Textbook of Traumatic Brain Injury - part 1 ppt

Textbook of
Traumatic Brain Injury
Editorial Board
Keith D. Cicerone, Ph.D.
Director of Neuropsychology, JFK-Johnson Rehabilitation Institute, Edison,
New Jersey
Jonathan L. Fellus, M.D.
Clinical Assistant Professor of Neurology and Director of Brain Injury Services,
Kessler Institute for Rehabilitation, University of Medicine and Dentistry of
New Jersey–New Jersey Medical School, East Orange, New Jersey
Gerard E. Francisco, M.D.
Clinical Associate Professor of Physical Medicine and Rehabilitation, University
of Texas Health Sciences Center; Adjunct Assistant Professor of Physical Medicine
and Rehabilitation, Baylor College of Medicine; Associate Director, Brain
Injury and Stroke Program, The Institute for Rehabilitation and Research,
Houston, Texas
Douglas I. Katz, M.D.
Associate Professor of Neurology, Boston University School of Medicine,
Boston, Massachusetts; Medical Director, Brain Injury Programs, Healthsouth
Braintree Rehabilitation Hospital, Braintree, Massachusetts
Jeffrey S. Kreutzer, Ph.D.
Professor of Physical Medicine and Rehabilitation, Neurosurgery, and
Psychiatry, Virginia Commonwealth University, Medical College of Virginia
Campus, Richmond, Virginia
Jose Leon-Carrion, Ph.D.
Professor, Human Neuropsychology Laboratory, University of Seville, Spain;
Center for Brain Injury Rehabilitation, Seville, Spain
Nathaniel H. Mayer, M.D.
Emeritus Professor of Physical Medicine and Rehabilitation, Temple University
Health Sciences Center, Philadelphia, Pennsylvania

Jennie Ponsford, Ph.D.
Associate Professor, Department of Psychology, Monash University; Director,
Monash-Epworth Rehabilitation Research Centre, Melbourne, Australia
Andres M. Salazar, M.D.
Ribopharm Inc., Washington, D.C.
Bruce Stern
Stark & Stark, Princeton, New Jersey
John Whyte, M.D., Ph.D.
Professor, Department of Rehabilitation Medicine, Thomas Jefferson
University; Director, Moss Rehabilitation Research Institute, Albert Einstein
Healthcare Network, Philadelphia, Pennsylvania
Washington, DC
London, England
Textbook of
Traumatic Brain Injury
Edited by
Jonathan M. Silver, M.D.
Thomas W. McAllister, M.D.
Stuart C. Yudofsky, M.D.
Note: The authors have worked to ensure that all information in this book is accurate at the time of publication and
consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules,
and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food
and Drug Administration and the general medical community. As medical research and practice continue to advance,
however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response
not included in this book. For these reasons and because human and mechanical errors sometimes occur, we recommend
that readers follow the advice of physicians directly involved in their care or the care of a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual authors
and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association.
Copyright © 2005 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED

Manufactured in the United States of America on acid-free paper
0908070605 54321
First Edition
Typeset in Adobe’s Janson and Frutiger.
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
Library of Congress Cataloging-in-Publication Data
Textbook of traumatic brain injury / edited by Jonathan M. Silver, Thomas W. McAllister,
Stuart C. Yudofsky 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58562-105-6 (hardcover : alk. paper)
1. Brain damage. I. Silver, Jonathan M., 1953- II. McAllister, Thomas W.
III. Yudofsky, Stuart C.
[DNLM: 1. Brain Injuries complications. 2. Mental Disorders etiology. 3. Brain
Injuries rehabilitation. 4. Mental Disorders diagnosis. 5. Mental Disorders therapy.
WL 354 T355 2005]
RC387.5.T46 2005
617.4'81044 dc22
2004050262
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
To the courage of our patients:
"Who can foresee what will come?
Do with all your might whatever you are able to do."
—Ecclesiastes
To the devotion of our families:
Orli, Elliot, Benjamin, and Leah

Jeanne, Ryan, Lindsay, and Craig
Beth, Elissa, Lynn, and Emily
"A fruitful bough by a well;
Whose branches run over the wall."
—Genesis 49:22
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Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Sarah and James Brady
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
PART
I
Epidemiology and Pathophysiology
1
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Jess F. Kraus, M.P.H., Ph.D.
Lawrence D. Chu, M.S., M.P.H., Ph.D.
2 Neuropathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Thomas A. Gennarelli, M.D.
David I. Graham, M.B.B.Ch., Ph.D.
3 Neurosurgical Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
Roger Hartl, M.D.
Jamshid Ghajar, M.D., Ph.D.
4 Neuropsychiatric Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Kimberly A. Arlinghaus, M.D.
Arif M. Shoaib, M.D.
Trevor R. P. Price, M.D.
5 Structural Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79
Erin D. Bigler, Ph.D.

6 Functional Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
Karen E. Anderson, M.D.
Katherine H. Taber, Ph.D.
Robin A. Hurley, M.D.
7 Electrophysiological Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135
David B. Arciniegas, M.D.
C. Alan Anderson, M.D.
Donald C. Rojas, Ph.D.
8 Issues in Neuropsychological Assessment . . . . . . . . . . . . . . . . . . . . . . . . . .159
Mary F. Pelham, Psy.D.
Mark R. Lovell, Ph.D.
PART
II
Neuropsychiatric Disorders
9
Delirium and Posttraumatic Amnesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Paula T. Trzepacz, M.D.
Richard E. Kennedy, M.D.
10
Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Robert G. Robinson, M.D.
Ricardo E. Jorge, M.D.
11 Psychotic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Cheryl Corcoran, M.D.
Thomas W. McAllister, M.D.
Dolores Malaspina, M.D.
12 Posttraumatic Stress Disorder and Other Anxiety Disorders . . . . . . . . . . . 231
Deborah L. Warden, M.D.
Lawrence A. Labbate, M.D.
13 Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Gregory J. O’Shanick, M.D.
Alison Moon O’Shanick, M.S., C.C.C S.L.P.
14 Aggressive Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Jonathan M. Silver, M.D.
Stuart C. Yudofsky, M.D.
Karen E. Anderson, M.D.
15
Mild Brain Injury and the Postconcussion Syndrome. . . . . . . . . . . . . . . . . 279
Thomas W. McAllister, M.D.
16 Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Gary J. Tucker, M.D.
PART
III
Neuropsychiatric Symptomatologies
17
Cognitive Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Scott McCullagh, M.D.
Anthony Feinstein, M.D., Ph.D.
18
Disorders of Diminished Motivation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Robert S. Marin, M.D.
Sudeep Chakravorty, M.D.
19 Awareness of Deficits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .353
Laura A. Flashman, Ph.D.
Xavier Amador, Ph.D.
Thomas W. McAllister, M.D.
20 Fatigue and Sleep Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .369
Vani Rao, M.D.
Pamela Rollings, M.D.
Jennifer Spiro, M.S.

21
Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .385
Thomas N. Ward, M.D.
Morris Levin, M.D.
22
Balance Problems and Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .393
Edwin F. Richter III, M.D.
23 Vision Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .405
Neera Kapoor, O.D., M.S.
Kenneth J. Ciuffreda, O.D., Ph.D.
24 Chronic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .419
Nathan D. Zasler, M.D.
Michael F. Martelli, Ph.D.
Keith Nicholson, Ph.D.
25
Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .437
Nathan D. Zasler, M.D.
Michael F. Martelli, Ph.D.
PART
IV
Special Populations and Issues
26 Sports Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .453
Jason R. Freeman, Ph.D.
Jeffrey T. Barth, Ph.D.
Donna K. Broshek, Ph.D.
Kirsten Plehn, Ph.D.
27 Children and Adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .477
Jeffrey E. Max, M.B.B.Ch.
28 Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .495
Edward Kim, M.D.

29 Alcohol and Drug Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .509
Norman S. Miller, M.D.
Jennifer Adams, B.S.
PART
V
Social Issues
30
The Family System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
Marie M. Cavallo, Ph.D.
Thomas Kay, Ph.D.
31
Systems of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
D. Nathan Cope, M.D.
William E. Reynolds, D.D.S., M.P.H.
32 Social Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
Andrew Hornstein, M.D.
33 Ethical and Clinical Legal Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Robert I. Simon, M.D.
PART
VI
Treatment
34
Psychopharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
Jonathan M. Silver, M.D.
David B. Arciniegas, M.D.
Stuart C. Yudofsky, M.D.
35
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641
Irwin W. Pollack, M.D., M.A.
36 Cognitive Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655

Wayne A. Gordon, Ph.D.
Mary R. Hibbard, Ph.D.
37 Behavioral Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661
Patrick W. Corrigan, Psy.D.
Patricia A. Bach, Ph.D.
38
Alternative Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679
Richard P. Brown, M.D.
Patricia L. Gerbarg, M.D.
PART
VII
Prevention
39
Pharmacotherapy of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .699
Saori Shimizu M.D., Ph.D.
Carl T. Fulp, M.S.
Nicolas C. Royo, Ph.D.
Tracy K. McIntosh, Ph.D.
40
Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .727
Elie Elovic, M.D.
Ross Zafonte, D.O.
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .749
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xiv Contributors
Laura A. Flashman, Ph.D.
Associate Professor of Psychiatry, Department of Psychi-
atry, Division of Neuropsychiatry, Dartmouth Medical
School, Lebanon, New Hampshire; New Hampshire
Hospital, Concord, New Hampshire

Jason R. Freeman, Ph.D.
Associate Director, Brain Injury and Sports Concussion
Institute, University of Virginia School of Medicine,
Charlottesville, Virginia
Carl T. Fulp, M.S.
Predoctoral Fellow, Traumatic Brain Injury Laboratory,
Department of Neurosurgery, University of Pennsylvania
School of Medicine, Philadelphia, Pennsylvania
Thomas A. Gennarelli, M.D.
Professor and Chair, Department of Neurosurgery, Med-
ical College of Wisconsin, Milwaukee, Wisconsin
Patricia L. Gerbarg, M.D.
Assistant Professor of Clinical Psychiatry, New York
Medical College, Valhalla, New York
Jamshid Ghajar, M.D., Ph.D.
President, Brain Trauma Foundation, New York, New York
Wayne A. Gordon, Ph.D.
Jack Nash Professor, Department of Rehabilitation Medi-
cine, Mount Sinai School of Medicine, New York, New York
David I. Graham, M.B.B.Ch., Ph.D.
Professor and Head of Neuropathology, Institute of Neu-
rological Sciences, Southern General Hospital, Glasgow,
Scotland
Roger Hartl, M.D.
Assistant Professor of Neurosurgery, Department of
Neurological Surgery, Joan and Sanford I. Weill Cornell
Medical College, Cornell University, New York, New
York
Mary R. Hibbard, Ph.D.
Professor, Department of Rehabilitation Medicine,

Mount Sinai School of Medicine, New York, New York
Andrew Hornstein, M.D.
Assistant Clinical Professor of Psychiatry, Columbia
University College of Physicians and Surgeons, New
York, New York; Attending Psychiatrist, Head Injury
Services, Helen Hayes Hospital, West Haverstraw, New
York
Robin A. Hurley, M.D.
Associate Professor, Departments of Psychiatry and
Radiology, Wake Forest University School of Medi-
cine, Winston-Salem, North Carolina; Clinical Associ-
ate Professor, Department of Psychiatry, Baylor
College of Medicine, Houston, Texas; Associate Chief
of Staff/Mental Health, Hefner VAMC, Salisbury,
North Carolina
Ricardo E. Jorge, M.D.
Assistant Professor of Psychiatry, Roy J. and Lucille A. Carv-
er College of Medicine, University of Iowa, Iowa City, Iowa
Neera Kapoor, O.D., M.S.
Associate Clinical Professor, Department of Clinical Sci-
ences and Director, Raymond J. Greenwald Rehabilitation
Center, SUNY State College of Optometry, New York,
New York
Thomas Kay, Ph.D.
Assistant Clinical Professor, Department of Rehabilitation
Medicine, New York University School of Medicine; Rusk
Institute of Rehabilitation Medicine, New York, New York
Richard E. Kennedy, M.D.
Assistant Professor, Departments of Psychiatry and Phys-
ical Medicine & Rehabilitation, Virginia Commonwealth

University School of Medicine, Richmond, Virginia
Edward Kim, M.D.
Associate Professor of Psychiatry, University of Medicine
and Dentistry of New Jersey–Robert Wood Johnson
Medical School, Piscataway, New Jersey
Jess F. Kraus, M.P.H., Ph.D.
Professor of Epidemiology, University of California, Los
Angeles, School of Public Health; Director, Southern Cal-
ifornia Injury Prevention Research Center, Los Angeles,
California
Lawrence A. Labbate, M.D.
Professor of Psychiatry and Behavioral Sciences, Medical
University of South Carolina, Charleston, South Carolina
Morris Levin, M.D.
Associate Professor of Medicine (Neurology) and Associ-
ate Professor of Psychiatry, Dartmouth Medical School,
Lebanon, New Hampshire
Mark R. Lovell, Ph.D.
Director, Sports Medicine Concussion Program, Universi-
ty of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Dolores Malaspina, M.D.
Professor of Clinical Psychiatry, New York State Psychi-
atric Institute, New York, New York
Robert S. Marin, M.D.
Associate Professor of Psychiatry, University of Pitts-
burgh School of Medicine, Western Psychiatric Institute
and Clinic, Pittsburgh, Pennsylvania
Michael F. Martelli, Ph.D.
Clinical Associate Professor, Department of Physical Medi-
cine and Rehabilitation, University of Virginia, Charlottes-

ville, Virginia; Clinical Assistant Professor, Departments of
Psychology and Psychiatry, Virginia Commonwealth Uni-
versity Health System, Richmond, Virginia; Concussion
Care Centre of Virginia, Ltd., Tree of Life, L.L.C., Glen
Allen, Virginia
Contributors xv
Jeffrey E. Max, M.B.B.Ch.
Professor, In-Residence, Department of Psychiatry, Uni-
versity of California, San Diego, School of Medicine; Di-
rector of Neuropsychiatric Research, Children's Hospital
and Health Center, San Diego, California
Thomas W. McAllister, M.D.
Professor of Psychiatry, Department of Psychiatry, Sec-
tion of Neuropsychiatry, Dartmouth Medical School,
Lebanon, New Hampshire
Scott McCullagh, M.D.
Assistant Professor, Neuropsychiatry Program, Universi-
ty of Toronto, Sunnybrook and Women’s College Hospi-
tal, Toronto, Ontario, Canada
Tracy K. McIntosh, Ph.D.
Professor of Neurosurgery and Director, Traumatic
Brain Injury Laboratory, Department of Neurosurgery,
University of Pennsylvania School of Medicine, Philadel-
phia, Pennsylvania
Norman S. Miller, M.D.
Professor of Psychiatry and Medicine, Department of
Psychiatry, Michigan State University College of Human
Medicine, East Lansing, Michigan
Keith Nicholson, Ph.D.
Comprehensive Pain Program, Toronto Western Hospi-

tal, Toronto, Ontario, Canada
Alison Moon O'Shanick, M.S., C.C.C S.L.P.
Center for Neurorehabilitation Services, Midlothian,
Virginia
Gregory J. O’Shanick, M.D.
Medical Director, Center for Neurorehabilitation Servic-
es, Midlothian, Virginia; National Medical Director, Brain
Injury Association of America, McLean, Virginia
Mary F. Pelham, Psy.D.
Neuropsychologist, Moss Rehab, Elkins Park Hospital,
Elkins Park, Pennsylvania
Kirsten Plehn, Ph.D.
Fellow in Clinical Neuropsychology, Department of Psy-
chiatric Medicine, University of Virginia School of Med-
icine, Charlottesville, Virginia
Irwin W. Pollack, M.D., M.A.
Emeritus Professor of Psychiatry, University of Medicine
and Dentistry of New Jersey–Robert Wood Johnson
Medical School, Piscataway, New Jersey
Trevor R. P. Price, M.D.
Private Practice of General Adult Psychiatry, Geriatric Psy-
chiatry, and Neuropsychiatry, Bryn Mawr, Pennsylvania
Vani Rao, M.D.
Assistant Professor, Division of Geriatric Psychiatry and
Neuropsychiatry, Department of Psychiatry and Behav-
ioral Sciences, Johns Hopkins University School of Med-
icine, Baltimore, Maryland
William E. Reynolds, D.D.S., M.P.H.
Public Service Professor, School of Social Welfare, and
Clinical Associate Professor, School of Public Health,

State University at Albany, Albany, New York
Edwin F. Richter III, M.D.
Associate Clinical Director, Rusk Institute of Rehabilita-
tion Medicine, New York, New York
Robert G. Robinson, M.D.
Paul W. Penningroth Professor and Head of Psychiatry,
Roy J. and Lucille A. Carver College of Medicine, Uni-
versity of Iowa, Iowa City, Iowa
Donald C. Rojas, Ph.D.
Associate Professor of Psychiatry, University of Colorado
Health Sciences Center, Denver, Colorado
Pamela Rollings, M.D.
Adult Psychiatry, Wellspan Behavioral Health, Division
of Neurosciences, Behavioral Health Services, Wellspan
Health–Delphic Office, York, Pennsylvania
Nicolas C. Royo, Ph.D.
Postdoctoral Fellow, Traumatic Brain Injury Laboratory,
Department of Neurosurgery, University of Pennsylvania
School of Medicine, Philadelphia, Pennsylvania
Saori Shimizu, M.D., Ph.D.
Postdoctoral Fellow, Traumatic Brain Injury Laboratory,
Department of Neurosurgery, University of Pennsylvania
School of Medicine, Philadelphia, Pennsylvania
Arif M. Shoaib, M.D.
Clinical Assistant Professor, Department of Psychiatry,
University of Texas Health Science Center at Houston,
Houston, Texas
Jonathan M. Silver, M.D.
Clinical Professor of Psychiatry, New York University
School of Medicine, New York, New York

Robert I. Simon, M.D.
Clinical Professor of Psychiatry and Director, Program in
Psychiatry and Law, Georgetown University School of
Medicine, Washington, D.C.
Jennifer Spiro, M.S.
Research Coordinator, Division of Geriatric Psychiatry
and Neuropsychiatry, Department of Psychiatry and Be-
havioral Sciences, Johns Hopkins University School of
Medicine, Baltimore, Maryland
xvi Contributors
Katherine H. Taber, Ph.D.
Research Health Scientist, Research and Education Ser-
vice Line, Hefner VAMC, Salisbury, North Carolina; Re-
search Fellow, School of Health Information Sciences,
University of Texas Health Science Center at Houston,
Houston, Texas
Paula T. Trzepacz, M.D.
Clinical Professor of Psychiatry, University of Missis-
sippi School of Medicine, Jackson, Mississippi; Adjunct
Professor of Psychiatry, Tufts University School of
Medicine, Boston, Massachusetts; Medical Director,
U.S. Neurosciences, Lilly Research Laboratories, Indi-
anapolis, Indiana
Gary J. Tucker, M.D.
Emeritus Professor, Department of Psychiatry, Uni-
versity of Washington School of Medicine, Seattle,
Washington
Thomas N. Ward, M.D.
Associate Professor of Medicine, Section of Neurology,
Dartmouth-Hitchcock Medical Center, Lebanon, New

Hampshire
Deborah L. Warden, M.D.
Associate Professor of Neurology and Psychiatry, Uni-
formed Services University of the Health Sciences, Be-
thesda, Maryland; National Director, Defense and
Veterans Brain Injury Center, Walter Reed Army Medical
Center, Washington, D.C.
Stuart C. Yudofsky, M.D.
D.C. and Irene Ellwood Professor and Chairman, Men-
ninger Department of Psychiatry and Behavioral Scienc-
es, Baylor College of Medicine; Chief, Psychiatry Service,
The Methodist Hospital, Houston, Texas
Ross Zafonte, D.O.
Professor and Chair, Department of Physical Medicine
and Rehabilitation, University of Pittsburgh School of
Medicine, Pittsburgh, Pennsylvania
Nathan D. Zasler, M.D.
Clinical Associate Professor, Department of Physical
Medicine and Rehabilitation, University of Virginia,
Charlottesville, Virginia; Concussion Care Centre of Vir-
ginia, Ltd., Pinnacle Rehabilitation, Inc., Tree of Life,
L.L.C., Glen Allen, Virginia
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4 TEXTBOOK OF TRAUMATIC BRAIN INJURY
TABLE 1–1. Case identification, source, and brain injury severity criteria and scoring: selected United
States incidence studies
Study
Location

and years Case definition and source Severity criteria/scoring
Annegers et al.
1980
Olmsted County,
Minnesota, 1965–
1974
Head injury with evidence of presumed
brain involvement (i.e., concussion
with LOC, PTA, or neurological
signs of brain injury or skull fracture.
1) Fatal (<28 days)
2) Severe: intracranial hematoma, contusion, or
LOC >24 hours, or PTA >24 hours
3) Moderate: LOC or PTA 30 minutes to 24 hours,
skull fracture or both
4) LOC or PTA <30 minutes without skull fracture
Klauber et al.
1981
San Diego County,
California, 1978
ICD A-8 Codes 800, 801, 804, 806, and
850–854 with hospital admission
diagnosis or cause of death with skull
fracture, LOC, PTA, neurological
deficit or seizure (no gunshot
wounds).
GCS (3, 4–5, 6–7, 8–15)
Rimel 1981 Central Virginia,
1977–1979
CNS referral patients with significant

head injury admitted to
neurosurgical service.
GCS (3–5, 6–8, 9–11, 12–15)
Severe=≤8; moderate=9–11; mild=12–15
Kraus et al. 1984 San Diego County,
California, 1981
Physician-diagnosed physical damage
from acute mechanical energy
exchange resulting in concussion,
hemorrhage, contusion, or laceration
of brain.
Modified GCS
Severe= ≤8; moderate=9–15 plus hospital stay
of 4–8 hours and brain surgery, or abnormal CT,
or GCS 9–12; mild=all others, GCS 13–15
Whitman et al.
1984
Chicago area, 1979–
1980
Any hospital discharge diagnosis of
ICD-9-CM 800–804, 830, 850–854,
873, 920, 959.0. Injury within 7 days
before hospital visit and blow to
head/face with LOC, or laceration of
scalp or forehead.
1) Fatal
2) Severe=intracranial hematoma, LOC/PTA >24
hours contusion
3) Moderate=LOC or PTA 30 minutes to <24 hours
4) Mild=LOC to PTA <30 minutes

5) Trivial=remainder
MacKenzie et al.
1989
Maryland 1986 ICD-9-CM codes 800, 801, 803, 804,
850–854.
ICDMAP—converts ICD codes to AIS scores
(Association for the Advancement of Automotive
Medicine [1990]) of 1–6
Thurman et al.
1996
Utah 1990–1992 Discharge data from all 40 acute care
hospitals using ICD-9-CM codes
800.0–801.9, 803.0–804.9, and
850.0–854.1 in any primary or
secondary data fields.
1) Initial GCS: severe=≤8; moderate=9–12;
mild=13–15
2) Demonstrated intracranial traumatic lesions
3) Focal abnormalities on neurologic examination
Centers for
Disease
Control and
Prevention
1997
Colorado, Missouri,
Oklahoma, Utah,
1990–1992
Discharge data from all state hospitals
or health care providers.
No severity data reported.

Gabella et al.
1997
Colorado 1991–
1992
Colorado surveillance system of
hospitalized and fatal TBI using
ICD-9-CM codes 800, 801, 803, 804,
and 850–854.
ICDMAP using as many as five ICD discharge
diagnoses
Severe TBI=fatal or ISS ≥9
Epidemiology 5
computed tomography (CT) (Marshall et al. 1991). The
Glasgow Coma Scale (GCS; Jennett and Teasdale 1981)
is commonly used for the initial assessment of severity.
The GCS, a clinical prognostic indicator, is an important
contribution to standardizing early assessment of the se-
verity of brain injury (Table 1–2). Although its application
was intended to be repeated, typical current practice gen-
erally consists of a single observation. Herein lies one of
the major difficulties in the application of the GCS: not
knowing in various studies when the GCS was adminis-
tered during the early stages of treatment. In some stud-
ies, the GCS was administered at the scene of the injury
or during emergency transport, whereas in others it was
done on arrival at the emergency department or just be-
fore hospital admission; in still others, the time of assess-
ment was not reported.
Obviously, GCS results during the hospital course
change according to patient improvement or deteriora-

tion. For proper comparison of research findings, the
GCS should be administered at approximately the same
time postinjury. Assessment on arrival at the emergency
department is recommended.
An inherent weakness of the GCS is its limited rele-
vance to some patients with brain injuries. The GCS is
Sosin et al. 1996 United States 1991 Self-reported data from U.S. National
Health Interview Survey Injury
Supplement for mild and moderate
brain injury defined as loss of
consciousness in previous 12 months.
Severity not evaluated
Thurman and
Guerrero 1999
United States 1980–
1995
All hospital discharge records with one
or more ICD codes of 800.0–801.9,
803.0–804.9, or 850.0–854.1 from the
National Hospital Discharge Survey.
ICDMAP used to convert ICD codes to
approximate AIS scores: 1–2=mild; 3=moderate;
4–6=severe
Jager et al. 2000 United States 1992–
1994
Same ICD codes as Thurman et al.
1996; identified from U.S. National
Hospital Ambulatory Medical Care
Survey.
Severity not evaluated

Guerrero et al.
2000
United States 1995–
1996
All visits to emergency departments
with same ICD codes as Thurman et
al. 1996; identified from U.S.
National Hospital Ambulatory
Medical Care Survey.
Severity not evaluated
Note. LOC=loss of consciousness; PTA=posttraumatic amnesia; GCS=Glasgow Coma Scale (Jennett and Teasdale 1981); ICD=International Clas-
sification of Diseases; ICD-9-CM=International Classification of Diseases, 9th Revision, Clinical Modification (World Health Organization 1986);
CNS=central nervous system; CT=computed tomography; TBI=traumatic brain injury; AIS=Abbreviated Injury Scale; ISS=Injury Severity Score.
TABLE 1–1. Case identification, source, and brain injury severity criteria and scoring: selected United
States incidence studies (continued)
Study
Location
and years Case definition and source Severity criteria/scoring
TABLE 1–2. Glasgow Coma Scale
Eye opening (E) Spontaneous 4
To speech 3
To pain 2
Nil 1
Best motor response (M) Obeys 6
Localizes 5
Withdrawn 4
Abnormal flexion 3
Extensor response 2
Nil 1
Verbal response (V) Oriented 5

Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
Nil 1
Coma score (E + M + V)=3–15
Source. Adapted from Jennett B, Teasdale G: Management of Head In-
juries. Philadelphia, PA, FA Davis, 1981.
6 TEXTBOOK OF TRAUMATIC BRAIN INJURY
difficult or impossible to apply to young children, patients
with significant facial swelling from blunt trauma, pa-
tients under the influence of alcohol or other substances,
and patients who are not able to respond to the verbal
component because of language differences or an inability
to comprehend. The current emergency department
practice of immediate intubation or sedation may further
invalidate (or restrict) GCS measurements. Regardless of
these restrictions, the GCS remains one of the most con-
sistently used measures of brain injury severity.
Epidemiological studies of patients with brain injuries
are infrequently undertaken, and in the past 10 years, more
reliance has been placed on administrative data sets to esti-
mate the incidence and features of persons with TBI. Such
data sources include the U.S. National Health Interview
Survey (NHIS), U.S. National Hospital Ambulatory Med-
ical Care Survey (NHAMCS), U.S. National Hospital Dis-
charge Survey (NHDS), and equivalent data sets from in-
dividual states and groups of states (see Table 1–1).
In discussing the nature and severity of injury, we have
drawn some information from a large brain injury cohort
study conducted in San Diego County, California, during

the early 1980s (Kraus et al. 1984). For the purposes of
this chapter, we focus on the specifics of diagnosis, con-
sidering skull fracture status as an important confounding
factor. In addition, we provide basic information on the
relationship between demographic characteristics such as
age, sex, and socioeconomic status (SES) and the severity
and type of brain injury. Finally, we develop a predictive
model for outcome at hospital discharge.
All epidemiological studies involving people hospital-
ized with brain injury indicate that a large majority of pa-
tients treated in emergency departments and admitted to
hospitals (for observation or treatment) have sustained
what has been termed mild traumatic brain injury
(MTBI)—that is, one with a GCS score of 13–15. Because
this injury occurs so often and the information on the in-
juries and outcomes is so incomplete, a Consequences of
Mild TBI section addressing the nature of the available
data and selected aggregate findings on outcome parame-
ters has been included toward the end of this chapter.
Estimates of Occurrence of Brain Injury
Incidence
Data summarized in Figure 1–1 show that brain injury
occurrence rates range from a low of 92 per 100,000 pop-
ulation in seven states (Thurman and Guerrero 1999) to
a high of 618 per 100,000 population in a United States
national survey (Sosin et al. 1996). Caution must be taken
in interpreting these findings because brain injury defini-
tions, criteria for diagnoses, and sources were not the
same in all studies (see Table 1–1). In addition, the preci-
sion of population-at-risk estimates varied considerably

(i.e., some rates were based on catchment area population
estimates in noncensus years).
Nevertheless, a current average rate of fatal plus nonfa-
tal hospitalized brain injuries reported in all United States
studies is approximately 150 per 100,000 population per
year. If the highest and lowest estimates are excluded from
consideration, the estimated rate is approximately 120 per
100,000 per year, which is the estimate used in this chapter
for purposes of disability estimation.
Brain Injury Death and Death Rates
In 2001, 157,078 people died from acute traumatic
injury—approximately 6.5% of all deaths in the United
States (Centers for Disease Control and Prevention
2002). The exact percentage of deaths involving signifi-
cant brain injury is not precisely known, but data from
Olmsted County, Minnesota (Annegers et al. 1980), and
San Diego County, California (Kraus et al. 1984), suggest
that approximately 50% are caused by trauma to the
brain. National Center for Health Statistics multiple-
cause-of-death data indicate that an average of approxi-
mately 28% of all injury deaths involve significant brain
trauma (Sosin et al. 1995). This percentage is probably
incorrect because, as the investigators pointed out, the
case-finding process relied on a limited set of specific
injury diagnoses. Furthermore, the actual death certifi-
cates were not examined—a crucial problem when “mas-
sive multiple trauma” is recorded on the death certificate
but specific body locations and types of trauma are not
recorded. Sosin et al. (1989) reported a possible underes-
timate in the actual proportion of fatal brain injury of

23%–44%.
The reported brain injury fatality rate varies from 14
to 30 per 100,000 population per year (Figure 1–2). The
range in rates probably reflects a lack of specificity of di-
agnosis on some death certificates.
Nonfatal Brain Injury
National estimates of nonfatal brain injury for the United
States have been derived from the National Health Inter-
view Survey (NHIS; Sosin et al. 1996), the National Hos-
pital Ambulatory Medical Care Survey (NHAMCS; Jager
et al. 2000), the National Hospital Discharge Survey
(NHDS; Thurman and Guerrero 1999), and the National
Center for Injury Prevention and Control (NCIPC;
Thurman et al. 1999). The NHIS reported that approxi-
Epidemiology 7
mately 1.5 million head injuries occur per year (Sosin et
al. 1996). However, this estimate includes self-reported
concussions and skull fractures, as well as a mixture of dif-
ferent types of intracranial injuries requiring professional
medical care, some with and some without neurological
trauma. The extent of emergency department and non–
emergency department diagnosis and treatment of brain
injury is unknown. The Centers for Disease Control and
Prevention (CDC) reported to Congress in 1999 that
more than 5 million Americans, or 2% of the nation’s
population, were living with TBI-related disabilities
(Thurman et al. 1999).
A large number of TBI cases are caused by sports and
physical activity. From July 2000 to June 2001, an esti-
mated 350,000 persons were treated in emergency de-

partments for sports- and recreation-related head inju-
ries; of these persons, 200,000 were diagnosed with a
brain injury (Gotsch et al. 2002). Countless sports-related
TBIs go unreported because the majority are MTBI
cases—for example, concussions without loss of con-
sciousness (Collins et al. 1999). Identification of these
cases is vital for proper treatment and prevention of long-
term deleterious effects.
On a reexamination of the NHIS database for 1985–
1986, Fife (1987) concluded that only 16% of all head in-
juries resulted in an admission to a hospital. Hence, only
one of six people with head (not necessarily brain) injury
require hospitalization. As expected, findings from NHIS,
NHAMCS, and NHDS vary widely (see Figure 1–1) be-
cause the data sources are so different from one another.
An estimate derived from published sources (summa-
rized in Figure 1–3 and Table 1–3) suggests that approxi-
FIGURE 1–1. Brain injury rates: selected United States studies.
A=United States estimate 1980–1995 (Thurman and Guerrero 1999); B=Colorado 1991–1992 (Gabella et al. 1997); C=Colorado,
Missouri, Oklahoma, Utah 1990–1992 (Centers for Disease Control and Prevention 1997); D=Utah 1990–1992 (Thurman et al.
1996); E=Maryland 1986 (MacKenzie et al. 1989); F=United States estimate 1981 (Fife 1987); G=Rhode Island 1979–1980 (Fife et
al. 1986); H=San Diego County, CA, 1981 (Kraus et al. 1986); I=Olmsted County, MN, 1965–1974 (Annegers et al. 1980); J=United
States estimate 1974 (Kalsbeek et al. 1980); K=Virginia 1978 (Jagger et al. 1984); L=Bronx, NY, 1980–1981 (Cooper et al. 1983);
M=San Diego County, CA, 1978 (Klauber et al. 1981); N=Chicago area 1979–1980 (Whitman et al. 1984); O=United States estimate
1992–1994 (Jager et al. 2000); P=United States estimate 1991 (Sosin et al. 1996).
8 TEXTBOOK OF TRAUMATIC BRAIN INJURY
mately 234,000 people were discharged from hospitals in
the United States in 1998 with a brain injury diagnosis;
based on 1998 census estimates of 270 million persons, a
hospital admission rate of approximately 87 per 100,000

population per year is deduced. The hospital discharge
rate is useful for estimating the annual disability rate from
injury (discussed later in Estimation of Number of New
Disabilities). The difference in estimates obtained using
average incidence values in aggregate United States stud-
ies versus data from hospital discharges or visits is because
of definitional variation. The actual United States inci-
dence rate is presumed, therefore, to range from 100 to
150 per 100,000 population per year.
The relative importance of brain injury discharge fre-
quencies is illustrated in Table 1–3. As seen, the brain in-
jury discharge rate is the third highest compared with
other major central nervous system (CNS) diagnoses.
The hospital discharge count (or rate) shown in Figure 1–3
and Table 1–3 is not the true figure, because not all cases
are found within the International Classification of Dis-
eases discharge diagnoses used to identify brain injury
cases (see Table 1–1). The purpose of gathering informa-
tion on brain injury occurrence rates is threefold: to mon-
itor changes in incidence in the population, to evaluate
the effects of specific countermeasures, and to identify
high- (or low-) risk groups and exposure circumstances.
Characteristics of High-Risk Groups
Age
All studies of brain injury occurrence in the United States
show that people ages 15–24 years are at the highest risk.
Patterns in age-specific rates (Figure 1–4) illustrate at
least two high-risk age groups: those ages 15–24 years and
those older than age 64 years. It is noteworthy that rates
for people younger than age 10 years (and particularly

FIGURE 1–2. Brain injury fatality rates: selected United States studies.
A=Virginia 1978 (Jagger et al. 1984); B=United States estimate 1981 (Fife 1987); C=United States estimate 1992 (Sosin et al. 1995);
D=Olmsted County, MN, 1965–1974 (Annegers et al. 1980); E=San Diego County, CA, 1978 (Klauber et al. 1981); F=Chicago area
1979–1980 (Whitman et al. 1984); G=Bronx, NY, 1980–1981 (Cooper et al. 1983); H=San Diego County, CA, 1981 (Kraus et al.
1984).
Epidemiology 9
those younger than age 5 years) are high in some studies
reporting age-specific data. The age-related risk distribu-
tion reflects differences in exposure, particularly to motor
vehicle crashes.
Gender
All incidence reports published worldwide indicate that
brain injuries are far more frequent among men than
women, and United States studies have found a rate ratio
of approximately 1.6–2.8 (Figure 1–5). Variation in rate
ratios cannot be attributed solely to reporting differences.
The differences in rate ratios may reflect different exposure
levels. For example, there may be a higher proportion of
injuries connected with motor vehicle crashes (which
involve more males) as compared with injuries connected
with falls in the home (which involve more females).
Race or Ethnicity
Some studies show higher brain injury incidence in non-
whites compared with whites, but there is justifiable concern
over the quality of the data used to derive the rates. Because
hospital reporting practices vary widely in recording ethni-
city or race in medical records, racial or ethnic differences in
brain injury rates have yet to be determined accurately.
Alcohol
The positive association between blood alcohol concen-

tration (BAC) and risk of injury is well established for all
external causes of injuries, including motor vehicle
crashes, general aviation crashes, drownings, and violence
(Smith and Kraus 1988). Less studied is the role of alco-
hol and the outcome of specific kinds and anatomical
locations of injuries such as CNS trauma and burns.
Although animal studies demonstrate a variety of physio-
logical effects of alcohol on CNS injuries, human data are
unequivocal. In one study (Kraus et al. 1989), 56% of
adults with a brain injury diagnosis had a positive BAC
test result. It is noteworthy that 49% of those adults
tested had a BAC that was at or above the legal level
(0.10%). The prevalence of a positive BAC varied by
severity of brain injury; the highest prevalence was among
those with MTBI compared with those with moderate or
severe brain injury (71% vs. 49%, respectively). However,
selection bias may occur in emergency department BAC
testing of injured people with different severities or types
TABLE 1–3. Frequency of selected first-listed diagnoses for inpatients discharged from short-stay,
nonfederal hospitals, 1998
ICD-9-CM code
a
Diagnosis
Number of
discharges (× 1000)
Discharge rate (per
100,000 population)
Multiple
b
Brain injury 234 86.6

191 Malignant neoplasm of brain 32 11.8
295 Schizophrenic disorders 256 94.7
331 Cerebral degeneration (nonchildhood) 64 23.7
331.0 Alzheimer’s disease 43 15.9
332 Parkinson’s disease 26 9.6
340 Multiple sclerosis 26 9.6
345 Epilepsy 52 19.2
346 Migraine 43 15.9
430 Subarachnoid hemorrhage 19 7.0
431, 432 Intracerebral and intracranial hemorrhage 87 32.2
434 Occlusion of cerebral arteries 309 114.3
436, 437 Other cerebrovascular disease 195 72.2
Note. Brain injuries include any listed diagnoses.
a
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM; World Health Organization 1986).
b
Includes ICD-9-CM codes 800, 801, 803, 804, 850, 851, 852, 853, 854, 905, 907. These codes may not include all admissions with brain injuries but
include diagnoses such as skull fracture with and without concussion, contusion, or hemorrhage and late effects of skull fracture or intracranial injury.
Source. Reprinted from Popovic JR, Kozak LJ: “National Hospital Discharge Survey: Annual Summary, 1998.” Vital and Health Statistics 13:1–194,
2000. Used with permission.