Marilyn Spivack Talks about Her Daughter

Anne Van Cott, MD, Talks about Our Military and Post-traumatic Epilepsy

By Rita Watson, MPH

You work with soldiers returning from war zones. Are you seeing veterans with traumatic brain injury (TBI) and epilepsy?

Yes, we are starting to see young veterans who suffered TBI and have recurrent seizures as a consequence. Traumatic brain injury (TBI) is a common cause of epilepsy. Post-traumatic epilepsy (PTE) is the cause of seizures in about 20% of the symptomatic epilepsies. The likelihood of developing PTE is linked to the severity of the TBI. Individuals who are in a coma following TBI, or who suffer a skull fracture or have bleeding within the brain are the people most likely to develop PTE. Even so, unfortunately, we have no way of knowing precisely which individuals who suffer a TBI will develop PTE or when - sometimes it is years before patients start having seizures.

I am very concerned about the impact of repetitive mild head injuries occurring in the battlefield. These injuries are also present in the general population, for example young athletes who play soccer, hockey, lacrosse and other contact sports. We think that these repetitive injuries can be problematic, but we do not have a good understanding about their role in the development of epilepsy.

Has routine EEG been helpful?

Unfortunately, routine scalp electroencephalography (EEG) has not helped determine which patients will go on to develop a seizure disorder after TBI. Currently there are no other available techniques to help determine which TBI patients will develop PTE. Although we can successfully treat seizures that occur after TBI, we do not know how to stop epilepsy from developing, even in those patients we recognize as being at high risk.

How have the recent conflicts in Afghanistan and Iraq affected our military?

There are 1.4 million troops that have served or are currently serving in Operation Iraqi Freedom (OIF)/ Operation Enduring Freedom (OEF). As of October 2007 there have been 27,004 soldiers listed as wounded. These men and women serving in the US military are suffering different types of injuries, including head injuries, compared to military forces in earlier wars. Blast injuries, sustained mainly from improvised explosive devices (IEDs), rocket propelled grenades (RPGs) and explosively formed projectiles (EFPs), are causing injuries that are dissimilar to those seen in previous wars.

The US military has examined the physical distribution of injuries in current soldiers and found the head/neck is the most frequently damaged area (31%), followed by the arms (30%), legs (26%), and trunk (14%). Some believe this is a consequence of changes in body armor. As already mentioned, the primary mechanism of injury in the current war is from exposure to a blast. It is estimated that 1/3 of all combat troops in Iraq and Afghanistan are exposed to a blast. Evidence of brain injury has been reported in 61% of returning soldiers who have been exposed to blast injuries. As a result, TBI has become the “signature” injury of the OIF/OEF troops.

In addition to TBI, many of these soldiers, especially those with more severe injuries, have other medical issues (e.g. amputations and cardio-respiratory failure) that may further contribute to brain injury.

Is the problem of TBI more widespread than reported?

Over 2,000 soldiers have “officially” been diagnosed with brain injury, but many health care professionals are concerned that the number of returning troops with TBI is much higher because cases of “mild” TBI may not be recognized early.

In the circumstance of war, a soldier may not report a relatively brief alteration in level of consciousness or amnesic period following blast exposure, since more severely injured service members are being emergently cared for. Many service members are being deployed repeatedly and are at risk for multiple TBIs. The cumulative effects of TBIs on the risk of developing PTE is unknown.

Is there a continuum of care for soldiers once they return home?

The Defense and Veteran Brain Injury Center (DVBIC) at Walter Reed Army Medical Center (WRAMC) is composed of seven military facilities, four VA medical centers and two civilian community re-entry programs. The DVBIC, a congressionally funded TBI program, cares for active duty and reserve service members, veterans and eligible dependents with TBI.

The goal of DVBIC is to provide state-of-the-art medical care, clinical research initiatives and educational programs. Unfortunately, the transfer of an individual from active duty to retired status creates challenges in the treatment of TBI patients. Because the Department of Defense (DoD) and the VA function on different computer systems, sharing medical information and records is itself a barrier to continuity of care in this vulnerable patient population.

How will specific risk factors for the development of PTE be identified?

There is much we will need to learn. We need to understand what proportion of returning troops will develop PTE. It would be extremely helpful if specific risk factors for the development of epilepsy in OEF/OIF soldiers are identified. We need to further examine the cumulative effect of recurrent minor TBI on the development of PTE. We need to determine the best methods for diagnosing and treating PTE. Ideally, through research we would like to develop treatments that would prevent the development of PTE following TBI. A multidisciplinary approach will need to be employed since many of these individuals will also have co-morbid medical and psychiatric issues requiring treatment.

About Dr. Van Cott

Anne Van Cott, MD, is Assistant Professor of Neurology at the VA Pittsburgh Health Care System, University of Pittsburgh. She has been with the VA for more than 10 years.In addition to caring for veterans with epilepsy, Dr. Van Cott directs the EEG laboratory at the VA Pittsburgh Health Care System. She plays an active role in the education of residents, specifically with regards to electroencephalography interpretation. She serves on the VA’s Internal Review Board. With her collaborators at the University of Pittsburgh, she continues her CDC-funded research in improving self management in persons with epilepsy.

Edited by Steven C. Schachter, MD