Letter to the Editor: Military Traumatic Brain Injury ( re: doi: 10.1089/neu.2022.0103)

To the Editor:

We read the review article by Lindberg and colleagues, “Military Traumatic Brain Injury: The History, Impact, and Future” (39:1133-1145, September 2022, doi: 10.1089/neu.2022.0103) with great interest and admiration. The authors masterfully detailed step by step surgical management of penetrating brain injury (including blast overpressure research) and the U.S. government–supported research aimed at better understanding clinical sequelae following blast injuries.

In addition to the authors' detailed narrative review of the American military's involvement in several wars since the American Civil War, we have witnessed an era of regional conflicts in which surgeons by default did not or could not follow the guidelines prescribed by the U.S. Department of Defense and Veterans Administration. The decade of the 1980s witnessed the Israeli Campaign in Lebanon, Lebanese Civil Strife, and the Iran-Iraq War. ^{1 -3} Evacuation of casualties in Israel, similar to that in Vietnam, was by helicopter within 1-2 h; however, in Iran, management of wounded soldiers was by neurosurgeons dispatched to University Hospitals in the vicinity of the Iran-Iraq border. Any additional casualties were air lifted by fixed-wing aircraft to six to seven provincial capitals, almost like the scheme prescribed by Eden during World War II. ⁴

The decade of the 1980s introduced the first generation of computed tomography scans and cerebral angiography used to rule out hematomas, retained bone and metallic fragments and vascular lesion due to penetrating brain injury. There was an additional chance to compare outcomes with the Vietnam Head Injury Study. ⁵ We compared the injury to exploration timing and rate of infection. ^6,7 We followed the guidelines of Dr. Haddad in Lebanon in order to explore the incidence of traumatic intracranial aneurysms. ^8,9 With the introduction of MS-DOS in 1981 and Quattro-Pro in 1988 for the first time, we composed spreadsheets for big data analysis. At the Shiraz University of Medical Sciences (Nemazee Hospital) we performed a detailed prospective study of 964 penetrating brain injury patients (1980-1988). ^{3,7,8,10 -12}

Traumatic Intracranial Aneurysms

Only one case of a false cerebral aneurysm was documented by Lunn during WWII and confirmed by Dr. Dorothy Russell. ¹⁸ Two separate cases of traumatic intracranial aneurysms (TICAs) were documented during the Vietnam War. ^19,20 In 1978 Dr. Haddad in his Wilder Penfield lecture proposed performing angiography in all patients with PBI. ^2,9 In a prospective observational study, we performed angiography in 255 patients a mean of 17 days post-PBI in order to define the incidence (2.7%) of dormant TICAs (Fig 1). ⁸ In this study projectiles with penetration near pterion, crossing one dural compartment and associated with intracerebral hematomas had higher chance of causing TICAs. Similarly, Amirjamshidi and colleagues reported on their extensive experience in management of TICAs at the Tehran University of Medical Sciences. ^21,22 In 2010 Bell and colleagues detailed surgical and endovascular management of TICAs encountered during Operation Iraqi Freedom and Operation Enduring Freedom. ²³

OPEN IN VIEWER

FIG. 1.

During the Iran-Iraq War (1980-1988), this 26-year-old male soldier was injured with a shell fragment near the right pterional region. The fragment crossed the midline and was stopped by the contralateral inner table. Thirty days following injury a traumatic intracranial aneurysm involving the right pericallosal branch of anterior cerebral artery was discovered by routine angiography. The patient did not agree with surgical intervention. He was neurologically intact 2 years following injury. It was assumed that the aneurysmal sac healed spontaneously.