Concussive brain injury in the military: September 2001 to the present.

Since the terrorist attacks of September 11, 2001, 1,348,405 citizens have been deployed to combat in Operation Iraqi Freedom (OIF), Operation New Dawn in Iraq, and Operation Enduring Freedom in Afghanistan (OEF). During this same period 266,810 (20%) of these individuals have been diagnosed with a traumatic brain injury (TBI). The majority of these were Army soldiers, with 155,282 (58%) receiving the diagnosis. Mild TBI comprised 82% of the total, with the remainder being moderate to severe. Over this same period the Department of Defense (DoD) has invested $374.9 million to enhance access and quality of care services, including 57 TBI treatment centers in the combat theater and throughout the U.S. The Army's medical research division, the Medical Research and Material Command (MRMC), has invested an additional $700 million to TBI research during this time. The effort has faced a number of challenges, including limited human subject basic and translational research, limited epidemiological data on combat-related injuries, limited capacity and standards for data acquisition, and a lack of standardized evidenced-based protocols for treatment. All these areas have undergone significant growth and development, leading to the comprehensive system of care present today. A further challenge in this patient population has been the clinical co-morbidity of TBI, post-traumatic stress disorder, and chronic pain syndrome. The Army and the DoD have created treatment programs that are interdisciplinary in clinical approach, targeting particular neuropsychological domains of dysfunction rather than diagnostic category or etiology of injury. This article presents the history of this effort, the challenges to accurate and adequate diagnosis and care that remain, and the future of brain injury clinical and research efforts in the military.

Integration of XNAT/PACS, DICOM, and Research Software for Automated Multi-modal Image Analysis.

Traumatic brain injury (TBI) is an increasingly important public health concern. While there are several promising avenues of intervention, clinical assessments are relatively coarse and comparative quantitative analysis is an emerging field. Imaging data provide potentially useful information for evaluating TBI across functional, structural, and microstructural phenotypes. Integration and management of disparate data types are major obstacles. In a multi-institution collaboration, we are collecting electroencephalogy (EEG), structural MRI, diffusion tensor MRI (DTI), and single photon emission computed tomography (SPECT) from a large cohort of US Army service members exposed to mild or moderate TBI who are undergoing experimental treatment. We have constructed a robust informatics backbone for this project centered on the DICOM standard and eXtensible Neuroimaging Archive Toolkit (XNAT) server. Herein, we discuss (1) optimization of data transmission, validation and storage, (2) quality assurance and workflow management, and (3) integration of high performance computing with research software.

Effects of military deployment on cognitive functioning.

Military deployment poses many risks for cognitive functioning. When deployed individuals are compared to a nondeployed control group, there is some evidence that deployment may be associated with declines in cognitive functioning. The current study examined cognitive performance before and following deployment in a large sample of active duty military personnel (N = 8002) who reported no traumatic brain injury (TBI). Cognition was assessed using the Automated Neuropsychological Assessment Metrics version 4 TBI Military (ANAM4 TBI-MIL) battery, a computer-based battery of tests measuring attention, processing speed, and general cognitive efficiency. Pre- and postdeployment scores were compared using repeated measures analyses. Although statistically significant differences were observed for all tests (with 5 of 7 tests demonstrating performance improvement), effect sizes were very small for all but 1 test, indicating that performance differences had minimal clinical significance. Likewise, determination of change for individuals using reliable change indices revealed that a very small percentage (<3%) of this presumed healthy sample showed meaningful decline in cognition following deployment. Analyses indicated that despite risks for cognitive decline while in theater, deployment had minimal to no lasting effect on cognition as measured by ANAM4 TBI-Mil upon return from deployment.

Cognitive change associated with self-reported mild traumatic brain injury sustained during the OEF/OIF conflicts.

Traumatic brain injury (TBI) has received much attention due to high rates of this injury in Service Members returning from the Iraq/Afghanistan conflicts. This study examined cognitive performance in Service Members tested with ANAM prior to and following deployment. The sample was divided into a control group (n=400) reporting no TBI injury prior to or during most recent deployment, and a group who self-reported a TBI injury (n=502) during most recent deployment. This latter group was divided further based on self-report of post-concussion symptoms at post-deployment testing. All three groups performed similarly at pre-deployment. The group reporting TBI with active symptoms performed worst at post-deployment and included the highest percentage of individuals showing significant decline in cognitive performance over time (30.5%). A small sample of symptomatic individuals with a non-TBI reported injury did not demonstrate similar declines in performance, suggesting that active symptoms alone cannot account for these findings. Of those reporting a TBI injury during deployment, 70% demonstrated no significant change in cognitive performance compared with baseline. Although the exact etiology of observed declines is uncertain, findings indicate that individuals who self-report TBI during deployment with active symptomatology at post-deployment are at greatest risk for declines in cognitive performance. These individuals can be identified using self-report and brief computer-based testing. Importantly, the majority of active-duty individuals reporting TBI during deployment do not present with lasting significant cognitive impairment, a finding consistent with the civilian literature on mild TBI.