The 8 January 2020 theatre ballistic missile attack on US soldiers stationed at Al Asad Air Base, Iraq: case series using a concussion subtypes framework to approach a real-world, chaotic blast-related TBI mass casualty event

OBJECTIVES: This study aims to describe which concussion subtype(s) result specifically from the explosions of theatre ballistic missiles (TBMs) blast waves, an extremely rare occurrence in modern warfare. We provide feedback from using the US military’s standard acute concussion screening tool, the Military Acute Concussion Examination version 2, in a deployed, chaotic, real-world environment. BACKGROUND: Iran launched 27 professionally manufactured TBMs into Iraq on 8 January 2020. Eleven detonated within Al Asad Air Base, exposing approximately 330 soldiers to TBM-blast waves. The concussion subtype(s) resultant from TBM blast-related concussion is not known. METHODS: Case series from the Al Asad TBM-blast exposed cohort who evacuated to Landstuhl Regional Medical Center (LRMC), Germany up to 3 months following the attack and were diagnosed with concussion. Around 4 weeks, TBM-blast exposed individuals still present on Al Asad were screened with the Neurobehavioural Symptom Inventory (NSI) and vestibular ocular motor screening (VOMS); positive screens evacuated to LRMC. Data from 8 January 2020 to 7 April 2020 were cross-sectionally analysed. RESULTS: 35/38 patients met criteria for mild traumatic brain injury/concussion. 34/35 were within a 100 m blast radius. Migraine/headache, cognitive and mood/anxiety subtypes were common. VOMS was abnormal in 18/18 tested; 16 deferred due to overt symptoms. The 4-week screen identified nine additional concussed individuals. CONCLUSIONS: Among TBM-blast concussion patients, migraine/headache, cognitive, mood/anxiety and likely vestibular/ocular motor subtypes were predominant. Our study supports postconcussion screening that includes both a subjective symptom inventory, for example, NSI, and a performance-based ocular motor/vestibular screening examination, for example, VOMS, to help identify patients who may under recognise or under-report/minimise symptoms.