1. The Nexus of Traumatic Brain Injury and Epilepsy in Veterans from Afghanistan and Iraq Mary Jo Pugh, PhD South Texas Veterans Health Care System, San Antonio, TX FUNDING SOURCE: VA Health Services Research and Development Service (DHI 09-237) The Authors Report No Disclosures

2. Background Traumatic Brain Injury (TBI) is a “signature wound” of the wars in Afghanistan and Iraq. There has been speculation over the past decade that epilepsy will be an increasing problem for Veterans from these conflicts due to TBI

3. TBI and Epilepsy: What is the Evidence? World War II – Walker AE. Posttraumatic epilepsy in WorldWar II veterans. Surg Neurol. 1989;32(3):235–236. Korea – Caveness WF,Walker AE, Ascroft PB. Incidence of posttraumatic epilepsy in Korean veterans as compared with those from World War I and World War II. J Neurosurg. 1962;19:122–129. Vietnam – Salazar AM, Jabbari B, Vance SC, Grafman J, Amin D, Dillon JD. Epilepsy after penetrating head injury, part I: clinical correlates: a report of the Vietnam Head Injury Study. Neurology. 1985;35(10):1406–1414. – Raymont V, Salazar A, Lipsky R, Goldman D, Tasick G, Grafman J. Correlates of posttraumatic epilepsy 35 years following combat brain injury. Neurology. 2010;75(3):224–229.

4. Institute of Medicine Recommendation

5. Goal To examine the association of TBI (including mild TBI) with epilepsy in OEF/OIF/OND veterans using VA administrative data.

6. Methods We first identified OEF/OIF/OND Veterans who received VA care from FY09 and FY10 using National VA Decision Support System (DSS) data. – OEF/OIF flag (inpatient, outpatient data) – ICD-9-CM codes (inpatient, outpatient data) – Medications (pharmacy data)

7. Variables TBI diagnosis – ICD-9 codes validated for use by the VA TBI Health Registry. Epilepsy (prevalent) – ICD-9 codes validated for use in VA data 780.39 and 345 – Seizure medication (AED) after diagnosis

8. Risk Factors Other conditions associated with TBI or Epilepsy – Eye injuries/ blindness/photophobia – Inner ear disorders/hyper-accusis – Spinal cord injury – Headache – Cardiac Disease – Hypertension

9. Potential Confounders/Risk Demographic characteristics – Age, sex, race, marital status, poverty indicator – Psychiatric comorbidity PTSD, depression, schizophrenia, anxiety, bipolar disorder

10. Analysis Logistic regression predicting prevalent epilepsy in 2010 as a function of TBI, other risk factors, and potential confounders.

11. Results 256,286 OEF/OIF/OND Veterans received VA care in both FY09 and FY10 2,901 met criteria for epilepsy 22,040 individuals had TBI diagnosis.

12. Key Logistic Regression Findings VariableOdds Ratio95% CI TBI2.8(2.5-3.0) Eye Injuries2.0(1.7-2.4) Spinal Injury6.5(5.2-8.2) Head Ache/ Migraine2.3(2.2-2.6) Post-traumatic Stress1.3(1.2-1.4) Disorder

13. Other Variables OR95% CI Race (vs. White) African American.82.73-.92 Hispanic.75.66-.85 Sex: Female.95.85-1.0 Age (vs. 30-39) 20-291.101.00-1.20 40-49.66.58-.74 50-59.55.45-.67 >60.46.29-.73

14. Limitations Mild vs. Moderate/ Severe/ Penetrating Non-epileptic seizures Multiple blast exposure Family history/ genetic component

15. Conclusions The influx of OEF/OIF/OND Veterans with TBI has been associated with increased prevalence of epilepsy associated with TBI.

16. Future Directions These data will be used as a foundation for a large scale epidemiologic study of epilepsy in TBI with foci including: – The role of mild TBI (e.g., difference between blast and non-blast, impact of multiple close blast exposures) – Examine the role of non-epileptic seizures in this population with a high prevalence of PTSD – Genetic/epigenetic component

17. Contact Information Mary Jo Pugh PhD, RN maryjo.pugh2@va.gov pughm@uthscsa.edu