THE MILITARY PERSPECTIVE (MJ MARTIN AND M SCHREIBER, SECTION EDITORS)
Traumatic Brain Injury in Combat Casualties
Published online: 11 May 2018
This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2018
Purpose of Review The purpose of this review is to give an overview of recent updates in the management of traumatic brain
injury (TBI) in military settings.
Recent Findings Studies from the recent conflicts in Central and Southwest Asia have demonstrated that appropriate aggressive
neurosurgical intervention in austere settings has been associated with improved outcomes.
Summary Modern management of military TBI has evolved from the era of Cushing in WWI to damage control and rapid
aeromedical evacuation today. Aggressive management of severe injuries has been shown to increase survival. These interven-
tions have included an emphasis on measures to reduce secondary brain injury—aggressive cranial decompression, addressing
intracranial vascular injuries, and aeromedical evacuation to facilities with neurosurgical capability. Additionally, advances in the
screening of mild TBI have led to increased awareness of the prevalence of this injury and potential associated long-term effects.
Keywords Military traumatic brain injury
Penetrating brain injury
With multiple components contributing to brain injury in com-
bat service members, blast-related traumatic brain injury
(TBI) has become a common injury pattern in modern war-
fare. Primary blast injury is related to the effects of the blast
pressure wave on the brain. Secondary blast injury occurs with
penetration of fragments through the cranium into the brain.
Acceleration and deceleration effects from blasts lead to ter-
tiary blast injury, and quaternary blast injury occurs from ex-
posure to heat and other toxins released from explosions .
Although there have been some recent comparable events in
civilian trauma, weapons used in combat typically generate
more kinetic energy and more tissue injury than those seen
in civilian settings, and penetrating craniocerebral injuries
from these weapons have commonly been associated with
worse neurologic outcomes . Further brain injury also
occurs from mass effect related to intracranial hemorrhage,
secondary insults from hypoxia, hypotension, hyperthermia,
and the prolonged inflammatory state induced by polytrauma.
However, the combat trauma population is also generally
younger and healthier than similar civilian trauma populations
and thus may warrant a more aggressive approach in terms of
interventions and resuscitation efforts. In this review, we will
give an overview of the epidemiology of combat-related TBI
as well as the evolution of neurosurgical intervention in com-
bat. Current medical and surgical management of combat-
related TBI will be described, as will considerations for aero-
medical evacuation, definitive care in the USA, and outcomes.
The recent wars in Iraq and Afghanistan have seen the largest
incidence of both closed and penetrating brain injury to US
service members since Vietnam . Since 2000, more than
310,000 have been diagnosed with TBI. Most of these have
been mild TBIs (82.4%) while only 1% have been severe
TBIs. Approximately 1.5% have been penetrating TBIs .
Among moderate to severe TBIs, penetrating TBI occurred at
an incidence greater than 2:1 compared to closed TBI in
Operation Iraqi Freedom (OIF). However, in Operation
Enduring Freedom (OEF) in Afghanistan, that ratio was less
This article is part of the Topical Collection on The Military Perspective
* Carlos Rodriguez
Department of Surgery, Uniformed Services University of the Health
Sciences and Walter Reed Military Medical Center, Bethesda, MD,
Naval Medical Research Center, Silver Spring, MD, USA
Current Trauma Reports (2018) 4:149–159