Brain injuries lead Iraq war injuries

By BRAD AMBURN, United Press International  |  July 23, 2004 at 4:42 PM
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WASHINGTON, July 23 (UPI) -- Nearly two-thirds of injured U.S. soldiers sent from Iraq to Walter Reed Army Medical Center have been diagnosed with traumatic brain injuries -- a percentage thought to be higher than any other past U.S. conflict, military officials told United Press International.

About 60 to 67 percent of soldiers coming through the hospital with wounds as well as injuries from blasts, severe falls and motor vehicle accidents have suffered these potentially life-altering brain injuries, said Dr. Deborah Warden, national director of the Defense and Veterans Brain Injury Center at Walter Reed, where the majority of patients with suspected head injuries from Iraq are sent.

Warden said this trend may seem grim but the increased number of cases actually serves as proof of an improved head injury survival rate from better armor, more sophisticated diagnostic tools, and soldiers and medical staff better trained to look for and treat these kinds of injuries that would have been fatal or gone unnoticed in past wars.

An ongoing investigation into the lifelong effects of war-related head injuries is at the forefront of these advancements in knowledge and treatment.

"As a medical field, we're much more sensitized to mild, closed brain injury ... and we know that there are consequences and ramifications for milder traumatic brain injury," Warden told UPI. "So we are screening and identify soldiers who have had less severe traumatic brain injury," which was not the case in Vietnam or earlier wars.

With the development of more sophisticated body armor and helmets made of Kevlar -- a bullet resistant material -- the survival rate of soldiers with traumatic brain injuries has greatly improved, whereas in past wars similar injuries would have been fatal, Warden explained.

She said soldiers who survive head injuries often suffer from a range of cognitive and emotional problems, including difficulty with memory, attention and reasoning, as well as high rates of depression, alcohol use, post-traumatic anxieties and irritability.

During the Vietnam era, brain-scanning technology, such as magnetic resonance imaging, did not exist to detect the extent of brain injuries, said Dr. Karen Schwab, assistant director at the Walter Reed brain injury center. This likely resulted in under-detection of traumatic head injury and inadequate treatment, she added.

This led to the beginning of a long-term investigation studying the effects of penetrating brain injuries on Vietnam veterans. A penetrating brain injury is one where a bullet or piece of shrapnel has passed through the skull and pierced the brain. The study is now entering its third phase of research at the National Naval Medical Center in Bethesda, Md.

The study was started in the 1960s at Walter Reed by Dr. William Caveness, who wanted to investigate how penetrating head injuries affected epilepsy in soldiers -- who had a high incidence rate of the disease, said Jordan Grafman, chief of cognitive neuroscience at the National Institute of Neurological Disorders and Stroke and the study's principal investigator.

Grafman and fellow investigator, Dr. Andres Salazar, wanted to expand the scope of the investigation to learn more about cognition and brain function, yielding results that improved the evaluation of patients with head injuries and identified key components to their long-term outcomes.

"If you have a brain injury and you can no longer do a specific task then it is likely that that area of the brain was very important -- perhaps stored the memories that enabled you to do that task," Grafman told UPI.

"We knew the patients' long-term outcome was going to depend a lot more on their cognitive status than it would on whether they had epilepsy or not," Grafman continued. "And we probably would learn a whole lot about how the brain works and help the military change how they handle head injuries because during Vietnam there was no real standard of care."

In the early 1980s, the Department of Defense granted funding for the second phase of the study, to conduct a 15-year follow-up evaluation of 520 Vietnam veterans with head injuries who had participated in the first phase of research.

The investigation led to many neuropsychological advances that proved the importance of the prefrontal cortex in social functioning, and showed the Army that veterans with head injuries still experienced cognitive deficits -- in social behavior, reasoning, attention and planning -- that needed effective diagnosis and rehabilitation.

"We were able to see that many of these guys were not worked up or evaluated well after Vietnam, which led to new (head injury) units being established in military hospitals," Grafman said. "It also got the military, especially the Army, just extremely interested in head injuries in general and trying to figure out ways to minimize injuries when they occur medically or even prevent them by changing the helmet. So it had a powerful clinical impact."

The development of better helmets has reduced the number of penetrating head injuries in Iraq, but internal, concussive head injuries are more of a problem in this war, Warden said, particularly among paratroopers injured by rough landings.

The brain injury center has worked with the Army to develop even better helmets that provide more internal cushioning to prevent against concussions. These helmets currently are being integrated into service, Warden said.

Despite "great improvements in body protection," however, the head still is the most vulnerable part of the body to injury, Grafman said, so even though shells and fragments might be blocked, that still will not prevent traumatic injuries to the brain through weaponry that causes damage by impact and sound waves.

"Given this, it becomes even more important to better evaluate and provide good rehabilitation for soldiers," he added.

The third phase of the study currently under way at the NNMC could provide important clues to improved rehabilitation by "looking at cognition in a slightly more sophisticated way," said Dr. Vanessa Raymont, NNMC's head neuropsychiatrist.

The 30-year follow-up of the same Vietnam veterans will evaluate more social and everyday cognition, Raymont said, by focusing on how these injuries continue to affect executive functioning in the brain, including decision-making and reasoning.

This part of the study also will involve a genetic analysis of blood samples from participating veterans to see if there are any specific genetic markers indicating some soldiers might be more susceptible to developing problems from these types of injuries, Raymont said.

Although the study has covered only 12 veterans since its launch last April, Raymont said preliminary reports suggest a higher incidence of short-term memory problems, which may indicate people with head injuries are more prone to memory difficulties.

Psychological problems also seem to continue for many participants who suffer from depression and anxiety disorders and use alcohol to cope with the problems they have experienced, she said.

This study focuses on penetrating head injuries instead of internal ones more prevalent in current conflict, Raymont said, "(so) it is very feasible we could be looking at different outcomes" for veterans of the Vietnam war and the war in Iraq.

Grafman said the study's findings still will help soldiers in Iraq know what to expect with these injuries and will drive the importance of long-term rehabilitation.

"In the case of more blast injuries, it is likely they're going to affect more widespread parts of the brain than the typical shell fragment would," Grafman explained. "The more we learn about individual areas of the brain and how they function, the more knowledge we'll have about the kind of impairments that can occur" and more specified and effective treatments can be developed.

Treatment already is improving for brain injury sufferers, Schwab said.

"Clinicians tell us here, that when people are brought back for follow-up a year after their treatment, how well they're doing. It's impressive," she said. "People continue to make recovery, which is not to minimize their injuries when in fact a lot of them will need ongoing help."

The study will conduct a fourth phase in another 10 to 15 years to further examine long-term effects on these veterans.


Brad Amburn is an intern for UPI Science News. E-mail

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