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Soldiers with TBI face long-term medical, cost challenges.

SALT LAKE CITY -- Neurologic injuries figure prominently in the 33,409 U.S. soldiers who have been wounded in Iraq, and traumatic brain injury alone or with posttraumatic stress disorder presents a "significant challenge" to the Department of Veterans Affairs, according to Col. Cornelius Maher, MC USA, a neurologist in Fort Sam Houston, San Antonio.

Traumatic brain injury (TBI) has been diagnosed in 32% of patients evacuated to Walter Reed Army Hospital in Washington, regardless of their primary injuries, Dr. Maher said at the annual meeting of the American Academy of Neurology.

To date, 7,694 Iraqi war veterans have been treated for TBI stateside at centralized Defense and Veterans Brain Injury Centers. Their wounds are evidence of the significant toll of blast injuries and direct contact wounds associated with improvised explosive devices (IEDs) and other weapons commonly used in the war.

Even in combat hospitals in the field, such as the one in Baghdad where Dr. Maher served from February 2004 to March 2005, the incidence of head injuries is noteworthy.

Compared with records from the Vietnam War, postconcussion syndrome is "the only diagnosis that [is] being seen a lot more by our service [in Baghdad]," he added. "A mild concussion probably would never make it to Baghdad [but would be treated in the field]."

In previous wars, thoracic and abdominal injuries predominated in soldiers who survived an attack, but the Iraq and Afghanistan conflicts have been largely fought by troops in protective body armor and against enemies using IEDs, mortars, booby traps, and land mines. The blasts from such weapons and the ensuing shock waves are causing an unprecedented number of head injuries, including some that are not immediately apparent in the field.

"A percussive wave going through the brain can result in very selective loss of neuronal populations," said Dr. Daniel H. Lowenstein, vice chair of neurology and director of the epilepsy center at the University of California, San Francisco.

Past experience and current data suggest a significant proportion of these veterans will need years of treatment, particularly as long-term sequelae are manifested.

One stark example is epilepsy, which is likely to be diagnosed in large numbers of veterans who have suffered TBI, he said.

By comparison, the overall risk of posttraumatic epilepsy after TBI is 2%-5% in the civilian population and approaches 50% following war injuries, depending on wound severity. Epidemiologic data suggest that the percentage of combat veterans who have developed epilepsy following combat head injuries is about 35% overall and 43% if the injury reaches the dura mater or beyond.

A longitudinal study of veterans with head wounds in World War II suggested that, although many cases of epilepsy develop within a year of the injury, significant numbers of patients suffered their first up to 8 years after their injuries.

Current figures list about 2,000 official brain injuries from the Iraq theater, nearly all caused by penetrating wounds. Of these, an estimated 700 soldiers will develop epilepsy, said Dr. Lowenstein. If lesser percentages of the "tens of thousands" of soldiers with nonpenetrating mild to moderate TBI also develop epilepsy, the cost of treatment for that diagnosis alone could reach or surpass $20 billion, he said.

In a separate presentation, Linda Blimes, an economist at Harvard University, Cambridge, Mass., said long-term medical care and disability payments for returning veterans will likely exceed the operating costs of the war, in part because of the costs of treating head injuries, posttraumatic stress disorder, and their sequelae. She put early estimates of long-term medical care for the troops at $700 billion, excluding the medical and psychological consequences of TBI, which could cost $25-$30 billion more.


Los Angeles Bureau
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Title Annotation:Clinical Rounds
Author:Bates, Betsy
Publication:Family Practice News
Date:Dec 1, 2008
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