Association Between 5-Year Clinical Outcome in Patients With Nonmedically Evacuated Mild Blast Traumatic Brain Injury and Clinical Measures Collected Within 7 Days Postinjury in Combat
Authors: Christine L. Mac Donald, Jason Barber, Jana Patterson, Ann M. Johnson, Sureyya Dikmen, Jesse R. Fann, Nancy Temkin
Journal: JAMA Network Open (2019)

<h3>Importance</h3> Although previous work has examined clinical outcomes in combat-deployed veterans, questions remain regarding how symptoms evolve or resolve following mild blast traumatic brain injury (TBI) treated in theater and their association with long-term outcomes. <h3>Objective</h3> To characterize 5-year outcome in patients with nonmedically evacuated blast concussion compared with combat-deployed controls and understand what clinical measures collected acutely in theater are associated with 5-year outcome. <h3>Design, Setting, and Participants</h3> A prospective, longitudinal cohort study including 45 service members with mild blast TBI within 7 days of injury (mean 4 days) and 45 combat deployed nonconcussed controls was carried out. Enrollment occurred in Afghanistan at the point of injury with evaluation of 5-year outcome in the United States. The enrollment occurred from March to September 2012 with 5-year follow up completed from April 2017 to May 2018. Data analysis was completed from June to July 2018. <h3>Exposures</h3> Concussive blast TBI. All patients were treated in theater, and none required medical evacuation. <h3>Main Outcomes and Measures</h3> Clinical measures collected in theater included measures for concussion symptoms, posttraumatic stress disorder (PTSD) symptoms, depression symptoms, balance performance, combat exposure intensity, cognitive performance, and demographics. Five-year outcome evaluation included measures for global disability, neurobehavioral impairment, PTSD symptoms, depression symptoms, and 10 domains of cognitive function. Forward selection multivariate regression was used to determine predictors of 5-year outcome for global disability, neurobehavior impairment, PTSD, and cognitive function. <h3>Results</h3> Nonmedically evacuated patients with concussive blast injury (n = 45; 44 men, mean [SD] age, 31 [5] years) fared poorly at 5-year follow-up compared with combat-deployed controls (n = 45; 35 men; mean [SD] age, 34 [7] years) on global disability, neurobehavioral impairment, and psychiatric symptoms, whereas cognitive changes were unremarkable. Acute predictors of 5-year outcome consistently identified TBI diagnosis with contribution from acute concussion and mental health symptoms and select measures of cognitive performance depending on the model for 5-year global disability (area under the curve following bootstrap validation [AUC<sub>BV</sub>] = 0.79), neurobehavioral impairment (correlation following bootstrap validation [R<sub>BV</sub>] = 0.60), PTSD severity (R<sub>BV</sub> = 0.36), or cognitive performance (R<sub>BV</sub> = 0.34). <h3>Conclusions and Relevance</h3> Service members with concussive blast injuries fared poorly at 5-year outcome. The results support a more focused acute screening of mental health following TBI diagnosis as strong indicators of poor long-term outcome. This extends prior work examining outcome in patients with concussive blast injury to the larger nonmedically evacuated population.