To investigate clinical characteristics of theatre ballistic missile (TBM) blast-related concussion.

Blast-related TBI is a signature injury from the U.S. con?icts in Iraq and Afghanistan. These have originated from ‘homemade’ improvised explosive devices carrying explosive payloads ranging from 1-5 pounds (e.g. small packages) to 4000 pounds (e.g. Van/SUV/Pick-up truck). The U.S. Military uses the Military Acute Concussion Evaluation 2 as its standard concussion screening tool.

On 2020-01-08, Iran launched 27 professionally manufactured TBMs into Iraq. Eleven, believed to be carrying 1100 to 1650-pound payloads each, detonated within Al Asad Air Base exposing approximately 330 individuals to TBM-blast waves. Clinical pro?les for patients concussed speci?cally from TBM- blast waves, an extremely rare occurrence in modern warfare, have not been described.

IRB-approved case series from the Al Asad TBM-blast exposed cohort who medevacked to Landstuhl Regional Medical Center, Germany (LRMC) and were formally diagnosed with concussion by a LRMC Neurologist/TBI medical provider.

Around 4 weeks, TBM-blast exposed individuals still present on Al Asad were screened with the Neurobehavioral Symptom Inventory and Vestibular Ocular-Motor Screening (VOMS); positive screens were medevacked to LRMC. Data from 2020-01-08 to 2020-04-07 was (cross-sectionally) analyzed.

35/38 patients met criteria for mild TBI/concussion (zero for moderate/severe). 34/35 were within a 100-meter blast radius (35/35 within 150-meters). Migraine/headache sub-type was most prominent; 27/31 (87.1%). VOMS was abnormal in 18/18 (100%); 16 deferred due to overt symptoms. MACE-2 cognitive results were abnormal (≤25) in 16/32 (50%). PTSD screens were positive in 13/32 (40.6%). Our ‘4-week screen’ identified nine additional concussed individuals.

Among TBM-blast concussion patients, migraine/headache was the predominant clinical sub-type. Vestibular, cognitive, and mood/anxiety sub-types were also common. Our study supports post-concussion screening which includes both a subjective symptom inventory and an objective, performance-based ocular-motor/vestibular screening exam (e.g. VOMS) to help identify patients who may under recognize or underreport/minimize symptoms.