Cerebrospinal fluid levels of neuroinflammatory biomarkers are increased in athletes with persistent post-concussive symptoms following sports-related concussion

Dietary supplementation roles in concussion management: A systematic review

Concussion, one of the most common types of mild traumatic brain injury, remains a global problem that poses substantial effects on individuals, families, and society. When dealing with concussion, clinicians primarily focus on symptomatic treatment and modified activity with no established therapies specifically addressing the underlying pathophysiological changes. In recent years, there has been a growing increase in attention to the effectiveness of dietary supplements (DS) and nutritional interventions as adjunctive therapy options for concussion. Hence, this review aims to comprehensively explore the existing human studies on using DS as adjunctive therapy in the management of concussion. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The search strategy was created based on the population, intervention, comparison, outcome framework. The findings are conveyed narratively and analyzed according to the timing of the intervention. DS administered within 7 days of onset were classified as acute interventions, while those given after this period were classified as nonacute interventions. After screening, we identified 21 reports for 19 studies involving 13 DS. Thirteen DS were included in this review. Notably, omega-3 polyunsaturated fatty acids were the most extensively studied and accounted for 23.81% of studies, followed by melatonin and pine bark extract (19.05% and 9.5%). At least 13 supplements were identified in clinical studies, with 77% demonstrating favorable outcomes. However, none of the interventions reviewed offer strong enough evidence to justify regular use in clinical practice.

Quantitative Susceptibility Mapping in Adults with Persistent Postconcussion Symptoms after Mild Traumatic Brain Injury: An Exploratory Study

BACKGROUND AND PURPOSE

It is estimated that 18%-30% of patients with concussion experience symptoms lasting more than 1 month, known as persistent post-concussion symptoms (PPCS). Symptoms can be debilitating, and include headache, dizziness, nausea, problems with memory and concentration, sleep and mood disruption, and exercise intolerance. Previous studies have used quantitative susceptibility mapping (QSM) to show altered tissue susceptibility levels in adults acutely following concussion, however this finding has yet to be investigated in participants with PPCS.

MATERIALS AND METHODS

In this exploratory case-controlled study, we measured tissue susceptibility using QSM in 24 participants with PPCS after mild traumatic brain injury (mTBI) and 23 healthy controls with no history of concussion. We compute tissue susceptibility for 7 white matter tracts and 3 deep gray matter regions and compare tissue susceptibility between groups using ANCOVA models controlling for age and sex. We also assess the relationship between regional tissue susceptibility and symptoms.

RESULTS

There were no significant differences between tissue susceptibility in participants with PPCS compared with control subjects in any of the evaluated regions. However, we show lower tissue susceptibility across 4 white matter tracts was generally associated with worse symptoms in the PPCS group. Specifically, we saw relationships between white matter susceptibility and headache (p = .006), time since injury (p = .03), depressive symptoms (p = .021), and daytime fatigue (p = .01) in participants with PPCS.

CONCLUSIONS

These results provide evidence in support of persistent changes in the brain months to years after injury and highlight the need to further understand the pathophysiology of PPCS, to determine effective prevention and treatment options.

Minimally invasive serial collection of cerebrospinal fluid reveals sex-dependent differences in neuroinflammation in a rat model of mild traumatic brain injury

Traumatic brain injuries (TBI) are the seventh leading cause of disability globally with 48.99 million prevalent cases and 7.08 million years lived with diability. Approximately 80 % of TBI patients are diagnosed with mild TBI (mTBI), or concussion, caused by nonpenetrating mechanical trauma to the head or body along with sudden rotational motion of the head. Studies investigating the temporal dynamics of neuroinflammation after mTBI are greatly needed. Without longitudinal studies, translating preclinical studies to clinical studies remains challenging as the difference in timing remains poorly understood. In this study, we describe a method of minimally invasive serial cerebrospinal fluid (CSF) collection that enables longitudinal investigation of CSF inflammation. The method described in this study can easily be adapted by any laboratory prepared for animal studies. Multiplex immunoassay of serially collected and singly collected CSF samples show collection frequency does not alter protein expression in the CSF. Further, sex-dependent differences in TBI have been reported, but remain poorly understood. This study establishes a framework for assessing sex difference in neuroinflammation after a concussion. We showed that results vary based on the framing of the statistical test. However, it is evident that males experience a more robust inflammatory response to a single concussion than females.

Concussion and the Autonomic, Immune, and Endocrine Systems: An Introduction to the Field and a Treatment Framework for Persisting Symptoms

A significant proportion of patients who sustain a concussion/mild traumatic brain injury endorse persisting, lingering symptoms. The symptoms associated with concussion are nonspecific, and many other medical conditions present with similar symptoms. Medical conditions that overlap symptomatically with concussion include anxiety, depression, insomnia, chronic pain, chronic fatigue, fibromyalgia, and cervical strain injuries. One of the factors that may account for these similarities is that these conditions all present with disturbances in the optimal functioning of the autonomic nervous system and its intricate interactions with the endocrine system and immune system-the three primary regulatory systems in the body. When clinicians are working with patients presenting with persisting symptoms after concussion, evidence-based treatment options drawn from the literature are limited. We present a framework for the assessment and treatment of persisting symptoms following concussion based on the available evidence (treatment trials), neuroanatomical principles (research into the physiology of concussion), and clinical judgment. We review the research supporting the premise that behavioral interventions designed to stabilize and optimize regulatory systems in the body following injury have the potential to reduce symptoms and improve functioning in patients. Foundational concussion rehabilitation strategies in the areas of sleep stabilization, fatigue management, physical exercise, nutrition, relaxation protocols, and behavioral activation are outlined along with practical strategies for implementing intervention modules with patients.

Widespread White Matter Abnormalities in Concussed Athletes Detected by 7T Diffusion Magnetic Resonance Imaging

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.

Serum neurofilament light chain, inflammatory markers, and kynurenine metabolites in patients with persistent post-concussion symptoms: A cohort study

BACKGROUND

Concussion leads to persistent post-concussion symptoms (PPCS) in up to one-third of those affected. While previous research has linked the initial trauma to elevated serum levels of neurofilament light chain (NFL), inflammatory markers, and neurotoxic metabolites within the kynurenine pathway, few studies have explored their relevance in PPCS. This study aims to investigate these biomarkers in PPCS patients, elucidating their relevance in the prolonged phase of concussion.

METHODS

Serum samples from 86 PPCS individuals aged 18-30 years, 2-6 months post-trauma were analyzed, with 54 providing follow-up samples after seven months. NFL was measured using single-molecule array (Simoa) technology, 13 inflammatory markers via a Luminex immunoassay, and five kynurenine metabolites using liquid chromatography-mass spectrometry. A control group of 120 healthy anonymous blood donors was recruited for comparison.

RESULTS

No significant NFL differences were found in PPCS participants compared with healthy individuals (p = 0.22). Intriguingly, a subset (9.3%) of PPCS participants initially exhibited abnormally high NFL levels (>9.7 pg/mL), which normalized upon follow-up (p = 0.032). Additionally, serum levels of the inflammatory markers, monocyte chemoattractant protein-1 (MCP-1/CCL2), and eotaxin-1/CCL11 were 25-40% lower than in healthy individuals (p ≤ 0.001). As hypothesized, PPCS participants exhibited a 22% reduction in the ratio of kynurenic acid to quinolinic acid (neuroprotective index) (p < 0.0001), indicating a shift towards the formation of neurotoxic metabolites.

CONCLUSION

NFL may serve as a biomarker to monitor recovery, and future studies should investigate the potential therapeutic benefits of modulating the kynurenine pathway to improve PPCS.

Early Blood-Brain Barrier Impairment as a Pathological Hallmark in a Novel Model of Closed-Head Concussive Brain Injury (CBI) in Mice

Concussion, caused by a rotational acceleration/deceleration injury mild enough to avoid structural brain damage, is insufficiently captured in recent preclinical models, hampering the relation of pathophysiological findings on the cellular level to functional and behavioral deficits. We here describe a novel model of unrestrained, single vs. repetitive concussive brain injury (CBI) in male C56Bl/6j mice. Longitudinal behavioral assessments were conducted for up to seven days afterward, alongside the evaluation of structural cerebral integrity by in vivo magnetic resonance imaging (MRI, 9.4 T), and validated ex vivo by histology. Blood-brain barrier (BBB) integrity was analyzed by means of fluorescent dextran- as well as immunoglobulin G (IgG) extravasation, and neuroinflammatory processes were characterized both in vivo by positron emission tomography (PET) using [18F]DPA-714 and ex vivo using immunohistochemistry. While a single CBI resulted in a defined, subacute neuropsychiatric phenotype, longitudinal cognitive testing revealed a marked decrease in spatial cognition, most pronounced in mice subjected to CBI at high frequency (every 48 h). Functional deficits were correlated to a parallel disruption of the BBB, (R2 = 0.29, p < 0.01), even detectable by a significant increase in hippocampal uptake of [18F]DPA-714, which was not due to activation of microglia, as confirmed immunohistochemically. Featuring a mild but widespread disruption of the BBB without evidence of macroscopic damage, this model induces a characteristic neuro-psychiatric phenotype that correlates to the degree of BBB disruption. Based on these findings, the BBB may function as both a biomarker of CBI severity and as a potential treatment target to improve recovery from concussion.