Correspondence

Traumatic Brain Injury in the War Zone

N Engl J Med 2005; 353:633-634August 11, 2005

Article

To the Editor:

In Okie's Perspective article (May 19 issue)1 on traumatic brain injury (TBI) from the war in Iraq, she alludes to mood disorders that result from such injuries. Patients with TBI have been described as the “walking wounded”2 owing to their lingering neuropsychological problems. Lishman studied 670 cases of head injuries from the Second World War and reported that “simple measures of the amount of brain damage . . . were indeed related to the amount of psychiatric disability encountered one to five years later.”3 As many as 77 percent of patients with TBI have been given a diagnosis of depression.4 Mood disorders may result in the restriction of social contact as well as increased loneliness and are major barriers to functional and social rehabilitation.5

Technological improvements and better emergency medical care have reduced the incidence of severe TBI while increasing the numbers of patients with mild or moderate TBI. Such patients are more adversely affected by their emotional problems than by their residual physical disabilities.6 It is important to screen these patients for depression and to conduct neuropsychological testing soon after head injury in order to facilitate treatment and reentry into the community, as well as to optimize the long-term outcome.

Rohit R. Das, M.B., B.S., M.P.H.
Boston Medical Center, Boston, MA 02118
rohit.das@bmc.org

Ranjani N. Moorthi, M.B., B.S., M.P.H.
Saint Vincent Hospital, Worcester, MA 01608

6 References

1. 1

   Okie S. Traumatic brain injury in the war zone. N Engl J Med 2005;352:2043-2047
   Full Text | Web of Science | Medline

2. 2

   Rao V, Lyketsos C. Neuropsychiatric sequelae of traumatic brain injury. Psychosomatics 2000;41:95-103
   CrossRef | Web of Science | Medline

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   Lishman WA. The psychiatric sequelae of head injury: a review. Psychol Med 1973;3:304-318
   CrossRef | Web of Science | Medline

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   Kreutzer JS, Seel RT, Gourley E. The prevalence and symptom rates of depression after traumatic brain injury: a comprehensive examination. Brain Inj 2001;15:563-576
   CrossRef | Web of Science | Medline

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   Morton MV, Wehman P. Psychosocial and emotional sequelae of individuals with traumatic brain injury: a literature review and recommendations. Brain Inj 1995;9:81-92
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   Satz P, Fourney DL, Zaucha K, et al. Depression, cognition, and functional correlates of recovery outcome after traumatic brain injury. Brain Inj 1998;12:537-553
   CrossRef | Web of Science | Medline

To the Editor:

Although Okie's article described well many of the issues involved in the current war in Iraq, we would like to clarify our comments, reported in the article, regarding the classification of mild TBI. We noted that the boundary between mild and moderate TBI is one hour of loss of consciousness and that the cutoff between moderate and severe TBI is one day of loss of consciousness. However, there is variation in the classification of mild TBI.

Some authors1 use 30 minutes of loss of consciousness as the criterion, and others 20 minutes,2 and still others3 define “brief” loss of consciousness as lasting less than 1 hour. In practice, we more often use the duration of post-traumatic amnesia to determine the level of severity, since that information is available to us more often than are data on loss of consciousness.

Deborah L. Warden, M.D.
Louis French, Psy.D.
Defense and Veterans Brain Injury Center, Washington, DC 20307

3 References

1. 1

   American Congress of Rehabilitation Medicine. Definition of mild traumatic brain injury. J Head Trauma Rehabil 1993;8:86-87
   CrossRef

2. 2

   Rimel RW, Giordani B, Barth JT, Boll TJ, Jane JA. Disability caused by minor head injury. Neurosurgery 1981;9:221-228
   CrossRef | Web of Science | Medline

3. 3

   International classification of diseases, hospital edition, 9th rev., clinical modification: ICD-9-CM. 6th ed. Vol. 1, 2 & 3. Los Angeles: Practice Management Information Corporation, 2002.
   

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   Nihal C. de Lanerolle, Faris Bandak, Dewey Kang, Alexander Y. Li, Fu Du, Peter Swauger, Steven Parks, Geoffrey Ling, Jung H. Kim. (2011) Characteristics of an Explosive Blast-Induced Brain Injury in an Experimental Model. Journal of Neuropathology and Experimental Neurology 70:11, 1046-1057
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   Peng Luo, Fei Fei, Lei Zhang, Yan Qu, Zhou Fei. (2011) The role of glutamate receptors in traumatic brain injury: Implications for postsynaptic density in pathophysiology. Brain Research Bulletin 85:6, 313-320
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   Denis H. J. Caro. (2010) Towards systemic sustainable performance of TBI care systems: emergency leadership frontiers. International Journal of Emergency Medicine 3:4, 357-365
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   Denes V. Agoston, Andrea Gyorgy, Ofer Eidelman, Harvey B. Pollard. (2009) Proteomic Biomarkers for Blast Neurotrauma: Targeting Cerebral Edema, Inflammation, and Neuronal Death Cascades. Journal of Neurotrauma 26:6, 901-911
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   Geoffrey S.F. Ling, Scott A. Marshall. (2008) Management of Traumatic Brain Injury in the Intensive Care Unit. Neurologic Clinics 26:2, 409-426
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