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Friberg S, Lindblad C, Zeiler FA, Zetterberg H, Granberg T, Svenningsson P, Piehl F, Thelin EP. Fluid biomarkers of chronic traumatic brain injury. Nat Rev Neurol 2024:10.1038/s41582-024-01024-z. [PMID: 39363129 DOI: 10.1038/s41582-024-01024-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2024] [Indexed: 10/05/2024]
Abstract
Traumatic brain injury (TBI) is a leading cause of long-term disability across the world. Evidence for the usefulness of imaging and fluid biomarkers to predict outcomes and screen for the need to monitor complications in the acute stage is steadily increasing. Still, many people experience symptoms such as fatigue and cognitive and motor dysfunction in the chronic phase of TBI, where objective assessments for brain injury are lacking. Consensus criteria for traumatic encephalopathy syndrome, a clinical syndrome possibly associated with the neurodegenerative disease chronic traumatic encephalopathy, which is commonly associated with sports concussion, have been defined only recently. However, these criteria do not fit all individuals living with chronic consequences of TBI. The pathophysiology of chronic TBI shares many similarities with other neurodegenerative and neuroinflammatory conditions, such as Alzheimer disease. As with Alzheimer disease, advancements in fluid biomarkers represent one of the most promising paths for unravelling the chain of pathophysiological events to enable discrimination between these conditions and, with time, provide prediction modelling and therapeutic end points. This Review summarizes fluid biomarker findings in the chronic phase of TBI (≥6 months after injury) that demonstrate the involvement of inflammation, glial biology and neurodegeneration in the long-term complications of TBI. We explore how the biomarkers associate with outcome and imaging findings and aim to establish mechanistic differences in biomarker patterns between types of chronic TBI and other neurodegenerative conditions. Finally, current limitations and areas of priority for future fluid biomarker research are highlighted.
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Affiliation(s)
- Susanna Friberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
| | - Frederick A Zeiler
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Pan Am Clinic Foundation, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Henrik Zetterberg
- UK Dementia Research Institute, University College London, London, UK
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Department of Neurodegenerative Disease, University College London, Queen Square Institute of Neurology, London, UK
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- 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, WI, USA
| | - Tobias Granberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Per Svenningsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Basic and Clinical Neuroscience, King's College London, London, UK
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.
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Wallingford A, Junn C. Chronic Traumatic Encephalopathy. Phys Med Rehabil Clin N Am 2024; 35:607-618. [PMID: 38945654 DOI: 10.1016/j.pmr.2024.02.011] [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: 07/02/2024]
Abstract
This article focuses on neuropathologic diagnostic criteria for chronic traumatic encephalopathy (CTE) and consensus research diagnostic criteria for traumatic encephalopathy syndrome (TES). CTE as a tauopathy has a unique pattern for diagnosis and differs from other neurodegenerative diseases. We discuss the history, neuropathology, and mechanism of CTE as well as the preliminary reasearch diagnostic criteria for TES, which is the proposed clinical presentation of suspected CTE.
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Affiliation(s)
- Allison Wallingford
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Cherry Junn
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue Box 359740, Seattle, WA 98104, USA.
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Del Bigio MR, Krawitz S, Sinha N. Chronic traumatic encephalopathy-neuropathologic change in a routine neuropathology service: 7-year follow-up. J Neuropathol Exp Neurol 2023; 82:948-957. [PMID: 37846159 PMCID: PMC10588000 DOI: 10.1093/jnen/nlad079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
To follow our 2016 study of chronic traumatic encephalopathy neuropathologic change (CTE-NC) in our forensic autopsy service, we prospectively screened all cases with clinical histories of multiple concussions, persistent post-head injury symptoms, or ≥3 hospital investigations for head injuries from 2016 to 2022 inclusive using hyperphosphorylated tau (p-tau) immunostaining. The cases had routine brain sampling plus 4-6 additional lateral hemisphere samples. When "pathognomonic" CTE-NC lesions were identified, additional p-tau immunostaining was done for CTE-NC staging. Of ∼1100 adult brains aged 18-65 years examined, 85 were screened, and 16 were positive for CTE-NC (2 women, 14 men, ages 35-61 years, median 47 years). Alcohol abuse was documented in 14 of 16 (8 in combination with other substances); 5 had developmental brain anomalies (2 presumed genetic, 3 from acquired perinatal insults). Widespread p-tau deposits (high CTE-NC) were found in 7 of 16. Old brain contusions were present in 9 of 16, but CTE-NC did not colocalize. Of particular interest were (1) a man with FGFR3 mutation/hypochondroplasia and life-long head banging, (2) a woman with cerebral palsy and life-long head banging, and (3) a man with bilateral peri-Sylvian polymicrogyria, alcohol abuse, and multiple head injuries. Thus, CTE-NC occurs in association with repeated head trauma outside contact sports. Substance abuse is a common determinant of risk behavior. The utility of diagnosing mild-/low-stage CTE-NC in this population remains to be determined.
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Affiliation(s)
- Marc R Del Bigio
- Department of Pathology, University of Manitoba & Shared Health Manitoba, Winnipeg, Manitoba, Canada
| | - Sherry Krawitz
- Department of Pathology, University of Manitoba & Shared Health Manitoba, Winnipeg, Manitoba, Canada
| | - Namita Sinha
- Department of Pathology, University of Manitoba & Shared Health Manitoba, Winnipeg, Manitoba, Canada
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Huang YQ, Wu Z, Lin S, Chen XR. The benefits of rehabilitation exercise in improving chronic traumatic encephalopathy: recent advances and future perspectives. Mol Med 2023; 29:131. [PMID: 37740180 PMCID: PMC10517475 DOI: 10.1186/s10020-023-00728-0] [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: 07/12/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023] Open
Abstract
Traumatic encephalopathy syndrome (TES) is used to describe the clinical manifestations of chronic traumatic encephalopathy (CTE). However, effective treatment and prevention strategies are lacking. Increasing evidence has shown that rehabilitation training could prevent cognitive decline, enhance brain plasticity, and effectively improve neurological function in neurodegenerative diseases. Therefore, the mechanisms involved in the effects of rehabilitation exercise therapy on the prognosis of CTE are worth exploring. The aim of this article is to review the pathogenesis of CTE and provide a potential clinical intervention strategy for CTE.
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Affiliation(s)
- Yin-Qiong Huang
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Quanzhou, 362000, Fujian, China
- Centre of Neurological and Metabolic Research, The Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Quanzhou, 362000, Fujian, China
| | - Zhe Wu
- Department of Neuronal Surgery, The Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Quanzhou, 362000, Fujian, China
| | - Shu Lin
- Centre of Neurological and Metabolic Research, The Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Quanzhou, 362000, Fujian, China.
- Group of Neuroendocrinology, Garvan Institute of Medical Research, 384 Victoria St, Sydney, Australia.
| | - Xiang-Rong Chen
- Department of Neuronal Surgery, The Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Quanzhou, 362000, Fujian, China.
- Centre of Neurological and Metabolic Research, The Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Quanzhou, 362000, Fujian, China.
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Beversdorf DQ, Paretsky M. Traumatic Encephalopathy Syndrome: Can It Stand the Test of Time? Neurology 2023; 101:461-462. [PMID: 37380430 DOI: 10.1212/wnl.0000000000207711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023] Open
Affiliation(s)
- David Q Beversdorf
- From the Department of Radiology, Neurology, and Psychology, College of Arts & Sciences, University of Missouri, Columbia.
| | - Melissa Paretsky
- From the Department of Radiology, Neurology, and Psychology, College of Arts & Sciences, University of Missouri, Columbia
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Rossi C, Campese N, Colosimo C. Emerging Symptomatic Treatment of Chronic Traumatic Encephalopathy (CTE): a narrative review. Expert Opin Pharmacother 2023; 24:1415-1425. [PMID: 37300418 DOI: 10.1080/14656566.2023.2224501] [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: 02/26/2023] [Accepted: 06/08/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Chronic traumatic encephalopathy (CTE) is an emergent neurodegenerative tauopathy well characterized pathologically but with limited consensus about clinical criteria. The clinical features include cognitive, behavioral, and motor symptoms such as parkinsonism, gait, balance disorder, and bulbar impairment. Their recognition derives from retrospective studies in pathologically confirmed CTE patients. This is one of the main reasons for the lack of specific pharmacological studies targeting symptoms or pathologic pathways of this disease. AREAS COVERED In this narrative review, we overview the possible symptomatic treatment options for CTE, based on pathological similarities with other neurodegenerative diseases that may share common pathological pathways with CTE. The PubMed database was screened for articles addressing the symptomatic treatment of CTE and Traumatic Encephalopathy Syndrome (TES). Additional references were retrieved by reference cross-check and retained if pertinent to the subject. The clinicaltrials.gov database was screened for ongoing trials on the treatment of CTE. EXPERT OPINION The similarities with the other tauopathies allow us, in the absence of disease-specific evidence, to translate some knowledge from these neurodegenerative disorders to CTE's symptomatic treatment, but any conclusion should be drawn cautiously and a patient-tailored strategy should be always preferred balancing the risks and benefits of each treatment.
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Affiliation(s)
- Carlo Rossi
- Neurology Unit, F. Lotti Hospital of Pontedera. Azienda Sanitaria Locale Toscana Nord-Ovest, Pisa, Italy
| | - Nicole Campese
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Carlo Colosimo
- Department of Neurology, S. Maria University Hospital, Terni, Italy
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LoBue C, Cullum CM, Hart J. Examination of the Proposed Criteria for Traumatic Encephalopathy Syndrome: Case Report of a Former Professional Football Player. J Neuropsychiatry Clin Neurosci 2022; 34:268-274. [PMID: 35272492 DOI: 10.1176/appi.neuropsych.21090225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Christian LoBue
- Department of Psychiatry (all authors), Department of Neurological Surgery (LoBue, Cullum), and Department of Neurology (Cullum, Hart), University of Texas Southwestern Medical Center, Dallas; School of Behavioral and Brain Sciences, University of Texas at Dallas (Hart)
| | - C Munro Cullum
- Department of Psychiatry (all authors), Department of Neurological Surgery (LoBue, Cullum), and Department of Neurology (Cullum, Hart), University of Texas Southwestern Medical Center, Dallas; School of Behavioral and Brain Sciences, University of Texas at Dallas (Hart)
| | - John Hart
- Department of Psychiatry (all authors), Department of Neurological Surgery (LoBue, Cullum), and Department of Neurology (Cullum, Hart), University of Texas Southwestern Medical Center, Dallas; School of Behavioral and Brain Sciences, University of Texas at Dallas (Hart)
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Nowinski CJ, Bureau SC, Buckland ME, Curtis MA, Daneshvar DH, Faull RLM, Grinberg LT, Hill-Yardin EL, Murray HC, Pearce AJ, Suter CM, White AJ, Finkel AM, Cantu RC. Applying the Bradford Hill Criteria for Causation to Repetitive Head Impacts and Chronic Traumatic Encephalopathy. Front Neurol 2022; 13:938163. [PMID: 35937061 PMCID: PMC9355594 DOI: 10.3389/fneur.2022.938163] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/22/2022] [Indexed: 02/05/2023] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with a history of repetitive head impacts (RHI). CTE was described in boxers as early as the 1920s and by the 1950s it was widely accepted that hits to the head caused some boxers to become "punch drunk." However, the recent discovery of CTE in American and Australian-rules football, soccer, rugby, ice hockey, and other sports has resulted in renewed debate on whether the relationship between RHI and CTE is causal. Identifying the strength of the evidential relationship between CTE and RHI has implications for public health and medico-legal issues. From a public health perspective, environmentally caused diseases can be mitigated or prevented. Medico-legally, millions of children are exposed to RHI through sports participation; this demographic is too young to legally consent to any potential long-term risks associated with this exposure. To better understand the strength of evidence underlying the possible causal relationship between RHI and CTE, we examined the medical literature through the Bradford Hill criteria for causation. The Bradford Hill criteria, first proposed in 1965 by Sir Austin Bradford Hill, provide a framework to determine if one can justifiably move from an observed association to a verdict of causation. The Bradford Hill criteria include nine viewpoints by which to evaluate human epidemiologic evidence to determine if causation can be deduced: strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experiment, and analogy. We explored the question of causation by evaluating studies on CTE as it relates to RHI exposure. Through this lens, we found convincing evidence of a causal relationship between RHI and CTE, as well as an absence of evidence-based alternative explanations. By organizing the CTE literature through this framework, we hope to advance the global conversation on CTE mitigation efforts.
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Affiliation(s)
- Christopher J. Nowinski
- Concussion Legacy Foundation, Boston, MA, United States,*Correspondence: Christopher J. Nowinski
| | | | - Michael E. Buckland
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia,School of Medical Sciences, University of Sydney, Camperdown, NSW, Australia
| | - Maurice A. Curtis
- Department of Anatomy and Medical Imaging and Centre for Brain Research, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Daniel H. Daneshvar
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MA, United States,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Richard L. M. Faull
- Department of Anatomy and Medical Imaging and Centre for Brain Research, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Lea T. Grinberg
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States,Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, United States,Department of Pathology, University of Sao Paulo Medical School, São Paulo, Brazil,Department of Pathology, University of California, San Francisco, San Francisco, CA, United States
| | - Elisa L. Hill-Yardin
- School of Health and Biomedical Sciences, STEM College, RMIT University, Bundoora, VIC, Australia,Department of Anatomy & Physiology, The University of Melbourne, Parkville, VIC, Australia
| | - Helen C. Murray
- Department of Anatomy and Medical Imaging and Centre for Brain Research, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Alan J. Pearce
- College of Science, Health, and Engineering, La Trobe University, Melbourne, VIC, Australia
| | - Catherine M. Suter
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia,School of Medical Sciences, University of Sydney, Camperdown, NSW, Australia
| | - Adam J. White
- Department of Sport, Health Science, and Social Work, Oxford Brookes University, Oxford, United Kingdom,Concussion Legacy Foundation UK, Cheltenham, United Kingdom
| | - Adam M. Finkel
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Robert C. Cantu
- Concussion Legacy Foundation, Boston, MA, United States,Department of Neurology, Boston University School of Medicine, Boston, MA, United States,Department of Neurosurgery, Emerson Hospital, Concord, MA, United States
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