Table Of ContentGulf War and Health,
Volume 7: Long-Term
Consequences of Traumatic
Brain Injury
THE NATIONAL ACADEMIES PRESS
Committee on Gulf War and Health: Brain Injury in Veterans and
Long-Term Health Outcomes
Board on Population Health and Public Health Practice
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National
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Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report
were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract V101(93) P-2136, Task Order 8 between the National Academy of Sciences
and Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this
publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that
provided support for this project.
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www.national-academies.org
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COMMITTEE ON GULF WAR AND HEALTH: BRAIN INJURY IN
VETERANS AND LONG-TERM HEALTH OUTCOMES
GEORGE W. RUTHERFORD, MD (Chair) Salvatore Pablo Lucia Professor and Vice Chair,
Department of Epidemiology and Biostatistics; Director, Prevention and Public Health
Group, Global Health Sciences, University of California, San Francisco School of
Medicine
JEFFREY J. BAZARIAN, MD, MPH, Associate Professor, Departments of Emergency
Medicine and Neurology, University of Rochester School of Medicine and Dentistry
IBOLJA CERNAK, PhD, MD, Medical Director, Johns Hopkins University, Applied Physics
Laboratory
JOHN D. CORRIGAN, PhD, Professor, Department of Physical Medicine and Rehabilitation,
Ohio State University
SUREYYA S. DIKMEN, PhD, Professor, Department of Rehabilitation Medicine and Adjunct
Professor of Neurological Surgery and Psychiatry and Behavioral Sciences, University of
Washington
M. SEAN GRADY, MD, Chairman, Department of Neurosurgery, University of Pennsylvania
School of Medicine
DALE C. HESDORFFER, PhD, MPH, Associate Professor of Clinical Epidemiology,
Gertrude H. Sergievsky Center, Columbia University
JESS F. KRAUS, PhD, MPH, Director, Southern California Injury Prevention Research Center,
Professor of Epidemiology, University of California, Los Angeles, School of Public
Health
HARVEY S. LEVIN, PhD, Professor, Director of Research, Cognitive Neuroscience
Laboratory, Department of Physical Medicine and Rehabilitation, Baylor College of
Medicine
LINDA NOBLE, PhD, Professor, Department of Neurological Surgery and Department of
Physical Therapy and Rehabilitation Science, University of California, San Francisco
SAMUEL J. POTOLICCHIO, MD, Professor, Department of Neurology, George Washington
University Medical Center
SCOTT L. RAUCH, MD, Chair, Partners Psychiatry and Mental Health; President and
Psychiatrist in Chief, McLean Hospital; Professor of Psychiatry, Harvard Medical School
WILLIAM STIERS, PhD, ABPP, Assistant Professor, Department of Physical Medicine and
Rehabilitation, Johns Hopkins University
CAROL A. TAMMINGA, MD, Professor, Department of Psychiatry, University of Texas
Southwestern Medical Center at Dallas
NANCY TEMKIN, PhD, Professor, Departments of Neurological Surgery and Biostatistics,
University of Washington
MARC G. WEISSKOPF, PhD, ScD, Mark and Catherine Winkler Assistant Professor,
Departments of Environmental Health and Epidemiology, Harvard School of Public
Health
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STAFF
CAROLYN FULCO, Senior Program Officer
ABIGAIL MITCHELL, Senior Program Officer
ROBERTA WEDGE, Senior Program Officer
NAOKO ISHIBE, Program Officer
JENNIFER SAUNDERS, Senior Program Associate
DEEPALI PATEL, Senior Program Associate (until October 2007)
RENEE WLODARCZYK, Senior Program Associate
JOE GOODMAN, Senior Program Assistant
NORMAN GROSSBLATT, Senior Editor
CHRISTIE BELL, Financial Officer
HOPE HARE, Administrative Assistant
ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice
CONSULTANTS
MIRIAM DAVIS, Independent Medical Writer, Silver Spring, MD
JOAN MACHAMER, Independent Consultant, University of Washington, Seattle, WA
vi
REVIEWERS
This report has been reviewed in draft form by persons chosen for their diverse
perspectives and technical expertise, in accordance with procedures approved by the National
Research Council’s Report Review Committee. The purpose of this independent review is to
provide candid and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional standards of
objectivity, evidence, and responsiveness to the study charge. The review comments and draft
manuscript remain confidential to protect the integrity of the deliberative process. We thank the
following for their review of this report:
Dan G. Blazer, Duke University Medical Center
Linda Cowan, Department of Biostatistics and Epidemiology, University of Oklahoma Health
Sciences Center
Ramon Diaz-Arrastia, Department of Neurology, University of Texas Southwestern Medical
School
Sandro Galea, Center for Social Epidemiology and Population Health, University of Michigan
Tessa Hart, Moss Rehabilitation Research Institute, Albert Einstein Healthcare Network
Janice L. Krupnick, Department of Psychiatry, Trauma and Loss Program, Georgetown
University Medical Center
James L. Levenson, Department of Psychiatry, Virginia Commonwealth School of Medicine
Kathryn Saatman, Spinal Cord and Brain Injury Research Center, University of Kentucky
Chandler Medical Center
Murray B. Stein, Department of Psychiatry, University of California, San Diego
Although the reviewers listed above have provided many constructive comments and
suggestions, they were not asked to endorse the conclusions or recommendations, nor did they
see the final draft of the report before its release. The review of this report was overseen by Dr.
Johanna T. Dwyer, Tufts University School of Medicine and Friedman School of Nutrition
Science and Policy, Frances Stern Nutrition Center, Tufts-New England Medical Center and Dr.
Robert S. Lawrence, Center for a Livable Future, Johns Hopkins Bloomberg School of Public
Health.Appointed by the National Research Council and the Institute of Medicine, they were
responsible for making certain that an independent examination of the report was carried out in
accordance with institutional procedures and that all review comments were carefully
considered. Responsibility for the final content of the report rests entirely with the author
committee and the institution.
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CONTENTS
PREFACE....................................................................................................................................xiii
SUMMARY.....................................................................................................................................1
1 INTRODUCTION....................................................................................................................13
Background...............................................................................................................................13
Traumatic Brain Injury..............................................................................................................14
Operation Enduring Freedom and Operation Iraqi Freedom....................................................15
Charge to the Committee..........................................................................................................15
Scope of the Report...................................................................................................................15
Organization of the Report........................................................................................................16
References.................................................................................................................................17
2 BIOLOGY OF TRAUMATIC BRAIN INJURY.....................................................................19
Pathobiology of Traumatic Brain Injury...................................................................................19
Traditional Classifications of Traumatic Brain Injury..............................................................25
Classification According to Extent of Pathology......................................................................25
Classification According to Biomechanics of Injury................................................................27
Therapeutics and Traumatic Brain Injury.................................................................................28
Summary of Pathobiology of Traumatic Brain Injury..............................................................29
Traumatic Brain Injuries Relevant to the Military....................................................................30
Basic Mechanisms of Explosive Injuries..................................................................................31
Severity Scoring of Blast Injuries and Traumatic Brain Injury................................................41
References.................................................................................................................................46
3 EPIDEMIOLOGY OF ADULT TRAUMATIC BRAIN INJURY..........................................59
Incidence of Traumatic Brain Injury.........................................................................................61
Brain Injury Severity.................................................................................................................63
Risk Factors for Traumatic Brain Injury...................................................................................64
Recurrent Traumatic Brain Injury.............................................................................................67
Traumatic Brain Injury and Short-Term Outcomes..................................................................68
Summary...................................................................................................................................69
References.................................................................................................................................96
4 CONSIDERATIONS IN IDENTIFYING AND EVALUATING THE LITERATURE.......103
Identification of the Literature................................................................................................103
Types of Evidence...................................................................................................................104
Inclusion Criteria.....................................................................................................................110
Considerations in Assessing the Strength of Evidence...........................................................112
Limitations of Studies.............................................................................................................113
References...............................................................................................................................115
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