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Goubran M, Mills BD, Georgiadis M, Karimpoor M, Mouchawar N, Sami S, Dennis EL, Akers C, Mitchell L, Boldt B, Douglas D, DiGiacomo PS, Rosenberg J, Grant G, Wintermark M, Camarillo DB, Zeineh M. Microstructural Alterations in Tract Development in College Football and Volleyball Players: A Longitudinal Diffusion MRI Study. Neurology 2023; 101:e953-e965. [PMID: 37479529 PMCID: PMC10501097 DOI: 10.1212/wnl.0000000000207543] [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: 08/10/2022] [Accepted: 05/05/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Repeated impacts in high-contact sports such as American football can affect the brain's microstructure, which can be studied using diffusion MRI. Most imaging studies are cross-sectional, do not include low-contact players as controls, or lack advanced tract-specific microstructural metrics. We aimed to investigate longitudinal changes in high-contact collegiate athletes compared with low-contact controls using advanced diffusion MRI and automated fiber quantification. METHODS We examined brain microstructure in high-contact (football) and low-contact (volleyball) collegiate athletes with up to 4 years of follow-up. Inclusion criteria included university and team enrollment. Exclusion criteria included history of neurosurgery, severe brain injury, and major neurologic or substance abuse disorder. We investigated diffusion metrics along the length of tracts using nested linear mixed-effects models to ascertain the acute and chronic effects of subconcussive and concussive impacts, and associations between diffusion changes with clinical, behavioral, and sports-related measures. RESULTS Forty-nine football and 24 volleyball players (271 total scans) were included. Football players had significantly divergent trajectories in multiple microstructural metrics and tracts. Longitudinal increases in fractional anisotropy and axonal water fraction, and decreases in radial/mean diffusivity and orientation dispersion index, were present in volleyball but absent in football players (all findings |T-statistic|> 3.5, p value <0.0001). This pattern was present in the callosum forceps minor, superior longitudinal fasciculus, thalamic radiation, and cingulum hippocampus. Longitudinal differences were more prominent and observed in more tracts in concussed football players (n = 24, |T|> 3.6, p < 0.0001). An analysis of immediate postconcussion scans (n = 12) demonstrated a transient localized increase in axial diffusivity and mean/radial kurtosis in the uncinate and cingulum hippocampus (|T| > 3.7, p < 0.0001). Finally, within football players, those with high position-based impact risk demonstrated increased intracellular volume fraction longitudinally (T = 3.6, p < 0.0001). DISCUSSION The observed longitudinal changes seen in football, and especially concussed athletes, could reveal diminished myelination, altered axonal calibers, or depressed pruning processes leading to a static, nondecreasing axonal dispersion. This prospective longitudinal study demonstrates divergent tract-specific trajectories of brain microstructure, possibly reflecting a concussive and repeated subconcussive impact-related alteration of white matter development in football athletes.
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Affiliation(s)
- Maged Goubran
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Brian David Mills
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Marios Georgiadis
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Mahta Karimpoor
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Nicole Mouchawar
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Sohrab Sami
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Emily Larson Dennis
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Carolyn Akers
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Lex Mitchell
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Brian Boldt
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - David Douglas
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Phillip Scott DiGiacomo
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Jarrett Rosenberg
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Gerald Grant
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Max Wintermark
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - David Benjamin Camarillo
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA
| | - Michael Zeineh
- From the Departments of Radiology (Maged Goubran, B.D.M., Marios Georgiadis, M.K., N.M., C.A., L.M., D.D., P.S.D., J.R., M.W., M.Z.), Neurosurgery (G.G.), and Bioengineering (D.B.C.), Stanford University, CA; Department of Medical Biophysics (Maged Goubran) and Physical Sciences Platform & Hurvitz Brain Sciences Research Program (Maged Goubran), Sunnybrook Research Institute, University of Toronto, ON, Canada; Stanford Center for Clinical Research (S.S.), CA; Department of Neurology (E.L.D.), University of Utah School of Medicine, Salt Lake City; Department of Radiology (B.B.), Uniformed Services University of the Health Sciences, Bethesda, MD; and Department of Radiology (B.B.), Madigan Army Medical Center, Tacoma, WA.
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