A new study by researchers at The University of Texas Health Science Center at San Antonio that reviewed the medical records of Afghanistan and Iraq war veterans who sustained traumatic brain injuries (TBIs), has revealed that subjects with mild TBIs (85 percent of veterans with such injuries) are approximately 28 percent more likely to develop epilepsy than individuals without TBIs.
The cross-sectional observational study, entitled “The Prevalence of Epilepsy and Association with Traumatic Brain Injury in Veterans of the Afghanistan and Iraq Wars” published online in the Journal of Head Trauma Rehabilitation, is coauthored by Mary Jo Pugh, Ph.D., RN, an associate professor in the Department of Epidemiology and Biostatistics at the UT Health Science Center School of Medicine with Jean A. Orman, ScD, MPH; Carlos A. Jaramillo, MD, PhD; Martin C. Salinsky, MD; Blessen C. Eapen, MD; Alan R. Towne, MD, MPH; Megan E. Amuan, MPH; Gustavo Roman, MD; Shane D. McNamee, MD; Thomas A.Kent, MD; Katharine K. McMillan, PhD; Hamada Hamid, MD, MPH; and Jordan H. Grafman, PhD.
Medical records of a total 256,284 Afghanistan/Iraq veterans who received inpatient and outpatient care in the Veterans Health Administration in fiscal years 2009 and 2010 were reviewed.
To aid in their analysis, researchers used algorithms developed for use with International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify epilepsy, TBI (penetrating TBI [pTBI]/other TBI), and other risk factors for epilepsy (eg, stroke). TBI and other risk factors were identified prior to the index date (first date of seizure or October 1, 2009) for primary analyses.
The coauthors determined that epilepsy prevalence was 10.6 per 1000 (N = 2719) in fiscal year 2010; age-adjusted prevalence was 6.1. Of 37,718 individuals with a diagnosis of TBI, 29,297 Veterans had a diagnosis of TBI prior to the index date. Statistically significant associations were found between epilepsy and prior TBI diagnosis (pTBI: adjusted odds ratio = 18.77 [95% confidence interval, 9.21-38.23]; other TBI: adjusted odds ratio = 1.64 [1.43-1.89]).
They conclude that among OEF/OIF Veterans, epilepsy was associated with previous TBI diagnosis, with pTBI having the strongest association, and observe that because war-related epilepsy in Vietnam War Veterans with TBI continued 35 years postwar, a detailed, prospective study is needed to understand the relationship between epilepsy and TBI severity in OEF/OIF Veterans.
“We saw that 24 percent of the veterans who had epilepsy also had experienced a TBI. That is compared to 11 percent of people without epilepsy,” says Dr. Pugh of the study, which was funded by the VA Health Services Research and Development Administration. “This is an important group to study because 15 percent to 19 percent of the more than 2 million returning veterans have suffered a TBI with either loss of consciousness or altered mental status.”
“The high prevalence of TBIs has raised concerns for the long-term consequences of neurotrauma in this population. Based on data from previous wars, there is a particular concern for the risk of post-traumatic epilepsy,” Dr. Pugh says in a release, adding that studies of veterans from World War II and the Korean War showed a link between combat-related head injury and epilepsy.
“This study shows us that we need to be prepared as a health care system,” she continues. “Given the large number of individuals who have sustained deployment-related TBI, a substantial increased burden of epilepsy in this population is possible. The long-term consequences on the patient and the health care system includes increased risk of medical and social complications, including accidents, social stigmatization, loss of employment, inability to drive, and even death. These veterans should be followed closely, and systems of care, such as the VHA Epilepsy Centers of Excellence, should be prepared to provide epilepsy specialty care for these individuals.”
A previous retrospective study of the prevalence of aphasia, fluency and voice disorders among veterans of the Iraq and Afghanistan wars with different severity levels of traumatic brain injury (TBI), published in the journal Brain Injury, entitled “Traumatic brain injury in veterans of the wars in Iraq and Afghanistan: communication disorders stratified by severity of brain injury” (Brain Inj. 2013;27(13-14):1623-30. doi: 10.3109/02699052.2013.834380. Epub 2013 Oct 16), is also coauthored by Dr. Pugh with R.S. Norman; Carlos A. Jaramillo, MD; Jaramillo; Megan E. Amuan, MPH; M.A. Wells; and Blessen C. Eapen, MD, all of the Polytrauma Rehabilitation Center, South Texas Veterans Health Care System (STVHCS) at San Antonio.
Data reviewed was obtained from the VA National repository for OEF/OIF/OND veterans who received VA care in Fiscal Years 2010 and 2011, finding that among the 303,716 veterans in this study, 1,848 were diagnosed with a communication disorder; 40% of these were also diagnosed with a TBI. Voice disorders were the most prevalent diagnosis (3.5 per 1000) followed by aphasia (1.9 per 1000) and fluency disorder (0.7 per 1000). Individuals with a TBI diagnosis were more likely to have a diagnosis of aphasia, followed by fluency and then voice disorder. The odds ratio (OR) of aphasia with TBI was 11.09-252.75 (95% CI = 8.78-441.52, p < 0.01). OR for fluency disorders with TBI was 3.58-10.41 (95% CI = 2.56-42.40, p < 0.01) and association of voice disorders with TBI was significant for all levels of TBI severity (OR = 1.5-6.61, 95% CI = 1.24-14.05, p < 0.01).
The researchers conclude that veterans who sustained a TBI were more likely to have a diagnosis of a communication disorder, regardless of TBI severity, and that those with TBI, including mild TBI, should be screened and evaluated for communication disorders.
The University of Texas Health Science Center at San Antonio, one of the country’s leading health sciences universities, ranks in the top 3 percent of all institutions worldwide receiving National Institutes of Health funding. The university’s schools of medicine, nursing, dentistry, health professions and graduate biomedical sciences have produced more than 29,000 graduates. The $765 million operating budget supports eight campuses in San Antonio, Laredo, Harlingen and Edinburg. For more information on the many ways “We make lives better,” visit www.uthscsa.edu.
South Texas Veterans Health Care System (STVHCS) is composed of two inpatient campuses: the Audie L. Murphy Campus in San Antonio and Kerrville Campus in Kerrville. The STVHCS serves one of the largest primary service areas in the nation and is part of the VA Heart of Texas Veterans Integrated Service Network (VISN 17), with offices located in Arlington. With an FY14 budget for STVHCS of $653 million and more than 3,400 employees, South Texas provides health care services for 81,000 unique veterans. In FY13, STVHCS provided almost 1,005,180 outpatient visits to area veterans.