Concussive brain injuries overlooked.

BAL HARBOUR, FLA. -- Clinicians across the country are facing the realities of the war in Iraq, as veterans with concussive blast brain injuries rejoin their communities. These soldiers are also giving researchers valuable insight into the way concussive forces disrupt brain function. Dr. Deborah Warden said at the annual meeting of the American Neuropsychiatric Association.

Because closed brain injuries due to blast are uncommon in civilian life, they have not been well studied, said Dr. Warden, director of the Defense and Veterans Brain Injury Center at Walter Reed Army Medical Center in Washington. Until now, most of the research has focused on blast injuries to the extremities or torso, and on penetrating head injuries caused by shrapnel. Since those injuries are usually life threatening, they are typically immediately identified and cared for. But closed head injuries may be overlooked.

"Data on blast-induced brain injury are limited," Dr. Warden said. "While this type of injury and the resultant cognitive dysfunction have been described in rat studies, the clinical characteristics of blast injury in humans are not well described in the literature."

This lack of data can contribute to problems some veterans with undiagnosed traumatic brain injury experience when they return to their communities. Although their obvious combat injuries have been treated, they may experience postconcussive symptoms that puzzle their physicians and leave the veterans questioning their own sanity. Those neurocognitive changes typically manifest as a reduced capacity for information processing, including problems with attention, concentration, and new learning, and slowed cognitive-processing speed.

"People think they're going out of their minds," Dr. Warden said in an interview. "They know they don't feel right, but they don't know why. They may be more irritable and have a lower tolerance for frustration. They may not want to be around crowds and feel insecure about their thinking, experiencing distractibility, memory problems, and a lack of concentration and focus."

Those symptoms result from a concussion caused primarily by an overpressurization wave that travels at the speed of sound. While air-filled organs are especially susceptible, the brain is vulnerable to direct injury from cerebral contusion or indirect injury--a cerebral infarction secondary to air emboli.

Understandably, Dr. Warden said, concussive brain injuries often go unnoticed in combat theater hospitals. Many soldiers who incur brain injuries present with much more obvious, lifethreatening problems: shrapnel wounds, amputations, and burns.

"These are people who walk and talk and pass for normal," Dr. Warden said. "Everyone is telling them, 'It's OK. You're fine now,' but they are thinking, 'No, it's not. I'm not thinking right.'"

Since the symptoms of postconcussive syndrome are ego dystonic, she said, the patient might try to adapt to this new, negative vision of himself, thinking that he is fundamentally changed forever. "Fortunately, the prognosis is generally good for these people," she said. "They do tend to get better over a period of time."

In an effort to better identify those closed head blast injuries and to track patients' long-term recovery, injured soldiers at risk for traumatic brain injury are now being screened. The group includes patients who have been involved in blasts, as well as those who have had amputations, falls, and motor vehicle accidents while serving in Operation Iraqi Freedom and Operation Enduring Freedom (the ongoing operations in Afghanistan).

After being stabilized, patients receive a cognitive screening and / or full neuropsychological evaluation, and audiologic, psychosocial, and psychiatric evaluations. EEGs and magnetic resonance spectroscopy are performed if clinically indicated.

To date, 155 patients injured in combat have been screened for traumatic brain injury; 57% of the group (88 patients) had been involved in blasts, and 54 of those patients had sustained a blast-related brain injury. Most (92%) were men; 60% were privates, and 34% were sergeants. The remaining 6% were warrant officers or officers. Their average age was 26 years.

Interestingly, 33% of the soldiers reported no loss of consciousness during the blast, but 80% reported at least some amnesia surrounding the event. "They might not even realize they had a loss of consciousness, so it's very important to ask them to recount the events that happened at the time of the blast and afterward," Dr. Warden said.

Follow-up on the group indicates a significant number of these patients experience acute stress or posttraumatic stress disorder (PTSD); headache; fatigue; irritability or aggression; sleep problems; and dizziness. Those symptoms occurred less often in blast-injured patients than in those who incurred brain injuries in falls or motor vehicle accidents.

"We don't know if that has something to do with the mechanism or injury or if perhaps the postconcussive symptoms of blast-injured patients are slower to appear," Dr. Warden said.

Physicians who treat these patients in civilian life should be alert to the possibility of postconcussive disorders, she stressed. Since headache is the most persistent physical postconcussive symptom, migraine medication may be helpful.

Some patients, especially those with significant symptoms of irritability, may benefit from a course of antidepressants. "Some nonblinded trials have indicated that selective serotonin reuptake inhibitors are helpful in these patients," Dr. Warden said. In fact, two ongoing randomized placebo-controlled studies are looking at antidepressant therapy. One is examining the use of sertraline (Zoloft) in postconcussive syndrome and another, citalopram (Celexa) in postinjury anxiety disorders.

Methylphenidate (Ritalin) can sometimes be helpful for those with attention and information-processing problems.

All of those patients should be counseled on good sleep hygiene, as fatigue exacerbates symptoms. They should minimize or avoid caffeine, exercise early in the day rather than late, and establish regular work and sleep routines.

Avoiding hyperstimulation might be helpful as well, she said. The most important thing the physician can do is tell the patient that he will get better, she stressed. Most patients will recover fully within 3 months of their injury.

RELATED ARTICLE: Caring for Injured Veterans: VA Learning Module Aims to Help

Physicians caring for veterans with traumatic brain injuries now have some help from the experts.

The Department of Veterans Affairs has released a new independent study course on traumatic brain injury. The 155-page document is accessible at no charge on the Veterans Health Initiative Web site (www.va.gov/vhi).

The course is designed for VA physicians, but civilian physicians caring for injured veterans are encouraged to use it, said Bob Smith, Ed.D., project coordinator for the Veterans Health Initiative. "We want to spread this information out to as many doctors taking care of these patients as possible," Dr. Smith said in an interview with this newspaper.

While not focusing specifically on concussive brain injuries due to blast forces, the manual does include a section on mild traumatic brain injury--the level that occurs in most veterans who experience a blast-related closed head injury, This section details acute concussion management, common sequelae and course of recovery, postacute management of mild traumatic brain injury (TBI), and factors complicating assessment.

The manual also includes a section designed for patients with mild TBI. It explains in layman's terms the mechanism of a head injury, what symptoms are most likely to appear, and how long those symptoms will last. This section expresses an empathetic understanding of the patient's concerns about impaired mental functioning. It carries a positive message: 80% of patients with mild TBI will recover fully within 3 months of their injury.

Continuing medical education credit may be available for civilian physicians who complete the course. Those interested in obtaining CME should contact Dr. Smith at 205-731-1812, ext. 317; e-mail, [e-mail].

BY MICHELE G. SULLIVAN

Mid-Atlantic Bureau