1
|
Elder GA, Gama Sosa MA, De Gasperi R, Perez Garcia G, Perez GM, Abutarboush R, Kawoos U, Zhu CW, Janssen WGM, Stone JR, Hof PR, Cook DG, Ahlers ST. The Neurovascular Unit as a Locus of Injury in Low-Level Blast-Induced Neurotrauma. Int J Mol Sci 2024; 25:1150. [PMID: 38256223 PMCID: PMC10816929 DOI: 10.3390/ijms25021150] [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: 12/12/2023] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Blast-induced neurotrauma has received much attention over the past decade. Vascular injury occurs early following blast exposure. Indeed, in animal models that approximate human mild traumatic brain injury or subclinical blast exposure, vascular pathology can occur in the presence of a normal neuropil, suggesting that the vasculature is particularly vulnerable. Brain endothelial cells and their supporting glial and neuronal elements constitute a neurovascular unit (NVU). Blast injury disrupts gliovascular and neurovascular connections in addition to damaging endothelial cells, basal laminae, smooth muscle cells, and pericytes as well as causing extracellular matrix reorganization. Perivascular pathology becomes associated with phospho-tau accumulation and chronic perivascular inflammation. Disruption of the NVU should impact activity-dependent regulation of cerebral blood flow, blood-brain barrier permeability, and glymphatic flow. Here, we review work in an animal model of low-level blast injury that we have been studying for over a decade. We review work supporting the NVU as a locus of low-level blast injury. We integrate our findings with those from other laboratories studying similar models that collectively suggest that damage to astrocytes and other perivascular cells as well as chronic immune activation play a role in the persistent neurobehavioral changes that follow blast injury.
Collapse
Affiliation(s)
- Gregory A. Elder
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA;
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; (M.A.G.S.); (R.D.G.)
- Mount Sinai Alzheimer’s Disease Research Center and the Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.W.Z.); (P.R.H.)
| | - Miguel A. Gama Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; (M.A.G.S.); (R.D.G.)
- General Medical Research Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY 10468, USA
| | - Rita De Gasperi
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; (M.A.G.S.); (R.D.G.)
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA;
| | - Georgina Perez Garcia
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA;
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA;
| | - Gissel M. Perez
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA;
| | - Rania Abutarboush
- Department of Neurotrauma, Operational and Undersea Medicine Directorate, Naval Medical ResearchCommand, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA; (R.A.); (U.K.); (S.T.A.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20817, USA
| | - Usmah Kawoos
- Department of Neurotrauma, Operational and Undersea Medicine Directorate, Naval Medical ResearchCommand, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA; (R.A.); (U.K.); (S.T.A.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20817, USA
| | - Carolyn W. Zhu
- Mount Sinai Alzheimer’s Disease Research Center and the Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.W.Z.); (P.R.H.)
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA;
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - William G. M. Janssen
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - James R. Stone
- Department of Radiology and Medical Imaging, University of Virginia, 480 Ray C Hunt Drive, Charlottesville, VA 22903, USA;
| | - Patrick R. Hof
- Mount Sinai Alzheimer’s Disease Research Center and the Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.W.Z.); (P.R.H.)
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David G. Cook
- Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA;
- Department of Medicine, University of Washington, 1959 NE Pacific St., Seattle, WA 98195, USA
| | - Stephen T. Ahlers
- Department of Neurotrauma, Operational and Undersea Medicine Directorate, Naval Medical ResearchCommand, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA; (R.A.); (U.K.); (S.T.A.)
| |
Collapse
|
2
|
Pierre K, Molina V, Shukla S, Avila A, Fong N, Nguyen J, Lucke-Wold B. Chronic traumatic encephalopathy: Diagnostic updates and advances. AIMS Neurosci 2022; 9:519-535. [PMID: 36660076 PMCID: PMC9826753 DOI: 10.3934/neuroscience.2022030] [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: 10/17/2022] [Revised: 12/04/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative disease that occurs secondary to repetitive mild traumatic brain injury. Current clinical diagnosis relies on symptomatology and structural imaging findings which often vary widely among those with the disease. The gold standard of diagnosis is post-mortem pathological examination. In this review article, we provide a brief introduction to CTE, current diagnostic workup and the promising research on imaging and fluid biomarker diagnostic techniques. For imaging, we discuss quantitative structural analyses, DTI, fMRI, MRS, SWI and PET CT. For fluid biomarkers, we discuss p-tau, TREM2, CCL11, NfL and GFAP.
Collapse
Affiliation(s)
- Kevin Pierre
- University of Florida Department of Radiology, Gainesville 32603, Florida, USA
| | - Vanessa Molina
- Sam Houston State University of Osteopathic Medicine, Conroe 77304, Texas, USA
| | - Shil Shukla
- Sam Houston State University of Osteopathic Medicine, Conroe 77304, Texas, USA
| | - Anthony Avila
- Sam Houston State University of Osteopathic Medicine, Conroe 77304, Texas, USA
| | - Nicholas Fong
- Sam Houston State University of Osteopathic Medicine, Conroe 77304, Texas, USA
| | - Jessica Nguyen
- Sam Houston State University of Osteopathic Medicine, Conroe 77304, Texas, USA
| | - Brandon Lucke-Wold
- University of Florida Department of Neurosurgery, Gainesville 32603, Florida, USA,* Correspondence:
| |
Collapse
|
3
|
Fusco A, Olowofela B, Dagra A, Hatem R, Pierre K, Siyanaki MRH, Lucke–Wold B. Management of Neuropsychiatric Symptoms for Chronic Traumatic Encephalopathy. MEDPRESS PSYCHIATRY AND BEHAVIORAL SCIENCES 2022; 1:202209003. [PMID: 36745148 PMCID: PMC9893853 DOI: 10.33582/mppbs.2022.202209003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with repeated head injury. The common presenting neuropsychiatric manifestations and diagnostic strategies for early diagnosis and subsequent treatment will be reviewed. This article discusses methods for injury prevention, risk assessment, and methods for supportive symptom management including lifestyle modifications, physical, occupational, and neurorehabilitation, and pharmaceutical management. Lastly, we propose the use of assessment tools validated for other neurodegenerative disorders in CTE to establish a baseline, track outcomes, and measure improvement in this population.
Collapse
Affiliation(s)
- Anna Fusco
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Abeer Dagra
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Rami Hatem
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Kevin Pierre
- University of Florida Department of Radiology, Gainesville, FL, USA
| | | | | |
Collapse
|
4
|
Golde TE. Alzheimer’s disease – the journey of a healthy brain into organ failure. Mol Neurodegener 2022; 17:18. [PMID: 35248124 PMCID: PMC8898417 DOI: 10.1186/s13024-022-00523-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/17/2022] [Indexed: 12/19/2022] Open
Abstract
As the most common dementia, Alzheimer’s disease (AD) exacts an immense personal, societal, and economic toll. AD was first described at the neuropathological level in the early 1900s. Today, we have mechanistic insight into select aspects of AD pathogenesis and have the ability to clinically detect and diagnose AD and underlying AD pathologies in living patients. These insights demonstrate that AD is a complex, insidious, degenerative proteinopathy triggered by Aβ aggregate formation. Over time Aβ pathology drives neurofibrillary tangle (NFT) pathology, dysfunction of virtually all cell types in the brain, and ultimately, overt neurodegeneration. Yet, large gaps in our knowledge of AD pathophysiology and huge unmet medical need remain. Though we largely conceptualize AD as a disease of aging, heritable and non-heritable factors impact brain physiology, either continuously or at specific time points during the lifespan, and thereby alter risk for devolvement of AD. Herein, I describe the lifelong journey of a healthy brain from birth to death with AD, while acknowledging the many knowledge gaps that remain regarding our understanding of AD pathogenesis. To ensure the current lexicon surrounding AD changes from inevitable, incurable, and poorly manageable to a lexicon of preventable, curable, and manageable we must address these knowledge gaps, develop therapies that have a bigger impact on clinical symptoms or progression of disease and use these interventions at the appropriate stage of disease.
Collapse
|
5
|
Perez Garcia G, De Gasperi R, Tschiffely AE, Gama Sosa MA, Abutarboush R, Kawoos U, Statz JK, Ciarlone S, Reed EM, Jeyarajah T, Perez G, Otero Pagan A, Pryor D, Hof P, Cook D, Gandy S, Elder G, Ahlers S. Repetitive low-level blast exposure improves behavioral deficits and chronically lowers Aβ42 in an Alzheimer's disease transgenic mouse model. J Neurotrauma 2021; 38:3146-3173. [PMID: 34353119 DOI: 10.1089/neu.2021.0184] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Public awareness of traumatic brain injury (TBI) in the military increased recently because of the conflicts in Iraq and Afghanistan where blast injury was the most common mechanism of injury. Besides overt injuries, concerns also exist over the potential adverse consequences of subclinical blast exposures, which are common for many service members. TBI is a risk factor for the later development of neurodegenerative diseases, including Alzheimer's disease (AD)-like disorders. Studies of acute TBI in humans and animals have suggested that increased processing of the amyloid precursor protein (APP) towards the amyloid beta protein (Aβ) may explain the epidemiological associations with AD. However, in a prior study we found in both rat and mouse models of blast overpressure exposure (BOP), that rather than increasing, rodent brain Aβ42 levels were decreased following acute blast exposure. Here we subjected APP/presenilin 1 transgenic mice (APP/PS1 Tg) to an extended sequence of repetitive low-level blast exposures (34.5 kPa) administered three times per week over 8 weeks. If initiated at 20 weeks of age, these repetitive exposures, which were designed to mimic human subclinical blast exposures, reduced anxiety and improved cognition as well as social interactions in APP/PS1 Tg mice, returning many behavioral parameters in APP/PS1 Tg mice to levels of non-transgenic wild type mice. Repetitive low-level blast exposure was less effective at improving behavioral deficits in APP/PS1 Tg mice when begun at 36 weeks of age. While amyloid plaque loads were unchanged, Aβ42 levels and Aβ oligomers were reduced in brain of mice exposed to repetitive low-level blast exposures initiated at 20 weeks of age, although levels did not directly correlate with behavioral parameters in individual animals. These results have implications for understanding the nature of blast effects on the brain and their relationship to human neurodegenerative diseases.
Collapse
Affiliation(s)
- Georgina Perez Garcia
- Icahn School of Medicine at Mount Sinai, 5925, Neurology, 1468 Madison Avenue Annenberg Building Floor 14 Room 60, New York, New York, New York, United States, 10029-6574.,James J Peters VA Medical Center, 20071, Research, 130 W Kingsbridge Rd, The Bronx, NY 10468, Bronx, United States, 10468-3904;
| | - Rita De Gasperi
- James J. Peters VA Medical Center, Research and Development, 130 west kingsbridge road, RD 3F-20, Bronx, New York, United States, 10468;
| | - Anna E Tschiffely
- Naval Medical Research Center, 19930, Silver Spring, Maryland, United States;
| | - Miguel A Gama Sosa
- James J. Peters VA Medical Center, Research and Development, 130 W Kingsbridge Rd, Bronx, New York, United States, 10468;
| | - Rania Abutarboush
- Naval Medical Research Center, 19930, Neurotrauma, 503 Robert Grant Ave, Silver Spring, Maryland, United States, 20910;
| | - Usmah Kawoos
- Naval Medical Research Center, 19930, Neurotrauma, 503 Robert Grant Ave, Silver Spring, Maryland, United States, 20910.,Henry M Jackson Foundation for the Advancement of Military Medicine Inc, 44069, Bethesda, Maryland, United States;
| | | | - Stephanie Ciarlone
- Naval Medical Research Center, 19930, Silver Spring, Maryland, United States;
| | - Eileen M Reed
- Naval Medical Research Center, 19930, Silver Spring, Maryland, United States;
| | - Theepica Jeyarajah
- Naval Medical Research Center, 19930, Silver Spring, Maryland, United States;
| | - Gissel Perez
- James J Peters VA Medical Center, 20071, Research and Development, Bronx, New York, United States;
| | - Alena Otero Pagan
- James J Peters VA Medical Center, 20071, Research and Development, Bronx, New York, United States;
| | - Dylan Pryor
- James J Peters VA Medical Center, 20071, Research, 130 W. Kingsbridge Rd., Bronx, New York, United States, 10468;
| | - Patrick Hof
- Icahn School of Medicine at Mount Sinai, 5925, New York, New York, United States;
| | - David Cook
- VA Puget Sound Health Care System, 20128, Geriatric Research, Education, and Clinical Center, 1660 S Columbian Way, Seattle, Washington, United States, 98108.,University of Washington, 7284, Division of Gerontology and Geriatric Medicine, Seattle, Washington, United States;
| | - Samuel Gandy
- 88 Mercer AvenueHartsdaleHartsdale, New York, United States, 10530.,Sam Gandy, 88 Mercer Avenue, United States;
| | - Gregory Elder
- James J. Peters VAMC, Research and Development 3F22, 130 West Kingsbridge Road, Bronx, New York, United States, 10468;
| | - Stephen Ahlers
- Naval Medical Research Center, OUMD, 503 Robert Grant Ave, Silver Spring, Maryland, United States, 20910;
| |
Collapse
|
6
|
Murugan NA, Nordberg A, Ågren H. Cryptic Sites in Tau Fibrils Explain the Preferential Binding of the AV-1451 PET Tracer toward Alzheimer's Tauopathy. ACS Chem Neurosci 2021; 12:2437-2447. [PMID: 34152739 PMCID: PMC8291571 DOI: 10.1021/acschemneuro.0c00340] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
![]()
Tauopathies are a subclass of neurodegenerative diseases characterized
by an accumulation of microtubule binding tau fibrils in brain regions.
Diseases such as Alzheimer’s (AD), chronic traumatic encephalopathy
(CTE), Pick’s disease (PiD), and corticobasal degeneration
(CBD) belong to this subclass. Development of tracers which can visualize
and discriminate between different tauopathies is of clinical importance
in the diagnosis of various tauopathies. Currently, several tau tracers
are available for in vivo imaging using a positron emission tomography
(PET) technique. Among these tracers, PBB3 is reported to bind to
various types of tau fibrils with comparable binding affinities.
In contrast, tau tracer AV-1451 is reported to bind to specific types
of tau fibrils (in particular to AD-associated and CTE) with higher
binding affinity and only show nonspecific or weaker binding toward
tau fibrils dominant with 3R isoforms (associated with PiD). The tau
fibrils associated with different tauopathies can adopt different
microstructures with different binding site microenvironments. By
using detailed studies of the binding profiles of tau tracers for
different types of tau fibrils, it may be possible to design tracers
with high selectivity toward a specific tauopathy. The microstructures
for the tau fibrils from patients with AD, PiD, and CTE have recently
been demonstrated by cryogenic electron microscopy (cryo-EM) measurements
allowing structure-based in silico simulations. In the present study,
we have performed a multiscale computational study involving molecular
docking, molecular dynamics, free energy calculations, and QM fragmentation
calculations to understand the binding profiles of tau tracer AV-1451
and its potential use for diagnosis of AD, CTE, and PiD tauopathies.
Our computational study reveals that different affinity binding sites
exist for AV-1451 in the tau fibrils associated with different tauopathies.
The binding affinity of this tracer toward different tau fibrils goes
in this order: PiD > AD > CTE. The interaction energies for different
tau fibril–tracer complexes using the QM fragmentation scheme
also showed the same trend. However, by carrying out molecular dynamics
simulations for the AD-derived tau fibrils in organic solvents, we
found additional high affinity binding sites for AV-1451. The AV-1451
binding profile in these cryptic sites correctly explains the preferential
binding of this tracer toward the AD fibrils when compared with the
PiD fibrils. This study clearly demonstrates having a cryo-EM structure
is still not sufficient for the structure-based tracer discovery for
certain targets, as they may have “potential but hidden”
high affinity binding sites, and we need additional strategies to
identify them.
Collapse
Affiliation(s)
- N. Arul Murugan
- School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, S-106 91 Stockholm, Sweden
| | - Agneta Nordberg
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, S-141 86 Stockholm, Sweden
- Theme Aging, The Aging Brain, Karolinska University Hospital, Huddinge, S-141 86 Stockholm, Sweden
| | - Hans Ågren
- Department of Physics and Astronomy, Uppsala University, Uppsala SE-75120, Sweden
- College of Chemistry and Chemical Engineering, Henan University, Kaifeng, Henan 475004, P. R. China
| |
Collapse
|
7
|
Pierre K, Dyson K, Dagra A, Williams E, Porche K, Lucke-Wold B. Chronic Traumatic Encephalopathy: Update on Current Clinical Diagnosis and Management. Biomedicines 2021; 9:biomedicines9040415. [PMID: 33921385 PMCID: PMC8069746 DOI: 10.3390/biomedicines9040415] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 02/05/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Kevin Pierre
- College of Medicine, University of Florida, Gainesville, FL 32611, USA; (K.P.); (K.D.); (A.D.); (E.W.)
| | - Kyle Dyson
- College of Medicine, University of Florida, Gainesville, FL 32611, USA; (K.P.); (K.D.); (A.D.); (E.W.)
| | - Abeer Dagra
- College of Medicine, University of Florida, Gainesville, FL 32611, USA; (K.P.); (K.D.); (A.D.); (E.W.)
| | - Eric Williams
- College of Medicine, University of Florida, Gainesville, FL 32611, USA; (K.P.); (K.D.); (A.D.); (E.W.)
| | - Ken Porche
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA;
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA;
- Correspondence:
| |
Collapse
|
8
|
Perez Garcia G, De Gasperi R, Gama Sosa MA, Perez GM, Otero-Pagan A, Pryor D, Abutarboush R, Kawoos U, Hof PR, Dickstein DL, Cook DG, Gandy S, Ahlers ST, Elder GA. Laterality and region-specific tau phosphorylation correlate with PTSD-related behavioral traits in rats exposed to repetitive low-level blast. Acta Neuropathol Commun 2021; 9:33. [PMID: 33648608 PMCID: PMC7923605 DOI: 10.1186/s40478-021-01128-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/07/2021] [Indexed: 12/14/2022] Open
Abstract
Military veterans who experience blast-related traumatic brain injuries often suffer from chronic cognitive and neurobehavioral syndromes. Reports of abnormal tau processing following blast injury have raised concerns that some cases may have a neurodegenerative basis. Rats exposed to repetitive low-level blast exhibit chronic neurobehavioral traits and accumulate tau phosphorylated at threonine 181 (Thr181). Using data previously reported in separate studies we tested the hypothesis that region-specific patterns of Thr181 phosphorylation correlate with behavioral measures also previously determined and reported in the same animals. Elevated p-tau Thr181 in anterior neocortical regions and right hippocampus correlated with anxiety as well as fear learning and novel object localization. There were no correlations with levels in amygdala or posterior neocortical regions. Particularly striking were asymmetrical effects on the right and left hippocampus. No systematic variation in head orientation toward the blast wave seems to explain the laterality. Levels did not correlate with behavioral measures of hyperarousal. Results were specific to Thr181 in that no correlations were observed for three other phospho-acceptor sites (threonine 231, serine 396, and serine 404). No consistent correlations were linked with total tau. These correlations are significant in suggesting that p-tau accumulation in anterior neocortical regions and the hippocampus may lead to disinhibited amygdala function without p-tau elevation in the amygdala itself. They also suggest an association linking blast injury with tauopathy, which has implications for understanding the relationship of chronic blast-related neurobehavioral syndromes in humans to neurodegenerative diseases.
Collapse
|
9
|
Costanza A, Radomska M, Zenga F, Amerio A, Aguglia A, Serafini G, Amore M, Berardelli I, Ojio Y, Nguyen KD. Severe Suicidality in Athletes with Chronic Traumatic Encephalopathy: A Case Series and Overview on Putative Ethiopathogenetic Mechanisms. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18030876. [PMID: 33498520 PMCID: PMC7908343 DOI: 10.3390/ijerph18030876] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) results from repetitive brain injuries and is a common neurotraumatic sequela in contact sports. CTE is often accompanied by neuropsychiatric symptoms, which could escalate to suicidal ideation (SI) and suicidal behaviour (SB). Nevertheless, fairly limited emphasis about the association between suicidality and CTE exists in medical literature. Here, we report two cases of retired professional athletes in high contact sports (boxing and ice hockey) who have developed similar clinical trajectories characterized by progressive neuropsychiatric symptoms compatible with a CTE diagnosis and subsequent SB in its severe forms (medical serious suicide attempt (SA) and completed suicide). In addition to the description of outlining clinical, neuropsychological, neuroimaging, and differential diagnosis elements related to these cases, we also hypothesized some mechanisms that might augment the suicide risk in CTE. They include those related to neurobiological (neuroanatomic/neuroinflammatory) dysfunctions as well as those pertaining to psychiatry and psychosocial maladaptation to neurotraumas and retirement from professional competitive activity. Findings described here can provide clinical pictures to improve the identification of patients with CTE and also potential mechanistic insights to refine the knowledge of eventual severe SB development, which might enable its earlier prevention.
Collapse
Affiliation(s)
- Alessandra Costanza
- Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), 1211 Geneva, Switzerland
- Department of Psychiatry, ASO Santi Antonio e Biagio e Cesare Arrigo Hospital, 15121 Alessandria, Italy
- Correspondence:
| | - Michalina Radomska
- Faculty of Psychology, University of Geneva (UNIGE), 1206 Geneva, Switzerland;
| | - Francesco Zenga
- Department of Neurosurgery, City of Health and Science Hospital, 10126 Torino, Italy;
| | - Andrea Amerio
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.A.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
- Department of Psychiatry, Tufts University, Boston, MA 02111, USA
| | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.A.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.A.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Mario Amore
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.A.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Isabella Berardelli
- Suicide Prevention Center, Department of Neurosciences, Mental Health and Sensory Organs, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy;
| | - Yasutaka Ojio
- National Center of Neurology and Psychiatry, Department of Community Mental Health Law, National Institute of Mental Health, Tokyo 187-8553, Japan;
| | - Khoa D. Nguyen
- Department of Microbiology and Immunology, Stanford University, Palo Alto, CA 94304, USA;
- Tranquis Therapeutics, Palo Alto, CA 94304, USA
- Hong Kong University of Science and Technology, Hong Kong, China
| |
Collapse
|
10
|
Current fluid biomarkers, animal models, and imaging tools for diagnosing chronic traumatic encephalopathy. Mol Cell Toxicol 2019. [DOI: 10.1007/s13273-019-0039-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
11
|
Rice V, Boykin G, Alfred P, Lindsay G, Overby C, Jeter A, Lester M, Allison S, Cooper D. The investigation of four technologies to assist in detecting mild to moderate traumatic brain injury of U.S. Military service members. Work 2019; 63:165-180. [PMID: 31156198 DOI: 10.3233/wor-192918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND A standard, reliable, objective measure is needed for identifying individuals with mild to moderate traumatic brain injury (TBI). OBJECTIVE The purpose of this study was to examine balance using an AMTI OR6-7 force platform (FP), neurocognition and mood using the Automated Neuropsychological Assessment Metric4 (ANAM4), blood flow comparisons using a Brain Acoustic Monitor (BAM), and voice using Voice Analysis software (VA) for screening service members for a mild to moderate TBI. METHODS Active duty and retired service member volunteers (n = 88, 35 with a diagnosis of mild to moderate TBI and 53 who never had a TBI) completed an informed consent document, and evaluations using the four technologies. RESULTS Development of a clinical prediction rule yielded two FP variables and one ANAM4 Mood Scale variable (vigor) as helpful in predicting the presence of a TBI. Assuming a 15% pre-test probability, these predictors yield a post-test probability of 75.7% for a positive result with any two or more measures being positive, and a post-test probability of 2.3% for a negative result with zero measures being positive. CONCLUSIONS This study demonstrated the usefulness of a force platform and a self-reported mood scale for predicting presence of mild to moderate TBI.
Collapse
Affiliation(s)
- Valerie Rice
- U.S. Army Research Laboratory, JBSA Fort Sam Houston, TX, USA
| | - Gary Boykin
- U.S. Army Research Laboratory, JBSA Fort Sam Houston, TX, USA
| | - Petra Alfred
- U.S. Army Research Laboratory, JBSA Fort Sam Houston, TX, USA
| | | | - Cory Overby
- General Dynamics Corporation, Falls Church, VA, USA
| | - Angela Jeter
- General Dynamics Corporation, Falls Church, VA, USA
| | - Mark Lester
- Brooke Army Medical Center, Institute for Surgical Research Laboratory, JBSA Fort Sam Houston, TX, USA
| | - Stephen Allison
- U.S. Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Douglas Cooper
- San Antonio Area Medical Center, JBSA Fort Sam Houston, TX, USA
| |
Collapse
|
12
|
Elder GA, Ehrlich ME, Gandy S. Relationship of traumatic brain injury to chronic mental health problems and dementia in military veterans. Neurosci Lett 2019; 707:134294. [PMID: 31141716 DOI: 10.1016/j.neulet.2019.134294] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/25/2019] [Accepted: 05/24/2019] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) is an unfortunately common event in military life. The conflicts in Iraq and Afghanistan have increased public awareness of TBI in the military. Certain injury mechanisms are relatively unique to the military, the most prominent being blast exposure. Blast-related mild TBI (mTBI) has been of particular concern in the most recent veterans although controversy remains concerning separation of the postconcussion syndrome associated with mTBI from post-traumatic stress disorder. TBI is also a risk factor for the development of neurodegenerative diseases including chronic traumatic encephalopathy (CTE) and Alzheimer's disease (AD). AD, TBI, and CTE are all associated with chronic inflammation. Genome wide association studies (GWAS) have identified multiple genetic loci associated with AD that implicate inflammation and - in particular microglia - as key modulators of the AD- and TBI-related degenerative processes. At the molecular level, recent studies have identified TREM2 and TYROBP/DAP12 as components of a key molecular hub linking inflammation and microglia to the pathophysiology of AD and possibly TBI. Evidence concerning the relationship of TBI to chronic mental health problems and dementia is reviewed in the context of its relevance to military veterans.
Collapse
Affiliation(s)
- Gregory A Elder
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA; Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; Mount Sinai Alzheimer's Disease Research Center and the Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Michelle E Ehrlich
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; Mount Sinai Alzheimer's Disease Research Center and the Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA
| | - Sam Gandy
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; Mount Sinai Alzheimer's Disease Research Center and the Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA; NFL Neurological Care Center, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| |
Collapse
|
13
|
Shin N, Kim HG, Shin HJ, Kim S, Kwon HH, Baek H, Yi MH, Zhang E, Kim JJ, Hong J, Lee SY, Lee W, Triantafillu UL, Kim CS, Kim Y, Kim DW. Uncoupled Endothelial Nitric Oxide Synthase Enhances p-Tau in Chronic Traumatic Encephalopathy Mouse Model. Antioxid Redox Signal 2019; 30:1601-1620. [PMID: 30070145 DOI: 10.1089/ars.2017.7280] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIMS Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative disease thought to be caused by repetitive traumatic brain injury (TBI) and subconcussive injuries. While hyperphosphorylation of tau (p-Tau), which is attributed to astrocytic tangles (ATs) and neurofibrillary tangles, is known to be involved in CTE, there are limited neuropathological or molecular data. By utilizing repetitive mild TBI (rmTBI) mouse models, our aim was to examine the pathological changes of CTE-associated structures, specifically the ATs. RESULTS Our rmTBI mouse models showed symptoms of depressive behavior and memory deficit, alongside an increased p-Tau expression in their neurons and astrocytes in both the hippocampus and cortex. rmTBI induced oxidative stress in endothelial cells and nitric oxide (NO) generation in astrocytes, which were mediated by hypoxia and increased hypoxia-inducible factor 1-α (HIF1α). There was also correlated decreased regional cerebral tissue perfusion units, mild activation of astrocytes and NFκB phosphorylation, increased expression of inducible nitric oxide synthase (iNOS), increased endothelial nitric oxide synthase (eNOS) uncoupling with decreased tetrahydrobiopterin, and increased expression of nitrotyrosine, NADPH oxidase 2 (Nox2)/nuclear factor (erythroid-derived 2) factor 2 (Nrf2) signaling proteins. Combined, these effects induced peroxynitrite formation and hyperphosphorylation of tau in the hippocampus and cortex toward the formation of ATs. INNOVATION Our model features molecular pathogenesis events of CTE with clinically relevant latency periods. In particular, this is the first demonstration of an increased astrocytic iNOS expression in an in vivo model. CONCLUSION We propose a novel mechanism of uncoupled eNOS and NO contribution to Tau phosphorylation and AT formation in rmTBI brain, toward an increased molecular understanding of the pathophysiology of human CTE.
Collapse
Affiliation(s)
- Nara Shin
- 1 Department of Anatomy, Brain Research Institute, Chungnam National University School of Medicine, Daejeon, Republic of Korea.,2 Department of Anesthesia and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea.,3 Department of Medical Science, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hyeong-Geug Kim
- 4 Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Hyo Jung Shin
- 1 Department of Anatomy, Brain Research Institute, Chungnam National University School of Medicine, Daejeon, Republic of Korea.,3 Department of Medical Science, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Sena Kim
- 1 Department of Anatomy, Brain Research Institute, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hyeok Hee Kwon
- 1 Department of Anatomy, Brain Research Institute, Chungnam National University School of Medicine, Daejeon, Republic of Korea.,3 Department of Medical Science, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hyunjung Baek
- 1 Department of Anatomy, Brain Research Institute, Chungnam National University School of Medicine, Daejeon, Republic of Korea.,3 Department of Medical Science, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Min-Hee Yi
- 5 Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Enji Zhang
- 1 Department of Anatomy, Brain Research Institute, Chungnam National University School of Medicine, Daejeon, Republic of Korea.,6 Department of Anesthesia Medicine, Yanbian University Hospital, Yanbian, China
| | - Jwa-Jin Kim
- 1 Department of Anatomy, Brain Research Institute, Chungnam National University School of Medicine, Daejeon, Republic of Korea.,7 LES Corporation, Inc., Daejeon, Republic of Korea
| | - Jinpyo Hong
- 1 Department of Anatomy, Brain Research Institute, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Sun Yeul Lee
- 2 Department of Anesthesia and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Wonhyung Lee
- 2 Department of Anesthesia and Pain Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Ursula L Triantafillu
- 8 Department of Chemical and Biological Engineering, The University of Alabama, Tuscaloosa, Alabama
| | - Cuk-Seong Kim
- 3 Department of Medical Science, Chungnam National University School of Medicine, Daejeon, Republic of Korea.,9 Department of Physiology, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Yonghyun Kim
- 8 Department of Chemical and Biological Engineering, The University of Alabama, Tuscaloosa, Alabama
| | - Dong Woon Kim
- 1 Department of Anatomy, Brain Research Institute, Chungnam National University School of Medicine, Daejeon, Republic of Korea.,3 Department of Medical Science, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| |
Collapse
|
14
|
Gama Sosa MA, De Gasperi R, Perez Garcia GS, Perez GM, Searcy C, Vargas D, Spencer A, Janssen PL, Tschiffely AE, McCarron RM, Ache B, Manoharan R, Janssen WG, Tappan SJ, Hanson RW, Gandy S, Hof PR, Ahlers ST, Elder GA. Low-level blast exposure disrupts gliovascular and neurovascular connections and induces a chronic vascular pathology in rat brain. Acta Neuropathol Commun 2019; 7:6. [PMID: 30626447 PMCID: PMC6327415 DOI: 10.1186/s40478-018-0647-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 12/06/2018] [Indexed: 01/15/2023] Open
Abstract
Much concern exists over the role of blast-induced traumatic brain injury (TBI) in the chronic cognitive and mental health problems that develop in veterans and active duty military personnel. The brain vasculature is particularly sensitive to blast injury. The aim of this study was to characterize the evolving molecular and histologic alterations in the neurovascular unit induced by three repetitive low-energy blast exposures (3 × 74.5 kPa) in a rat model mimicking human mild TBI or subclinical blast exposure. High-resolution two-dimensional differential gel electrophoresis (2D-DIGE) and matrix-assisted laser desorption/ionization (MALDI) mass spectrometry of purified brain vascular fractions from blast-exposed animals 6 weeks post-exposure showed decreased levels of vascular-associated glial fibrillary acidic protein (GFAP) and several neuronal intermediate filament proteins (α-internexin and the low, middle, and high molecular weight neurofilament subunits). Loss of these proteins suggested that blast exposure disrupts gliovascular and neurovascular interactions. Electron microscopy confirmed blast-induced effects on perivascular astrocytes including swelling and degeneration of astrocytic endfeet in the brain cortical vasculature. Because the astrocyte is a major sensor of neuronal activity and regulator of cerebral blood flow, structural disruption of gliovascular integrity within the neurovascular unit should impair cerebral autoregulation. Disrupted neurovascular connections to pial and parenchymal blood vessels might also affect brain circulation. Blast exposures also induced structural and functional alterations in the arterial smooth muscle layer. Interestingly, by 8 months after blast exposure, GFAP and neuronal intermediate filament expression had recovered to control levels in isolated brain vascular fractions. However, despite this recovery, a widespread vascular pathology was still apparent at 10 months after blast exposure histologically and on micro-computed tomography scanning. Thus, low-level blast exposure disrupts gliovascular and neurovascular connections while inducing a chronic vascular pathology.
Collapse
|
15
|
|
16
|
Singla A, Leineweber B, Monteith S, Oskouian RJ, Tubbs RS. The anatomy of concussion and chronic traumatic encephalopathy: A comprehensive review. Clin Anat 2018; 32:310-318. [DOI: 10.1002/ca.23313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 11/09/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Amit Singla
- Swedish Neuroscience Institute; Seattle Washington
| | | | | | | | - R. Shane Tubbs
- Seattle Science Foundation; Seattle Washington
- Department of Anatomical Sciences; St. Georges University; St. Georges Grenada
| |
Collapse
|
17
|
Al-Dahhak R, Khoury R, Qazi E, Grossberg GT. Traumatic Brain Injury, Chronic Traumatic Encephalopathy, and Alzheimer Disease. Clin Geriatr Med 2018; 34:617-635. [PMID: 30336991 DOI: 10.1016/j.cger.2018.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Traumatic brain injury (TBI) is a major health and economic burden. With increasing aging population, this issue is expected to continue to rise. Neurodegenerative disorders are more common with aging population in general regardless of history of TBI. Recent evidence continues to support a relation between a TBI and neurocognitive decline later in life (such as in athletes and military). This article summarizes the pathologic and clinical effects of TBI (regardless of severity) on the later development of dementia in individuals 65 years or older.
Collapse
Affiliation(s)
- Roula Al-Dahhak
- Department of Neurology, Saint Louis University, 1438 South Grand Boulevard, Suite 105, St Louis, MO 63104, USA.
| | - Rita Khoury
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University, 1438 South Grand Boulevard, St Louis, MO 63104, USA
| | - Erum Qazi
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University, 1438 South Grand Boulevard, St Louis, MO 63104, USA
| | - George T Grossberg
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University, 1438 South Grand Boulevard, St Louis, MO 63104, USA
| |
Collapse
|
18
|
Abstract
Extensive exposure of boxers to neurotrauma in the early 20th century led to the so-called punch drunk syndrome, which was formally recognized in the medical literature in 1928. "Punch drunk" terminology was replaced by the less derisive 'dementia pugilistica' in 1937. In the early case material, the diagnosis of dementia pugilistica required neurological deficits, including slurring dysarthria, ataxia, pyramidal signs, extrapyramidal signs, memory impairment, and personality changes, although the specific clinical substrate has assumed lesser importance in recent years with a shift in focus on molecular pathogenesis. The postmortem neuropathology of dementia pugilistica has also evolved substantially over the past 90 years, from suspected concussion-related hemorrhages to diverse structural and neurofibrillary changes to geographic tauopathy. Progressive neurodegenerative tauopathy is among the prevailing theories for disease pathogenesis currently, although this may be overly simplistic. Careful examination of historical cases reveals both misdiagnoses and a likelihood that dementia pugilistica at that time was caused by cumulative structural brain injury. More recent neuropathological studies indicate subclinical and possibly static tauopathy in some athletes and non-athletes. Indeed, it is unclear from the literature whether retired boxers reach the inflection point that tends toward progressive neurodegeneration in the manner of Alzheimer's disease due to boxing. Even among historical cases with extreme levels of exposure, progressive disease was exceptional.
Collapse
Affiliation(s)
- Rudy J Castellani
- Center for Neuropathology, Western Michigan University School of Medicine, Kalamazoo, MI, USA
| | - George Perry
- College of Sciences, University of Texas, San Antonio, San Antonio, TX, USA
| |
Collapse
|
19
|
Abstract
Concussions are a common injury for which patients often present first to primary care physicians. They can affect the day-to-day function of patients in school and work, as well as in sports and recreational activities. Recognizing common physical signs and symptoms after injury facilitates timely diagnosis and treatment, permitting initiation of an active management approach to recovery while preventing secondary injury. For persons with persistent symptoms, active rehabilitation may be utilized, with the goal of returning patients to full function.
Collapse
Affiliation(s)
- Christina L Master
- From the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. (C.L.M., M.F.G.)
| | - Andrew R Mayer
- From the Mind Research Network, Albuquerque, New Mexico. (A.R.M.)
| | - Davin Quinn
- From the University of New Mexico, Albuquerque, New Mexico. (D.Q.)
| | - Matthew F Grady
- From the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. (C.L.M., M.F.G.)
| |
Collapse
|
20
|
Aldag M, Armstrong RC, Bandak F, Bellgowan PSF, Bentley T, Biggerstaff S, Caravelli K, Cmarik J, Crowder A, DeGraba TJ, Dittmer TA, Ellenbogen RG, Greene C, Gupta RK, Hicks R, Hoffman S, Latta RC, Leggieri MJ, Marion D, Mazzoli R, McCrea M, O'Donnell J, Packer M, Petro JB, Rasmussen TE, Sammons-Jackson W, Shoge R, Tepe V, Tremaine LA, Zheng J. The Biological Basis of Chronic Traumatic Encephalopathy following Blast Injury: A Literature Review. J Neurotrauma 2018; 34:S26-S43. [PMID: 28937953 DOI: 10.1089/neu.2017.5218] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The United States Department of Defense Blast Injury Research Program Coordinating Office organized the 2015 International State-of-the-Science meeting to explore links between blast-related head injury and the development of chronic traumatic encephalopathy (CTE). Before the meeting, the planning committee examined articles published between 2005 and October 2015 and prepared this literature review, which summarized broadly CTE research and addressed questions about the pathophysiological basis of CTE and its relationship to blast- and nonblast-related head injury. It served to inform participants objectively and help focus meeting discussion on identifying knowledge gaps and priority research areas. CTE is described generally as a progressive neurodegenerative disorder affecting persons exposed to head injury. Affected individuals have been participants primarily in contact sports and military personnel, some of whom were exposed to blast. The symptomatology of CTE overlaps with Alzheimer's disease and includes neurological and cognitive deficits, psychiatric and behavioral problems, and dementia. There are no validated diagnostic criteria, and neuropathological evidence of CTE has come exclusively from autopsy examination of subjects with histories of exposure to head injury. The perivascular accumulation of hyperphosphorylated tau (p-tau) at the depths of cortical sulci is thought to be unique to CTE and has been proposed as a diagnostic requirement, although the contribution of p-tau and other reported pathologies to the development of clinical symptoms of CTE are unknown. The literature on CTE is limited and is focused predominantly on head injuries unrelated to blast exposure (e.g., football players and boxers). In addition, comparative analyses of clinical case reports has been challenging because of small case numbers, selection biases, methodological differences, and lack of matched controls, particularly for blast-exposed individuals. Consequently, the existing literature is not sufficient to determine whether the development of CTE is associated with head injury frequency (e.g., single vs. multiple exposures) or head injury type (e.g., impact, nonimpact, blast-related). Moreover, the incidence and prevalence of CTE in at-risk populations is unknown. Future research priorities should include identifying additional risk factors, pursuing population-based longitudinal studies, and developing the ability to detect and diagnose CTE in living persons using validated criteria.
Collapse
Affiliation(s)
- Matt Aldag
- 1 Booz Allen Hamilton , McLean, Virginia
| | - Regina C Armstrong
- 2 Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Faris Bandak
- 3 Defense Advanced Research Projects Agency , Arlington, Virginia
| | | | | | - Sean Biggerstaff
- 6 Office of the Assistant Secretary of Defense , Health Affairs, Falls Church, Virginia
| | | | - Joan Cmarik
- 7 Office of the Principal Assistant for Acquisition, United States Army Medical Research and Materiel Command , Frederick, Maryland
| | - Alicia Crowder
- 8 Combat Casualty Care Research Program , United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | | | | | - Richard G Ellenbogen
- 10 Departments of Neurological Surgery and Global Health Medicine, University of Washington , Seattle, Washington
| | - Colin Greene
- 11 Joint Trauma Analysis and Prevention of Injuries in Combat Program, Frederick, Maryland
| | - Raj K Gupta
- 12 Department of Defense Blast Injury Research Program Coordinating Office, United States Army Medical Research and Materiel Command , Frederick, Maryland
| | | | | | | | - Michael J Leggieri
- 12 Department of Defense Blast Injury Research Program Coordinating Office, United States Army Medical Research and Materiel Command , Frederick, Maryland
| | - Donald Marion
- 16 Defense and Veterans Brain Injury Center , Silver Spring, Maryland
| | | | | | | | - Mark Packer
- 20 Hearing Center of Excellence , Lackland, Texas
| | - James B Petro
- 21 Office of the Assistant Secretary of Defense, Research and Engineering, Arlington, Virginia
| | - Todd E Rasmussen
- 8 Combat Casualty Care Research Program , United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Wendy Sammons-Jackson
- 22 Office of the Principal Assistant for Research and Technology , United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Richard Shoge
- 23 Military Operational Medicine Research Program, United States Army Medical Research and Materiel Command , Fort Detrick, Maryland
| | | | | | - James Zheng
- 25 Program Executive Office Soldier , Fort Belvoir, Virginia
| |
Collapse
|
21
|
DePalma RG, Hoffman SW. Combat blast related traumatic brain injury (TBI): Decade of recognition; promise of progress. Behav Brain Res 2018; 340:102-105. [DOI: 10.1016/j.bbr.2016.08.036] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/17/2016] [Accepted: 08/19/2016] [Indexed: 12/22/2022]
|
22
|
Klunk WE. Molecular imaging: What is right and what is an illusion? ALZHEIMER'S & DEMENTIA: DIAGNOSIS, ASSESSMENT & DISEASE MONITORING 2018; 10:217-220. [PMID: 29780866 PMCID: PMC5956935 DOI: 10.1016/j.dadm.2018.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Over the past 40 years, brain molecular imaging has evolved from measuring cerebral metabolism with fluorodeoxyglucose, to neuroreceptor imaging, to imaging pathological protein deposits. In the early going, the characteristics of successful molecular imaging radiotracers were defined, and a detailed “Process” was developed for the collection of basic pharmacodynamic and pharmacokinetic data. These data are essential for the interpretation of in vivo imaging data and for defining the strengths, weaknesses, and limitations of new tracers. This perspective discusses the use of this “Process” in the development of the amyloid β positron emission tomography radiotracer, Pittsburgh Compound-B, and discusses some of the current controversies and difficulties in the field of tau positron emission tomography in the context of human data that preceded completion of this radiotracer characterization process—which still remains to be completed. As a field, we must decide which data are valid and which are artifacts and determine that when the artifacts are so overwhelming, the data are merely an illusion.
Collapse
|
23
|
PTSD-Related Behavioral Traits in a Rat Model of Blast-Induced mTBI Are Reversed by the mGluR2/3 Receptor Antagonist BCI-838. eNeuro 2018; 5:eN-NWR-0357-17. [PMID: 29387781 PMCID: PMC5790754 DOI: 10.1523/eneuro.0357-17.2018] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/15/2017] [Accepted: 01/11/2018] [Indexed: 01/31/2023] Open
Abstract
Battlefield blast exposure related to improvised explosive devices (IEDs) has become the most common cause of traumatic brain injury (TBI) in the recent conflicts in Iraq and Afghanistan. Mental health problems are common after TBI. A striking feature in the most recent veterans has been the frequency with which mild TBI (mTBI) and posttraumatic stress disorder (PTSD) have appeared together, in contrast to the classical situations in which the presence of mTBI has excluded the diagnosis of PTSD. However, treatment of PTSD-related symptoms that follow blast injury has become a significant problem. BCI-838 (MGS0210) is a Group II metabotropic glutamate receptor (mGluR2/3) antagonist prodrug, and its active metabolite BCI-632 (MGS0039) has proneurogenic, procognitive, and antidepressant activities in animal models. In humans, BCI-838 is currently in clinical trials for refractory depression and suicidality. The aim of the current study was to determine whether BCI-838 could modify the anxiety response and reverse PTSD-related behaviors in rats exposed to a series of low-level blast exposures designed to mimic a human mTBI or subclinical blast exposure. BCI-838 treatment reversed PTSD-related behavioral traits improving anxiety and fear-related behaviors as well as long-term recognition memory. Treatment with BCI-838 also increased neurogenesis in the dentate gyrus (DG) of blast-exposed rats. The safety profile of BCI-838 together with the therapeutic activities reported here, make BCI-838 a promising drug for the treatment of former battlefield Warfighters suffering from PTSD-related symptoms following blast-induced mTBI.
Collapse
|
24
|
Grinberg LT, Anghinah R, Nascimento CF, Amaro E, Leite RP, Martin MDGM, Naslavsky MS, Takada LT, Filho WJ, Pasqualucci CA, Nitrini R. Chronic Traumatic Encephalopathy Presenting as Alzheimer's Disease in a Retired Soccer Player. J Alzheimers Dis 2018; 54:169-74. [PMID: 27472879 DOI: 10.3233/jad-160312] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The relationship between soccer and chronic traumatic encephalopathy (CTE) is not well established. We report clinicopathological correlations in an 83-year-old retired center-back soccer player, with no history of concussion, manifesting typical Alzheimer-type dementia. Examination revealed mixed pathology including widespread CTE, moderate Alzheimer's disease, hippocampal sclerosis, and TDP-43 proteinopathy. This case adds to a few CTE cases described in soccer players. Furthermore, it corroborates that CTE may present clinically as typical Alzheimer-type dementia. Further studies investigating the extent to which soccer is a risk for CTE are needed.
Collapse
Affiliation(s)
- Lea T Grinberg
- Memory and Aging Center, University of California, San Francisco, San Francisco, CA, USA.,Department of Pathology - LIM-22, University of São Paulo Medical School, São Paulo, Brazil.,Hospital Albert Einstein, São Paulo, Brazil
| | - Renato Anghinah
- Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Edson Amaro
- Institute of Radiology, University of São Paulo Medical School, São Paulo, Brazil
| | - Renata P Leite
- Division of Geriatrics, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Michel S Naslavsky
- Human Genome Research Center, University of São Paulo, São Paulo, Brazil
| | - Leonel T Takada
- Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Wilson Jacob Filho
- Division of Geriatrics, University of São Paulo Medical School, São Paulo, Brazil
| | - Carlos A Pasqualucci
- Department of Pathology - LIM-22, University of São Paulo Medical School, São Paulo, Brazil
| | - Ricardo Nitrini
- Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| |
Collapse
|
25
|
Chen ST, Siddarth P, Merrill DA, Martinez J, Emerson ND, Liu J, Wong KP, Satyamurthy N, Giza CC, Huang SC, Fitzsimmons RP, Bailes J, Omalu B, Barrio JR, Small GW. FDDNP-PET Tau Brain Protein Binding Patterns in Military Personnel with Suspected Chronic Traumatic Encephalopathy1. J Alzheimers Dis 2018; 65:79-88. [PMID: 30040711 PMCID: PMC6728605 DOI: 10.3233/jad-171152] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Our group has shown that in vivo tau brain binding patterns from FDDNP-PET scans in retired professional football players with suspected chronic traumatic encephalopathy differ from those of tau and amyloid aggregate binding observed in Alzheimer's disease (AD) patients and cognitively-intact controls. OBJECTIVE To compare these findings with those from military personnel with histories of mild traumatic brain injury(mTBI). METHODS FDDNP-PET brain scans were compared among 7 military personnel and 15 retired players with mTBI histories and cognitive and/or mood symptoms, 24 AD patients, and 28 cognitively-intact controls. Nonparametric ANCOVAs with Tukey-Kramer adjusted post-hoc comparisons were used to test for significant differences in regional FDDNP binding among subject groups. RESULTS FDDNP brain binding was higher in military personnel compared to controls in the amygdala, midbrain, thalamus, pons, frontal and anterior and posterior cingulate regions (p < 0.01-0.0001). Binding patterns in the military personnel were similar to those of the players except for the amygdala and striatum (binding higher in players; p = 0.02-0.003). Compared with the AD group, the military personnel showed higher binding in the midbrain (p = 0.0008) and pons (p = 0.002) and lower binding in the medial temporal, lateral temporal, and parietal regions (all p = 0.02). CONCLUSION This first study of in vivo tau and amyloid brain signals in military personnel with histories of mTBI shows binding patterns similar to those of retired football players and distinct from the binding patterns in AD and normal aging, suggesting the potential value of FDDNP-PET for early detection and treatment monitoring in varied at-risk populations.
Collapse
Affiliation(s)
- Stephen T. Chen
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Prabha Siddarth
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
- UCLA Longevity Center at the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - David A. Merrill
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
- UCLA Longevity Center at the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jacqueline Martinez
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
- UCLA Longevity Center at the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - Natacha D. Emerson
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
- UCLA Longevity Center at the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jie Liu
- Department of Medical and Molecular Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Koon-Pong Wong
- Department of Medical and Molecular Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nagichettiar Satyamurthy
- Department of Medical and Molecular Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christopher C. Giza
- Department of Neurosurgery at the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sung-Cheng Huang
- Department of Medical and Molecular Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Julian Bailes
- Department of Neurosurgery, North Shore University Health System and University of Chicago Pritzker School of Medicine, Evanston, IL, USA
| | - Bennet Omalu
- Department of Medical Pathology and Laboratory Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Jorge R. Barrio
- Department of Medical and Molecular Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Gary W. Small
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
- UCLA Longevity Center at the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
26
|
Figaji AA. Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care. Front Neurol 2017; 8:685. [PMID: 29312119 PMCID: PMC5735372 DOI: 10.3389/fneur.2017.00685] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/30/2017] [Indexed: 01/08/2023] Open
Abstract
General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.
Collapse
Affiliation(s)
- Anthony A Figaji
- Neuroscience Institute, Division of Neurosurgery, University of Cape Town, Red Cross Children's Hospital, Rondebosch, Cape Town, South Africa
| |
Collapse
|
27
|
Transcriptome analyses of chronic traumatic encephalopathy show alterations in protein phosphatase expression associated with tauopathy. Exp Mol Med 2017; 49:e333. [PMID: 28524178 PMCID: PMC5454448 DOI: 10.1038/emm.2017.56] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 01/05/2017] [Accepted: 01/17/2017] [Indexed: 12/14/2022] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative disorder that is associated with repetitive head injury and has distinctive neuropathological features that differentiate this disease from other neurodegenerative diseases. Intraneuronal tau aggregates, although they occur in different patterns, are diagnostic neuropathological features of CTE, but the precise mechanism of tauopathy is not known in CTE. We performed whole RNA sequencing analysis of post-mortem brain tissue from patients with CTE and compared the results to normal controls to determine the transcriptome signature changes associated with CTE. The results showed that the genes related to the MAP kinase and calcium-signaling pathways were significantly downregulated in CTE. The altered expression of protein phosphatases (PPs) in these networks further suggested that the tauopathy observed in CTE involves common pathological mechanisms similar to Alzheimer's disease (AD). Using cell lines and animal models, we also showed that reduced PPP3CA/PP2B phosphatase activity is directly associated with increases in phosphorylated (p)-tau proteins. These findings provide important insights into PP-dependent neurodegeneration and may lead to novel therapeutic approaches to reduce the tauopathy associated with CTE.
Collapse
|
28
|
Hanlon FM, McGrew CA, Mayer AR. Does a Unique Neuropsychiatric Profile Currently Exist for Chronic Traumatic Encephalopathy? Curr Sports Med Rep 2017; 16:30-35. [PMID: 28067738 DOI: 10.1249/jsr.0000000000000324] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There is evidence that repetitive mild traumatic brain injury leads to specific patterns of neuropathological findings, labeled chronic traumatic encephalopathy (CTE). However, questions remain about whether these neuropathological changes produce changes in behavior, cognition, and emotional status that are associated with a unique neuropsychiatric profile that can be assessed using currently available clinical tools. Our review of the literature indicates that insufficient evidence currently exists to suggest a distinct neuropsychiatric profile for CTE. Major limitations to the field presently include the relatively nascent nature of the topic, reliance on retrospective next-of-kin reporting, the lack of prospective studies, and similarities in neuropsychiatric symptoms between CTE, other neurodegenerative disorders and forms of psychopathology. Clinicians and researchers alike have a responsibility to adopt a cautious and balanced approach for antemortem assessments to minimize the potential unintended negative consequences of both overdiagnosing and underdiagnosing a clinical entity that has yet to be clearly established.
Collapse
Affiliation(s)
- Faith M Hanlon
- 1The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM; 2Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM; 3Department of Orthopedics and Rehabilitation, Sports Medicine Division, University of New Mexico School of Medicine, Albuquerque, NM; 4Departments of Neurology and Psychiatry, University of New Mexico School of Medicine, Albuquerque, NM; 5Department of Psychology, University of New Mexico, Albuquerque, NM
| | | | | |
Collapse
|
29
|
Disordered APP metabolism and neurovasculature in trauma and aging: Combined risks for chronic neurodegenerative disorders. Ageing Res Rev 2017; 34:51-63. [PMID: 27829172 DOI: 10.1016/j.arr.2016.11.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/20/2016] [Accepted: 11/04/2016] [Indexed: 11/20/2022]
Abstract
Traumatic brain injury (TBI), advanced age, and cerebral vascular disease are factors conferring increased risk for late onset Alzheimer's disease (AD). These conditions are also related pathologically through multiple interacting mechanisms. The hallmark pathology of AD consists of pathological aggregates of amyloid-β (Aβ) peptides and tau proteins. These molecules are also involved in neuropathology of several other chronic neurodegenerative diseases, and are under intense investigation in the aftermath of TBI as potential contributors to the risk for developing AD and chronic traumatic encephalopathy (CTE). The pathology of TBI is complex and dependent on injury severity, age-at-injury, and length of time between injury and neuropathological evaluation. In addition, the mechanisms influencing pathology and recovery after TBI likely involve genetic/epigenetic factors as well as additional disorders or comorbid states related to age and central and peripheral vascular health. In this regard, dysfunction of the aging neurovascular system could be an important link between TBI and chronic neurodegenerative diseases, either as a precipitating event or related to accumulation of AD-like pathology which is amplified in the context of aging. Thus with advanced age and vascular dysfunction, TBI can trigger self-propagating cycles of neuronal injury, pathological protein aggregation, and synaptic loss resulting in chronic neurodegenerative disease. In this review we discuss evidence supporting TBI and aging as dual, interacting risk factors for AD, and the role of Aβ and cerebral vascular dysfunction in this relationship. Evidence is discussed that Aβ is involved in cyto- and synapto-toxicity after severe TBI, and that its chronic effects are potentiated by aging and impaired cerebral vascular function. From a therapeutic perspective, we emphasize that in the fields of TBI- and aging-related neurodegeneration protective strategies should include preservation of neurovascular function.
Collapse
|
30
|
Marquié M, Normandin MD, Meltzer AC, Chong MST, Andrea NV, Antón-Fernández A, Klunk WE, Mathis CA, Ikonomovic MD, Debnath M, Bien EA, Vanderburg CR, Costantino I, Makaretz S, DeVos SL, Oakley DH, Gomperts SN, Growdon JH, Domoto-Reilly K, Lucente D, Dickerson BC, Frosch MP, Hyman BT, Johnson KA, Gómez-Isla T. Pathological correlations of [F-18]-AV-1451 imaging in non-alzheimer tauopathies. Ann Neurol 2017; 81:117-128. [PMID: 27997036 PMCID: PMC5319193 DOI: 10.1002/ana.24844] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/08/2016] [Accepted: 12/04/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Recent studies have shown that positron emission tomography (PET) tracer AV-1451 exhibits high binding affinity for paired helical filament (PHF)-tau pathology in Alzheimer's brains. However, the ability of this ligand to bind to tau lesions in other tauopathies remains controversial. Our goal was to examine the correlation of in vivo and postmortem AV-1451 binding patterns in three autopsy-confirmed non-Alzheimer tauopathy cases. METHODS We quantified in vivo retention of [F-18]-AV-1451 and performed autoradiography, [H-3]-AV-1451 binding assays, and quantitative tau measurements in postmortem brain samples from two progressive supranuclear palsy (PSP) cases and a MAPT P301L mutation carrier. They all underwent [F-18]-AV-1451 PET imaging before death. RESULTS The three subjects exhibited [F-18]-AV-1451 in vivo retention predominantly in basal ganglia and midbrain. Neuropathological examination confirmed the PSP diagnosis in the first two subjects; the MAPT P301L mutation carrier had an atypical tauopathy characterized by grain-like tau-containing neurites in gray and white matter with heaviest burden in basal ganglia. In all three cases, autoradiography failed to show detectable [F-18]-AV-1451 binding in multiple brain regions examined, with the exception of entorhinal cortex (reflecting incidental age-related neurofibrillary tangles) and neuromelanin-containing neurons in the substantia nigra (off-target binding). The lack of a consistent significant correlation between in vivo [F-18]-AV-1541 retention and postmortem in vitro binding and tau measures in these cases suggests that this ligand has low affinity for tau lesions primarily made of straight tau filaments. INTERPRETATION AV-1451 may have limited utility for in vivo selective and reliable detection of tau aggregates in these non-Alzheimer tauopathies. ANN NEUROL 2017;81:117-128.
Collapse
Affiliation(s)
- Marta Marquié
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | | | - Avery C. Meltzer
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Michael Siao Tick Chong
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | | | | | - William E. Klunk
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Chester A. Mathis
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Milos D. Ikonomovic
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Geriatric Research Education and Clinical Center, VA Pittsburgh Clinical System, Pittsburgh, PA
| | - Manik Debnath
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Elizabeth A. Bien
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- Department of Neurology, Massachusetts General Hospital, Boston, MA
- Harvard Neurodiscovery Center, Massachusetts General Hospital, Boston, MA
| | - Charles R. Vanderburg
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- Department of Neurology, Massachusetts General Hospital, Boston, MA
- Harvard Neurodiscovery Center, Massachusetts General Hospital, Boston, MA
| | - Isabel Costantino
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
| | - Sara Makaretz
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Sarah L. DeVos
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Derek H. Oakley
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- C.S. Kubik Neuropathology Center, Massachusetts General Hospital, Boston, MA
| | - Stephen N. Gomperts
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - John H. Growdon
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | | | - Diane Lucente
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA
| | | | - Matthew P. Frosch
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- C.S. Kubik Neuropathology Center, Massachusetts General Hospital, Boston, MA
| | - Bradley T. Hyman
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Keith A. Johnson
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Teresa Gómez-Isla
- MassGeneral Institute for NeuroDegenerative Disease, Charlestown, MA
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
31
|
Abstract
Traumatic brain injuries (TBIs) are clinically grouped by severity: mild, moderate and severe. Mild TBI (the least severe form) is synonymous with concussion and is typically caused by blunt non-penetrating head trauma. The trauma causes stretching and tearing of axons, which leads to diffuse axonal injury - the best-studied pathogenetic mechanism of this disorder. However, mild TBI is defined on clinical grounds and no well-validated imaging or fluid biomarkers to determine the presence of neuronal damage in patients with mild TBI is available. Most patients with mild TBI will recover quickly, but others report persistent symptoms, called post-concussive syndrome, the underlying pathophysiology of which is largely unknown. Repeated concussive and subconcussive head injuries have been linked to the neurodegenerative condition chronic traumatic encephalopathy (CTE), which has been reported post-mortem in contact sports athletes and soldiers exposed to blasts. Insights from severe injuries and CTE plausibly shed light on the underlying cellular and molecular processes involved in mild TBI. MRI techniques and blood tests for axonal proteins to identify and grade axonal injury, in addition to PET for tau pathology, show promise as tools to explore CTE pathophysiology in longitudinal clinical studies, and might be developed into diagnostic tools for CTE. Given that CTE is attributed to repeated head trauma, prevention might be possible through rule changes by sports organizations and legislators.
Collapse
|
32
|
Chiu CC, Liao YE, Yang LY, Wang JY, Tweedie D, Karnati HK, Greig NH, Wang JY. Neuroinflammation in animal models of traumatic brain injury. J Neurosci Methods 2016; 272:38-49. [PMID: 27382003 PMCID: PMC5201203 DOI: 10.1016/j.jneumeth.2016.06.018] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide. Neuroinflammation is prominent in the short and long-term consequences of neuronal injuries that occur after TBI. Neuroinflammation involves the activation of glia, including microglia and astrocytes, to release inflammatory mediators within the brain, and the subsequent recruitment of peripheral immune cells. Various animal models of TBI have been developed that have proved valuable to elucidate the pathophysiology of the disorder and to assess the safety and efficacy of novel therapies prior to clinical trials. These models provide an excellent platform to delineate key injury mechanisms that associate with types of injury (concussion, contusion, and penetration injuries) that occur clinically for the investigation of mild, moderate, and severe forms of TBI. Additionally, TBI modeling in genetically engineered mice, in particular, has aided the identification of key molecules and pathways for putative injury mechanisms, as targets for development of novel therapies for human TBI. This Review details the evidence showing that neuroinflammation, characterized by the activation of microglia and astrocytes and elevated production of inflammatory mediators, is a critical process occurring in various TBI animal models, provides a broad overview of commonly used animal models of TBI, and overviews representative techniques to quantify markers of the brain inflammatory process. A better understanding of neuroinflammation could open therapeutic avenues for abrogation of secondary cell death and behavioral symptoms that may mediate the progression of TBI.
Collapse
Affiliation(s)
- Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan
| | - Yi-En Liao
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Ling-Yu Yang
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jing-Ya Wang
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - David Tweedie
- Drug Design & Development Section, Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD 21224, USA
| | - Hanuma K Karnati
- Drug Design & Development Section, Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD 21224, USA
| | - Nigel H Greig
- Drug Design & Development Section, Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD 21224, USA
| | - Jia-Yi Wang
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Physiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
33
|
Dambinova SA, Maroon JC, Sufrinko AM, Mullins JD, Alexandrova EV, Potapov AA. Functional, Structural, and Neurotoxicity Biomarkers in Integrative Assessment of Concussions. Front Neurol 2016; 7:172. [PMID: 27761129 PMCID: PMC5050199 DOI: 10.3389/fneur.2016.00172] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/21/2016] [Indexed: 12/20/2022] Open
Abstract
Concussion is a complex, heterogeneous process affecting the brain. Accurate assessment and diagnosis and appropriate management of concussion are essential to ensure that athletes do not prematurely return to play or others to work or active military duty, risking re-injury. To date, clinical diagnosis relies primarily on evaluating subjects for functional impairment using instruments that include neurocognitive testing, subjective symptom report, and neurobehavioral assessments, such as balance and vestibular-ocular reflex testing. Structural biomarkers, defined as advanced neuroimaging techniques and biomarkers assessing neurotoxicity and immunoexcitotoxicity, may complement the use of functional biomarkers. We hypothesize that neurotoxicity AMPA, NMDA, and kainite receptor biomarkers might be utilized as a part of comprehensive approach to concussion evaluations, with the goal of increasing diagnostic accuracy and facilitating treatment planning and prognostic assessment.
Collapse
Affiliation(s)
| | - Joseph C. Maroon
- Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | | |
Collapse
|
34
|
Cifu DX, Uchima OK, Davis AS, Lower AE, Jin JL, Lew HL. Significance of Concussions in Hawai'i: From Land to Sea. HAWAI'I JOURNAL OF MEDICINE & PUBLIC HEALTH : A JOURNAL OF ASIA PACIFIC MEDICINE & PUBLIC HEALTH 2016; 75:262-265. [PMID: 27688951 PMCID: PMC5030788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Head injuries are a particular concern in Hawai'i given the large military population, the presence of many land and water sports such as football and surfing, and the lenient helmet laws for motorcycle and bicycle riders. Physical, psychological, and cognitive symptoms from single or repeated concussions can affect an individual's reentry to society and activity. Current literature indicates that repeated head injuries are associated with chronic traumatic encephalopathy (CTE) which is thought to lead to dementia. This paper reviews literature discussing causes of concussion including its incidence and prevalence in Hawai'i. Furthermore, the neurophysiological and neurobiological etiologies are discussed followed by an overview of methods for identification and management of concussion. The paper serves as information for professionals in the community such as educators, military personnel, and healthcare workers to identify risks of concussion, management of symptoms, and to connect with resources and programs available in Hawai'i.
Collapse
Affiliation(s)
- David X Cifu
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond VA; Department of Physical Medicine and Rehabilitation, Department of Veteran's Affairs, Washington, DC (DXC)
| | - Olivia K Uchima
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond VA; Department of Physical Medicine and Rehabilitation, Department of Veteran's Affairs, Washington, DC (DXC)
| | - Alaina S Davis
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond VA; Department of Physical Medicine and Rehabilitation, Department of Veteran's Affairs, Washington, DC (DXC)
| | - Amy E Lower
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond VA; Department of Physical Medicine and Rehabilitation, Department of Veteran's Affairs, Washington, DC (DXC)
| | - Jingyu L Jin
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond VA; Department of Physical Medicine and Rehabilitation, Department of Veteran's Affairs, Washington, DC (DXC)
| | - Henry L Lew
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond VA; Department of Physical Medicine and Rehabilitation, Department of Veteran's Affairs, Washington, DC (DXC)
| |
Collapse
|
35
|
Dickstein DL, Pullman MY, Fernandez C, Short JA, Kostakoglu L, Knesaurek K, Soleimani L, Jordan BD, Gordon WA, Dams-O'Connor K, Delman BN, Wong E, Tang CY, DeKosky ST, Stone JR, Cantu RC, Sano M, Hof PR, Gandy S. Cerebral [ 18 F]T807/AV1451 retention pattern in clinically probable CTE resembles pathognomonic distribution of CTE tauopathy. Transl Psychiatry 2016; 6:e900. [PMID: 27676441 PMCID: PMC5048212 DOI: 10.1038/tp.2016.175] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 12/14/2022] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disorder most commonly associated with repetitive traumatic brain injury (TBI) and characterized by the presence of neurofibrillary tangles of tau protein, known as a tauopathy. Currently, the diagnosis of CTE can only be definitively established postmortem. However, a new positron emission tomography (PET) ligand, [18F]T807/AV1451, may provide the antemortem detection of tau aggregates, and thus various tauopathies, including CTE. Our goal was to examine [18F]T807/AV1451 retention in athletes with neuropsychiatric symptoms associated with a history of multiple concussions. Here we report a 39-year-old retired National Football League player who suffered 22 concussions and manifested progressive neuropsychiatric symptoms. Emotional lability and irritability were the chief complaints. Serial neuropsychological exams revealed a decline in executive functioning, processing speed and fine motor skills. Naming was below average but other cognitive functions were preserved. Structural analysis of longitudinally acquired magenetic resonance imaging scans revealed cortical thinning in the left frontal and lateral temporal areas, as well as volume loss in the basal ganglia. PET with [18F]florbetapir was negative for amyloidosis. The [18F]T807/AV1451 PET showed multifocal areas of retention at the cortical gray matter-white matter junction, a distribution considered pathognomonic for CTE. [18F]T807/AV1451 standard uptake value (SUV) analysis showed increased uptake (SUVr⩾1.1) in bilateral cingulate, occipital, and orbitofrontal cortices, and several temporal areas. Although definitive identification of the neuropathological underpinnings basis for [18F]T807/AV1451 retention requires postmortem correlation, our data suggest that [18F]T807/AV1451 tauopathy imaging may be a promising tool to detect and diagnose CTE-related tauopathy in living subjects.
Collapse
Affiliation(s)
- D L Dickstein
- Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029 USA. E-mail:
| | - M Y Pullman
- Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Fernandez
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J A Short
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - L Kostakoglu
- Department of Nuclear Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K Knesaurek
- Department of Nuclear Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - L Soleimani
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - B D Jordan
- Burke Rehabilitaiton Hospital, White Plains, NY, USA
| | - W A Gordon
- The NFL Neurological Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K Dams-O'Connor
- The NFL Neurological Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - B N Delman
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - E Wong
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Y Tang
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - S T DeKosky
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - J R Stone
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA,Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - R C Cantu
- Centre for the Study of Traumatic Encephalopathy, Boston University School of Medicine, Boston, MA, USA,Department of Neurosurgery, Emerson Hospital, Concord, MA, USA
| | - M Sano
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - P R Hof
- Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - S Gandy
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029 USA. E-mail:
| |
Collapse
|
36
|
Bigler ED. Systems Biology, Neuroimaging, Neuropsychology, Neuroconnectivity and Traumatic Brain Injury. Front Syst Neurosci 2016; 10:55. [PMID: 27555810 PMCID: PMC4977319 DOI: 10.3389/fnsys.2016.00055] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/08/2016] [Indexed: 01/03/2023] Open
Abstract
The patient who sustains a traumatic brain injury (TBI) typically undergoes neuroimaging studies, usually in the form of computed tomography (CT) and magnetic resonance imaging (MRI). In most cases the neuroimaging findings are clinically assessed with descriptive statements that provide qualitative information about the presence/absence of visually identifiable abnormalities; though little if any of the potential information in a scan is analyzed in any quantitative manner, except in research settings. Fortunately, major advances have been made, especially during the last decade, in regards to image quantification techniques, especially those that involve automated image analysis methods. This review argues that a systems biology approach to understanding quantitative neuroimaging findings in TBI provides an appropriate framework for better utilizing the information derived from quantitative neuroimaging and its relation with neuropsychological outcome. Different image analysis methods are reviewed in an attempt to integrate quantitative neuroimaging methods with neuropsychological outcome measures and to illustrate how different neuroimaging techniques tap different aspects of TBI-related neuropathology. Likewise, how different neuropathologies may relate to neuropsychological outcome is explored by examining how damage influences brain connectivity and neural networks. Emphasis is placed on the dynamic changes that occur following TBI and how best to capture those pathologies via different neuroimaging methods. However, traditional clinical neuropsychological techniques are not well suited for interpretation based on contemporary and advanced neuroimaging methods and network analyses. Significant improvements need to be made in the cognitive and behavioral assessment of the brain injured individual to better interface with advances in neuroimaging-based network analyses. By viewing both neuroimaging and neuropsychological processes within a systems biology perspective could represent a significant advancement for the field.
Collapse
Affiliation(s)
- Erin D. Bigler
- Department of Psychology, Neuroscience Center, Brigham Young UniversityProvo, UT, USA
| |
Collapse
|
37
|
Pan J, Connolly ID, Dangelmajer S, Kintzing J, Ho AL, Grant G. Sports-related brain injuries: connecting pathology to diagnosis. Neurosurg Focus 2016; 40:E14. [DOI: 10.3171/2016.1.focus15607] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Brain injuries are becoming increasingly common in athletes and represent an important diagnostic challenge. Early detection and management of brain injuries in sports are of utmost importance in preventing chronic neurological and psychiatric decline. These types of injuries incurred during sports are referred to as mild traumatic brain injuries, which represent a heterogeneous spectrum of disease. The most dramatic manifestation of chronic mild traumatic brain injuries is termed chronic traumatic encephalopathy, which is associated with profound neuropsychiatric deficits. Because chronic traumatic encephalopathy can only be diagnosed by postmortem examination, new diagnostic methodologies are needed for early detection and amelioration of disease burden. This review examines the pathology driving changes in athletes participating in high-impact sports and how this understanding can lead to innovations in neuroimaging and biomarker discovery.
Collapse
Affiliation(s)
| | | | | | - James Kintzing
- 3Bioengineering, Stanford University School of Medicine, Stanford, California
| | | | | |
Collapse
|
38
|
Kochanek PM, Bayır H. Hidden Perils of the "Wild Blue Yonder" after Traumatic Brain Injury. J Neurotrauma 2015; 33:1729-1731. [PMID: 26625357 DOI: 10.1089/neu.2015.4329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research , University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Hülya Bayır
- Department of Critical Care Medicine, Safar Center for Resuscitation Research , University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| |
Collapse
|
39
|
Dani M, Brooks DJ, Edison P. Tau imaging in neurodegenerative diseases. Eur J Nucl Med Mol Imaging 2015; 43:1139-50. [PMID: 26572762 PMCID: PMC4844651 DOI: 10.1007/s00259-015-3231-2] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 10/15/2015] [Indexed: 12/14/2022]
Abstract
Aggregated tau protein is a major neuropathological substrate central to the pathophysiology of neurodegenerative diseases such as Alzheimer's disease (AD), frontotemporal dementia, progressive supranuclear palsy, corticobasal degeneration and chronic traumatic encephalopathy. In AD, it has been shown that the density of hyperphosphorylated tau tangles correlates closely with neuronal dysfunction and cell death, unlike β-amyloid. Until now, diagnostic and pathologic information about tau deposition has only been available from invasive techniques such as brain biopsy or autopsy. The recent development of selective in-vivo tau PET imaging ligands including [(18)F]THK523, [(18)F]THK5117, [(18)F]THK5105 and [(18)F]THK5351, [(18)F]AV1451(T807) and [(11)C]PBB3 has provided information about the role of tau in the early phases of neurodegenerative diseases, and provided support for diagnosis, prognosis, and imaging biomarkers to track disease progression. Moreover, the spatial and longitudinal relationship of tau distribution compared with β - amyloid and other pathologies in these diseases can be mapped. In this review, we discuss the role of aggregated tau in tauopathies, the challenges posed in developing selective tau ligands as biomarkers, the state of development in tau tracers, and the new clinical information that has been uncovered, as well as the opportunities for improving diagnosis and designing clinical trials in the future.
Collapse
Affiliation(s)
- M Dani
- Neurology Imaging Unit, Division of Neuroscience, Imperial College London, 1st Floor, B Block, Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK
| | - D J Brooks
- Neurology Imaging Unit, Division of Neuroscience, Imperial College London, 1st Floor, B Block, Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK.,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - P Edison
- Neurology Imaging Unit, Division of Neuroscience, Imperial College London, 1st Floor, B Block, Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK.
| |
Collapse
|
40
|
Amyot F, Arciniegas DB, Brazaitis MP, Curley KC, Diaz-Arrastia R, Gandjbakhche A, Herscovitch P, Hinds SR, Manley GT, Pacifico A, Razumovsky A, Riley J, Salzer W, Shih R, Smirniotopoulos JG, Stocker D. A Review of the Effectiveness of Neuroimaging Modalities for the Detection of Traumatic Brain Injury. J Neurotrauma 2015; 32:1693-721. [PMID: 26176603 PMCID: PMC4651019 DOI: 10.1089/neu.2013.3306] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The incidence of traumatic brain injury (TBI) in the United States was 3.5 million cases in 2009, according to the Centers for Disease Control and Prevention. It is a contributing factor in 30.5% of injury-related deaths among civilians. Additionally, since 2000, more than 260,000 service members were diagnosed with TBI, with the vast majority classified as mild or concussive (76%). The objective assessment of TBI via imaging is a critical research gap, both in the military and civilian communities. In 2011, the Department of Defense (DoD) prepared a congressional report summarizing the effectiveness of seven neuroimaging modalities (computed tomography [CT], magnetic resonance imaging [MRI], transcranial Doppler [TCD], positron emission tomography, single photon emission computed tomography, electrophysiologic techniques [magnetoencephalography and electroencephalography], and functional near-infrared spectroscopy) to assess the spectrum of TBI from concussion to coma. For this report, neuroimaging experts identified the most relevant peer-reviewed publications and assessed the quality of the literature for each of these imaging technique in the clinical and research settings. Although CT, MRI, and TCD were determined to be the most useful modalities in the clinical setting, no single imaging modality proved sufficient for all patients due to the heterogeneity of TBI. All imaging modalities reviewed demonstrated the potential to emerge as part of future clinical care. This paper describes and updates the results of the DoD report and also expands on the use of angiography in patients with TBI.
Collapse
Affiliation(s)
- Franck Amyot
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - David B. Arciniegas
- Beth K. and Stuart C. Yudofsky Division of Neuropsychiatry, Baylor College of Medicine, Houston, Texas
- Brain Injury Research, TIRR Memorial Hermann, Houston, Texas
| | | | - Kenneth C. Curley
- Combat Casualty Care Directorate (RAD2), U.S. Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Ramon Diaz-Arrastia
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Amir Gandjbakhche
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Peter Herscovitch
- Positron Emission Tomography Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Sidney R. Hinds
- Defense and Veterans Brain Injury Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Silver Spring, Maryland
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Anthony Pacifico
- Congressionally Directed Medical Research Programs, Fort Detrick, Maryland
| | | | - Jason Riley
- Queens University, Kingston, Ontario, Canada
- ArcheOptix Inc., Picton, Ontario, Canada
| | - Wanda Salzer
- Congressionally Directed Medical Research Programs, Fort Detrick, Maryland
| | - Robert Shih
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - James G. Smirniotopoulos
- Department of Radiology, Neurology, and Biomedical Informatics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Derek Stocker
- Walter Reed National Military Medical Center, Bethesda, Maryland
| |
Collapse
|
41
|
Sundman M, Doraiswamy PM, Morey RA. Neuroimaging assessment of early and late neurobiological sequelae of traumatic brain injury: implications for CTE. Front Neurosci 2015; 9:334. [PMID: 26441507 PMCID: PMC4585087 DOI: 10.3389/fnins.2015.00334] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 09/04/2015] [Indexed: 12/14/2022] Open
Abstract
Traumatic brain injury (TBI) has been increasingly accepted as a major external risk factor for neurodegenerative morbidity and mortality. Recent evidence indicates that the resultant chronic neurobiological sequelae following head trauma may, at least in part, contribute to a pathologically distinct disease known as Chronic Traumatic Encephalopathy (CTE). The clinical manifestation of CTE is variable, but the symptoms of this progressive disease include impaired memory and cognition, affective disorders (i.e., impulsivity, aggression, depression, suicidality, etc.), and diminished motor control. Notably, mounting evidence suggests that the pathology contributing to CTE may be caused by repetitive exposure to subconcussive hits to the head, even in those with no history of a clinically evident head injury. Given the millions of athletes and military personnel with potential exposure to repetitive subconcussive insults and TBI, CTE represents an important public health issue. However, the incidence rates and pathological mechanisms are still largely unknown, primarily due to the fact that there is no in vivo diagnostic tool. The primary objective of this manuscript is to address this limitation and discuss potential neuroimaging modalities that may be capable of diagnosing CTE in vivo through the detection of tau and other known pathological features. Additionally, we will discuss the challenges of TBI research, outline the known pathology of CTE (with an emphasis on Tau), review current neuroimaging modalities to assess the potential routes for in vivo diagnosis, and discuss the future directions of CTE research.
Collapse
Affiliation(s)
- Mark Sundman
- Duke-UNC Brain Imaging and Analysis Center, Duke University Medical Center Durham, NC, USA
| | - P Murali Doraiswamy
- Department of Psychiatry, Duke University Medical Center Durham, NC, USA ; Duke Institute for Brain Sciences, Duke University Medical Center Durham, NC, USA
| | - Rajendra A Morey
- Duke-UNC Brain Imaging and Analysis Center, Duke University Medical Center Durham, NC, USA
| |
Collapse
|
42
|
|
43
|
Chronic Traumatic Encephalopathy and Traumatic Brain Injury: Bridging Pathology, Function, and Prognosis. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0089-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
44
|
Repetitive concussions--How dangerous are they? Mol Cell Neurosci 2015; 66:73-4. [PMID: 25655012 DOI: 10.1016/j.mcn.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 02/02/2015] [Indexed: 11/20/2022] Open
|
45
|
Elder GA, Stone JR, Ahlers ST. Effects of low-level blast exposure on the nervous system: is there really a controversy? Front Neurol 2014; 5:269. [PMID: 25566175 PMCID: PMC4271615 DOI: 10.3389/fneur.2014.00269] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 11/29/2014] [Indexed: 12/20/2022] Open
Abstract
High-pressure blast waves can cause extensive CNS injury in human beings. However, in combat settings, such as Iraq and Afghanistan, lower level exposures associated with mild traumatic brain injury (mTBI) or subclinical exposure have been much more common. Yet controversy exists concerning what traits can be attributed to low-level blast, in large part due to the difficulty of distinguishing blast-related mTBI from post-traumatic stress disorder (PTSD). We describe how TBI is defined in human beings and the problems posed in using current definitions to recognize blast-related mTBI. We next consider the problem of applying definitions of human mTBI to animal models, in particular that TBI severity in human beings is defined in relation to alteration of consciousness at the time of injury, which typically cannot be assessed in animals. However, based on outcome assessments, a condition of "low-level" blast exposure can be defined in animals that likely approximates human mTBI or subclinical exposure. We review blast injury modeling in animals noting that inconsistencies in experimental approach have contributed to uncertainty over the effects of low-level blast. Yet, animal studies show that low-level blast pressure waves are transmitted to the brain. In brain, low-level blast exposures cause behavioral, biochemical, pathological, and physiological effects on the nervous system including the induction of PTSD-related behavioral traits in the absence of a psychological stressor. We review the relationship of blast exposure to chronic neurodegenerative diseases noting the paradoxical lowering of Abeta by blast, which along with other observations suggest that blast-related TBI is pathophysiologically distinct from non-blast TBI. Human neuroimaging studies show that blast-related mTBI is associated with a variety of chronic effects that are unlikely to be explained by co-morbid PTSD. We conclude that abundant evidence supports low-level blast as having long-term effects on the nervous system.
Collapse
Affiliation(s)
- Gregory A. Elder
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James R. Stone
- Department of Radiology, University of Virginia, Charlottesville, VA, USA
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Stephen T. Ahlers
- Department of Neurotrauma, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, MD, USA
| |
Collapse
|
46
|
Abstract
A new molecular ligand for positron emission tomography (PET) of the human brain, [18F]-T807, is under investigation for the antemortem detection of pathological neurofibrillary aggregates, which are evidence of neurofibrillary tangle (NFT) diseases, also known as tauopathies. Repetitive mild traumatic brain injuries in athletes and battlefield veterans are associated with one such tauopathy, known as chronic traumatic encephalopathy (CTE). In a recent case report, a former NFL player with clinically probable CTE and a concurrent Progressive Supranuclear Palsy (PSP) –like syndrome was studied using [18F]-T807. The interpretation of this player’s [18F]-T807 PET imaging was complicated by the overlap of tracer uptake in brain regions involved in CTE and PSP with regions associated with either nonspecific [18F]-T807 ligand binding or “aging-associated” binding of [18F]-T807 to authentic tauopathy known to be associated with aging and disease severity (i.e., NFT in the mesial temporal lobe). The implications of these data for the utility of [18F]-T807 in the pre-mortem detection of CTE are summarized.
Collapse
Affiliation(s)
- Sam Gandy
- Icahn School of Medicine at Mount Sinai, New York, 10029, USA
| | - Steven T DeKosky
- University of Virginia School of Medicine, Charlottesville, 22908, USA
| |
Collapse
|
47
|
Mitsis EM, Riggio S, Kostakoglu L, Dickstein DL, Machac J, Delman B, Goldstein M, Jennings D, D'Antonio E, Martin J, Naidich TP, Aloysi A, Fernandez C, Seibyl J, DeKosky ST, Elder GA, Marek K, Gordon W, Hof PR, Sano M, Gandy S. Tauopathy PET and amyloid PET in the diagnosis of chronic traumatic encephalopathies: studies of a retired NFL player and of a man with FTD and a severe head injury. Transl Psychiatry 2014; 4:e441. [PMID: 25226550 PMCID: PMC4203018 DOI: 10.1038/tp.2014.91] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 08/12/2014] [Accepted: 08/13/2014] [Indexed: 12/14/2022] Open
Abstract
Single, severe traumatic brain injury (TBI) which elevates CNS amyloid, increases the risk of Alzheimer's disease (AD); while repetitive concussive and subconcussive events as observed in athletes and military personnel, may increase the risk of chronic traumatic encephalopathy (CTE). We describe two clinical cases, one with a history of multiple concussions during a career in the National Football League (NFL) and the second with frontotemporal dementia and a single, severe TBI. Both patients presented with cognitive decline and underwent [(18)F]-Florbetapir positron emission tomography (PET) imaging for amyloid plaques; the retired NFL player also underwent [(18)F]-T807 PET imaging, a new ligand binding to tau, the main constituent of neurofibrillary tangles (NFT). Case 1, the former NFL player, was 71 years old when he presented with memory impairment and a clinical profile highly similar to AD. [(18)F]-Florbetapir PET imaging was negative, essentially excluding AD as a diagnosis. CTE was suspected clinically, and [(18)F]-T807 PET imaging revealed striatal and nigral [(18)F]-T807 retention consistent with the presence of tauopathy. Case 2 was a 56-year-old man with personality changes and cognitive decline who had sustained a fall complicated by a subdural hematoma. At 1 year post injury, [(18)F]-Florbetapir PET imaging was negative for an AD pattern of amyloid accumulation in this subject. Focal [(18)F]-Florbetapir retention was noted at the site of impact. In case 1, amyloid imaging provided improved diagnostic accuracy where standard clinical and laboratory criteria were inadequate. In that same case, tau imaging with [(18)F]-T807 revealed a subcortical tauopathy that we interpret as a novel form of CTE with a distribution of tauopathy that mimics, to some extent, that of progressive supranuclear palsy (PSP), despite a clinical presentation of amnesia without any movement disorder complaints or signs. A key distinguishing feature is that our patient presented with hippocampal involvement, which is more frequently seen in CTE than in PSP. In case 2, focal [(18)F]-Florbetapir retention at the site of injury in an otherwise negative scan suggests focal amyloid aggregation. In each of these complex cases, a combination of [(18)F]-fluorodeoxyglucose, [(18)F]-Florbetapir and/or [(18)F]-T807 PET molecular imaging improved the accuracy of diagnosis and prevented inappropriate interventions.
Collapse
Affiliation(s)
- E M Mitsis
- 1] Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA [2] Mount Sinai's Alzheimer's Disease Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA [3] James J. Peters VA Medical Center, Bronx, NY, USA
| | - S Riggio
- 1] Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA [2] James J. Peters VA Medical Center, Bronx, NY, USA [3] Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA [4] The NFL Neurological Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - L Kostakoglu
- Department of Nuclear Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - D L Dickstein
- 1] Mount Sinai's Alzheimer's Disease Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA [2] Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Machac
- Department of Nuclear Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - B Delman
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M Goldstein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - D Jennings
- Institute for Neurodegenerative Disorders, Yale University, New Haven, CT, USA
| | - E D'Antonio
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Martin
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - T P Naidich
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Aloysi
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Fernandez
- 1] Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA [2] Mount Sinai's Alzheimer's Disease Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA [3] James J. Peters VA Medical Center, Bronx, NY, USA
| | - J Seibyl
- Institute for Neurodegenerative Disorders, Yale University, New Haven, CT, USA
| | - S T DeKosky
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - G A Elder
- 1] Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA [2] James J. Peters VA Medical Center, Bronx, NY, USA [3] Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K Marek
- Institute for Neurodegenerative Disorders, Yale University, New Haven, CT, USA
| | - W Gordon
- 1] The NFL Neurological Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA [2] Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - P R Hof
- 1] Mount Sinai's Alzheimer's Disease Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA [2] Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M Sano
- 1] Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA [2] Mount Sinai's Alzheimer's Disease Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA [3] James J. Peters VA Medical Center, Bronx, NY, USA
| | - S Gandy
- 1] Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA [2] Mount Sinai's Alzheimer's Disease Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA [3] James J. Peters VA Medical Center, Bronx, NY, USA [4] Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA [5] The NFL Neurological Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|