New IOM Report Predicts Long-Term Health Problems, Including Neurological Disorders, for Returning Gulf War Vets

Neurology Today
15 January 2009; Volume 9(2); pp 1,10-11

Fallik, Dawn

In wars past, blasts meant death. In Iraq and Afghanistan, soldiers survive, thanks to better armor and earlier medical care, but they live with traumatic brain injury (TBI). That leaves neurologists wondering how to care for these patients and their long-term health consequences. Now a new review by the Institute of Medicine (IOM), Gulf War and Health: Long-Term Consequences of TBI, finds that those consequences might be more devastating than expected, even for apparently mild cases.

The first thing that comes out of this report is that there is an enormous amount we don't know about TBI, said David Brody, MD, PhD, assistant professor of neurology at Washington University in St. Louis. And one of the big gaps in the literature is what the effects of mild but repetitive brain injury are.

Figure. AS OF JANUARY, more than 5,500 military personnel suffered traumatic brain injury during the wars in Iraq and Afghanistan.

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The review was commissioned by the US Department of Defense so that the Veterans Administration could work out disability determinations, said George Rutherford, MD, director of the Prevention and Public Health Group at the University of California-San Francisco School of Medicine, who chaired the committee.

As of January, more than 5,500 military personnel had suffered TBI during the wars in Iraq and Afghanistan, according to the US Department of Defense. But most of the 1,900 studies the committee reviewed focused on similar civilian injuries - car accidents, football - simply because that's all that's out there, Dr. Rutherford said.

There is some military literature, but it's largely focused on penetrating brain injuries, like gunshot or shrapnel, he said. There's almost no research on blast injuries.

From the research, the committee reported that those who suffered from TBI were far more likely to develop epilepsy, dementia, Parkinson disease (PD), and other brain disorders than those in the general population. The more severe the brain injury, the more likely it was that the patient would develop those problems, said Samuel J. Potolicchio, MD, chair of the Neurophysiology Center at the George Washington University Hospital.

If you look at people with TBI, you can see lesions in their brain, and the more severe the injury, the more likely you are to see those lesions deeply situated in the basal ganglia and underline Parkinson disease, said Dr. Potolicchio. You'll see white matter tracks that go in and out of the basal ganglia.

The link between repetitive brain injury, PD, and dementia pugilistica has been well documented. But it's unclear why even mild cases would result in an increased association, physicians told Neurology Today.

Figure. DR. SAMUEL J. POTOLICCHIO: If you look at people with TBI, you can see lesions in their brain, and the more severe the injury, the more likely you are to see those lesions deeply situated in the basal ganglia and underline Parkinson disease.

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Ibolja Cerka, MD, PhD, medical director at the Johns Hopkins University Applied Physics Laboratory and a member of the IOM committee, is working with animal and computer models to determine what happens in the brain when it's hit with a shock wave.

She said trying to draw conclusions about war TBI from material about brain injuries sustained in car crashes and on the football field is an exercise in frustration.

First there's the primary shock wave that interacts with the body, then there's the secondary blast effect, whether its shrapnel that originates during the explosion or its caused by energy released by the explosion, she said. When the body is not thrown through the air, it still has the primary blast - even if it's not a direct blow to the head, there's a transfer of kinetic energy through the body. When we try to compare this to civilian injuries, it's not the same beast.

She said the military needs to start keeping track of even mild cases of TBI, like a concussion, which currently go undocumented - not only to track such major complications as seizures, but also to determine if TBI is linked to social dysfunction - unemployment, marital problems, and social disengagement.

Figure. DR. DAVID BRODY: The first thing that comes out of this report is that there is an enormous amount we don't know about TBI. And one of the big gaps in the literature is what the effects of mild but repetitive brain injury are.

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Even with the limitations on the literature, the potential ramifications for the Department of Defense (DoD) and the VA are vast, said researchers. Millions of veterans diagnosed with even mild TBI will need care for serious brain illness down the road, said Dr. Rutherford.

That documentation needs to start right away, he agreed, so researchers can start answering the questions the IOM report developed.

What the report doesn't answer is how likely are these outcomes, he said. If I have a TBI, does that double the risk of PD? How much does it really jump? And treatment itself is an open question. So let's figure out how many brain injuries there are in Iraq - how many people are we really talking about here and what's the long-term risk in real numbers in terms of getting certain diseases?

Dr. Brody hopes that as brain imaging improves, it will become easier to detect the trauma TBI leaves behind. That way neurologists can start treating patients sooner.

Without imaging, it's like we've been looking at brain injuries through a keyhole, and the existing imaging methods haven't added much until recently, he said. With advanced MRI, we may have the potential to accurately characterize injuries non-invasively, and this may help answer questions.

Now that the VA and the DoD have the report in hand, Dr. Potolicchio said, they need to start screening and accessing veterans returning from war who are complaining about TBI. And they also need to assess whether those with other blast wounds - such as amputated limbs - received head trauma as well.

According to the IOM committee, they are going to have to look at the long-term ramifications and the financial burdens of TBI, not just medically but socially.

This is just the tip of the iceberg, said Dr. Potolicchio. It's going to evolve into much more work for these two agencies.

Symbol A new review by a committee of the Institute of Medicine reports that people who suffer from TBI are far more likely to develop epilepsy, dementia, Parkinson disease (PD), and other brain disorders than those in the general population.

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Gulf War and Health: Long-Term Consequences of TBI, follows another report by the Congressionally-mandated Research Advisory Committee on Gulf War Veteran's Illnesses, which identified Gulf War syndrome - a constellation of neurological systems - for returning vets from the 1991 Persian Gulf War. (See www.neurotodayonline.com , for the Dec. 18 article, Gulf War Syndrome - A Constellation of Neurological Symptoms - Exists, According to New Federal Report.)

* Although more than 5,500 soldiers sustained blast injuries in Iraq and Afghanistan, there are few clinical studies looking at the consequences of TBI, both on a medical and psychosocial level.

* The IOM report called for the US Department of Defense and the US Department of Veterans Affairs to increase clinical and animal studies of blast-induced neurotrauma.

* Studies linked both moderate and severe TBI with long-term consequences, including increased risk for Alzheimer-like dementia and premature death.

* There is a strong association between penetrating and severe closed TBI and a suggestive association between mild TBI and unprovoked seizures. The risk appears to be highest within the first year after trauma.

* There was sufficient evidence of an association between moderate-to-severe TBI and hormone insufficiency and hypopituitarism; however, the studies only supported a finding of limited and suggestive evidence of an association between moderate-to-severe TBI and diabetes insipidus (excessive urination).

* The literature supported a finding of limited but suggestive evidence of an association between moderate-to-severe TBI and psychoses generally appearing in the second and third years after TBI.

* A predominance of studies indicated that people with TBI (mild, moderate, or severe) had higher rates of major depression six months or more after TBI than did comparison groups.

* There was an association between penetrating TBI and long-term unemployment and between moderate-to-severe TBI and long-term adverse social-function outcomes, particularly unemployment and diminished social relationships. With regard to mild TBI, the evidence was inadequate in respect to long-term adverse social functioning.

* The committee recommended that the Department of Defense use the Brief Traumatic Brain Injury Screen and the Military Acute Concussion Evaluation for every soldier who has a history of blast exposure (even of low-intensity blast exposure).