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Huang S, Li M, Huang C, Liu J. Acute limbic system connectivity predicts chronic cognitive function in mild traumatic brain injury: An individualized differential structural covariance network study. Pharmacol Res 2024; 206:107274. [PMID: 38906205 DOI: 10.1016/j.phrs.2024.107274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 06/16/2024] [Accepted: 06/18/2024] [Indexed: 06/23/2024]
Abstract
Mild traumatic brain injury (mTBI) is a known risk factor for neurodegenerative diseases, yet the precise pathophysiological mechanisms remain poorly understand, often obscured by group-level analysis in non-invasive neuroimaging studies. Individual-based method is critical to exploring heterogeneity in mTBI. We recruited 80 mTBI patients and 40 matched healthy controls, obtaining high-resolution structural MRI for constructing Individual Differential Structural Covariance Networks (IDSCN). Comparisons were conducted at both the individual and group levels. Connectome-based Predictive Modeling (CPM) was applied to predict cognitive performance based on whole-brain connectivity. During the acute stage of mTBI, patients exhibited significant heterogeneity in the count and direction of altered edges, obscured by group-level analysis. In the chronic stage, the number of altered edges decreased and became more consistent, aligning with clinical observations of acute cognitive impairment and gradual improvement. Subgroup analysis based on loss of consciousness/post-traumatic amnesia revealed distinct patterns of alterations. The temporal lobe, particularly regions related to the limbic system, significantly predicted cognitive function from acute to chronic stage. The use of IDSCN and CPM has provided valuable individual-level insights, reconciling discrepancies from previous studies. Additionally, the limbic system may be an appropriate target for future intervention efforts.
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Affiliation(s)
- Sihong Huang
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Mengjun Li
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Chuxin Huang
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jun Liu
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Department of Radiology Quality Control Center, Hunan Province, Changsha, Hunan 410011, China; Clinical Research Center for Medical Imaging in Hunan Province, Changsha, Hunan 410011, China.
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Meier TB, Huber DL, Goeckner BD, Gill JM, Pasquina P, Broglio SP, McAllister TW, Harezlak J, McCrea MA. Research Letter: Relationship of Blood Biomarkers of Inflammation With Acute Concussion Symptoms and Recovery in the CARE Consortium. J Head Trauma Rehabil 2024:00001199-990000000-00163. [PMID: 38833710 DOI: 10.1097/htr.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVE Determine the association of inflammatory biomarkers with clinical measures and recovery in participants with concussion. SETTING Multicenter study in National Collegiate Athletic Association member institutions including military service academies. PARTICIPANTS Four hundred twenty-two participants with acute concussion. DESIGN Clinical visits and blood draws were completed preinjury and at multiple visits postconcussion (0-12 hours, 12-36 hours, and 36-60 hours postinjury). Clinical measures included Sport Concussion Assessment Tool (SCAT) symptom severity, Balance Error Scoring System, Standardized Assessment of Concussion (SAC), Brief Symptom Inventory-18 (BSI-18) scores, time to initiation of graduated return-to-play (RTP) protocol, and time to RTP. Interleukin (IL)-6, IL-10, IL-8, IL-1 receptor antagonist (RA), tumor necrosis factor (TNF), c-reactive protein, and vascular endothelial growth factor (VEGF) were measured in serum. Prespecified analyses focused on IL-6 and IL-1RA at 0 to 12 hours; exploratory analyses were conducted with false discovery rate correction. RESULTS For prespecified analyses, IL-1RA at 0 to 12 hours in female participants was positively associated with more errors on the SAC (B(standard error, SE) = 0.58(0.27), P < .05) and worse SCAT symptom severity (B(SE) = 0.96(0.44), P < .05). For exploratory analyses, higher levels of IL-1RA at 12 to 36 hours were associated with higher global (B(SE) = 0.55(0.14), q < 0.01), depression (B(SE) = 0.45(0.10), q < 0.005), and somatization scores on the BSI (B(SE) = 0.46(0.12), q < 0.01) in participants with concussion; Higher TNF at 12 to 36 hours was associated with fewer errors on the SAC (B(SE) = - 0.46(0.14), q < 0.05). Subanalyses showed similar results for male participants and participants who were athletes. No associations were discovered in nonathlete cadets. Higher IL-8 at 0 to 12 hours was associated with slower RTP in female participants (OR = 14.47; 95% confidence interval, 2.96-70.66, q < 0.05); no other associations with recovery were observed. CONCLUSIONS Peripheral inflammatory markers are associated with clinical symptoms following concussion and potentially represent one mechanism for psychological symptoms observed postinjury. Current results do not provide strong support for a potential prognostic role for these markers.
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Affiliation(s)
- Timothy B Meier
- Author Affiliations: Department of Neurosurgery (Dr Meier, Mr Huber, and Dr McCrea), Department of Biomedical Engineering (Dr Meier), Department of Biophysics (Ms Goeckner), Department of Cell Biology, Neurobiology and Anatomy (Dr Meier), Department of Neurology (Dr McCrea), Medical College of Wisconsin, Milwaukee, Wisconsin; National Institute of Nursing Research (Dr Gill), National Institutes of Health, Bethesda, Maryland, USA; Johns Hopkins School of Nursing and Medicine (Dr Gill), Baltimore, MD; Department of Physical Medicine and Rehabilitation (Dr Pasquina), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Michigan Concussion Center (Dr Broglio), University of Michigan, Ann Arbor, Michigan; Department of Psychiatry (Dr McAllister), Indiana University School of Medicine, Indianapolis, IN; and Department of Epidemiology and Biostatistics (Dr Harezlak), School of Public Health-Bloomington, Indiana University, Bloomington, Indiana
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Visser K, de Koning ME, Ciubotariu D, Kok MGJ, Sibeijn-Kuiper AJ, Bourgonje AR, van Goor H, van der Naalt J, van der Horn HJ. An exploratory study on the association between blood-based biomarkers and subacute neurometabolic changes following mild traumatic brain injury. J Neurol 2024; 271:1985-1998. [PMID: 38157029 DOI: 10.1007/s00415-023-12146-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND OBJECTIVES Blood-based biomarkers and advanced neuroimaging modalities such as magnetic resonance spectroscopy (MRS) or diffusion tensor imaging (DTI) have enhanced our understanding of the pathophysiology of mild traumatic brain injury (mTBI). However, there is limited published data on how blood biomarkers relate to neuroimaging biomarkers post-mTBI. METHODS To investigate this, 30 patients with mTBI and 21 healthy controls were enrolled. Data was collected at two timepoints postinjury: acute, < 24 h, (blood) and subacute, four-to-six weeks, (blood and imaging). Interleukin (IL) 6 and 10 (inflammation), free thiols (systemic oxidative stress) and neurofilament light (NF-L) (axonal injury) were quantified in plasma. The neurometabolites total N-acetyl aspartate (tNAA) (neuronal energetics), Myo-Inositol (Ins) and total Choline (tCh) (inflammation) and, Glutathione (GSH, oxidative stress) were quantified using MRS. RESULTS Concentrations of IL-6 and IL-10 were significantly elevated in the acute phase post-mTBI, while NF-L was elevated only in the subacute phase. Total NAA was lowered in patients with mTBI, although this difference was only nominally significant (uncorrected P < 0.05). Within the patient group, acute IL-6 and subacute tNAA levels were negatively associated (r = - 0.46, uncorrected-P = 0.01), albeit not at a threshold corrected for multiple testing (corrected-P = 0.17). When age was added as a covariate a significant increase in correlation magnitude was observed (ρ = - 0.54, corrected-P = 0.03). CONCLUSION This study demonstrates potential associations between the intensity of the inflammatory response in the acute phase post-mTBI and neurometabolic perturbations in the subacute phase. Future studies should assess the longitudinal dynamics of blood-based and imaging biomarkers after injury.
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Affiliation(s)
- Koen Visser
- Department of Neurology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Myrthe E de Koning
- Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ, Enschede, The Netherlands
| | - Diana Ciubotariu
- Department of Neurology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Marius G J Kok
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Anita J Sibeijn-Kuiper
- Department of Neuroscience, BCN Neuroimaging Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Arno R Bourgonje
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Harm Jan van der Horn
- Department of Neurology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
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Clarke GJB, Skandsen T, Zetterberg H, Follestad T, Einarsen CE, Vik A, Mollnes TE, Pischke SE, Blennow K, Håberg AK. Longitudinal Associations Between Persistent Post-Concussion Symptoms and Blood Biomarkers of Inflammation and CNS-Injury After Mild Traumatic Brain Injury. J Neurotrauma 2024; 41:862-878. [PMID: 38117157 DOI: 10.1089/neu.2023.0419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
The aim of our study was to investigate the biological underpinnings of persistent post-concussion symptoms (PPCS) at 3 months following mild traumatic brain injury (mTBI). Patients (n = 192, age 16-60 years) with mTBI, defined as Glasgow Coma Scale (GCS) score between 13 and 15, loss of consciousness (LOC) <30 min, and post-traumatic amnesia (PTA) <24 h were included. Blood samples were collected at admission (within 72 h), 2 weeks, and 3 months. Concentrations of blood biomarkers associated with central nervous system (CNS) damage (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], and tau) and inflammation (interferon gamma [IFNγ], interleukin [IL]-8, eotaxin, macrophage inflammatory protein-1-beta [MIP]-1β, monocyte chemoattractant protein [MCP]-1, interferon-gamma-inducible protein [IP]-10, IL-17A, IL-9, tumor necrosis factor [TNF], basic fibroblast growth factor [FGF]-basic platelet-derived growth factor [PDGF], and IL-1 receptor antagonist [IL-1ra]) were obtained. Demographic and injury-related factors investigated were age, sex, GCS score, LOC, PTA duration, traumatic intracranial finding on magnetic resonance imaging (MRI; within 72 h), and extracranial injuries. Delta values, that is, time-point differences in biomarker concentrations between 2 weeks minus admission and 3 months minus admission, were also calculated. PPCS was assessed with the British Columbia Post-Concussion Symptom Inventory (BC-PSI). In single variable analyses, longer PTA duration and a higher proportion of intracranial findings on MRI were found in the PPCS group, but no single biomarker differentiated those with PPCS from those without. In multi-variable models, female sex, longer PTA duration, MRI findings, and lower GCS scores were associated with increased risk of PPCS. Inflammation markers, but not GFAP, NFL, or tau, were associated with PPCS. At admission, higher concentrations of IL-8 and IL-9 and lower concentrations of TNF, IL-17a, and MCP-1 were associated with greater likelihood of PPCS; at 2 weeks, higher IL-8 and lower IFNγ were associated with PPCS; at 3 months, higher PDGF was associated with PPCS. Higher delta values of PDGF, IL-17A, and FGF-basic at 2 weeks compared with admission, MCP-1 at 3 months compared with admission, and TNF at 2 weeks and 3 months compared with admission were associated with greater likelihood of PPCS. Higher IL-9 delta values at both time-point comparisons were negatively associated with PPCS. Discriminability of individual CNS-injury and inflammation biomarkers for PPCS was around chance level, whereas the optimal combination of biomarkers yielded areas under the curve (AUCs) between 0.62 and 0.73. We demonstrate a role of biological factors on PPCS, including both positive and negative effects of inflammation biomarkers that differed based on sampling time-point after mTBI. PPCS was associated more with acute inflammatory processes, rather than ongoing inflammation or CNS-injury biomarkers. However, the modest discriminative ability of the models suggests other factors are more important in the development of PPCS.
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Affiliation(s)
- Gerard Janez Brett Clarke
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Toril Skandsen
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- UK Dementia Research Institute at UCL, University College London, London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Turid Follestad
- Department of Clinical and Molecular Medicine, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinical Research Unit Central Norway, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Cathrine Elisabeth Einarsen
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Vik
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tom Eirik Mollnes
- Department of Immunology, Department of Anesthesiology and Intensive Care Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
- Center of Molecular Inflammation Research, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Søren Erik Pischke
- Department of Immunology, Department of Anesthesiology and Intensive Care Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
- Clinic for Emergencies and Critical Care, Department of Anesthesiology and Intensive Care Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Asta Kristine Håberg
- Department of Radiology and Nuclear Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Sciences, Department of Clinical and Molecular Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Meier TB, Huber DL, Goeckner BD, Gill JM, Pasquina P, Broglio SP, McAllister TW, Harezlak J, McCrea MA. Association of Blood Biomarkers of Inflammation With Acute Concussion in Collegiate Athletes and Military Service Academy Cadets. Neurology 2024; 102:e207991. [PMID: 38165315 DOI: 10.1212/wnl.0000000000207991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/20/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The objective was to characterize the acute effects of concussion (a subset of mild traumatic brain injury) on serum interleukin (IL)-6 and IL-1 receptor antagonist (RA) and 5 additional inflammatory markers in athletes and military service academy members from the Concussion Assessment, Research, and Education Consortium and to determine whether these markers aid in discrimination of concussed participants from controls. METHODS Athletes and cadets with concussion and matched controls provided blood at baseline and postinjury visits between January 2015 and March 2020. Linear models investigated changes in inflammatory markers measured using Meso Scale Discovery assays across time points (baseline and 0-12, 12-36, 36-60 hours). Subanalyses were conducted in participants split by sex and injury population. Logistic regression analyses tested whether acute levels of IL-6 and IL-1RA improved discrimination of concussed participants relative to brain injury markers (glial fibrillary acidic protein, tau, neurofilament light, ubiquitin c-terminal hydrolase-L1) or clinical data (Sport Concussion Assessment Tool-Third Edition, Standardized Assessment of Concussion, Balance Error Scoring System). RESULTS Participants with concussion (total, N = 422) had elevated IL-6 and IL-1RA at 0-12 hours vs controls (n = 345; IL-6: mean difference [MD] (standard error) = 0.701 (0.091), p < 0.0001; IL-1RA: MD = 0.283 (0.042), p < 0.0001) and relative to baseline (IL-6: MD = 0.656 (0.078), p < 0.0001; IL-1RA: MD = 0.242 (0.038), p < 0.0001), 12-36 hours (IL-6: MD = 0.609 (0.086), p < 0.0001; IL-1RA: MD = 0.322 (0.041), p < 0.0001), and 36-60 hours (IL-6: MD = 0.818 (0.084), p < 0.0001; IL-1RA: MD = 0.317 (0.040), p < 0.0001). IL-6 and IL-1RA were elevated in participants with sport (IL-6: MD = 0.748 (0.115), p < 0.0001; IL-1RA: MD = 0.304 (0.055), p < 0.0001) and combative-related concussions (IL-6: MD = 0.583 (0.178), p = 0.001; IL-1RA: MD = 0.312 (0.081), p = 0.0001). IL-6 was elevated in male (MD = 0.734 (0.105), p < 0.0001) and female participants (MD = 0.600 (0.177), p = 0.0008); IL-1RA was only elevated in male participants (MD = 0.356 (0.047), p < 0.0001). Logistic regression showed the inclusion of IL-6 and IL-1RA at 0-12 hours improved the discrimination of participants with concussion from controls relative to brain injury markers (χ2(2) = 17.855, p = 0.0001; area under the receiver operating characteristic curve [AUC] 0.73 [0.66-0.80] to 0.78 [0.71-0.84]), objective clinical measures (balance and cognition; χ2(2) = 40.661, p < 0.0001; AUC 0.81 [0.76-0.86] to 0.87 [0.83-0.91]), and objective and subjective measures combined (χ2(2) = 13.456, p = 0.001; AUC 0.97 [0.95-0.99] to 0.98 [0.96-0.99]), although improvement in AUC was only significantly relative to objective clinical measures. DISCUSSION IL-6 and IL-1RA (male participants only) are elevated in the early-acute window postconcussion and may aid in diagnostic decisions beyond traditional blood markers and common clinical measures. IL-1RA results highlight sex differences in the immune response to concussion which should be considered in future biomarker work.
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Affiliation(s)
- Timothy B Meier
- From the Departments of Neurosurgery (T.B.M., D.L.H., M.A.M.), Biomedical Engineering (T.B.M.), Cell Biology, Neurobiology and Anatomy (T.B.M.), Biophysics (B.D.G.), and Neurology (M.A.M.), Medical College of Wisconsin, Milwaukee; National Institute of Nursing Research (J.M.G.), NIH, Bethesda; Johns Hopkins School of Nursing and Medicine (J.M.G.), Baltimore, MD; Department of Physical Medicine and Rehabilitation (P.P.), Uniformed Services University of the Health Sciences, Bethesda, MD; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis; Department of Epidemiology and Biostatistics (J.H.), School of Public Health-Bloomington, Indiana University
| | - Daniel L Huber
- From the Departments of Neurosurgery (T.B.M., D.L.H., M.A.M.), Biomedical Engineering (T.B.M.), Cell Biology, Neurobiology and Anatomy (T.B.M.), Biophysics (B.D.G.), and Neurology (M.A.M.), Medical College of Wisconsin, Milwaukee; National Institute of Nursing Research (J.M.G.), NIH, Bethesda; Johns Hopkins School of Nursing and Medicine (J.M.G.), Baltimore, MD; Department of Physical Medicine and Rehabilitation (P.P.), Uniformed Services University of the Health Sciences, Bethesda, MD; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis; Department of Epidemiology and Biostatistics (J.H.), School of Public Health-Bloomington, Indiana University
| | - Bryna D Goeckner
- From the Departments of Neurosurgery (T.B.M., D.L.H., M.A.M.), Biomedical Engineering (T.B.M.), Cell Biology, Neurobiology and Anatomy (T.B.M.), Biophysics (B.D.G.), and Neurology (M.A.M.), Medical College of Wisconsin, Milwaukee; National Institute of Nursing Research (J.M.G.), NIH, Bethesda; Johns Hopkins School of Nursing and Medicine (J.M.G.), Baltimore, MD; Department of Physical Medicine and Rehabilitation (P.P.), Uniformed Services University of the Health Sciences, Bethesda, MD; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis; Department of Epidemiology and Biostatistics (J.H.), School of Public Health-Bloomington, Indiana University
| | - Jessica M Gill
- From the Departments of Neurosurgery (T.B.M., D.L.H., M.A.M.), Biomedical Engineering (T.B.M.), Cell Biology, Neurobiology and Anatomy (T.B.M.), Biophysics (B.D.G.), and Neurology (M.A.M.), Medical College of Wisconsin, Milwaukee; National Institute of Nursing Research (J.M.G.), NIH, Bethesda; Johns Hopkins School of Nursing and Medicine (J.M.G.), Baltimore, MD; Department of Physical Medicine and Rehabilitation (P.P.), Uniformed Services University of the Health Sciences, Bethesda, MD; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis; Department of Epidemiology and Biostatistics (J.H.), School of Public Health-Bloomington, Indiana University
| | - Paul Pasquina
- From the Departments of Neurosurgery (T.B.M., D.L.H., M.A.M.), Biomedical Engineering (T.B.M.), Cell Biology, Neurobiology and Anatomy (T.B.M.), Biophysics (B.D.G.), and Neurology (M.A.M.), Medical College of Wisconsin, Milwaukee; National Institute of Nursing Research (J.M.G.), NIH, Bethesda; Johns Hopkins School of Nursing and Medicine (J.M.G.), Baltimore, MD; Department of Physical Medicine and Rehabilitation (P.P.), Uniformed Services University of the Health Sciences, Bethesda, MD; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis; Department of Epidemiology and Biostatistics (J.H.), School of Public Health-Bloomington, Indiana University
| | - Steven P Broglio
- From the Departments of Neurosurgery (T.B.M., D.L.H., M.A.M.), Biomedical Engineering (T.B.M.), Cell Biology, Neurobiology and Anatomy (T.B.M.), Biophysics (B.D.G.), and Neurology (M.A.M.), Medical College of Wisconsin, Milwaukee; National Institute of Nursing Research (J.M.G.), NIH, Bethesda; Johns Hopkins School of Nursing and Medicine (J.M.G.), Baltimore, MD; Department of Physical Medicine and Rehabilitation (P.P.), Uniformed Services University of the Health Sciences, Bethesda, MD; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis; Department of Epidemiology and Biostatistics (J.H.), School of Public Health-Bloomington, Indiana University
| | - Thomas W McAllister
- From the Departments of Neurosurgery (T.B.M., D.L.H., M.A.M.), Biomedical Engineering (T.B.M.), Cell Biology, Neurobiology and Anatomy (T.B.M.), Biophysics (B.D.G.), and Neurology (M.A.M.), Medical College of Wisconsin, Milwaukee; National Institute of Nursing Research (J.M.G.), NIH, Bethesda; Johns Hopkins School of Nursing and Medicine (J.M.G.), Baltimore, MD; Department of Physical Medicine and Rehabilitation (P.P.), Uniformed Services University of the Health Sciences, Bethesda, MD; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis; Department of Epidemiology and Biostatistics (J.H.), School of Public Health-Bloomington, Indiana University
| | - Jaroslaw Harezlak
- From the Departments of Neurosurgery (T.B.M., D.L.H., M.A.M.), Biomedical Engineering (T.B.M.), Cell Biology, Neurobiology and Anatomy (T.B.M.), Biophysics (B.D.G.), and Neurology (M.A.M.), Medical College of Wisconsin, Milwaukee; National Institute of Nursing Research (J.M.G.), NIH, Bethesda; Johns Hopkins School of Nursing and Medicine (J.M.G.), Baltimore, MD; Department of Physical Medicine and Rehabilitation (P.P.), Uniformed Services University of the Health Sciences, Bethesda, MD; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis; Department of Epidemiology and Biostatistics (J.H.), School of Public Health-Bloomington, Indiana University
| | - Michael A McCrea
- From the Departments of Neurosurgery (T.B.M., D.L.H., M.A.M.), Biomedical Engineering (T.B.M.), Cell Biology, Neurobiology and Anatomy (T.B.M.), Biophysics (B.D.G.), and Neurology (M.A.M.), Medical College of Wisconsin, Milwaukee; National Institute of Nursing Research (J.M.G.), NIH, Bethesda; Johns Hopkins School of Nursing and Medicine (J.M.G.), Baltimore, MD; Department of Physical Medicine and Rehabilitation (P.P.), Uniformed Services University of the Health Sciences, Bethesda, MD; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis; Department of Epidemiology and Biostatistics (J.H.), School of Public Health-Bloomington, Indiana University
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Goeckner BD, Brett BL, Mayer AR, España LY, Banerjee A, Muftuler LT, Meier TB. Associations of prior concussion severity with brain microstructure using mean apparent propagator magnetic resonance imaging. Hum Brain Mapp 2024; 45:e26556. [PMID: 38158641 PMCID: PMC10789198 DOI: 10.1002/hbm.26556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 10/16/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024] Open
Abstract
Magnetic resonance imaging (MRI) diffusion studies have shown chronic microstructural tissue abnormalities in athletes with history of concussion, but with inconsistent findings. Concussions with post-traumatic amnesia (PTA) and/or loss of consciousness (LOC) have been connected to greater physiological injury. The novel mean apparent propagator (MAP) MRI is expected to be more sensitive to such tissue injury than the conventional diffusion tensor imaging. This study examined effects of prior concussion severity on microstructure with MAP-MRI. Collegiate-aged athletes (N = 111, 38 females; ≥6 months since most recent concussion, if present) completed semistructured interviews to determine the presence of prior concussion and associated injury characteristics, including PTA and LOC. MAP-MRI metrics (mean non-Gaussian diffusion [NG Mean], return-to-origin probability [RTOP], and mean square displacement [MSD]) were calculated from multi-shell diffusion data, then evaluated for associations with concussion severity through group comparisons in a primary model (athletes with/without prior concussion) and two secondary models (athletes with/without prior concussion with PTA and/or LOC, and athletes with/without prior concussion with LOC only). Bayesian multilevel modeling estimated models in regions of interest (ROI) in white matter and subcortical gray matter, separately. In gray matter, the primary model showed decreased NG Mean and RTOP in the bilateral pallidum and decreased NG Mean in the left putamen with prior concussion. In white matter, lower NG Mean with prior concussion was present in all ROI across all models and was further decreased with LOC. However, only prior concussion with LOC was associated with decreased RTOP and increased MSD across ROI. Exploratory analyses conducted separately in male and female athletes indicate associations in the primary model may differ by sex. Results suggest microstructural measures in gray matter are associated with a general history of concussion, while a severity-dependent association of prior concussion may exist in white matter.
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Affiliation(s)
- Bryna D. Goeckner
- Department of BiophysicsMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Benjamin L. Brett
- Department of NeurosurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- Department of NeurologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Andrew R. Mayer
- The Mind Research Network/Lovelace Biomedical and Environmental Research InstituteAlbuquerqueNew MexicoUSA
- Departments of Neurology and PsychiatryUniversity of New Mexico School of MedicineAlbuquerqueNew MexicoUSA
- Department of PsychologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Lezlie Y. España
- Department of NeurosurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Anjishnu Banerjee
- Department of BiostatisticsMedical College of WisconsinMilwaukeeWisconsinUSA
| | - L. Tugan Muftuler
- Department of NeurosurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Timothy B. Meier
- Department of NeurosurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- Department of Biomedical EngineeringMedical College of WisconsinMilwaukeeWisconsinUSA
- Department of Cell Biology, Neurobiology and AnatomyMedical College of WisconsinMilwaukeeWisconsinUSA
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7
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Mayer AR, Dodd AB, Robertson-Benta CR, Zotev V, Ryman SG, Meier TB, Campbell RA, Phillips JP, van der Horn HJ, Hogeveen J, Tarawneh R, Sapien RE. Multifaceted neural and vascular pathologies after pediatric mild traumatic brain injury. J Cereb Blood Flow Metab 2024; 44:118-130. [PMID: 37724718 PMCID: PMC10905640 DOI: 10.1177/0271678x231197188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/01/2023] [Accepted: 07/25/2023] [Indexed: 09/21/2023]
Abstract
Dynamic changes in neurodevelopment and cognitive functioning occur during adolescence, including a switch from reactive to more proactive forms of cognitive control, including response inhibition. Pediatric mild traumatic brain injury (pmTBI) affects these cognitions immediately post-injury, but the role of vascular versus neural injury in cognitive dysfunction remains debated. This study consecutively recruited 214 sub-acute pmTBI (8-18 years) and age/sex-matched healthy controls (HC; N = 186), with high retention rates (>80%) at four months post-injury. Multimodal imaging (functional MRI during response inhibition, cerebral blood flow and cerebrovascular reactivity) assessed for pathologies within the neurovascular unit. Patients exhibited increased errors of commission and hypoactivation of motor circuitry during processing of probes. Evidence of increased/delayed cerebrovascular reactivity within motor circuitry during hypercapnia was present along with normal perfusion. Neither age-at-injury nor post-concussive symptom load were strongly associated with imaging abnormalities. Collectively, mild cognitive impairments and clinical symptoms may continue up to four months post-injury. Prolonged dysfunction within the neurovascular unit was observed during proactive response inhibition, with preliminary evidence that neural and pure vascular trauma are statistically independent. These findings suggest pmTBI is characterized by multifaceted pathologies during the sub-acute injury stage that persist several months post-injury.
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Affiliation(s)
- Andrew R Mayer
- The Mind Research Network/LBERI, Albuquerque, NM, USA
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - Andrew B Dodd
- The Mind Research Network/LBERI, Albuquerque, NM, USA
| | | | - Vadim Zotev
- The Mind Research Network/LBERI, Albuquerque, NM, USA
| | | | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard A Campbell
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - John P Phillips
- The Mind Research Network/LBERI, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | | | - Jeremy Hogeveen
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | - Rawan Tarawneh
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
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8
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Hossain I, Marklund N, Czeiter E, Hutchinson P, Buki A. Blood biomarkers for traumatic brain injury: A narrative review of current evidence. BRAIN & SPINE 2023; 4:102735. [PMID: 38510630 PMCID: PMC10951700 DOI: 10.1016/j.bas.2023.102735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/05/2023] [Accepted: 12/11/2023] [Indexed: 03/22/2024]
Abstract
Introduction A blood-based biomarker (BBBM) test could help to better stratify patients with traumatic brain injury (TBI), reduce unnecessary imaging, to detect and treat secondary insults, predict outcomes, and monitor treatment effects and quality of care. Research question What evidence is available for clinical applications of BBBMs in TBI and how to advance this field? Material and methods This narrative review discusses the potential clinical applications of core BBBMs in TBI. A literature search in PubMed, Scopus, and ISI Web of Knowledge focused on articles in English with the words "traumatic brain injury" together with the words "blood biomarkers", "diagnostics", "outcome prediction", "extracranial injury" and "assay method" alone-, or in combination. Results Glial fibrillary acidic protein (GFAP) combined with Ubiquitin C-terminal hydrolase-L1(UCH-L1) has received FDA clearance to aid computed tomography (CT)-detection of brain lesions in mild (m) TBI. Application of S100B led to reduction of head CT scans. GFAP may also predict magnetic resonance imaging (MRI) abnormalities in CT-negative cases of TBI. Further, UCH-L1, S100B, Neurofilament light (NF-L), and total tau showed value for predicting mortality or unfavourable outcome. Nevertheless, biomarkers have less role in outcome prediction in mTBI. S100B could serve as a tool in the multimodality monitoring of patients in the neurointensive care unit. Discussion and conclusion Largescale systematic studies are required to explore the kinetics of BBBMs and their use in multiple clinical groups. Assay development/cross validation should advance the generalizability of those results which implicated GFAP, S100B and NF-L as most promising biomarkers in the diagnostics of TBI.
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Affiliation(s)
- Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
- Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | - Endre Czeiter
- Department of Neurosurgery, Medical School, Neurotrauma Research Group, Szentagothai Research Centre, And HUN-REN-PTE Clinical Neuroscience MR Research Group, University of Pecs, Pecs, Hungary
| | - Peter Hutchinson
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Andras Buki
- Department of Neurosurgery, University of Örebro, Örebro, Sweden
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9
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Mayer AR, Meier TB, Ling JM, Dodd AB, Brett BL, Robertson-Benta CR, Huber DL, Van der Horn HJ, Broglio SP, McCrea MA, McAllister T. Increased brain age and relationships with blood-based biomarkers following concussion in younger populations. J Neurol 2023; 270:5835-5848. [PMID: 37594499 PMCID: PMC10632216 DOI: 10.1007/s00415-023-11931-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/19/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE Brain age is increasingly being applied to the spectrum of brain injury to define neuropathological changes in conjunction with blood-based biomarkers. However, data from the acute/sub-acute stages of concussion are lacking, especially among younger cohorts. METHODS Predicted brain age differences were independently calculated in large, prospectively recruited cohorts of pediatric concussion and matched healthy controls (total N = 446), as well as collegiate athletes with sport-related concussion and matched non-contact sport controls (total N = 184). Effects of repetitive head injury (i.e., exposure) were examined in a separate cohort of contact sport athletes (N = 82), as well as by quantifying concussion history through semi-structured interviews and years of contact sport participation. RESULTS Findings of increased brain age during acute and sub-acute concussion were independently replicated across both cohorts, with stronger evidence of recovery for pediatric (4 months) relative to concussed athletes (6 months). Mixed evidence existed for effects of repetitive head injury, as brain age was increased in contact sport athletes, but was not associated with concussion history or years of contact sport exposure. There was no difference in brain age between concussed and contact sport athletes. Total tau decreased immediately (~ 1.5 days) post-concussion relative to the non-contact group, whereas pro-inflammatory markers were increased in both concussed and contact sport athletes. Anti-inflammatory markers were inversely related to brain age, whereas markers of axonal injury (neurofilament light) exhibited a trend positive association. CONCLUSION Current and previous findings collectively suggest that the chronicity of brain age differences may be mediated by age at injury (adults > children), with preliminary findings suggesting that exposure to contact sports may also increase brain age.
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Affiliation(s)
- Andrew R Mayer
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, 1101 Yale Blvd. NE, Albuquerque, NM, 87106, USA.
- Neurology and Psychiatry Departments, University of New Mexico School of Medicine, Albuquerque, NM, USA.
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA.
| | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Josef M Ling
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, 1101 Yale Blvd. NE, Albuquerque, NM, 87106, USA
| | - Andrew B Dodd
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, 1101 Yale Blvd. NE, Albuquerque, NM, 87106, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cidney R Robertson-Benta
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, 1101 Yale Blvd. NE, Albuquerque, NM, 87106, USA
| | - Daniel L Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Harm J Van der Horn
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, 1101 Yale Blvd. NE, Albuquerque, NM, 87106, USA
| | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas McAllister
- Department of Psychiatry, Indiana University School of Medicine, Bloomington, IN, USA
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10
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Parks A, Hogg-Johnson S. Autonomic nervous system dysfunction in pediatric sport-related concussion: a systematic review. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2023; 67:246-268. [PMID: 38283159 PMCID: PMC10814701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Objective To identify, appraise and synthesize the evidence of autonomic nervous system (ANS) dysfunction following sport-related concussion in pediatric populations. Methods A literature search was conducted using MEDLINE (Ovid), SportDiscus (EBSCO), CINAHL (EBSCO), EMBASE (Ovid) and PsycINFO (Ovid). Studies were selected and appraised using the Joanna Briggs Institute (JBI) critical appraisal tools. Data was extracted from the included studies and qualitatively synthesized. Results Eleven studies were included in the synthesis. There was variability in the methods used to measure ANS function between studies, and sample populations and time to assessment following concussion varied considerably. There was also variability in the direction of change of ANS function between some studies. Conclusion This systematic review identifies that concussion is associated with dysregulation of ANS function in pediatric athletes. We identified some weaknesses in the extant literature which may be due to existing logistical and financial barriers to implementing valid ANS measurements in clinical and sports settings.
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Affiliation(s)
- Andrew Parks
- Division of Graduate Studies, Sports Sciences, Canadian Memorial Chiropractic College
- Private Practice
| | - Sheilah Hogg-Johnson
- Department of Research and Innovation, Canadian Memorial Chiropractic College
- Dalla Lana School of Public Health, University of Toronto
- Institute for Disability and Rehabilitation Research, Ontario Tech University
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11
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Reyes J, Spitz G, Major BP, O'Brien WT, Giesler LP, Bain JWP, Xie B, Rosenfeld JV, Law M, Ponsford JL, O'Brien TJ, Shultz SR, Willmott C, Mitra B, McDonald SJ. Utility of Acute and Subacute Blood Biomarkers to Assist Diagnosis in CT-Negative Isolated Mild Traumatic Brain Injury. Neurology 2023; 101:e1992-e2004. [PMID: 37788938 PMCID: PMC10662993 DOI: 10.1212/wnl.0000000000207881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/22/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Blood biomarkers glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) have recently been Food and Drug Administration approved as predictors of intracranial lesions on CT after mild traumatic brain injury (mTBI). However, most cases with mTBI are CT negative, and no biomarkers are approved to assist diagnosis in these individuals. In this study, we aimed to determine the optimal combination of blood biomarkers to assist mTBI diagnosis in otherwise healthy adults younger than 50 years presenting to an emergency department within 6 hours of injury. To further understand the utility of biomarkers, we assessed how biological sex, presence or absence of loss of consciousness and/or post-traumatic amnesia (LOC/PTA), and delayed presentation affected classification performance. METHODS Blood samples, symptom questionnaires, and cognitive tests were prospectively conducted for participants with mTBI recruited from The Alfred Hospital Level 1 Emergency & Trauma Center and uninjured controls. Follow-up testing was conducted at 7 days. Simoa quantified plasma GFAP, UCH-L1, tau, neurofilament light chain (NfL), interleukin (IL)-6, and IL-1β. Area under the receiver operating characteristic (AUC) analysis assessed classification accuracy for diagnosed mTBI, and logistic regression models identified optimal biomarker combinations. RESULTS Plasma IL-6 (AUC 0.91, 95% CI 0.86-0.96), GFAP (AUC 0.85, 95% CI 0.78-0.93), and UCH-L1 (AUC 0.79, 95% CI 0.70-0.88) best differentiated mTBI (n = 74) from controls (n = 44) acutely (<6 hours), with NfL (AUC 0.81, 95% CI 0.72-0.90) the only marker to have such utility subacutely (7 days). Biomarker performance was similar between sexes and for participants with and without LOC/PTA, with the exception at 7 days, where GFAP and IL-6 retained some utility in female participants (GFAP: AUC 0.71, 95% CI 0.55-0.88; IL-6: AUC 0.71, 95% CI 0.55-0.87) and in those with LOC/PTA (GFAP: AUC 0.73, 95% CI 0.59-0.86; IL-6: AUC 0.71, 95% CI 0.57-0.84). Acute IL-6 (R 2 = 0.50, 95% CI 0.34-0.64) outperformed GFAP and UCH-L1 combined (R 2 = 0.35, 95% CI 0.17-0.50), with the best acute model featuring GFAP and IL-6 (R 2 = 0.54, 95% CI 0.34-0.68). DISCUSSION These findings indicate that adding IL-6 to a panel of brain-specific proteins such as GFAP and UCH-L1 might assist in the acute diagnosis of mTBI in adults younger than 50 years. Multiple markers had high classification accuracy in participants without LOC/PTA. When compared with the best-performing acute markers, subacute measures of plasma NfL resulted in minimal reduction in classification accuracy. Future studies will investigate the optimal time frame over which plasma IL-6 might assist diagnostic decisions and how extracranial trauma affects utility.
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Affiliation(s)
- Jonathan Reyes
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Gershon Spitz
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Brendan P Major
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - William T O'Brien
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Lauren P Giesler
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Jesse W P Bain
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Becca Xie
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Jeffrey V Rosenfeld
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Meng Law
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Jennie L Ponsford
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Terence J O'Brien
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Sandy R Shultz
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Catherine Willmott
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Biswadev Mitra
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia
| | - Stuart J McDonald
- From the Department of Neuroscience (J.R., G.S., B.P.M., W.T.O.B., L.P.G., J.W.P.B., B.X., M.L., T.J.O.B., S.R.S., S.J.M.), School of Psychological Sciences (J.R., G.S., C.W.), Monash University; Monash-Epworth Rehabilitation Research Centre (J.R., G.S., J.L.P., C.W.), Epworth Hospital; Department of Neurosurgery (J.V.R.), The Alfred Hospital; Department of Surgery (J.V.R.), Monash University; Department of Radiology (M.L.), The Alfred Hospital; Department of Electrical and Computer Systems Engineering (M.L.), Monash University; Department of Neurology (T.J.O.B., S.R.S., S.J.M.), The Alfred Hospital, Melbourne; Department of Medicine (T.J.O.B., S.R.S.), Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Health Sciences (S.R.S.), Vancouver Island University, Nanaimo, British Columbia, Canada; Australian Football League (AFL) (C.W.); Emergency & Trauma Centre (B.M.), The Alfred Hospital; and School of Public Health & Preventive Medicine (B.M.), Monash University, Melbourne, Australia.
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12
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Savitz J, Goeckner BD, Ford BN, Kent Teague T, Zheng H, Harezlak J, Mannix R, Tugan Muftuler L, Brett BL, McCrea MA, Meier TB. The effects of cytomegalovirus on brain structure following sport-related concussion. Brain 2023; 146:4262-4273. [PMID: 37070698 PMCID: PMC10545519 DOI: 10.1093/brain/awad126] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 03/06/2023] [Accepted: 03/27/2023] [Indexed: 04/19/2023] Open
Abstract
The neurotrophic herpes virus cytomegalovirus is a known cause of neuropathology in utero and in immunocompromised populations. Cytomegalovirus is reactivated by stress and inflammation, possibly explaining the emerging evidence linking it to subtle brain changes in the context of more minor disturbances of immune function. Even mild forms of traumatic brain injury, including sport-related concussion, are major physiological stressors that produce neuroinflammation. In theory, concussion could predispose to the reactivation of cytomegalovirus and amplify the effects of physical injury on brain structure. However, to our knowledge this hypothesis remains untested. This study evaluated the effect of cytomegalovirus serostatus on white and grey matter structure in a prospective study of athletes with concussion and matched contact-sport controls. Athletes who sustained concussion (n = 88) completed MRI at 1, 8, 15 and 45 days post-injury; matched uninjured athletes (n = 73) completed similar visits. Cytomegalovirus serostatus was determined by measuring serum IgG antibodies (n = 30 concussed athletes and n = 21 controls were seropositive). Inverse probability of treatment weighting was used to adjust for confounding factors between athletes with and without cytomegalovirus. White matter microstructure was assessed using diffusion kurtosis imaging metrics in regions previously shown to be sensitive to concussion. T1-weighted images were used to quantify mean cortical thickness and total surface area. Concussion-related symptoms, psychological distress, and serum concentration of C-reactive protein at 1 day post-injury were included as exploratory outcomes. Planned contrasts compared the effects of cytomegalovirus seropositivity in athletes with concussion and controls, separately. There was a significant effect of cytomegalovirus on axial and radial kurtosis in athletes with concussion but not controls. Cytomegalovirus positive athletes with concussion showed greater axial (P = 0.007, d = 0.44) and radial (P = 0.010, d = 0.41) kurtosis than cytomegalovirus negative athletes with concussion. Similarly, there was a significant association of cytomegalovirus with cortical thickness in athletes with concussion but not controls. Cytomegalovirus positive athletes with concussion had reduced mean cortical thickness of the right hemisphere (P = 0.009, d = 0.42) compared with cytomegalovirus negative athletes with concussion and showed a similar trend for the left hemisphere (P = 0.036, d = 0.33). There was no significant effect of cytomegalovirus on kurtosis fractional anisotropy, surface area, symptoms and C-reactive protein. The results raise the possibility that cytomegalovirus infection contributes to structural brain abnormalities in the aftermath of concussion perhaps via an amplification of concussion-associated neuroinflammation. More work is needed to identify the biological pathways underlying this process and to clarify the clinical relevance of this putative viral effect.
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Affiliation(s)
- Jonathan Savitz
- Laureate Institute for Brain Research, Tulsa, OK 74136, USA
- Oxley College of Health Sciences, The University of Tulsa, Tulsa, OK 74119, USA
| | - Bryna D Goeckner
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Bart N Ford
- Department of Pharmacology and Physiology, Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA
| | - T Kent Teague
- Department of Psychiatry, The University of Oklahoma School of Community Medicine, Tulsa, OK 74135, USA
- Department of Surgery, The University of Oklahoma School of Community Medicine, Tulsa, OK 74135, USA
- Department of Pharmaceutical Sciences, University of Oklahoma College of Pharmacy, Tulsa, OK 74135, USA
| | - Haixia Zheng
- Laureate Institute for Brain Research, Tulsa, OK 74136, USA
| | - Jaroslaw Harezlak
- Department of Epidemiology and Biostatistics, School of Public Health-Bloomington, Indiana University, Bloomington, IN 47405, USA
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - L Tugan Muftuler
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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13
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Mayer AR, Dodd AB, Dodd RJ, Stephenson DD, Ling JM, Mehos CJ, Patton DA, Robertson-Benta CR, Gigliotti AP, Vermillion MS, Noghero A. Head Kinematics, Blood Biomarkers, and Histology in Large Animal Models of Traumatic Brain Injury and Hemorrhagic Shock. J Neurotrauma 2023; 40:2205-2216. [PMID: 37341029 PMCID: PMC10701512 DOI: 10.1089/neu.2022.0338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Traumatic brain injury (TBI) and severe blood loss resulting in hemorrhagic shock (HS) are each leading causes of mortality and morbidity worldwide, and present additional treatment considerations when they are comorbid (TBI+HS) as a result of competing pathophysiological responses. The current study rigorously quantified injury biomechanics with high precision sensors and examined whether blood-based surrogate markers were altered in general trauma as well as post-neurotrauma. Eighty-nine sexually mature male and female Yucatan swine were subjected to a closed-head TBI+HS (40% of circulating blood volume; n = 68), HS only (n = 9), or sham trauma (n = 12). Markers of systemic (e.g., glucose, lactate) and neural functioning were obtained at baseline, and at 35 and 295 min post-trauma. Opposite and approximately twofold differences existed for both magnitude (device > head) and duration (head > device) of quantified injury biomechanics. Circulating levels of neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), and ubiquitin C-terminal hydrolase L1 (UCH-L1) demonstrated differential sensitivity for both general trauma (HS) and neurotrauma (TBI+HS) relative to shams in a temporally dynamic fashion. GFAP and NfL were both strongly associated with changes in systemic markers during general trauma and exhibited consistent time-dependent changes in individual sham animals. Finally, circulating GFAP was associated with histopathological markers of diffuse axonal injury and blood-brain barrier breach, as well as variations in device kinematics following TBI+HS. Current findings therefore highlight the need to directly quantify injury biomechanics with head mounted sensors and suggest that GFAP, NfL, and UCH-L1 are sensitive to multiple forms of trauma rather than having a single pathological indication (e.g., GFAP = astrogliosis).
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Affiliation(s)
- Andrew R. Mayer
- The Mind Research Network/Lovelace Biomedical Research Institute, Pete & Nancy Domenici Hall, Albuquerque, New Mexico, USA
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Department of Psychiatry, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Department of Psychology, and University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Andrew B. Dodd
- The Mind Research Network/Lovelace Biomedical Research Institute, Pete & Nancy Domenici Hall, Albuquerque, New Mexico, USA
| | - Rebecca J. Dodd
- The Mind Research Network/Lovelace Biomedical Research Institute, Pete & Nancy Domenici Hall, Albuquerque, New Mexico, USA
| | - David D. Stephenson
- The Mind Research Network/Lovelace Biomedical Research Institute, Pete & Nancy Domenici Hall, Albuquerque, New Mexico, USA
| | - Josef M. Ling
- The Mind Research Network/Lovelace Biomedical Research Institute, Pete & Nancy Domenici Hall, Albuquerque, New Mexico, USA
| | - Carissa J. Mehos
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Declan A. Patton
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Cidney R. Robertson-Benta
- The Mind Research Network/Lovelace Biomedical Research Institute, Pete & Nancy Domenici Hall, Albuquerque, New Mexico, USA
| | - Andrew P. Gigliotti
- The Mind Research Network/Lovelace Biomedical Research Institute, Pete & Nancy Domenici Hall, Albuquerque, New Mexico, USA
| | - Meghan S. Vermillion
- The Mind Research Network/Lovelace Biomedical Research Institute, Pete & Nancy Domenici Hall, Albuquerque, New Mexico, USA
| | - Alessio Noghero
- The Mind Research Network/Lovelace Biomedical Research Institute, Pete & Nancy Domenici Hall, Albuquerque, New Mexico, USA
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14
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Neumann KD, Broshek DK, Newman BT, Druzgal TJ, Kundu BK, Resch JE. Concussion: Beyond the Cascade. Cells 2023; 12:2128. [PMID: 37681861 PMCID: PMC10487087 DOI: 10.3390/cells12172128] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023] Open
Abstract
Sport concussion affects millions of athletes each year at all levels of sport. Increasing evidence demonstrates clinical and physiological recovery are becoming more divergent definitions, as evidenced by several studies examining blood-based biomarkers of inflammation and imaging studies of the central nervous system (CNS). Recent studies have shown elevated microglial activation in the CNS in active and retired American football players, as well as in active collegiate athletes who were diagnosed with a concussion and returned to sport. These data are supportive of discordance in clinical symptomology and the inflammatory response in the CNS upon symptom resolution. In this review, we will summarize recent advances in the understanding of the inflammatory response associated with sport concussion and broader mild traumatic brain injury, as well as provide an outlook for important research questions to better align clinical and physiological recovery.
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Affiliation(s)
- Kiel D. Neumann
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
| | - Donna K. Broshek
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA 22903, USA;
| | - Benjamin T. Newman
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA 22903, USA; (B.T.N.); (T.J.D.); (B.K.K.)
| | - T. Jason Druzgal
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA 22903, USA; (B.T.N.); (T.J.D.); (B.K.K.)
| | - Bijoy K. Kundu
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA 22903, USA; (B.T.N.); (T.J.D.); (B.K.K.)
| | - Jacob E. Resch
- Department of Kinesiology, University of Virginia, Charlottesville, VA 22903, USA
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15
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Gard A, Vedung F, Piehl F, Khademi M, Wernersson MP, Rorsman I, Tegner Y, Pessah-Rasmussen H, Ruscher K, Marklund N. Cerebrospinal fluid levels of neuroinflammatory biomarkers are increased in athletes with persistent post-concussive symptoms following sports-related concussion. J Neuroinflammation 2023; 20:189. [PMID: 37592277 PMCID: PMC10433539 DOI: 10.1186/s12974-023-02864-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/29/2023] [Indexed: 08/19/2023] Open
Abstract
A sports-related concussion (SRC) is often caused by rapid head rotation at impact, leading to shearing and stretching of axons in the white matter and initiation of secondary inflammatory processes that may exacerbate the initial injury. We hypothesized that athletes with persistent post-concussive symptoms (PPCS) display signs of ongoing neuroinflammation, as reflected by altered profiles of cerebrospinal fluid (CSF) biomarkers, in turn relating to symptom severity. We recruited athletes with PPCS preventing sports participation as well as limiting work, school and/or social activities for ≥ 6 months for symptom rating using the Sport Concussion Assessment Tool, version 5 (SCAT-5) and for cognitive assessment using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Following a spinal tap, we analysed 27 CSF inflammatory biomarkers (pro-inflammatory chemokines and cytokine panels) by a multiplex immunoassay using antibodies as electrochemiluminescent labels to quantify concentrations in PPCS athletes, and in healthy age- and sex-matched controls exercising ≤ 2 times/week at low-to-moderate intensity. Thirty-six subjects were included, 24 athletes with PPCS and 12 controls. The SRC athletes had sustained a median of five concussions, the most recent at a median of 17 months prior to the investigation. CSF cytokines and chemokines levels were significantly increased in eight (IL-2, TNF-α, IL-15, TNF-β, VEGF, Eotaxin, IP-10, and TARC), significantly decreased in one (Eotaxin-3), and unaltered in 16 in SRC athletes when compared to controls, and two were un-detectable. The SRC athletes reported many and severe post-concussive symptoms on SCAT5, and 10 out of 24 athletes performed in the impaired range (Z < - 1.5) on cognitive testing. Individual biomarker concentrations did not strongly correlate with symptom rating or cognitive function. Limitations include evaluation at a single post-injury time point in relatively small cohorts, and no control group of concussed athletes without persisting symptoms was included. Based on CSF inflammatory marker profiling we find signs of ongoing neuroinflammation persisting months to years after the last SRC in athletes with persistent post-concussive symptoms. Since an ongoing inflammatory response may exacerbate the brain injury these results encourage studies of treatments targeting the post-injury inflammatory response in sports-related concussion.
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Affiliation(s)
- Anna Gard
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
| | - Fredrik Vedung
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Mohsen Khademi
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | | | - Ia Rorsman
- Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Yelverton Tegner
- Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
| | - Hélène Pessah-Rasmussen
- Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | - Karsten Ruscher
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skåne University Hospital EA-Blocket Plan 4, Klinikgatan 17A7, 221 85 Lund, Sweden
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16
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Irwin G, Rogatzki MJ, Wiltshire HD, Williams GKR, Gu Y, Ash GI, Tao D, Baker JS. Sports-Related Concussion Assessment: A New Physiological, Biomechanical, and Cognitive Methodology Incorporating a Randomized Controlled Trial Study Protocol. BIOLOGY 2023; 12:1089. [PMID: 37626975 PMCID: PMC10452437 DOI: 10.3390/biology12081089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/28/2023] [Accepted: 08/02/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Taking part in moderate-to-vigorous exercise in contact sports on a regular basis may be linked to an increase in cerebrovascular injury and head trauma. Validated objective measures are lacking in the initial post-event diagnosis of head injury. The exercise style, duration, and intensity may also confound diagnostic indicators. As a result, we propose that the new Interdisciplinary Group in Movement & Performance from Acute & Chronic Head Trauma (IMPACT) analyze a variety of functional (biomechanical and motor control) tests as well as related biochemistry to see how they are affected by contact in sports and head injury. The study's goal will be to look into the performance and physiological changes in rugby players after a game for head trauma and injury. METHODS This one-of-a-kind study will use a randomized controlled trial (RCT) utilizing a sport participation group and a non-participation control group. Forty male rugby 7 s players will be recruited for the study and allocated randomly to the experimental groups. The intervention group will participate in three straight rugby matches during a local 7 s rugby event. At the pre-match baseline, demographic and anthropometric data will be collected. This will be followed by the pre-match baseline collection of biochemical, biomechanical, and cognitive-motor task data. After three consecutive matches, the same measures will be taken. During each match, a notational analysis will be undertaken to obtain contact information. All measurements will be taken again 24, 48, and 72 h after the third match. DISCUSSION When the number of games increases owing to weariness and/or stressful circumstances, we expect a decline in body movement, coordination, and cognitive-motor tasks. Changes in blood biochemistry are expected to correspond to changes in biomechanics and cognitive-motor processes. This research proposal will generate considerable, ecologically valid data on the occurrence of head trauma events under game conditions, as well as the influence of these events on the biological systems of the performers. This will lead to a greater understanding of how sports participants react to exercise-induced injuries. This study's scope will have far-reaching ramifications for doctors, coaches, managers, scientists, and sports regulatory bodies concerned with the health and well-being of athletic populations at all levels of competition, including all genders and ages.
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Affiliation(s)
- Gareth Irwin
- Faculty of Sports Science, Ningbo University, Ningbo 315010, China; (G.I.); (Y.G.); (J.S.B.)
- Research Academy of Medicine Combining Sports, Ningbo No.2 Hospital, Ningbo 315010, China
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff CF52YB, UK;
- Sport and Health Interdisciplinary Group in Movement & Performance from Acute & Chronic Head Trauma (IMPACT) Group, Cardiff Metropolitan University, Cardiff CF52YB, UK; (M.J.R.); (G.K.R.W.); (G.I.A.)
| | - Matthew J. Rogatzki
- Sport and Health Interdisciplinary Group in Movement & Performance from Acute & Chronic Head Trauma (IMPACT) Group, Cardiff Metropolitan University, Cardiff CF52YB, UK; (M.J.R.); (G.K.R.W.); (G.I.A.)
- Department of Health & Exercise Science, Appalachian State University, Boone, NC 28608, USA
| | - Huw D. Wiltshire
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff CF52YB, UK;
- Sport and Health Interdisciplinary Group in Movement & Performance from Acute & Chronic Head Trauma (IMPACT) Group, Cardiff Metropolitan University, Cardiff CF52YB, UK; (M.J.R.); (G.K.R.W.); (G.I.A.)
| | - Genevieve K. R. Williams
- Sport and Health Interdisciplinary Group in Movement & Performance from Acute & Chronic Head Trauma (IMPACT) Group, Cardiff Metropolitan University, Cardiff CF52YB, UK; (M.J.R.); (G.K.R.W.); (G.I.A.)
- Department of Sport and Health Sciences, University of Exeter, Exeter EX44QJ, UK
| | - Yaodong Gu
- Faculty of Sports Science, Ningbo University, Ningbo 315010, China; (G.I.); (Y.G.); (J.S.B.)
- Research Academy of Medicine Combining Sports, Ningbo No.2 Hospital, Ningbo 315010, China
- Sport and Health Interdisciplinary Group in Movement & Performance from Acute & Chronic Head Trauma (IMPACT) Group, Cardiff Metropolitan University, Cardiff CF52YB, UK; (M.J.R.); (G.K.R.W.); (G.I.A.)
| | - Garrett I. Ash
- Sport and Health Interdisciplinary Group in Movement & Performance from Acute & Chronic Head Trauma (IMPACT) Group, Cardiff Metropolitan University, Cardiff CF52YB, UK; (M.J.R.); (G.K.R.W.); (G.I.A.)
- Section of General Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06510, USA
- Center for Pain, Research, Informatics, Medical Comorbidities and Education Center (PRIME), VA Connecticut Healthcare System, West Haven, CT 06510, USA
| | - Dan Tao
- Sport and Health Interdisciplinary Group in Movement & Performance from Acute & Chronic Head Trauma (IMPACT) Group, Cardiff Metropolitan University, Cardiff CF52YB, UK; (M.J.R.); (G.K.R.W.); (G.I.A.)
- Department of Government and International Studies, Hong Kong Baptist University, Hong Kong 999077, China
| | - Julien S. Baker
- Faculty of Sports Science, Ningbo University, Ningbo 315010, China; (G.I.); (Y.G.); (J.S.B.)
- Research Academy of Medicine Combining Sports, Ningbo No.2 Hospital, Ningbo 315010, China
- Sport and Health Interdisciplinary Group in Movement & Performance from Acute & Chronic Head Trauma (IMPACT) Group, Cardiff Metropolitan University, Cardiff CF52YB, UK; (M.J.R.); (G.K.R.W.); (G.I.A.)
- Centre for Health and Exercise Science Research, Hong Kong Baptist University, Hong Kong 999077, China
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17
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Tsitsipanis C, Miliaraki M, Paflioti E, Lazarioti S, Moustakis N, Ntotsikas K, Theofanopoulos A, Ilia S, Vakis A, Simos P, Venihaki M. Inflammation biomarkers IL‑6 and IL‑10 may improve the diagnostic and prognostic accuracy of currently authorized traumatic brain injury tools. Exp Ther Med 2023; 26:364. [PMID: 37408863 PMCID: PMC10318605 DOI: 10.3892/etm.2023.12063] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/04/2023] [Indexed: 07/07/2023] Open
Abstract
Traumatic brain injury (TBI) is currently one of the leading causes of mortality and disability worldwide. At present, no reliable inflammatory or specific molecular neurobiomarker exists in any of the standard models proposed for TBI classification or prognostication. Therefore, the present study was designed to assess the value of a group of inflammatory mediators for evaluating acute TBI, in combination with clinical, laboratory and radiological indices and prognostic clinical scales. In the present single-centre, prospective observational study, 109 adult patients with TBI, 20 adult healthy controls and a pilot group of 17 paediatric patients with TBI from a Neurosurgical Department and two intensive care units of University General Hospital of Heraklion, Greece were recruited. Blood measurements using the ELISA method, of cytokines IL-6, IL-8 and IL-10, ubiquitin C-terminal hydrolase L1 (UCH-L1) and glial fibrillary acidic protein, were performed. Compared with those in healthy control individuals, elevated IL-6 and IL-10 but reduced levels of IL-8 were found on day 1 in adult patients with TBI. In terms of TBI severity classifications, higher levels of IL-6 (P=0.001) and IL-10 (P=0.009) on day 1 in the adult group were found to be associated with more severe TBI according to widely used clinical and functional scales. Moreover, elevated IL-6 and IL-10 in adults were found to be associated with more serious brain imaging findings (rs<0.442; P<0.007). Subsequent multivariate logistic regression analysis in adults revealed that early-measured (day 1) IL-6 [odds ratio (OR)=0.987; P=0.025] and UCH-L1 (OR=0.993; P=0.032) are significant independent predictors of an unfavourable outcome. In conclusion, results from the present study suggest that inflammatory molecular biomarkers may prove to be valuable diagnostic and prognostic tools for TBI.
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Affiliation(s)
- Christos Tsitsipanis
- Department of Neurosurgery, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | - Marianna Miliaraki
- Pediatric Intensive Care Unit, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | - Elina Paflioti
- Department of Clinical Chemistry, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | - Sofia Lazarioti
- Department of Neurosurgery, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | - Nikolaos Moustakis
- Department of Neurosurgery, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | - Konstantinos Ntotsikas
- Department of Neurosurgery, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | | | - Stavroula Ilia
- Pediatric Intensive Care Unit, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | - Antonis Vakis
- Department of Neurosurgery, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | - Panagiotis Simos
- Department of Psychiatry, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | - Maria Venihaki
- Department of Clinical Chemistry, School of Medicine, University of Crete, 70013 Heraklion, Greece
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18
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Wu YC, Wen Q, Thukral R, Yang HC, Gill JM, Gao S, Lane KA, Meier TB, Riggen LD, Harezlak J, Giza CC, Goldman J, Guskiewicz KM, Mihalik JP, LaConte SM, Duma SM, Broglio SP, Saykin AJ, McAllister TW, McCrea MA. Longitudinal Associations Between Blood Biomarkers and White Matter MRI in Sport-Related Concussion: A Study of the NCAA-DoD CARE Consortium. Neurology 2023; 101:e189-e201. [PMID: 37328299 PMCID: PMC10351550 DOI: 10.1212/wnl.0000000000207389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 03/22/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To study longitudinal associations between blood-based neural biomarkers (including total tau, neurofilament light [NfL], glial fibrillary acidic protein [GFAP], and ubiquitin C-terminal hydrolase-L1) and white matter neuroimaging biomarkers in collegiate athletes with sport-related concussion (SRC) from 24 hours postinjury to 1 week after return to play. METHODS We analyzed clinical and imaging data of concussed collegiate athletes in the Concussion Assessment, Research, and Education (CARE) Consortium. The CARE participants completed same-day clinical assessments, blood draws, and diffusion tensor imaging (DTI) at 3 time points: 24-48 hours postinjury, point of becoming asymptomatic, and 7 days after return to play. DTI probabilistic tractography was performed for each participant at each time point to render 27 participant-specific major white matter tracts. The microstructural organization of these tracts was characterized by 4 DTI metrics. Mixed-effects models with random intercepts were applied to test whether white matter microstructural abnormalities are associated with the blood-based biomarkers at the same time point. An interaction model was used to test whether the association varies across time points. A lagged model was used to test whether early blood-based biomarkers predict later microstructural changes. RESULTS Data from 77 collegiate athletes were included in the following analyses. Among the 4 blood-based biomarkers, total tau had significant associations with the DTI metrics across the 3 time points. In particular, high tau level was associated with high radial diffusivity (RD) in the right corticospinal tract (β = 0.25, SE = 0.07, p FDR-adjusted = 0.016) and superior thalamic radiation (β = 0.21, SE = 0.07, p FDR-adjusted = 0.042). NfL and GFAP had time-dependent associations with the DTI metrics. NfL showed significant associations only at the asymptomatic time point (|β|s > 0.12, SEs <0.09, psFDR-adjusted < 0.05) and GFAP showed a significant association only at 7 days after return to play (βs > 0.14, SEs <0.06, psFDR-adjusted < 0.05). The p values for the associations of early tau and later RD were not significant after multiple comparison adjustment, but were less than 0.1 in 7 white matter tracts. DISCUSSION This prospective study using data from the CARE Consortium demonstrated that in the early phase of SRC, white matter microstructural integrity detected by DTI neuroimaging was associated with elevated levels of blood-based biomarkers of traumatic brain injury. Total tau in the blood showed the strongest association with white matter microstructural changes.
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Affiliation(s)
- Yu-Chien Wu
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis.
| | - Qiuting Wen
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Rhea Thukral
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Ho-Ching Yang
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Jessica M Gill
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Sujuan Gao
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Kathleen A Lane
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Timothy B Meier
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Larry D Riggen
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Jaroslaw Harezlak
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Christopher C Giza
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Joshua Goldman
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Kevin M Guskiewicz
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Jason P Mihalik
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Stephen M LaConte
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Stefan M Duma
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Steven P Broglio
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Andrew J Saykin
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Thomas Walker McAllister
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
| | - Michael A McCrea
- From the Department of Radiology and Imaging Sciences (Y.-C.W., Q.W., R.T., H.-C.Y., A.J.S.), Indiana University School of Medicine, Indianapolis; School of Nursing (J.M.G.), Johns Hopkins University, Baltimore, MD; Department of Biostatistics and Health Data Science (S.G., K.A.L., L.D.R.), Indiana University School of Medicine, Indianapolis; Department of Neurosurgery (T.B.M., M.A.M.), Medical College of Wisconsin, Milwaukee; Department of Epidemiology and Biostatistics (J.H.), School of Public Health, Indiana University, Bloomington; Department of Neurosurgery (C.C.G.), David Geffen School of Medicine at University of California Los Angeles; Family Medicine (J.G.), Ronald Reagan UCLA Medical Center, UCLA Health-Santa Monica Medical Center; Matthew Gfeller Center (K.M.G., J.P.M.), Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; School of Biomedical Engineering and Sciences (S.M.L., S.M.D.), Wake-Forest and Virginia Tech University, Blacksburg; Michigan Concussion Center (S.P.B.), University of Michigan, Ann Arbor; and Department of Psychiatry (T.W.M.), Indiana University School of Medicine, Indianapolis
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19
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Echemendia RJ, Burma JS, Bruce JM, Davis GA, Giza CC, Guskiewicz KM, Naidu D, Black AM, Broglio S, Kemp S, Patricios JS, Putukian M, Zemek R, Arango-Lasprilla JC, Bailey CM, Brett BL, Didehbani N, Gioia G, Herring SA, Howell D, Master CL, Valovich McLeod TC, Meehan WP, Premji Z, Salmon D, van Ierssel J, Bhathela N, Makdissi M, Walton SR, Kissick J, Pardini J, Schneider KJ. Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review. Br J Sports Med 2023; 57:722-735. [PMID: 37316213 DOI: 10.1136/bjsports-2022-106661] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6). DATA SOURCES Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation. ELIGIBILITY CRITERIA (1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC. DATA EXTRACTION Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool. RESULTS Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children. CONCLUSION Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes. PROSPERO REGISTRATION NUMBER CRD42020154787.
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Affiliation(s)
- Ruben J Echemendia
- Concussion Care Clinic, University Orthopedics, State College, Pennsylvania, USA
- University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Joel S Burma
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Jared M Bruce
- Biomedical and Health Informatics, University of Missouri - Kansas City, Kansas City, Missouri, USA
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Cabrini Health, Malvern, Victoria, Australia
| | - Christopher C Giza
- Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, California, USA
- Pediatrics/Pediatric Neurology, Mattel Children's Hospital UCLA, Los Angeles, California, USA
| | - Kevin M Guskiewicz
- Matthew Gfeller Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dhiren Naidu
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Steven Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Simon Kemp
- Sports Medicine, Rugby Football Union, London, UK
| | - Jon S Patricios
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | | | - Roger Zemek
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Christopher M Bailey
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Benjamin L Brett
- Neurosurgery/ Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Gerry Gioia
- Depts of Pediatrics and Psychiatry & Behavioral Sciences, Children's National Health System, Washington, District of Columbia, USA
| | - Stanley A Herring
- Department of Rehabilitation Medicine, Orthopaedics and Sports Medicine, and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - David Howell
- Orthopedics, Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Tamara C Valovich McLeod
- Department of Athletic Training and School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa, Arizona, USA
| | - William P Meehan
- Sports Medicine, Children's Hospital Boston, Boston, Massachusetts, USA
- Emergency Medicine, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Zahra Premji
- Libraries, University of Victoria, Victoria, British Columbia, Canada
| | | | | | - Neil Bhathela
- UCLA Health Steve Tisch BrainSPORT Program, Los Angeles, California, USA
| | - Michael Makdissi
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- La Trobe Sport and Exercise Medicine Research Centre, Melbourne, Victoria, Australia
| | - Samuel R Walton
- Department of Physical Medicine and Rehabilitation, School of Medicine, Richmond, Virginia, USA
| | - James Kissick
- Dept of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jamie Pardini
- Departments of Internal Medicine and Neurology, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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20
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Tabor JB, Brett BL, Nelson L, Meier T, Penner LC, Mayer AR, Echemendia RJ, McAllister T, Meehan WP, Patricios J, Makdissi M, Bressan S, Davis GA, Premji Z, Schneider KJ, Zetterberg H, McCrea M. Role of biomarkers and emerging technologies in defining and assessing neurobiological recovery after sport-related concussion: a systematic review. Br J Sports Med 2023; 57:789-797. [PMID: 37316184 DOI: 10.1136/bjsports-2022-106680] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Determine the role of fluid-based biomarkers, advanced neuroimaging, genetic testing and emerging technologies in defining and assessing neurobiological recovery after sport-related concussion (SRC). DESIGN Systematic review. DATA SOURCES Searches of seven databases from 1 January 2001 through 24 March 2022 using keywords and index terms relevant to concussion, sports and neurobiological recovery. Separate reviews were conducted for studies involving neuroimaging, fluid biomarkers, genetic testing and emerging technologies. A standardised method and data extraction tool was used to document the study design, population, methodology and results. Reviewers also rated the risk of bias and quality of each study. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies were included if they: (1) were published in English; (2) represented original research; (3) involved human research; (4) pertained only to SRC; (5) included data involving neuroimaging (including electrophysiological testing), fluid biomarkers or genetic testing or other advanced technologies used to assess neurobiological recovery after SRC; (6) had a minimum of one data collection point within 6 months post-SRC; and (7) contained a minimum sample size of 10 participants. RESULTS A total of 205 studies met inclusion criteria, including 81 neuroimaging, 50 fluid biomarkers, 5 genetic testing, 73 advanced technologies studies (4 studies overlapped two separate domains). Numerous studies have demonstrated the ability of neuroimaging and fluid-based biomarkers to detect the acute effects of concussion and to track neurobiological recovery after injury. Recent studies have also reported on the diagnostic and prognostic performance of emerging technologies in the assessment of SRC. In sum, the available evidence reinforces the theory that physiological recovery may persist beyond clinical recovery after SRC. The potential role of genetic testing remains unclear based on limited research. CONCLUSIONS Advanced neuroimaging, fluid-based biomarkers, genetic testing and emerging technologies are valuable research tools for the study of SRC, but there is not sufficient evidence to recommend their use in clinical practice. PROSPERO REGISTRATION NUMBER CRD42020164558.
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Affiliation(s)
- Jason B Tabor
- Sport Injury Prevention Research Centre, Faculty of Kinesiology; University of Calgary, Calgary, Alberta, Canada
| | - Benjamin L Brett
- Department of Neurosurgery and Center for Neurotrauma Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lindsay Nelson
- Department of Neurosurgery and Center for Neurotrauma Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Timothy Meier
- Department of Neurosurgery and Center for Neurotrauma Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Linden C Penner
- Sport Injury Prevention Research Centre, Faculty of Kinesiology; University of Calgary, Calgary, Alberta, Canada
| | - Andrew R Mayer
- The Mind Research Network, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Ruben J Echemendia
- Psychology, University of Missouri Kansas City, Kansas City, Missouri, USA
- Psychological and Neurobehavioral Associates, Inc, State College, PA, USA
| | - Thomas McAllister
- Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - William P Meehan
- Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Boston, Massachusetts, USA
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Patricios
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand South, Johannesburg, South Africa
| | - Michael Makdissi
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- Australian Football League, Melbourne, Victoria, Australia
| | - Silvia Bressan
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Zahra Premji
- Libraries, University of Victoria, Victoria, British Columbia, Canada
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology; University of Calgary, Calgary, Alberta, Canada
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Molndal, Sweden
| | - Michael McCrea
- Department of Neurosurgery and Center for Neurotrauma Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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21
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Malik S, Alnaji O, Malik M, Gambale T, Farrokhyar F, Rathbone MP. Inflammatory cytokines associated with mild traumatic brain injury and clinical outcomes: a systematic review and meta-analysis. Front Neurol 2023; 14:1123407. [PMID: 37251220 PMCID: PMC10213278 DOI: 10.3389/fneur.2023.1123407] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Mild traumatic brain injuries (mTBIs) trigger a neuroinflammatory response, which leads to perturbations in the levels of inflammatory cytokines, resulting in a distinctive profile. A systematic review and meta-analysis were conducted to synthesize data related to levels of inflammatory cytokines in patients with mTBI. The electronic databases EMBASE, MEDLINE, and PUBMED were searched from January 2014 to December 12, 2021. A total of 5,138 articles were screened using a systematic approach based on the PRISMA and R-AMSTAR guidelines. Of these articles, 174 were selected for full-text review and 26 were included in the final analysis. The results of this study demonstrate that within 24 hours, patients with mTBI have significantly higher levels of Interleukin-6 (IL-6), Interleukin-1 Receptor Antagonist (IL-1RA), and Interferon-γ (IFN-γ) in blood, compared to healthy controls in majority of the included studies. Similarly one week following the injury, patients with mTBI have higher circulatory levels of Monocyte Chemoattractant Protein-1/C-C Motif Chemokine Ligand 2 (MCP-1/CCL2), compared to healthy controls in majority of the included studies. The results of the meta-analysis also confirmed these findings by demonstrating significantly elevated blood levels of IL-6, MCP-1/CCL2, and Interleukin-1 beta (IL-1β) in the mTBI population compared to healthy controls (p < 0.0001), particularly in the acute stages (<7 days). Furthermore, it was found that IL-6, Tumor Necrosis Factor-alpha (TNF-α), IL-1RA, IL-10, and MCP-1/CCL2 were associated with poor clinical outcomes following the mTBI. Finally, this research highlights the lack of consensus in the methodology of mTBI studies that measure inflammatory cytokines in the blood, and also provides direction for future mTBI research.
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Affiliation(s)
- Shazia Malik
- Neurosciences Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Omar Alnaji
- Faculty of Life Sciences, McMaster University, Hamilton, ON, Canada
| | - Mahnoor Malik
- Bachelor of Health Sciences Program, McMaster University, Hamilton, ON, Canada
| | - Teresa Gambale
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Surgery and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Michel P. Rathbone
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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22
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Vorn R, Devoto C, Meier TB, Lai C, Yun S, Broglio SP, Mithani S, McAllister TW, Giza CC, Kim HS, Huber D, Harezlak J, Cameron KL, McGinty G, Jackson J, Guskiewicz KM, Mihalik JP, Brooks A, Duma S, Rowson S, Nelson LD, Pasquina P, McCrea MA, Gill JM. Are EPB41 and alpha-synuclein diagnostic biomarkers of sport-related concussion? Findings from the NCAA and Department of Defense CARE Consortium. JOURNAL OF SPORT AND HEALTH SCIENCE 2023; 12:379-387. [PMID: 36403906 DOI: 10.1016/j.jshs.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 07/15/2022] [Accepted: 10/08/2022] [Indexed: 05/17/2023]
Abstract
BACKGROUND Current protein biomarkers are only moderately predictive at identifying individuals with mild traumatic brain injury or concussion. Therefore, more accurate diagnostic markers are needed for sport-related concussion. METHODS This was a multicenter, prospective, case-control study of athletes who provided blood samples and were diagnosed with a concussion or were a matched non-concussed control within the National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research, and Education Consortium conducted between 2015 and 2019. The blood was collected within 48 h of injury to identify protein abnormalities at the acute and subacute timepoints. Athletes with concussion were divided into 6 h post-injury (0-6 h post-injury) and after 6 h post-injury (7-48 h post-injury) groups. We applied a highly multiplexed proteomic technique that used a DNA aptamers assay to target 1305 proteins in plasma samples from athletes with and without sport-related concussion. RESULTS A total of 140 athletes with concussion (79.3% males; aged 18.71 ± 1.10 years, mean ± SD) and 21 non-concussed athletes (76.2% males; 19.14 ± 1.10 years) were included in this study. We identified 338 plasma proteins that significantly differed in abundance (319 upregulated and 19 downregulated) in concussed athletes compared to non-concussed athletes. The top 20 most differentially abundant proteins discriminated concussed athletes from non-concussed athletes with an area under the curve (AUC) of 0.954 (95% confidence interval: 0.922‒0.986). Specifically, after 6 h of injury, the individual AUC of plasma erythrocyte membrane protein band 4.1 (EPB41) and alpha-synuclein (SNCA) were 0.956 and 0.875, respectively. The combination of EPB41 and SNCA provided the best AUC (1.000), which suggests this combination of candidate plasma biomarkers is the best for diagnosing concussion in athletes after 6 h of injury. CONCLUSION Our data suggest that proteomic profiling may provide novel diagnostic protein markers and that a combination of EPB41 and SNCA is the most predictive biomarker of concussion after 6 h of injury.
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Affiliation(s)
- Rany Vorn
- Johns Hopkins School of Nursing and Medicine, Baltimore, MD 21205, USA; National Institutes of Health, Bethesda, MD 20892, USA
| | | | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Chen Lai
- National Institutes of Health, Bethesda, MD 20892, USA
| | - Sijung Yun
- Predictiv Care, Inc., Mountain View, CA 94086, USA
| | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sara Mithani
- National Institutes of Health, Bethesda, MD 20892, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Christopher C Giza
- Departments of Pediatrics and Neurosurgery, University of California at Los Angeles (UCLA), Los Angeles, CA 90024, USA
| | - Hyung-Suk Kim
- National Institutes of Health, Bethesda, MD 20892, USA
| | - Daniel Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Jaroslaw Harezlak
- Department of Epidemiology and Biostatistics School of Public Health - Bloomington, Indiana University, Bloomington, IN 47405, USA
| | - Kenneth L Cameron
- John A. Feagin Sports Medicine Fellowship, Keller Army Community Hospital, West Point, NY 10996, USA
| | - Gerald McGinty
- United States Air Force Academy, Colorado Springs, CO 80840, USA
| | - Jonathan Jackson
- United States Air Force Academy, Colorado Springs, CO 80840, USA
| | - Kevin M Guskiewicz
- Mathew Gfeller Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Jason P Mihalik
- Mathew Gfeller Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Alison Brooks
- Department of Orthopedics, Division of Sports Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
| | - Stefan Duma
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA 24061, USA
| | - Steven Rowson
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA 24061, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Paul Pasquina
- Center for Neuroscience & Regenerative Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Jessica M Gill
- Johns Hopkins School of Nursing and Medicine, Baltimore, MD 21205, USA.
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23
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Bazarian JJ, Abar B, Merchant-Borna K, Pham DL, Rozen E, Mannix R, Kawata K, Chou Y, Stephen S, Gill JM. Effects of Physical Exertion on Early Changes in Blood-Based Brain Biomarkers: Implications for the Acute Point of Care Diagnosis of Concussion. J Neurotrauma 2023; 40:693-705. [PMID: 36200628 PMCID: PMC10061333 DOI: 10.1089/neu.2022.0267] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Blood-based brain biomarkers (BBM) such as glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) have potential to aid in the diagnosis of concussion. Recently developed point-of-care test devices would enable BBMs to be measured in field settings such military and sport environments within minutes of a suspicious head hit. However, head hits in these environments typically occur in the setting of vigorous physical exertion, which can itself increase BBMs levels. Thus, efforts to develop BBMs as acute concussion aids in field settings need to account for the effects of physical exertion. To determine the acute effects of physical exertion on the BBMs, we measured GFAP, UCH-L1, tau, and neurofilament light chain (NF-L) immediately before, immediately after, and 45 min after a single workout session consisting of aerobic and resistance exercises in 30 collegiate football players. Subjects wore body sensors measuring several aspects of exertion and underwent diffusion tensor imaging 24 h before and 48 h after exertion. All subjects were male with a mean age of 19.5 ± 1.2 years. The mean duration of activity during the workout session was 94 ± 31 min. There was a significant decrease in serum GFAP immediately after (median decrease of 27.76%, p < 0.0001) and a significant increase in serum UCH-L1 45 min after (median increase of 37.11%, p = 0.016) exertion, compared with pre-exertion baseline. No significant changes in tau or NF-L were identified. The duration of exertion had a significant independent linear correlation to the increase in serum UCHL1 from pre-exertion to 45 min after exertion (r = 0.68, p = 0.004). There were no significant pre- to post-exertional changes in any of the 39 examined brain white matter regions, and biomarker changes did not correlate to variation in white matter integrity in any of these regions. Thus, exertion appeared to be associated with immediate decreases in serum GFAP and very acute (45 min) increases in UCH-L1. These changes were related to the duration of exertion, but not to changes in brain white matter integrity. Our results have important implications for how these BBMs might be used to aid in the on-scene diagnosis of concussion occurring in the setting of physical exertion.
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Affiliation(s)
- Jeffrey J. Bazarian
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kian Merchant-Borna
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Dzung L. Pham
- Center for Neuroscience and Regenerative Medicine, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Eric Rozen
- Department of Athletics and Recreation, University of Rochester, Rochester, New York, USA
| | - Rebekah Mannix
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Keisuke Kawata
- Department of Kinesiology, Indiana University, Bloomington, Indiana, USA
| | - Yiyu Chou
- Center for Neuroscience and Regenerative Medicine, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Steve Stephen
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Jessica M. Gill
- Johns Hopkins School of Nursing and School of Medicine, Baltimore, Maryland, USA
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24
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Tomaiuolo R, Zibetti M, Di Resta C, Banfi G. Challenges of the Effectiveness of Traumatic Brain Injuries Biomarkers in the Sports-Related Context. J Clin Med 2023; 12:jcm12072563. [PMID: 37048647 PMCID: PMC10095236 DOI: 10.3390/jcm12072563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Traumatic brain injury affects 69 million people every year. One of the main limitations in managing TBI patients is the lack of univocal diagnostic criteria, including the absence of standardized assessment methods and guidelines. Computerized axial tomography is the first-choice examination, despite the limited prevalence of positivity; moreover, its performance is undesirable due to the risk of radiological exposure, prolonged stay in emergency departments, inefficient use of resources, high cost, and complexity. Furthermore, immediacy and accuracy in diagnosis and management of TBIs are critically unmet medical needs. Especially in the context of sports-associated TBI, there is a strong need for prognostic indicators to help diagnose and identify at-risk subjects to avoid their returning to play while the brain is still highly vulnerable. Fluid biomarkers may emerge as new prognostic indicators to develop more accurate prediction models, improving risk stratification and clinical decision making. This review describes the current understanding of the cellular sources, temporal profile, and potential utility of leading and emerging blood-based protein biomarkers of TBI; its focus is on biomarkers that could improve the management of mild TBI cases and can be measured readily and directly in the field, as in the case of sports-related contexts.
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Affiliation(s)
- Rossella Tomaiuolo
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Martina Zibetti
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Chiara Di Resta
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
- Correspondence:
| | - Giuseppe Banfi
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
- IRCCS Galeazzi-Sant’Ambrogio, 20157 Milan, Italy
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25
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Neumann KD, Seshadri V, Thompson XD, Broshek DK, Druzgal J, Massey JC, Newman B, Reyes J, Simpson SR, McCauley KS, Patrie J, Stone JR, Kundu BK, Resch JE. Microglial activation persists beyond clinical recovery following sport concussion in collegiate athletes. Front Neurol 2023; 14:1127708. [PMID: 37034078 PMCID: PMC10080132 DOI: 10.3389/fneur.2023.1127708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction In concussion, clinical and physiological recovery are increasingly recognized as diverging definitions. This study investigated whether central microglial activation persisted in participants with concussion after receiving an unrestricted return-to-play (uRTP) designation using [18F]DPA-714 PET, an in vivo marker of microglia activation. Methods Eight (5 M, 3 F) current athletes with concussion (Group 1) and 10 (5 M, 5 F) healthy collegiate students (Group 2) were enrolled. Group 1 completed a pre-injury (Visit1) screen, follow-up Visit2 within 24 h of a concussion diagnosis, and Visit3 at the time of uRTP. Healthy participants only completed assessments at Visit2 and Visit3. At Visit2, all participants completed a multidimensional battery of tests followed by a blood draw to determine genotype and study inclusion. At Visit3, participants completed a clinical battery of tests, brain MRI, and brain PET; no imaging tests were performed outside of Visit3. Results For Group 1, significant differences were observed between Visits 1 and 2 (p < 0.05) in ImPACT, SCAT5 and SOT performance, but not between Visit1 and Visit3 for standard clinical measures (all p > 0.05), reflecting clinical recovery. Despite achieving clinical recovery, PET imaging at Visit3 revealed consistently higher [18F]DPA-714 tracer distribution volume (VT) of Group 1 compared to Group 2 in 10 brain regions (p < 0.001) analyzed from 164 regions of the whole brain, most notably within the limbic system, dorsal striatum, and medial temporal lobe. No notable differences were observed between clinical measures and VT between Group 1 and Group 2 at Visit3. Discussion Our study is the first to demonstrate persisting microglial activation in active collegiate athletes who were diagnosed with a sport concussion and cleared for uRTP based on a clinical recovery.
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Affiliation(s)
- Kiel D Neumann
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, United States
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, United States
| | - Vikram Seshadri
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, United States
| | - Xavier D Thompson
- Department of Kinesiology, University of Virginia, Charlottesville, VA, United States
| | - Donna K Broshek
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA, United States
| | - Jason Druzgal
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, United States
| | - James C Massey
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, United States
| | - Benjamin Newman
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, United States
| | - Jose Reyes
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, United States
| | - Spenser R Simpson
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Katelyenn S McCauley
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, United States
| | - James Patrie
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - James R Stone
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Bijoy K Kundu
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, United States
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, United States
| | - Jacob E Resch
- Department of Kinesiology, University of Virginia, Charlottesville, VA, United States
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Oris C, Durif J, Rouzaire M, Pereira B, Bouvier D, Kahouadji S, Abbot M, Brailova M, Lehmann S, Hirtz C, Decq P, Dusfour B, Marchi N, Sapin V. Blood Biomarkers for Return to Play after Concussion in Professional Rugby Players. J Neurotrauma 2023; 40:283-295. [PMID: 36047487 DOI: 10.1089/neu.2022.0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We prospectively evaluated a panel of seven blood biomarkers (S100 calcium-binding protein B [S100B], neuron specific enolase [NSE], spectrin breakdown products [SBDP], ubiquitin C-terminal hydrolase L1 [UCHL1], glial fibrillary acidic protein [GFAP], neurofilament light chain [NFL], and tubulin-associated unit [Tau]) for sport-related concussion (SRC) in a large multi-centric cohort of 496 professional rugby players from 14 French elite teams. Players were sampled twice during the season (beginning and end) away from any sport practice. From these two baseline samples, we evaluated the intra-individual variability to establish the effect of rugby on blood biomarkers over a season. Only S100B and GFAP remained stable over the course of a season. During the period of the study, a total of 45 SRC cases was reported for 42 players. In 45 SRCs, the head injury assessment (HIA) process was performed and blood collection was realized 36 h after the concussion (HIA-3 stage). For each biomarker, raw concentrations measured 36 h after SRC were not significantly different between players with a non-resolutive SRC (n = 28) and those with a resolutive SRC (n = 17; p between 0.06 and 0.92). In a second step, blood concentrations measured 36 h after SRC were expressed according to the basal concentrations as an individual percentage change (PCH36[%]), calculated as follows: PCH36 = 100 × (([Biomarker]36h - [Biomarker]basal)/[Biomarker]basal). S100B and NFL concentrations expressed as PCH36[%] were significantly different between non-resolutive and resolutive SRCs (p = 0.006 and 0.01 respectively), with a positive delta found in non-resolutive SRCs. Among the two biomarkers, it is important to note that only the S100B protein was stable during the season. In the context of our study, during HIA-3 assessment, S100B seems to perform better than NSE, SBDP, UCHL1, GFAP, NFL, and Tau as biomarker for SRC. From a clinical standpoint, the S100B modification over baseline may be valuable, at 36 h after concussion to distinguish non-resolutive SRC from resolutive SRC.
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Affiliation(s)
- Charlotte Oris
- Department of Biochemistry and Molecular Genetics, University Hospital, Clermont-Ferrand, France
- Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France
| | - Julie Durif
- Department of Biochemistry and Molecular Genetics, University Hospital, Clermont-Ferrand, France
| | - Marion Rouzaire
- Department of Biochemistry and Molecular Genetics, University Hospital, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics unit (DRCI) Department, University Hospital, Clermont-Ferrand, France
| | - Damien Bouvier
- Department of Biochemistry and Molecular Genetics, University Hospital, Clermont-Ferrand, France
- Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France
| | - Samy Kahouadji
- Department of Biochemistry and Molecular Genetics, University Hospital, Clermont-Ferrand, France
- Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France
| | - Mathieu Abbot
- Department of Sport Medicine and Functional Explorations, University Hospital, Clermont-Ferrand, France
| | - Marina Brailova
- Department of Biochemistry and Molecular Genetics, University Hospital, Clermont-Ferrand, France
| | | | | | - Philippe Decq
- Neurosurgery Department, Beaujon Hospital, Paris University, Paris, France
- Assistance Publique-Hôpitaux de Paris, Clichy, France
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers ParisTech, Paris, France
| | - Bernard Dusfour
- Medical Committee, French National Rugby League, Paris, France
| | - Nicola Marchi
- Cerebrovascular and Glia Research, Department of Neuroscience, Institute of Functional Genomics (UMR 5203 CNRS-U 1191 INSERM, University of Montpellier), Montpellier, France
| | - Vincent Sapin
- Department of Biochemistry and Molecular Genetics, University Hospital, Clermont-Ferrand, France
- Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France
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27
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Mayer AR, Meier TB, Dodd AB, Stephenson DD, Robertson-Benta CR, Ling JM, Pabbathi Reddy S, Zotev V, Vakamudi K, Campbell RA, Sapien RE, Erhardt EB, Phillips JP, Vakhtin AA. Prospective Study of Gray Matter Atrophy Following Pediatric Mild Traumatic Brain Injury. Neurology 2023; 100:e516-e527. [PMID: 36522161 PMCID: PMC9931084 DOI: 10.1212/wnl.0000000000201470] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 09/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The clinical and physiologic time course for recovery following pediatric mild traumatic brain injury (pmTBI) remains actively debated. The primary objective of the current study was to prospectively examine structural brain changes (cortical thickness and subcortical volumes) and age-at-injury effects. A priori study hypotheses predicted reduced cortical thickness and hippocampal volumes up to 4 months postinjury, which would be inversely associated with age at injury. METHODS Prospective cohort study design with consecutive recruitment. Study inclusion adapted from American Congress of Rehabilitation Medicine (upper threshold) and Zurich Concussion in Sport Group (minimal threshold) and diagnosed by Emergency Department and Urgent Care clinicians. Major neurologic, psychiatric, or developmental disorders were exclusionary. Clinical (Common Data Element) and structural (3 T MRI) evaluations within 11 days (subacute visit [SA]) and at 4 months (early chronic visit [EC]) postinjury. Age- and sex-matched healthy controls (HC) to control for repeat testing/neurodevelopment. Clinical outcomes based on self-report and cognitive testing. Structural images quantified with FreeSurfer (version 7.1.1). RESULTS A total of 208 patients with pmTBI (age = 14.4 ± 2.9; 40.4% female) and 176 HC (age = 14.2 ± 2.9; 42.0% female) were included in the final analyses (>80% retention). Reduced cortical thickness (right rostral middle frontal gyrus; d = -0.49) and hippocampal volumes (d = -0.24) observed for pmTBI, but not associated with age at injury. Hippocampal volume recovery was mediated by loss of consciousness/posttraumatic amnesia. Significantly greater postconcussive symptoms and cognitive deficits were observed at SA and EC visits, but were not associated with the structural abnormalities. Structural abnormalities slightly improved balanced classification accuracy above and beyond clinical gold standards (∆+3.9%), with a greater increase in specificity (∆+7.5%) relative to sensitivity (∆+0.3%). DISCUSSION Current findings indicate that structural brain abnormalities may persist up to 4 months post-pmTBI and are partially mediated by initial markers of injury severity. These results contribute to a growing body of evidence suggesting prolonged physiologic recovery post-pmTBI. In contrast, there was no evidence for age-at-injury effects or physiologic correlates of persistent symptoms in our sample.
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Affiliation(s)
- Andrew R Mayer
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque.
| | - Timothy B Meier
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Andrew B Dodd
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - David D Stephenson
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Cidney R Robertson-Benta
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Josef M Ling
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Sharvani Pabbathi Reddy
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Vadim Zotev
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Kishore Vakamudi
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Richard A Campbell
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Robert E Sapien
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Erik B Erhardt
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - John P Phillips
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Andrei A Vakhtin
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
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Ahmadi S, Roshdi Dizaji S, Babahajian A, Alizadeh M, Sarveazad A, Yousefifard M. Serum Glial Fibrillary Acidic Protein in Detecting Intracranial Injuries Following Minor Head Trauma; a Systematic Review and Meta-Analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e9. [PMID: 36620734 PMCID: PMC9807952 DOI: 10.22037/aaem.v11i1.1682] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Introduction Developing novel diagnostic and screening tools for exploring intracranial injuries following minor head trauma is a necessity. This study aimed to evaluate the diagnostic value of serum glial fibrillary acidic protein (GFAP) in detecting intracranial injuries following minor head trauma. Methods An extensive search was performed in Medline, Embase, Scopus, and Web of Science databases up to the end of April 2022. Human observational studies were chosen, regardless of sex and ethnicity of their participants. Pediatrics studies, report of diagnostic value of GFAP combined with other biomarkers (without reporting the GFAP alone), articles including patients with all trauma severity, defining minor head trauma without intracranial lesions as the outcome of the study, not reporting sensitivity/specificity or any other values essential for computation of true positive, true negative, false positive and false-negative, being performed in the prehospital setting, assessing the prognostic value of GFAP, duplicated reports, preclinical studies, retracted articles, and review papers were excluded. The result was provided as pooled sensitivity, specificity, diagnostic score and diagnostic odds ratio, and area under the summary receiver operating characteristic (SROC) curve with a 95% confidence interval (95% CI). Results Eventually, 11 related articles were introduced into the meta-analysis. The pooled analysis implies that the area under the SROC curve for serum GFAP level in minor traumatic brain injuries (TBI) was 0.75 (95% CI: 0.71 to 0.78). Sensitivity and specificity of this biomarker in below 100 pg/ml cut-off were 0.83 (95% CI: 0.78 to 0.89) and 0.39 (95% CI: 0.24 to 0.53), respectively. The diagnostic score and diagnostic odds ratio of GFAP in detection of minor TBI were 1.13 (95% CI: 0.53 to 1.74) and 3.11 (95% CI: 1.69 to 5.72), respectively. The level of evidence for the presented results were moderate. Conclusion The present study's findings demonstrate that serum GFAP can detect intracranial lesions in mild TBI patients. The optimum cut-off of GFAP in detection of TBI was below 100 pg/ml. As a result, implementing serum GFAP may be beneficial in mild TBI diagnosis for preventing unnecessary computed tomography (CT) scans and their related side effects.
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Affiliation(s)
- Sajjad Ahmadi
- Emergency Medicine Research Team, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Asrin Babahajian
- Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | | | - Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran.,Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran.,Corresponding authors:Arash Sarveazad; Colorectal Research Center, Rasoul-e-Akram Hospital, Nyaiesh Ave., Tehran, Iran; Tel/Fax: +982166554790; . ORCID: 0000-0001-9273-1940
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran.,Pediatric Chronic Kidney Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Corresponding Author: Mahmoud Yousefifard; Physiology Research Center,
Iran University of Medical Sciences, Hemmat Highway, P.O Box: 14665-354,
Tehran, Iran; Phone/Fax: +982186704771; ,
ORCID: https://orcid.org/0000-0001-5181-4985
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29
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Mayer AR, Ling JM, Dodd AB, Stephenson DD, Pabbathi Reddy S, Robertson-Benta CR, Erhardt EB, Harms RL, Meier TB, Vakhtin AA, Campbell RA, Sapien RE, Phillips JP. Multicompartmental models and diffusion abnormalities in paediatric mild traumatic brain injury. Brain 2022; 145:4124-4137. [PMID: 35727944 DOI: 10.1093/brain/awac221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/29/2022] [Accepted: 06/09/2022] [Indexed: 01/23/2023] Open
Abstract
The underlying pathophysiology of paediatric mild traumatic brain injury and the time-course for biological recovery remains widely debated, with clinical care principally informed by subjective self-report. Similarly, clinical evidence indicates that adolescence is a risk factor for prolonged recovery, but the impact of age-at-injury on biomarkers has not been determined in large, homogeneous samples. The current study collected diffusion MRI data in consecutively recruited patients (n = 203; 8-18 years old) and age and sex-matched healthy controls (n = 170) in a prospective cohort design. Patients were evaluated subacutely (1-11 days post-injury) as well as at 4 months post-injury (early chronic phase). Healthy participants were evaluated at similar times to control for neurodevelopment and practice effects. Clinical findings indicated persistent symptoms at 4 months for a significant minority of patients (22%), along with residual executive dysfunction and verbal memory deficits. Results indicated increased fractional anisotropy and reduced mean diffusivity for patients, with abnormalities persisting up to 4 months post-injury. Multicompartmental geometric models indicated that estimates of intracellular volume fractions were increased in patients, whereas estimates of free water fractions were decreased. Critically, unique areas of white matter pathology (increased free water fractions or increased neurite dispersion) were observed when standard assumptions regarding parallel diffusivity were altered in multicompartmental models to be more biologically plausible. Cross-validation analyses indicated that some diffusion findings were more reproducible when ∼70% of the total sample (142 patients, 119 controls) were used in analyses, highlighting the need for large-sample sizes to detect abnormalities. Supervised machine learning approaches (random forests) indicated that diffusion abnormalities increased overall diagnostic accuracy (patients versus controls) by ∼10% after controlling for current clinical gold standards, with each diffusion metric accounting for only a few unique percentage points. In summary, current results suggest that novel multicompartmental models are more sensitive to paediatric mild traumatic brain injury pathology, and that this sensitivity is increased when using parameters that more accurately reflect diffusion in healthy tissue. Results also indicate that diffusion data may be insufficient to achieve a high degree of objective diagnostic accuracy in patients when used in isolation, which is to be expected given known heterogeneities in pathophysiology, mechanism of injury and even criteria for diagnoses. Finally, current results indicate ongoing clinical and physiological recovery at 4 months post-injury.
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Affiliation(s)
- Andrew R Mayer
- The Mind Research Network/LBERI, Albuquerque, NM 87106, USA.,Department of Psychology, University of New Mexico, Albuquerque, NM 87131, USA.,Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA.,Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | - Josef M Ling
- The Mind Research Network/LBERI, Albuquerque, NM 87106, USA
| | - Andrew B Dodd
- The Mind Research Network/LBERI, Albuquerque, NM 87106, USA
| | | | | | | | - Erik B Erhardt
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM 87131, USA
| | | | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.,Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI 53226, USA.,Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | | | - Richard A Campbell
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM 87131, USA
| | - John P Phillips
- The Mind Research Network/LBERI, Albuquerque, NM 87106, USA.,Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
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30
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Agoston DV, McCullough J, Aniceto R, Lin IH, Kamnaksh A, Eklund M, Graves WM, Dunbar C, Engall J, Schneider EB, Leonessa F, Duckworth JL. Blood-Based Biomarkers of Repetitive, Subconcussive Blast Overpressure Exposure in the Training Environment: A Pilot Study. Neurotrauma Rep 2022; 3:479-490. [PMID: 36337080 PMCID: PMC9634979 DOI: 10.1089/neur.2022.0029] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Because of their unknown long-term effects, repeated mild traumatic brain injuries (TBIs), including the low, subconcussive ones, represent a specific challenge to healthcare systems. It has been hypothesized that they can have a cumulative effect, and they may cause molecular changes that can lead to chronic degenerative processes. Military personnel are especially vulnerable to consequences of subconcussive TBIs because their training involves repeated exposures to mild explosive blasts. In this pilot study, we collected blood samples at baseline, 6 h, 24 h, 72 h, 2 weeks, and 3 months after heavy weapons training from students and instructors who were exposed to repeated subconcussive blasts. Samples were analyzed using the reverse and forward phase protein microarray platforms. We detected elevated serum levels of glial fibrillary acidic protein, ubiquitin C-terminal hydrolase L1 (UCH-L1), nicotinic alpha 7 subunit (CHRNA7), occludin (OCLN), claudin-5 (CLDN5), matrix metalloprotease 9 (MMP9), and intereukin-6 (IL-6). Importantly, serum levels of most of the tested protein biomarkers were the highest at 3 months after exposures. We also detected elevated autoantibody titers of proteins related to vascular and neuroglia-specific proteins at 3 months after exposures as compared to baseline levels. These findings suggest that repeated exposures to subconcussive blasts can induce molecular changes indicating not only neuron and glia damage, but also vascular changes and inflammation that are detectable for at least 3 months after exposures whereas elevated titers of autoantibodies against vascular and neuroglia-specific proteins can indicate an autoimmune process.
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Affiliation(s)
- Denes V. Agoston
- Department of Anatomy, Physiology, and Genetics, Uniformed Services University, Bethesda, Maryland, USA.,Address correspondence to: Denes V. Agoston, MD, PhD, Department of Anatomy, Physiology, and Genetics, Uniformed Services University, 4301 Jones Bridge Road, Building B, Room 2036, Bethesda, MD 20814, USA.
| | - Jesse McCullough
- Department of Anatomy, Physiology, and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Roxanne Aniceto
- Department of Anatomy, Physiology, and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - I-Hsuan Lin
- Department of Anatomy, Physiology, and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Alaa Kamnaksh
- Department of Anatomy, Physiology, and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Michael Eklund
- Department of Anatomy, Physiology, and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Wallace M. Graves
- NeuroTactical Research Team, Marine Corps Base Camp Pendleton, Camp Pendleton, California, USA.,Department of Neurology, Uniformed Services University, Bethesda, Maryland, USA
| | - Cyrus Dunbar
- NeuroTactical Research Team, Marine Corps Base Camp Pendleton, Camp Pendleton, California, USA.,Department of Neurology, Uniformed Services University, Bethesda, Maryland, USA
| | - James Engall
- NeuroTactical Research Team, Marine Corps Base Camp Pendleton, Camp Pendleton, California, USA.,Department of Neurology, Uniformed Services University, Bethesda, Maryland, USA
| | - Eric B. Schneider
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Fabio Leonessa
- Department of Neurology, Uniformed Services University, Bethesda, Maryland, USA
| | - Josh L. Duckworth
- NeuroTactical Research Team, Marine Corps Base Camp Pendleton, Camp Pendleton, California, USA.,Department of Neurology, Uniformed Services University, Bethesda, Maryland, USA
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31
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Khan NA, Asim M, El-Menyar A, Biswas KH, Rizoli S, Al-Thani H. The evolving role of extracellular vesicles (exosomes) as biomarkers in traumatic brain injury: Clinical perspectives and therapeutic implications. Front Aging Neurosci 2022; 14:933434. [PMID: 36275010 PMCID: PMC9584168 DOI: 10.3389/fnagi.2022.933434] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
Developing effective disease-modifying therapies for neurodegenerative diseases (NDs) requires reliable diagnostic, disease activity, and progression indicators. While desirable, identifying biomarkers for NDs can be difficult because of the complex cytoarchitecture of the brain and the distinct cell subsets seen in different parts of the central nervous system (CNS). Extracellular vesicles (EVs) are heterogeneous, cell-derived, membrane-bound vesicles involved in the intercellular communication and transport of cell-specific cargos, such as proteins, Ribonucleic acid (RNA), and lipids. The types of EVs include exosomes, microvesicles, and apoptotic bodies based on their size and origin of biogenesis. A growing body of evidence suggests that intercellular communication mediated through EVs is responsible for disseminating important proteins implicated in the progression of traumatic brain injury (TBI) and other NDs. Some studies showed that TBI is a risk factor for different NDs. In terms of therapeutic potential, EVs outperform the alternative synthetic drug delivery methods because they can transverse the blood–brain barrier (BBB) without inducing immunogenicity, impacting neuroinflammation, immunological responses, and prolonged bio-distribution. Furthermore, EV production varies across different cell types and represents intracellular processes. Moreover, proteomic markers, which can represent a variety of pathological processes, such as cellular damage or neuroinflammation, have been frequently studied in neurotrauma research. However, proteomic blood-based biomarkers have short half-lives as they are easily susceptible to degradation. EV-based biomarkers for TBI may represent the complex genetic and neurometabolic abnormalities that occur post-TBI. These biomarkers are not caught by proteomics, less susceptible to degradation and hence more reflective of these modifications (cellular damage and neuroinflammation). In the current narrative and comprehensive review, we sought to discuss the contemporary knowledge and better understanding the EV-based research in TBI, and thus its applications in modern medicine. These applications include the utilization of circulating EVs as biomarkers for diagnosis, developments of EV-based therapies, and managing their associated challenges and opportunities.
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Affiliation(s)
- Naushad Ahmad Khan
- Clinical Research, Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- *Correspondence: Ayman El-Menyar
| | - Kabir H. Biswas
- Division of Biological and Biomedical Sciences, College of Health and Life Sciences, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar
| | - Sandro Rizoli
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
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32
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Sports-Related Concussion Is a Personalized Issue—Evaluation of Medical Assessment and Subjective Feeling of the Athlete in a German Level 1 Trauma Center. J Pers Med 2022; 12:jpm12101596. [PMID: 36294735 PMCID: PMC9605563 DOI: 10.3390/jpm12101596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/17/2022] Open
Abstract
Sports-related concussions (SRC) have developed into a highly discussed topic in sports medicine over the last few years and demonstrate a severe issue in the personalized treatment of patients. This retrospective cohort study investigated 86 patients with sports-related concussions in a level 1 trauma center, relating to the mechanism, symptoms, medical history, acute therapy including first assessment and the return to sport. The research is based on medical records as well as questionnaires six months after hospitalization. Loss of consciousness for under 30 min (41.2%), headache (36.5%) and amnesia (29.4%) were the most frequent symptoms when presenting in the emergency room. During the hospitalization, mainly headache and vertigo were documented. Most concussions occurred after incidents in equitation and cycling sports; the most common mechanism was falling to the ground with a subsequent impact (59.3%). At the time of discharge from hospital, in 13.4% of all cases, concussion symptoms were still documented in medical records, in contrast to 39.5% of the concerned athletes who reported symptoms for longer than 24 h, and 41.0% who reported ongoing post-concussion symptoms after six months. Concussions are difficult-to-treat disorders with a challenging diagnostic process and many symptoms in various values and levels of persistence. Therefore, a patient-involving treatment with a complaint-dependent return to sport process should be applied to concerned athletes.
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33
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Vorn R, Mithani S, Devoto C, Meier TB, Lai C, Yun S, Broglio SP, McAllister TW, Giza CC, Kim HS, Huber D, Harezlak J, Cameron KL, McGinty G, Jackson J, Guskiewicz KM, Mihalik JP, Brooks A, Duma S, Rowson S, Nelson LD, Pasquina P, McCrea MA, Gill JM. Proteomic Profiling of Plasma Biomarkers Associated With Return to Sport Following Concussion: Findings From the NCAA and Department of Defense CARE Consortium. Front Neurol 2022; 13:901238. [PMID: 35928129 PMCID: PMC9343581 DOI: 10.3389/fneur.2022.901238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/08/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the plasma proteomic profiling in identifying biomarkers related to return to sport (RTS) following a sport-related concussion (SRC). Methods This multicenter, prospective, case-control study was part of a larger cohort study conducted by the NCAA-DoD Concussion Assessment, Research, and Education (CARE) Consortium, athletes (n = 140) with blood collected within 48 h of injury and reported day to asymptomatic were included in this study, divided into two groups: (1) recovery <14-days (n = 99) and (2) recovery ≥14-days (n = 41). We applied a highly multiplexed proteomic technique that uses DNA aptamers assay to target 1,305 proteins in plasma samples from concussed athletes with <14-days and ≥14-days. Results We identified 87 plasma proteins significantly dysregulated (32 upregulated and 55 downregulated) in concussed athletes with recovery ≥14-days relative to recovery <14-days groups. The significantly dysregulated proteins were uploaded to Ingenuity Pathway Analysis (IPA) software for analysis. Pathway analysis showed that significantly dysregulated proteins were associated with STAT3 pathway, regulation of the epithelial mesenchymal transition by growth factors pathway, and acute phase response signaling. Conclusion Our data showed the feasibility of large-scale plasma proteomic profiling in concussed athletes with a <14-days and ≥ 14-days recovery. These findings provide a possible understanding of the pathophysiological mechanism in neurobiological recovery. Further study is required to determine whether these proteins can aid clinicians in RTS decisions.
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Affiliation(s)
- Rany Vorn
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Sara Mithani
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
- School of Nursing, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - Christina Devoto
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Timothy B. Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Chen Lai
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Sijung Yun
- Predictiv Care, Mountain View, CA, United States
| | - Steven P. Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, United States
| | - Thomas W. McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Christopher C. Giza
- Departments of Pediatrics and Neurosurgery, University of California, Los Angeles, Los Angeles, CA, United States
- UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Los Angeles, CA, United States
| | - Hyung-Suk Kim
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Daniel Huber
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jaroslaw Harezlak
- Department of Epidemiology and Biostatistics School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Kenneth L. Cameron
- John A. Feagin Sports Medicine Fellowship, Keller Army Hospital, West Point, NY, United States
| | - Gerald McGinty
- United States Air Force Academy, Colorado Springs, CO, United States
| | - Jonathan Jackson
- United States Air Force Academy, Colorado Springs, CO, United States
| | - Kevin M. Guskiewicz
- Matthew Gfeller Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jason P. Mihalik
- Matthew Gfeller Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alison Brooks
- Department of Orthopedics, Division of Sports Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Stefan Duma
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, United States
| | - Steven Rowson
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, United States
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Paul Pasquina
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jessica M. Gill
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
- *Correspondence: Jessica M. Gill
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34
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Ubiquitin carboxyl-terminal esterase L1 is not elevated in the serum of concussed rugby players: an observational cross-sectional study. Sci Rep 2022; 12:12230. [PMID: 35851288 PMCID: PMC9293898 DOI: 10.1038/s41598-022-16447-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
Concussion diagnosis is complicated by a lack of objective measures. Ubiquitin carboxyl-terminal esterase L1 (UCHL1) is a biomarker that has been shown to increase following traumatic brain injury but has not been investigated in concussed athletes on the sideline of athletic events. Therefore, this study was conducted to determine if UCHL1 can be used to aid in sideline concussion diagnosis. Blood was taken via standard venipuncture from a recreationally active control group, a group of rugby players prior to match play (pre-match), rugby players following match-play (match-control), and rugby players after suffering a sport-related concussion (SRC). UCHL1 was not significantly different among groups (p > 0.05) and was unable to distinguish between SRC and controls (AUROC < 0.400, p > 0.05). However, when sex-matched data were used, it was found that the female match-control group had a significantly higher serum UCHL1 concentration than the pre-match group (p = 0.041). Differences were also found in serum UCHL1 concentrations between male and female athletes in the match-control group (p = 0.007). This study does not provide evidence supporting the use of UCHL1 in sideline concussion diagnosis when blood is collected soon after concussion but does show differences in serum UCHL1 accumulation between males and females.
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35
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Shahim P, Zetterberg H, Simren J, Ashton NJ, Norato G, Schöll M, Tegner Y, Diaz-Arrastia R, Blennow K. Association of Plasma Biomarker Levels With Their CSF Concentration and the Number and Severity of Concussions in Professional Athletes. Neurology 2022; 99:e347-e354. [PMID: 35654597 DOI: 10.1212/wnl.0000000000200615] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 03/15/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine whether the brain biomarkers total-tau (T-tau), glial fibrillary acidic protein (GFAP), and β-amyloid (Aβ) isomers 40 and 42 in plasma relate to the corresponding concentrations in cerebrospinal fluid (CSF), blood-brain barrier integrity, and duration of post-concussion syndrome (PCS) due to repetitive head impacts (RHI) in professional athletes. METHOD In this cross-sectional study, professional athletes with persistent PCS due to RHI (median of 1.5 years after recent concussion) and uninjured controls were assessed with blood and CSF sampling. The diagnosis of PCS was based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). The athletes were enrolled through information flyers about the study sent to the Swedish hockey league (SHL) and the SHL Medicine Committee. The controls were enrolled through flyers at University of Gothenburg and Sahlgrenska University Hospital, Sweden. The participants underwent lumbar puncture and blood assessment at Sahlgrenska University Hospital. The main outcome measures were history of RHI and PCS severity (PCS> 1 year versus PCS< 1 year) in relation to plasma and CSF concentrations of T-tau, GFAP, Aβ40, and Aβ42. Plasma T-tau, GFAP, Aβ40, and Aβ42 were quantified using an ultrasensitive assay technology. RESULTS A total of 47 participants (28 athletes [median age 28 years, range 18-52] with persistent PCS, due to RHI and 19 controls [median age, 25 years, range 21-35]) underwent paired blood and cerebrospinal fluid (CSF) sampling. T-tau, Aβ40 and Aβ42 concentrations measured in plasma did not correlate with the corresponding CSF concentrations, while there was a correlation between plasma and CSF levels of GFAP (r=0.45, p=0.020). There were no significant relationships between plasma T-tau, GFAP, and blood-brain barrier integrity as measured by CSF:serum albumin ratio. T-tau, GFAP, Aβ40, and Aβ42 measured in plasma did not relate to PCS severity. None of the markers measured in plasma correlated with number of concussions, except decreased Aβ42 in those with higher number of concussions (r=-0.40, p=0.04). CONCLUSIONS T-tau, GFAP, Aβ40 and Aβ42 measured in plasma do not correspond to CSF measures, and may have limited utility for the evaluation of the late effects of RHI, compared with when measured in CSF. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that in professional athletes with post-concussion symptoms, plasma concentrations of T-tau, GFAP, Aβ40, and Aβ42 are not informative in the diagnosis of late effects of repetitive head injuries.
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Affiliation(s)
- Pashtun Shahim
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden .,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute, London, UK
| | - Joel Simren
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Nicholas J Ashton
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden.,King's College London, Institute of Psychiatry, Psychology and Neuroscience, Maurice Wohl Institute Clinical Neuroscience Institute, London, UK.,NIHR Biomedical Research Centre for Mental Health and Biomedical Research Unit for Dementia at South London and Maudsley NHS Foundation, London, UK
| | - Gina Norato
- Clinical Trials Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Michael Schöll
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Yelverton Tegner
- Division of Health, Medicine and Rehabilitation, Department of Health Science, Luleå University of Technology, Luleå, Sweden
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
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36
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Tabor JB, McCrea MA, Meier TB, Emery CA, Debert CT. Hiding in Plain Sight: Factors Influencing the Neuroinflammatory Response to Sport-Related Concussion. Neurotrauma Rep 2022; 3:200-206. [PMID: 35734393 PMCID: PMC9153987 DOI: 10.1089/neur.2021.0081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Sport-related concussion (SRC) is a major concern among athletes and clinicians around the world. Research into fluid biomarkers of SRC has made significant progress in understanding the complex underlying pathophysiology of concussion. However, little headway has been made toward clinically validating any biomarkers to improve the clinical management of SRC. A major obstacle toward clinical translation of any fluid biomarker is the heterogeneity of SRC overlapping with multiple physiological systems involved in pathology and recovery. Neuroinflammation post-SRC is one such system that may confound fluid biomarker data on many fronts. Neuroinflammatory processes consist of cell mediators, both within the central nervous system and the periphery, that play vital roles in regulating the response to brain injury. Further, neuroinflammation is influenced by many biopsychosocial variables present in most athletic populations. In this commentary, we propose that future fluid biomarker research should take a systems biology approach in the context of the neuroinflammatory response to SRC. We highlight how biological variables, such as age, sex, immune challenges, and hypothalamic-pituitary-adrenal (HPA)-axis responses to stress, may alter neuroinflammation. Further, we underscore the importance of accounting for health and lifestyle variables, such as diet, exercise, sleep, and pre-morbid medical factors, when measuring inflammatory markers of SRC. To successfully move toward clinical translation, fluid biomarker research should take a more holistic approach in study design and data interpretation, collecting information on hidden variables that may be influencing the neuroinflammatory response to SRC.
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Affiliation(s)
- Jason B. Tabor
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Timothy B. Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Carolyn A. Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Chantel T. Debert
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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37
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Vorn R, Naunheim R, Lai C, Wagner C, Gill JM. Elevated Axonal Protein Markers Following Repetitive Blast Exposure in Military Personnel. Front Neurosci 2022; 16:853616. [PMID: 35573288 PMCID: PMC9099432 DOI: 10.3389/fnins.2022.853616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
Blast exposures that occur during training are common in military personnel; however, the biomarkers that relate to these subtle injuries is not well understood. Therefore, the purpose of this study is to identify the acute biomarkers related to blast injury in a cohort of military personnel exposure to blast-related training. Thirty-four military personnel who participated in the training program were included in this study. Blood samples were collected before and after repetitive blast-related training on days 2 (n = 19) and days 7 (n = 15). Serum concentration (pg/mL) of tau, glial fibrillary acidic protein (GFAP), neurofilament light chain (NfL), and phosphorylated tau181 (p-tau181) were measured using an ultrasensitive immunoassay platform. We observed that serum p-tau181 concentrations were elevated after exposed to repetitive blast on days 2 (z = −2.983, p = 0.003) and days 7 (z = −2.158, p = 0.031). Serum tau (z = −2.272, p = 0.023) and NfL (z = −2.158, p = 0.031) levels were significantly elevated after exposure to repetitive blasts on days 7. Our findings indicate that blast exposure affects serum biomarkers indicating axonal injury.
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Affiliation(s)
- Rany Vorn
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
- *Correspondence: Rany Vorn,
| | - Rosanne Naunheim
- Department of Emergency Medicine, Washington University Barnes Jewish Medical Center, St. Louis, MO, United States
| | - Chen Lai
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of Health Sciences, Bethesda, MD, United States
| | - Chelsea Wagner
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
| | - Jessica M. Gill
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of Health Sciences, Bethesda, MD, United States
- School of Nursing and Medicine, Johns Hopkins University, Baltimore, MD, United States
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38
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Posti JP, Tenovuo O. Blood-based biomarkers and traumatic brain injury-A clinical perspective. Acta Neurol Scand 2022; 146:389-399. [PMID: 35383879 DOI: 10.1111/ane.13620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/08/2022] [Accepted: 03/27/2022] [Indexed: 12/19/2022]
Abstract
Blood-based biomarkers are promising tools to complement clinical variables and imaging findings in the diagnosis, monitoring and outcome prediction of traumatic brain injury (TBI). Several promising biomarker candidates have been found for various clinical questions, but the translation of TBI biomarkers into clinical applications has been negligible. Measured biomarker levels are influenced by patient-related variables such as age, blood-brain barrier integrity and renal and liver function. It is not yet fully understood how biomarkers enter the bloodstream from the interstitial fluid of the brain. In addition, the diagnostic performance of TBI biomarkers is affected by sampling timing and analytical methods. In this focused review, the clinical aspects of glial fibrillary acidic protein, neurofilament light, S100 calcium-binding protein B, tau and ubiquitin C-terminal hydrolase-L1 are examined. Current findings and clinical caveats are addressed.
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Affiliation(s)
- Jussi P. Posti
- Neurocenter Department of Neurosurgery and Turku Brain Injury Center Turku University Hospital and University of Turku Turku Finland
| | - Olli Tenovuo
- Neurocenter Turku Brain Injury Center Turku University Hospital and University of Turku Turku Finland
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Biological Breakdown of Sports in Athletics Based on Multimedia Image Acquisition Techniques. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:3497942. [PMID: 35392036 PMCID: PMC8983211 DOI: 10.1155/2022/3497942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/25/2022] [Accepted: 03/10/2022] [Indexed: 11/19/2022]
Abstract
This paper provides an in-depth analysis and study of the decomposition of sports biology of athletics events through multimedia image acquisition techniques. The proposed design uses SOPC hardware-software collaboration technology, which makes full use of the parallelism of hardware as well as the flexibility of software to essentially improve the speed of image processing and greatly improve the efficiency of image processing. The high speed and parallelism of hardware are used to realize the image acquisition part with high timing requirements and the preprocessing algorithm with a large number of operations and strong repetition, in addition to the difficulties of many initialization configuration parameters of each peripheral. Additionally, the need for frequent adjustment of peripheral working parameters is solved by making full use of the scalability and flexibility of software, and the control signals output by software can coordinate the work of each hardware module to ensure that each module of the system cooperates. It is also possible to coordinate the work of each hardware module through the control signal output from the software to ensure that each module of the system cooperates and operates in an orderly and efficient manner and provides the possibility of realizing a higher level of the image processing algorithm. The system includes four main factors: swinging action, supporting action, vacating action, and speed rhythm. Based on this system, 14 key kinematic indicators were selected to reflect the technical status of the youth walkers. The landing angle decreased with the increase of speed, and the landing technique was insufficient; it had better control of the large and small arm angle, and their stride width was open, while the other four athletes showed increased tension in the hip joint and upper limb with the increase of walking speed, as well as the wrong action of forward and internal rotation of the large and small arms.
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40
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Salivary S100 calcium-binding protein beta (S100B) and neurofilament light (NfL) after acute exposure to repeated head impacts in collegiate water polo players. Sci Rep 2022; 12:3439. [PMID: 35236877 PMCID: PMC8891257 DOI: 10.1038/s41598-022-07241-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/04/2022] [Indexed: 11/08/2022] Open
Abstract
Blood-based biomarkers of brain injury may be useful for monitoring brain health in athletes at risk for concussions. Two putative biomarkers of sport-related concussion, neurofilament light (NfL), an axonal structural protein, and S100 calcium-binding protein beta (S100B), an astrocyte-derived protein, were measured in saliva, a biofluid which can be sampled in an athletic setting without the risks and burdens associated with blood sampled by venipuncture. Samples were collected from men’s and women’s collegiate water polo players (n = 65) before and after a competitive tournament. Head impacts were measured using sensors previously evaluated for use in water polo, and video recordings were independently reviewed for the purpose of validating impacts recorded by the sensors. Athletes sustained a total of 107 head impacts, all of which were asymptomatic (i.e., no athlete was diagnosed with a concussion or more serious). Post-tournament salivary NfL was directly associated with head impact frequency (RR = 1.151, p = 0.025) and cumulative head impact magnitude (RR = 1.008, p = 0.014), while controlling for baseline salivary NfL. Change in S100B was not associated with head impact exposure (RR < 1.001, p > 0.483). These patterns suggest that repeated head impacts may cause axonal injury, even in asymptomatic athletes.
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Shahim P, Zetterberg H. Neurochemical Markers of Traumatic Brain Injury: Relevance to Acute Diagnostics, Disease Monitoring, and Neuropsychiatric Outcome Prediction. Biol Psychiatry 2022; 91:405-412. [PMID: 34857362 DOI: 10.1016/j.biopsych.2021.10.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 12/13/2022]
Abstract
Considerable advancements have been made in the quantification of biofluid-based biomarkers for traumatic brain injury (TBI), which provide a clinically accessible window to investigate disease mechanisms and progression. Methods with improved analytical sensitivity compared with standard immunoassays are increasingly used, and blood tests are being used in the diagnosis, monitoring, and outcome prediction of TBI. Most work to date has focused on acute TBI diagnostics, while the literature on biomarkers for long-term sequelae is relatively scarce. In this review, we give an update on the latest developments in biofluid-based biomarker research in TBI and discuss how acute and prolonged biomarker changes can be used to detect and quantify brain injury and predict clinical outcome and neuropsychiatric sequelae.
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Affiliation(s)
- Pashtun Shahim
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland.
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; UK Dementia Research Institute at University College London, London, United Kingdom; Department of Neurodegenerative Disease, University College London Institute of Neurology, London, United Kingdom; Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China.
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Machan M, Tabor JB, Wang M, Sutter B, Wiley JP, Mychasiuk R, Debert CT. The Impact of Concussion, Sport, and Time in Season on Saliva Telomere Length in Healthy Athletes. Front Sports Act Living 2022; 4:816607. [PMID: 35243342 PMCID: PMC8886719 DOI: 10.3389/fspor.2022.816607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
To date, sport-related concussion diagnosis and management is primarily based on subjective clinical tests in the absence of validated biomarkers. A major obstacle to clinical validation and application is a lack of studies exploring potential biomarkers in non-injured populations. This cross-sectional study examined the associations between saliva telomere length (TL) and multiple confounding variables in a healthy university athlete population. One hundred eighty-three (108 male and 75 female) uninjured varsity athletes were recruited to the study and provided saliva samples at either pre- or mid-season, for TL analysis. Multiple linear regression was used to determine the associations between saliva TL and history of concussion, sport contact type, time in season (pre vs. mid-season collection), age, and sex. Results showed no significant associations between TL and history of concussion, age, or sport contact type. However, TL from samples collected mid-season were longer than those collected pre-season [β = 231.4, 95% CI (61.9, 401.0), p = 0.008], and males had longer TL than females [β = 284.8, 95% CI (111.5, 458.2), p = 0.001] when adjusting for all other variables in the model. These findings population suggest that multiple variables may influence TL. Future studies should consider these confounders when evaluating saliva TL as a plausible fluid biomarker for SRC.
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Affiliation(s)
- Matthew Machan
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Jason B. Tabor
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Meng Wang
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Bonnie Sutter
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - J. Preston Wiley
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- University of Calgary Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Richelle Mychasiuk
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Chantel T. Debert
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- *Correspondence: Chantel T. Debert
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Meier TB, Guedes VA, Smith EG, Sass D, Mithani S, Vorn R, Savitz J, Teague TK, McCrea MA, Gill JM. Extracellular vesicle-associated cytokines in sport-related concussion. Brain Behav Immun 2022; 100:83-87. [PMID: 34848337 PMCID: PMC8895755 DOI: 10.1016/j.bbi.2021.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/21/2021] [Accepted: 11/22/2021] [Indexed: 02/03/2023] Open
Abstract
Growing evidence suggests that sport-related concussion results in a robust inflammatory response that can be measured in serum or plasma and is predictive of symptom recovery. Recently, extracellular vesicles (EV) derived from serum or plasma have emerged as a promising source of biomarkers for neurological disorders like concussion because they may better reflect central immunological activity. However, the association of acute concussion with EV-associated cytokines has not yet been systematically studied in humans. We tested the hypothesis that EV-associated cytokines are elevated acutely and predictive of symptom duration following concussion in a cohort of high-school and collegiate football players. Players were enrolled and provided serum samples at a preseason baseline visit (N = 857). An additional blood draw was obtained in players that subsequently suffered a concussion (N = 23) within 6-hours post-injury and in matched, uninjured players (N = 44). Concentrations of Interleukin-6 (IL-6), IL-1β, IL-1 receptor antagonist (IL-1RA), IL-10, and tumor necrosis factor were measured in EV and EV-depleted serum samples. EV-associated IL-6 was significantly elevated post-injury relative to baseline levels and controls (ps < 0.01). In EV-depleted samples, IL-1RA was significantly elevated post-injury relative to baseline levels and controls (ps < 0.01). Time-to-event analyses showed that post-injury EV-associated IL-6 levels were positively associated with the number of days that injured athletes reported symptoms (p < 0.05). These results highlight the potential of EV-associated cytokines as biomarkers of concussion.
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Affiliation(s)
- Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, United States.
| | - Vivian A Guedes
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Ethan G Smith
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Dilorom Sass
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Sara Mithani
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Rany Vorn
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Jonathan Savitz
- Laureate Institute for Brain Research, Tulsa, OK, United States; Oxley College of Health Sciences, Tulsa, OK, United States
| | - T Kent Teague
- Departments of Surgery and Psychiatry, The University of Oklahoma School of Community Medicine, Tulsa, OK, United States; Department of Pharmaceutical Sciences, University of Oklahoma College of Pharmacy, Tulsa, OK, United States; Department of Biochemistry and Microbiology, Oklahoma State University Center for Health Sciences, United States
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jessica M Gill
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
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Hoffman JR, Ostfeld I, Zamir A, Amedi R, Fonville TR, Horstemeyer MF, Gepner Y. Examination of Cognitive Function, Neurotrophin Concentrations, and both Brain and Systemic Inflammatory Markers Following a Simulated Game of American Football. J Strength Cond Res 2022; 36:686-694. [DOI: 10.1519/jsc.0000000000004218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Forstenpointner J, Elman I, Freeman R, Borsook D. The Omnipresence of Autonomic Modulation in Health and Disease. Prog Neurobiol 2022; 210:102218. [PMID: 35033599 DOI: 10.1016/j.pneurobio.2022.102218] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/13/2021] [Accepted: 01/10/2022] [Indexed: 10/19/2022]
Abstract
The Autonomic Nervous System (ANS) is a critical part of the homeostatic machinery with both central and peripheral components. However, little is known about the integration of these components and their joint role in the maintenance of health and in allostatic derailments leading to somatic and/or neuropsychiatric (co)morbidity. Based on a comprehensive literature search on the ANS neuroanatomy we dissect the complex integration of the ANS: (1) First we summarize Stress and Homeostatic Equilibrium - elucidating the responsivity of the ANS to stressors; (2) Second we describe the overall process of how the ANS is involved in Adaptation and Maladaptation to Stress; (3) In the third section the ANS is hierarchically partitioned into the peripheral/spinal, brainstem, subcortical and cortical components of the nervous system. We utilize this anatomical basis to define a model of autonomic integration. (4) Finally, we deploy the model to describe human ANS involvement in (a) Hypofunctional and (b) Hyperfunctional states providing examples in the healthy state and in clinical conditions.
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Affiliation(s)
- Julia Forstenpointner
- Center for Pain and the Brain, Boston Children's Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, SH, Germany.
| | - Igor Elman
- Center for Pain and the Brain, Boston Children's Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David Borsook
- Center for Pain and the Brain, Boston Children's Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Departments of Psychiatry and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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46
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Malik S, Alnaji O, Malik M, Gambale T, Rathbone MP. Correlation between Mild Traumatic Brain Injury-Induced Inflammatory Cytokines and Emotional Symptom Traits: A Systematic Review. Brain Sci 2022; 12:brainsci12010102. [PMID: 35053845 PMCID: PMC8773760 DOI: 10.3390/brainsci12010102] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 01/09/2023] Open
Abstract
Both mild traumatic brain injuries (mTBI) and systemic injuries trigger a transient neuroinflammatory response that result in similar clinical outcome. The ensuing physical, cognitive, and emotional symptoms fail to subside in approximately 15–20% of the concussed population. Emotional impairments, particularly depression, anxiety, and post-traumatic stress disorder (PTSD), are commonly associated with poor recovery following mTBI. These emotional impairments also have a significant neuroinflammatory component. We hypothesized that the inflammatory cytokines seen in mTBI patients with emotional symptoms would coincide with those commonly seen in patients with emotional symptoms without mTBI. A systematic review was conducted to identify the most common neuroinflammatory cytokines in the mTBI population with psychological symptoms (depression, anxiety, PTSD). The electronic databases EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, and PSYCINFO were searched from data inception to 31 August 2021. A systematic screening approach was employed from screening to data analysis. A total of 994 articles were screened, 108 were selected for full article review, and 8 were selected for data analysis. The included studies consisted of 875 patients of which 81.3% were male. The mean sample size of patients with at least one mTBI was 73.8 ± 70.3 (range, 9–213), with a mean age of 33.9 ± 4.8 years. The most common cytokines associated with poor psychological outcomes involving PTSD and/or depression in the chronic mTBI population were IL-6, TNFα, IL-10, and CRP.
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Affiliation(s)
- Shazia Malik
- Neurosciences Graduate Program, McMaster University, Hamilton, ON L8S 4L8, Canada
- Correspondence:
| | - Omar Alnaji
- Faculty of Life Sciences, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Mahnoor Malik
- Bachelor of Health Sciences Program, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Teresa Gambale
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (T.G.); (M.P.R.)
| | - Michel Piers Rathbone
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; (T.G.); (M.P.R.)
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Visser K, Koggel M, Blaauw J, van der Horn HJ, Jacobs B, van der Naalt J. Blood-based biomarkers of inflammation in mild traumatic brain injury: A systematic review. Neurosci Biobehav Rev 2021; 132:154-168. [PMID: 34826510 DOI: 10.1016/j.neubiorev.2021.11.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 10/17/2021] [Accepted: 11/22/2021] [Indexed: 12/27/2022]
Abstract
VISSER, K., M. Koggel, J. Blaauw, H.J.v.d. Horn, B. Jacobs, and J.v.d. Naalt. Blood based biomarkers of inflammation in mild traumatic brain injury: A systematic review. NEUROSCI BIOBEHAV REV XX(X) XXX-XXX, 2021. - Inflammation is an important secondary physiological response to traumatic brain injury (TBI). Most of the current knowledge on this response is derived from research in moderate and severe TBI. In this systematic review we summarize the literature on clinical studies measuring blood based inflammatory markers following mild traumatic brain injury (mTBI) and identify the value of inflammatory markers as biomarkers. Twenty-three studies were included. This review suggests a distinct systemic inflammatory response following mTBI, quantifiable within 6 h up to 12 months post-injury. Interleukin-6 is the most promising biomarker for the clinical diagnosis of brain injury while interleukin-10 is a potential candidate for triaging CT scans. The diagnostic and prognostic utility of inflammatory markers may be more fully appreciated as a component of a panel of biomarkers. However, discrepancies in study design, analysis and reporting make it difficult to draw any definite conclusions. For the same reasons, a meta-analysis was not possible. We provide recommendations to follow standardized methodologies to allow for reproducibility of results in future studies.
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Affiliation(s)
- Koen Visser
- Department of Neurology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Milou Koggel
- Faculty of Science, Department of Biology, Utrecht University, Padualaan 8, 3584 CH, Utrecht, the Netherlands
| | - Jurre Blaauw
- Department of Neurology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Harm Jan van der Horn
- Department of Neurology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
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McDonald SJ, Shultz SR, Agoston DV. The Known Unknowns: An Overview of the State of Blood-Based Protein Biomarkers of Mild Traumatic Brain Injury. J Neurotrauma 2021; 38:2652-2666. [PMID: 33906422 DOI: 10.1089/neu.2021.0011] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Blood-based protein biomarkers have revolutionized several fields of medicine by enabling molecular level diagnosis, as well as monitoring disease progression and treatment efficacy. Traumatic brain injury (TBI) so far has benefitted only moderately from using protein biomarkers to improve injury outcome. Because of its complexity and dynamic nature, TBI, especially its most prevalent mild form (mild TBI; mTBI), presents unique challenges toward protein biomarker discovery and validation given that blood is frequently obtained and processed outside of the clinical laboratory (e.g., athletic fields, battlefield) under variable conditions. As it stands, the field of mTBI blood biomarkers faces a number of outstanding questions. Do elevated blood levels of currently used biomarkers-ubiquitin carboxy-terminal hydrolase L1, glial fibrillary acidic protein, neurofilament light chain, and tau/p-tau-truly mirror the extent of parenchymal damage? Do these different proteins represent distinct injury mechanisms? Is the blood-brain barrier a "brick wall"? What is the relationship between intra- versus extracranial values? Does prolonged elevation of blood levels reflect de novo release or extended protein half-lives? Does biological sex affect the pathobiological responses after mTBI and thus blood levels of protein biomarkers? At the practical level, it is unknown how pre-analytical variables-sample collection, preparation, handling, and stability-affect the quality and reliability of biomarker data. The ever-increasing sensitivity of assay systems and lack of quality control of samples, combined with the almost complete reliance on antibody-based assay platforms, represent important unsolved issues given that false-negative results can lead to false clinical decision making and adverse outcomes. This article serves as a commentary on the state of mTBI biomarkers and the landscape of significant challenges. We highlight and discusses several biological and methodological "known unknowns" and close with some practical recommendations.
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Affiliation(s)
- Stuart J McDonald
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Physiology, Anatomy and Microbiology, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Denes V Agoston
- Department of Anatomy, Physiology and Genetics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Owens TS, Calverley TA, Stacey BS, Rose G, Fall L, Tsukamoto H, Jones G, Corkill R, Tuaillon E, Hirtz C, Lehmann S, Marchi N, Marley CJ, Bailey DM. Concussion history in rugby union players is associated with depressed cerebrovascular reactivity and cognition. Scand J Med Sci Sports 2021; 31:2291-2299. [PMID: 34487582 DOI: 10.1111/sms.14046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/24/2021] [Accepted: 09/03/2021] [Indexed: 01/06/2023]
Abstract
Recurrent contact and concussion in rugby union remains a significant public health concern given the potential increased risk of neurodegeneration in later life. This study determined to what extent prior-recurrent contact impacts molecular-hemodynamic biomarkers underpinning cognition in current professional rugby union players with a history of concussion. Measurements were performed in 20 professional rugby union players with an average of 16 (interquartile range [IQR] 13-19) years playing history reporting 3 (IQR 1-4) concussions. They were compared to 17 sex-age-physical activity-and education-matched non-contact controls with no prior history of self-reported concussion. Venous blood was assayed directly for the ascorbate free radical (A•- electron paramagnetic resonance spectroscopy) nitric oxide metabolites (NO reductive ozone-based chemiluminescence) and select biomarkers of neurovascular unit integrity (NVU chemiluminescence/ELISA). Middle cerebral artery blood flow velocity (MCAv doppler ultrasound) was employed to determine basal perfusion and cerebrovascular reactivity (CVR) to hyper/hypocapnia ( CVR CO 2 Hyper / Hypo ). Cognition was assessed by neuropsychometric testing. Elevated systemic oxidative-nitrosative stress was confirmed in the players through increased A•- (p < 0.001) and suppression of NO bioavailability (p < 0.001). This was accompanied by a lower CVR range ( CVR CO 2 Range ; p = 0.045) elevation in neurofilament light-chain (p = 0.010) and frontotemporal impairments in immediate-memory (p = 0.001) delayed-recall (p = 0.048) and fine-motor coordination (p < 0.001). Accelerated cognitive decline subsequent to prior-recurrent contact and concussion history is associated with a free radical-mediated suppression of CVR and neuronal injury providing important mechanistic insight that may help better inform clinical management.
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Affiliation(s)
- Thomas S Owens
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Thomas A Calverley
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Benjamin S Stacey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - George Rose
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Lewis Fall
- Faculty of Computing, Engineering and Science, University of South Wales, Pontypridd, UK
| | - Hayato Tsukamoto
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK.,Faculty of Sport and Health Science, Ritsumeikan University, Shiga, Japan
| | - Gareth Jones
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Robin Corkill
- Department of Neurology, University Hospital of Wales, Cardiff, UK
| | - Edouard Tuaillon
- Department of Infectious Diseases, University of Montpellier, INSERM, Montpellier, France
| | - Christophe Hirtz
- University of Montpellier, CHU of Montpellier, INSERM, Montpellier, France
| | - Sylvain Lehmann
- University of Montpellier, CHU of Montpellier, INSERM, Montpellier, France
| | - Nicola Marchi
- Laboratory of Cerebrovascular and Glia Research, Department of Neuroscience, Institute of Functional Genomics, University of Montpellier, Montpellier, France
| | - Christopher J Marley
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
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Kearns J, Ross AM, Walsh DR, Cahalane RM, Hinchion R, Ryan MC, Conway E, Comyns TM, Kenny IC, O'Connor EM, McGourty KD, Mulvihill JJE. A blood biomarker and clinical correlation cohort study protocol to diagnose sports-related concussion and monitor recovery in elite rugby. BMJ Open Sport Exerc Med 2021; 6:e000948. [PMID: 34422289 PMCID: PMC8323462 DOI: 10.1136/bmjsem-2020-000948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/14/2020] [Accepted: 10/30/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction In professional rugby, sports-related concussion (SRC) remains the most frequent time loss injury. Therefore, accurately diagnosing SRC and monitoring player recovery, through a multi-modal assessment process, is critical to SRC management. In this protocol study, we aim to assess SRC over multiple time points post-injury to determine the value of multi-modal assessments to monitor player recovery. This is of significance to minimise premature return-to-play and, ultimately, to reduce the long-term effects associated with SRC. The study will also establish the logistics of implementing such a study in a professional setting to monitor a player's SRC recovery. Methods and analysis All players from the participating professional rugby club within the Irish Rugby Football Union are invited to participate in the current study. Player assessment includes head injury assessment (HIA), neuropsychometric assessment (ImPACT), targeted biomarker analysis and untargeted biomarker analysis. Baseline HIA, ImPACT, and blood draws are performed prior to the start of playing season. During the baseline tests, player's complete consent forms and an SRC history questionnaire. Subsequently, any participant that enters the HIA process over the playing season due to a suspected SRC will be clinically assessed (HIA and ImPACT) and their blood will be drawn within 3 days of injury, 6 days post-injury, and 13 days post-injury. Ethics and dissemination Ethical approval was attained from the Science and Engineering Research Ethics Committee, University of Limerick (Approval Code: 2018_06_11_S&E). On completion of the study, further manuscripts will be published to present the results of the tests and their ability to measure player recovery from SRC. Trial registration number NCT04485494.
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Affiliation(s)
- Jamie Kearns
- Munster Rugby Club, High Performance Centre, Limerick, Ireland
| | - Aisling M Ross
- School of Engineering, University of Limerick, Limerick, Ireland
| | - Darragh R Walsh
- School of Engineering, University of Limerick, Limerick, Ireland
| | | | - Rita Hinchion
- Clinical Research Support Unit, University Hospital Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Maria C Ryan
- Clinical Research Support Unit, University Hospital Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Elaine Conway
- Clinical Research Support Unit, University Hospital Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Tom M Comyns
- Health Research Institute, University of Limerick, Limerick, Ireland
| | - Ian C Kenny
- Health Research Institute, University of Limerick, Limerick, Ireland.,Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland
| | - Eibhlís M O'Connor
- Health Research Institute, University of Limerick, Limerick, Ireland.,Biological Sciences, University of Limerick, Limerick, Ireland.,Bernal Institute, University of Limerick, Limerick, Ireland
| | - Kieran D McGourty
- Health Research Institute, University of Limerick, Limerick, Ireland.,Bernal Institute, University of Limerick, Limerick, Ireland.,Chemical Sciences, University of Limerick, Limerick, Ireland
| | - John Joseph Eugene Mulvihill
- School of Engineering, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland.,Bernal Institute, University of Limerick, Limerick, Ireland
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