title: Clinical and imaging assessment of acute combat mild traumatic brain injury in Afghanistan.
abstract: OBJECTIVE
  To evaluate whether diffusion tensor imaging (DTI) will noninvasively reveal white matter changes not present on conventional MRI in acute blast-related mild traumatic brain injury (mTBI) and to determine correlations with clinical measures and recovery.
  
  
  METHODS
  Prospective observational study of 95 US military service members with mTBI enrolled within 7 days from injury in Afghanistan and 101 healthy controls. Assessments included Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ), Post-Traumatic Stress Disorder Checklist Military (PCLM), Beck Depression Inventory (BDI), Balance Error Scoring System (BESS), Automated Neuropsychological Assessment Metrics (ANAM), conventional MRI, and DTI.
  
  
  RESULTS
  Significantly greater impairment was observed in participants with mTBI vs controls: RPCSQ (19.7 ± 12.9 vs 3.6 ± 7.1, p < 0.001), PCLM (32 ± 13.2 vs 20.9 ± 7.1, p < 0.001), BDI (7.4 ± 6.8 vs 2.5 ± 4.9, p < 0.001), and BESS (18.2 ± 8.4 vs 15.1 ± 8.3, p = 0.01). The largest effect size in ANAM performance decline was in simple reaction time (mTBI 74.5 ± 148.4 vs control -11 ± 46.6 milliseconds, p < 0.001). Fractional anisotropy was significantly reduced in mTBI compared with controls in the right superior longitudinal fasciculus (0.393 ± 0.022 vs 0.405 ± 0.023, p < 0.001). No abnormalities were detected with conventional MRI. Time to return to duty correlated with RPCSQ (r = 0.53, p < 0.001), ANAM simple reaction time decline (r = 0.49, p < 0.0001), PCLM (r = 0.47, p < 0.0001), and BDI (r = 0.36 p = 0.0005).
  
  
  CONCLUSIONS
  Somatic, behavioral, and cognitive symptoms and performance deficits are substantially elevated in acute blast-related mTBI. Postconcussive symptoms and performance on measures of posttraumatic stress disorder, depression, and neurocognitive performance at initial presentation correlate with return-to-duty time. Although changes in fractional anisotropy are uncommon and subtle, DTI is more sensitive than conventional MRI in imaging white matter integrity in blast-related mTBI acutely.
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI. oadam@bhs1.org.
authors.forename: Octavian
authors.initials: O
authors.lastname: Adam
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: Christine L
authors.initials: CL
authors.lastname: Mac Donald
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: Dennis
authors.initials: D
authors.lastname: Rivet
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: John
authors.initials: J
authors.lastname: Ritter
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: Todd
authors.initials: T
authors.lastname: May
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: Maria
authors.initials: M
authors.lastname: Barefield
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: Josh
authors.initials: J
authors.lastname: Duckworth
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: Donald
authors.initials: D
authors.lastname: LaBarge
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: Dean
authors.initials: D
authors.lastname: Asher
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Drinkwine
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: Yvette
authors.initials: Y
authors.lastname: Woods
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: Michael
authors.initials: M
authors.lastname: Connor
authors.affiliation: From the Division of Neurology (O.A.) and Departments of Neurological Surgery (D.R.) and Radiology (D.L.), Naval Medical Center Portsmouth, VA; Department of Neurology (C.L.M., D.L.B.), Washington University, St. Louis, MO; Department of Neurosurgery (D.R.), Virginia Commonwealth University, Richmond; Department of Radiology (J.R.) and Department of Orthopedics and Rehabilitation, Occupational Therapy Service (Y.W.), San Antonio Military Medical Center, TX; Department of Sports Medicine (T.M.), Naval Hospital, Camp Pendleton, CA; Department of Occupational Therapy (M.B.), Naval Hospital Jacksonville, FL; Departments of Neurology (J.D.) and Radiology (D.A., B.D.), San Diego Naval Medical Center, CA; and Branch Health Clinic (M.C.), Naval Air Station Jacksonville, FL. O.A. is currently affiliated with the Department of Neurology, Berkshire Medical Center, Pittsfield, MA; C.L.M. is currently affiliated with the Department of Neurological Surgery, University of Washington, Seattle; and D.L. is currently affiliated with Midland Radiology Associates, MI.
authors.forename: David L
authors.initials: DL
authors.lastname: Brody
mesh_terms: D000208:Acute Disease; D000328:Adult; D055826:Afghan Campaign 2001-; D000346:Afghanistan; D001930:Brain Injuries / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology; D056324:Diffusion Tensor Imaging / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D055815:Young Adult