War-Related Epilepsy on the Rise in Soldiers and Civilians

Allison Gandey

September 23, 2008

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Dr. Daniel Lowenstein discusses traumatic brain injury.

September 23, 2008 (Salt Lake City, Utah) — Blast injuries arising from the conflicts in Iraq and Afghanistan are having serious neurologic consequences, researchers warn. Presenting here at the American Neurological Association 133rd Annual Meeting, experts described the link between traumatic brain injury and acquired epilepsy and forewarned that the long-term consequences for soldiers and civilians are likely to be substantial.

"Traumatic brain injury is the signature injury of the war in Iraq," Daniel Lowenstein, MD, from the University of California, San Francisco, said during the presidential symposium at the meeting. "These injuries are often caused by weapons such as improvised explosive devices, grenades, mortars, and land mines."

Dr. Lowenstein estimates that between 70,000 and 350,000 Iraqi civilians have died in the conflict. "These numbers are more conservative than some of the reports we've seen in the media, but we estimate that is the range of excess deaths," he said.

While body armor tends to protect the thorax and abdomen of soldiers, injuries to the head, neck, and extremities remain problematic. Civilians are also often exposed to explosive devices, but they typically do not wear protective gear.

"The numbers are very compelling as to the percentage of patients who have had moderate to severe traumatic brain injury who then go on to develop epilepsy," session chair Timothy Pedley, MD, from Columbia University in New York told Medscape Neurology & Neurosurgery.

"Combatants returning from Iraq and Afghanistan and civilians are at major neurologic risk, and we can anticipate large increases in the number of posttraumatic epilepsy in years ahead," he said.

No Antiepileptogenics

Dr. Lowenstein suggested that studies evaluating the consequences of missile injuries to the head from World War I and II, Vietnam, and conflicts in the Middle East have shown a remarkably consistent pattern in terms of the development of epilepsy.

Five years after injury, the incidence of epilepsy ranges from 22% to 43%. "And no antiepileptogenics currently exist," Dr. Lowenstein pointed out.

But not everyone agrees that traumatic brain injury may develop into epilepsy. During the question period at the meeting, an attendee said these concerns may prove to be an overreaction, if cases of acquired epilepsy do not develop.

"It's a valid concern, and I think we need to be extremely cautious about making conclusions on limited data," Dr. Lowenstein said during an interview.

"At the moment, we don't have the kind of information that is going to be required to nail down in a really reliable and valid way what the true effects will be," he noted. "But for skeptics who think it doesn't exist, I would be very cautious about that perspective. Medicine has a long history of not believing what cannot directly be measured or seen, and I think in the case of mild traumatic brain injury and certainly psychological and psychiatric diseases, this has been a problem from the beginning of time."

Dr. Lowenstein said that current studies have looked at a cross-section of veterans and are all suggesting extraordinarily high numbers of acquired epilepsy. "What are needed are prospective cohort studies in which we can follow selected individuals over a long period of time. And fortunately, those cohort studies are under way," he said

Medical Care and Disability Second-Largest Cost of War

Also presenting during the presidential symposium was Linda Bilmes, PhD, from the John F. Kennedy School of Government at Harvard University. in Cambridge, Massachusetts. Dr. Bilmes served as chief financial officer and as assistant secretary for management and budget at the US Department of Commerce. She is the coauthor of the New York Times bestselling book The Three Trillion Dollar War: the True Cost of the Iraq Conflict.

Dr. Bilmes told the meeting that medical care and disability will be the second-largest expense of the war. She estimates this will cost $700 billion and will represent the primary long-term expense of the conflict.

Dr. Bilmes suggests that of this amount, $25 billion will be spent on the growing number of patients with traumatic brain injury.

"This is a very modest estimate, and we may be significantly underestimating the amount," she said. Dr. Bilmes anticipates that medical care, disability, and Social Security will exceed the operating cost of the war.

Anticipated $25 Billion to be Spent on Traumatic Brain Injuries

Many challenges remain, the presenters noted. For example, the precise mechanism of acquired epilepsy after traumatic brain injury remains unknown, and there are no reliable or validated biomarkers.

"I think we're actually quite close to having biomarkers that will allow clinicians to detect these diseases," Dr. Lowenstein said.

His team is working to help the healthcare system in Iraq. Dr. Lowenstein told the meeting he is looking for help in locating medical supplies for donation and is interested in collaborating on ideas for education programs and telemedicine initiatives.

Dr. Lowenstein welcomes input and can be contacted at the University of California in San Francisco. For information on medical sponsorships of Iraqi civilians, he suggests that clinicians visit the website No More Victims.

Dr. Daniel Lowenstein reports having received honoraria from Bioneuronics, Neurovista, and GlaxoSmithKline.

American Neurological Association 133rd Annual Meeting: Presidential Symposium. Presented September 22, 2008.


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