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Gard A, Kornaropoulos EN, Portonova Wernersson M, Rorsman I, Blennow K, Zetterberg H, Tegner Y, De Maio A, Markenroth Bloch K, Björkman-Burtscher I, Pessah-Rasmussen H, Nilsson M, Marklund N. Widespread White Matter Abnormalities in Concussed Athletes Detected by 7T Diffusion Magnetic Resonance Imaging. J Neurotrauma 2024; 41:1533-1549. [PMID: 38481124 DOI: 10.1089/neu.2023.0099] [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: 05/04/2024] Open
Abstract
Sports-related concussions may cause white matter injuries and persistent post-concussive symptoms (PPCS). We hypothesized that athletes with PPCS would have neurocognitive impairments and white matter abnormalities that could be revealed by advanced neuroimaging using ultra-high field strength diffusion tensor (DTI) and diffusion kurtosis (DKI) imaging metrics and cerebrospinal fluid (CSF) biomarkers. A cohort of athletes with PPCS severity limiting the ability to work/study and participate in sport school and/or social activities for ≥6 months completed 7T magnetic resonance imaging (MRI) (morphological T1-weighed volumetry, DTI and DKI), extensive neuropsychological testing, symptom rating, and CSF biomarker sampling. Twenty-two athletes with PPCS and 22 controls were included. Concussed athletes performed below norms and significantly lower than controls on all but one of the psychometric neuropsychology tests. Supratentorial white and gray matter, as well as hippocampal volumes did not differ between concussed athletes and controls. However, of the 72 examined white matter tracts, 16% of DTI and 35% of DKI metrics (in total 28%) were significantly different between concussed athletes and controls. DKI fractional anisotropy and axial kurtosis were increased, and DKI radial diffusivity and radial kurtosis decreased in concussed athletes when compared with controls. CSF neurofilament light (NfL; an axonal injury marker), although not glial fibrillary acidic protein, correlated with several diffusion metrics. In this first 7T DTI and DKI study investigating PPCS, widespread microstructural alterations were observed in the white matter, correlating with CSF markers of axonal injury. More white matter changes were observed using DKI than using DTI. These white matter alterations may indicate persistent pathophysiological processes following concussion in sport.
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Affiliation(s)
- Anna Gard
- Department of Clinical Sciences Lund, Neurosurgery, Neurology, Lund University, Lund, Sweden
| | - Evgenios N Kornaropoulos
- Department of Clinical Sciences Lund, Diagnostic Radiology, Neurology, Lund University, Lund, Sweden
| | - Maria Portonova Wernersson
- Department of Neurology, Rehabilitation Medicine, Memory Disorders and Geriatrics, Skåne University Hospital, Neurology, Lund University, Lund, Sweden
| | - Ia Rorsman
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Yelverton Tegner
- Department of Health, Education and Technology, Division of Health and Rehabilitation, Luleå University of Technology, Luleå, Sweden
| | - Alessandro De Maio
- Department of Radiological, Oncological and Pathological Sciences. Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Karin Markenroth Bloch
- Department of Clinical Sciences Lund, Lund University Bioimaging Center, Lund University, Lund, Sweden
| | - Isabella Björkman-Burtscher
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hélène Pessah-Rasmussen
- Department of Neurology, Rehabilitation Medicine, Memory Disorders and Geriatrics, Skåne University Hospital, Neurology, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | - Markus Nilsson
- Department of Clinical Sciences Lund, Diagnostic Radiology, Neurology, Lund University, Lund, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, and Skåne University Hospital, Lund, Sweden
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Al-Husseini A, Fazel Bakhsheshi M, Gard A, Tegner Y, Marklund N. Shorter recovery time in concussed elite ice hockey players by early head-and-neck cooling - a clinical trial. J Neurotrauma 2022. [PMID: 36222612 DOI: 10.1089/neu.2022.0248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A sports-related concussion (SRC) is most commonly sustained in contact sports, and is defined as a mild traumatic brain injury. An exercise-induced elevation of core body temperature is associated with increased brain temperature that may accelerate secondary injury processes following SRC, and exacerbate the brain injury. In a recent pilot study, acute head-neck cooling of 29 concussed ice hockey players resulted in shorter time to return-to-play. Here, we extended the clinical trial to include players of 19 male elite Swedish ice hockey teams over 5 seasons (2016-2021). In the intervention teams, acute head-neck cooling was implemented using a head cap for ≥45 minutes in addition to the standard SRC management used in controls. The primary endpoint was time from SRC until return-to-play (RTP). Sixty-one SRCs were included in the intervention group and 71 SRCs in the control group. The number of previous SRCs was 2 (median and interquartile range (IQR): 1.0 - 2.0) and 1 (IQR 1.0 - 2.0) in the intervention and control groups, respectively; p= 0.293. Median time to initiate head-neck cooling was 10 min (IQR 7-15; range 5-30 min) and median duration of cooling was 45 min (IQR 45-50; range 45-70 min). The median time to RTP was 9 days in the intervention group (IQR 7-13.5 days) and 13 days in the control group (IQR 9-30; p<0.001). The proportion of players out from play for more than the expected recovery time of 14 days was 24.7% in the intervention group, and 43.7% in controls (p<0.05). Study limitations include that a) allocation to cooling or control management was at the discretion of the medical staff of each teams, decided prior to each season, and not by strict randomization, b) no sham cap was used and evaluations could not be performed by blinded assessors and c) it could not be established with certainty that injury severity was similar between groups. While the results should thus be interpreted with caution, early head-neck cooling, with the aim of attenuating cerebral hyperthermia, may reduce post-SRC symptoms and lead to earlier return-to-play in elite ice hockey players.
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Affiliation(s)
- Ali Al-Husseini
- Lund University, 5193, Department of Clinical Sciences, Neurosurgery, Lund, Sweden;
| | | | - Anna Gard
- Lund University, 5193, Department of Clinical Sciences Lund, Entregatan 7, Hisshall EA, plan 4, Lund, Lund, Skane, Sweden, 22242;
| | - Yelverton Tegner
- Luleå University of Technology, Division of Medical Sciences, Department of Health Sciences, Department of Health Sciences, Luleå, Sweden, SE 971 87;
| | - Niklas Marklund
- Lund University, 5193, Clinical Sciences, Neurosurgery, Klinikgatan 17B, Lund, Sweden, 221 85.,Skåne University Hospital Lund, 59564, Neurosurgery, Lund, Sweden, 221 85;
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Gard A, Al-Husseini A, Kornaropoulos EN, De Maio A, Tegner Y, Björkman-Burtscher I, Markenroth Bloch K, Nilsson M, Magnusson M, Marklund N. Post-Concussive Vestibular Dysfunction Is Related to Injury to the Inferior Vestibular Nerve. J Neurotrauma 2022; 39:829-840. [PMID: 35171721 PMCID: PMC9225415 DOI: 10.1089/neu.2021.0447] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Symptoms of vestibular dysfunction such as dizziness and vertigo are common after sports-related concussions (SRC) and associated with a worse outcome and a prolonged recovery. Vestibular dysfunction after SRC can be because of an impairment of the peripheral or central neural parts of the vestibular system. The aim of the present study was to establish the cause of vestibular impairment in athletes with SRC who have persisting post-concussive symptoms (PPCS). We recruited 42 participants-21 athletes with previous SRCs and PPCS ≥6 months and 21 healthy athletic age- and sex-matched controls-who underwent symptom rating, a detailed test battery of vestibular function and 7T magnetic resonance imaging with diffusion tensor imaging (DTI) and diffusion kurtosis imaging (DKI) of cerebellar white matter tracts, and T1-weighted imaging for cerebellar volumetrics. Vestibular dysfunction was observed in 13 SRC athletes and three controls (p = 0.001). Athletes with vestibular dysfunction reported more pronounced symptoms on the Dizziness Handicap Inventory (DHI; p < 0.001) and the Hospital Anxiety and Depression Scale (HADS; p < 0.001). No significant differences in DTI metrics were found, while in DKI two metrics were observed in the superior and/or inferior cerebellar tracts. Cerebellar gray and white matter volumes were similar in athletes with SRC and controls. Compared with controls, pathological video head impulse test results (vHIT; p < 0.001) and cervical vestibular evoked myogenic potentials (cVEMP; p = 0.002) were observed in athletes with SRC, indicating peripheral vestibular dysfunction and specifically suggesting injury to the inferior vestibular nerve. In athletes with persisting symptoms after SRC, vestibular dysfunction is associated with injury to the inferior vestibular nerve.
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Affiliation(s)
- Anna Gard
- Department of Clinical Sciences Lund, Lund University, Neurosurgery, Skåne University Hospital, Lund, Sweden
| | - Ali Al-Husseini
- Department of Clinical Sciences Lund, Lund University, Neurosurgery, Skåne University Hospital, Lund, Sweden
| | - Evgenios N. Kornaropoulos
- Department of Clinical Sciences Lund, Diagnostic Radiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Alessandro De Maio
- Department of Radiological, Oncological and Pathological Sciences. Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Yelverton Tegner
- Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
| | - Isabella Björkman-Burtscher
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Markus Nilsson
- Department of Clinical Sciences Lund, Diagnostic Radiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Måns Magnusson
- Department of Clinical Sciences Lund, Otorhinolaryngology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Lund University, Neurosurgery, Skåne University Hospital, Lund, Sweden
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