Brainscope's prototype device could be used to diagnose traumatic brain injuries suffered by soldiers. Photo: Andrew Burton / AFP / Getty Images

The Pentagon has reported that 34 US soldiers experienced lingering headaches, dizziness, sensitivity to light, nausea and other symptoms caused by the rocket attack on the Ayn al-Asad Air Base in Iraq.

According to the US Military Times, “While service members were initially screened for concussion following the blasts, more than 30 continued to experience symptoms throughout the last two weeks. In total, 16 were treated on-site in Iraq, one was transported to Kuwait for treatment and has since returned to duty, while 17 were flown to US facilities in Landstuhl, Germany. As of Friday morning [January 24] … eight of those have returned to the US, either to be treated at Walter Reed National Military Medical Center in Bethesda, Maryland, or at their duty stations’ base hospitals.”

Shelters not designed to protect from brain injuries

While the soldiers were all in shelters, the shelters did not protect them from the impact of the blast on their bodies, particularly the brain. Today’s shelters are not designed to reduce the shock to the brain of blasts from rockets, artillery or mortars.

What the soldiers in Iraq experienced, known as traumatic brain injury (TBI), was caused in the case of the Ayn al-Asad Air Base by the impact and explosion of rockets near the place where the soldiers were sheltering. Twenty-two missiles were fired altogether, 17 toward Ayn al-Asad base and five at Erbil. Four of the missiles missed their targets or malfunctioned, but the US military says that 11 landed inside the Ayn al-Asad Air Base.

The missiles, fired from Iranian territory, were most likely Fateh-313 short-range ballistic missiles (an upgrade of the Fateh-110 with longer range thanks to a composite body). This missile flies at Mach 3 (three times the speed of sound) and carries a 650 kg high-explosive warhead.

Although initial reports emphasized that little damage was done, satellite photos show considerable destruction. While Iran claims the missile has an accuracy of three meters.  The true accuracy is probably at least five meters and could be more, depending on many factors (wind, temperature, stability, the accuracy of mapping).

Brain injury hard to treat

Traumatic brain injury is very hard both to accurately diagnose and to treat. In cases where there is an actual trauma that is immediately visible, treatments that are somewhat effective are diuretics to reduce the amount of fluid in brain tissue and to increase urine output; anti-seizure drugs similar to what are used for treating strokes; and coma-inducing drugs for cases in which the brain is not getting enough blood because of compressed blood vessels coming from the concussive effects of a blast.

Traumatic brain injury caused by improvised explosive devices is sometimes called the “signature injury” for troops in those combat zones. Soldiers wounded by IEDs often have TBI along with loss of limbs or other injuries, but even those who do not have conventional wounds can end up with traumatic brain injury.

TBI injuries are classified as mild, moderate and severe. Severe TBI is easy to recognize because the victim will immediately be disoriented, may have blurred vision or difficulty hearing, and may be confused or even incoherent. Moderate and mild TBI are much more difficult to diagnose and the symptoms may not show up for hours or even days after the injury happened.

Most doctors in the military, as in medical diagnosis generally, use the Glasgow Coma Scale questionnaire to assess TBI. The Glasgow Coma Scale has three main components: it measures eye-opening and how the eyes respond to stimuli, a verbal response to questions (e.g., does the assessed victim cry or smile appropriately) and various checks for motor response.

TBI is much more common for combat soldiers than most realize and represents a major problem for fighting forces and the willingness of troops to serve in war zones. There are many long term consequences for TBI injuries.  Among them is PTSD or Post Traumatic Stress Disorder that includes psychological and emotional impairment and suicidal thoughts among victims.

Johns Hopkins research team recently studied veterans who had died from causes other than from blast war wounds and found “distinctive lesions in a number of places in veterans’ brains, including in the frontal lobes, which control decision making, memory, reasoning and other executive functions. The lesions may be fragments of nerve fibers that broke at the time of the blast and slowly deteriorated, or they may have been weakened by the blast and broken by some later insult like a concussion or drug overdose.”

Similar lesions have been found in the brains of American football players who committed suicide and suffered from multiple concussions playing the sport. The list of brain injuries among US football players is a long one.

Numbers high

In the US military, the number of TBI known victims is quite large. The Defense and Veterans Brain Injury Center (DVBIC) reports nearly 350,000 incident diagnoses of TBI in the US military since 2000. Among those deployed in combat zones, estimated rates of probable TBI range from 11-23%. But those in combat zones may never get close to actual combat, suggesting that the percentage of active warfighters who are victims may be far higher. Other studies put the number higher than 400,000. Some soldiers may not report their condition, worrying that if they do so they will be sent home or doing so will damage their military careers.

Some conclusions are (1) that the number of traumatic brain injuries in combat zones is much higher than most people realize and has a long term impact on soldiers, even well after they return to civilian life; (2) that the medical consequences of even moderate TBI are worse than first realized; (3) that more research is needed to find treatment therapies that can mitigate the physical damage to the brain from TBI; and (4) that consideration should be given to upgrading shelters that can mitigate shock along with the physical protection of troops.

The Center for New American Security says that the US Army “does not currently have a requirement to protect against brain injury from exposure to blast pressure waves from explosions (aka primary blast injury).”  CNAS goes on to say that “computer models and physical experiments have suggested that existing Army helmets provide some modest protection against blast waves and that improved helmet designs, such as adding a modular face shield, could reduce blast pressure in the brain by up to 80 percent.”

These and other shelter improvements could contribute to reducing the prevalence of brain injuries both in fixed shelters and in vehicles.

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