1
|
O’Brien WT, Spitz G, Xie B, Major BP, Mutimer S, Giesler LP, Bain J, Evans LJ, Duarte Martins B, Piantella S, Alhassan A, Brady S, Cappellari D, Somma V, McColl T, Symons GF, Gore T, Sun M, Kuek T, Horan S, Bei M, Ponsford JL, Willmott C, Reyes J, Ashton NJ, Zetterberg H, Mitra B, O’Brien TJ, Shultz SR, McDonald SJ. Biomarkers of Neurobiologic Recovery in Adults With Sport-Related Concussion. JAMA Netw Open 2024; 7:e2415983. [PMID: 38848061 PMCID: PMC11161851 DOI: 10.1001/jamanetworkopen.2024.15983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/04/2024] [Indexed: 06/10/2024] Open
Abstract
Importance Sport-related concussion (SRC), a form of mild traumatic brain injury, is a prevalent occurrence in collision sports. There are no well-established approaches for tracking neurobiologic recovery after SRC. Objective To examine the levels of serum glial fibrillary acidic protein (GFAP) and neurofilament light (NfL) in Australian football athletes who experience SRC. Design, Setting, and Participants A cohort study recruiting from April 10, 2021, to September 17, 2022, was conducted through the Victorian Amateur Football Association, Melbourne, Australia. Participants included adult Australian football players with or without SRC. Data analysis was performed from May 26, 2023, to March 27, 2024. Exposure Sport-related concussion, defined as at least 1 observable sign and/or 2 or more symptoms. Main Outcomes and Measures Primary outcomes were serum GFAP and NfL levels at 24 hours, and 1, 2, 4, 6, 8, 12, and 26 weeks. Secondary outcomes were symptoms, cognitive performance, and return to training times. Results Eighty-one individuals with SRC (median age, 22.8 [IQR, 21.3-26.0] years; 89% male) and 56 control individuals (median age, 24.6 [IQR, 22.4-27.3] years; 96% male) completed a total of 945 of 1057 eligible testing sessions. Compared with control participants, those with SRC exhibited higher GFAP levels at 24 hours (mean difference [MD] in natural log, pg/mL, 0.66 [95% CI, 0.50-0.82]) and 4 weeks (MD, 0.17 [95% CI, 0.02-0.32]), and NfL from 1 to 12 weeks (1-week MD, 0.31 [95% CI, 0.12-0.51]; 2-week MD, 0.38 [95% CI, 0.19-0.58]; 4-week MD, 0.31 [95% CI, 0.12-0.51]; 6-week MD, 0.27 [95% CI, 0.07-0.47]; 8-week MD, 0.36 [95% CI, 0.15-0.56]; and 12-week MD, 0.25 [95% CI, 0.04-0.46]). Growth mixture modeling identified 2 GFAP subgroups: extreme prolonged (16%) and moderate transient (84%). For NfL, 3 subgroups were identified: extreme prolonged (7%), moderate prolonged (15%), and minimal or no change (78%). Individuals with SRC who reported loss of consciousness (LOC) (33% of SRC cases) had higher GFAP at 24 hours (MD, 1.01 [95% CI, 0.77-1.24]), 1 week (MD, 0.27 [95% CI, 0.06-0.49]), 2 weeks (MD, 0.21 [95% CI, 0.004-0.42]) and 4 weeks (MD, 0.34 [95% CI, 0.13-0.55]), and higher NfL from 1 week to 12 weeks (1-week MD, 0.73 [95% CI, 0.42-1.03]; 2-week MD, 0.91 [95% CI, 0.61-1.21]; 4-week MD, 0.90 [95% CI, 0.59-1.20]; 6-week MD, 0.81 [95% CI, 0.50-1.13]; 8-week MD, 0.73 [95% CI, 0.42-1.04]; and 12-week MD, 0.54 [95% CI, 0.22-0.85]) compared with SRC participants without LOC. Return to training times were longer in the GFAP extreme compared with moderate subgroup (incident rate ratio [IRR], 1.99 [95% CI, 1.69-2.34]; NfL extreme (IRR, 3.24 [95% CI, 2.63-3.97]) and moderate (IRR, 1.43 [95% CI, 1.18-1.72]) subgroups compared with the minimal subgroup, and for individuals with LOC compared with those without LOC (IRR, 1.65 [95% CI, 1.41-1.93]). Conclusions and Relevance In this cohort study, a subset of SRC cases, particularly those with LOC, showed heightened and prolonged increases in GFAP and NfL levels, that persisted for at least 4 weeks. These findings suggest that serial biomarker measurement could identify such cases, guiding return to play decisions based on neurobiologic recovery. While further investigation is warranted, the association between prolonged biomarker elevations and LOC may support the use of more conservative return to play timelines for athletes with this clinical feature.
Collapse
Affiliation(s)
- William T. O’Brien
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Gershon Spitz
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- Monash-Epworth Rehabilitation Research Centre, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Becca Xie
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Brendan P. Major
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Steven Mutimer
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Lauren P. Giesler
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Jesse Bain
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Lauren J. Evans
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | | | - Stefan Piantella
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Afizu Alhassan
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Shelby Brady
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - David Cappellari
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Vincenzo Somma
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Thomas McColl
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Georgia F. Symons
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Tenae Gore
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Matthew Sun
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Timothy Kuek
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Seamus Horan
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Michael Bei
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Jennie L. Ponsford
- Monash-Epworth Rehabilitation Research Centre, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Catherine Willmott
- Monash-Epworth Rehabilitation Research Centre, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Australian Football League, Melbourne, Victoria, Australia
| | - Jonathan Reyes
- Monash-Epworth Rehabilitation Research Centre, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Australian Football League, Melbourne, Victoria, Australia
| | - Nicholas J. Ashton
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- King’s College London, Institute of Psychiatry, Psychology and Neuroscience, Maurice Wohl Institute Clinical Neuroscience Institute, London, United Kingdom
- NIHR Biomedical Research Centre for Mental Health and Biomedical Research Unit for Dementia at South London and Maudsley NHS Foundation, London, United Kingdom
- Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, University College London Institute of Neurology, Queen Square, London, United Kingdom
- UK Dementia Research Institute at University College London, London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, Hong Kong SAR, China
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison
| | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Terence J. O’Brien
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Sandy R. Shultz
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Health Sciences, Vancouver Island University, Nanaimo, British Columbia, Canada
| | - Stuart J. McDonald
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|