Chronic traumatic encephalopathy: fluid biomarkers

Concussion in Female Athletes of Contact Sports: A Scoping Review

Background

Recent studies have described higher incidences of concussion, with more severe symptoms and worse outcomes in female athletes compared with male athletes.

Purpose

To compile current knowledge about sex-specific differences in incidence, biomechanics, biomarkers, imaging, and outcomes of concussion in athletes participating in contact sports to better understand which fields should be explored in more detail.

Study Design

Scoping review; Level of evidence, 3.

Methods

The PubMed database was searched for articles published between January 2000 and November 2020 using the Medical Subject Headings terms "craniocerebral trauma" and "brain concussion" combined with the contact sports "football,""soccer,""hockey," and "boxing." Eligibility criteria were based on the recommendations of the Scottish Intercollegiate Guidelines Network. It focused on sex-specific differences within 5 major topics: (1) epidemiology, (2) biomechanics, (3) biomarkers, (4) imaging, and (5) specific concussion outcome variables, including neurocognitive performance, injury severity, and behavioral and psychological symptoms.

Results

A total of 22 studies were included. Eight studies investigated the incidence of concussion, with 4 of the 8 finding a significantly higher incidence rate for female versus male athletes. Six studies that focused on biomechanics found that female athletes received fewer impacts with lower magnitudes. One study addressed biomarkers, showing that S100 calcium-binding protein B and neuron-specific enolase were increased after a game in female athletes, and the level of increase was similar to the changes found in male athletes. Based on the 3 imaging studies, affected brain tissue was greatest in areas associated with tau pathology in chronic traumatic encephalopathy. One study showed a lower hypointensity burden index after a season of ice hockey for female athletes, while another study showed more regions with white matter alterations. Seven studies examined concussion outcomes, with 4 studies showing more severe neuropsychological deficits; in addition, female athletes reported more and worse symptoms than male athletes.

Conclusion

The results of this review indicated that female athletes had a higher risk of sustaining a concussion, although they received fewer impacts with lower magnitudes than male athletes. Biomarkers were able to be used equally for both sexes. Female athletes also had a higher neuropsychological deficit and increasingly worse symptoms after a concussion.

Repetitive head injuries in German American football players do not change blood-based biomarker candidates for CTE during a single season

BACKGROUND

Repetitive traumatic brain injuries in American football players (AFPs) can lead to the neurodegenerative disease chronic traumatic encephalopathy (CTE). Clinical symptoms of CTE range from mood and behavioral changes to cognitive impairment, depression, and suicidality. So far, CTE cannot be diagnosed in vivo and thus specific diagnostic parameters for CTE need to be found, to observe and treat exposed athletes as early as possible. Promising blood-based biomarkers for CTE include total tau (tTau), hyperphosphorylated tau (pTau), neurofilament light protein (NF-L), glial fibrillary acidic protein (GFAP), amyloid-β40 (Aβ40), amyloid-β42 (Aβ42) and calcium-binding protein B (S100-B). Previous studies have found elevated levels of these biomarkers in subjects exposed to TBIs, whereas cerebrospinal fluid (CSF) levels of Aβ40 and Aβ42 were decreased in CTE subjects. Here, we investigated whether young AFPs already exhibit changes of these biomarker candidates during the course of a single active season.

METHODS

Blood samples were drawn from n = 18 American Football Players before and after a full season and n = 18 male age-matched control subjects. The plasma titers of tTau, pTau, NF-L, GFAP, Aβ40, Aβ42 and S100-B were determined. Additionally, Apathy, Depression, and Health status as well as the concussion history and medical care were assessed and analyzed for correlations.

RESULTS

Here we show, that the selected biomarker candidates for CTE do not change significantly during the seven-month period of a single active season of American Football in blood samples of AFPs compared to healthy controls. But interestingly, they exhibit generally elevated pTau titers. Furthermore, we found correlations of depression, quality-of-life, career length, training participation and training continuation with headache after concussion with various titers.

CONCLUSION

Our data indicates, that changes of CTE marker candidates either occur slowly over several active seasons of American Football or are exclusively found in CSF. Nevertheless, our results underline the importance of a long-term assessment of these biomarker candidates, which might be possible through repeated blood biomarker monitoring in exposed athletes in the future.

A brief descriptive outline of the rules of mixed martial arts and concussion in mixed martial arts

Mixed martial arts (MMA), a combat sport consisting of wrestling, box-ing, and martial arts, is a popular activity associated with danger and vi-olence. Of concern are the repetitive head impacts, both subconcussive and concussive, sustained by MMA athletes. The rules of MMA en-courage head strikes, but there was no formal concussion protocol in the Ultimate Fighting Championship (UFC) until 2021. Because the UFC was established less than 30 years, the long-term consequences of these repetitive concussive head blows are lacking. In this review, we focus on current literature sought to summarize the current knowledge of repetitive head impacts and concussions in MMA. The objectives were to outline (a) the rules of MMA; (b) the postconcussion protocol for UFC athletes; (c) current behavioral and biochemical diagnostic measures; (d) epidemiology and prevalence of concussion in MMA; (e) long-term effects of subconcussive repetitive head impacts; (f) biome-chanics of head impacts; and (g) considerations and research topics that warrant future research.

Cerebrolysin restores balance between excitatory and inhibitory amino acids in brain following concussive head injury. Superior neuroprotective effects of TiO2 nanowired drug delivery

Concussive head injury (CHI) often associated with military personnel, soccer players and related sports personnel leads to serious clinical situation causing lifetime disabilities. About 3-4k head injury per 100k populations are recorded in the United States since 2000-2014. The annual incidence of concussion has now reached to 1.2% of population in recent years. Thus, CHI inflicts a huge financial burden on the society for rehabilitation. Thus, new efforts are needed to explore novel therapeutic strategies to treat CHI cases to enhance quality of life of the victims. CHI is well known to alter endogenous balance of excitatory and inhibitory amino acid neurotransmitters in the central nervous system (CNS) leading to brain pathology. Thus, a possibility exists that restoring the balance of amino acids in the CNS following CHI using therapeutic measures may benefit the victims in improving their quality of life. In this investigation, we used a multimodal drug Cerebrolysin (Ever NeuroPharma, Austria) that is a well-balanced composition of several neurotrophic factors and active peptide fragments in exploring its effects on CHI induced alterations in key excitatory (Glutamate, Aspartate) and inhibitory (GABA, Glycine) amino acids in the CNS in relation brain pathology in dose and time-dependent manner. CHI was produced in anesthetized rats by dropping a weight of 114.6g over the right exposed parietal skull from a distance of 20cm height (0.224N impact) and blood-brain barrier (BBB), brain edema, neuronal injuries and behavioral dysfunctions were measured 8, 24, 48 and 72h after injury. Cerebrolysin (CBL) was administered (2.5, 5 or 10mL/kg, i.v.) after 4-72h following injury. Our observations show that repeated CBL induced a dose-dependent neuroprotection in CHI (5-10mL/kg) and also improved behavioral functions. Interestingly when CBL is delivered through TiO₂ nanowires superior neuroprotective effects were observed in CHI even at a lower doses (2.5-5mL/kg). These observations are the first to demonstrate that CBL is effectively capable to attenuate CHI induced brain pathology and behavioral disturbances in a dose dependent manner, not reported earlier.

Chronic Traumatic Encephalopathy: Update on Current Clinical Diagnosis and Management

Chronic traumatic encephalopathy is a disease afflicting individuals exposed to repetitive neurotrauma. Unfortunately, diagnosis is made by postmortem pathologic analysis, and treatment options are primarily symptomatic. In this clinical update, we review clinical and pathologic diagnostic criteria and recommended symptomatic treatments. We also review animal models and recent discoveries from pre-clinical studies. Furthermore, we highlight the recent advances in diagnosis using diffusor tensor imaging, functional magnetic resonance imaging, positron emission tomography, and the fluid biomarkers t-tau, sTREM2, CCL11, NFL, and GFAP. We also provide an update on emerging pharmaceutical treatments, including immunotherapies and those that target tau acetylation, tau phosphorylation, and inflammation. Lastly, we highlight the current literature gaps and guide future directions to further improve clinical diagnosis and management of patients suffering from this condition.

Longitudinal changes in blood-based biomarkers in chronic moderate to severe traumatic brain injury: preliminary findings

Objectives: This longitudinal study aims at 1) providing preliminary evidence of changes in blood-based biomarkers across time in chronic TBI and 2) relating these changes to outcome measures and cerebral structure and activity.Methods: Eight patients with moderate-to-severe TBI (7 males, 35 ± 7.6 years old, 5 severe TBI, 17.52 ± 3.84 months post-injury) were evaluated at monthly intervals across 6 time-points using: a) Blood-based biomarkers (GFAP, NSE, S100A12, SDBP145, UCH-L1, T-tau, P-tau, P-tau/T-tau ratio); b) Magnetic Resonance Imaging to evaluate changes in brain structure; c) Resting-state electroencephalograms to evaluate changes in brain function; and d) Outcome measures to assess cognition, emotion, and functional recovery (MOCA, RBANS, BDI-II, and DRS).Results: Changes in P-tau levels were found across time [p = .007]. P-tau was positively related to functional [p < .001] and cognitive [p = .006] outcomes, and negatively related to the severity of depression, 6 months later [R = -0.901; p =.006]. P-tau and P-tau/T-tau ratio were also positively correlated to shape change in subcortical areas such as brainstem [T(7) = 4.71, p = .008] and putamen [T(7) = 3.25, p = .012].Conclusions: Our study provides preliminary findings that suggest a positive relationship between P-tau and the recovery of patients with chronic TBI.

Evolution of neuronal and glial tau isoforms in chronic traumatic encephalopathy

Chronic traumatic encephalopathy (CTE) is a neurodegenerative tauopathy characterized by accumulation of hyperphosphorylated tau (p-tau) in perivascular aggregates in neurons and glia at the depths of neocortical sulci and progresses to diffuse neocortical, allocortical and brainstem structures. The strongest risk factor is exposure to repetitive head impacts acquired most commonly through contact sports and military service. Given that CTE can only be definitively diagnosed after death, a better understanding of the cellular and molecular changes in CTE brains may lead to identification of mechanisms that could be used for novel biomarkers, monitoring progression or therapeutic development. Disruption of alternative pre-mRNA splicing of tau mRNA plays a pathogenic role in tauopathy, with multiple characteristic patterns of isoform accumulation varying among tauopathies. Limited data are available on CTE, particularly at early stages. Using biochemical and histological approaches, we performed a detailed characterization of tau isoform signatures in post-mortem human brain tissue from individuals with a range of CTE stages (n = 99). In immunoblot analyses, severity was associated with decreased total monomeric tau and increased total oligomeric tau. Immunoblot with isoform-specific antisera revealed that oligomeric tau with three and four microtubule binding domain repeats (3R and 4R) also increased with CTE severity. Similarly, immunohistochemical studies revealed p-tau accumulation consisting of both 3R and 4R in perivascular lesions. When the ratio of 4R:3R was analyzed, there was mixed expression throughout CTE stages, although 4R predominated in early CTE stages (I-II), a 3R shift was observed in later stages (III-IV). While neurons were found to contain both 3R and 4R, astrocytes only contained 4R. These 4R-positive cells were exclusively neuronal at early stages. Overall, these findings demonstrate that CTE is a mixed 4R/3R tauopathy. Furthermore, histologic analysis reveals a progressive shift in tau isoforms that correlates with CTE stage and extent of neuronal pathology.

Chronic Traumatic Encephalopathy: A Comparison with Alzheimer's Disease and Frontotemporal Dementia

The clinical diagnosis of chronic traumatic encephalopathy (CTE) is challenging due to heterogeneous clinical presentations and overlap with other neurodegenerative dementias. Depending on the clinical presentation, the differential diagnosis of CTE includes Alzheimer's disease (AD), behavioral variant frontotemporal dementia (bvFTD), Parkinson's disease, amyotrophic lateral sclerosis, primary mood disorders, posttraumatic stress disorder, and psychotic disorders. The aim of this article is to compare the clinical aspects, genetics, fluid biomarkers, imaging, treatment, and pathology of CTE to those of AD and bvFTD. A detailed clinical evaluation, neurocognitive assessment, and structural brain imaging can inform the differential diagnosis, while molecular biomarkers can help exclude underlying AD pathology. Prospective studies that include clinicopathological correlations are needed to establish tools that can more accurately determine the cause of neuropsychiatric decline in patients at risk for CTE.

Chronic Traumatic Encephalopathy and Neuropathological Comorbidities

With age, the presence of multiple neuropathologies in a single individual becomes increasingly common. Given that traumatic brain injury and the repetitive head impacts (RHIs) that occur in contact sports have been associated with the development of many neurodegenerative diseases, including chronic traumatic encephalopathy (CTE), Alzheimer's disease, Lewy body disease, and amyotrophic lateral sclerosis, it is becoming critical to understand the relationship and interactions between these pathologies. In fact, comorbid pathology is common in CTE and likely influenced by both age and the severity and type of exposure to RHI as well as underlying genetic predisposition. Here, we review the major comorbid pathologies seen with CTE and in former contact sports athletes and discuss what is known about the associations between RHI, age, and the development of neuropathologies. In addition, we examine the distinction between CTE and age-related pathology including primary age-related tauopathy and age-related tau astrogliopathy.

Blood biomarkers for assessment of mild traumatic brain injury and chronic traumatic encephalopathy

Mild traumatic brain injuries (mTBI) are prevalent and can result in significant debilitation. Current diagnostic methods have implicit limitations, with clinical assessment tools reliant on subjective self-reported symptoms or non-specific clinical observations, and commonly available imaging techniques lacking sufficient sensitivity to detect mTBI. A blood biomarker would provide a readily accessible detector of mTBI to meet the current measurement gap. Suitable options would provide objective and quantifiable information in diagnosing mTBI, in monitoring recovery, and in establishing a prognosis of resultant neurodegenerative disease, such as chronic traumatic encephalopathy (CTE). A biomarker would also assist in progressing research, providing suitable endpoints for testing therapeutic modalities and for further exploring mTBI pathophysiology. This review highlights the most promising blood-based protein candidates that are expressed in the central nervous system (CNS) and released into systemic circulation following mTBI. To date, neurofilament light (NF-L) may be the most suitable candidate for assessing neuronal damage, and glial fibrillary acidic protein (GFAP) for assessing astrocyte activation, although further work is required. Ultimately, the heterogeneity of cells in the brain and each marker's limitations may require a combination of biomarkers, and recent developments in microRNA (miRNA) markers of mTBI show promise and warrant further exploration.

Brain injury-induced dysfunction of the blood brain barrier as a risk for dementia

The blood-brain barrier (BBB) is a complex and dynamic physiological interface between brain parenchyma and cerebral vasculature. It is composed of closely interacting cells and signaling molecules that regulate movement of solutes, ions, nutrients, macromolecules, and immune cells into the brain and removal of products of normal and abnormal brain cell metabolism. Dysfunction of multiple components of the BBB occurs in aging, inflammatory diseases, traumatic brain injury (TBI, severe or mild repetitive), and in chronic degenerative dementing disorders for which aging, inflammation, and TBI are considered risk factors. BBB permeability changes after TBI result in leakage of serum proteins, influx of immune cells, perivascular inflammation, as well as impairment of efflux transporter systems and accumulation of aggregation-prone molecules involved in hallmark pathologies of neurodegenerative diseases with dementia. In addition, cerebral vascular dysfunction with persistent alterations in cerebral blood flow and neurovascular coupling contribute to brain ischemia, neuronal degeneration, and synaptic dysfunction. While the idea of TBI as a risk factor for dementia is supported by many shared pathological features, it remains a hypothesis that needs further testing in experimental models and in human studies. The current review focusses on pathological mechanisms shared between TBI and neurodegenerative disorders characterized by accumulation of pathological protein aggregates, such as Alzheimer's disease and chronic traumatic encephalopathy. We discuss critical knowledge gaps in the field that need to be explored to clarify the relationship between TBI and risk for dementia and emphasize the need for longitudinal in vivo studies using imaging and biomarkers of BBB dysfunction in people with single or multiple TBI.

Association of Blood and Cerebrospinal Fluid Tau Level and Other Biomarkers With Survival Time in Sporadic Creutzfeldt-Jakob Disease

IMPORTANCE

Fluid biomarkers that can predict survival time in sporadic Creutzfeldt-Jakob disease (sCJD) will be critical for clinical care and for treatment trials.

OBJECTIVE

To assess whether plasma and cerebrospinal fluid (CSF) biomarkers are associated with survival time in patients with sCJD.

DESIGN, SETTING, AND PARTICIPANTS

In this longitudinal cohort study, data from 193 patients with probable or definite sCJD who had codon 129 genotyping referred to a tertiary national referral service in the United States were collected from March 2004 to January 2018. Participants were evaluated until death or censored at the time of statistical analysis (range, 0.03-38.3 months). We fitted Cox proportional hazard models with time to event as the outcome. Fluid biomarkers were log-transformed, and models were run with and without nonfluid biomarkers of survival. Five patients were excluded because life-extending measures were performed.

MAIN OUTCOMES AND MEASURES

Biomarkers of survival included sex, age, codon 129 genotype, Barthel Index, Medical Research Council Prion Disease Rating Scale, 8 CSF biomarkers (total tau [t-tau] level, phosphorylated tau [p-tau] level, t-tau:p-tau ratio, neurofilament light [NfL] level, β-amyloid 42 level, neuron-specific enolase level, 14-3-3 test result, and real-time quaking-induced conversion test), and 3 plasma biomarkers (t-tau level, NfL level, and glial fibrillary acidic protein level).

RESULTS

Of the 188 included participants, 103 (54.8%) were male, and the mean (SD) age was 63.8 (9.2) years. Plasma t-tau levels (hazard ratio, 5.8; 95% CI, 2.3-14.8; P < .001) and CSF t-tau levels (hazard ratio, 1.6; 95% CI, 1.2-2.1; P < .001) were significantly associated with survival after controlling for codon 129 genotype and Barthel Index, which are also associated with survival time. Plasma and CSF t-tau levels were correlated (r = 0.74; 95% CI, 0.50-0.90; P < .001). Other fluid biomarkers associated with survival included plasma NfL levels, CSF NfL levels, t-tau:p-tau ratio, 14-3-3 test result, and neuron-specific enolase levels. In a restricted subset of 23 patients with data for all significant biomarkers, the hazard ratio for plasma t-tau level was more than 40% larger than any other biomarkers (hazard ratio, 3.4; 95% CI, 1.8-6.4).

CONCLUSIONS AND RELEVANCE

Cerebrospinal fluid and plasma tau levels, along with several other fluid biomarkers, were significantly associated with survival time in patients with sCJD. The correlation between CSF and plasma t-tau levels and the association of plasma t-tau level with survival time suggest that plasma t-tau level may be a minimally invasive fluid biomarker in sCJD that could improve clinical trial stratification and guide clinical care.