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Shahim P, Gill JM, Blennow K, Zetterberg H. Fluid Biomarkers for Chronic Traumatic Encephalopathy. Semin Neurol 2020; 40:411-419. [PMID: 32740901 DOI: 10.1055/s-0040-1715095] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neuropathological condition that has been described in individuals who have been exposed to repetitive head impacts, including concussions and subconcussive trauma. Currently, there is no fluid or imaging biomarker for diagnosing CTE during life. Based on retrospective clinical data, symptoms of CTE include changes in behavior, cognition, and mood, and may develop after a latency phase following the injuries. However, these symptoms are often nonspecific, making differential diagnosis based solely on clinical symptoms unreliable. Thus, objective biomarkers for CTE pathophysiology would be helpful in understanding the course of the disease as well as in the development of preventive and therapeutic measures. Herein, we review the literature regarding fluid biomarkers for repetitive concussive and subconcussive head trauma, postconcussive syndrome, as well as potential candidate biomarkers for CTE. We also discuss technical challenges with regard to the current fluid biomarkers and potential pathways to advance the most promising biomarker candidates into clinical routine.
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Affiliation(s)
- Pashtun Shahim
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | | | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, Queen Square, London, United Kingdom.,UK Dementia Research Institute at UCL, London, United Kingdom
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102
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Mariani M, Alosco ML, Mez J, Stern RA. Clinical Presentation of Chronic Traumatic Encephalopathy. Semin Neurol 2020; 40:370-383. [PMID: 32740900 DOI: 10.1055/s-0040-1713624] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with repetitive head impacts (RHI), such as those received in contact/collision sports, blast injury in military veterans, and domestic violence. Currently, CTE can only be diagnosed following death. Although the clinical features of former boxers have been described for almost a century, and there is increasing evidence of long-term cognitive and neuropsychiatric impairments in living former American football players, the specific clinical presentation associated with underlying CTE neuropathology remains unclear. These features include diverse and nonspecific changes in cognition, mood, behavior, and motor functioning. Currently, there are no validated and widely accepted clinical diagnostic criteria. Proposed criteria are primarily based on retrospective telephonic interviews with the next of kin of individuals who were diagnosed with CTE postmortem. Prospective studies involving individuals presumably at high risk for CTE are underway; these will hopefully clarify the clinical features and course of CTE, allow the diagnostic criteria to be refined, and lead to the development and validation of in vivo biomarkers. This article reviews what is currently known about the clinical presentation of CTE and describes the evolution of this knowledge from early case reports of "punch drunk" boxers through larger case series of neuropathologically confirmed CTE. This article concludes with a discussion of gaps in research and future directions to address these areas.
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Affiliation(s)
- Megan Mariani
- Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, Massachusetts
| | - Michael L Alosco
- Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Jesse Mez
- Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Robert A Stern
- Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Neurosurgery, and Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
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103
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Qi B, Jin S, Qian H, Zou Y. Bibliometric Analysis of Chronic Traumatic Encephalopathy Research from 1999 to 2019. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155411. [PMID: 32731338 PMCID: PMC7432826 DOI: 10.3390/ijerph17155411] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/18/2020] [Accepted: 07/24/2020] [Indexed: 02/07/2023]
Abstract
Research on chronic traumatic encephalopathy (CTE) has increased over the past two decades. However, few studies have statistically analyzed these publications. In this work, we conducted a bibliometric analysis of studies on CTE to track research trends and highlight current research hotspots. Relevant original articles were obtained from the Web of Science Core Collection database between 1999 and 2019. CiteSpace and VOSviewer software were used to perform analysis and visualization of scientific productivity and emerging trends. Our results show that the publications related to CTE dramatically increased from four publications in 1999 to 160 publications in 2019. The United States dominated this field with 732 publications (75.934%), followed by Canada with 88 publications (9.129%). Most of related publications were published in the journals with a focus on molecular biology, immunology, neurology, sports and ophthalmology, as represented by the dual-map overlay. A total of 11 major clusters were explored based on the reference co-citation analysis. In addition, three predominant research topics were summarized by clustering high-frequency keywords: epidemiological, clinical and pathological studies. The research frontiers were the diagnosis of diseases using new neuroimaging techniques, and the investigation of the molecular mechanism of tau aggregation. This study provides researchers with valuable guidance in the selection of research topics.
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Affiliation(s)
- Bote Qi
- Department of Sport and Exercise Science, College of Education, Zhejiang University, 886 Yuhangtang Road, Hangzhou 310058, China;
| | - Shuting Jin
- College of Computer Science and Technology, Zhejiang University, 886 Yuhangtang Road, Hangzhou 310058, China;
| | - Hongsheng Qian
- College of Physical Education, Central China Normal University, 152 Luoyu Avenue, Wuhan 430079, China;
| | - Yu Zou
- Department of Sport and Exercise Science, College of Education, Zhejiang University, 886 Yuhangtang Road, Hangzhou 310058, China;
- Correspondence:
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104
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McKee AC. The Neuropathology of Chronic Traumatic Encephalopathy: The Status of the Literature. Semin Neurol 2020; 40:359-369. [PMID: 32712946 DOI: 10.1055/s-0040-1713632] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic traumatic encephalopathy (CTE) is a tauopathy associated with repetitive mild head trauma, including concussion and asymptomatic subconcussive impacts. CTE was first recognized in boxers almost a century ago and has been identified more recently in contact sports athletes, military veterans exposed to blast, and victims of domestic violence. Like most neurodegenerative diseases, CTE is diagnosed conclusively by a neuropathological examination of brain tissue. CTE is characterized by the buildup of hyperphosphorylated tau (p-tau) in neurofibrillary tangles (NFTs), neurites, and, sometimes, astrocytes, surrounding small blood vessels in a patchy distribution at the sulcal depths of the cerebral cortex. In 2015, using the McKee proposed criteria for the neuropathological diagnosis of CTE, a consensus panel of expert neuropathologists confirmed CTE as a unique neurodegenerative disease with a pathognomonic lesion and published the preliminary NINDS (National Institute of Neurological Disorders and Stroke) criteria for CTE. Since that time, the NINDS criteria for CTE have been implemented and validated in multiple international publications. Using the NINDS criteria, the largest clinicopathological series of CTE to date was reported that included 177 former American football players, including 110 (99%) of 111 former National Football League players, 48 (91%) of 53 former college football players, and 3 (21%) of 14 former high school players. Studies have also shown a significant association between cumulative exposure to repetitive head trauma, as judged by the length of American football playing career, and risk for and severity of CTE. There is also a significant relationship of the length of football playing career with p-tau pathology, inflammation, white matter rarefaction, and age at death in CTE. While p-tau pathology, inflammation, white matter rarefaction, and arteriolosclerosis contribute to dementia in CTE, whether they also influence the behavioral and mood symptoms in CTE has yet to be determined. There have been several instances of aging-related tau astrogliopathy (ARTAG), a common astrocytic pathology in the elderly, misdiagnosed as CTE in the recent literature, provoking claims that CTE pathology is present in people not known to have experienced repetitive head trauma. Although ARTAG is often found in CTE, the pathognomonic lesion of CTE is a neuronal lesion consisting of NFTs and neurites, with or without p-tau immunoreactive astrocytes. Some authors consider β-amyloid (Aβ) to be a primary feature of CTE, yet the data indicate that CTE is a primary tauopathy, with Aβ deposition a function of age and inheritance of the ApoEe4 allele. Some authors also question the progressive nature of CTE pathology, although there is clear evidence in most individuals that p-tau pathology increases in density and affects more brain regions with survival. This review is intended to outline the status of the evidence-based literature regarding CTE neuropathology and to address the misrepresentations and confusions that have arisen in recent reviews and a letter of correspondence.
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Affiliation(s)
- Ann C McKee
- Boston University School of Medicine, Boston, Massachusetts.,Boston University Alzheimer's Disease Center, Boston, Massachusetts.,Chronic Traumatic Encephalopathy Center, Boston University, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts
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105
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Smirl JD, Peacock D, Wright AD, Bouliane KJ, Dierijck J, Burma JS, Kennefick M, Wallace C, van Donkelaar P. An Acute Bout of Soccer Heading Subtly Alters Neurovascular Coupling Metrics. Front Neurol 2020; 11:738. [PMID: 32849205 PMCID: PMC7396491 DOI: 10.3389/fneur.2020.00738] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 06/16/2020] [Indexed: 01/22/2023] Open
Abstract
Objective: The current investigation examined how a bout of soccer heading may impact brain function. Design: Semi-randomized crossover cohort. Setting: Controlled soccer heading. Participants: Seven male soccer players (24.1 ± 1.5 years). Intervention: 40 successful soccer headers were performed in 20 min (25 m, launch velocity ~80 km/h). X2 xPatch recorded linear and rotational head accelerations during each impact. A contact control “sham” condition – ball made body contact, but not by the head; and a no activity time “control” condition were also completed. Main Outcome Measures: Posterior and middle cerebral artery (PCA and MCA, respectively), cerebral blood velocity (CBV) was recorded during a visual task (neurovascular coupling: NVC) alongside SCAT3 symptoms scores pre/post a controlled bout of soccer heading. Results: Cumulative linear and rotational accelerations were 1,574 ± 97.9 g and 313,761 ± 23,966 rads/s2, respectively, during heading and changes in SCAT3 symptom number (pre: 2.6 ± 3.0; post: 6.7 ± 6.2, p = 0.13) and severity (pre: 3.7 ± 3.6, post: 9.4 ± 7.6, p = 0.11) were unchanged. In the PCA, no NVC differences were observed, including: relative CBV increase (28.0 ± 7.6%, p = 0.71) and total activation (188.7 ± 68.1 cm, p = 0.93). However, MCA-derived NVC metrics were blunted following heading, demonstrating decreased relative CBV increase (7.8 ± 3.1%, p = 0.03) and decreased total activation (26.7 ± 45.3 cm, p = 0.04). Conclusion: Although an acute bout of soccer heading did not result in an increase of concussion-like symptoms, there were alterations in NVC responses within the MCA during a visual task. This suggests an acute bout of repetitive soccer heading can alter CBV regulation within the region of the brain associated with the header impacts.
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Affiliation(s)
- Jonathan D Smirl
- Concussion Research Laboratory, University of British Columbia, Kelowna, BC, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.,Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada.,Human Performance Laboratory, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Dakota Peacock
- Southern Medical Program, University of British Columbia, Kelowna, BC, Canada
| | - Alexander D Wright
- Concussion Research Laboratory, University of British Columbia, Kelowna, BC, Canada.,Southern Medical Program, University of British Columbia, Kelowna, BC, Canada.,MD/PhD Program, University of British Columbia, Vancouver, BC, Canada.,Experimental Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kevin J Bouliane
- Concussion Research Laboratory, University of British Columbia, Kelowna, BC, Canada
| | - Jill Dierijck
- Concussion Research Laboratory, University of British Columbia, Kelowna, BC, Canada.,Faculty of Health, School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | - Joel S Burma
- Concussion Research Laboratory, University of British Columbia, Kelowna, BC, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.,Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada.,Human Performance Laboratory, University of Calgary, Calgary, AB, Canada
| | - Michael Kennefick
- Concussion Research Laboratory, University of British Columbia, Kelowna, BC, Canada
| | - Colin Wallace
- Concussion Research Laboratory, University of British Columbia, Kelowna, BC, Canada
| | - Paul van Donkelaar
- Concussion Research Laboratory, University of British Columbia, Kelowna, BC, Canada
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106
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Phelps A, Mez J, Stern RA, Alosco ML. Risk Factors for Chronic Traumatic Encephalopathy: A Proposed Framework. Semin Neurol 2020; 40:439-449. [PMID: 32674182 DOI: 10.1055/s-0040-1713633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative disease that has been neuropathologically diagnosed in contact and collision sport athletes, military veterans, and others with a history of exposure to repetitive head impacts (RHI). Identifying methods to diagnose and prevent CTE during life is a high priority. Timely diagnosis and implementation of treatment and preventative strategies for neurodegenerative diseases, including CTE, partially hinge upon early and accurate risk characterization. Here, we propose a framework of risk factors that influence the neuropathological development of CTE. We provide an up-to-date review of the literature examining cumulative exposure to RHI as the environmental trigger for CTE. Because not all individuals exposed to RHI develop CTE, the direct and/or indirect influence of nonhead trauma exposure characteristics (e.g., age, sex, race, genetics) on the pathological development of CTE is reviewed. We conclude with recommendations for future directions, as well as opinions for preventative strategies that could mitigate risk.
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Affiliation(s)
- Alyssa Phelps
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Jesse Mez
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Robert A Stern
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts.,Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
| | - Michael L Alosco
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
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107
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Mooney J, Self M, ReFaey K, Elsayed G, Chagoya G, Bernstock JD, Johnston JM. Concussion in soccer: a comprehensive review of the literature. Concussion 2020; 5:CNC76. [PMID: 33005435 PMCID: PMC7506470 DOI: 10.2217/cnc-2020-0004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Sports-related concussion has been examined extensively in collision sports such as football and hockey. However, historically, lower-risk contact sports such as soccer have only more recently garnered increased attention. Here, we review articles examining the epidemiology, injury mechanisms, sex differences, as well as the neurochemical, neurostructural and neurocognitive changes associated with soccer-related concussion. From 436 titles and abstracts, 121 full texts were reviewed with a total of 64 articles identified for inclusion. Concussion rates are higher during competitions and in female athletes with purposeful heading rarely resulting in concussion. Given a lack of high-level studies examining sports-related concussion in soccer, clinicians and scientists must focus research efforts on large-scale data gathering and development of improved technologies to better detect and understand concussion.
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Affiliation(s)
- James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, 1813 6th Ave S #516, Birmingham, AL 35233, USA
| | - Mitchell Self
- Department of Neurosurgery, University of Alabama at Birmingham, 1813 6th Ave S #516, Birmingham, AL 35233, USA
| | - Karim ReFaey
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA
| | - Galal Elsayed
- Department of Neurosurgery, University of Alabama at Birmingham, 1813 6th Ave S #516, Birmingham, AL 35233, USA
| | - Gustavo Chagoya
- Department of Neurosurgery, University of Alabama at Birmingham, 1813 6th Ave S #516, Birmingham, AL 35233, USA
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - James M Johnston
- Department of Neurosurgery, University of Alabama at Birmingham, 1813 6th Ave S #516, Birmingham, AL 35233, USA
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108
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LoBue C, Schaffert J, Cullum CM, Peters ME, Didehbani N, Hart J, White CL. Clinical and neuropsychological profile of patients with dementia and chronic traumatic encephalopathy. J Neurol Neurosurg Psychiatry 2020; 91:586-592. [PMID: 32332103 PMCID: PMC7231625 DOI: 10.1136/jnnp-2019-321567] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/08/2019] [Accepted: 01/12/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine whether subjects with chronic traumatic encephalopathy (CTE) and dementia have distinct clinical features compared to subjects with pathologically confirmed Alzheimer's disease (AD). METHODS Among 339 subjects assessed for CTE in the National Alzheimer's Coordinating Center dataset, 6 subjects with CTE and 25 subjects with AD neuropathologic change matched for age (±5 years) and sex were identified. All subjects had a clinical diagnosis of dementia. Neurological examination, neuropsychological testing and emotional/behavioural data were compared between CTE and AD subjects at the time of dementia diagnosis and last clinical visit near death. RESULTS A history of traumatic brain injury with loss of consciousness (LOC) was reported in one CTE and one AD subject; information about injuries without LOC or multiple injuries was unavailable. CTE and AD subjects did not differ significantly at the time of diagnosis or last visit on the Unified Parkinson's Disease Rating Scale-Motor Exam, global measures of cognitive functioning (Mini-Mental State Exam and Clinical Dementia Rating Scale), emotional/behaviour symptoms as assessed with the Neuropsychiatric Inventory questionnaire or across neuropsychological measures. All CTE participants had co-occurring neuropathologic processes, including AD and most had TAR DNA-binding protein 43 (TDP-43) neuropathology. CONCLUSIONS CTE pathology was rare in a large multicentre national dataset, and when present, was accompanied by AD and TDP-43 pathologies. CTE was not associated with a different clinical presentation from AD or with greater cognitive impairment or neurobehavioral symptoms. These findings suggest that CTE may not have a distinct clinical profile when other neuropathologic processes are coexistent with CTE pathology.
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Affiliation(s)
- Christian LoBue
- Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
- Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jeff Schaffert
- Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
| | - C Munro Cullum
- Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
- Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
- Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew E Peters
- Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nyaz Didehbani
- Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
| | - John Hart
- Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
- Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, Texas, USA
- Callier Center, School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, Texas, USA
| | - Charles L White
- Pathology, UT Southwestern Medical Center, Dallas, Texas, USA
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109
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Iverson GL, Terry DP, Luz M, Zafonte R, McCrory P, Solomon GS, Gardner AJ. Anger and Depression in Middle-Aged Men: Implications for a Clinical Diagnosis of Chronic Traumatic Encephalopathy. J Neuropsychiatry Clin Neurosci 2020; 31:328-336. [PMID: 31018811 DOI: 10.1176/appi.neuropsych.18110280] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In recent years, it has been proposed that problems with anger control and depression define clinical features of chronic traumatic encephalopathy (CTE). The authors examined anger problems and depression in middle-aged men from the general population and related those findings to the proposed clinical criteria for CTE. METHODS A sample of 166 community-dwelling men ages 40-60 was extracted from the normative database of the National Institutes of Health Toolbox. All participants denied prior head injury or traumatic brain injury (TBI). Participants completed scales assessing anger, hostility, aggression, anxiety, and depression. RESULTS In response to the item "I felt angry," 21.1% of men reported "sometimes," and 4.8% reported "often." When asked "If I am provoked enough I may hit another person," 11.4% endorsed the statement as true. There were moderate correlations between anger and anxiety (Spearman's ρ=0.61) and between depression and affective anger (ρ=0.51), hostility (ρ=0.56), and perceived hostility (ρ=0.35). Participants were dichotomized into a possible depression group (N=49) and a no-depression group (N=117) on the basis of the question "I feel depressed," specific to the past 7 days. The possible depression group reported higher anxiety (p<0.001, Cohen's d=1.51), anger (p<0.001, Cohen's d=0.96), and hostility (p<0.001, Cohen's d=0.95). CONCLUSIONS Some degree of anger and aggression are reported by a sizable minority of middle-aged men in the general population with no known history of TBI. Anger and hostility are correlated with depression and anxiety, indicating that all tend to co-occur. The base rates and comorbidity of affective dysregulation in men in the general population is important to consider when conceptualizing CTE phenotypes.
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Affiliation(s)
- Grant L Iverson
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Douglas P Terry
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Matthew Luz
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Ross Zafonte
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Paul McCrory
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Gary S Solomon
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Andrew J Gardner
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
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110
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Yang C, Nag S, Xing G, Aggarwal NT, Schneider JA. A Clinicopathological Report of a 93-Year-Old Former Street Boxer With Coexistence of Chronic Traumatic Encephalopathy, Alzheimer's Disease, Dementia With Lewy Bodies, and Hippocampal Sclerosis With TDP-43 Pathology. Front Neurol 2020; 11:42. [PMID: 32117011 PMCID: PMC7028767 DOI: 10.3389/fneur.2020.00042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/13/2020] [Indexed: 12/20/2022] Open
Abstract
Chronic traumatic encephalopathy (CTE) was recently recognized as a new tauopathy in which multifocal perivascular phosphorylated tau aggregates accumulate in neurons, astrocytes, and neurites at the depths of the cortical sulci. Traumatic brain injury (TBI) in early or mid-life is known to be associated with an increased risk of dementia in late life. This case report describes a 93-year-old former street boxer with a premortem diagnosis of severe dementia, who showed pathological evidence of the coexistence of Alzheimer's disease, CTE, dementia with Lewy bodies, and hippocampal sclerosis with TDP-43 pathology. These findings suggest that TBI may trigger a variety of misfolded proteins leading to dementia. Currently, clear clinical diagnostic criteria for CTE have not been established. Therefore, clinicians should be aware that TBI is a risk factor for dementia and that CTE can overlap with other neurodegenerative diseases.
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Affiliation(s)
- Chunhui Yang
- Rush Alzheimer Disease Center, Rush University Medical Center, Chicago, IL, United States
| | - Sukriti Nag
- Rush Alzheimer Disease Center, Rush University Medical Center, Chicago, IL, United States.,Department of Pathology (Neuropathology), Rush University Medical Center, Chicago, IL, United States
| | - Guoqiang Xing
- The Affiliated Hospital of the North Sichuan Medical College, Nanchong, China
| | - Neelum T Aggarwal
- Rush Alzheimer Disease Center, Rush University Medical Center, Chicago, IL, United States.,Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Julie A Schneider
- Rush Alzheimer Disease Center, Rush University Medical Center, Chicago, IL, United States.,Department of Pathology (Neuropathology), Rush University Medical Center, Chicago, IL, United States.,Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States
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111
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Smith DH, Johnson VE, Trojanowski JQ, Stewart W. Chronic traumatic encephalopathy - confusion and controversies. Nat Rev Neurol 2020; 15:179-183. [PMID: 30664683 DOI: 10.1038/s41582-018-0114-8] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The term chronic traumatic encephalopathy (CTE) has recently entered public consciousness via media reports and even a Hollywood movie. However, in contrast to general impressions, the incidence of CTE is unknown, the clinical diagnostic criteria have not been agreed upon and the current neuropathological characterization of CTE is acknowledged as preliminary. Additionally, few studies have compared the pathologies of CTE with those of other neurodegenerative disorders or of age-matched controls. Consequently, disagreement continues about the neuropathological aspects that make CTE unique. Furthermore, CTE is widely considered to be a consequence of exposure to repeated head blows, but evidence suggests that a single moderate or severe traumatic brain injury can also induce progressive neuropathological changes. These unresolved aspects of CTE underlie disparate claims about its clinical and pathological features, leading to confusion among the public and health-care professionals alike.
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Affiliation(s)
- Douglas H Smith
- Department of Neurosurgery, Penn Center for Brain Injury and Repair, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Victoria E Johnson
- Department of Neurosurgery, Penn Center for Brain Injury and Repair, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John Q Trojanowski
- Department of Pathology and Laboratory Medicine, Institute on Aging, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Institute on Aging, University of Pennsylvania, Philadelphia, PA, USA.,Center for Neurodegenerative Disease Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK.,Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
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112
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Mez J, Daneshvar DH, Abdolmohammadi B, Chua AS, Alosco ML, Kiernan PT, Evers L, Marshall L, Martin BM, Palmisano JN, Nowinski CJ, Mahar I, Cherry JD, Alvarez VE, Dwyer B, Huber BR, Stein TD, Goldstein LE, Katz DI, Cantu RC, Au R, Kowall NW, Stern RA, McClean MD, Weuve J, Tripodis Y, McKee AC. Duration of American Football Play and Chronic Traumatic Encephalopathy. Ann Neurol 2020; 87:116-131. [PMID: 31589352 PMCID: PMC6973077 DOI: 10.1002/ana.25611] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 08/27/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with exposure to contact and collision sports, including American football. We hypothesized a dose-response relationship between duration of football played and CTE risk and severity. METHODS In a convenience sample of 266 deceased American football players from the Veterans Affairs-Boston University-Concussion Legacy Foundation and Framingham Heart Study Brain Banks, we estimated the association of years of football played with CTE pathological status and severity. We evaluated the ability of years played to classify CTE status using receiver operating characteristic curve analysis. Simulation analyses quantified conditions that might lead to selection bias. RESULTS In total, 223 of 266 participants met neuropathological diagnostic criteria for CTE. More years of football played were associated with having CTE (odds ratio [OR] = 1.30 per year played, 95% confidence interval [CI] = 1.19-1.41; p = 3.8 × 10-9 ) and with CTE severity (severe vs mild; OR = 1.14 per year played, 95% CI = 1.07-1.22; p = 3.1 × 10-4 ). Participants with CTE were 1/10th as likely to have played <4.5 years (negative likelihood ratio [LR] = 0.102, 95% CI = 0.100-0.105) and were 10 times as likely to have played >14.5 years (positive LR = 10.2, 95% CI = 9.8-10.7) compared with participants without CTE. Sensitivity and specificity were maximized at 11 years played. Simulation demonstrated that years played remained adversely associated with CTE status when years played and CTE status were both related to brain bank selection across widely ranging scenarios. INTERPRETATION The odds of CTE double every 2.6 years of football played. After accounting for brain bank selection, the magnitude of the relationship between years played and CTE status remained consistent. ANN NEUROL 2020;87:116-131.
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113
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Alosco ML, Tripodis Y, Koerte IK, Jackson JD, Chua AS, Mariani M, Haller O, Foley ÉM, Martin BM, Palmisano J, Singh B, Green K, Lepage C, Muehlmann M, Makris N, Cantu RC, Lin AP, Coleman M, Pasternak O, Mez J, Bouix S, Shenton ME, Stern RA. Interactive Effects of Racial Identity and Repetitive Head Impacts on Cognitive Function, Structural MRI-Derived Volumetric Measures, and Cerebrospinal Fluid Tau and Aβ. Front Hum Neurosci 2019; 13:440. [PMID: 31920598 PMCID: PMC6933867 DOI: 10.3389/fnhum.2019.00440] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 12/02/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Factors of increased prevalence among individuals with Black racial identity (e.g., cardiovascular disease, CVD) may influence the association between exposure to repetitive head impacts (RHI) from American football and later-life neurological outcomes. Here, we tested the interaction between racial identity and RHI on neurobehavioral outcomes, brain volumetric measures, and cerebrospinal fluid (CSF) total tau (t-tau), phosphorylated tau (p-tau181), and Aβ1 - 42 in symptomatic former National Football League (NFL) players. METHODS 68 symptomatic male former NFL players (ages 40-69; n = 27 Black, n = 41 White) underwent neuropsychological testing, structural MRI, and lumbar puncture. FreeSurfer derived estimated intracranial volume (eICV), gray matter volume (GMV), white matter volume (WMV), subcortical GMV, hippocampal volume, and white matter (WM) hypointensities. Multivariate generalized linear models examined the main effects of racial identity and its interaction with a cumulative head impact index (CHII) on all outcomes. Age, years of education, Wide Range Achievement Test, Fourth Edition (WRAT-4) scores, CVD risk factors, and APOEε4 were included as covariates; eICV was included for MRI models. P-values were false discovery rate adjusted. RESULTS Compared to White former NFL players, Black participants were 4 years younger (p = 0.04), had lower WRAT-4 scores (mean difference = 8.03, p = 0.002), and a higher BMI (mean difference = 3.09, p = 0.01) and systolic blood pressure (mean difference = 8.15, p = 0.03). With regards to group differences on the basis of racial identity, compared to White former NFL players, Black participants had lower GMV (mean adjusted difference = 45649.00, p = 0.001), lower right hippocampal volume (mean adjusted difference = 271.96, p = 0.02), and higher p-tau181/t-tau ratio (mean adjusted difference = -0.25, p = 0.01). There was not a statistically significant association between the CHII with GMV, right hippocampal volume, or p-tau181/t-tau ratio. However, there was a statistically significant Race x CHII interaction for GMV (b = 2206.29, p = 0.001), right hippocampal volume (b = 12.07, p = 0.04), and p-tau181/t-tau ratio concentrations (b = -0.01, p = 0.004). CONCLUSION Continued research on racial neurological disparities could provide insight into risk factors for long-term neurological disorders associated with American football play.
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Affiliation(s)
- Michael L. Alosco
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Yorghos Tripodis
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Inga K. Koerte
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatic, and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
| | - Jonathan D. Jackson
- CARE Research Center, Massachusetts General Hospital, Boston, MA, United States
| | - Alicia S. Chua
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Megan Mariani
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Olivia Haller
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Éimear M. Foley
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
| | - Brett M. Martin
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, United States
| | - Joseph Palmisano
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, United States
| | - Bhupinder Singh
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Katie Green
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Christian Lepage
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Marc Muehlmann
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Nikos Makris
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Center for Morphometric Analysis, Massachusetts General Hospital, Boston, MA, United States
- Center for Neural Systems Investigations, Massachusetts General Hospital, Boston, MA, United States
| | - Robert C. Cantu
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
- Concussion Legacy Foundation, Boston, MA, United States
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA, United States
- Department of Neurosurgery, Emerson Hospital, Concord, MA, United States
| | - Alexander P. Lin
- Department of Radiology, Center for Clinical Spectroscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael Coleman
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Ofer Pasternak
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Jesse Mez
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Sylvain Bouix
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Martha E. Shenton
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Brockton, MA, United States
| | - Robert A. Stern
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA, United States
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, United States
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114
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Affiliation(s)
- Robert A Stern
- From the Boston University Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston
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115
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Mackay DF, Russell ER, Stewart K, MacLean JA, Pell JP, Stewart W. Neurodegenerative Disease Mortality among Former Professional Soccer Players. N Engl J Med 2019; 381:1801-1808. [PMID: 31633894 PMCID: PMC8747032 DOI: 10.1056/nejmoa1908483] [Citation(s) in RCA: 224] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neurodegenerative disorders have been reported in elite athletes who participated in contact sports. The incidence of neurodegenerative disease among former professional soccer players has not been well characterized. METHODS We conducted a retrospective cohort study to compare mortality from neurodegenerative disease among 7676 former professional soccer players (identified from databases of Scottish players) with that among 23,028 controls from the general population who were matched to the players on the basis of sex, age, and degree of social deprivation. Causes of death were determined from death certificates. Data on medications dispensed for the treatment of dementia in the two cohorts were also compared. Prescription information was obtained from the national Prescribing Information System. RESULTS Over a median of 18 years, 1180 former soccer players (15.4%) and 3807 controls (16.5%) died. All-cause mortality was lower among former players than among controls up to the age of 70 years and was higher thereafter. Mortality from ischemic heart disease was lower among former players than among controls (hazard ratio, 0.80; 95% confidence interval [CI], 0.66 to 0.97; P = 0.02), as was mortality from lung cancer (hazard ratio, 0.53; 95% CI, 0.40 to 0.70; P<0.001). Mortality with neurodegenerative disease listed as the primary cause was 1.7% among former soccer players and 0.5% among controls (subhazard ratio [the hazard ratio adjusted for competing risks of death from ischemic heart disease and death from any cancer], 3.45; 95% CI, 2.11 to 5.62; P<0.001). Among former players, mortality with neurodegenerative disease listed as the primary or a contributory cause on the death certificate varied according to disease subtype and was highest among those with Alzheimer's disease (hazard ratio [former players vs. controls], 5.07; 95% CI, 2.92 to 8.82; P<0.001) and lowest among those with Parkinson's disease (hazard ratio, 2.15; 95% CI, 1.17 to 3.96; P = 0.01). Dementia-related medications were prescribed more frequently to former players than to controls (odds ratio, 4.90; 95% CI, 3.81 to 6.31; P<0.001). Mortality with neurodegenerative disease listed as the primary or a contributory cause did not differ significantly between goalkeepers and outfield players (hazard ratio, 0.73; 95% CI, 0.43 to 1.24; P = 0.24), but dementia-related medications were prescribed less frequently to goalkeepers (odds ratio, 0.41; 95% CI, 0.19 to 0.89; P = 0.02). CONCLUSIONS In this retrospective epidemiologic analysis, mortality from neurodegenerative disease was higher and mortality from other common diseases lower among former Scottish professional soccer players than among matched controls. Dementia-related medications were prescribed more frequently to former players than to controls. These observations need to be confirmed in prospective matched-cohort studies. (Funded by the Football Association and Professional Footballers' Association.).
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Affiliation(s)
- Daniel F Mackay
- Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 8RZ, UK
| | - Emma R Russell
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow G12 8QQ, UK
| | - Katy Stewart
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
- Hampden Sports Clinic, Hampden Stadium, Glasgow G42 9ED, UK
| | - John A MacLean
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
- Hampden Sports Clinic, Hampden Stadium, Glasgow G42 9ED, UK
| | - Jill P Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 8RZ, UK
| | - William Stewart
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow G12 8QQ, UK
- Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
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116
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Alosco ML, Stein TD, Tripodis Y, Chua AS, Kowall NW, Huber BR, Goldstein LE, Cantu RC, Katz DI, Palmisano JN, Martin B, Cherry JD, Mahar I, Killiany RJ, McClean MD, Au R, Alvarez V, Stern RA, Mez J, McKee AC. Association of White Matter Rarefaction, Arteriolosclerosis, and Tau With Dementia in Chronic Traumatic Encephalopathy. JAMA Neurol 2019; 76:1298-1308. [PMID: 31380975 PMCID: PMC6686769 DOI: 10.1001/jamaneurol.2019.2244] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/28/2019] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with repetitive head impacts, including those from US football, that presents with cognitive and neuropsychiatric disturbances that can progress to dementia. Pathways to dementia in CTE are unclear and likely involve tau and nontau pathologic conditions. OBJECTIVE To investigate the association of white matter rarefaction and cerebrovascular disease with dementia in deceased men older than 40 years who played football and had CTE. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study involves analyses of data from the ongoing Understanding Neurologic Injury and Traumatic Encephalopathy (UNITE) Study, which is conducted via and included brain donors from the Veterans Affairs-Boston University-Concussion Legacy Foundation brain bank between 2008 and 2017. An original sample of 224 men who had played football and were neuropathologically diagnosed with CTE was reduced after exclusion of those younger than 40 years and those missing data. EXPOSURES The number of years of football play as a proxy for repetitive head impacts. MAIN OUTCOMES AND MEASURES Neuropathological assessment of white matter rarefaction and arteriolosclerosis severity (on a scale of 0-3, where 3 is severe); number of infarcts, microinfarcts, and microbleeds; and phosphorylated tau accumulation determined by CTE stage and semiquantitative rating of dorsolateral frontal cortex (DLFC) neurofibrillary tangles (NFTs) (none or mild vs moderate or severe). Informant-based retrospective clinical interviews determined dementia diagnoses via diagnostic consensus conferences. RESULTS A total of 180 men were included. The mean (SD) age of the sample at death was 67.9 (12.7) years. Of 180, 120 [66.7%]) were found to have had dementia prior to death. Moderate to severe white matter rarefaction (84 of 180 [46.6%]) and arteriolosclerosis (85 of 180 [47.2%]) were common; infarcts, microinfarcts, and microbleeds were not. A simultaneous equations regression model controlling for age and race showed that more years of play was associated with more severe white matter rarefaction (β, 0.16 [95% CI, 0.02-0.29]; P = .03) and greater phosphorylated tau accumulation (DLFC NFTs: β, 0.15 [95% CI, 0.004-0.30]; P = .04; CTE stage: β, 0.27 [95% CI, 0.14-0.41]; P < .001). White matter rarefaction (β, 0.16 [95% CI, 0.02-0.29]; P = .03) and DLFC NFTs (β, 0.16 [95% CI, 0.03-0.28]; P = .01) were associated with dementia. Arteriolosclerosis and years of play were not associated, but arteriolosclerosis was independently associated with dementia (β, 0.21 [95% CI, 0.07-0.35]; P = .003). CONCLUSIONS AND RELEVANCE Among older men who had played football and had CTE, more years of football play were associated with more severe white matter rarefaction and greater DLFC NFT burden. White matter rarefaction, arteriolosclerosis, and DLFC NFTs were independently associated with dementia. Dementia in CTE is likely a result of neuropathologic changes, including white matter rarefaction and phosphorylated tau, associated with repetitive head impact and pathologic changes not associated with head trauma, such as arteriolosclerosis.
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Affiliation(s)
- Michael L. Alosco
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Thor D. Stein
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Bedford Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Yorghos Tripodis
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Alicia S. Chua
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Neil W. Kowall
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Bertrand Russell Huber
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- National Center for Posttraumatic Stress Disorder, VA Boston Healthcare, Boston, Massachusetts
| | - Lee E. Goldstein
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
- Department of Electrical & Computer Engineering, Boston University College of Engineering, Boston, Massachusetts
- Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts
- Department of Biomedical Engineering, Boston University College of Engineering, Boston, Massachusetts
| | - Robert C. Cantu
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts
- Concussion Legacy Foundation, Boston, Massachusetts
- Department of Neurosurgery, Emerson Hospital, Concord, Massachusetts
| | - Douglas I. Katz
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Braintree Rehabilitation Hospital, Braintree, Massachusetts
| | - Joseph N. Palmisano
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Brett Martin
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Jonathan D. Cherry
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Ian Mahar
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Ronald J. Killiany
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
- Center for Biomedical Imaging, Boston University School of Medicine, Boston, Massachusetts
| | - Michael D. McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, Massachusetts
| | - Rhoda Au
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
- Framingham Heart Study, National Heart, Lung, and Blood Institute, Boston, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Victor Alvarez
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Robert A. Stern
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
| | - Jesse Mez
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Ann C. McKee
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Bedford Veterans Affairs Medical Center, Bedford, Massachusetts
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117
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Liu W, Bai X, Zhang A, Huang J, Xu S, Zhang J. Role of Exosomes in Central Nervous System Diseases. Front Mol Neurosci 2019; 12:240. [PMID: 31636538 PMCID: PMC6787718 DOI: 10.3389/fnmol.2019.00240] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 09/19/2019] [Indexed: 12/18/2022] Open
Abstract
There are many types of intercellular communication, and extracellular vesicles are one of the important forms of this. They are released by a variety of cell types, are heterogeneous, and can roughly be divided into microvesicles and exosomes according to their occurrence and function. Of course, exosomes do not just play a role in cell-to-cell communication. In the nervous system, exosomes can participate in intercellular communication, maintain the myelin sheath, and eliminate waste. Similarly, exosomes in the brain can play a role in central nervous system diseases, such as stroke, Alzheimer's disease (AD), Parkinson's disease (PD), prion disease, and traumatic encephalopathy (CTE), with both positive and negative effects (such as the transfer of misfolded proteins). Exosomes contain a variety of key bioactive substances and can therefore be considered as a snapshot of the intracellular environment. Studies have shown that exosomes from the central nervous system can be found in cerebrospinal fluid and peripheral body fluids, and that their contents will change with disease occurrence. Because exosomes can penetrate the blood brain barrier (BBB) and are highly stable in peripheral circulation, they can protect disease-related molecules well and therefore, using exosomes as a biomarker of central nervous system diseases is an attractive prospect as they can be used to monitor disease development and enable early diagnosis and treatment optimization. In this review, we discuss the current state of knowledge of exosomes, and introduce their pathophysiological roles in different diseases of the central nervous system as well as their roles and applications as a viable pathological biomarker.
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Affiliation(s)
- Wanying Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin Key Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, China.,Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xiaodan Bai
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin Key Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, China.,Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ao Zhang
- Epidemiology, College of Global Public Health, New York University, New York, NY, United States
| | - Juanjuan Huang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin Key Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, China.,Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shixin Xu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin Key Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, China
| | - Junping Zhang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
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118
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Barnes DE, Byers AL, Gardner RC, Seal KH, Boscardin WJ, Yaffe K. Association of Mild Traumatic Brain Injury With and Without Loss of Consciousness With Dementia in US Military Veterans. JAMA Neurol 2019; 75:1055-1061. [PMID: 29801145 DOI: 10.1001/jamaneurol.2018.0815] [Citation(s) in RCA: 248] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Traumatic brain injury (TBI) is common in both veteran and civilian populations. Prior studies have linked moderate and severe TBI with increased dementia risk, but the association between dementia and mild TBI, particularly mild TBI without loss of consciousness (LOC), remains unclear. Objective To examine the association between TBI severity, LOC, and dementia diagnosis in veterans. Design, Setting, and Participants This cohort study of all patients diagnosed with a TBI in the Veterans Health Administration health care system from October 1, 2001, to September 30, 2014, and a propensity-matched comparison group. Patients with dementia at baseline were excluded. Researchers identified TBIs through the Comprehensive TBI Evaluation database, which is restricted to Iraq and Afghanistan veterans, and the National Patient Care Database, which includes veterans of all eras. The severity of each TBI was based on the most severe injury recorded and classified as mild without LOC, mild with LOC, mild with LOC status unknown, or moderate or severe using Department of Defense or Defense and Veterans Brain Injury Center criteria. International Classification of Diseases, Ninth Revision codes were used to identify dementia diagnoses during follow-up and medical and psychiatric comorbidities in the 2 years prior to the index date. Main Outcomes and Measures Dementia diagnosis in veterans who had experienced TBI with or without LOC and control participants without TBI exposure. Results The study included 178 779 patients diagnosed with a TBI in the Veterans Health Administration health care system and 178 779 patients in a propensity-matched comparison group. Veterans had a mean (SD) age of nearly 49.5 (18.2) years at baseline; 33 250 (9.3%) were women, and 259 136 (72.5%) were non-Hispanic white individuals. Differences between veterans with and without TBI were small. A total of 4698 veterans (2.6%) without TBI developed dementia compared with 10 835 (6.1%) of those with TBI. After adjustment for demographics and medical and psychiatric comobidities, adjusted hazard ratios for dementia were 2.36 (95% CI, 2.10-2.66) for mild TBI without LOC, 2.51 (95% CI, 2.29-2.76) for mild TBI with LOC, 3.19 (95% CI, 3.05-3.33) for mild TBI with LOC status unknown, and 3.77 (95% CI, 3.63-3.91) for moderate to severe TBI. Conclusions and Relevance In this cohort study of more than 350 000 veterans, even mild TBI without LOC was associated with more than a 2-fold increase in the risk of dementia diagnosis. Studies of strategies to determine mechanisms, prevention, and treatment of TBI-related dementia in veterans are urgently needed.
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Affiliation(s)
- Deborah E Barnes
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Amy L Byers
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Raquel C Gardner
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Department of Neurology, University of California, San Francisco
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco.,Department of Medicine, University of California, San Francisco
| | - W John Boscardin
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Department of Medicine, University of California, San Francisco
| | - Kristine Yaffe
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco.,Department of Neurology, University of California, San Francisco
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119
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Zuckerman SL, Brett BL, Jeckell A, Yengo-Kahn AM, Solomon GS. Chronic Traumatic Encephalopathy and Neurodegeneration in Contact Sports and American Football. J Alzheimers Dis 2019; 66:37-55. [PMID: 30223396 DOI: 10.3233/jad-180218] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease characterized by the presence of abnormally phosphorylated tau protein in the depths of one or more cortical sulci. Controversy over the risk of CTE and neurologic disorders later in life among contact sport athletes has taken hold in the public spotlight, most notably in American football. Players, parents, coaches, and legislators have taken action based on the commonly held notion that contact sports invariably lead to neurodegenerative disorders. However, to fully understand the science behind this assumed association, a critical appraisal of the evidence is warranted. With regards to CTE in sports, the objectives of the current report are to: 1) describe the history of CTE, 2) review current CTE definitions, 3) critically evaluate the empiric data, divided into all contact sports and exclusively American football, and 4) summarize notable themes for future research.
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Affiliation(s)
- Scott L Zuckerman
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin L Brett
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department Neurology, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aaron Jeckell
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron M Yengo-Kahn
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gary S Solomon
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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120
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Di Virgilio TG, Ietswaart M, Wilson L, Donaldson DI, Hunter AM. Understanding the Consequences of Repetitive Subconcussive Head Impacts in Sport: Brain Changes and Dampened Motor Control Are Seen After Boxing Practice. Front Hum Neurosci 2019; 13:294. [PMID: 31551732 PMCID: PMC6746992 DOI: 10.3389/fnhum.2019.00294] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/12/2019] [Indexed: 01/24/2023] Open
Abstract
Objectives The potential effects of exposure to repetitive subconcussive head impacts through routine participation in sport are not understood. To investigate the effects of repetitive subconcussive head impacts we studied boxers following customary training (sparring) using transcranial magnetic stimulation (TMS), decomposition electromyographic (EMG) and tests of memory. Methods Twenty amateur boxers performed three 3-min sparring bouts. Parameters of brain function and motor control were assessed prior to sparring and again immediately, 1 h and 24 h post-sparring. Twenty control participants were assessed following mock-sparring. Results One hour after sparring boxers showed increased corticomotor inhibition, altered motor unit recruitment strategies, and decreased memory performance relative to controls, with values returning to baseline by the 24 h follow up. Conclusion Repetitive subconcussive head impacts associated with sparring resulted in acute and transient brain changes similar to those previously reported in soccer heading, providing convergent evidence that sport-related head impacts produce a GABAergic response. These acute changes in brain health are reminiscent of effects seen following brain injury, and suggest a potential mechanism underlying the damaging long-term effects of routine repetitive head impacts in sport.
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Affiliation(s)
- Thomas G Di Virgilio
- Physiology, Exercise and Nutrition Research Group, University of Stirling, Stirling, United Kingdom
| | - Magdalena Ietswaart
- Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, United Kingdom
| | - Lindsay Wilson
- Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, United Kingdom
| | - David I Donaldson
- Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, United Kingdom
| | - Angus M Hunter
- Physiology, Exercise and Nutrition Research Group, University of Stirling, Stirling, United Kingdom
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121
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Lee EB, Kinch K, Johnson VE, Trojanowski JQ, Smith DH, Stewart W. Chronic traumatic encephalopathy is a common co-morbidity, but less frequent primary dementia in former soccer and rugby players. Acta Neuropathol 2019; 138:389-399. [PMID: 31152201 PMCID: PMC6689293 DOI: 10.1007/s00401-019-02030-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/25/2019] [Indexed: 02/07/2023]
Abstract
Chronic traumatic encephalopathy (CTE) is reported at high prevalence in selected autopsy case series of former contact sports athletes. Nevertheless, the contribution of CTE pathology to clinical presentation and its interaction with co-morbid neurodegenerative pathologies remain unclear. To address these issues, we performed comprehensive neuropathology assessments on the brains of former athletes with dementia and considered these findings together with detailed clinical histories to derive an integrated clinicopathological diagnosis for each case. Consecutive, autopsy-acquired brains from former soccer and rugby players with dementia were assessed for neurodegenerative pathologies using established and preliminary consensus protocols. Thereafter, next of kin interviews were conducted to obtain detailed accounts of the patient’s clinical presentation and course of disease to inform a final, integrated clinicopathological diagnosis. Neuropathologic change consistent with CTE (CTE-NC) was confirmed in five of seven former soccer and three of four former rugby players’ brains, invariably in combination with mixed, often multiple neurodegenerative pathologies. However, in just three cases was the integrated dementia diagnosis consistent with CTE, the remainder having alternate diagnoses, with the most frequent integrated diagnosis Alzheimer’s disease (AD) (four cases; one as mixed AD and vascular dementia). This consecutive autopsy series identifies neuropathologic change consistent with preliminary diagnostic criteria for CTE (CTE-NC) in a high proportion of former soccer and rugby players dying with dementia. However, in the majority, CTE-NC appears as a co-morbidity rather than the primary, dementia causing pathology. As such, we suggest that while CTE-NC might be common in former athletes with dementia, in many cases its clinical significance remains uncertain.
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Affiliation(s)
- Edward B Lee
- Translational Neuropathology Research Laboratory, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kevin Kinch
- Department of Neuropathology, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow, G51 4TF, UK
| | - Victoria E Johnson
- Department of Neurosurgery, Penn Center for Brain Injury and Repair, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - John Q Trojanowski
- Department of Pathology and Laboratory Medicine, Center for Neurodegenerative Disease Research, Institute on Aging, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Douglas H Smith
- Department of Neurosurgery, Penn Center for Brain Injury and Repair, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow, G51 4TF, UK.
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, G12 8QQ, UK.
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122
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Ramkumar PN, Navarro SM, Haeberle HS, Luu BC, Jang A, Frangiamore SJ, Farrow LD, Schickendantz MS, Williams RJ. Concussion in American Versus European Professional Soccer: A Decade-Long Comparative Analysis of Incidence, Return to Play, Performance, and Longevity. Am J Sports Med 2019; 47:2287-2293. [PMID: 31303010 DOI: 10.1177/0363546519859542] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence and effect of sports-related concussions (SRCs) within the global sport of professional soccer is poorly described. PURPOSE To comparatively examine the effects of SRC on athletes in Major League Soccer (MLS) and the English Premier League (EPL) in terms of incidence, return to play (RTP), performance, and career longevity. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Contracts, transactions, injury reports, and performance statistics from 2008 to 2017 were obtained and cross-referenced across 6 publicly available websites detailing MLS and EPL data, including official league publications. For each league, players who sustained a concussion were compared with the 2008-2017 uninjured player pool. RTP and games missed were analyzed and compared. Career length was analyzed with Kaplan-Meier survival curves. Player performance changes were evaluated before and after concussion. RESULTS Of the 1784 eligible MLS and 2001 eligible EPL players evaluated over the 10-year period, the incidence of publicly reported concussions per 1000 athlete-exposures was 20.22 and 18.68, respectively (P = .53). The incidence of reported concussions steadily increased in both leagues. MLS players missed a mean 7.3 games after concussion (37.0 days missed); EPL players missed a mean 0.6 games after concussion (10.9 days missed) (P < .0001, P < .0001). Statistical performance in terms of games started, assists, shots on goal, and total shots after concussion was significantly reduced at all nongoalie positions for players in the EPL; however, MLS nongoalie positions with concussion had no significant decreases in these categories. Goalies in both leagues had no significant change in performance or games started. The probability of playing a full season after concussion was not significantly decreased when compared with the uninjured pool in both leagues. CONCLUSION This study established the SRC incidence among elite soccer players in 2 international professional leagues and identified major RTP and performance differences between EPL and MLS players. While career longevity was unaffected, the approach to managing concussion as in MLS may better promote player safety and preserve on-field performance.
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Affiliation(s)
- Prem N Ramkumar
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Heather S Haeberle
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Bryan C Luu
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Albert Jang
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Lutul D Farrow
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Riley J Williams
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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123
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Ströhle A. Sports psychiatry: mental health and mental disorders in athletes and exercise treatment of mental disorders. Eur Arch Psychiatry Clin Neurosci 2019; 269:485-498. [PMID: 29564546 DOI: 10.1007/s00406-018-0891-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 03/19/2018] [Indexed: 12/11/2022]
Abstract
Sports psychiatry has developed for the past 3 decades as an emerging field within psychiatry and sports medicine. An International society has been established in 1994 and also national interest groups were implemented, mostly within the national organizations for psychiatry, some also containing the topic of exercise treatment of mental disorders. Where are we now 30 years later? We systematically but also selectively review the medical literature on exercise, sport, psychiatry, mental health and mental disorders and related topics. The number of publications in the field has increased exponentially. Most topics keep remaining on the agenda, e.g., head trauma and concussion, drug abuse and doping, performance enhancement, overtraining, ADHD or eating disorders. Supported by the growing literature, evidence-based recommendations have become available now in many clinical areas. A relatively new phenomenon is muscle dysmorphia, observed in weightlifters, bodybuilders but also in college students and gym users. Further, sports therapy of mental disorders has been studied by more and more high-quality randomized controlled clinical trials. Mostly as a complementary treatment, however, for some disorders already with a 1a evidence level, e.g., depression, dementia or MCI but also post-traumatic stress disorder. Being grown up and accepted nowadays, sports psychiatry still represents a fast-developing field. The reverse side of the coin, sport therapy of mental disorders has received a scientific basis now. Who else than sports psychiatry could advance sport therapy of mental disorders? We need this enthusiasm for sports and psychiatry for our patients with mental disorders and it is time now for a broadening of the scope. Optimized psychiatric prevention and treatment of athletes and ideal sport-related support for individuals with mental disorders should be our main purpose and goal.
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Affiliation(s)
- Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, corporate member of the Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Charité Mitte, Charitéplatz 1, 10117, Berlin, Germany.
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124
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Alosco ML, Stern RA. Youth Exposure to Repetitive Head Impacts From Tackle Football and Long-term Neurologic Outcomes: A Review of the Literature, Knowledge Gaps and Future Directions, and Societal and Clinical Implications. Semin Pediatr Neurol 2019; 30:107-116. [PMID: 31235012 DOI: 10.1016/j.spen.2019.03.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Youth participation in contact and collision sports, particularly tackle football, is associated with exposure to repetitive head impacts during a time period when tremendous brain maturation is occurring. Accumulating evidence suggests that exposure to repetitive head impacts from youth tackle football may increase vulnerability to long-term cognitive, neuropsychiatric, and neurologic disturbances. There are limitations to the current literature and conflicting findings exist. Nonetheless, participation in youth football has become a cause of concern to clinicians, scientists, politicians, coaches, parents, and children. The objective of this paper is to review the literature on the long-term cognitive, neuropsychiatric, and neurologic outcomes associated with participation in youth contact and collision sports, with a focus on tackle football. We provide an overview of the empirically derived framework that has served as the foundation for the investigation of youth tackle football and neurologic outcomes. The extant research studies on age of first exposure to tackle football and later-life cognitive and neuropsychiatric functioning, as well as structural brain changes are reviewed. We discuss the limitations of the current evidence, suggest future directions, and conclude with our opinions on societal and clinical implications.
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Affiliation(s)
- Michael L Alosco
- Boston University (BU), Alzheimer's Disease Center, BU CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Robert A Stern
- Boston University (BU), Alzheimer's Disease Center, BU CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA; Departments of Neurosurgery and Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA.
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125
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Nelson PT, Dickson DW, Trojanowski JQ, Jack CR, Boyle PA, Arfanakis K, Rademakers R, Alafuzoff I, Attems J, Brayne C, Coyle-Gilchrist ITS, Chui HC, Fardo DW, Flanagan ME, Halliday G, Hokkanen SRK, Hunter S, Jicha GA, Katsumata Y, Kawas CH, Keene CD, Kovacs GG, Kukull WA, Levey AI, Makkinejad N, Montine TJ, Murayama S, Murray ME, Nag S, Rissman RA, Seeley WW, Sperling RA, White III CL, Yu L, Schneider JA. Limbic-predominant age-related TDP-43 encephalopathy (LATE): consensus working group report. Brain 2019; 142:1503-1527. [PMID: 31039256 PMCID: PMC6536849 DOI: 10.1093/brain/awz099] [Citation(s) in RCA: 824] [Impact Index Per Article: 164.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/10/2019] [Accepted: 02/25/2019] [Indexed: 12/18/2022] Open
Abstract
We describe a recently recognized disease entity, limbic-predominant age-related TDP-43 encephalopathy (LATE). LATE neuropathological change (LATE-NC) is defined by a stereotypical TDP-43 proteinopathy in older adults, with or without coexisting hippocampal sclerosis pathology. LATE-NC is a common TDP-43 proteinopathy, associated with an amnestic dementia syndrome that mimicked Alzheimer's-type dementia in retrospective autopsy studies. LATE is distinguished from frontotemporal lobar degeneration with TDP-43 pathology based on its epidemiology (LATE generally affects older subjects), and relatively restricted neuroanatomical distribution of TDP-43 proteinopathy. In community-based autopsy cohorts, ∼25% of brains had sufficient burden of LATE-NC to be associated with discernible cognitive impairment. Many subjects with LATE-NC have comorbid brain pathologies, often including amyloid-β plaques and tauopathy. Given that the 'oldest-old' are at greatest risk for LATE-NC, and subjects of advanced age constitute a rapidly growing demographic group in many countries, LATE has an expanding but under-recognized impact on public health. For these reasons, a working group was convened to develop diagnostic criteria for LATE, aiming both to stimulate research and to promote awareness of this pathway to dementia. We report consensus-based recommendations including guidelines for diagnosis and staging of LATE-NC. For routine autopsy workup of LATE-NC, an anatomically-based preliminary staging scheme is proposed with TDP-43 immunohistochemistry on tissue from three brain areas, reflecting a hierarchical pattern of brain involvement: amygdala, hippocampus, and middle frontal gyrus. LATE-NC appears to affect the medial temporal lobe structures preferentially, but other areas also are impacted. Neuroimaging studies demonstrated that subjects with LATE-NC also had atrophy in the medial temporal lobes, frontal cortex, and other brain regions. Genetic studies have thus far indicated five genes with risk alleles for LATE-NC: GRN, TMEM106B, ABCC9, KCNMB2, and APOE. The discovery of these genetic risk variants indicate that LATE shares pathogenetic mechanisms with both frontotemporal lobar degeneration and Alzheimer's disease, but also suggests disease-specific underlying mechanisms. Large gaps remain in our understanding of LATE. For advances in prevention, diagnosis, and treatment, there is an urgent need for research focused on LATE, including in vitro and animal models. An obstacle to clinical progress is lack of diagnostic tools, such as biofluid or neuroimaging biomarkers, for ante-mortem detection of LATE. Development of a disease biomarker would augment observational studies seeking to further define the risk factors, natural history, and clinical features of LATE, as well as eventual subject recruitment for targeted therapies in clinical trials.
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Affiliation(s)
| | | | | | | | | | - Konstantinos Arfanakis
- Rush University Medical Center, Chicago, IL, USA
- Illinois Institute of Technology, Chicago, IL, USA
| | | | | | | | | | | | - Helena C Chui
- University of Southern California, Los Angeles, CA, USA
| | | | | | - Glenda Halliday
- The University of Sydney Brain and Mind Centre and Central Clinical School Faculty of Medicine and Health, Sydney, Australia
| | | | | | | | | | | | | | - Gabor G Kovacs
- Institute of Neurology Medical University of Vienna, Vienna, Austria
| | | | | | | | | | - Shigeo Murayama
- Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | | | - Sukriti Nag
- Rush University Medical Center, Chicago, IL, USA
| | | | | | | | | | - Lei Yu
- Rush University Medical Center, Chicago, IL, USA
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126
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Hiskens MI, Angoa-Pérez M, Schneiders AG, Vella RK, Fenning AS. Modeling sports-related mild traumatic brain injury in animals-A systematic review. J Neurosci Res 2019; 97:1194-1222. [PMID: 31135069 DOI: 10.1002/jnr.24472] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/22/2019] [Accepted: 05/07/2019] [Indexed: 12/14/2022]
Abstract
Sports-related head trauma has emerged as an important public health issue, as mild traumatic brain injuries (mTBIs) may result in neurodegenerative disorders such as chronic traumatic encephalopathy (CTE). Research into mTBI and CTE pathophysiology are difficult to undertake in athletes, with observational trials and post-mortem analysis the current mainstays. Thus, animal models play an important role in the study of mTBI, however, traditional animal models have focused on acute, severe injuries rather than the more typical mTBI's seen in sport injuries. Recently, a number of animal models have been developed that are both appropriately scaled and biomechanically relevant to the forces sustained by athletes. This review aimed to examine the literature for variables included in these animal models, and the resulting neurotrauma as evidenced by pathology and behavioral deficits. A systematic search of the literature was performed in multiple electronic databases. The inclusion criteria required mimicry of athlete mTBI conditions: freedom of head movement, lack of surgical alteration of the skull, and application of direct contact force. Studies were analyzed for variables including apparatus design features (impact force, change in animal head velocity, and kinetic energy transfer to the head), demonstrated pathology (phosphorylated tau, TDP-43 aggregation, diffuse axonal injury, gliosis, cytokine inflammation response, and genetic integrity), and behavioral changes. These studies suggested that appropriate animal models can assist in understanding the pathological and functional outcomes of athlete mTBI, and could be used as a platform for future studies of diagnostic/prognostic markers and in the development of treatment interventions.
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Affiliation(s)
- Matthew I Hiskens
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Australia
| | - Mariana Angoa-Pérez
- Research & Development Service, John D. Dingell VA Medical Center, Detroit, Michigan.,Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan
| | - Anthony G Schneiders
- School of Health, Medical and Applied Sciences, Central Queensland University, Branyan, Australia
| | - Rebecca K Vella
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Australia
| | - Andrew S Fenning
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Australia
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127
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Russell ER, Stewart K, Mackay DF, MacLean J, Pell JP, Stewart W. Football's InfluencE on Lifelong health and Dementia risk (FIELD): protocol for a retrospective cohort study of former professional footballers. BMJ Open 2019; 9:e028654. [PMID: 31123003 PMCID: PMC6538057 DOI: 10.1136/bmjopen-2018-028654] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION In the past decade, evidence has emerged suggesting a potential link between contact sport participation and increased risk of late neurodegenerative disease, in particular chronic traumatic encephalopathy. While there remains a lack of clear evidence to test the hypothesis that contact sport participation is linked to an increased incidence of dementia, there is growing public concern regarding the risk. There is, therefore, a pressing need for research to gain greater understanding of the potential risks involved in contact sports participation, and to contextualise these within holistic health benefits of sport. METHODS AND ANALYSIS Football's InfluencE on Lifelong health and Dementia risk is designed as a retrospective cohort study, with the aim to analyse data from former professional footballers (FPF) in order to assess the incidence of neurodegenerative disease in this population. Comprehensive electronic medical and death records will be analysed and compared with those of a demographically matched population control cohort. As well as neurodegenerative disease incidence, all-cause, and disease-specific mortality, will be analysed in order to assess lifelong health. Cox proportional hazards models will be run to compare the data collected from FPFs to matched population controls. ETHICS AND DISSEMINATION Approvals for study have been obtained from the University of Glasgow College of Medical, Veterinary and Life Sciences Research Ethics Committee (Project Number 200160147) and from National Health Service Scotland's Public Benefits and Privacy Panel (Application 1718-0120).
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Affiliation(s)
- Emma R Russell
- Glasgow Brain Injury Research Group, Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - Katy Stewart
- Sport and Exercise Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Hampden Sports Clinic, Hampden Stadium, Glasgow, UK
| | - Daniel F Mackay
- Public Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - John MacLean
- Sport and Exercise Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Hampden Sports Clinic, Hampden Stadium, Glasgow, UK
| | - Jill P Pell
- Public Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - William Stewart
- Glasgow Brain Injury Research Group, Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
- Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK
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Stern RA, Adler CH, Chen K, Navitsky M, Luo J, Dodick DW, Alosco ML, Tripodis Y, Goradia DD, Martin B, Mastroeni D, Fritts NG, Jarnagin J, Devous MD, Mintun MA, Pontecorvo MJ, Shenton ME, Reiman EM. Tau Positron-Emission Tomography in Former National Football League Players. N Engl J Med 2019; 380:1716-1725. [PMID: 30969506 PMCID: PMC6636818 DOI: 10.1056/nejmoa1900757] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that has been associated with a history of repetitive head impacts. The neuropathological diagnosis is based on a specific pattern of tau deposition with minimal amyloid-beta deposition that differs from other disorders, including Alzheimer's disease. The feasibility of detecting tau and amyloid deposition in the brains of living persons at risk for CTE has not been well studied. METHODS We used flortaucipir positron-emission tomography (PET) and florbetapir PET to measure deposition of tau and amyloid-beta, respectively, in the brains of former National Football League (NFL) players with cognitive and neuropsychiatric symptoms and in asymptomatic men with no history of traumatic brain injury. Automated image-analysis algorithms were used to compare the regional tau standardized uptake value ratio (SUVR, the ratio of radioactivity in a cerebral region to that in the cerebellum as a reference) between the two groups and to explore the associations of SUVR with symptom severity and with years of football play in the former-player group. RESULTS A total of 26 former players and 31 controls were included in the analysis. The mean flortaucipir SUVR was higher among former players than among controls in three regions of the brain: bilateral superior frontal (1.09 vs. 0.98; adjusted mean difference, 0.13; 95% confidence interval [CI], 0.06 to 0.20; P<0.001), bilateral medial temporal (1.23 vs. 1.12; adjusted mean difference, 0.13; 95% CI, 0.05 to 0.21; P<0.001), and left parietal (1.12 vs. 1.01; adjusted mean difference, 0.12; 95% CI, 0.05 to 0.20; P = 0.002). In exploratory analyses, the correlation coefficients in these three regions between the SUVRs and years of play were 0.58 (95% CI, 0.25 to 0.79), 0.45 (95% CI, 0.07 to 0.71), and 0.50 (95% CI, 0.14 to 0.74), respectively. There was no association between tau deposition and scores on cognitive and neuropsychiatric tests. Only one former player had levels of amyloid-beta deposition similar to those in persons with Alzheimer's disease. CONCLUSIONS A group of living former NFL players with cognitive and neuropsychiatric symptoms had higher tau levels measured by PET than controls in brain regions that are affected by CTE and did not have elevated amyloid-beta levels. Further studies are needed to determine whether elevated CTE-associated tau can be detected in individual persons. (Funded by Avid Radiopharmaceuticals and others.).
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Affiliation(s)
- Robert A Stern
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Charles H Adler
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Kewei Chen
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Michael Navitsky
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Ji Luo
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - David W Dodick
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Michael L Alosco
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Yorghos Tripodis
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Dhruman D Goradia
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Brett Martin
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Diego Mastroeni
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Nathan G Fritts
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Johnny Jarnagin
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Michael D Devous
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Mark A Mintun
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Michael J Pontecorvo
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Martha E Shenton
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
| | - Eric M Reiman
- From the Boston University School of Medicine (R.A.S., M.L.A., N.G.F., J.J.), Boston University School of Public Health (Y.T., B.M.), Brigham and Women's Hospital (M.E.S.), Harvard Medical School (M.E.S.), and the Veterans Affairs Boston Healthcare System (M.E.S.) - all in Boston; Mayo Clinic Arizona, Scottsdale (C.H.A., D.W.D.), Banner Alzheimer's Institute, Phoenix (K.C., J.L., D.D.G., E.M.R.), and Arizona State University, Tempe (D.M.) - all in Arizona; and Avid Radiopharmaceuticals, Philadelphia (M.N., M.D.D., M.A.M., M.J.P.)
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Sugarman MA, McKee AC, Stein TD, Tripodis Y, Besser LM, Martin B, Palmisano JN, Steinberg EG, O'Connor MK, Au R, McClean M, Killiany R, Mez J, Weiner MW, Kowall NW, Stern RA, Alosco ML. Failure to detect an association between self-reported traumatic brain injury and Alzheimer's disease neuropathology and dementia. Alzheimers Dement 2019; 15:686-698. [PMID: 30852157 PMCID: PMC6511462 DOI: 10.1016/j.jalz.2018.12.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/26/2018] [Accepted: 12/29/2018] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Recent research with neuropathologic or biomarker evidence of Alzheimer's disease (AD) casts doubt on traumatic brain injury (TBI) as a risk factor for AD. We leveraged the National Alzheimer's Coordinating Center to examine the association between self-reported TBI with loss of consciousness and AD neuropathologic changes, and with baseline and longitudinal clinical status. METHODS The sample included 4761 autopsy participants (453 with remote TBI with loss of consciousness; 2822 with AD neuropathologic changes) from National Alzheimer's Coordinating Center. RESULTS Self-reported TBI did not predict AD neuropathologic changes (P > .10). Reported TBI was not associated with baseline or change in dementia severity or cognitive function in participants with or without autopsy-confirmed AD. DISCUSSION Self-reported TBI with loss of consciousness may not be an independent risk factor for clinical or pathological AD. Research that evaluates number and severity of TBIs is needed to clarify the neuropathological links between TBI and dementia documented in other large clinical databases.
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Affiliation(s)
- Michael A Sugarman
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Edith Nourse Rogers Memorial Veterans Hospital, Department of Neuropsychology, Bedford, MA, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA; Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA; VA Boston Healthcare System, Boston, MA, USA; Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Thor D Stein
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA; VA Boston Healthcare System, Boston, MA, USA; Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Lilah M Besser
- National Alzheimer's Coordinating Center, University of Washington, Seattle, WA, USA
| | - Brett Martin
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Joseph N Palmisano
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Eric G Steinberg
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA
| | - Maureen K O'Connor
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Edith Nourse Rogers Memorial Veterans Hospital, Department of Neuropsychology, Bedford, MA, USA
| | - Rhoda Au
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA; Framingham Heart Study, National Heart, Lung, and Blood Institute, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA; Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA
| | - Michael McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Ronald Killiany
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA; Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA; Center for Biomedical Imaging, Boston University School of Medicine, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Michael W Weiner
- Department of Veteran Affairs Medical Center, Center for Imaging and Neurodegenerative Diseases, San Francisco, CA, USA; Departments of Radiology and Biomedical Imaging, Medicine, Psychiatry, and Neurology, University of California, San Francisco, CA, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA; Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA; Neurology Service, VA Boston Healthcare System, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA; Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA; Department of Neurosurgery, Boston University School of Medicine, Boston, MA, USA
| | - Michael L Alosco
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA.
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Rodrigues AC, Lima MDM, de Souza LC, Furtado C, Marques CE, Gonçalves L, Lima MV, Lasmar RP, Caramelli P. No Evidence of Association Between Soccer Heading and Cognitive Performance in Professional Soccer Players: Cross-Sectional Results. Front Neurol 2019; 10:209. [PMID: 30915024 PMCID: PMC6422927 DOI: 10.3389/fneur.2019.00209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 02/18/2019] [Indexed: 12/29/2022] Open
Abstract
Although the scientific community has focused on the effects of concussions in contact sports, the role of subconcussive impacts, as it can occur during soccer heading, has recently gained attention, considering that it may represent an additional mechanism of cumulative brain injury. The aim of this study is to investigate the effects of soccer heading on cognitive functioning in active professional soccer players. Male soccer players (n = 44), from two soccer teams that play in the Brazilian A Series Championship, and non-athletes (n = 47), comparable in age and education, were submitted to cognitive assessment, consisting of computerized and conventional neuropsychological testing (Neupsilin battery). In the computerized cognitive assessment, soccer players performed better than controls on reaction time measures in general motor coordination, executive functioning and memory tests, and on accuracy measures in executive functioning tests. There were no significant differences between groups on the Neupsilin battery. A comparison between two sub-groups of soccer players, based on the self-reported number of headings, did not show significant differences on tests performance. No significant correlations were found between an estimate of exposure to heading during professional soccer career and cognitive performance. Our data demonstrate no evidence of cognitive impairment in soccer players, compared to non-athletes, and no association between heading exposure and performance on neuropsychological tests. Longitudinal investigations, including neuroimaging assessment, will help to clarify whether soccer heading may be associated with brain injury and cognitive dysfunction.
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Affiliation(s)
- Ana Carolina Rodrigues
- Pró-Reitoria de Graduação, Reitoria da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Grupo de Pesquisa em Neurologia Cognitiva e do Comportamento, Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Mariana Drummond Martins Lima
- Grupo de Pesquisa em Neurologia Cognitiva e do Comportamento, Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Leonardo Cruz de Souza
- Grupo de Pesquisa em Neurologia Cognitiva e do Comportamento, Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Celso Furtado
- Departamento Médico do América Futebol Clube, Belo Horizonte, Brazil
| | | | - Lucas Gonçalves
- Departamento de Análise de Desempenho do Clube Atlético Mineiro, Belo Horizonte, Brazil
| | | | - Rodrigo Pace Lasmar
- Departamento Médico do Clube Atlético Mineiro, Belo Horizonte, Brazil.,Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil
| | - Paulo Caramelli
- Grupo de Pesquisa em Neurologia Cognitiva e do Comportamento, Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Abstract
BACKGROUND When participating in contact sports, (mild) head trauma is a common incident-observed in both professional and amateur sports. When head trauma results in transient neurological impairment, a sports-related concussion has occurred. Acute concussion, repetitive concussions, as well as cumulative "sub-concussive" head impacts may increase the risk of developing cognitive and behavioral deficits for athletes, as well as accelerated cerebral degeneration. While this concept has been well established for classic contact sports like American Football, Rugby, or Boxing, there is still an awareness gap for the role of sports-related concussion in the context of the world's most popular sport-Soccer. METHODS Here, we review the relevance of sport-related concussion for Soccer as well as its diagnosis and management. Finally, we provide insight into future directions for research in this field. RESULTS Soccer fulfills the criteria of a contact sport and is characterized by a high incidence of concussion. There is ample evidence that these events cause functional and structural cerebral disorders. Furthermore, heading, as a repeat sub-concussive impact, has been linked to structural brain changes and neurocognitive impairment. As a consequence, recommendations for the diagnosis and management of concussion in soccer have been formulated by consensus groups. In order to minimize the risk of repetitive concussion in soccer the rapid and reliable side-line diagnosis of concussion with adoption of a strict remove-from-play protocol is essential, followed by a supervised, graduated return-to-play protocol. Recent studies, however, demonstrate that adherence to these recommendations by players, coaches, clubs, and officials is insufficient, calling for stricter enforcement. In addition, future research to solidify the pathophysiological relevance of concussion for soccer athletes seems to be needed. Advanced neuroimaging and neurochemical biomarker analyses (e.g. S100β, tau and neurofilament light (NfL)) may assist in detecting concussion-related structural brain changes and selecting athletes at risk for irreversible damage. CONCLUSION Sports-related concussion represents a genuine neurosurgical field of interest. Given the high socioeconomic relevance, neurosurgeons should get involved in prevention and management of concussion in soccer.
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Putukian M, Echemendia RJ, Chiampas G, Dvorak J, Mandelbaum B, Lemak LJ, Kirkendall D. Head Injury in Soccer: From Science to the Field; summary of the head injury summit held in April 2017 in New York City, New York. Br J Sports Med 2019; 53:1332. [DOI: 10.1136/bjsports-2018-100232] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2019] [Indexed: 12/15/2022]
Abstract
There has been an increased focus and awareness of head injury and sport-related concussion (SRC) across all sports from the medical and scientific communities, sports organisations, legislators, the media and the general population. Soccer, in particular, has been a focus of attention due to the popularity of the game, the frequency of SRC and the hypothesised effects of repetitive heading of the ball. Major League Soccer, US Soccer and the National Women’s Soccer League jointly hosted a conference entitled, ‘Head Injury in Soccer: From Science to the Field’, on 21–22 April 2017 in New York City, New York. The mission of this conference was to identify, discuss and disseminate evidence-based science related to the findings and conclusions of the fifth International Conference on Concussion in Sport held by the Concussion in Sport Group and apply them to the sport of soccer. In addition, we reviewed information regarding the epidemiology and mechanism of head injuries in soccer at all levels of play, data regarding the biomechanics and effects of repetitive head impacts and other soccer-specific considerations. We discussed how to release the information raised during the summit to key stakeholders including athletes, parents, coaches and healthcare providers. We identified future areas for research and collaboration to enhance the health and safety of soccer (football) players.
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Satarasinghe P, Hamilton DK, Buchanan RJ, Koltz MT. Unifying Pathophysiological Explanations for Sports-Related Concussion and Concussion Protocol Management: Literature Review. J Exp Neurosci 2019; 13:1179069518824125. [PMID: 30675103 PMCID: PMC6330734 DOI: 10.1177/1179069518824125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/19/2018] [Indexed: 11/15/2022] Open
Abstract
Objective There is a plethora of theories about the pathophysiology behind a sport-related concussion. In this review of the literature, the authors evaluated studies on the pathophysiology of sport-related concussion and professional athlete return-to-play guidelines. The goal of this article is to summarize the most common hypotheses for sport-related concussion, evaluate if there are common underlying mechanisms, and determine if correlations are seen between published mechanisms and the most current return-to-play recommendations. Methods Two authors selected papers from the past 5 years for literature review involving discussion of sport-related concussion and pathophysiology, pathology, or physiology of concussion using mutually agreed-upon search criteria. After the articles were filtered based on search criteria, pathophysiological explanations for concussion were organized into tables. Following analysis of pathophysiology, concussion protocols and return-to-play guidelines were obtained via a Google search for the major professional sports leagues and synthesized into a summary table. Results Out of 1112 initially identified publications, 53 met our criteria for qualitative analysis. The 53 studies revealed 5 primary neuropathological explanations for sport-related concussion, regardless of the many theories talked about in the different papers. These 5 explanations, in order of predominance in the articles analyzed, were (1) tauopathy, (2) white matter changes, (3) neural connectivity alterations, (4) reduction in cerebral perfusion, and (5) gray matter atrophy. Pathology may be sport specific: white matter changes are seen in 47% of football reports, tauopathy is seen in 50% of hockey reports, and soccer reports 50% tauopathy as well as 50% neural connectivity alterations. Analysis of the return-to-play guidelines across professional sports indicated commonalities in concussion management despite individual policies. Conclusions Current evidence on pathophysiology for sport-related concussion does not yet support one unifying mechanism, but published hypotheses may potentially be simplified into 5 primary groups. The unification of the complex, likely multifactorial mechanisms for sport-related concussion to a few common explanations, combined with unique findings within individual sports presented in this report, may help filter and link concussion pathophysiology in sport. By doing so, the authors hope that this review will help guide future concussion research, treatment, and management.
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Affiliation(s)
- Praveen Satarasinghe
- Department of Neurosurgery, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - D Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert J Buchanan
- Department of Neurosurgery, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
- Department of Neurosurgery, Seton Brain and Spine Institute, Austin, TX, USA
| | - Michael T Koltz
- Department of Neurosurgery, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
- Department of Neurosurgery, Seton Brain and Spine Institute, Austin, TX, USA
- Michael T Koltz, Department of Neurosurgery, Dell Medical School, The University of Texas at Austin, Austin, TX 78712, USA.
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134
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Castellani RJ, Perry G. Tau Biology, Tauopathy, Traumatic Brain Injury, and Diagnostic Challenges. J Alzheimers Dis 2019; 67:447-467. [PMID: 30584140 PMCID: PMC6398540 DOI: 10.3233/jad-180721] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2018] [Indexed: 12/12/2022]
Abstract
There is considerable interest in the pathobiology of tau protein, given its potential role in neurodegenerative diseases and aging. Tau is an important microtubule associated protein, required for the assembly of tubulin into microtubules and maintaining structural integrity of axons. Tau has other diverse cellular functions involving signal transduction, cellular proliferation, developmental neurobiology, neuroplasticity, and synaptic activity. Alternative splicing results in tau isoforms with differing microtubule binding affinity, differing representation in pathological inclusions in certain disease states, and differing roles in developmental biology and homeostasis. Tau haplotypes confer differing susceptibility to neurodegeneration. Tau phosphorylation is a normal metabolic process, critical in controlling tau's binding to microtubules, and is ongoing within the brain at all times. Tau may be hyperphosphorylated, and may aggregate as detectable fibrillar deposits in tissues, in both aging and neurodegenerative disease. The hypothesis that p-tau is neurotoxic has prompted constructs related to isomers, low-n assembly intermediates or oligomers, and the "tau prion". Human postmortem studies have elucidated broad patterns of tauopathy, with tendencies for those patterns to differ as a function of disease phenotype. However, there is extensive overlap, not only between genuine neurodegenerative diseases, but also between aging and disease. Recent studies highlight uniqueness to pathological patterns, including a pattern attributed to repetitive head trauma, although clinical correlations have been elusive. The diagnostic process for tauopathies and neurodegenerative diseases in general is challenging in many respects, and may be particularly problematic for postmortem evaluation of former athletes and military service members.
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Affiliation(s)
- Rudy J. Castellani
- Departments of Pathology and Neuroscience, West Virginia University School of Medicine, Morgantown, WV, USA
| | - George Perry
- College of Sciences, University of Texas, San Antonio, San Antonio, TX, USA
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135
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Alosco ML, Stern RA. The long-term consequences of repetitive head impacts: Chronic traumatic encephalopathy. HANDBOOK OF CLINICAL NEUROLOGY 2019; 167:337-355. [PMID: 31753141 DOI: 10.1016/b978-0-12-804766-8.00018-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with exposure to repetitive head impacts (RHI). Although described in boxers for almost a century, scientific and public interest in CTE grew tremendously following a report of postmortem evidence of CTE in the first former professional American football player in 2005. Neuropathologic diagnostic criteria for CTE have been defined, with abnormal perivascular deposition of hyperphosphorylated tau at the sulcal depths as the pathognomonic feature. CTE can currently only be diagnosed postmortem, but clinical research criteria for the in vivo diagnosis of CTE have been proposed. The clinical phenotype of CTE is still ill-defined and there are currently no validated biomarkers to support an in-life diagnosis of "Probable CTE." Many knowledge gaps remain regarding the neuropathologic and clinical make-up of CTE. An increased understanding of CTE is critical given the millions that could potentially be impacted by this disease. This chapter describes the state of the literature on CTE. The historical origins of CTE are first presented, followed by a comprehensive description of the neuropathologic and clinical features. The chapter concludes with discussion on future research directions, emphasizing the importance of diagnosing CTE during life to facilitate development of preventative and intervention strategies.
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Affiliation(s)
- Michael L Alosco
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Robert A Stern
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, MA, United States; Departments of Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, United States.
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137
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Sweeney MD, Zhao Z, Montagne A, Nelson AR, Zlokovic BV. Blood-Brain Barrier: From Physiology to Disease and Back. Physiol Rev 2019; 99:21-78. [PMID: 30280653 PMCID: PMC6335099 DOI: 10.1152/physrev.00050.2017] [Citation(s) in RCA: 1187] [Impact Index Per Article: 237.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 12/12/2022] Open
Abstract
The blood-brain barrier (BBB) prevents neurotoxic plasma components, blood cells, and pathogens from entering the brain. At the same time, the BBB regulates transport of molecules into and out of the central nervous system (CNS), which maintains tightly controlled chemical composition of the neuronal milieu that is required for proper neuronal functioning. In this review, we first examine molecular and cellular mechanisms underlying the establishment of the BBB. Then, we focus on BBB transport physiology, endothelial and pericyte transporters, and perivascular and paravascular transport. Next, we discuss rare human monogenic neurological disorders with the primary genetic defect in BBB-associated cells demonstrating the link between BBB breakdown and neurodegeneration. Then, we review the effects of genes underlying inheritance and/or increased susceptibility for Alzheimer's disease (AD), Parkinson's disease (PD), Huntington's disease, and amyotrophic lateral sclerosis (ALS) on BBB in relation to other pathologies and neurological deficits. We next examine how BBB dysfunction relates to neurological deficits and other pathologies in the majority of sporadic AD, PD, and ALS cases, multiple sclerosis, other neurodegenerative disorders, and acute CNS disorders such as stroke, traumatic brain injury, spinal cord injury, and epilepsy. Lastly, we discuss BBB-based therapeutic opportunities. We conclude with lessons learned and future directions, with emphasis on technological advances to investigate the BBB functions in the living human brain, and at the molecular and cellular level, and address key unanswered questions.
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Affiliation(s)
- Melanie D Sweeney
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California , Los Angeles, California ; and Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California , Los Angeles, California
| | - Zhen Zhao
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California , Los Angeles, California ; and Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California , Los Angeles, California
| | - Axel Montagne
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California , Los Angeles, California ; and Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California , Los Angeles, California
| | - Amy R Nelson
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California , Los Angeles, California ; and Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California , Los Angeles, California
| | - Berislav V Zlokovic
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California , Los Angeles, California ; and Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California , Los Angeles, California
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138
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Wahlquist VE, Glutting JJ, Kaminski TW. Examining neurocognitive performance and heading in interscholastic female football players over their playing careers. SCI MED FOOTBALL 2018. [DOI: 10.1080/24733938.2018.1532104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Victoria E. Wahlquist
- Department of Kinesiology and Applied Physiology, Athletic Training Research Lab, University of Delaware, Newark, DE, USA
| | | | - Thomas W. Kaminski
- Department of Kinesiology and Applied Physiology, Athletic Training Research Lab, University of Delaware, Newark, DE, USA
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139
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Kuczinski A, Newman JM, Piuzzi NS, Sodhi N, Doran JP, Khlopas A, Beyer GA, Paulino CB, Mont MA. Trends and Epidemiologic Factors Contributing to Soccer-Related Fractures That Presented to Emergency Departments in the United States. Sports Health 2018; 11:27-31. [PMID: 30247999 PMCID: PMC6299351 DOI: 10.1177/1941738118798629] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Understanding the risks and trends of soccer-related injuries may prove beneficial in creating preventative strategies against season-ending injuries. Hypothesis: Soccer-related fractures will have decreased over the past 7 years. Study Design: Descriptive epidemiology study. Level of Evidence: Level 3. Methods: The National Electronic Injury Surveillance System (NEISS) database was queried to identify soccer-related injuries from 2010 through 2016. The sum of the weighted values provided in the NEISS database was used to determine injury frequency and allowed us to estimate the incidence and annual trends of soccer-related fractures. The estimated annual number of hospital admissions resulting from each fracture location was calculated. Statistical analyses were performed, and a linear regression was used to analyze the annual injury trends, reported as the correlation coefficient. Results: Over the 6-year period, there were an estimated 1,590,365 soccer-related injuries. The estimated annual frequency of soccer-related injuries slightly increased from 225,910 in 2010 to 226,150 in 2016 (P = 0.477). The most common injuries were sprains/strains (32.4%), followed by fractures (20.4%). Fractures at the wrist were the most common (18%), while upper leg fractures were the most common soccer-related fractures to be admitted to the hospital (51.6%). The annual trends of the most common soccer-related fractures demonstrated increases in shoulder (r = 0.740; R2 = 0.547; P = 0.057) and wrist (r = 0.308; R2 = 0.095; P = 0.502) fractures. There were no significant changes in the trends of soccer-related fractures of the lower arm (r = 0.009; R2 = 7.3 × 10−5; P = 0.986), finger (r = 0.679; R2 = 0.460; P = 0.094), lower leg (r = 0.153; R2 = 0.024; P = 0.743), ankle (r = 0.650; R2 = 0.422; P = 0.114), toe (r = 0.417; R2 = 0.174; P = 0.353), or foot (r = 0.485; R2 = 0.235; P = 0.270). Conclusion: Despite the reported growing number of soccer players in the United States, the overall number of soccer-related injuries has remained relatively stable. Overall, 60% of reported fractures occurred in the upper extremity, with the wrist being the most common site, while lower extremity fractures were the most likely to lead to hospital admission. Clinical Relevance: This study offers an overview of the most common types of fractures that affect soccer players and may prove beneficial in creating preventative strategies against season-ending injuries.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Michael A. Mont
- Michael A. Mont, MD, Vice President, Strategic Initiatives; System Chief of Joint Reconstruction, Department of Orthopaedic Surgery, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10075 ()
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140
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Wallace C, Smirl JD, Zetterberg H, Blennow K, Bryk K, Burma J, Dierijck J, Wright AD, van Donkelaar P. Heading in soccer increases serum neurofilament light protein and SCAT3 symptom metrics. BMJ Open Sport Exerc Med 2018; 4:e000433. [PMID: 30233810 PMCID: PMC6135427 DOI: 10.1136/bmjsem-2018-000433] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2018] [Indexed: 11/26/2022] Open
Abstract
Objectives To determine the effect of heading a soccer ball on serum neurofilament light (NF-L) protein, plasma tau protein and symptom metrics including total number of symptoms reported and symptom severity scores on the Standardized Concussion Assessment Tool— 3rd edition (SCAT3). Methods Eleven male collegiate soccer players were recruited to take part in three experimental conditions including heading, sham and control conditions. Participants were required to perform 40 headers in 20 min in the heading condition, and control 40 soccer balls directed at them with their hands, chest or thigh in the sham condition. No ball contact was made during the control condition. Blood sampling and SCAT3 symptom assessments were completed prior to and 1 hour following conditions. A subset of participants returned 3 weeks following the heading condition for blood sampling. Results NF-L was elevated at 1 hour (p=0.004) and 1 month (p=0.04) following the heading condition, and at 1 hour (p=0.02) following the control condition. Tau levels remained unchanged following all conditions. The total number of symptoms (TS) and symptom severity (SS) scores from the SCAT3 were both elevated following the heading condition (p=0.01 and p=0.03, respectively). Both TS and SS decreased following sham (p=0.04 and p=0.04) and control conditions (p=0.04 and p=0.04). Conclusion An acute bout of soccer heading is associated with increased NF-L concentrations at 1 hour and 1 month following the session and can lead to symptoms commonly reported following sport-related concussion.
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Affiliation(s)
- Colin Wallace
- Faculty of Medicine, Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Jonathan D Smirl
- School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kelsey Bryk
- College of Health Sciences, University of Delaware, Newark, Delaware, USA
| | - Joel Burma
- School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Jill Dierijck
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexander David Wright
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul van Donkelaar
- School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
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141
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Iverson GL, Keene CD, Perry G, Castellani RJ. The Need to Separate Chronic Traumatic Encephalopathy Neuropathology from Clinical Features. J Alzheimers Dis 2018; 61:17-28. [PMID: 29103039 PMCID: PMC5734127 DOI: 10.3233/jad-170654] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There is tremendous recent interest in chronic traumatic encephalopathy (CTE) in former collision sport athletes, civilians, and military veterans. This critical review places important recent research results into a historical context. In 2015, preliminary consensus criteria were developed for defining the neuropathology of CTE, which substantially narrowed the pathology previously reported to be characteristic. There are no agreed upon clinical criteria for diagnosis, although sets of criteria have been proposed for research purposes. A prevailing theory is that CTE is an inexorably progressive neurodegenerative disease within the molecular classification of the tauopathies. However, historical and recent evidence suggests that CTE, as it is presented in the literature, might not be pathologically or clinically progressive in a substantial percentage of people. At present, it is not known whether the emergence, course, or severity of clinical symptoms can be predicted by specific combinations of neuropathologies, thresholds for accumulation of pathology, or regional distributions of pathologies. More research is needed to determine the extent to which the neuropathology ascribed to long-term effects of neurotrauma is static, progressive, or both. Disambiguating the pathology from the broad array of clinical features that have been reported in recent studies might facilitate and accelerate research- and improve understanding of CTE.
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Affiliation(s)
- Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, MassGeneral Hospital for Children™ Sports Concussion Program, and Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA, USA
| | - C Dirk Keene
- Department of Pathology, Division of Neuropathology, University of Washington School of Medicine, Seattle, WA, USA
| | - George Perry
- College of Sciences, University of Texas, San Antonio, San Antonio, TX, USA
| | - Rudolph J Castellani
- Center for Neuropathology, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
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142
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Mondello S, Sorinola A, Czeiter E, Vámos Z, Amrein K, Synnot A, Donoghue E, Sándor J, Wang KKW, Diaz-Arrastia R, Steyerberg EW, Menon DK, Maas AIR, Buki A. Blood-Based Protein Biomarkers for the Management of Traumatic Brain Injuries in Adults Presenting to Emergency Departments with Mild Brain Injury: A Living Systematic Review and Meta-Analysis. J Neurotrauma 2018; 38:1086-1106. [PMID: 29020853 PMCID: PMC8054517 DOI: 10.1089/neu.2017.5182] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Accurate diagnosis of traumatic brain injury (TBI) is critical to effective management and intervention, but can be challenging in patients with mild TBI. A substantial number of studies have reported the use of circulating biomarkers as signatures for TBI, capable of improving diagnostic accuracy and clinical decision making beyond current practice standards. We performed a systematic review and meta-analysis to comprehensively and critically evaluate the existing body of evidence for the use of blood protein biomarkers (S100 calcium binding protein B [S100B], glial fibrillary acidic protein [GFAP], neuron specific enolase [NSE], ubiquitin C-terminal hydrolase-L1 [UCH-L1]. tau, and neurofilament proteins) for diagnosis of intracranial lesions on CT following mild TBI. Effects of potential confounding factors and differential diagnostic performance of the included markers were explored. Further, appropriateness of study design, analysis, quality, and demonstration of clinical utility were assessed. Studies published up to October 2016 were identified through searches of MEDLINE®, Embase, EBM Reviews, the Cochrane Library, World Health Organization (WHO), International Clinical Trials Registry Platform (ICTRP), and clinicaltrials.gov. Following screening of the identified articles, 26 were selected as relevant. We found that measurement of S100B can help informed decision making in the emergency department, possibly reducing resource use; however, there is insufficient evidence that any of the other markers is ready for clinical application. Our work pointed out serious problems in the design, analysis, and reporting of many of the studies, and identified substantial heterogeneity and research gaps. These findings emphasize the importance of methodologically rigorous studies focused on a biomarker's intended use, and defining standardized, validated, and reproducible approaches. The living nature of this systematic review, which will summarize key updated information as it becomes available, can inform and guide future implementation of biomarkers in the clinical arena.
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Affiliation(s)
- Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | | | - Endre Czeiter
- Department of Neurosurgery, University of Pecs, Pecs, Hungary.,János Szentágothai Research Centre, University of Pecs, Pecs, Hungary.,MTA-PTE Clinical Neuroscience MR Research Group, Pecs, Hungary
| | - Zoltán Vámos
- Anesthesiology and Intensive Therapy, University of Pecs, Pecs, Hungary
| | - Krisztina Amrein
- Department of Neurosurgery, University of Pecs, Pecs, Hungary.,János Szentágothai Research Centre, University of Pecs, Pecs, Hungary.,MTA-PTE Clinical Neuroscience MR Research Group, Pecs, Hungary
| | - Anneliese Synnot
- Australian & New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia.,Cochrane Consumers and Communication Group, Centre for Health Communication and Participation, La Trobe University, Melbourne, Victoria, Australia
| | - Emma Donoghue
- Australian & New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia.,Cochrane Consumers and Communication Group, Centre for Health Communication and Participation, La Trobe University, Melbourne, Victoria, Australia
| | - János Sándor
- Department of Preventive Medicine, Division of Biostatistics and Epidemiology, University of Debrecen, Debrecen, Hungary
| | - Kevin K W Wang
- Program for Neuroproteomics & Biomarkers Research, Departments of Psychiatry & Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, Florida
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ewout W Steyerberg
- Center for Clinical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Andras Buki
- Department of Neurosurgery, University of Pecs, Pecs, Hungary.,János Szentágothai Research Centre, University of Pecs, Pecs, Hungary.,MTA-PTE Clinical Neuroscience MR Research Group, Pecs, Hungary
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143
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Tharmaratnam T, Iskandar MA, Tabobondung TC, Tobbia I, Gopee-Ramanan P, Tabobondung TA. Chronic Traumatic Encephalopathy in Professional American Football Players: Where Are We Now? Front Neurol 2018; 9:445. [PMID: 29971037 PMCID: PMC6018081 DOI: 10.3389/fneur.2018.00445] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 05/28/2018] [Indexed: 12/14/2022] Open
Abstract
Repetitive head trauma provides a favorable milieu for the onset of inflammatory and neurodegenerative processes. The result of long-lasting head trauma is chronic traumatic encephalopathy (CTE), a disease process well-recognized in boxers, military personnel, and more recently, in American football players. CTE is a chronic neurodegenerative disease with hallmarks of hyperphosphorylated tau (p-tau) aggregates and intercellular lesions of neurofibrillary tangles. The criteria for CTE diagnosis requires at least 1-2 focal perivascular lesions of p-tau in the cerebral cortex, at the depth of the sulci. These pathognomonic lesions aggregate within neurons and glial cells such as astrocytes, and cell processes within the vicinity of small blood vessels. CTE presents in a distinct topographical distribution pattern compared to other tauopathies such as AD and other age-related astrogliopathies. CTE also has an insidious onset, years after repetitive head trauma. The disease course of CTE is characterized by cognitive dysfunction, behavioral changes, and can progress to altered motor function with parkinsonian-like manifestations in later stages. This short review aims to summarize CTE in professional football, epidemiology, diagnosis based on neuroanatomical abnormalities, cognitive degeneration, and adverse mental health effects, as well as gaps in the literature and future directions in diagnostics, therapeutics, and preventive measures.
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Affiliation(s)
- Tharmegan Tharmaratnam
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Medicine, Royal College of Surgeons in Ireland-Bahrain, Al Muharraq, Bahrain
| | - Mina A. Iskandar
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tyler C. Tabobondung
- Department of Family Medicine, Michael G. DeGroote School of Medicine, McMaster University, Brantford General Hospital, Hamilton, ON, Canada
| | - Iqdam Tobbia
- Department of Pathology and Clinical Microbiology, School of Medicine, Royal College of Surgeons in Ireland-Bahrain, Adliya, Bahrain
| | - Prasaanthan Gopee-Ramanan
- Hamilton Health Sciences Centre, Department of Radiology, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Taylor A. Tabobondung
- Department of Physical and Environmental Sciences, University of Toronto, Toronto, ON, Canada
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144
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Ling H, Neal JW, Revesz T. Evolving concepts of chronic traumatic encephalopathy as a neuropathological entity. Neuropathol Appl Neurobiol 2018; 43:467-476. [PMID: 28664614 DOI: 10.1111/nan.12425] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 06/20/2017] [Accepted: 06/30/2017] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a long-term neurodegenerative consequence of repetitive head impacts which can only be definitively diagnosed in post-mortem. Recently, the consensus neuropathological criteria for the diagnosis of CTE was published requiring the presence of the accumulation of abnormal tau in neurons and astroglia distributed around small blood vessels at the depths of cortical sulci in an irregular pattern as the mandatory features. The clinical diagnosis and antemortem prediction of CTE pathology remain challenging if not impossible due to the common co-existing underlying neurodegenerative pathologies and the lack of specific clinical pointers and reliable biomarkers. This review summarizes the historical evolution of CTE as a neuropathological entity and highlights the latest advances and future directions of research studies on the topic of CTE.
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Affiliation(s)
- H Ling
- Queen Square Brain Bank for Neurological Disorders, UCL Institute of Neurology, University College London, London, UK.,Reta Lila Weston Institute for Neurological Studies, UCL Institute of Neurology, London, UK.,Department of Molecular Neuroscience, UCL Institute of Neurology, University College London, London, UK
| | - J W Neal
- Department of Cellular Pathology, Cardiff University, Wales, UK
| | - T Revesz
- Queen Square Brain Bank for Neurological Disorders, UCL Institute of Neurology, University College London, London, UK.,Reta Lila Weston Institute for Neurological Studies, UCL Institute of Neurology, London, UK.,Department of Molecular Neuroscience, UCL Institute of Neurology, University College London, London, UK
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145
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Jaunmuktane Z, Quaegebeur A, Taipa R, Viana-Baptista M, Barbosa R, Koriath C, Sciot R, Mead S, Brandner S. Evidence of amyloid-β cerebral amyloid angiopathy transmission through neurosurgery. Acta Neuropathol 2018; 135:671-679. [PMID: 29450646 PMCID: PMC5904220 DOI: 10.1007/s00401-018-1822-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 12/14/2022]
Abstract
Amyloid-β (Aβ) is a peptide deposited in the brain parenchyma in Alzheimer's disease and in cerebral blood vessels, causing cerebral amyloid angiopathy (CAA). Aβ pathology is transmissible experimentally in animals and through medical procedures in humans, such as contaminated growth hormone or dura mater transplantation in the context of iatrogenic prion disease. Here, we present four patients who underwent neurosurgical procedures during childhood or teenage years and presented with intracerebral haemorrhage approximately three decades later, caused by severe CAA. None of these patients carried pathogenic mutations associated with early Aβ pathology development. In addition, we identified in the literature four patients with a history of neurosurgical intervention and subsequent development of CAA. These findings raise the possibility that Aβ pathology may be transmissible, as prion disease is, through neurosurgical procedures.
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Affiliation(s)
- Zane Jaunmuktane
- Division of Neuropathology, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London, WC1N 3BG, UK
- Department of Molecular Neuroscience, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Annelies Quaegebeur
- Division of Neuropathology, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London, WC1N 3BG, UK
| | - Ricardo Taipa
- Portuguese Brain Bank, Neuropathology Unit, Department of Neuroscience, Centro Hospitalar Universitario do Porto, 4099-001, Porto, Portugal
| | - Miguel Viana-Baptista
- Department of Neurology, Hospital Egas Moniz, Centro Hospitalar de Lisboa Ocidental, 1449-005, Lisbon, Portugal
| | - Raquel Barbosa
- Department of Neurology, Hospital Egas Moniz, Centro Hospitalar de Lisboa Ocidental, 1449-005, Lisbon, Portugal
| | - Carolin Koriath
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Raf Sciot
- Department of Imaging and Pathology, University of Leuven, 3000, Louvain, Belgium
| | - Simon Mead
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
- Medical Research Council Prion Unit at UCL, UCL Institute of Prion Diseases, Queen Square, London, WC1N 3BG, UK
- National Prion Clinic, National Hospital for Neurology and Neurosurgery, UCL Hospitals NHS Foundation Trust, Queen Square, London, WC1N 3BG, UK
| | - Sebastian Brandner
- Division of Neuropathology, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London, WC1N 3BG, UK.
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK.
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146
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Stewart WF, Kim N, Ifrah C, Sliwinski M, Zimmerman ME, Kim M, Lipton RB, Lipton ML. Heading Frequency Is More Strongly Related to Cognitive Performance Than Unintentional Head Impacts in Amateur Soccer Players. Front Neurol 2018; 9:240. [PMID: 29740384 PMCID: PMC5928847 DOI: 10.3389/fneur.2018.00240] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 03/26/2018] [Indexed: 12/17/2022] Open
Abstract
Objective Compared to heading, unintentional head impacts (e.g., elbow to head, head to head, head to goalpost) in soccer are more strongly related to risk of moderate to very severe Central Nervous System (CNS) symptoms. But, most head impacts associated with CNS symptoms that occur in soccer are mild and are more strongly related to heading. We tested for a differential relation of heading and unintentional head impacts with neuropsychological (NP) test performance. Method Active adult amateur soccer players were recruited in New York City and the surrounding areas for this repeated measures longitudinal study of individuals who were enrolled if they had 5+ years of soccer play and were active playing soccer 6+ months/year. All participants completed a baseline validated questionnaire (“HeadCount-2w”), reporting 2-week recall of soccer activity, heading and unintentional head impacts. In addition, participants also completed NP tests of verbal learning, verbal memory, psychomotor speed, attention, and working memory. Most participants also completed one or more identical follow-up protocols (i.e., HeadCount-2w and NP tests) at 3- to 6-month intervals over a 2-year period. Repeated measures General Estimating Equations (GEE) linear models were used to determine if variation in NP tests at each visit was related to variation in either heading or unintentional head impacts in the 2-week period before testing. Results 308 players (78% male) completed 741 HeadCount-2w. Mean (median) heading/2-weeks was 50 (17) for men and 26 (7) for women. Heading was significantly associated with poorer performance on psychomotor speed (p < 0.001) and attention (p = 0.02) tasks and was borderline significant with poorer performance on the working memory (p = 0.06) task. Unintentional head impacts were not significantly associated with any NP test. Results did not differ after excluding 22 HeadCount-2w with reported concussive or borderline concussive symptoms. Conclusion Poorer NP test performance was consistently related to frequent heading during soccer practice and competition in the 2 weeks before testing. In contrast, unintentional head impacts incurred during soccer were not related to cognitive performance.
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Affiliation(s)
| | - Namhee Kim
- The Gruss Magnetic Resonance Research Center, Bronx, NY, United States.,Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
| | - Chloe Ifrah
- The Gruss Magnetic Resonance Research Center, Bronx, NY, United States.,Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
| | - Martin Sliwinski
- Department of Human Development and Family Studies, Pennsylvania State University, University Park, PA, United States
| | - Molly E Zimmerman
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States.,Fordham University, Bronx, NY, United States
| | - Mimi Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
| | - Richard B Lipton
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States.,Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
| | - Michael L Lipton
- The Gruss Magnetic Resonance Research Center, Bronx, NY, United States.,Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States.,Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States.,The Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
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147
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Abstract
My objectives are to review: 1) a brief history of sport-related concussion (SRC) and chronic traumatic encephalopathy (CTE), 2) the evolution of CTE in American professional football, 3) the data regarding SRC/CTE as they relate to depression and suicide, 4) the data on the neurocognitive effects of subconcussion/repetitive head trauma (with emphases on heading the ball in soccer and early exposure to football), 5) the evidence related to SRC and neurodegenerative diseases, 6) the published studies of CTE, 7) the NINDS neuropathological criteria for CTE, 8) public beliefs about SRC/CTE, and 9) the scientific questions regarding CTE.
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Affiliation(s)
- Gary Solomon
- a Department of Neurological Surgery, Vanderbilt Sports Concussion Center , Vanderbilt University School of Medicine , Nashville , Tennessee , USA
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148
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Keene CD, Latimer CS, Steele LM, Mac Donald CL. First confirmed case of chronic traumatic encephalopathy in a professional bull rider. Acta Neuropathol 2018; 135:303-305. [PMID: 29285625 PMCID: PMC5773642 DOI: 10.1007/s00401-017-1801-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 12/22/2017] [Accepted: 12/22/2017] [Indexed: 11/09/2022]
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149
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Zetterberg H, Blennow K. Chronic traumatic encephalopathy: fluid biomarkers. HANDBOOK OF CLINICAL NEUROLOGY 2018; 158:323-333. [PMID: 30482360 DOI: 10.1016/b978-0-444-63954-7.00030-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neuropathologic condition that has been described in individuals who have been exposed to repetitive head impacts, including concussions and subconcussive trauma. CTE cannot currently be diagnosed during life. Clinical symptoms of CTE (including changes in mood, behavior, and cognition) are nonspecific and may develop after a latency phase following the injuries. Differential diagnosis based solely on clinical features is, therefore, difficult. For example, some younger patients who do not experience the latency phase (i.e., symptoms of CTE may begin while still being exposed to the repetitive head impacts) may be clinically diagnosed with postconcussive syndrome, a vaguely defined condition that is described in a minority of concussed patients. Some older patients whose initial features of CTE include memory and executive dysfunction and progress to impaired activities of daily living may be clinically diagnosed with Alzheimer disease or another dementia. Although concussions are common in athletes and nonathletes, contact/collision sport athletes, such as boxers, American football players, and ice hockey players, are at greater risk of exposure to both concussion and repetitive subconcussive head impacts. Biomarkers for CTE pathophysiology would be of great value to study and improve our understanding of when and how the disease process starts and develops, as well as how it can be prevented or treated. Here, we review the literature regarding fluid biomarkers for repetitive subconcussive impacts, concussion, postconcussive syndrome, and CTE. We also discuss technical issues and potential pathways forward regarding how to move the most promising biomarker candidates into clinical laboratory practice.
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Affiliation(s)
- Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom; UK Dementia Research Institute, UCL, London, United Kingdom.
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
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150
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Lin A, Charney M, Shenton ME, Koerte IK. Chronic traumatic encephalopathy: neuroimaging biomarkers. HANDBOOK OF CLINICAL NEUROLOGY 2018; 158:309-322. [PMID: 30482359 DOI: 10.1016/b978-0-444-63954-7.00029-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disorder associated with repetitive head impact exposure, such as that resulting from sports-related concussive and subconcussive brain trauma. Currently, the only way to diagnose CTE is by using neuropathologic markers obtained postmortem. To diagnose CTE earlier, so that possible treatment interventions may be employed, there is a need to develop noninvasive in vivo biomarkers of CTE. Neuroimaging provides promising biomarkers for the diagnosis of CTE and may also help elucidate pathophysiologic changes that occur with chronic sports-related brain injury. To describe the use of neuroimaging as presumed biomarkers of CTE, this chapter focuses on only those studies that report the chronic stages of sports-related brain injury, as opposed to previous chapters that described neuroimaging in the context of acute and subacute injury. Studies using positron emission tomography and magnetic resonance imaging and spectroscopy will be discussed for contact/collision sports such as American football, boxing, mixed martial arts, rugby, and soccer, in which repetitive head impacts are common.
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Affiliation(s)
- Alexander Lin
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Molly Charney
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Martha E Shenton
- Psychiatric Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; VA Boston Healthcare System, Boston, MA, United States
| | - Inga Katharina Koerte
- Psychiatric Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Child and Adolescent Psychiatry, Psychosomatic, and Psychotherapy, Ludwig-Maximilians-Universität, Munich, Germany.
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