pituitary–adrenal (HPA) , 185 athletes , 90 Hypothalamus secretes hormones , 181–182 cognitive functioning , 95 conventional focus , 95 guidelines , 97 I head injury , 90 Immediate Post-Assessment of Concussion Test (ImPACT) , 53, 95 Improvised explosive devices (IEDs) , 9, 208–209 M Impulsive aggression , 228 Magnetic Resonance Imaging (MRI) Initiation , 254–258 DWI , 18–19 Innovative diagnostic techniques FLAIR , 18 cognitive de fi cits , 317–318 GRE T2*-weighted , 18 electrophysiology , 318–319 MRS , 19 energy sensors , 320–321 MSI , 20 molecular biomarkers , 320 MTI , 19 neurologic/physiologic dysfunction , 316 perfusion MRI , 19–20 physical abnormality , 317 PET , 20 physiologic abnormality , 317 SPECT , 20 structural and functional imaging , 319–320 SWI , 18 International Classi fi cation of Diseases, Ninth Revision, Magnetic source imaging (MSI) , 20 Clinical Modi fi cation (ICD-9-CM) Codes Magnetization transfer imaging (MTI) , 19 acute injury codes , 327 Maintenance of wakefulness test (MWT) , 124 CPT , 331 Medication overuse headaches (MOH) , 263 manifestation codes Memory Global War on Terrorism , 330 goal-directed control , 290 late effects , 330 theory-driven cognitive interventions , 299–300 military population , 330–331 Migraine headaches , 154–155 screening , 330 Mild traumatic brain injury (mTBI) 799-series codes , 329 acceleration–deceleration forces , 51 with skull fracture , 327–328 ACRM de fi nition , 229 without skull fracture , 328–329 biopsychosocial factors , 50 International Classi fi cation of Headache Disorders, 2nd classi fi cation , 229–230 Edition (ICHD-2) , 150 cognitive recovery , 232–233 International Classi fi cation of Sleep Disorders (ICSD) , 134 de fi nition , 50, 258–259 Intracerebral pressure (ICP) management diagnosis , 230, 259 brain code , 80–82 incidence , 229 cerebral herniation , 77 injury severity vs. outcome , 231 clinical approach , 81 neurocognitive assessment , 53–54 EVD , 78 neurocognitive testing , 51–53 exacerbating factors , 78 neurological symptoms and signs , 50 HTS , 78 outcomes , 230–231 Index 335

persistent symptoms , 51 exacerbating factors , 78 post-concussion syndrome (see Post-concussion HTS , 78 syndrome) hypertonic saline , 79 post-mTBI hyperventilation , 80 neurological and neurocognitive functions , induced hypothermia , 80 57–59 internal jugular , 77 patient study , 56–57 IVC , 78 sports and patient groups , 56 mannitol , 78–79 sports study , 55–56 pharmacologic agents , 79–80 psychological outcomes treatment , 77–78 attributions and expectations , 60 ICU admission , 75–76 children and adolescents , 61–62 initial emergency department , 71 diathesis-stressor models , 59 neuroimaging , 72 psychological reaction , 59–60 prognostic and management implications , 70 risk factors , 50 skin breakdown , 84 self-rating scales , 54–55 spectrum , 70 sleep ( see Sleep) surgical treatment symptoms , 231–232 DC , 81, 83 Military Acute Concussion Evaluation (MACE) , extraventicular drains , 81 94, 109, 215, 317–318 treatment guidelines , 76 Military health care vasospasm , 72 agressive behaviour , 227 ventilation , 76 mTBI , 229 VTE , 84 traumatic brain injury Mood disorder. See Depression adjunctive problem-focused methods , 219 Motor disorder assessment of , 215–216, 218 ankle-foot inversion , 251 clinical practice guideline , 214 anticholinergic agents , 250 cognitive therapies/CBT , 216, 219 ataxia , 247 diagnostic de fi nition , 206 baclofen , 249 Glasgow Coma Scale , 214–215 baclofen pump , 251 hyperbaric oxygen therapy , 215 benzodiazapenes , 250 Military Acute Concussion Evaluation , 215 botulinum toxin , 250–251 pharmacotherapy , 219 casting and orthotics , 249 prevalence , 208–209 clonidine , 249 rescripting/reprocessing approach , 219 constraint-induced movement therapy , 248 symptoms , 207 cyproheptadine , 249 Minnesota Multiphasic Personality Inventory-2 dantrolene , 249–250 (MMPI-2) , 212 diazepam , 249 Moderate and severe TBI disodium etidronate , 252 airway management , 76 dystonia , 248 anticonvulsants , 83–84 electrical stimulation , 249 ATLS secondary survey examination , 71, 72 gabapentin , 249 fi eld management , 71 heterotopic ossi fi cation , 252 gastric ulcer prophylaxis , 84 involuntary fl exor/extensor spasms , 248 GCS , 70, 71 local anesthetic nerve blocks , 251 guidelines , 71 muscle/tendon lengthening , 251 herniation muscle tone central , 73 rigidity , 247–248 extracranial , 73, 75 spasticity , 247 paradoxical , 73 neurotomy , 251 subfalcine , 73 NSAID , 252 uncal , 73, 74 phenol , 250–251 upward , 75 range of motion exercise , 248 herniation syndromes , 72–73 serial casting , 251–252 ICH , 70 therapeutic exercise and functional ICP training , 248 brain code , 80–82 tilt-in-space wheelchair , 248–249 cerebral herniation , 77 weakness , 247 clinical approach , 81 MR spectroscopy (MRS) , 19 EVD , 78 Multiple sleep latency test (MSLT) , 123 336 Index

N Post-concussion syndrome (PCS) , 114–115, 233–234, National Transportation Safety Board (NTSB) , 135 235, 237–238 Neurocognitive assessment tools (NCATs) , 318 cognitive impairment , 260–261 Neuroendocrine dysfunction de fi nition , 50, 259 BINT , 198–199 indication , 259–260 brain acceleration/deceleration movement , 180 neurocognitive functions , 50 depression and chronic stress , 199 no concentration problems , 259 eugonadal sick syndrome , 197 organic andpsychogenic factors , 50 hormonal abnormality , 197 psychiatric co-morbidity , 59 HRT , 198 psychological reaction , 59 hypothalamic/pituitary structures , 180, 181, 197 PTSD , 260 literature reviews rehabilitation clinical research study , 189–194 cognitive behavioral therapy , 262–263 CT fi ndings , 196 educational interventions , 262 diabetes insipidus , 186 pharmacological interventions , 263–264 endocrine abnormality , 186 physical therapy , 263 GCS scores , 195–196 psychological issues vs. recovery process , 262 GH and ACTH de fi ciency , 195 repositioning maneuvers , 264 gonadal and/or thyroid de fi ciency , 195 vestibular rehabilitation , 264 hormonal de fi ciency , 186 self-rating scales , 54–55 hyperprolactinemia , 186 sporadic memory problems , 259 hypopituitarism , 186, 188–189 symptoms , 260 neuroendocrine disorder , 186–188 vicious cycles , 50 pituitary abnormality , 196 Post-traumatic benign positional vertigo (PTBPV) , pituitary dysfunction , 186 141, 143 mechanisms of , 181–182 Posttraumatic epilepsy (PTE) , 168 military medical setting , 200 Post-traumatic exercise-induced dizziness (PTEID) , 141 military TBI Post-traumatic headaches (PTHAs) Brigade Combat Team , 184 abortive medications DVBIC , 184 analgesic products , 161 explosive blast , 184 headache relief , 159 hormonal de fi ciencie , 186 medication-overuse headache treatment , 160, 161 HPA , 185 midrin , 161 neurological and psychiatric comorbidity , 185 NSAIDs , 159–161 neuropsychiatric sequelae , 185 opioid medications , 161 US troops , 184 triptan class , 161 post-acute screening , 196 acute and chronic headache , 151 prevalence and symptoms of , 182–184 botulinum toxin injections , 163 PTSD , 199 clinical features research objectives , 200 cervicogenic headaches , 156 TBI-related neuroendocrine , 180 cranial neuralgias , 155 thyroid baseline testing , 198 headache syndromes , 154, 155 Neurologic signs and symptoms , 316 ICHD-2 criteria , 154 Neuron-speci fi c enolase (NSE) , 320 medication-overuse headache , 156 migraine headaches , 154–155 post-traumatic migraine , 155 O tension-type headache , 154 Overt Aggression Scale , 226 trigeminal autonomic cephalalgias , 155 whiplash injury , 154 comorbid conditions , 164 P CSF pressure , 159 Persistent post-concussive symptoms , 7–8 diagnostic criteria , 150 Pittsburgh Sleep Quality Index (PSQI) , 123, 125 differential diagnosis , 156, 157 Pontine-geniculate-occipital (PGO) , 121 epidemiology , 151–152 Pore elasticity , 6 headache prevention medications , 160, 162–163 Positron emission tomography (PET) , 20 imaging , 158–159 Post-blast BPV (PBBPV) , 142 lumbar puncture , 159 Post-blast dizziness (PBD) , 142 non-pharmacologic therapy , 160, 163 Post-blast dizziness with vertigo (PBDV) , 142 occipital nerve blocks , 163 Post-blast exertional dizziness (PBED) , 142 occipital neurolysis , 164 Index 337

pathophysiology , 152–154 symptoms , 207 patient history , 157–158 vs. TBI , 208 physical exam , 158 TBI-PTSD primary headaches disorders , 149–150 attention, executive functions, and memory , 296 secondary headaches disorders , 150 cognition and emotion , 295–296 treatment algorithm , 159, 160 core self-regulatory control function , 298 Post-traumatic migraine-associated dizziness (PTMAD) , interaction , 295 141, 143–144 intervention , 297–298 Post-traumatic neuralgiform headaches , 163 modi fi cation to treatment , 297 Posttraumatic seizures neural bases of , 298 antiepileptogenic therapy , 168 PTSD symptom development/sustainment , 296 de fi nition , 168–169 Posttraumatic stress disorder checklist (PCL) , 211, 213 diagnostic testing , 174–175 Primary traumatic brain damage , 2 epidemiology and risk factors Progesterone , 322 brain tumors , 169 Proprioceptive Neuromuscular Facilitation (PNF) , 144 hospitalized patient study , 170–171 population-based study , 169–170 relative risks , 169 R subarachnoid hemorrhage , 169 Randomized clinical trials (RCTs) , 3 epileptogenesis , 177 Rehabilitation military experience , 171–173 cognitive function (see Cognitive neuroscience) pathophysiology , 173 training (see Cognitive training) patient outcomes , 176–177 Repeatable Battery for the Assessment of Neuropsycho- primary epilepsies , 168 logical Status (RBANS) , 215 PTE , 168 Revised Westmead Post-traumatic Amnesia Scale secondary epilepsies , 168 (R-WPTAS) , 57 treatment , 175–176 types of , 173–174 Post-traumatic spatial disorientation (PTSpD) , 141 S Post-traumatic stress disorder (PTSD) , 11–12, 59–60 Secondary traumatic brain damage , 2 aggression , 227, 228 Semicircular canals (SCCs) , 140 combined combat neurotrauma syndrome , 277 Sideline Assessment of Concussion (SAC) , 215 mild TBI Signature injuries . See Post-traumatic stress disorder (PTSD) acute and chronic stress , 236 Single photon emission tomography (SPECT) , 20 amnesia , 235 Sleep , 283–284 bodily injuries , 234 brain and brainstem , 119 combat-related injuries , 235–236 case study post-concussion symptoms , 235 auto accident , 127, 128 psychological trauma , 234–235 boxer , 129–130 relationship , 228–229 football player , 127–129 military health care cognitive function , 122–123 acceptance and commitment therapy , 213–214 cognitive performance , 134–135 APA treatment guidelines , 210–211 deprivation , 124 CAPS assessment tool , 211–212, 217 disorders (see Sleep disorders) Cluster D hyperarousal symptoms , 219 driving performance , 135 cognitive behavioral therapy , 213 EDS , 131 cognitive processing therapy , 212–213 endogenous factor , 134 complementary and alternative medicine , 214 environmental sleep disorder , 124 diagnostic de fi nition , 206 exogenous factor , 134 exposure and behavioral therapy , 212 glial myelin , 119 fear-conditioned memory , 209 hygiene , 131, 132 incidence and prevalence , 205–206 ICSD , 134 Keane posttraumatic stress disorder Scale , 212 motor vehicle accident patients , 122 LOC , 209–210 neuronal synaptic circuitry , 119 Mississippi Scale , 211 pattern analysis posttraumatic stress disorder checklist , 211 ESS , 123, 124 prevalence , 208 MSLT , 123 psychopharmacology , 213 MWT , 124 PTSD/TBI comorbidity , 209–210 PSQI , 123, 125 self-reported screens , 220 SSS , 123 338 Index

Sleep (cont.) computerized tests , 94–95 physiology concussive sports injury , 93 circadian rhythms , 121–122 congnitive Recovery , 96 NREM sleep , 120–121 conventional tests , 94–95 REM sleep , 121 CSI , 95 speed and accuracy , 135 ImPACT , 95 symptoms , 131 LOC , 95–96 visual performance , 135–136 MACE , 94 WASO , 122 Maddocks questions , 94 Sleep disorders neuropsychological testing , 94 breathing disorders , 127 postural stability Recovery , 96 circadian rhythms , 126 PTA , 97 CTE , 127 SAC , 93, 94 environmental , 124 SCAT , 93, 94 inadequate sleep hygiene , 126 symptom Recovery , 96 insomnia , 126 Zurich conference , 97 long sleeper , 124 Sports Concussion Assessment Tool (SCAT) , 318 sleep-related movement , 127 Standardized Assessment of Concussion (SAC) , 93 treatment , 131, 133 Statins , 321–322 armoda fi nil , 134 Subarachnoid hemorrhage (SAH) , 29, 31 caffeine , 133 Subdural hematoma (SDH) dextroamphetamine , 134 acute , 27 Doxepine (Sinequan, Silenor) , 132 brain parenchyma , 27 EDS , 131 calvarium , 27 hypnotics , 131, 133 chronic , 28, 29 insomnia monotherapy , 132–133 falx and tentorium , 27 methylphenidate , 134 FLAIR images , 28, 30 moda fi nil , 133 hematocrit effect , 27 Quetiapine (Seroquel) , 132 inner meningeal layer , 24 sleep hygiene , 131, 132 isodense subacute , 28 Sodium oxybate (Xyrem) , 132 MRI signal characteristics , 28, 30 Trazodone hydrochloride (Desyrel) , 132 parenchymal injury , 27 Sodium channel metabolism , 316 Suicide Sport Concussion Assessment Tool (SCAT) , 94 agressive behaviour , 226 Sports concussion depression , 225–226 age and developmental level , 93 Susceptibility-weighted imaging (SWI) , 18 athletic competition , 89 Symbol digit modalities test (SDMT) , 53, 54 autopsy , 92 CSTE , 93 CTE , 92, 93 T etiology and symptoms , 90–91 Tonic alertness , 281 football players , 92 Traumatic brain injury (TBI) head injury , 92 behavioral and psychiatric disorders LOC , 92 agression (see Aggression) malignant brain swelling , 92 anticonvulsants , 236 neurochemical and metabolic cascade , 92 anxiety , 224, 225 neurocognitive testing , 90 beta-adrenergic receptor blocking agents , 236 neuroimaging and concussions , 98 carbamazepine and valproic acid , 236 neuropathology , 92 comprehensive holistic rehabilitation programs , 257 NFL players , 93 depression (see Depression) post-concussion syndrome , 91 differential diagnosis , 256–257 prevention , 98–99 motivation and engagement , 258 second impact syndrome , 92 prazosin , 236 SIS , 92 premorbid behavior , 238–239 triage and treatment psycho-education , 237–238 amnesia , 95 PTSD (see Post-traumatic stress disorder (PTSD)) ANAM , 95 selective serotonin reuptake inhibitors , 236 benching and return-to-play decisions , 94 social support , 258 Cantu guidelines , 97, 98 symptom management , 237–239 clinical symptoms , 96 treatment algorithm , 236–237 Index 339

biology concussion U AOC and LOC , 5 Ubiquitin C-terminal hydrolase 1 (UCHL1) , 320 cholinergic reticular inhibitory system , 4 neurobiology , 4 PTA , 5 V brain concussion/ , 1–2 Venous thromboembolism (VTE) , 84 CDE , 3 Vestibular consequences cognitive functioning (see Cognitive neuroscience; anatomy and physiology , 140 Cognitive training) blunt trauma/overpressure , 139 commotio cerebri , 2 blunt vs. explosive blast trauma constitutive properties , 6–7 balance disorders , 142 contusio cerebri , 2 blast-related mTBI , 141–142 DTI , 2 blunt head injury , 140 GCS , 2 dizziness vs. blast injury , 142, 143 intracranial anatomy complexity , 2, 3 dizziness vs.blunt head trauma , mechanism concussion 141, 142 angular acceleration , 5 PBBPV , 142 brain linear acceleration , 5 PBD , 142 Newton-Euler equations , 6 PBDV , 142 precipitating concussion , 5 PBED , 142 shearing strain , 6 PTBPV , 141 military and civilian contexts , 1 PTEID , 141, 142 military concussion models and PTSD , 11–12 PTMAD , 141 military health care (see Military health care) PTSpD , 141 military medicine perspective sports-related injury , 140 bio- fi delic head models , 11 vestibular disorders , 141 blast-associated polytrauma , 9 BPV , 140 blast wave exposure , 10 head injured patients , 140 blast waveform , 11 TBI-related dizziness algorithm , 145–146 clinical descriptions , 9 treatment CNS injury , 10, 11 CDP , 145 3D complex fl uid fl ow fi eld , 11 GCS , 144 energy conversion , 10 GST , 145 explosive detonation , 10 PNF techniques , 144 explosives’ detonation , 11 VPT , 144–145 Friedlander waveform , 10 vestibular dysfunction , 140 IEDs , 9 vestibular organ , 139 in-the-atmosphere explosion , 9–10 Vestibular physical therapy (VPT) , 144–145 kinetic energy , 10 Veteran health care. See also Military health care material properties , 11 aggression , 227 nonlinear blast wave , 11 impulsive aggression , 228 shock-wave overpressure , 10 Vietnam Head Injury Study (VHIS) , 171 neuroimaging , 8–9 Vocational rehabilitation , 264 patho-anatomic framework , 3 persistent post-concussive symptoms , 7–8 PTA , 2 W PTSD ( see Post-traumatic stress disorder (PTSD)) Wakenings after sleep onset (WASO) , 122 RCTs , 3 spectrum , 4, 5 strain-rate continuum , 8 Z woodpecker analogy , 7 Zurich Conference , 97