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Liang B, Alosco ML, Armañanzas R, Martin BM, Tripodis Y, Stern RA, Prichep LS. Long-Term Changes in Brain Connectivity Reflected in Quantitative Electrophysiology of Symptomatic Former National Football League Players. J Neurotrauma 2023; 40:309-317. [PMID: 36324216 PMCID: PMC9902050 DOI: 10.1089/neu.2022.0029] [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] [Indexed: 11/06/2022] Open
Abstract
Exposure to repetitive head impacts (RHI) has been associated with long-term disturbances in cognition, mood, and neurobehavioral dysregulation, and reflected in neuroimaging. Distinct patterns of changes in quantitative features of the brain electrical activity (quantitative electroencephalogram [qEEG]) have been demonstrated to be sensitive to brain changes seen in neurodegenerative disorders and in traumatic brain injuries (TBI). While these qEEG biomarkers are highly sensitive at time of injury, the long-term effects of exposure to RHI on brain electrical activity are relatively unexplored. Ten minutes of eyes closed resting EEG data were collected from a frontal and frontotemporal electrode montage (BrainScope Food and Drug Administration-cleared EEG acquisition device), as well as assessments of neuropsychiatric function and age of first exposure (AFE) to American football. A machine learning methodology was used to derive a qEEG-based algorithm to discriminate former National Football League (NFL) players (n = 87, 55.40 ± 7.98 years old) from same-age men without history of RHI (n = 68, 54.94 ± 7.63 years old), and a second algorithm to discriminate former players with AFE <12 years (n = 33) from AFE ≥12 years (n = 54). The algorithm separating NFL retirees from controls had a specificity = 80%, a sensitivity = 60%, and an area under curve (AUC) = 0.75. Within the NFL population, the algorithm separating AFE <12 from AFE ≥12 resulted in a sensitivity = 76%, a specificity = 52%, and an AUC = 0.72. The presence of a profile of EEG abnormalities in the NFL retirees and in those with younger AFE includes features associated with neurodegeneration and the disruption of neuronal transmission between regions. These results support the long-term consequences of RHI and the potential of EEG as a biomarker of persistent changes in brain function.
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Affiliation(s)
- Bo Liang
- BrainScope Company, Chevy Chase, Maryland, USA
| | - Michael L. Alosco
- Boston University CTE Center, Boston University, Boston, Massachusetts, USA
- Department of Neurology, Boston University, Boston, Massachusetts, USA
| | - Ruben Armañanzas
- BrainScope Company, Chevy Chase, Maryland, USA
- Institute for Data Science and Artificial Intelligence, Universidad de Navarra, Pamplona, Spain
- Tecnun School of Engineering, Universidad de Navarra, Donostia-San Sebastian, Spain
| | - Brett M. Martin
- Boston University CTE Center, Boston University, Boston, Massachusetts, USA
| | - Yorghos Tripodis
- Boston University CTE Center, Boston University, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University, Boston, Massachusetts, USA
| | - Robert A. Stern
- Boston University CTE Center, Boston University, Boston, Massachusetts, USA
- Department of Neurology, Boston University, Boston, Massachusetts, USA
- Departments of Neurosurgery and Anatomy & Neurobiology, Boston University, Boston, Massachusetts, USA
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Morgan R, Prosapio J, Kara S, Sonty S, Youssef P, Nedd K. Preliminary clinical diagnostic criteria for chronic traumatic encephalopathy: A case report and literature review. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Alosco ML, Mariani ML, Adler CH, Balcer LJ, Bernick C, Au R, Banks SJ, Barr WB, Bouix S, Cantu RC, Coleman MJ, Dodick DW, Farrer LA, Geda YE, Katz DI, Koerte IK, Kowall NW, Lin AP, Marcus DS, Marek KL, McClean MD, McKee AC, Mez J, Palmisano JN, Peskind ER, Tripodis Y, Turner RW, Wethe JV, Cummings JL, Reiman EM, Shenton ME, Stern RA. Developing methods to detect and diagnose chronic traumatic encephalopathy during life: rationale, design, and methodology for the DIAGNOSE CTE Research Project. Alzheimers Res Ther 2021; 13:136. [PMID: 34384490 PMCID: PMC8357968 DOI: 10.1186/s13195-021-00872-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/29/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that has been neuropathologically diagnosed in brain donors exposed to repetitive head impacts, including boxers and American football, soccer, ice hockey, and rugby players. CTE cannot yet be diagnosed during life. In December 2015, the National Institute of Neurological Disorders and Stroke awarded a seven-year grant (U01NS093334) to fund the "Diagnostics, Imaging, and Genetics Network for the Objective Study and Evaluation of Chronic Traumatic Encephalopathy (DIAGNOSE CTE) Research Project." The objectives of this multicenter project are to: develop in vivo fluid and neuroimaging biomarkers for CTE; characterize its clinical presentation; refine and validate clinical research diagnostic criteria (i.e., traumatic encephalopathy syndrome [TES]); examine repetitive head impact exposure, genetic, and other risk factors; and provide shared resources of anonymized data and biological samples to the research community. In this paper, we provide a detailed overview of the rationale, design, and methods for the DIAGNOSE CTE Research Project. METHODS The targeted sample and sample size was 240 male participants, ages 45-74, including 120 former professional football players, 60 former collegiate football players, and 60 asymptomatic participants without a history of head trauma or participation in organized contact sports. Participants were evaluated at one of four U.S. sites and underwent the following baseline procedures: neurological and neuropsychological examinations; tau and amyloid positron emission tomography; magnetic resonance imaging and spectroscopy; lumbar puncture; blood and saliva collection; and standardized self-report measures of neuropsychiatric, cognitive, and daily functioning. Study partners completed similar informant-report measures. Follow-up evaluations were intended to be in-person and at 3 years post-baseline. Multidisciplinary diagnostic consensus conferences are held, and the reliability and validity of TES diagnostic criteria are examined. RESULTS Participant enrollment and all baseline evaluations were completed in February 2020. Three-year follow-up evaluations began in October 2019. However, in-person evaluation ceased with the COVID-19 pandemic, and resumed as remote, 4-year follow-up evaluations (including telephone-, online-, and videoconference-based cognitive, neuropsychiatric, and neurologic examinations, as well as in-home blood draw) in February 2021. CONCLUSIONS Findings from the DIAGNOSE CTE Research Project should facilitate detection and diagnosis of CTE during life, and thereby accelerate research on risk factors, mechanisms, epidemiology, treatment, and prevention of CTE. TRIAL REGISTRATION NCT02798185.
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Affiliation(s)
- Michael L Alosco
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Megan L Mariani
- Boston University CTE Center, Boston University School of Medicine, Boston, MA, USA
| | - Charles H Adler
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Laura J Balcer
- Departments of Neurology, Population Health and Ophthalmology, NYU Grossman School of Medicine, New York, NY, USA
| | - Charles Bernick
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Rhoda Au
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Framingham Heart Study, and Slone Epidemiology Center, Boston, MA, USA
- Departments of Anatomy & Neurobiology and Neurology, Boston University School of Medicine, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sarah J Banks
- Departments of Neuroscience and Psychiatry, University of California, San Diego, CA, USA
| | - William B Barr
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
| | - Sylvain Bouix
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert C Cantu
- Boston University Alzheimer's Disease Research Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, Boston, MA, USA
| | - Michael J Coleman
- Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Boston, MA, USA
| | - David W Dodick
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Lindsay A Farrer
- Departments of Medicine (Biomedical Genetics), Neurology, Ophthalmology, Epidemiology, and Biostatistics, BU Schools of Medicine and Public Health, Boston, MA, USA
| | - Yonas E Geda
- Alzheimer's Disease and Memory Disorders Program, Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Douglas I Katz
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA
- Encompass Health Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Inga K Koerte
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany
| | - Neil W Kowall
- Boston University Alzheimer's Disease Research Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
| | - Alexander P Lin
- Center for Clinical Spectroscopy, Department of Radiology, Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel S Marcus
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Kenneth L Marek
- Institute for Neurodegenerative Disorders, Invicro, LLC, New Haven, CT, USA
| | - Michael D McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Framingham Heart Study, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Joseph N Palmisano
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Elaine R Peskind
- VA Northwest Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Robert W Turner
- Department of Clinical Research & Leadership, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Jennifer V Wethe
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Jeffrey L Cummings
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Eric M Reiman
- Banner Alzheimer's Institute, University of Arizona, Arizona State University, Translational Genomics Research Institute, and Arizona Alzheimer's Consortium, Phoenix, AZ, USA
| | - Martha E Shenton
- Psychiatry Neuroimaging Laboratory, Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA.
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Alosco ML, Culhane J, Mez J. Neuroimaging Biomarkers of Chronic Traumatic Encephalopathy: Targets for the Academic Memory Disorders Clinic. Neurotherapeutics 2021; 18:772-791. [PMID: 33847906 PMCID: PMC8423967 DOI: 10.1007/s13311-021-01028-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with exposure to repetitive head impacts, such as those from contact sports. The pathognomonic lesion for CTE is the perivascular accumulation of hyper-phosphorylated tau in neurons and other cell process at the depths of sulci. CTE cannot be diagnosed during life at this time, limiting research on risk factors, mechanisms, epidemiology, and treatment. There is an urgent need for in vivo biomarkers that can accurately detect CTE and differentiate it from other neurological disorders. Neuroimaging is an integral component of the clinical evaluation of neurodegenerative diseases and will likely aid in diagnosing CTE during life. In this qualitative review, we present the current evidence on neuroimaging biomarkers for CTE with a focus on molecular, structural, and functional modalities routinely used as part of a dementia evaluation. Supporting imaging-pathological correlation studies are also presented. We targeted neuroimaging studies of living participants at high risk for CTE (e.g., aging former elite American football players, fighters). We conclude that an optimal tau PET radiotracer with high affinity for the 3R/4R neurofibrillary tangles in CTE has not yet been identified. Amyloid PET scans have tended to be negative. Converging structural and functional imaging evidence together with neuropathological evidence show frontotemporal and medial temporal lobe neurodegeneration, and increased likelihood for a cavum septum pellucidum. The literature offers promising neuroimaging biomarker targets of CTE, but it is limited by cross-sectional studies of small samples where the presence of underlying CTE is unknown. Imaging-pathological correlation studies will be important for the development and validation of neuroimaging biomarkers of CTE.
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Affiliation(s)
- Michael L Alosco
- Department of Neurology, Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Boston University School of Medicine, 72 E Concord St, Suite B7800, MA, 02118, Boston, USA.
| | - Julia Culhane
- Department of Neurology, Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Boston University School of Medicine, 72 E Concord St, Suite B7800, MA, 02118, Boston, USA
| | - Jesse Mez
- Department of Neurology, Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Boston University School of Medicine, 72 E Concord St, Suite B7800, MA, 02118, Boston, USA
- Framingham Heart Study, Boston University School of Medicine, MA, Boston, USA
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Lesman-Segev OH, Edwards L, Rabinovici GD. Chronic Traumatic Encephalopathy: A Comparison with Alzheimer's Disease and Frontotemporal Dementia. Semin Neurol 2020; 40:394-410. [PMID: 32820492 DOI: 10.1055/s-0040-1715134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The clinical diagnosis of chronic traumatic encephalopathy (CTE) is challenging due to heterogeneous clinical presentations and overlap with other neurodegenerative dementias. Depending on the clinical presentation, the differential diagnosis of CTE includes Alzheimer's disease (AD), behavioral variant frontotemporal dementia (bvFTD), Parkinson's disease, amyotrophic lateral sclerosis, primary mood disorders, posttraumatic stress disorder, and psychotic disorders. The aim of this article is to compare the clinical aspects, genetics, fluid biomarkers, imaging, treatment, and pathology of CTE to those of AD and bvFTD. A detailed clinical evaluation, neurocognitive assessment, and structural brain imaging can inform the differential diagnosis, while molecular biomarkers can help exclude underlying AD pathology. Prospective studies that include clinicopathological correlations are needed to establish tools that can more accurately determine the cause of neuropsychiatric decline in patients at risk for CTE.
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Affiliation(s)
- Orit H Lesman-Segev
- Department of Neurology, University of California San Francisco, San Francisco, California
| | - Lauren Edwards
- Department of Neurology, University of California San Francisco, San Francisco, California
| | - Gil D Rabinovici
- Department of Neurology, University of California San Francisco, San Francisco, California.,Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California.,Weill Neuroscience Institute, University of California San Francisco, San Francisco, California
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6
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Phelps A, Mez J, Stern RA, Alosco ML. Risk Factors for Chronic Traumatic Encephalopathy: A Proposed Framework. Semin Neurol 2020; 40:439-449. [PMID: 32674182 DOI: 10.1055/s-0040-1713633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative disease that has been neuropathologically diagnosed in contact and collision sport athletes, military veterans, and others with a history of exposure to repetitive head impacts (RHI). Identifying methods to diagnose and prevent CTE during life is a high priority. Timely diagnosis and implementation of treatment and preventative strategies for neurodegenerative diseases, including CTE, partially hinge upon early and accurate risk characterization. Here, we propose a framework of risk factors that influence the neuropathological development of CTE. We provide an up-to-date review of the literature examining cumulative exposure to RHI as the environmental trigger for CTE. Because not all individuals exposed to RHI develop CTE, the direct and/or indirect influence of nonhead trauma exposure characteristics (e.g., age, sex, race, genetics) on the pathological development of CTE is reviewed. We conclude with recommendations for future directions, as well as opinions for preventative strategies that could mitigate risk.
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Affiliation(s)
- Alyssa Phelps
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Jesse Mez
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Robert A Stern
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts.,Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
| | - Michael L Alosco
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
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Iverson GL, Terry DP, Luz M, Zafonte R, McCrory P, Solomon GS, Gardner AJ. Anger and Depression in Middle-Aged Men: Implications for a Clinical Diagnosis of Chronic Traumatic Encephalopathy. J Neuropsychiatry Clin Neurosci 2020; 31:328-336. [PMID: 31018811 DOI: 10.1176/appi.neuropsych.18110280] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In recent years, it has been proposed that problems with anger control and depression define clinical features of chronic traumatic encephalopathy (CTE). The authors examined anger problems and depression in middle-aged men from the general population and related those findings to the proposed clinical criteria for CTE. METHODS A sample of 166 community-dwelling men ages 40-60 was extracted from the normative database of the National Institutes of Health Toolbox. All participants denied prior head injury or traumatic brain injury (TBI). Participants completed scales assessing anger, hostility, aggression, anxiety, and depression. RESULTS In response to the item "I felt angry," 21.1% of men reported "sometimes," and 4.8% reported "often." When asked "If I am provoked enough I may hit another person," 11.4% endorsed the statement as true. There were moderate correlations between anger and anxiety (Spearman's ρ=0.61) and between depression and affective anger (ρ=0.51), hostility (ρ=0.56), and perceived hostility (ρ=0.35). Participants were dichotomized into a possible depression group (N=49) and a no-depression group (N=117) on the basis of the question "I feel depressed," specific to the past 7 days. The possible depression group reported higher anxiety (p<0.001, Cohen's d=1.51), anger (p<0.001, Cohen's d=0.96), and hostility (p<0.001, Cohen's d=0.95). CONCLUSIONS Some degree of anger and aggression are reported by a sizable minority of middle-aged men in the general population with no known history of TBI. Anger and hostility are correlated with depression and anxiety, indicating that all tend to co-occur. The base rates and comorbidity of affective dysregulation in men in the general population is important to consider when conceptualizing CTE phenotypes.
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Affiliation(s)
- Grant L Iverson
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Douglas P Terry
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Matthew Luz
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Ross Zafonte
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Paul McCrory
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Gary S Solomon
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
| | - Andrew J Gardner
- From the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Mass. (Iverson, Terry, Luz, Zafonte); Massachusetts General Hospital for Children Sports Concussion Program (Iverson, Terry, Zafonte); Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Mass. (Iverson, Terry, Zafonte); the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. (Zafonte); the Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia (McCrory); the Departments of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); the Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tenn. (Solomon); and the Hunter New England Local Health District Sports Concussion Program and Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia (Gardner)
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Alosco ML, Stein TD, Tripodis Y, Chua AS, Kowall NW, Huber BR, Goldstein LE, Cantu RC, Katz DI, Palmisano JN, Martin B, Cherry JD, Mahar I, Killiany RJ, McClean MD, Au R, Alvarez V, Stern RA, Mez J, McKee AC. Association of White Matter Rarefaction, Arteriolosclerosis, and Tau With Dementia in Chronic Traumatic Encephalopathy. JAMA Neurol 2019; 76:1298-1308. [PMID: 31380975 PMCID: PMC6686769 DOI: 10.1001/jamaneurol.2019.2244] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/28/2019] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with repetitive head impacts, including those from US football, that presents with cognitive and neuropsychiatric disturbances that can progress to dementia. Pathways to dementia in CTE are unclear and likely involve tau and nontau pathologic conditions. OBJECTIVE To investigate the association of white matter rarefaction and cerebrovascular disease with dementia in deceased men older than 40 years who played football and had CTE. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study involves analyses of data from the ongoing Understanding Neurologic Injury and Traumatic Encephalopathy (UNITE) Study, which is conducted via and included brain donors from the Veterans Affairs-Boston University-Concussion Legacy Foundation brain bank between 2008 and 2017. An original sample of 224 men who had played football and were neuropathologically diagnosed with CTE was reduced after exclusion of those younger than 40 years and those missing data. EXPOSURES The number of years of football play as a proxy for repetitive head impacts. MAIN OUTCOMES AND MEASURES Neuropathological assessment of white matter rarefaction and arteriolosclerosis severity (on a scale of 0-3, where 3 is severe); number of infarcts, microinfarcts, and microbleeds; and phosphorylated tau accumulation determined by CTE stage and semiquantitative rating of dorsolateral frontal cortex (DLFC) neurofibrillary tangles (NFTs) (none or mild vs moderate or severe). Informant-based retrospective clinical interviews determined dementia diagnoses via diagnostic consensus conferences. RESULTS A total of 180 men were included. The mean (SD) age of the sample at death was 67.9 (12.7) years. Of 180, 120 [66.7%]) were found to have had dementia prior to death. Moderate to severe white matter rarefaction (84 of 180 [46.6%]) and arteriolosclerosis (85 of 180 [47.2%]) were common; infarcts, microinfarcts, and microbleeds were not. A simultaneous equations regression model controlling for age and race showed that more years of play was associated with more severe white matter rarefaction (β, 0.16 [95% CI, 0.02-0.29]; P = .03) and greater phosphorylated tau accumulation (DLFC NFTs: β, 0.15 [95% CI, 0.004-0.30]; P = .04; CTE stage: β, 0.27 [95% CI, 0.14-0.41]; P < .001). White matter rarefaction (β, 0.16 [95% CI, 0.02-0.29]; P = .03) and DLFC NFTs (β, 0.16 [95% CI, 0.03-0.28]; P = .01) were associated with dementia. Arteriolosclerosis and years of play were not associated, but arteriolosclerosis was independently associated with dementia (β, 0.21 [95% CI, 0.07-0.35]; P = .003). CONCLUSIONS AND RELEVANCE Among older men who had played football and had CTE, more years of football play were associated with more severe white matter rarefaction and greater DLFC NFT burden. White matter rarefaction, arteriolosclerosis, and DLFC NFTs were independently associated with dementia. Dementia in CTE is likely a result of neuropathologic changes, including white matter rarefaction and phosphorylated tau, associated with repetitive head impact and pathologic changes not associated with head trauma, such as arteriolosclerosis.
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Affiliation(s)
- Michael L. Alosco
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Thor D. Stein
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Bedford Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Yorghos Tripodis
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Alicia S. Chua
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Neil W. Kowall
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Bertrand Russell Huber
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- National Center for Posttraumatic Stress Disorder, VA Boston Healthcare, Boston, Massachusetts
| | - Lee E. Goldstein
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
- Department of Electrical & Computer Engineering, Boston University College of Engineering, Boston, Massachusetts
- Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts
- Department of Biomedical Engineering, Boston University College of Engineering, Boston, Massachusetts
| | - Robert C. Cantu
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts
- Concussion Legacy Foundation, Boston, Massachusetts
- Department of Neurosurgery, Emerson Hospital, Concord, Massachusetts
| | - Douglas I. Katz
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Braintree Rehabilitation Hospital, Braintree, Massachusetts
| | - Joseph N. Palmisano
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Brett Martin
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Jonathan D. Cherry
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Ian Mahar
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Ronald J. Killiany
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
- Center for Biomedical Imaging, Boston University School of Medicine, Boston, Massachusetts
| | - Michael D. McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, Massachusetts
| | - Rhoda Au
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
- Framingham Heart Study, National Heart, Lung, and Blood Institute, Boston, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Victor Alvarez
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Robert A. Stern
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
| | - Jesse Mez
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Ann C. McKee
- Boston University Alzheimer’s Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Bedford Veterans Affairs Medical Center, Bedford, Massachusetts
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9
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Lesman-Segev OH, La Joie R, Stephens ML, Sonni I, Tsai R, Bourakova V, Visani AV, Edwards L, O'Neil JP, Baker SL, Gardner RC, Janabi M, Chaudhary K, Perry DC, Kramer JH, Miller BL, Jagust WJ, Rabinovici GD. Tau PET and multimodal brain imaging in patients at risk for chronic traumatic encephalopathy. Neuroimage Clin 2019; 24:102025. [PMID: 31670152 PMCID: PMC6831941 DOI: 10.1016/j.nicl.2019.102025] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/03/2019] [Accepted: 09/27/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To characterize individual and group-level neuroimaging findings in patients at risk for Chronic Traumatic Encephalopathy (CTE). METHODS Eleven male patients meeting criteria for Traumatic Encephalopathy Syndrome (TES, median age: 64) underwent neurologic evaluation, 3-Tesla MRI, and PET with [18F]-Flortaucipir (FTP, tau-PET) and [11C]-Pittsburgh compound B (PIB, amyloid-PET). Six patients underwent [18F]-Fluorodeoxyglucose-PET (FDG, glucose metabolism). We assessed imaging findings at the individual patient level, and in group-level comparisons with modality-specific groups of cognitively normal older adults (CN). Tau-PET findings in patients with TES were also compared to a matched group of patients with mild cognitive impairment or dementia due to Alzheimer's disease (AD). RESULTS All patients with TES sustained repetitive head injury participating in impact sports, ten in American football. Three patients met criteria for dementia and eight had mild cognitive impairment. Two patients were amyloid-PET positive and harbored the most severe MRI atrophy, FDG hypometabolism, and FTP-tau PET binding. Among the nine amyloid-negative patients, tau-PET showed either mildly elevated frontotemporal binding, a "dot-like" pattern, or no elevated binding. Medial temporal FTP was mildly elevated in a subset of amyloid-negative patients, but values were considerably lower than in AD. Voxelwise analyses revealed a convergence of imaging abnormalities (higher FTP binding, lower FDG, lower gray matter volumes) in frontotemporal areas in TES compared to controls. CONCLUSIONS Mildly elevated tau-PET binding was observed in a subset of amyloid-negative patients at risk for CTE, in a distribution consistent with CTE pathology stages III-IV. FTP-PET may be useful as a biomarker of tau pathology in CTE but is unlikely to be sensitive to early disease stages.
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Affiliation(s)
- Orit H Lesman-Segev
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States.
| | - Renaud La Joie
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States
| | - Melanie L Stephens
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States
| | - Ida Sonni
- Life Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
| | - Richard Tsai
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States
| | - Viktoriya Bourakova
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States
| | - Adrienne V Visani
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States
| | - Lauren Edwards
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States
| | - James P O'Neil
- Life Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
| | - Suzanne L Baker
- Life Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
| | - Raquel C Gardner
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States; San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121, United States
| | - Mustafa Janabi
- Life Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
| | - Kiran Chaudhary
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States
| | - David C Perry
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States
| | - Joel H Kramer
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States
| | - Bruce L Miller
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States
| | - William J Jagust
- Life Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States; Helen Wills Neuroscience Institute, University of California Berkeley, Berkeley, CA 94720, United States
| | - Gil D Rabinovici
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, 94158, United States; Departments of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94158, United States; Life Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States; Helen Wills Neuroscience Institute, University of California Berkeley, Berkeley, CA 94720, United States
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10
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Willer BS, Zivadinov R, Haider MN, Miecznikowski JC, Leddy JJ. A Preliminary Study of Early-Onset Dementia of Former Professional Football and Hockey Players. J Head Trauma Rehabil 2019; 33:E1-E8. [PMID: 30080796 PMCID: PMC6126972 DOI: 10.1097/htr.0000000000000421] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To provide an overview of 3 studies of the same population of retired professional contact sport athletes compared with age-matched noncontact sport athlete controls on cognition, executive function, behavior, and advanced brain imaging. SETTING University Concussion Management Clinic. PARTICIPANTS Twenty-two retired professional hockey and football athletes (average age 56 years) and 21 age-matched noncontact sport athlete controls. DESIGN Case control. MAIN MEASURES Participants were assessed on a broad range of neuropsychological measures that are associated with identification of mild cognitive impairment and executive function. Athletes were also assessed using self-report measures of executive function and personality. Advanced structural and functional imaging techniques were utilized as well. RESULTS The former National Football League and National Hockey League athletes perceived themselves to have impaired executive function, but this was not confirmed by objective neurocognitive assessment. No significant differences were found when comparing contact-sport athletes with controls on the presence of mild cognitive impairment or brain structural and functional tissue injury. Contact sport athletes were more anxious and more likely to report unusual beliefs and experiences. CONCLUSION None of the retired contact sport athletes qualified as having early-onset dementia consistent with chronic traumatic encephalopathy. There were no remarkable differences in imaging, cognition, behavior, or executive function from noncontact sport athletes. The results underscore an apparent disconnect between public perceptions and evidence-based conclusions about the inevitability of chronic traumatic encephalopathy and the potential neurodegenerative effect on former athletes from contact sports.
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Affiliation(s)
- Barry S Willer
- Departments of Psychiatry (Dr Willer), Neurology (Dr Zivadinov), Orthopedics and Sports Medicine (Drs Haider and Leddy), Biostatistics (Miecznikowski), School of Medicine and Biomedical Sciences, University at Buffalo, New York
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11
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Alosco ML, Stern RA. Youth Exposure to Repetitive Head Impacts From Tackle Football and Long-term Neurologic Outcomes: A Review of the Literature, Knowledge Gaps and Future Directions, and Societal and Clinical Implications. Semin Pediatr Neurol 2019; 30:107-116. [PMID: 31235012 DOI: 10.1016/j.spen.2019.03.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Youth participation in contact and collision sports, particularly tackle football, is associated with exposure to repetitive head impacts during a time period when tremendous brain maturation is occurring. Accumulating evidence suggests that exposure to repetitive head impacts from youth tackle football may increase vulnerability to long-term cognitive, neuropsychiatric, and neurologic disturbances. There are limitations to the current literature and conflicting findings exist. Nonetheless, participation in youth football has become a cause of concern to clinicians, scientists, politicians, coaches, parents, and children. The objective of this paper is to review the literature on the long-term cognitive, neuropsychiatric, and neurologic outcomes associated with participation in youth contact and collision sports, with a focus on tackle football. We provide an overview of the empirically derived framework that has served as the foundation for the investigation of youth tackle football and neurologic outcomes. The extant research studies on age of first exposure to tackle football and later-life cognitive and neuropsychiatric functioning, as well as structural brain changes are reviewed. We discuss the limitations of the current evidence, suggest future directions, and conclude with our opinions on societal and clinical implications.
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Affiliation(s)
- Michael L Alosco
- Boston University (BU), Alzheimer's Disease Center, BU CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Robert A Stern
- Boston University (BU), Alzheimer's Disease Center, BU CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA; Departments of Neurosurgery and Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA.
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12
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Sugarman MA, McKee AC, Stein TD, Tripodis Y, Besser LM, Martin B, Palmisano JN, Steinberg EG, O'Connor MK, Au R, McClean M, Killiany R, Mez J, Weiner MW, Kowall NW, Stern RA, Alosco ML. Failure to detect an association between self-reported traumatic brain injury and Alzheimer's disease neuropathology and dementia. Alzheimers Dement 2019; 15:686-698. [PMID: 30852157 PMCID: PMC6511462 DOI: 10.1016/j.jalz.2018.12.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/26/2018] [Accepted: 12/29/2018] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Recent research with neuropathologic or biomarker evidence of Alzheimer's disease (AD) casts doubt on traumatic brain injury (TBI) as a risk factor for AD. We leveraged the National Alzheimer's Coordinating Center to examine the association between self-reported TBI with loss of consciousness and AD neuropathologic changes, and with baseline and longitudinal clinical status. METHODS The sample included 4761 autopsy participants (453 with remote TBI with loss of consciousness; 2822 with AD neuropathologic changes) from National Alzheimer's Coordinating Center. RESULTS Self-reported TBI did not predict AD neuropathologic changes (P > .10). Reported TBI was not associated with baseline or change in dementia severity or cognitive function in participants with or without autopsy-confirmed AD. DISCUSSION Self-reported TBI with loss of consciousness may not be an independent risk factor for clinical or pathological AD. Research that evaluates number and severity of TBIs is needed to clarify the neuropathological links between TBI and dementia documented in other large clinical databases.
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Affiliation(s)
- Michael A Sugarman
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Edith Nourse Rogers Memorial Veterans Hospital, Department of Neuropsychology, Bedford, MA, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA; Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA; VA Boston Healthcare System, Boston, MA, USA; Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Thor D Stein
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA; VA Boston Healthcare System, Boston, MA, USA; Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Lilah M Besser
- National Alzheimer's Coordinating Center, University of Washington, Seattle, WA, USA
| | - Brett Martin
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Joseph N Palmisano
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Eric G Steinberg
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA
| | - Maureen K O'Connor
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Edith Nourse Rogers Memorial Veterans Hospital, Department of Neuropsychology, Bedford, MA, USA
| | - Rhoda Au
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA; Framingham Heart Study, National Heart, Lung, and Blood Institute, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA; Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA
| | - Michael McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Ronald Killiany
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA; Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA; Center for Biomedical Imaging, Boston University School of Medicine, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Michael W Weiner
- Department of Veteran Affairs Medical Center, Center for Imaging and Neurodegenerative Diseases, San Francisco, CA, USA; Departments of Radiology and Biomedical Imaging, Medicine, Psychiatry, and Neurology, University of California, San Francisco, CA, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA; Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA; Neurology Service, VA Boston Healthcare System, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA; Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA; Department of Neurosurgery, Boston University School of Medicine, Boston, MA, USA
| | - Michael L Alosco
- Boston University Alzheimer's Disease Center and CTE Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA.
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13
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Takahashi M, Yasuno F, Yamamuro K, Matsuoka K, Kitamura S, Yoshikawa H, Yamamoto A, Iida H, Fukuda T, Ihara M, Nagatsuka K, Kishimoto T. Detection of brain amyloid-β deposits due to the repetitive head trauma in a former karate player. Psychogeriatrics 2019; 19:276-281. [PMID: 30565811 DOI: 10.1111/psyg.12383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/30/2018] [Accepted: 09/24/2018] [Indexed: 11/30/2022]
Abstract
Head trauma is a well-established epidemiological risk factor for Alzheimer's disease, but a study of early detection of its pathology has not yet been performed in human patients in vivo. To address this issue, we performed 11 C-labelled Pittsburgh compound B-positron emission tomography on a right-handed 30-year-old man with cognitive deterioration after repetitive head trauma during karate matches. Structural magnetic resonance imaging was also performed on this patient. The same positron emission tomography analysis was performed on elderly healthy controls (15 men, mean age: 70.7 ± 6.2 years). To analyze grey matter volume, structural magnetic resonance imaging was performed on age-matched healthy controls (15 men, mean age: 28.5 ± 3.6 years). The cognitive deterioration in our patient was fixed and partially improved in the 10 years after the repetitive head trauma. However, Pittsburgh compound B-non-displaceable binding potential was significantly elevated in the patient. Volume reduction was shown in the medial temporal region, cerebellum, and the basal frontal cortex, while amyloid-β increase was shown in the bilateral prefrontal cortex. This is the first study to show an early degenerative process due to head trauma in the prefrontal cortex, where structural damage is not yet visible. Early recognition of the degenerative pathology due to repetitive head trauma by amyloid and possibly tau imaging would help clinicians determine how to treat those with early symptoms.
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Affiliation(s)
- Masato Takahashi
- Department of Psychiatry, Nara Medical University, Kashihara, Japan
| | - Fumihiko Yasuno
- Department of Psychiatry, Nara Medical University, Kashihara, Japan.,Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Psychiatry, National Center for Geriatrics and Gerontology, Obu, Japan
| | | | - Kiwamu Matsuoka
- Department of Psychiatry, Nara Medical University, Kashihara, Japan
| | | | | | - Akihide Yamamoto
- Department of Investigative Radiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hidehiro Iida
- Department of Investigative Radiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ihara
- Department of Psychiatry, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Kazuyuki Nagatsuka
- Department of Psychiatry, National Center for Geriatrics and Gerontology, Obu, Japan
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14
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Alosco ML, Stern RA. The long-term consequences of repetitive head impacts: Chronic traumatic encephalopathy. HANDBOOK OF CLINICAL NEUROLOGY 2019; 167:337-355. [PMID: 31753141 DOI: 10.1016/b978-0-12-804766-8.00018-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with exposure to repetitive head impacts (RHI). Although described in boxers for almost a century, scientific and public interest in CTE grew tremendously following a report of postmortem evidence of CTE in the first former professional American football player in 2005. Neuropathologic diagnostic criteria for CTE have been defined, with abnormal perivascular deposition of hyperphosphorylated tau at the sulcal depths as the pathognomonic feature. CTE can currently only be diagnosed postmortem, but clinical research criteria for the in vivo diagnosis of CTE have been proposed. The clinical phenotype of CTE is still ill-defined and there are currently no validated biomarkers to support an in-life diagnosis of "Probable CTE." Many knowledge gaps remain regarding the neuropathologic and clinical make-up of CTE. An increased understanding of CTE is critical given the millions that could potentially be impacted by this disease. This chapter describes the state of the literature on CTE. The historical origins of CTE are first presented, followed by a comprehensive description of the neuropathologic and clinical features. The chapter concludes with discussion on future research directions, emphasizing the importance of diagnosing CTE during life to facilitate development of preventative and intervention strategies.
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Affiliation(s)
- Michael L Alosco
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Robert A Stern
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, MA, United States; Departments of Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, United States.
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15
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Lee BG, Leavitt MJ, Bernick CB, Leger GC, Rabinovici G, Banks SJ. A Systematic Review of Positron Emission Tomography of Tau, Amyloid Beta, and Neuroinflammation in Chronic Traumatic Encephalopathy: The Evidence To Date. J Neurotrauma 2018; 35:2015-2024. [PMID: 29609516 PMCID: PMC6421996 DOI: 10.1089/neu.2017.5558] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Chronic traumatic encephalopathy (CTE) is associated with pathological changes, yet detecting these changes during life has proven elusive. Positron emission tomography (PET) offers the potential for identifying such pathology. Few studies have been completed to date and their approaches and results have been diverse. It was the objective of this review to systematically examine relevant research using ligands for PET that bind to identified pathology in CTE. We focused on identification of patterns of binding and addressing gaps in knowledge of PET imaging for CTE. A comprehensive literature search was conducted. Data used were published on or before May 22, 2017. As the extant literature is limited, any peer-reviewed article assessing military, contact sports athletes, or professional fighters was considered for inclusion. The main outcomes were regional binding to brain regions identified through control comparisons or through clinical metrics (e.g., standardized uptake volume ratios). A total of 1207 papers were identified for review, of which six met inclusion criteria. Meta-analyses were planned but were deemed inappropriate given the small number of studies identified. Methodological concerns in these initial papers included small sample sizes, lack of a control comparison, use of nonstandard statistical procedures to quantify data, and interpretation of potentially off-target binding areas. Across studies, the hippocampi, amygdalae, and midbrain had reasonably consistent increased uptake. Evidence for increased uptake in cortical regions was less consistent. The evidence suggests that the field of PET imaging in those at risk for CTE remains nascent. As the field evolves to include more stringent studies, ligands for PET may prove an important tool in identifying CTE in vivo.
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Affiliation(s)
- Bern G. Lee
- Cleveland Clinic Lou Ruvo Center for Brain Health and Lerner College of Medicine, Las Vegas, Nevada
- University of Nevada, Las Vegas, Las Vegas, Nevada
| | - MacKenzie J. Leavitt
- Cleveland Clinic Lou Ruvo Center for Brain Health and Lerner College of Medicine, Las Vegas, Nevada
| | - Charles B. Bernick
- Cleveland Clinic Lou Ruvo Center for Brain Health and Lerner College of Medicine, Las Vegas, Nevada
| | - Gabriel C. Leger
- Cleveland Clinic Lou Ruvo Center for Brain Health and Lerner College of Medicine, Las Vegas, Nevada
| | - Gil Rabinovici
- Department of Neurology, Memory and Aging Center, University of California, San Francisco
| | - Sarah J. Banks
- Cleveland Clinic Lou Ruvo Center for Brain Health and Lerner College of Medicine, Las Vegas, Nevada
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D'Ascanio S, Alosco ML, Stern RA. Chronic traumatic encephalopathy: clinical presentation and in vivo diagnosis. HANDBOOK OF CLINICAL NEUROLOGY 2018; 158:281-296. [PMID: 30482356 DOI: 10.1016/b978-0-444-63954-7.00027-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Exposure to repetitive head impacts from contact sport participation (e.g., American football, boxing, soccer) is associated with the neurodegenerative disorder known as chronic traumatic encephalopathy (CTE). The neuropathology of CTE is becoming well defined, and diagnostic criteria have been developed and are being refined. The critical next step in this emerging field is the diagnosis of CTE during life. The objective of this chapter is to describe what is currently known about the clinical presentation and in vivo diagnosis of CTE. This chapter reviews studies in which clinical manifestation of CTE was examined through retrospective telephone interviews with informants of individuals whose brains were donated and were diagnosed with CTE through neuropathologic examination. In vivo research examining the long-term neurobehavioral consequences of repetitive head impacts is also reviewed, followed by a comparison of the existing provisional clinical diagnostic criteria for CTE, as well as preliminary research on possible fluid and neuroimaging biomarkers. An illustrative case study of CTE is presented, and the chapter concludes with a discussion of gaps in knowledge and future directions.
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Affiliation(s)
- Steven D'Ascanio
- Boston University Alzheimer's Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Michael L Alosco
- Boston University Alzheimer's Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Robert A Stern
- Boston University Alzheimer's Disease Center and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, United States.
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White matter signal abnormalities in former National Football League players. ALZHEIMER'S & DEMENTIA: DIAGNOSIS, ASSESSMENT & DISEASE MONITORING 2017; 10:56-65. [PMID: 29201991 PMCID: PMC5699890 DOI: 10.1016/j.dadm.2017.10.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction Later-life brain alterations in former tackle football players are poorly understood, particularly regarding their relationship with repetitive head impacts (RHIs) and clinical function. We examined white matter signal abnormalities (WMSAs) and their association with RHIs and clinical function in former National Football League (NFL) players. Methods Eighty-six clinically symptomatic former NFL players and 23 same-age reportedly asymptomatic controls without head trauma exposure underwent magnetic resonance imaging and neuropsychological testing. FreeSurfer calculated WMSAs. A cumulative head impact index quantified RHIs. Results In former NFL players, increased volume of WMSAs was associated with higher cumulative head impact index scores (P = .043) and worse psychomotor speed and executive function (P = .015). Although former NFL players had greater WMSA volume than controls (P = .046), these findings are inconclusive due to recruitment of controls based on lack of clinical symptoms and head trauma exposure. Discussion In former NFL players, WMSAs may reflect long-term microvascular and nonmicrovascular pathologies from RHIs that negatively impact cognition. Repetitive head impact exposure was positively associated with WMSAs in former NFL players. In former NFL players, greater WMSAs was associated with worse psychomotor speed and executive function. The pathologies of WMSAs may contribute to the clinical presentation of chronic traumatic encephalopathy.
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18
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Age of first exposure to American football and long-term neuropsychiatric and cognitive outcomes. Transl Psychiatry 2017; 7:e1236. [PMID: 28926003 PMCID: PMC5639242 DOI: 10.1038/tp.2017.197] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/16/2017] [Accepted: 07/30/2017] [Indexed: 12/14/2022] Open
Abstract
Previous research suggests that age of first exposure (AFE) to football before age 12 may have long-term clinical implications; however, this relationship has only been examined in small samples of former professional football players. We examined the association between AFE to football and behavior, mood and cognition in a large cohort of former amateur and professional football players. The sample included 214 former football players without other contact sport history. Participants completed the Brief Test of Adult Cognition by Telephone (BTACT), and self-reported measures of executive function and behavioral regulation (Behavior Rating Inventory of Executive Function-Adult Version Metacognition Index (MI), Behavioral Regulation Index (BRI)), depression (Center for Epidemiologic Studies Depression Scale (CES-D)) and apathy (Apathy Evaluation Scale (AES)). Outcomes were continuous and dichotomized as clinically impaired. AFE was dichotomized into <12 and ⩾12, and examined continuously. Multivariate mixed-effect regressions controlling for age, education and duration of play showed AFE to football before age 12 corresponded with >2 × increased odds for clinically impaired scores on all measures but BTACT: (odds ratio (OR), 95% confidence interval (CI): BRI, 2.16,1.19-3.91; MI, 2.10,1.17-3.76; CES-D, 3.08,1.65-5.76; AES, 2.39,1.32-4.32). Younger AFE predicted increased odds for clinical impairment on the AES (OR, 95% CI: 0.86, 0.76-0.97) and CES-D (OR, 95% CI: 0.85, 0.74-0.97). There was no interaction between AFE and highest level of play. Younger AFE to football, before age 12 in particular, was associated with increased odds for impairment in self-reported neuropsychiatric and executive function in 214 former American football players. Longitudinal studies will inform youth football policy and safety decisions.
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Alosco ML, Jarnagin J, Tripodis Y, Martin B, Chaisson C, Baugh CM, Torres A, Nowinski CJ, Cantu RC, Stern RA. Utility of providing a concussion definition in the assessment of concussion history in former NFL players. Brain Inj 2017; 31:1116-1123. [PMID: 28471243 DOI: 10.1080/02699052.2017.1294709] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Former National Football League (NFL) players' working knowledge of concussion has not yet been evaluated, despite this population being a major clinical research target due to the association between repetitive head impacts (RHI) and long-term clinical impairments. This study examined former NFL players' understanding of the current concussion definition, and the association between number of concussions with clinical function. METHODS 95 former NFL players (mean age = 55.29; mean NFL year = 8.10) self-reported number of concussions before being provided with a concussion definition and after being read a modern definition of concussion. Subjects reported number of concussions with loss of consciousness (LOC). Principal Component Analysis of a battery of tests generated behaviour/mood, psychomotor speed/executive function, and verbal and visual memory factor scores. RESULTS Post-definition number of concussions (median = 50) was five times the pre-definition (median = 10; p < 0.001). Greater pre- (p = 0.019) and post-definition concussions (p = 0.036) correlated with worse behaviour/mood scores, after controlling for years of football played, with specific effects for depressive symptoms and impulsivity. LOC did not account for variance beyond number of concussions. CONCLUSIONS Practitioners and clinical researchers should provide a definition of concussion in the assessment of concussion history in former football players to facilitate accuracy and standardization.
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Affiliation(s)
- Michael L Alosco
- a Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston , MA , USA.,b Department of Neurology , Boston University School of Medicine , Boston , MA , USA
| | - Johnny Jarnagin
- a Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston , MA , USA.,b Department of Neurology , Boston University School of Medicine , Boston , MA , USA
| | - Yorghos Tripodis
- c Department of Biostatistics , Boston University School of Public Health , Boston , MA , USA
| | - Brett Martin
- a Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston , MA , USA.,d Data Coordinating Center , Boston University School of Public Health , Boston , MA , USA
| | - Christine Chaisson
- a Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston , MA , USA.,c Department of Biostatistics , Boston University School of Public Health , Boston , MA , USA.,d Data Coordinating Center , Boston University School of Public Health , Boston , MA , USA
| | - Christine M Baugh
- a Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston , MA , USA.,b Department of Neurology , Boston University School of Medicine , Boston , MA , USA.,e Interfaculty Initiative in Health Policy , Harvard University , Cambridge , MA , USA
| | - Alcy Torres
- f Pediatric Neurology , Boston University School of Medicine , Boston , MA , USA.,g Pediatric Neurology , Boston Medical Center , Boston , MA , USA
| | | | - Robert C Cantu
- a Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston , MA , USA.,b Department of Neurology , Boston University School of Medicine , Boston , MA , USA.,h Concussion Legacy Foundation , Waltham , MA , USA.,i Department of Neurosurgery , Boston University School of Medicine , Boston , MA , USA
| | - Robert A Stern
- a Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston , MA , USA.,b Department of Neurology , Boston University School of Medicine , Boston , MA , USA.,i Department of Neurosurgery , Boston University School of Medicine , Boston , MA , USA.,j Department of Anatomy & Neurobiology , Boston University School of Medicine , Boston , MA , USA
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20
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Asken BM, Sullan MJ, Snyder AR, Houck ZM, Bryant VE, Hizel LP, McLaren ME, Dede DE, Jaffee MS, DeKosky ST, Bauer RM. Factors Influencing Clinical Correlates of Chronic Traumatic Encephalopathy (CTE): a Review. Neuropsychol Rev 2016; 26:340-363. [PMID: 27561662 PMCID: PMC5507554 DOI: 10.1007/s11065-016-9327-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 08/08/2016] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neuropathologically defined disease reportedly linked to a history of repetitive brain trauma. As such, retired collision sport athletes are likely at heightened risk for developing CTE. Researchers have described distinct pathological features of CTE as well a wide range of clinical symptom presentations, recently termed traumatic encephalopathy syndrome (TES). These clinical symptoms are highly variable, non-specific to individuals described as having CTE pathology in case reports, and are often associated with many other factors. This review describes the cognitive, emotional, and behavioral changes associated with 1) developmental and demographic factors, 2) neurodevelopmental disorders, 3) normal aging, 4) adjusting to retirement, 5) drug and alcohol abuse, 6) surgeries and anesthesia, and 7) sleep difficulties, as well as the relationship between these factors and risk for developing dementia-related neurodegenerative disease. We discuss why some professional athletes may be particularly susceptible to many of these effects and the importance of choosing appropriate controls groups when designing research protocols. We conclude that these factors should be considered as modifiers predominantly of the clinical outcomes associated with repetitive brain trauma within a broader biopsychosocial framework when interpreting and attributing symptom development, though also note potential effects on neuropathological outcomes. Importantly, this could have significant treatment implications for improving quality of life.
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Affiliation(s)
- Breton M Asken
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA.
| | - Molly J Sullan
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Aliyah R Snyder
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Zachary M Houck
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Vaughn E Bryant
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Loren P Hizel
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Molly E McLaren
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Duane E Dede
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Michael S Jaffee
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Steven T DeKosky
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Russell M Bauer
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
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21
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Alosco ML, Jarnagin J, Tripodis Y, Platt M, Martin B, Chaisson CE, Baugh CM, Fritts NG, Cantu RC, Stern RA. Olfactory Function and Associated Clinical Correlates in Former National Football League Players. J Neurotrauma 2016; 34:772-780. [PMID: 27430424 DOI: 10.1089/neu.2016.4536] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Professional American football players incur thousands of repetitive head impacts (RHIs) throughout their lifetime. The long-term consequences of RHI are not well characterized, but may include olfactory dysfunction. RHI has been associated with changes to brain regions involved in olfaction, and olfactory impairment is common after traumatic brain injury. Olfactory dysfunction is a frequent early sequelae of neurodegenerative diseases (e.g., Alzheimer's disease), and RHI is associated with the neurodegenerative disease, chronic traumatic encephalopathy (CTE). We examined olfaction, and its association with clinical measures, in former National Football League (NFL) players. Ninety-five former NFL players (ages 40-69) and 28 same-age controls completed a neuropsychological and neuropsychiatric evaluation as part of a National Institutes of Health-funded study. The Brief Smell Identification Test (B-SIT) assessed olfaction. Principal component analysis generated a four-factor structure of the clinical measures: behavioral/mood, psychomotor speed/executive function, and verbal and visual memory. Former NFL players had worse B-SIT scores relative to controls (p = 0.0096). A B-SIT cutoff of 11 had the greatest accuracy (c-statistic = 0.61) and specificity (79%) for discriminating former NFL players from controls. In the former NFL players, lower B-SIT scores correlated with greater behavioral/mood impairment (p = 0.0254) and worse psychomotor speed/executive functioning (p = 0.0464) after controlling for age and education. Former NFL players exhibited lower olfactory test scores relative to controls, and poorer olfactory test performance was associated with worse neuropsychological and neuropsychiatric functioning. Future work that uses more-comprehensive tests of olfaction and structural and functioning neuroimaging may improve understanding on the association between RHI and olfaction.
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Affiliation(s)
- Michael L Alosco
- 1 Department of Neurology, Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston, Massachusetts
| | - Johnny Jarnagin
- 2 Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston, Massachusetts
| | - Yorghos Tripodis
- 3 Department of Biostatistics, Boston University School of Public Health , Boston, Massachusetts
| | - Michael Platt
- 4 Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine , Boston, Massachusetts
| | - Brett Martin
- 2 Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston, Massachusetts.,5 Data Coordinating Center, Boston University School of Public Health , Boston, Massachusetts
| | - Christine E Chaisson
- 2 Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston, Massachusetts.,6 Department of Biostatistics, Data Coordinating Center, Boston University School of Public Health , Boston, Massachusetts
| | - Christine M Baugh
- 1 Department of Neurology, Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston, Massachusetts.,7 Interfaculty Initiative in Health Policy , Cambridge, Massachusetts
| | - Nathan G Fritts
- 2 Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston, Massachusetts
| | - Robert C Cantu
- 8 Department of Neurology and Neurosurgery, Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston, Massachusetts
| | - Robert A Stern
- 1 Department of Neurology, Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston, Massachusetts.,8 Department of Neurology and Neurosurgery, Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine , Boston, Massachusetts.,9 Department of Anatomy & Neurobiology, Boston University School of Medicine , Boston, Massachusetts
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22
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Sethi NK, Gardner RC, Rabinovici GD. Evaluating and treating neurobehavioral symptoms in professional American football players: Lessons from a case seriesAuthors Respond:. Neurol Clin Pract 2016; 6:7-8. [DOI: 10.1212/cpj.0000000000000223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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