Clinical and imaging assessment of acute combat mild traumatic brain injury in Afghanistan

Adam, Octavian R.; Donald, Christine L. Mac; Rivet, Dennis J.; Ritter, John L.; May, Todd; Barefield, Maria; Duckworth, Josh; LaBarge, Donald; Asher, Dean; Drinkwine, Benjamin; Woods, Yvette; Connor, Michael; Brody, David L.

doi:10.1212/wnl.0000000000001758

Cited by 50 publications

(46 citation statements)

References 37 publications

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“…FA in white matter regions has been shown to be affected by a variety of factors such as injury, axonal caliber, myelin sheath thickness, and the density and distribution of white matter tracts20. Our findings are consistent with those seen in clinical populations where FA is regularly shown to be reduced following mTBI 41, 42, 43, 44, 45, 46. Decreased FA values have been reported acutely,35 as well as chronically47, in the corpus callosum of patients with mTBI.…”

Section: Discussionsupporting

confidence: 88%

Diffusion MRI abnormalities in adolescent rats given repeated mild traumatic brain injury

Wortman

Meconi

Neale

et al. 2018

Ann Clin Transl Neurol

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ObjectiveMild traumatic brain injury (mTBI) is a serious health concern in the adolescent population. Repeated mTBI may result in more pronounced deficits, and has been associated with long‐term neurological consequences including neurodegeneration. As such, there is a critical need for the development of objective mTBI biomarkers to help guide medical management. Diffusion‐weighted imaging (DWI) is an advanced magnetic resonance imaging (MRI) technique that may detect brain abnormalities after mTBI. Diffusion tensor imaging (DTI) is the most commonly applied DWI method, and initial studies have reported DTI changes in mTBI patients. Furthermore, new DWI methods (e.g., track‐weighted imaging; TWI) are being developed that may also be sensitive to mTBIs, but remain to be comprehensively studied.MethodsThis study utilized the Awake Closed Head Injury (ACHI) model of mTBI to investigate changes in DTI and TWI following repeated mTBI in adolescent male and female rats. A total of four ACHI impacts, two/day over two consecutive days, were delivered beginning on postnatal day 25. At 1 day and 7 days postinjury, rats were euthanized and brains were collected for DWI analyses.ResultsRats given repeated mTBI displayed changes in fractional anisotropy and radial diffusivity (i.e., DTI measures), as well as track density (i.e., TWI).InterpretationThese findings are consistent with initial DTI findings in mTBI patients, suggest that TWI may complement DTI, support the utility of DWI measures as biomarkers in mTBI, and further validate the ACHI rat model of mTBI.

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Section: Discussionsupporting

confidence: 88%

Diffusion MRI abnormalities in adolescent rats given repeated mild traumatic brain injury

Wortman

Meconi

Neale

et al. 2018

Ann Clin Transl Neurol

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“…9–12,29,30 The present study is the 5-year evaluation in a continued prospective, observational, longitudinal research study. We report the 5-year clinical outcomes compared with 1-year findings in the following participant groups: patients with concussive blast TBI and combat-deployed control individuals.…”

Section: Methodsmentioning

confidence: 99%

“…Inclusion criteria are reported elsewhere. 9,10,30 In brief, participants were service members deployed to combat from November 1, 2008, through July 1, 2013, for whom original enrollment was completed directly in Afghanistan 9,29 or after medical evacuation to Landstuhl Regional Medical Center in Landstuhl, Germany. 10–12,30 Diagnosis of head injury was determined by trained medical personnel working in the TBI clinics in Germany.…”

Section: Methodsmentioning

confidence: 99%

“…In contrast, our group was provided the unique opportunity to examine patients in the acute 9,29 to subacute 10–12,30 stage after combat-related concussive TBI with prospective follow-up to 1-year 9–12,30 and now 5-year evaluations. This longitudinal observation has allowed for a greater appreciation of functional postinjury trajectory and the effect on long-term outcome.…”

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confidence: 99%

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Early Clinical Predictors of 5-Year Outcome After Concussive Blast Traumatic Brain Injury

et al. 2017

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The long-term clinical effects of wartime traumatic brain injuries (TBIs), most of which are mild, remain incompletely described. Current medical disability cost estimates from world conflicts continually surpass projections. Additional information regarding long-term functional trajectory is needed to reduce this extensive public health burden.OBJECTIVES To examine 5-year clinical outcomes leveraging existing clinical data collected at 1 year after injury in the same patients and to identify early risk factors for long-term disability. DESIGN, SETTING, AND PARTICIPANTSThis prospective, longitudinal study enrolled active-duty US military after concussive blast injury (n = 50) in the acute to subacute stage and combat-deployed control individuals (n = 44) in Afghanistan or after medical evacuation to Germany from November 1, 2008, through July 1, 2013. One-and 5-year clinical evaluations were completed in the United States. All concussive blast injuries met the Department of Defense definition of mild, uncomplicated TBI. In-person clinical evaluations included standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden that were essentially identical to the evaluations completed at 1-year follow-up. Data were analyzed from October 1 through November 30, 2016. MAIN OUTCOMES AND MEASURESChanges in the in-person standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden from the 1-to 5-year follow-up. Predictive modeling was used to identify early risk factors for long-term disability. RESULTS Among the 94 participants (87 men [93%] and 7 women [7%]; mean [SD] age, 34[8] years), global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI compared with combat-deployed controls, whereas performance on cognitive measures was no different between groups at the 5-year evaluation. Logistic regression on the dichotomized Extended Glasgow Outcome Scale (GOS-E) at 5 years as a measure of overall disability identified brain injury diagnosis, preinjury intelligence, motor strength, verbal fluency, and neurobehavioral symptom severity at 1 year as risk factors for a poor outcome at 5 years, with an area under the curve of 0.92 indicating excellent prediction strength. Thirty-six of 50 patients with concussive blast TBI (72%) had a decline in the GOS-E from the 1-to 5-year evaluations, in contrast with only 5 of 44 combat-deployed controls (11%). Worsening of symptoms in concussive blast TBI was also observed on measures of posttraumatic stress disorder and depression. Service members with concussive blast TBI experienced evolution, not resolution, of symptoms from the 1-to 5-year outcomes.CONCLUSIONS AND RELEVANCE Considerable decline was observed in military service members with concussive blast TBI when comparing 1-and 5-year clinical outcomes. These results advocate for new treatment strategies to combat the long-te...

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“…Diffusion tensor imaging (DTI) can be used to image white mater (WM-) integrity, which may be a predictor of mild bTBI [27]. White matter in the brain constrains water and causes it to diffuse along the myelinated axons in an anisotropic pattern of diffusion.…”

Section: Noninvasive Evaluation Of Mild Btbimentioning

confidence: 99%

Explosive Blast Mild Traumatic Brain Injury

Magnuson¹,

Ling²

2018

Traumatic Brain Injury - Pathobiology, Advanced Diagnostics and Acute Management

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In the recent wars in Iraq and Afghanistan, US military personnel have suffered over 333,000 traumatic brain injuries (TBIs), with over 85% being mild TBI. A variety of improvised munitions, such as improvised explosive devices (IEDs) and improvised rocket assisted mortars (IRAMs), have resulted in the explosive blast-induced TBI (bTBI). Due to its prevalence, TBI has been referred to as the signature wound of US warfighters in Afghanistan and Iraq. Explosive blast produces damage to the brain by creating a dynamic environment in forms of overpressure shock wave, heat impulse, blast-propelled projectiles, and debris, whose impact can cause complex injuries in the brain and other visceral organ systems, such as lung and bowel. Mechanisms of bTBI incorporate all forms of TBI such as falls, motor vehicle accidents, and coup-contrecoup injury. Some of the unique aspects of bTBI include the rate at which the injury occurs, the differential pressure load on and within the tissue, and the pressure-loaded tissue response. Mild bTBI is the most problematic injury within the US military in terms of number of warfighters affected and recognition of the injury. The pathobiology of mild bTBI is not fully understood. Here, we review mild bTBI injury, symptomology, and diagnosis. Finally, multi-modality testing is discussed, including functional, structural, and evidence-based evaluation with an intention to describe and diagnose mild bTBI affecting the US warfighter.

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Clinical and imaging assessment of acute combat mild traumatic brain injury in Afghanistan

Cited by 50 publications

References 37 publications

Diffusion MRI abnormalities in adolescent rats given repeated mild traumatic brain injury

Diffusion MRI abnormalities in adolescent rats given repeated mild traumatic brain injury

Early Clinical Predictors of 5-Year Outcome After Concussive Blast Traumatic Brain Injury

Explosive Blast Mild Traumatic Brain Injury

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