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Moseley GA, Lincoln AE, Drezner JA, DeLong R, Shore E, Walker N, Register-Mihalik JK, Cantu RC, Kucera KL. Catastrophic injuries and exertional medical events in lacrosse among youth, high school and collegiate athletes: longitudinal surveillance over four decades (1982-2020). Ann Med 2024; 56:2311223. [PMID: 38335556 PMCID: PMC10860437 DOI: 10.1080/07853890.2024.2311223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/04/2023] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVE To determine the incidence rates (IRs) of catastrophic injuries and exertional medical events in lacrosse athletes. METHODS Catastrophic injuries and exertional medical events in lacrosse in the US among youth or amateur, high school and college athletes were analysed from the National Center for Catastrophic Sport Injury Research (NCCSIR) database from 1982/83 to 2019/20. Frequencies, IRs per 100,000 athlete-seasons (AS) with 95% confidence intervals (CIs), and incidence rate ratios (IRRs) with 95% CIs were calculated. Participation data were gathered from the National Federation of State High School Associations (NFHS), National Collegiate Athletic Association (NCAA) and USA Lacrosse. RESULTS Sixty-nine catastrophic events (16 youth or amateur, 36 high school and 17 college; 84% male) occurred in US lacrosse from 7/1/1982 to 6/30/2020. Thirty-six percent of all incidents were fatal. The overall IR was 0.5 per 100,000 AS (95% CI: 0.4-0.7). There were 15 cases of non-traumatic sudden cardiac arrests (SCAs) and 15 incidents of commotio cordis. Fatality rates from SCA and commotio cordis decreased 95% (IRR = 0.05; 95% CI: 0, 0.2) from 1982/83-2006/07 to 2007/08-2019/20. Incidence rates were higher for collegiate versus high school 1982/83-2019/20 (IRR = 3.2; 95% CI: 1.8, 5.7) and collegiate versus youth 2005/06-2019/20 (IRR = 8.0; 95% CI: 3.0, 21.4) level. Contact with a stick or ball (41%) and contact with another player (20%) were the primary mechanisms of injury. CONCLUSIONS The incidence of catastrophic events during lacrosse was higher among collegiate than high school or youth athletes. SCA from an underlying cardiac condition or from commotio cordis was the most common catastrophic event. Fatality rates from catastrophic injuries have declined significantly over the study period, perhaps driven by protective measures adopted by lacrosse governing bodies.
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Affiliation(s)
- Garrett A. Moseley
- Department of Exercise and Sport Science, National Center for Catastrophic Sports Injury Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Jonathan A. Drezner
- Department of Family Medicine, Center for Sports Cardiology, University of Washington, Seattle, WA, USA
| | - Randi DeLong
- Department of Exercise and Sport Science, National Center for Catastrophic Sports Injury Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Erin Shore
- Department of Exercise and Sport Science, National Center for Catastrophic Sports Injury Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nina Walker
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Johna K. Register-Mihalik
- Department of Exercise and Sport Science, National Center for Catastrophic Sports Injury Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Matthew Gfeller Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Kristen L. Kucera
- Department of Exercise and Sport Science, National Center for Catastrophic Sports Injury Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Culhane JE, Jackson CE, Tripodis Y, Nowinski CJ, Dams-O'Connor K, Pettway E, Uretsky M, Abdolmohammadi B, Nair E, Martin B, Palmisano J, Katz DI, Dwyer B, Daneshvar DH, Goldstein LE, Kowall NW, Cantu RC, Stern RA, Huber BR, Crary JF, Mez J, Stein TD, McKee AC, Alosco ML. Lack of Association of Informant-Reported Traumatic Brain Injury and Chronic Traumatic Encephalopathy. J Neurotrauma 2024. [PMID: 38445389 DOI: 10.1089/neu.2023.0391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
Repetitive head impacts (RHIs) from football are associated with the neurodegenerative tauopathy chronic traumatic encephalopathy (CTE). It is unclear whether a history of traumatic brain injury (TBI) is sufficient to precipitate CTE neuropathology. We examined the association between TBI and CTE neuropathology in 580 deceased individuals exposed to RHIs from football. TBI history was assessed using a modified version of the Ohio State University TBI Identification Method Short Form administered to informants. There were 22 donors who had no TBI, 213 who had at least one TBI without loss of consciousness (LOC), 345 who had TBI with LOC, and, of those with a history of TBI with LOC, 36 who had at least one moderate-to-severe TBI (msTBI, LOC >30 min). CTE neuropathology was diagnosed in 405. There was no association between CTE neuropathology status or severity and TBI with LOC (odds ratio [OR] = 0.95, 95% confidence interval [CI] = 0.64-1.41; OR = 1.22, 95% CI = 0.71-2.09) or msTBI (OR = 0.70, 95% CI = 0.33-1.50; OR = 1.01, 95% CI = 0.30-3.41). There were no associations with other neurodegenerative or cerebrovascular pathologies examined. TBI with LOC and msTBI were not associated with CTE neuropathology in this sample of brain donors exposed to RHIs from American football.
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Affiliation(s)
- Julia E Culhane
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Colleen E Jackson
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Christopher J Nowinski
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Concussion Legacy Foundation, Boston, Massachusetts, USA
| | - Kristen Dams-O'Connor
- Brain Injury Research Center, Department of Rehabilitation and Human Performance, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erika Pettway
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Madeline Uretsky
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Bobak Abdolmohammadi
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Evan Nair
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Brett Martin
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Joseph Palmisano
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Douglas I Katz
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Brigid Dwyer
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Daniel H Daneshvar
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Lee E Goldstein
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Departments of Biomedical, Electrical & Computer Engineering, Boston University College of Engineering, Boston, Massachusetts, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, Massachusetts, USA
| | - Robert C Cantu
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Concussion Legacy Foundation, Boston, Massachusetts, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Department of Anatomy and Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Bertrand Russell Huber
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, Massachusetts, USA
- VA Bedford Healthcare System, Bedford, Massachusetts, USA
- National Center for PTSD, VA Boston Healthcare, Boston, Massachusetts, USA
| | - John F Crary
- Brain Injury Research Center, Department of Rehabilitation and Human Performance, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Pathology, Molecular, and Cell-Based Medicine, Nash Family Department of Neuroscience, Friedman Brain Institute, Mount Sinai, New York, New York, USA
- Department of Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neuropathology Brain Bank & Research Core, Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Thor D Stein
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, Massachusetts, USA
- VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, Massachusetts, USA
- VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Michael L Alosco
- Boston University Alzheimer's Disease Research Center, BU CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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Alosco ML, Adler CH, Dodick DW, Tripodis Y, Balcer LJ, Bernick C, Banks SJ, Barr WB, Wethe JV, Palmisano JN, Martin B, Hartlage K, Cantu RC, Geda YE, Katz DI, Mez J, Cummings JL, Shenton ME, Reiman EM, Stern RA. Examination of parkinsonism in former elite American football players. Parkinsonism Relat Disord 2024; 120:105903. [PMID: 37981539 PMCID: PMC10922636 DOI: 10.1016/j.parkreldis.2023.105903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/20/2023] [Accepted: 10/21/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Former American football players are at risk for chronic traumatic encephalopathy (CTE) which may have parkinsonism as a clinical feature. OBJECTIVE Former football players were prospectively assessed for parkinsonism. METHODS 120 former professional football players, 58 former college football players, and 60 same-age asymptomatic men without repetitive head impacts, 45-74 years, were studied using the MDS-UPDRS to assess for parkinsonism, and the Timed Up and Go (TUG). Traumatic encephalopathy syndrome (TES), the clinical syndrome of CTE, was adjudicated and includes parkinsonism diagnosis. Fisher's Exact Test compared groups on parkinsonism due to small cell sizes; analysis of covariance or linear regressions controlling for age and body mass index were used otherwise. RESULTS Twenty-two (12.4%) football players (13.3% professional, 10.3% college) met parkinsonism criteria compared with two (3.3%) in the unexposed group. Parkinsonism was higher in professional (p = 0.037) but not college players (p = 0.16). There were no differences on the MDS-UPDRS Part III total scores. Scores on the individual MDS-UPDRS items were low. TUG times were longer in former professional but not college players compared with unexposed men (13.09 versus 11.35 s, p < 0.01). There were no associations between years of football, age of first exposure, position or level of play on motor outcomes. TES status was not associated with motor outcomes. CONCLUSIONS Parkinsonism rates in this sample of football players was low and highest in the professional football players. The association between football and parkinsonism is inconclusive and depends on factors related to sample selection, comparison groups, and exposure characteristics.
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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 Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Charles H Adler
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA.
| | - David W Dodick
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, 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
| | - 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
| | - Jennifer V Wethe
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Joseph N Palmisano
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Brett Martin
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Kaitlin Hartlage
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Robert C Cantu
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | - Douglas I Katz
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA; Framingham Heart Study, Framingham, MA, USA
| | - Jeffery 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
| | - Martha E Shenton
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Department of Radiology, Brigham and Women's Hospital, And Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 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
| | - Robert A Stern
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA; Department of Anatomy & Neurobiology, Boston University Chobanian & Avedisian, Boston, MA, USA
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4
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Alexander A, Alvarez VE, Huber BR, Alosco ML, Mez J, Tripodis Y, Nicks R, Katz DI, Dwyer B, Daneshvar DH, Martin B, Palmisano J, Goldstein LE, Crary JF, Nowinski C, Cantu RC, Kowall NW, Stern RA, Delalle I, McKee AC, Stein TD. Cortical-sparing chronic traumatic encephalopathy (CSCTE): a distinct subtype of CTE. Acta Neuropathol 2024; 147:45. [PMID: 38407651 DOI: 10.1007/s00401-024-02690-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 02/27/2024]
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease caused by repetitive head impacts (RHI) and pathologically defined as neuronal phosphorylated tau aggregates around small blood vessels and concentrated at sulcal depths. Cross-sectional studies suggest that tau inclusions follow a stereotyped pattern that begins in the neocortex in low stage disease, followed by involvement of the medial temporal lobe and subcortical regions with significant neocortical burden in high stage CTE. Here, we define a subset of brain donors with high stage CTE and with a low overall cortical burden of tau inclusions (mean semiquantitative value ≤1) and classify them as cortical-sparing CTE (CSCTE). Of 620 brain donors with pathologically diagnosed CTE, 66 (11%) met criteria for CSCTE. Compared to typical high stage CTE, those with CSCTE had a similar age at death and years of contact sports participation and were less likely to carry apolipoprotein ε4 (p < 0.05). CSCTE had less overall tau pathology severity, but a proportional increase of disease burden in medial temporal lobe and brainstem regions compared to the neocortex (p's < 0.001). CSCTE also had lower prevalence of comorbid neurodegenerative disease. Clinically, CSCTE participants were less likely to have dementia (p = 0.023) and had less severe cognitive difficulties (as reported by informants using the Functional Activities Questionnaire (FAQ); p < 0.001, meta-cognitional index T score; p = 0.002 and Cognitive Difficulties Scale (CDS); p < 0.001,) but had an earlier onset age of behavioral (p = 0.006) and Parkinsonian motor (p = 0.013) symptoms when compared to typical high stage CTE. Other comorbid tauopathies likely contributed in part to these differences: when cases with concurrent Alzheimer dementia or frontal temporal lobar degeneration with tau pathology were excluded, differences were largely retained, but only remained significant for FAQ (p = 0.042), meta-cognition index T score (p = 0.014) and age of Parkinsonian motor symptom onset (p = 0.046). Overall, CSCTE appears to be a distinct subtype of high stage CTE with relatively greater involvement of subcortical and brainstem regions and less severe cognitive symptoms.
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Affiliation(s)
- Abigail Alexander
- Division of Neuropathology, Lifespan Academic Medical Center, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Victor E Alvarez
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Bedford Healthcare System, Bedford, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
| | - Bertrand R Huber
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
| | - Michael L Alosco
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Raymond Nicks
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Bedford Healthcare System, Bedford, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
| | - Douglas I Katz
- Department of Neurology, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Brigid Dwyer
- Department of Neurology, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Daniel H Daneshvar
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Brett Martin
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Joseph Palmisano
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Lee E Goldstein
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Radiology, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Departments of Pathology and Laboratory Medicine, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Psychiatry, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Departments of Biomedical, Electrical & Computer Engineering, Boston University College of Engineering, Boston, MA, USA
| | - John F Crary
- Department of Pathology, Nash Family Department of Neuroscience, Department of Artificial Intelligence and Human Health, Ronald M. Loeb Center for Alzheimer's Disease, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Nowinski
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Concussion Legacy Foundation, Boston, MA, USA
| | - Robert C Cantu
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Concussion Legacy Foundation, Boston, MA, USA
- Department of Neurosurgery, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Emerson Hospital, Concord, MA, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, USA
| | - Ivana Delalle
- Division of Neuropathology, Lifespan Academic Medical Center, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
| | - Thor D Stein
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
- VA Bedford Healthcare System, Bedford, MA, USA.
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA.
- Departments of Pathology and Laboratory Medicine, Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA.
- , 150 S. Huntington Avenue, Boston, MA, 02130, USA.
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5
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Alosco ML, White M, Bell C, Faheem F, Tripodis Y, Yhang E, Baucom Z, Martin B, Palmisano J, Dams-O'Connor K, Crary JF, Goldstein LE, Katz DI, Dwyer B, Daneshvar DH, Nowinski C, Cantu RC, Kowall NW, Stern RA, Alvarez VE, Huber BR, Stein TD, McKee AC, Mez J. Cognitive, functional, and neuropsychiatric correlates of regional tau pathology in autopsy-confirmed chronic traumatic encephalopathy. Mol Neurodegener 2024; 19:10. [PMID: 38317248 PMCID: PMC10845638 DOI: 10.1186/s13024-023-00697-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 12/11/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease characterized by hyperphosphorylated tau (p-tau) accumulation. The clinical features associated with CTE pathology are unclear. In brain donors with autopsy-confirmed CTE, we investigated the association of CTE p-tau pathology density and location with cognitive, functional, and neuropsychiatric symptoms. METHODS In 364 brain donors with autopsy confirmed CTE, semi-quantitative p-tau severity (range: 0-3) was assessed in 10 cortical and subcortical regions. We summed ratings across regions to form a p-tau severity global composite (range: 0-30). Informants completed standardized scales of cognition (Cognitive Difficulties Scale, CDS; BRIEF-A Metacognition Index, MI), activities of daily living (Functional Activities Questionnaire), neurobehavioral dysregulation (BRIEF-A Behavioral Regulation Index, BRI; Barratt Impulsiveness Scale, BIS-11), aggression (Brown-Goodwin Aggression Scale), depression (Geriatric Depression Scale-15, GDS-15), and apathy (Apathy Evaluation Scale, AES). Ordinary least squares regression models examined associations between global and regional p-tau severity (separate models for each region) with each clinical scale, adjusting for age at death, racial identity, education level, and history of hypertension, obstructive sleep apnea, and substance use treatment. Ridge regression models that incorporated p-tau severity across all regions in the same model assessed which regions showed independent effects. RESULTS The sample was predominantly American football players (333; 91.2%); 140 (38.5%) had low CTE and 224 (61.5%) had high CTE. Global p-tau severity was associated with higher (i.e., worse) scores on the cognitive and functional scales: MI ([Formula: see text] standardized = 0.02, 95%CI = 0.01-0.04), CDS ([Formula: see text] standardized = 0.02, 95%CI = 0.01-0.04), and FAQ ([Formula: see text] standardized = 0.03, 95%CI = 0.01-0.04). After false-discovery rate correction, p-tau severity in the frontal, inferior parietal, and superior temporal cortex, and the amygdala was associated with higher CDS ([Formula: see text] sstandardized = 0.17-0.29, ps < 0.01) and FAQ ([Formula: see text] sstandardized = 0.21-0.26, ps < 0.01); frontal and inferior parietal cortex was associated with higher MI ([Formula: see text] sstandardized = 0.21-0.29, ps < 0.05); frontal cortex was associated with higher BRI ([Formula: see text] standardized = 0.21, p < 0.01). Regions with effects independent of other regions included frontal cortex (CDS, MI, FAQ, BRI), inferior parietal cortex (CDS) and amygdala (FAQ). P-tau explained 13-49% of variance in cognitive and functional scales and 6-14% of variance in neuropsychiatric scales. CONCLUSION Accumulation of p-tau aggregates, especially in the frontal cortex, are associated with cognitive, functional, and certain neurobehavioral symptoms in CTE.
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Affiliation(s)
- Michael L Alosco
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Micaela White
- Davis School of Medicine, University of California, Sacramento, CA, USA
| | - Carter Bell
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Farwa Faheem
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Eukyung Yhang
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Zachary Baucom
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Brett Martin
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Joseph Palmisano
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John F Crary
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lee E Goldstein
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Departments of Biomedical, Electrical & Computer Engineering, Boston University College of Engineering, Boston, MA, USA
| | - Douglas I Katz
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Brigid Dwyer
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Daniel H Daneshvar
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Christopher Nowinski
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Concussion Legacy Foundation, Boston, MA, USA
| | - Robert C Cantu
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Concussion Legacy Foundation, Boston, MA, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Emerson Hospital, Concord, MA, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Anatomy and Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Victor E Alvarez
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- System, U.S. Department of Veteran Affairs, VA Boston Healthcare, Boston, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Bertrand Russell Huber
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- System, U.S. Department of Veteran Affairs, VA Boston Healthcare, 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 Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- System, U.S. Department of Veteran Affairs, VA Boston Healthcare, Boston, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- System, U.S. Department of Veteran Affairs, VA Boston Healthcare, Boston, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Center and CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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6
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Saltiel N, Tripodis Y, Menzin T, Olaniyan A, Baucom Z, Yhang E, Palmisano JN, Martin B, Uretsky M, Nair E, Abdolmohammadi B, Shah A, Nicks R, Nowinski C, Cantu RC, Daneshvar DH, Dwyer B, Katz DI, Stern RA, Alvarez V, Huber B, Boyle PA, Schneider JA, Mez J, McKee A, Alosco ML, Stein TD. Relative Contributions of Mixed Pathologies to Cognitive and Functional Symptoms in Brain Donors Exposed to Repetitive Head Impacts. Ann Neurol 2024; 95:314-324. [PMID: 37921042 PMCID: PMC10842014 DOI: 10.1002/ana.26823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 10/12/2023] [Accepted: 10/19/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE Exposure to repetitive head impacts (RHI) is associated with later-life cognitive symptoms and neuropathologies, including chronic traumatic encephalopathy (CTE). Cognitive decline in community cohorts is often due to multiple pathologies; however, the frequency and contributions of these pathologies to cognitive impairment in people exposed to RHI are unknown. Here, we examined the relative contributions of 13 neuropathologies to cognitive symptoms and dementia in RHI-exposed brain donors. METHODS Neuropathologists examined brain tissue from 571 RHI-exposed donors and assessed for the presence of 13 neuropathologies, including CTE, Alzheimer disease (AD), Lewy body disease (LBD), and transactive response DNA-binding protein 43 (TDP-43) inclusions. Cognitive status was assessed by presence of dementia, Functional Activities Questionnaire, and Cognitive Difficulties Scale. Spearman rho was calculated to assess intercorrelation of pathologies. Additionally, frequencies of pathological co-occurrence were compared to a simulated distribution assuming no intercorrelation. Logistic and linear regressions tested associations between neuropathologies and dementia status and cognitive scale scores. RESULTS The sample age range was 18-97 years (median = 65.0, interquartile range = 46.0-76.0). Of the donors, 77.2% had at least one moderate-severe neurodegenerative or cerebrovascular pathology. Stage III-IV CTE was the most common neurodegenerative disease (43.1%), followed by TDP-43 pathology, AD, and hippocampal sclerosis. Neuropathologies were intercorrelated, and there were fewer unique combinations than expected if pathologies were independent (p < 0.001). The greatest contributors to dementia were AD, neocortical LBD, hippocampal sclerosis, cerebral amyloid angiopathy, and CTE. INTERPRETATION In this sample of RHI-exposed brain donors with wide-ranging ages, multiple neuropathologies were common and correlated. Mixed neuropathologies, including CTE, underlie cognitive impairment in contact sport athletes. ANN NEUROL 2024;95:314-324.
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Affiliation(s)
- Nicole Saltiel
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
- VA Bedford Healthcare System, U.S. Department of Veteran Affairs, Bedford, MA
| | - Yorghos Tripodis
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Talia Menzin
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Aliyah Olaniyan
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Zach Baucom
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Eukyung Yhang
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Joseph N. Palmisano
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Brett Martin
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Madeline Uretsky
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
| | - Evan Nair
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
| | - Bobak Abdolmohammadi
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
| | - Arsal Shah
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
- VA Bedford Healthcare System, U.S. Department of Veteran Affairs, Bedford, MA
| | - Raymond Nicks
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
- VA Bedford Healthcare System, U.S. Department of Veteran Affairs, Bedford, MA
| | | | - Robert C. Cantu
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- Concussion Legacy Foundation, Boston, MA, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Emerson Hospital, Concord, MA, USA
| | - Daniel H. Daneshvar
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
| | - Brigid Dwyer
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Douglas I. Katz
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Robert A. Stern
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Anatomy and Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Victor Alvarez
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
- VA Bedford Healthcare System, U.S. Department of Veteran Affairs, Bedford, MA
- National Center for PTSD, VA Boston Healthcare System, Jamaica Plain, MA, USA
| | - Bertrand Huber
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
- National Center for PTSD, VA Boston Healthcare System, Jamaica Plain, MA, USA
| | - Patricia A. Boyle
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, USA
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Julie A. Schneider
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
- Department of Pathology, Rush University Medical Center, Chicago, IL, USA
| | - Jesse Mez
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Ann McKee
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
- VA Bedford Healthcare System, U.S. Department of Veteran Affairs, Bedford, MA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Michael L. Alosco
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
| | - Thor D. Stein
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
- VA Bedford Healthcare System, U.S. Department of Veteran Affairs, Bedford, MA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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7
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Ly MT, Tuz-Zahra F, Tripodis Y, Adler CH, Balcer LJ, Bernick C, Zetterberg H, Blennow K, Peskind ER, Au R, Banks SJ, Barr WB, Wethe JV, Bondi MW, Delano-Wood LM, Cantu RC, Coleman MJ, Dodick DW, McClean MD, Mez JB, Palmisano J, Martin B, Hartlage K, Lin AP, Koerte IK, Cummings JL, Reiman EM, Shenton ME, Stern RA, Bouix S, Alosco ML. Association of Vascular Risk Factors and CSF and Imaging Biomarkers With White Matter Hyperintensities in Former American Football Players. Neurology 2024; 102:e208030. [PMID: 38165330 PMCID: PMC10870736 DOI: 10.1212/wnl.0000000000208030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/13/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Recent data link exposure to repetitive head impacts (RHIs) from American football with increased white matter hyperintensity (WMH) burden. WMH might have unique characteristics in the context of RHI beyond vascular risk and normal aging processes. We evaluated biological correlates of WMH in former American football players, including markers of amyloid, tau, inflammation, axonal injury, neurodegeneration, and vascular health. METHODS Participants underwent clinical interviews, MRI, and lumbar puncture as part of the Diagnostics, Imaging, and Genetics Network for the Objective Study and Evaluation of Chronic Traumatic Encephalopathy Research Project. Structural equation modeling tested direct and indirect effects between log-transformed total fluid-attenuated inversion recovery (FLAIR) lesion volumes (TLV) and the revised Framingham stroke risk profile (rFSRP), MRI-derived global metrics of cortical thickness and fractional anisotropy (FA), and CSF levels of amyloid β1-42, p-tau181, soluble triggering receptor expressed on myeloid cells 2 (sTREM2), and neurofilament light. Covariates included age, race, education, body mass index, APOE ε4 carrier status, and evaluation site. Models were performed separately for former football players and a control group of asymptomatic men unexposed to RHI. RESULTS In 180 former football players (mean age = 57.2, 36% Black), higher log(TLV) had direct associations with the following: higher rFSRP score (B = 0.26, 95% CI 0.07-0.40), higher p-tau181 (B = 0.17, 95% CI 0.01-0.43), lower FA (B = -0.28, 95% CI -0.42 to -0.13), and reduced cortical thickness (B = -0.25, 95% CI -0.45 to -0.08). In 60 asymptomatic unexposed men (mean age = 59.3, 40% Black), there were no direct effects on log(TLV) (rFSRP: B = -0.03, 95% CI -0.48 to 0.57; p-tau181: B = -0.30, 95% CI -1.14 to 0.37; FA: B = -0.07, 95% CI -0.48 to 0.42; or cortical thickness: B = -0.28, 95% CI -0.64 to 0.10). The former football players showed stronger associations between log(TLV) and rFSRP (1,069% difference in estimates), p-tau181 (158%), and FA (287%) than the unexposed men. DISCUSSION Risk factors and biological correlates of WMH differed between former American football players and asymptomatic unexposed men. In addition to vascular health, p-tau181 and diffusion tensor imaging indices of white matter integrity showed stronger associations with WMH in the former football players. FLAIR WMH may have specific risk factors and pathologic underpinnings in RHI-exposed individuals.
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Affiliation(s)
- Monica T Ly
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Fatima Tuz-Zahra
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Yorghos Tripodis
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Charles H Adler
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Laura J Balcer
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Charles Bernick
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Henrik Zetterberg
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Kaj Blennow
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Elaine R Peskind
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Rhoda Au
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Sarah J Banks
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - William B Barr
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Jennifer V Wethe
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Mark W Bondi
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Lisa M Delano-Wood
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Robert C Cantu
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Michael J Coleman
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - David W Dodick
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Michael D McClean
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Jesse B Mez
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Joseph Palmisano
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Brett Martin
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Kaitlin Hartlage
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Alexander P Lin
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Inga K Koerte
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Jeffrey L Cummings
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Eric M Reiman
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Martha E Shenton
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Robert A Stern
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Sylvain Bouix
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Michael L Alosco
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
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McKee AC, Mez J, Abdolmohammadi B, Butler M, Huber BR, Uretsky M, Babcock K, Cherry JD, Alvarez VE, Martin B, Tripodis Y, Palmisano JN, Cormier KA, Kubilus CA, Nicks R, Kirsch D, Mahar I, McHale L, Nowinski C, Cantu RC, Stern RA, Daneshvar D, Goldstein LE, Katz DI, Kowall NW, Dwyer B, Stein TD, Alosco ML. Neuropathologic and Clinical Findings in Young Contact Sport Athletes Exposed to Repetitive Head Impacts. JAMA Neurol 2023; 80:1037-1050. [PMID: 37639244 PMCID: PMC10463175 DOI: 10.1001/jamaneurol.2023.2907] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/06/2023] [Indexed: 08/29/2023]
Abstract
Importance Young contact sport athletes may be at risk for long-term neuropathologic disorders, including chronic traumatic encephalopathy (CTE). Objective To characterize the neuropathologic and clinical symptoms of young brain donors who were contact sport athletes. Design, Setting, and Participants This case series analyzes findings from 152 of 156 brain donors younger than 30 years identified through the Understanding Neurologic Injury and Traumatic Encephalopathy (UNITE) Brain Bank who donated their brains from February 1, 2008, to September 31, 2022. Neuropathologic evaluations, retrospective telephone clinical assessments, and online questionnaires with informants were performed blinded. Data analysis was conducted between August 2021 and June 2023. Exposures Repetitive head impacts from contact sports. Main Outcomes and Measures Gross and microscopic neuropathologic assessment, including diagnosis of CTE, based on defined diagnostic criteria; and informant-reported athletic history and informant-completed scales that assess cognitive symptoms, mood disturbances, and neurobehavioral dysregulation. Results Among the 152 deceased contact sports participants (mean [SD] age, 22.97 [4.31] years; 141 [92.8%] male) included in the study, CTE was diagnosed in 63 (41.4%; median [IQR] age, 26 [24-27] years). Of the 63 brain donors diagnosed with CTE, 60 (95.2%) were diagnosed with mild CTE (stages I or II). Brain donors who had CTE were more likely to be older (mean difference, 3.92 years; 95% CI, 2.74-5.10 years) Of the 63 athletes with CTE, 45 (71.4%) were men who played amateur sports, including American football, ice hockey, soccer, rugby, and wrestling; 1 woman with CTE played collegiate soccer. For those who played football, duration of playing career was significantly longer in those with vs without CTE (mean difference, 2.81 years; 95% CI, 1.15-4.48 years). Athletes with CTE had more ventricular dilatation, cavum septum pellucidum, thalamic notching, and perivascular pigment-laden macrophages in the frontal white matter than those without CTE. Cognitive and neurobehavioral symptoms were frequent among all brain donors. Suicide was the most common cause of death, followed by unintentional overdose; there were no differences in cause of death or clinical symptoms based on CTE status. Conclusions and Relevance This case series found that young brain donors exposed to repetitive head impacts were highly symptomatic regardless of CTE status, and the causes of symptoms in this sample are likely multifactorial. Future studies that include young brain donors unexposed to repetitive head impacts are needed to clarify the association among exposure, white matter and microvascular pathologic findings, CTE, and clinical symptoms.
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Affiliation(s)
- Ann C. McKee
- Veterans Affairs (VA) Boston Healthcare System, US Department of Veteran Affairs, Boston, Massachusetts
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- VA Bedford Healthcare System, US Department of Veteran Affairs, Bedford, Massachusetts
- National Center for PTSD, VA Boston Healthcare, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Jesse Mez
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Bobak Abdolmohammadi
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Morgane Butler
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Anatomy and Neurobiology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Bertrand Russell Huber
- Veterans Affairs (VA) Boston Healthcare System, US Department of Veteran Affairs, Boston, Massachusetts
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- VA Bedford Healthcare System, US Department of Veteran Affairs, Bedford, Massachusetts
- National Center for PTSD, VA Boston Healthcare, Boston, Massachusetts
| | - Madeline Uretsky
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Katharine Babcock
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Anatomy and Neurobiology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Jonathan D. Cherry
- Veterans Affairs (VA) Boston Healthcare System, US Department of Veteran Affairs, Boston, Massachusetts
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Victor E. Alvarez
- Veterans Affairs (VA) Boston Healthcare System, US Department of Veteran Affairs, Boston, Massachusetts
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- VA Bedford Healthcare System, US Department of Veteran Affairs, Bedford, Massachusetts
| | - Brett Martin
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Yorghos Tripodis
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Joseph N. Palmisano
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Kerry A. Cormier
- Veterans Affairs (VA) Boston Healthcare System, US Department of Veteran Affairs, Boston, Massachusetts
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- VA Bedford Healthcare System, US Department of Veteran Affairs, Bedford, Massachusetts
| | - Caroline A. Kubilus
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- VA Bedford Healthcare System, US Department of Veteran Affairs, Bedford, Massachusetts
| | - Raymond Nicks
- Veterans Affairs (VA) Boston Healthcare System, US Department of Veteran Affairs, Boston, Massachusetts
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- VA Bedford Healthcare System, US Department of Veteran Affairs, Bedford, Massachusetts
| | - Daniel Kirsch
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Ian Mahar
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Lisa McHale
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Concussion Legacy Foundation, Boston, Massachusetts
| | - Christopher Nowinski
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Concussion Legacy Foundation, Boston, Massachusetts
| | - Robert C. Cantu
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Concussion Legacy Foundation, Boston, Massachusetts
- Department of Neurosurgery, Emerson Hospital, Concord, Massachusetts
- Department of Neurosurgery, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Robert A. Stern
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Neurosurgery, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Daniel Daneshvar
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Rehabilitation Medicine, Harvard Medical School, Boston, Massachusetts
| | - Lee E. Goldstein
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Psychiatry, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Biomedical, Electrical, and Computer Engineering, Boston University College of Engineering, Boston, Massachusetts
| | - Douglas I. Katz
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Braintree Rehabilitation Hospital, Braintree, Massachusetts
| | - Neil W. Kowall
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Brigid Dwyer
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Braintree Rehabilitation Hospital, Braintree, Massachusetts
| | - Thor D. Stein
- Veterans Affairs (VA) Boston Healthcare System, US Department of Veteran Affairs, Boston, Massachusetts
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- VA Bedford Healthcare System, US Department of Veteran Affairs, Bedford, Massachusetts
| | - Michael L. Alosco
- Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
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Daneshvar DH, Nair ES, Baucom ZH, Rasch A, Abdolmohammadi B, Uretsky M, Saltiel N, Shah A, Jarnagin J, Baugh CM, Martin BM, Palmisano JN, Cherry JD, Alvarez VE, Huber BR, Weuve J, Nowinski CJ, Cantu RC, Zafonte RD, Dwyer B, Crary JF, Goldstein LE, Kowall NW, Katz DI, Stern RA, Tripodis Y, Stein TD, McClean MD, Alosco ML, McKee AC, Mez J. Leveraging football accelerometer data to quantify associations between repetitive head impacts and chronic traumatic encephalopathy in males. Nat Commun 2023; 14:3470. [PMID: 37340004 PMCID: PMC10281995 DOI: 10.1038/s41467-023-39183-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 05/30/2023] [Indexed: 06/22/2023] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative tauopathy associated with repetitive head impacts (RHI), but the components of RHI exposure underlying this relationship are unclear. We create a position exposure matrix (PEM), composed of American football helmet sensor data, summarized from literature review by player position and level of play. Using this PEM, we estimate measures of lifetime RHI exposure for a separate cohort of 631 football playing brain donors. Separate models examine the relationship between CTE pathology and players' concussion count, athletic positions, years of football, and PEM-derived measures, including estimated cumulative head impacts, linear accelerations, and rotational accelerations. Only duration of play and PEM-derived measures are significantly associated with CTE pathology. Models incorporating cumulative linear or rotational acceleration have better model fit and are better predictors of CTE pathology than duration of play or cumulative head impacts alone. These findings implicate cumulative head impact intensity in CTE pathogenesis.
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Affiliation(s)
- Daniel H Daneshvar
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MA, USA.
- Department of Physical Medicine and Rehabilitation, Mass General Brigham-Spaulding Rehabilitation, Charlestown, MA, USA.
| | - Evan S Nair
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Zachary H Baucom
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Abigail Rasch
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Bobak Abdolmohammadi
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Madeline Uretsky
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Nicole Saltiel
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Arsal Shah
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Johnny Jarnagin
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Christine M Baugh
- Center for Bioethics and Humanities, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brett M Martin
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Joseph N Palmisano
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Jonathan D Cherry
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Victor E Alvarez
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Bertrand R Huber
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jennifer Weuve
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Christopher J Nowinski
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Concussion Legacy Foundation, Boston, MA, USA
| | - Robert C Cantu
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Concussion Legacy Foundation, Boston, MA, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Emerson Hospital, Concord, MA, USA
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Mass General Brigham-Spaulding Rehabilitation, Charlestown, MA, USA
- Department of Physical Medicine and Rehabilitation, Brigham and Women's Hospital, Boston, MA, USA
| | - Brigid Dwyer
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - John F Crary
- Neuropathology Brain Bank & Research Core, Department of Pathology, Nash Family Department of Neuroscience, Ronald M. Loeb Center for Alzheimer's Disease, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lee E Goldstein
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Douglas I Katz
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Anatomy & Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Thor D Stein
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Michael D McClean
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Michael L Alosco
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Research and CTE Centers, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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10
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Schneider KJ, Patricios JS, Meeuwisse W, Schneider GM, Hayden KA, Premji Z, Ahmed OH, Blauwet C, Broglio S, Cantu RC, Davis GA, Dvorak J, Echemendia RJ, Emery CA, Iverson GL, Leddy JJ, Makdissi M, McCrea M, McNamee M, Putukian M, Yeates KO, Black AM, Burma JS, Critchley M, Eliason PH, Räisänen AM, Tabor JB, Toomey C, Ronksley PE, Cassidy JD. Amsterdam 2022 process: A summary of the methodology for the Amsterdam International Consensus on Concussion in Sport. Br J Sports Med 2023; 57:712-721. [PMID: 37316208 DOI: 10.1136/bjsports-2022-106663] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/16/2023]
Abstract
The purpose of this paper is to summarise the consensus methodology that was used to inform the International Consensus Statement on Concussion in Sport (Amsterdam 2022). Building on a Delphi process to inform the questions and outcomes from the 5th International Conference on Concussion in Sport, the Scientific Committee identified key questions, the answers to which would help encapsulate the current science in sport-related concussion and help guide clinical practice. Over 3½ years, delayed by 2 years due to the pandemic, author groups conducted systematic reviews on each selected topic. The 6th International Conference on Concussion in Sport was held in Amsterdam (27-30 October 2022) and consisted of 2 days of systematic review presentations, panel discussions, question and answer engagement with the 600 attendees, and abstract presentations. This was followed by a closed third day of consensus deliberations by an expert panel of 29 with observers in attendance. The fourth day, also closed, was dedicated to a workshop to discuss and refine the sports concussion tools (Concussion Recognition Tool 6 (CRT6), Sport Concussion Assessment Tool 6 (SCAT6), Child SCAT6, Sport Concussion Office Assessment Tool 6 (SCOAT6) and Child SCOAT6). We include a summary of recommendations for methodological improvements for future research that grew out of the systematic reviews.
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Affiliation(s)
- Kathryn J Schneider
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jon S Patricios
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Geoff M Schneider
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - K Alix Hayden
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Zahra Premji
- Libraries, University of Victoria, Victoria, British Columbia, Canada
| | - Osman Hassan Ahmed
- Physiotherapy Department, University Hospitals Dorset NHS Foundation Trust, Poole, UK
- The FA Centre for Para Football Research, The Football Association, Burton-Upon-Trent, UK
- School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, UK
| | - Cheri Blauwet
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation, Spaulding Hospital/Brigham and Women's Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
- Kelley Adaptive Sports Research Institute, Boston, Massachusetts, USA
| | - Steven Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert C Cantu
- Centre for the Study of Traumatic Encephalopathy, Boston University School of Medicine, Boston, Massachusetts, USA
- Neurosurgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Cabrini Health, Malvern, Victoria, Australia
| | - Jiri Dvorak
- Spine Unit, Schulthess Clinic Human Performance Lab, Zurich, Switzerland
| | - Ruben J Echemendia
- Psychology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Carolyn A Emery
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Grant L Iverson
- Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- Sports Concussion Program, MassGeneral Hospital for Children, Boston, Massachusetts, USA
| | - John J Leddy
- UBMD Orthopaedics and Sports Medicine, SUNY Buffalo, Buffalo, New York, USA
| | - Michael Makdissi
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- La Trobe Sport and Exercise Medicine Research Centre, Melbourne, Victoria, Australia
| | - Michael McCrea
- Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael McNamee
- Department of Movement Sciences, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
- Swansea University, Swansea, UK
| | - Margot Putukian
- Major League Soccer, Major League Soccer, New York, New York, USA
| | - Keith Owen Yeates
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Amanda M Black
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Joel S Burma
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Anu M Räisänen
- Department of Physical Therapy Education - Oregon, Western University of Health Sciences College of Health Sciences - Northwest, Lebanon, Oregon, USA
| | | | - Clodagh Toomey
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Paul E Ronksley
- Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - J David Cassidy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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11
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Makdissi M, Critchley ML, Cantu RC, Caron JG, Davis GA, Echemendia RJ, Fremont P, Hayden KA, Herring SA, Hinds SR, Jordan B, Kemp S, McNamee M, Maddocks D, Nagahiro S, Patricios J, Putukian M, Turner M, Sick S, Schneider KJ. When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review. Br J Sports Med 2023; 57:822-830. [PMID: 37316181 DOI: 10.1136/bjsports-2023-106815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To systematically review the scientific literature regarding factors to consider when providing advice or guidance to athletes about retirement from contact or collision sport following sport-related concussion (SRC), and to define contraindications to children/adolescent athletes entering or continuing with contact or collision sports after SRC. DATA SOURCES Medline, Embase, SPORTSDiscus, APA PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials were searched systematically. STUDY ELIGIBILITY CRITERIA Studies were included if they were (1) original research, (2) reported on SRC as the primary source of injury, (3) evaluated the history, clinical assessment and/or investigation of findings that may preclude participation in sport and (4) evaluated mood disturbance and/or neurocognitive deficits, evidence of structural brain injury or risk factors for increased risk of subsequent SRC or prolonged recovery. RESULTS Of 4355 articles identified, 93 met the inclusion criteria. None of the included articles directly examined retirement and/or discontinuation from contact or collision sport. Included studies examined factors associated with increased risk of recurrent SRC or prolonged recovery following SRC. In general, these were low-quality cohort studies with heterogeneous results and moderate risk of bias. Higher number and/or severity of symptoms at presentation, sleep disturbance and symptom reproduction with Vestibular Ocular Motor Screen testing were associated with prolonged recovery and history of previous concussion was associated with a risk of further SRC. CONCLUSION No evidence was identified to support the inclusion of any patient-specific, injury-specific or other factors (eg, imaging findings) as absolute indications for retirement or discontinued participation in contact or collision sport following SRC. PROSPERO REGISTRATION NUMBER CRD42022155121.
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Affiliation(s)
- Michael Makdissi
- Australian Football League, Melbourne, Victoria, Australia
- Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
| | - Meghan L Critchley
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Robert C Cantu
- Neurosurgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jeffrey G Caron
- School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, Québec, Canada
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Cabrini Health, Malvern, Victoria, Australia
| | - Ruben J Echemendia
- Psychology, University of Missouri-Kansas City, Kansas City, MO, USA
- Orthopedics Center Concussion Care Clinic, State College, Pennsylvania, Pennsylvania, USA
| | - Pierre Fremont
- Rehabilitation, Laval University, Quebec, Quebec, Canada
| | - K Alix Hayden
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Stanley A Herring
- Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | - Barry Jordan
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Simon Kemp
- Sports Medicine, Rugby Football Union, London, UK
- London School of Hygiene & Tropical Medicine, London, UK
| | - Michael McNamee
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
- School of Sport and Exercise Sciences, Swansea University, Swansea, UK
| | - David Maddocks
- Perry Maddocks Trollope Lawyers, Melbourne, Victoria, Australia
| | - Shinji Nagahiro
- Department of Neurosurgery, Yoshinogawa Hospital, Tokushima, Japan
| | - Jon Patricios
- Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Margot Putukian
- Major League Soccer, Princeton University, Princeton, New Jersey, USA
| | - Michael Turner
- International Concussion and Head Injury Research Foundation, London, UK
- University College London, London, UK
| | - Stacy Sick
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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12
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Iverson GL, Castellani RJ, Cassidy JD, Schneider GM, Schneider KJ, Echemendia RJ, Bailes JE, Hayden KA, Koerte IK, Manley GT, McNamee M, Patricios JS, Tator CH, Cantu RC, Dvorak J. Examining later-in-life health risks associated with sport-related concussion and repetitive head impacts: a systematic review of case-control and cohort studies. Br J Sports Med 2023; 57:810-821. [PMID: 37316187 DOI: 10.1136/bjsports-2023-106890] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Concern exists about possible problems with later-in-life brain health, such as cognitive impairment, mental health problems and neurological diseases, in former athletes. We examined the future risk for adverse health effects associated with sport-related concussion, or exposure to repetitive head impacts, in former athletes. DESIGN Systematic review. DATA SOURCES Search of MEDLINE, Embase, Cochrane, CINAHL Plus and SPORTDiscus in October 2019 and updated in March 2022. ELIGIBILITY CRITERIA Studies measuring future risk (cohort studies) or approximating that risk (case-control studies). RESULTS Ten studies of former amateur athletes and 18 studies of former professional athletes were included. No postmortem neuropathology studies or neuroimaging studies met criteria for inclusion. Depression was examined in five studies in former amateur athletes, none identifying an increased risk. Nine studies examined suicidality or suicide as a manner of death, and none found an association with increased risk. Some studies comparing professional athletes with the general population reported associations between sports participation and dementia or amyotrophic lateral sclerosis (ALS) as a cause of death. Most did not control for potential confounding factors (eg, genetic, demographic, health-related or environmental), were ecological in design and had high risk of bias. CONCLUSION Evidence does not support an increased risk of mental health or neurological diseases in former amateur athletes with exposure to repetitive head impacts. Some studies in former professional athletes suggest an increased risk of neurological disorders such as ALS and dementia; these findings need to be confirmed in higher quality studies with better control of confounding factors. PROSPERO REGISTRATION NUMBER CRD42022159486.
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Affiliation(s)
- Grant L Iverson
- Sports Concussion Program, MassGeneral Hospital for Children, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, Massachusetts, USA
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Rudolph J Castellani
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - J David Cassidy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Geoff M Schneider
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Ruben J Echemendia
- Department of Psychology, University of Missouri-Kansas City, Kansas City, Missouri, USA
- University Orthopedic Centre, Concussion Care Clinic, State College, Pennsylvania, USA
| | - Julian E Bailes
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - K Alix Hayden
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Inga K Koerte
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatic, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Mass General Brigham, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Michael McNamee
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
- School of Sport and Exercise Sciences, Swansea University, Swansea, UK
| | - Jon S Patricios
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles H Tator
- Department of Surgery and Division of Neurosurgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Canadian Concussion Centre, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Robert C Cantu
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
- Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Jiri Dvorak
- Schulthess Clinic Zurich, Zurich, Switzerland
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13
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Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, Davis GA, Echemendia RJ, Makdissi M, McNamee M, Broglio S, Emery CA, Feddermann-Demont N, Fuller GW, Giza CC, Guskiewicz KM, Hainline B, Iverson GL, Kutcher JS, Leddy JJ, Maddocks D, Manley G, McCrea M, Purcell LK, Putukian M, Sato H, Tuominen MP, Turner M, Yeates KO, Herring SA, Meeuwisse W. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Br J Sports Med 2023; 57:695-711. [PMID: 37316210 DOI: 10.1136/bjsports-2023-106898] [Citation(s) in RCA: 96] [Impact Index Per Article: 96.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 06/16/2023]
Abstract
For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27-30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete's perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.
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Affiliation(s)
- Jon S Patricios
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Jiri Dvorak
- Spine Unit, Schulthess Clinic Human Performance Lab, Zurich, Switzerland
| | - Osman Hassan Ahmed
- Physiotherapy Department, University Hospitals Dorset NHS Foundation Trust, Poole, UK
- The FA Centre for Para Football Research, The Football Association, Burton-Upon-Trent, Staffordshire, UK
| | - Cheri Blauwet
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation/Harvard Medical School, Boston, Massachusetts, USA
- Kelley Adaptive Sports Research Institute, Spaulding Rehabilitation, Boston, Massachusetts, USA
| | - Robert C Cantu
- CTE Center, Boston University School of Medicine, Boston, Massachusetts, USA
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Cabrini Health, Malvern, Victoria, Australia
| | - Ruben J Echemendia
- Psychology, University of Missouri Kansas City, Kansas City, Missouri, USA
- Psychological and Neurobehavioral Associates, Inc, Miami, Florida, USA
| | - Michael Makdissi
- Florey Institute of Neuroscience and Mental Health-Austin Campus, Heidelberg, Victoria, Australia
- La Trobe Sport and Exercise Medicine Research Centre, Melbourne, Victoria, Australia
| | - Michael McNamee
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
- School of Sport and Exercise Medicine, Swansea University, Swansea, UK
| | - Steven Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Carolyn A Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Nina Feddermann-Demont
- University Hospital Zurich, Zurich, Switzerland
- Sports Neuroscience, University of Zurich, Zurich, Switzerland
| | - Gordon Ward Fuller
- School of Health and Related Research, University of Sheffield, Sheffield, South Yorkshire, UK
| | - Christopher C Giza
- Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, California, USA
- Pediatrics/Pediatric Neurology, Mattel Children's Hospital UCLA, Los Angeles, California, USA
| | - Kevin M Guskiewicz
- Matthew Gfeller Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brian Hainline
- National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA
| | - Grant L Iverson
- Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- Sports Concussion Program, MassGeneral Hospital for Children, Boston, Massachusetts, USA
| | | | - John J Leddy
- UBMD Orthopaedics and Sports Medicne, SUNY Buffalo, Buffalo, New York, USA
| | - David Maddocks
- Melbourne Neuropsychology Services & Perry Maddocks Trollope Lawyers, Melbourne, Victoria, Australia
| | - Geoff Manley
- Neurosurgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael McCrea
- Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Laura K Purcell
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | | | - Haruhiko Sato
- Neurosurgery, Seirei Mikatahara Hospital, Hamamatsu, Japan
| | | | - Michael Turner
- International Concussion and Head Injury Research Foundation, London, UK
- University College London, London, UK
| | | | - Stanley A Herring
- Department of Rehabilitation Medicine, Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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14
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Alosco ML, Tripodis Y, Baucom ZH, Adler CH, Balcer LJ, Bernick C, Mariani ML, Au R, Banks SJ, Barr WB, Wethe JV, Cantu RC, Coleman MJ, Dodick DW, McClean MD, McKee AC, Mez J, Palmisano JN, Martin B, Hartlage K, Lin AP, Koerte IK, Cummings JL, Reiman EM, Stern RA, Shenton ME, Bouix S. White matter hyperintensities in former American football players. Alzheimers Dement 2023; 19:1260-1273. [PMID: 35996231 PMCID: PMC10351916 DOI: 10.1002/alz.12779] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 06/24/2022] [Accepted: 07/27/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION The presentation, risk factors, and etiologies of white matter hyperintensities (WMH) in people exposed to repetitive head impacts are unknown. We examined the burden and distribution of WMH, and their association with years of play, age of first exposure, and clinical function in former American football players. METHODS A total of 149 former football players and 53 asymptomatic unexposed participants (all men, 45-74 years) completed fluid-attenuated inversion recovery magnetic resonance imaging, neuropsychological testing, and self-report neuropsychiatric measures. Lesion Segmentation Toolbox estimated WMH. Analyses were performed in the total sample and stratified by age 60. RESULTS In older but not younger participants, former football players had greater total, frontal, temporal, and parietal log-WMH compared to asymptomatic unexposed men. In older but not younger former football players, greater log-WMH was associated with younger age of first exposure to football and worse executive function. DISCUSSION In older former football players, WMH may have unique presentations, risk factors, and etiologies. HIGHLIGHTS Older but not younger former football players had greater total, frontal, temporal, and parietal lobe white matter hyperintensities (WMH) compared to same-age asymptomatic unexposed men. Younger age of first exposure to football was associated with greater WMH in older but not younger former American football players. In former football players, greater WMH was associated with worse executive function and verbal memory.
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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
| | - Yorghos Tripodis
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Boston University School of Medicine, Boston, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Zachary H. Baucom
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Charles H. Adler
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ
| | - Laura J. Balcer
- Departments of Neurology, Population Health and Ophthalmology, NYU Grossman School of Medicine, New York, NY
| | - Charles Bernick
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV
- Department of Neurology, University of Washington, Seattle, WA
| | - Megan L. Mariani
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Boston University School of Medicine, Boston, MA
| | - Rhoda Au
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
- Framingham Heart Study, Framingham, MA
- Slone Epidemiology Center, Boston University, Boston, MA
- Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Sarah J. Banks
- Departments of Neuroscience and Psychiatry, University of California, San Diego, CA
| | - William B. Barr
- Department of Neurology, NYU Grossman School of Medicine, New York, NY
| | - Jennifer V. Wethe
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ
| | - Robert C. Cantu
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Michael J. Coleman
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA
| | - David W. Dodick
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ
| | - Michael D. McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | - Ann C. McKee
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
- VA Boston Healthcare System, Boston, MA
| | - Jesse Mez
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
- Framingham Heart Study, Framingham, MA
| | - Joseph N. Palmisano
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA
| | - Brett Martin
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA
| | - Kaitlin Hartlage
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA
| | - Alexander P. Lin
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Inga K. Koerte
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany
| | - 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
| | - Eric M. Reiman
- Banner Alzheimer’s Institute, University of Arizona, Arizona State University, Translational Genomics Research Institute, and Arizona Alzheimer’s Consortium, Phoenix, AZ
| | - Robert A. Stern
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
- Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA
| | - Martha E. Shenton
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Sylvain Bouix
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA
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15
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Alosco ML, Ly M, Mosaheb S, Saltiel N, Uretsky M, Tripodis Y, Martin B, Palmisano J, Delano-Wood L, Bondi MW, Meng G, Xia W, Daley S, Goldstein LE, Katz DI, Dwyer B, Daneshvar DH, Nowinski C, Cantu RC, Kowall NW, Stern RA, Alvarez VE, Mez J, Huber BR, McKee AC, Stein TD. Decreased myelin proteins in brain donors exposed to football-related repetitive head impacts. Brain Commun 2023; 5:fcad019. [PMID: 36895961 PMCID: PMC9990992 DOI: 10.1093/braincomms/fcad019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/02/2022] [Accepted: 01/30/2023] [Indexed: 03/09/2023] Open
Abstract
American football players and other individuals exposed to repetitive head impacts can exhibit a constellation of later-life cognitive and neuropsychiatric symptoms. While tau-based diseases such as chronic traumatic encephalopathy can underpin certain symptoms, contributions from non-tau pathologies from repetitive head impacts are increasingly recognized. We examined cross-sectional associations between myelin integrity using immunoassays for myelin-associated glycoprotein and proteolipid protein 1 with risk factors and clinical outcomes in brain donors exposed to repetitive head impacts from American football. Immunoassays for myelin-associated glycoprotein and proteolipid protein 1 were conducted on dorsolateral frontal white matter tissue samples of 205 male brain donors. Proxies of exposure to repetitive head impacts included years of exposure and age of first exposure to American football play. Informants completed the Functional Activities Questionnaire, Behavior Rating Inventory of Executive Function-Adult Version (Behavioral Regulation Index), and Barratt Impulsiveness Scale-11. Associations between myelin-associated glycoprotein and proteolipid protein 1 with exposure proxies and clinical scales were tested. Of the 205 male brain donors who played amateur and professional football, the mean age was 67.17 (SD = 16.78), and 75.9% (n = 126) were reported by informants to be functionally impaired prior to death. Myelin-associated glycoprotein and proteolipid protein 1 correlated with the ischaemic injury scale score, a global indicator of cerebrovascular disease (r = -0.23 and -0.20, respectively, Ps < 0.01). Chronic traumatic encephalopathy was the most common neurodegenerative disease (n = 151, 73.7%). Myelin-associated glycoprotein and proteolipid protein 1 were not associated with chronic traumatic encephalopathy status, but lower proteolipid protein 1 was associated with more severe chronic traumatic encephalopathy (P = 0.03). Myelin-associated glycoprotein and proteolipid protein 1 were not associated with other neurodegenerative disease pathologies. More years of football play was associated with lower proteolipid protein 1 [beta = -2.45, 95% confidence interval (CI) [-4.52, -0.38]] and compared with those who played <11 years of football (n = 78), those who played 11 or more years (n = 128) had lower myelin-associated glycoprotein (mean difference = 46.00, 95% CI [5.32, 86.69]) and proteolipid protein 1 (mean difference = 24.72, 95% CI [2.40, 47.05]). Younger age of first exposure corresponded to lower proteolipid protein 1 (beta = 4.35, 95% CI [0.25, 8.45]). Among brain donors who were aged 50 or older (n = 144), lower proteolipid protein 1 (beta = -0.02, 95% CI [-0.047, -0.001]) and myelin-associated glycoprotein (beta = -0.01, 95% CI [-0.03, -0.002]) were associated with higher Functional Activities Questionnaire scores. Lower myelin-associated glycoprotein correlated with higher Barratt Impulsiveness Scale-11 scores (beta = -0.02, 95% CI [-0.04, -0.0003]). Results suggest that decreased myelin may represent a late effect of repetitive head impacts that contributes to the manifestation of cognitive symptoms and impulsivity. Clinical-pathological correlation studies with prospective objective clinical assessments are needed to confirm our findings.
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Affiliation(s)
- Michael L Alosco
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Monica Ly
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego Health, La Jolla, CA, USA
| | - Sydney Mosaheb
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Nicole Saltiel
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Madeline Uretsky
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Brett Martin
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Joseph Palmisano
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Lisa Delano-Wood
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego Health, La Jolla, CA, USA
| | - Mark W Bondi
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego Health, La Jolla, CA, USA
| | | | - Weiming Xia
- VA Bedford Healthcare System, Bedford, MA, USA
- Department of Pharmacology and Experimental Therapeutics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sarah Daley
- VA Bedford Healthcare System, Bedford, MA, USA
- Department of Pharmacology and Experimental Therapeutics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Lee E Goldstein
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Departments of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Departments of Biomedical, Electrical & Computer Engineering, Boston University College of Engineering, Boston, MA, USA
| | - Douglas I Katz
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Brigid Dwyer
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Daniel H Daneshvar
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | - Robert C Cantu
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Concussion Legacy Foundation, Boston, MA, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Emerson Hospital, Concord, MA, USA
| | - Neil W Kowall
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Departments of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, USA
| | - Victor E Alvarez
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Bedford Healthcare System, Bedford, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, Boston, MA, USA
- National Center for PTSD, VA Boston Healthcare, Jamaica Plain, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Bertrand Russell Huber
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, Boston, MA, USA
- National Center for PTSD, VA Boston Healthcare, Jamaica Plain, Boston, MA, USA
| | - Ann C McKee
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Bedford Healthcare System, Bedford, MA, USA
- Departments of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, Boston, MA, USA
- National Center for PTSD, VA Boston Healthcare, Jamaica Plain, Boston, MA, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Thor D Stein
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Bedford Healthcare System, Bedford, MA, USA
- Departments of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, Boston, MA, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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16
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Alosco ML, Barr WB, Banks SJ, Wethe JV, Miller JB, Pulukuri SV, Culhane J, Tripodis Y, Adler CH, Balcer LJ, Bernick C, Mariani ML, Cantu RC, Dodick DW, McClean MD, Au R, Mez J, Turner RW, Palmisano JN, Martin B, Hartlage K, Cummings JL, Reiman EM, Shenton ME, Stern RA, Chen K, Protas H, Boker C, Farrer L, Helm R, Katz DI, Kowall N, Mercier G, Otis J, Weller J, Simkin I, Andino A, Conneely S, Diamond C, Fagle T, Haller O, Hunt T, Gullotti N, Mayville B, McLaughlin K, Nanna M, Platt T, Rice F, Sestak M, Annis D, Chaisson C, Dixon DB, Finney C, Gallagher K, Lu J, Ojo E, Pine B, Ramachandran J, Bouix S, Fitzsimmons J, Lin AP, Koerte IK, Pasternak O, Arciniega H, Billah T, Bonke E, Breedlove K, Coello E, Coleman MJ, Jung L, Liao H, Loy M, Rizzoni E, Schultz V, Silva A, Vessey B, Wiegand TLT, Ritter A, Sabbagh M, de la Cruz R, Durant J, Golceker M, Harmon N, Kaylegian K, Long R, Nance C, Sandoval P, Marek KL, Serrano A, Geda Y, Falk B, Duffy A, Howard M, Montague M, Osgood T, Babcock D, Bellgowan P, Goldberg J, Wisniewski T, Kirov I, Lui Y, Marmar C, Hasanaj L, Serrano L, Al-Kharafi A, George A, Martin S, Riley E, Runge W, Peskind ER, Colasurdo E, Marcus DS, Gurney J, Greenwald R, Johnson KA. Neuropsychological test performance of former American football players. Alzheimers Res Ther 2023; 15:1. [PMID: 36597138 PMCID: PMC9808953 DOI: 10.1186/s13195-022-01147-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/16/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patterns of cognitive impairment in former American football players are uncertain because objective neuropsychological data are lacking. This study characterized the neuropsychological test performance of former college and professional football players. METHODS One hundred seventy male former football players (n=111 professional, n=59 college; 45-74 years) completed a neuropsychological test battery. Raw scores were converted to T-scores using age, sex, and education-adjusted normative data. A T-score ≤ 35 defined impairment. A domain was impaired if 2+ scores fell in the impaired range except for the language and visuospatial domains due to the limited number of tests. RESULTS Most football players had subjective cognitive concerns. On testing, rates of impairments were greatest for memory (21.2% two tests impaired), especially for recall of unstructured (44.7%) versus structured verbal stimuli (18.8%); 51.8% had one test impaired. 7.1% evidenced impaired executive functions; however, 20.6% had impaired Trail Making Test B. 12.1% evidenced impairments in the attention, visual scanning, and psychomotor speed domain with frequent impairments on Trail Making Test A (18.8%). Other common impairments were on measures of language (i.e., Multilingual Naming Test [21.2%], Animal Fluency [17.1%]) and working memory (Number Span Backward [14.7%]). Impairments on our tasks of visuospatial functions were infrequent. CONCLUSIONS In this sample of former football players (most of whom had subjective cognitive concerns), there were diffuse impairments on neuropsychological testing with verbal memory being the most frequently impaired domain.
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Affiliation(s)
- Michael L. Alosco
- grid.189504.10000 0004 1936 7558Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Robinson Building, Suite B7800, Boston, MA 02118 USA
| | - William B. Barr
- grid.137628.90000 0004 1936 8753Department of Neurology, NYU Grossman School of Medicine, New York, NY USA
| | - Sarah J. Banks
- grid.266100.30000 0001 2107 4242Department of Neuroscience, University of California, San Diego, CA USA ,grid.266100.30000 0001 2107 4242Department of Psychiatry, University of California, San Diego, CA USA
| | - Jennifer V. Wethe
- grid.417468.80000 0000 8875 6339Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ USA
| | - Justin B. Miller
- grid.239578.20000 0001 0675 4725Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV USA
| | - Surya Vamsi Pulukuri
- grid.189504.10000 0004 1936 7558Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Robinson Building, Suite B7800, Boston, MA 02118 USA
| | - Julia Culhane
- grid.189504.10000 0004 1936 7558Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Robinson Building, Suite B7800, Boston, MA 02118 USA
| | - Yorghos Tripodis
- grid.189504.10000 0004 1936 7558Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA USA ,grid.189504.10000 0004 1936 7558Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Charles H. Adler
- grid.417468.80000 0000 8875 6339Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ USA
| | - Laura J. Balcer
- grid.137628.90000 0004 1936 8753Department of Neurology, NYU Grossman School of Medicine, New York, NY USA ,grid.137628.90000 0004 1936 8753Department of Population Health, NYU Grossman School of Medicine, New York, NY USA ,grid.137628.90000 0004 1936 8753Department of Ophthalmology, NYU Grossman School of Medicine, New York, NY USA
| | - Charles Bernick
- grid.239578.20000 0001 0675 4725Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV USA ,grid.34477.330000000122986657Department of Neurology, University of Washington, Seattle, WA USA
| | - Megan L. Mariani
- grid.189504.10000 0004 1936 7558Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Robinson Building, Suite B7800, Boston, MA 02118 USA
| | - Robert C. Cantu
- grid.189504.10000 0004 1936 7558Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Robinson Building, Suite B7800, Boston, MA 02118 USA
| | - David W. Dodick
- grid.417468.80000 0000 8875 6339Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ USA
| | - Michael D. McClean
- grid.189504.10000 0004 1936 7558Department of Environmental Health, Boston University School of Public Health, Boston, MA USA
| | - Rhoda Au
- grid.189504.10000 0004 1936 7558Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Robinson Building, Suite B7800, Boston, MA 02118 USA ,grid.510954.c0000 0004 0444 3861Framingham Heart Study, Framingham, MA USA ,grid.189504.10000 0004 1936 7558Slone Epidemiology Center, Boston University, Boston, MA USA ,grid.189504.10000 0004 1936 7558Department of Anatomy & Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA USA ,grid.189504.10000 0004 1936 7558Department of Epidemiology, Boston University School of Public Health, Boston, MA USA
| | - Jesse Mez
- grid.189504.10000 0004 1936 7558Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Robinson Building, Suite B7800, Boston, MA 02118 USA ,grid.510954.c0000 0004 0444 3861Framingham Heart Study, Framingham, MA USA
| | - Robert W. Turner
- grid.253615.60000 0004 1936 9510Department of Clinical Research & Leadership, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Joseph N. Palmisano
- grid.189504.10000 0004 1936 7558Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA USA
| | - Brett Martin
- grid.189504.10000 0004 1936 7558Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA USA
| | - Kaitlin Hartlage
- grid.189504.10000 0004 1936 7558Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA USA
| | - Jeffrey L. Cummings
- grid.272362.00000 0001 0806 6926Chambers-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
- grid.62560.370000 0004 0378 8294Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Department of Radiology, Brigham and Women’s Hospital, Boston, MA USA ,grid.410370.10000 0004 4657 1992VA Boston Healthcare System, Boston, MA USA
| | - Robert A. Stern
- grid.189504.10000 0004 1936 7558Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Robinson Building, Suite B7800, Boston, MA 02118 USA ,grid.189504.10000 0004 1936 7558Department of Anatomy & Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA USA ,grid.189504.10000 0004 1936 7558Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA USA
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Wu YN, Stanwicks A, Pang P, Cantu RC, Kim Y, Gu Y. Acute Effects Of Interval Training With Body Cooling And Limb Compression In Healthy Young Adults. Med Sci Sports Exerc 2022. [DOI: 10.1249/01.mss.0000878428.72737.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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18
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Nowinski CJ, Bureau SC, Buckland ME, Curtis MA, Daneshvar DH, Faull RLM, Grinberg LT, Hill-Yardin EL, Murray HC, Pearce AJ, Suter CM, White AJ, Finkel AM, Cantu RC. Applying the Bradford Hill Criteria for Causation to Repetitive Head Impacts and Chronic Traumatic Encephalopathy. Front Neurol 2022; 13:938163. [PMID: 35937061 PMCID: PMC9355594 DOI: 10.3389/fneur.2022.938163] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/22/2022] [Indexed: 02/05/2023] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with a history of repetitive head impacts (RHI). CTE was described in boxers as early as the 1920s and by the 1950s it was widely accepted that hits to the head caused some boxers to become "punch drunk." However, the recent discovery of CTE in American and Australian-rules football, soccer, rugby, ice hockey, and other sports has resulted in renewed debate on whether the relationship between RHI and CTE is causal. Identifying the strength of the evidential relationship between CTE and RHI has implications for public health and medico-legal issues. From a public health perspective, environmentally caused diseases can be mitigated or prevented. Medico-legally, millions of children are exposed to RHI through sports participation; this demographic is too young to legally consent to any potential long-term risks associated with this exposure. To better understand the strength of evidence underlying the possible causal relationship between RHI and CTE, we examined the medical literature through the Bradford Hill criteria for causation. The Bradford Hill criteria, first proposed in 1965 by Sir Austin Bradford Hill, provide a framework to determine if one can justifiably move from an observed association to a verdict of causation. The Bradford Hill criteria include nine viewpoints by which to evaluate human epidemiologic evidence to determine if causation can be deduced: strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experiment, and analogy. We explored the question of causation by evaluating studies on CTE as it relates to RHI exposure. Through this lens, we found convincing evidence of a causal relationship between RHI and CTE, as well as an absence of evidence-based alternative explanations. By organizing the CTE literature through this framework, we hope to advance the global conversation on CTE mitigation efforts.
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Affiliation(s)
- Christopher J. Nowinski
- Concussion Legacy Foundation, Boston, MA, United States,*Correspondence: Christopher J. Nowinski
| | | | - Michael E. Buckland
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia,School of Medical Sciences, University of Sydney, Camperdown, NSW, Australia
| | - Maurice A. Curtis
- Department of Anatomy and Medical Imaging and Centre for Brain Research, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Daniel H. Daneshvar
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MA, United States,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Richard L. M. Faull
- Department of Anatomy and Medical Imaging and Centre for Brain Research, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Lea T. Grinberg
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States,Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, United States,Department of Pathology, University of Sao Paulo Medical School, São Paulo, Brazil,Department of Pathology, University of California, San Francisco, San Francisco, CA, United States
| | - Elisa L. Hill-Yardin
- School of Health and Biomedical Sciences, STEM College, RMIT University, Bundoora, VIC, Australia,Department of Anatomy & Physiology, The University of Melbourne, Parkville, VIC, Australia
| | - Helen C. Murray
- Department of Anatomy and Medical Imaging and Centre for Brain Research, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Alan J. Pearce
- College of Science, Health, and Engineering, La Trobe University, Melbourne, VIC, Australia
| | - Catherine M. Suter
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia,School of Medical Sciences, University of Sydney, Camperdown, NSW, Australia
| | - Adam J. White
- Department of Sport, Health Science, and Social Work, Oxford Brookes University, Oxford, United Kingdom,Concussion Legacy Foundation UK, Cheltenham, United Kingdom
| | - Adam M. Finkel
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Robert C. Cantu
- Concussion Legacy Foundation, Boston, MA, United States,Department of Neurology, Boston University School of Medicine, Boston, MA, United States,Department of Neurosurgery, Emerson Hospital, Concord, MA, United States
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19
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Atherton K, Han X, Chung J, Cherry JD, Baucom Z, Saltiel N, Nair E, Abdolmohammadi B, Uretsky M, Khan MM, Shea C, Durape S, Martin BM, Palmisano JN, Farrell K, Nowinski CJ, Alvarez VE, Dwyer B, Daneshvar DH, Katz DI, Goldstein LE, Cantu RC, Kowall NW, Alosco ML, Huber BR, Tripodis Y, Crary JF, Farrer L, Stern RA, Stein TD, McKee AC, Mez J. Association of APOE Genotypes and Chronic Traumatic Encephalopathy. JAMA Neurol 2022; 79:787-796. [PMID: 35759276 PMCID: PMC9237800 DOI: 10.1001/jamaneurol.2022.1634] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Repetitive head impact (RHI) exposure is the chief risk factor for chronic traumatic encephalopathy (CTE). However, the occurrence and severity of CTE varies widely among those with similar RHI exposure. Limited evidence suggests that the APOEε4 allele may confer risk for CTE, but previous studies were small with limited scope. Objective To test the association between APOE genotype and CTE neuropathology and related endophenotypes. Design, Setting, and Participants This cross-sectional genetic association study analyzed brain donors from February 2008 to August 2019 from the Veterans Affairs-Boston University-Concussion Legacy Foundation Brain Bank. All donors had exposure to RHI from contact sports or military service. All eligible donors were included. Analysis took place between June 2020 and April 2022. Exposures One or more APOEε4 or APOEε2 alleles. Main Outcomes and Measures CTE neuropathological status, CTE stage (0-IV), semiquantitative phosphorylated tau (p-tau) burden in 11 brain regions (0-3), quantitative p-tau burden in the dorsolateral frontal lobe (log-transformed AT8+ pixel count per mm2), and dementia. Results Of 364 consecutive brain donors (100% male; 53 [14.6%] self-identified as Black and 311 [85.4%] as White; median [IQR] age, 65 [47-77] years) 20 years or older, there were 294 individuals with CTE and 70 controls. Among donors older than 65 years, APOEε4 status was significantly associated with CTE stage (odds ratio [OR], 2.34 [95% CI, 1.30-4.20]; false discovery rate [FDR]-corrected P = .01) and quantitative p-tau burden in the dorsolateral frontal lobe (β, 1.39 [95% CI, 0.83-1.94]; FDR-corrected P = 2.37 × 10-5). There was a nonsignificant association between APOEε4 status and dementia (OR, 2.64 [95% CI, 1.06-6.61]; FDR-corrected P = .08). Across 11 brain regions, significant associations were observed for semiquantitative p-tau burden in the frontal and parietal cortices, amygdala, and entorhinal cortex (OR range, 2.45-3.26). Among football players, the APOEε4 association size for CTE stage was similar to playing more than 7 years of football. Associations were significantly larger in the older half of the sample. There was no significant association for CTE status. Association sizes were similar when donors with an Alzheimer disease neuropathological diagnosis were excluded and were reduced but remained significant after adjusting for neuritic and diffuse amyloid plaques. No associations were observed for APOEε2 status. Models were adjusted for age at death and race. Conclusions and Relevance APOEε4 may confer increased risk for CTE-related neuropathological and clinical outcomes among older individuals with RHI exposure. Further work is required to validate these findings in an independent sample.
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Affiliation(s)
- Kathryn Atherton
- Boston University Bioinformatics Graduate Program, Boston, Massachusetts
| | - Xudong Han
- Boston University Bioinformatics Graduate Program, Boston, Massachusetts.,Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
| | - Jaeyoon Chung
- Department of Medicine (Biomedical Genetics), Boston University School of Medicine, Boston, Massachusetts
| | - Jonathan D Cherry
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Zachary Baucom
- Boston University Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Nicole Saltiel
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Evan Nair
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
| | - Bobak Abdolmohammadi
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
| | - Madeline Uretsky
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
| | | | - Conor Shea
- Boston University Bioinformatics Graduate Program, Boston, Massachusetts
| | - Shruti Durape
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
| | - Brett M Martin
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Biostatistics & Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Joseph N Palmisano
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Biostatistics & Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Kurt Farrell
- Department of Pathology, Fishberg Department of Neuroscience, Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christopher J Nowinski
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Concussion Legacy Foundation, Boston, Massachusetts
| | - Victor E Alvarez
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Brigid Dwyer
- Braintree Rehabilitation Hospital, Braintree, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Daniel H Daneshvar
- Department of Rehabilitation Medicine, Harvard Medical School, Boston, Massachusetts
| | - Douglas I Katz
- Braintree Rehabilitation Hospital, Braintree, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Lee E Goldstein
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Robert C Cantu
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurosurgery, Emerson Hospital, Concord, Massachusetts
| | - Neil W Kowall
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Michael L Alosco
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Bertrand R Huber
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Boston University Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - John F Crary
- Department of Pathology, Fishberg Department of Neuroscience, Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lindsay Farrer
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Department of Medicine (Biomedical Genetics), Boston University School of Medicine, Boston, Massachusetts.,Boston University Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Robert A Stern
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Thor D Stein
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Ann C McKee
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Jesse Mez
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
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20
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Turk KW, Geada A, Alvarez VE, Xia W, Cherry JD, Nicks R, Meng G, Daley S, Tripodis Y, Huber BR, Budson AE, Dwyer B, Kowall NW, Cantu RC, Goldstein LE, Katz DI, Stern RA, Alosco ML, Mez J, McKee AC, Stein TD. A comparison between tau and amyloid-β cerebrospinal fluid biomarkers in chronic traumatic encephalopathy and Alzheimer disease. Alzheimers Res Ther 2022; 14:28. [PMID: 35139894 PMCID: PMC8830027 DOI: 10.1186/s13195-022-00976-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 02/02/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) tau and beta-amyloid levels in chronic traumatic encephalopathy (CTE), a disease which can be clinically indistinguishable from Alzheimer's disease (AD), are largely unknown. We examined postmortem CSF analytes among participants with autopsy confirmed CTE and AD. METHODS In this cross-sectional study 192 participants from the Boston University AD Research Center, VA-BU-CLF Center, and Framingham Heart Study (FHS) had post-mortem CSF collected at autopsy. Participants were divided into pathological groups based on AD and CTE criteria, with 61 CTE participants (18 low, 43 high stage), 79 AD participants (23 low, 56 intermediate to high), 11 participants with CTE combined with AD, and 41 participants lacking both CTE and AD neuropathology. The Meso Scale Discovery immunoassay system was utilized to measure amyloid-beta (Aβ1-40, Aβ1-42), total tau (t-tau), and phosphorylated tau (p-tau181 and p-tau231). CSF analytes were then compared across the pathological groups: no CTE/no AD (control), Low CTE, Low AD, High CTE, Intermediate/High AD, and AD+CTE. RESULTS Among the Low disease state groups, the Low CTE group had significantly higher levels of p-tau231 versus the control group and compared to the Low AD group. The Low CTE group was also found to have significantly lower levels of Aβ1-42 compared to the control group. The high CTE group had higher levels of p-tau231 and lower levels of Aβ1-42 compared to Intermediate/High AD group. CONCLUSIONS Importantly, p-tau231 and Aβ1-42 were predictors of diagnosis of CTE vs. control and CTE vs. AD. Increased CSF p-tau231 is a promising potentially sensitive biomarker of CTE, and CSF Aβ1-42 needs further investigation in CTE.
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Affiliation(s)
- Katherine W Turk
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Alexandra Geada
- Boston University School of Medicine, Boston, MA, 02118, USA
| | - Victor E Alvarez
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
- VA Bedford Healthcare System, Bedford, MA, 01730, USA
| | - Weiming Xia
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- VA Bedford Healthcare System, Bedford, MA, 01730, USA
| | - Jonathan D Cherry
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Raymond Nicks
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- VA Bedford Healthcare System, Bedford, MA, 01730, USA
| | - Gaoyuan Meng
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- VA Bedford Healthcare System, Bedford, MA, 01730, USA
| | - Sarah Daley
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- VA Bedford Healthcare System, Bedford, MA, 01730, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, 20118, USA
| | - Bertrand R Huber
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Andrew E Budson
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Brigid Dwyer
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
- Braintree Rehabilitation Hospital, Braintree, MA, 02118, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Robert C Cantu
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, 20119, USA
- Concussion Legacy Foundation, Boston, MA, 02115, USA
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA, 02118, USA
- Department of Neurosurgery, Emerson Hospital, Concord, MA, 01742, USA
| | - Lee E Goldstein
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- Departments of Psychiatry, Ophthalmology, Boston University School of Medicine, Boston, USA
- Departments of Biomedical, Electrical & Computer Engineering, Boston University College of Engineering, Boston, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Douglas I Katz
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
- Braintree Rehabilitation Hospital, Braintree, MA, 02118, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, 20119, USA
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Michael L Alosco
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
- VA Bedford Healthcare System, Bedford, MA, 01730, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Thor D Stein
- Boston University Alzheimer's Disease Research and CTE Center, Boston University School of Medicine, Boston, MA, 02118, USA.
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA.
- VA Bedford Healthcare System, Bedford, MA, 01730, USA.
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.
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21
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Daneshvar DH, Baugh CM, Lama RD, Yutsis M, Pea RD, Goldman S, Grant GA, Cantu RC, Sanders LM, Zafonte RD, Hainline B, Sorcar P. Participating in Two Video Concussion Education Programs Sequentially Improves Concussion-Reporting Intention. Neurotrauma Rep 2022; 2:581-591. [PMID: 35018360 PMCID: PMC8742279 DOI: 10.1089/neur.2021.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Undiagnosed concussions increase the risk of additional concussion and persistent symptoms from concussion. Because there are no reliable objective markers of concussion, self-reporting of subjective and non-visible symptoms are critical to ensuring proper concussion management. For this reason, educational interventions target concussion reporting, but the majority of studies have examined the efficacy of single educational interventions or compared interventions to one another. This randomized crossover study sought to identify whether there was benefit to administering multiple concussion education programs in tandem, back to back. The study randomized 313 male high school football players to first receive CrashCourse concussion education (CC) or Centers for Disease Control and Prevention video concussion education (CDC) followed by crossover with the other education. Athlete concussion-reporting intention, attitudes, subjective norms, perceived behavioral control, and enjoyment of education were assessed at baseline and after each intervention. There were statistically significant improvements across all measures, both after single intervention and crossover (all p < 0.001). Secondary analyses examining differences between education found that athletes reported higher enjoyment of concussion education immediately after participating in CC, as compared to CDC (p < 0.001). These findings demonstrate an additive benefit to implementing CC and CDC education in tandem, without decrement in enjoyment of concussion education after experiencing dual educations; in fact, enjoyment of concussion education improved after receiving education programs back to back. These educational programs appear to complement one another, and the results support the use of multi-modal concussion education to differentially target and maximize concussion reporting.
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Affiliation(s)
- Daniel H Daneshvar
- Department of Physical Medicine and Rehabilitation, Harvard Medical School; Boston, Massachusetts, USA; Massachusetts General Hospital; Boston, Massachusetts, USA; Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA.,Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Christine M Baugh
- Center for Bioethics and Humanities, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado, USA; Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Roberto D Lama
- School of Engineering, Stanford University, Stanford, California, USA
| | - Maya Yutsis
- Department of Neurology, Stanford School of Medicine, Palo Alto, California, USA
| | - Roy D Pea
- Graduate School of Education, Stanford University, Stanford, California, USA
| | - Shelley Goldman
- Graduate School of Education, Stanford University, Stanford, California, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford School of Medicine, Palo Alto, California, USA
| | - Robert C Cantu
- Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, Massachusetts, USA.,Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Lee M Sanders
- Department of Pediatrics, Stanford School of Medicine, Palo Alto, California, USA
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School; Boston, Massachusetts, USA; Massachusetts General Hospital; Boston, Massachusetts, USA; Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA.,Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Brian Hainline
- Indiana University School of Medicine, Indianapolis, Indiana, USA; New York University Langone Medical Center, New York, New York, USA
| | - Piya Sorcar
- Stanford Center for Innovation in Global Health, Stanford School of Medicine, Palo Alto, California, USA
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22
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Foley ÉM, Tripodis Y, Yhang E, Koerte IK, Martin BM, Palmisano J, Makris N, Schultz V, Lepage C, Muehlmann M, Wróbel PP, Guenette JP, Cantu RC, Lin AP, Coleman M, Mez J, Bouix S, Shenton ME, Stern RA, Alosco ML. Quantifying and Examining Reserve in Symptomatic Former National Football League Players. J Alzheimers Dis 2022; 85:675-689. [PMID: 34864657 PMCID: PMC8926024 DOI: 10.3233/jad-210379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Repetitive head impacts (RHI) from contact sports have been associated with cognitive and neuropsychiatric disorders. However, not all individuals exposed to RHI develop such disorders. This may be explained by the reserve hypothesis. It remains unclear if the reserve hypothesis accounts for the heterogenous symptom presentation in RHI-exposed individuals. Moreover, optimal measurement of reserve in this population is unclear and likely unique from non-athlete populations. OBJECTIVE We examined the association between metrics of reserve and cognitive and neuropsychiatric functioning in 89 symptomatic former National Football League players. METHODS Individual-level proxies (e.g., education) defined reserve. We additionally quantified reserve as remaining residual variance in 1) episodic memory and 2) executive functioning performance, after accounting for demographics and brain pathology. Associations between reserve metrics and cognitive and neuropsychiatric functioning were examined. RESULTS Higher reading ability was associated with better attention/information processing (β=0.25; 95% CI, 0.05-0.46), episodic memory (β=0.27; 95% CI, 0.06-0.48), semantic and phonemic fluency (β=0.24; 95% CI, 0.02-0.46; β=0.38; 95% CI, 0.17-0.59), and behavioral regulation (β=-0.26; 95% CI, -0.48, -0.03) performance. There were no effects for other individual-level proxies. Residual episodic memory variance was associated with better attention/information processing (β=0.45; 95% CI, 0.25, 0.65), executive functioning (β=0.36; 95% CI, 0.15, 0.57), and semantic fluency (β=0.38; 95% CI, 0.17, 0.59) performance. Residual executive functioning variance was associated with better attention/information processing (β=0.44; 95% CI, 0.24, 0.64) and episodic memory (β=0.37; 95% CI, 0.16, 0.58) performance. CONCLUSION Traditional reserve proxies (e.g., years of education, occupational attainment) have limitations and may be unsuitable for use in elite athlete samples. Alternative approaches of reserve quantification may prove more suitable for this population.
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Affiliation(s)
- Éimear M. Foley
- Boston University Alzheimer’s Disease Research Center and Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA,Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands,Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Yorghos Tripodis
- Boston University Alzheimer’s Disease Research Center and Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Eukyung Yhang
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Inga K. Koerte
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatic, and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
| | - Brett M. Martin
- Boston University Alzheimer’s Disease Research Center and Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA,Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Joseph Palmisano
- Boston University Alzheimer’s Disease Research Center and Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA,Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Nikos Makris
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Psychiatry, Center for Morphometric Analysis, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vivian Schultz
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatic, and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany,Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Chris Lepage
- QEII Health Sciences Centre, Nova Scotia, Canada
| | - Marc Muehlmann
- Department of Radiology, Ludwig-Maximilian-University, Munich, Germany
| | - Paweł P. Wróbel
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatic, and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany,Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeffrey P. Guenette
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert C. Cantu
- Boston University Alzheimer’s Disease Research Center and Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA,Concussion Legacy Foundation, Boston, MA, USA,Department of Neurosurgery, Boston University School of Medicine, Boston, MA, USA,Department of Neurosurgery, Emerson Hospital, Concord, MA, USA
| | - Alexander P. Lin
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Coleman
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer’s Disease Research Center and Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA,Framingham Heart Study, Boston University School of Medicine, Boston, MA, USA
| | - Sylvain Bouix
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Martha E. Shenton
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert A. Stern
- Boston University Alzheimer’s Disease Research Center and Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA,Department of Anatomy and 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 Research Center and Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA,Correspondence to: Michael L. Alosco, PhD, Boston University Alzheimer’s Disease Research Center and Boston University CTE Center, Department of Neurology, Boston University School of Medicine, 72 E. Concord Street, Suite B7800, Boston, MA 02118, USA. Tel.: +1 617 358 6029;
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23
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Alosco ML, Mian AZ, Buch K, Farris CW, Uretsky M, Tripodis Y, Baucom Z, Martin B, Palmisano J, Puzo C, Ang TFA, Joshi P, Goldstein LE, Au R, Katz DI, Dwyer B, Daneshvar DH, Nowinski C, Cantu RC, Kowall NW, Huber BR, Alvarez VE, Stern RA, Stein TD, Killiany RJ, McKee AC, Mez J. Structural MRI profiles and tau correlates of atrophy in autopsy-confirmed CTE. Alzheimers Res Ther 2021; 13:193. [PMID: 34876229 PMCID: PMC8653514 DOI: 10.1186/s13195-021-00928-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/31/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic traumatic encephalopathy (CTE), a neurodegenerative tauopathy, cannot currently be diagnosed during life. Atrophy patterns on magnetic resonance imaging could be an effective in vivo biomarker of CTE, but have not been characterized. Mechanisms of neurodegeneration in CTE are unknown. Here, we characterized macrostructural magnetic resonance imaging features of brain donors with autopsy-confirmed CTE. The association between hyperphosphorylated tau (p-tau) and atrophy on magnetic resonance imaging was examined. METHODS Magnetic resonance imaging scans were obtained by medical record requests for 55 deceased symptomatic men with autopsy-confirmed CTE and 31 men (n = 11 deceased) with normal cognition at the time of the scan, all >60 years Three neuroradiologists visually rated regional atrophy and microvascular disease (0 [none]-4 [severe]), microbleeds, and cavum septum pellucidum presence. Neuropathologists rated tau severity and atrophy at autopsy using semi-quantitative scales. RESULTS Compared to unimpaired males, donors with CTE (45/55=stage III/IV) had greater atrophy of the orbital-frontal (mean diff.=1.29), dorsolateral frontal (mean diff.=1.31), superior frontal (mean diff.=1.05), anterior temporal (mean diff.=1.57), and medial temporal lobes (mean diff.=1.60), and larger lateral (mean diff.=1.72) and third (mean diff.=0.80) ventricles, controlling for age at scan (ps<0.05). There were no effects for posterior atrophy or microvascular disease. Donors with CTE had increased odds of a cavum septum pellucidum (OR = 6.7, p < 0.05). Among donors with CTE, greater tau severity across 14 regions corresponded to greater atrophy on magnetic resonance imaging (beta = 0.68, p < 0.01). CONCLUSIONS These findings support frontal-temporal atrophy as a magnetic resonance imaging finding of CTE and show p-tau accumulation is associated with atrophy in CTE.
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Affiliation(s)
- Michael L Alosco
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
| | - Asim Z Mian
- Department of Radiology, Boston University School of Medicine, Boston, USA
| | - Karen Buch
- Department of Radiology, Massachusetts General Hospital, Boston, USA
| | - Chad W Farris
- Department of Radiology, Boston University School of Medicine, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
| | - Madeline Uretsky
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, USA
| | - Zachary Baucom
- Department of Biostatistics, Boston University School of Public Health, Boston, USA
| | - Brett Martin
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, USA
| | - Joseph Palmisano
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, USA
| | - Christian Puzo
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
| | - Ting Fang Alvin Ang
- Framingham Heart Study, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
| | - Prajakta Joshi
- Framingham Heart Study, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
| | - Lee E Goldstein
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Department of Radiology, Boston University School of Medicine, Boston, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, USA
- Departments of Biomedical, Electrical & Computer Engineering, Boston University College of Engineering, Boston, USA
| | - Rhoda Au
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Framingham Heart Study, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Douglas I Katz
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Brigid Dwyer
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Daniel H Daneshvar
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
| | | | - Robert C Cantu
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Concussion Legacy Foundation, Boston, MA, USA
- Department of Neurosurgery, Boston University School of Medicine, Boston, USA
- Department of Neurosurgery, Emerson Hospital, Concord, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, USA
- US Department of Veteran Affairs, VA Boston Healthcare System, Boston, USA
| | - Bertrand Russell Huber
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- US Department of Veteran Affairs, VA Boston Healthcare System, Boston, USA
- National Center for PTSD, VA Boston Healthcare, Boston, USA
| | - Victor E Alvarez
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- US Department of Veteran Affairs, VA Boston Healthcare System, Boston, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, USA
- Department of Neurosurgery, Boston University School of Medicine, Boston, USA
| | - Thor D Stein
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Framingham Heart Study, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, USA
- US Department of Veteran Affairs, VA Boston Healthcare System, Boston, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Ronald J Killiany
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, USA
- Center for Biomedical Imaging, Boston University School of Medicine, Boston, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Framingham Heart Study, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, USA
- US Department of Veteran Affairs, VA Boston Healthcare System, Boston, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Research Center and CTE Center, Department of Neurology, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA.
- Framingham Heart Study, Boston University School of Medicine, 72 E Concord Street, Suite B7800, Boston, MA, 02118, USA.
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24
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Daneshvar DH, Mez J, Alosco ML, Baucom ZH, Mahar I, Baugh CM, Valle JP, Weuve J, Paganoni S, Cantu RC, Zafonte RD, Stern RA, Stein TD, Tripodis Y, Nowinski CJ, McKee AC. Incidence of and Mortality From Amyotrophic Lateral Sclerosis in National Football League Athletes. JAMA Netw Open 2021; 4:e2138801. [PMID: 34910152 PMCID: PMC8674746 DOI: 10.1001/jamanetworkopen.2021.38801] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/18/2021] [Indexed: 12/27/2022] Open
Abstract
Importance Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease; understanding ALS risk factors is a critical public health issue. Objectives To evaluate the incidence of and mortality from ALS in National Football League (NFL) athletes and to describe characteristics associated with ALS within this cohort. Design, Setting, and Participants This population-based cohort study included all 19 423 NFL athletes who debuted between 1960 and 2019 and played 1 or more professional game. It was conducted between October 3, 2020, and July 19, 2021. Exposure Participation in the NFL, including playing 1 or more professional games. Main Outcomes and Measures Cases of ALS and death information were identified based on public records from NFL statistics aggregators, news reports, obituaries, and National Death Index results. The standardized incidence ratio and the standardized mortality ratio were calculated based on data acquired from surveillance studies of ALS accounting for age, sex, and race. Secondary analyses examined the association of body mass index, NFL career duration, race, birth location, and markers of fame, using a nested case-control design, matching athletes with ALS to athletes without ALS, by NFL debut year. Results A total of 19 423 male former and current NFL players (age range, 23-78 years) were included in this cohort study and were followed up for a cumulative 493 168 years (mean [SD] follow-up, 30.6 [13.7] years). Thirty-eight players received a diagnosis of ALS, and 28 died during the study time frame, representing a significantly higher incidence of ALS diagnosis (standardized incidence ratio, 3.59; 95% CI, 2.58-4.93) and mortality (standardized mortality ratio, 3.94; 95% CI, 2.62-5.69) among NFL players compared with the US male population, adjusting for age and race. Among NFL athletes, nested-case-control analyses found that those who received a diagnosis of ALS had significantly longer careers (mean [SD] duration, 7.0 [3.9] years) than athletes without ALS (mean [SD] duration, 4.5 [3.6] years; odds ratio, 1.2; 95% CI, 1.1-1.3). There were no differences in ALS status based on proxies of NFL fame, body mass index, position played, birth location, or race. Conclusions and Relevance The age-, sex-, and race-adjusted incidence of and mortality from ALS among all NFL players who debuted between 1960 and 2019 were nearly 4 times as high as those of the general population. Athletes with a diagnosis of ALS had longer NFL careers than those without ALS, suggesting an association between NFL duration of play and ALS. The identification of these risk factors for ALS helps to inform the study of pathophysiological mechanisms responsible for this fatal neurodegenerative disease.
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Affiliation(s)
- Daniel H. Daneshvar
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Boston University Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
| | - Jesse Mez
- Boston University Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Framingham Heart Study, Boston University School of Medicine, Boston, Massachusetts
| | - Michael L. Alosco
- Boston University Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Zachary H. Baucom
- Boston University Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Ian Mahar
- Boston University Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Christine M. Baugh
- Center for Bioethics and Humanities, University of Colorado Denver Anschutz Medical Campus, Aurora
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | | | - Jennifer Weuve
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Sabrina Paganoni
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Boston
| | - Robert C. Cantu
- Boston University Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurosurgery, Emerson Hospital, Concord, Massachusetts
- Concussion Legacy Foundation, Boston, Massachusetts
| | - Ross D. Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Department of Physical Medicine and Rehabilitation, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Robert A. Stern
- Boston University Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts
- Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, Massachusetts
| | - Thor D. Stein
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, Department of Veterans Affairs, Boston, Massachusetts
- Department of Veterans Affairs Medical Center, Bedford, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Yorghos Tripodis
- Boston University Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Christopher J. Nowinski
- Boston University Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurosurgery, Emerson Hospital, Concord, Massachusetts
| | - Ann C. McKee
- Boston University Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Framingham Heart Study, Boston University School of Medicine, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, Department of Veterans Affairs, Boston, Massachusetts
- Department of Veterans Affairs Medical Center, Bedford, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
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25
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Cournoyer J, Karton C, Koncan D, Gilchrist MD, Cantu RC, Hoshizaki TB. Brain trauma exposure for American tackle football players 5 to 9 and 9 to 14 years of age. J Biomech 2021; 127:110689. [PMID: 34416530 DOI: 10.1016/j.jbiomech.2021.110689] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/28/2021] [Accepted: 08/09/2021] [Indexed: 01/13/2023]
Abstract
American football helmets used by youth players are currently designed and tested to the same standards as professionals. The National Operating Committee on Standard and Safety requested research aiming at understanding the differences in brain trauma in youth American football for players aged five to nine and nine to fourteen years old to inform a youth specific American football standard. Video analysis and laboratory reconstructions of head impacts were undertaken to measure differences in head impact frequency, event types, and magnitudes of maximum principal strain (MPS) for the two age groups. Overall frequencies and frequencies for five categories of MPS representing different magnitudes of risk were tabulated. The MPS categories were very low (<0.08), low (0.08-0.169), medium (0.17-0.259), high (0.26-0.349) and very high (>0.35). Both cohorts experienced a majority of head impacts (>56%) at very low magnitude of MPS. Youth American football players aged 9-14 yrs. sustained a greater frequency of head impacts at MPS between 0.08 and 0.169 % associated with changes in brain structure and function. There were no differences in overall frequency, or in frequency of head impacts in other categories of MPS. The proportion of impacts considered injurious (MPS > 0.08) was greater in the 5-9 group (44%), than the 9-14 group (39%), and impacts above 0.35 % were only reported for the younger age group. The larger helmet-to-shoulder ratio in the younger age groups may have contributed to this finding suggesting that youth American football players under the age of nine would benefit from a child-specific football helmet.
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Affiliation(s)
- J Cournoyer
- University of Ottawa, School of Human Kinetics, Ottawa, Canada.
| | - C Karton
- University of Ottawa, School of Human Kinetics, Ottawa, Canada
| | - D Koncan
- University of Ottawa, School of Human Kinetics, Ottawa, Canada
| | - M D Gilchrist
- University College Dublin, School of Mechanical and Materials Engineering
| | - R C Cantu
- Boston University Alzheimer's Disease and Chronic Encephalopathy Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA; Department of neurosurgery, Boston University School of Medicine, Boston, MA, USA; Department of neurosurgery, Emerson Hospital, Concord, MA, USA; Concussion Legacy Foundation, Boston, MA, USA
| | - T B Hoshizaki
- University of Ottawa, School of Human Kinetics, Ottawa, Canada
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26
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Nordberg B, Lopez-Hernandez DW, Bueno A, Victor TL, Saravia S, Baez AJ, Sidhu J, Munoz I, Cantu RC, Guskiewicz KM, Kelly DF, Swerdloff R, Hardy DJ, Woo E, Litvin PY, Wright MJ. A-122 Verbal Fluency Switching and Clustering Performance in Retired Professional Football Players. Arch Clin Neuropsychol 2021. [DOI: 10.1093/arclin/acab062.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Repeated sports-related concussion has been associated with cognitive deficits, like other forms of traumatic brain injury. Football speed players (FSP; e.g., quarterbacks) are at greater risk of cognitive impairment compared to football non-speed players (FNP). Verbal fluency is typically comprised of two tasks: letter fluency (LF) and semantic fluency (SF). Verbal clustering (production of continuous words belonging to the same category or subcategory) and switching (abandoning an exhausted semantic cluster to a new one in order to produce more words) reflect executive control and strategy use. We examined LF, SF, as well as LF and SF switching and clustering performance in retired FSP, FNP, and healthy comparison (HC) participants.
Methods
The sample consisted of 28 HC, 17 retired FSP, and 53 retired FNP. ANOVAs were conducted to determine group differences on LF, SF, switching, and clustering. FSP and FNP did not differ in concussion frequency.
Results
We found the HC group outperformed the FSP group in LF, p = 0.042, ηp2 = 0.07. For SF, the HC and FNP groups outperformed the FSP group, p = 0.013, ηp2 = 0.09. Furthermore, we found the HC group outperformed both football groups in SF switching, p = 0.000, ηp2 = 0.17.
Conclusion
As expected, the HC group outperformed the FSP group on LF and SF. Also, the FNP group outperformed the FSP group on SF. Interestingly, FSP displayed generally worse performances, supporting the notion that their experience of sub-concussive blows puts them at greater risk for cognitive impairment. Further investigation is needed with larger sample sizes to evaluate SF and other cognitive deficits in the FSP participants.
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27
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Lopez-Hernandez DW, Nordberg BA, Bueno A, Litvin PY, Bichlmeier A, Smith KE, Olmos W, Sidhu J, Saravia S, Mangassarian S, Fatoorechi S, Hardy D, Woo E, Schmitter-Edgecombe M, Cantu RC, Guskiewicz KM, Kelly DF, Swerdloff R, Wright MJ. A-104 Examining Methods of Executive Ability from Trail Making Test Part B in Retired Football Players. Arch Clin Neuropsychol 2021. [DOI: 10.1093/arclin/acab062.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Repeated sports-related concussions have been associated with cognitive deficits, similar to other forms of traumatic brain injury. We investigated three different measures of executive ability derived from the Trail Making Test part B (TMT-B) in healthy comparison (HC) adults and retired football players.
Methods
The sample consisted of 32 HC, 15 retired football speed players (FSP; e.g., quarterbacks), and 53 retired football non-speed players (FNP) participants. Participants were administered both TMT part A (TMT-A) and TMT-B, and total time for completion was recorded. A series of ANCOVAs, controlling for age and education were conducted to evaluate group differences in executive abilities. Executive measures included the TMT-B raw score (i.e., seconds to complete TMT-B), the raw score difference (in seconds) between TMT-A and TMT-B (TMT-BA), and the difference between a predicted TMT-B score (TMT-BP) and the obtained TMT-B score (TMT-BBP). Correlations between TMT-B, TMT-BA, and TMT-BBP and other executive functioning tests (i.e., letter fluency and animal naming) were evaluated.
Results
Results revealed that the HC group outperformed both retired football player groups on all measures of executive ability derived from TMT-B, p’s < 0.05, ηps2 = 0.18–0.45. Furthermore, the retired FNP TMT-B and TMT-BA were significantly correlated with both letter fluency and animal naming, r’s = −0.40 to −0.36, p’s < 0.05.
Discussion
We found that the HC group outperformed both retired football player groups on all three TMT variables. In our retired FNP sample, more TMT variables correlated with executive functioning measures which suggests that TMT-B and TMT-BA are likely better measures of executive ability than TMT-BBP.
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28
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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: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Zuckerman SL, Yengo-Kahn AM, Tang AR, Bailes JE, Beauchamp K, Berger MS, Bonfield CM, Camarata PJ, Cantu RC, Davis GA, Ellenbogen RG, Ellis MJ, Feuer H, Guazzo E, Harris OA, Heppner P, Honeybul S, Manley G, Maroon JC, Miele VJ, Nahed BV, Okonkwo DO, Oppenlander ME, Petty J, Sabin HI, Samadani U, Sherburn EW, Sheridan M, Tator CH, Theodore N, Timmons SD, Woodworth GF, Solomon GS, Sills AK. Sport-Related Structural Brain Injury and Return to Play: Systematic Review and Expert Insight. Neurosurgery 2021; 88:E495-E504. [PMID: 33693899 DOI: 10.1093/neuros/nyab041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/28/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI. OBJECTIVE To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions. METHODS A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted. RESULTS Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033). CONCLUSION RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.
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Affiliation(s)
- Scott L Zuckerman
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aaron M Yengo-Kahn
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alan R Tang
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Julian E Bailes
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Kathryn Beauchamp
- Division of Neurological Surgery, Denver Health Medical Center, Department of Neurological Surgery University of Colorado, Denver, Colorado, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher M Bonfield
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Paul J Camarata
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Gavin A Davis
- Department of Neurosurgery, Austin and Cabrini Health, Melbourne, Australia
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington, USA
| | - Michael J Ellis
- Department of Surgery and Pediatrics, Section of Neurosurgery, University of Manitoba, Pan Am Concussion Program, Winnipeg, Canada
| | - Hank Feuer
- Player Health and Safety Department, National Football League, New York, New York, USA
| | - Eric Guazzo
- Department of Neurosurgery, Townsville University Hospital, Townsville, Australia
| | - Odette A Harris
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Peter Heppner
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth Western Australia
| | - Geoff Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Joseph C Maroon
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vincent J Miele
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mark E Oppenlander
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jerry Petty
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | | | - Uzma Samadani
- Division of Neurosurgery, Minneapolis VAMC; Department of Bioinformatics and Computational Biology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Eric W Sherburn
- The Center for Concussion, University of Oklahoma College of Medicine, Tulsa, Oklahoma, USA
| | - Mark Sheridan
- Department of Neurosurgery, Liverpool Hospital, Liverpool, Australia
| | - Charles H Tator
- Canadian Concussion Centre and Division of Neurosurgery, Toronto Western Hospital and University of Toronto, Toronto, Canada
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University Medical Center, Baltimore, Maryland, USA
| | - Shelly D Timmons
- Department of Neurological Surgery, Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Graeme F Woodworth
- Department of Neurosurgery & R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
| | - Gary S Solomon
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Player Health and Safety Department, National Football League, New York, New York, USA
| | - Allen K Sills
- Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Player Health and Safety Department, National Football League, New York, New York, USA
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30
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Daneshvar DH, Baugh CM, Yutsis M, Pea RD, Goldman S, Grant GA, Cantu RC, Sanders LM, Chen CL, Lama RD, Zafonte RD, Sorcar P. Athlete Enjoyment of Prior Education Moderates change in Concussion-Reporting Intention after Interactive Education. Inquiry 2021; 58:469580211022641. [PMID: 34053328 PMCID: PMC8170270 DOI: 10.1177/00469580211022641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Undiagnosed concussions increase risk of additional injuries and can prolong recovery. Because of the difficulties recognizing concussive symptoms, concussion education must specifically target improving athlete concussion reporting. Many concussion education programs are designed without significant input from athletes, resulting in a less enjoyable athlete experience, with potential implications on program efficacy. Athlete enjoyment of previous concussion education programs moderates the improvement in concussion-reporting intention after experiencing the research version of CrashCourse (CC) concussion education. Prospective cohort study. Level of evidence: Level IV. Quantitative assessment utilizing ANOVA with moderation analysis of 173 male high school football players, aged 13 to 17, who completed baseline assessments of concussion knowledge, concussion reporting, and attitudes about prior educational interventions. Athletes were subsequently shown CC, before a follow-up assessment was administered assessing the same domains. At baseline, only 58.5% of athletes reported that they enjoyed their previous concussion education. After CC, athletes were significantly more likely to endorse that they would report a suspected concussion (from 69.3% of athletes to 85.6%; P < .01). Enjoyment of previous concussion education moderated concussion-reporting intention after CC (P = .02), with CC having a greater effect on concussion-reporting intention in athletes with low enjoyment of previous concussion education (b = 0.21, P = .02), than on individuals with high enjoyment of previous concussion education (P = .99). Enjoyment of CC did not have a moderating effect on concussion-reporting intention. Athletes who previously did not enjoy concussion education exhibited greater gains in concussion-reporting intention than athletes who enjoyed previous education. Given the potential risks associated with undiagnosed concussions, concussion education has sought to improve concussion reporting. Because most athletes participate in concussion education programs due to league or state mandates, improving concussion-reporting intention in these low-enjoyment athletes is of particular relevance to improving concussion-reporting intention broadly.
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Affiliation(s)
- Daniel H Daneshvar
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Boston, MA, USA.,Spaulding Rehabilitation Hospital, Boston, MA, USA.,Boston University School of Medicine, Boston, MA, USA
| | - Christine M Baugh
- University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Maya Yutsis
- Stanford School of Medicine, Palo Alto, CA, USA
| | - Roy D Pea
- Stanford University, Stanford, CA, USA
| | | | | | - Robert C Cantu
- Boston University School of Medicine, Boston, MA, USA.,Emerson Hospital, Concord, MA, USA
| | | | - Christine L Chen
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Ross D Zafonte
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Boston, MA, USA.,Spaulding Rehabilitation Hospital, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Piya Sorcar
- Stanford School of Medicine, Palo Alto, CA, USA
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31
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Katz DI, Bernick C, Dodick DW, Mez J, Mariani ML, Adler CH, Alosco ML, Balcer LJ, Banks SJ, Barr WB, Brody DL, Cantu RC, Dams-O'Connor K, Geda YE, Jordan BD, McAllister TW, Peskind ER, Petersen RC, Wethe JV, Zafonte RD, Foley ÉM, Babcock DJ, Koroshetz WJ, Tripodis Y, McKee AC, Shenton ME, Cummings JL, Reiman EM, Stern RA. National Institute of Neurological Disorders and Stroke Consensus Diagnostic Criteria for Traumatic Encephalopathy Syndrome. Neurology 2021; 96:848-863. [PMID: 33722990 PMCID: PMC8166432 DOI: 10.1212/wnl.0000000000011850] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/01/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To develop evidence-informed, expert consensus research diagnostic criteria for traumatic encephalopathy syndrome (TES), the clinical disorder associated with neuropathologically diagnosed chronic traumatic encephalopathy (CTE). METHODS A panel of 20 expert clinician-scientists in neurology, neuropsychology, psychiatry, neurosurgery, and physical medicine and rehabilitation, from 11 academic institutions, participated in a modified Delphi procedure to achieve consensus, initiated at the First National Institute of Neurological Disorders and Stroke Consensus Workshop to Define the Diagnostic Criteria for TES, April, 2019. Before consensus, panelists reviewed evidence from all published cases of CTE with neuropathologic confirmation, and they examined the predictive validity data on clinical features in relation to CTE pathology from a large clinicopathologic study (n = 298). RESULTS Consensus was achieved in 4 rounds of the Delphi procedure. Diagnosis of TES requires (1) substantial exposure to repetitive head impacts (RHIs) from contact sports, military service, or other causes; (2) core clinical features of cognitive impairment (in episodic memory and/or executive functioning) and/or neurobehavioral dysregulation; (3) a progressive course; and (4) that the clinical features are not fully accounted for by any other neurologic, psychiatric, or medical conditions. For those meeting criteria for TES, functional dependence is graded on 5 levels, ranging from independent to severe dementia. A provisional level of certainty for CTE pathology is determined based on specific RHI exposure thresholds, core clinical features, functional status, and additional supportive features, including delayed onset, motor signs, and psychiatric features. CONCLUSIONS New consensus diagnostic criteria for TES were developed with a primary goal of facilitating future CTE research. These criteria will be revised as updated clinical and pathologic information and in vivo biomarkers become available.
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Affiliation(s)
- Douglas I. Katz
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Charles Bernick
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - David W. Dodick
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Jesse Mez
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Megan L. Mariani
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Charles H. Adler
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Michael L. Alosco
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Laura J. Balcer
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Sarah J. Banks
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - William B. Barr
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - David L. Brody
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Robert C. Cantu
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Kristen Dams-O'Connor
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Yonas E. Geda
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Barry D. Jordan
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Thomas W. McAllister
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Elaine R. Peskind
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Ronald C. Petersen
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Jennifer V. Wethe
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Ross D. Zafonte
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Éimear M. Foley
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Debra J. Babcock
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Walter J. Koroshetz
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Yorghos Tripodis
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Ann C. McKee
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Martha E. Shenton
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Jeffrey L. Cummings
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Eric M. Reiman
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
| | - Robert A. Stern
- From the Boston University CTE Center (D.I.K.), Department of Neurology, Boston University School of Medicine, Boston; Brain Injury Program (D.I.K.), Encompass Health Braintree Rehabilitation Hospital, Braintree, MA; University of Washington Memory & Brain Wellness Clinic (C.B.), Department of Neurology, University of Washington School of Medicine, Seattle; Department of Neurology (D.W.D., C.H.A.), Mayo Clinic, Scottsdale, AZ; Boston University CTE Center (J.M., M.L.A.), Boston University Alzheimer's Disease Center, Department of Neurology, Boston University School of Medicine; Boston University CTE Center (M.L.M.), Boston University School of Medicine, MA; Departments of Neurology (L.J.B.), Ophthalmology, and Population Health, New York University Grossman School of Medicine; Departments of Neurosciences and Psychiatry University of California San Diego (S.J.B.), La Jolla; Departments of Neurology and Psychiatry (W.B.B.), New York University Grossman School of Medicine; Center for Neuroscience and Regenerative Medicine (D.L.B.), Uniformed Services University of the Health Sciences, Department of Neurology, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Boston University CTE Center (R.C.C.), Boston University Alzheimer's Disease Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, MA; Departments of Rehabilitation Medicine and Neurology (K.D.-O.C.), Icahn School of Medicine, Mount Sinai, New York; Department of Neurology (Y.E.G.), Barrow Neurological Institute, Phoenix, AZ; Rancho Los Amigos National Rehabilitation Center (B.D.J.), Downey, CA; Department of Neurology (B.D.J.), Keck School of Medicine of USC. Los Angeles, CA; Departments of Psychiatry and Neurology (T.W.M.), Indiana University School of Medicine, Indianapolis; Veterans Affairs Northwest Mental Illness (E.R.P.), Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Mayo Clinic Alzheimer's Disease Research Center (R.C.P.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.V.W.), Mayo Clinic, Scottsdale, AZ; Department of Physical Medicine and Rehabilitation (R.D.Z.), Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston; Faculty of Psychology and Neuroscience (É.M.F.), Maastricht University, the Netherlands, Department of Psychiatry, University of Cambridge, United Kingdom; National Institute of Neurological Disorders and Stroke (D.J.B.), National Institutes of Health; National Institute of Neurological Disorders and Stroke (W.J.K.), Bethesda, MD; Boston University CTE Center (Y.T.), Boston University Alzheimer's Disease Center, Boston University School of Medicine, Department of Biostatistics, Boston University School of Public Health; Boston University CTE Center (A.C.M.), Boston University Alzheimer's Disease Center, Departments of Neurology and Pathology & Laboratory Medicine, Boston University School of Medicine; VA Boston Healthcare System (A.C.M.), US Department of Veteran Affairs, MA; Psychiatry Neuroimaging Laboratory (M.E.S.), Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, University of Nevada School of Integrated Health Sciences; Cleveland Clinic Lou Ruvo Center for Brain Health (J.L.C.), Las Vegas, NV; Banner Alzheimer's Institute (E.M.R.), Arizona State University; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix, AZ; and Boston University CTE Center (R.A.S.), Boston University Alzheimer's Disease Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, MA
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Mez J, Alosco ML, Daneshvar DH, Saltiel N, Baucom Z, Abdolmohammadi B, Uretsky M, Nicks R, Martin BM, Palmisano JN, Nowinski CJ, Montenigro P, Solomon TM, Mahar I, Cherry JD, Alvarez VE, Dwyer B, Goldstein LE, Katz DI, Cantu RC, Kowall NW, Tripodis Y, Huber BR, Stein TD, Stern RA, McKee AC. Validity of the 2014 traumatic encephalopathy syndrome criteria for CTE pathology. Alzheimers Dement 2021; 17:1709-1724. [PMID: 33826224 PMCID: PMC8596795 DOI: 10.1002/alz.12338] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/19/2021] [Accepted: 03/05/2021] [Indexed: 12/14/2022]
Abstract
Introduction Validity of the 2014 traumatic encephalopathy syndrome (TES) criteria, proposed to diagnose chronic traumatic encephalopathy (CTE) in life, has not been assessed. Methods A total of 336 consecutive brain donors exposed to repetitive head impacts from contact sports, military service, and/or physical violence were included. Blinded to clinical information, neuropathologists applied National Institute on Neurological Disorders and Stroke/National Institute of Biomedical Imaging and Bioengineering CTE criteria. Blinded to neuropathological information, clinicians interviewed informants and reviewed medical records. An expert panel adjudicated TES diagnoses. Results A total of 309 donors were diagnosed with TES; 244 donors had CTE pathology. TES criteria demonstrated sensitivity and specificity of 0.97 and 0.21, respectively. Cognitive (odds ratio [OR] = 3.6; 95% confidence interval [CI]: 1.2–5.1), but not mood/behavior or motor symptoms, were significantly associated with CTE pathology. Having Alzheimer's disease (AD) pathology was significantly associated with reduced TES accuracy (OR = 0.27; 95% CI: 0.12–0.59). Discussion TES criteria provided good evidence to rule out, but limited evidence to rule in, CTE pathology. Requiring cognitive symptoms in revised criteria and using AD biomarkers may improve CTE pathology prediction.
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Affiliation(s)
- Jesse Mez
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michael L Alosco
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Daniel H Daneshvar
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Rehabilitation Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Saltiel
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA.,VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts, USA
| | - Zachary Baucom
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Boston University Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Bobak Abdolmohammadi
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Madeline Uretsky
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Raymond Nicks
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA.,VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts, USA
| | - Brett M Martin
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Biostatistics & Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Joseph N Palmisano
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Biostatistics & Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Christopher J Nowinski
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Concussion Legacy Foundation, Boston, Massachusetts, USA
| | - Philip Montenigro
- Department of Neuropsychology, University of New Hampshire, Durham, New Hampshire, USA
| | - Todd M Solomon
- Avanir Pharmaceuticals Inc, Aliso Viejo, California, USA
| | - Ian Mahar
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jonathan D Cherry
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts, USA.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Victor E Alvarez
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts, USA
| | - Brigid Dwyer
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA.,Braintree Rehabilitation Hospital, Braintree, Massachusetts, USA
| | - Lee E Goldstein
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA.,Departments of Biomedical, Electrical & Computer Engineering, Boston University College of Engineering, Boston, Massachusetts, USA
| | - Douglas I Katz
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA.,Braintree Rehabilitation Hospital, Braintree, Massachusetts, USA
| | - Robert C Cantu
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Concussion Legacy Foundation, Boston, Massachusetts, USA.,Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurosurgery, Emerson Hospital, Concord, Massachusetts, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA.,VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Boston University Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Bertrand R Huber
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA.,VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts, USA
| | - Thor D Stein
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts, USA.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA.,VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Veterans Affairs Medical Center, Bedford, Massachusetts, USA.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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Affiliation(s)
| | - Robert C Cantu
- Concussion Legacy Foundation, Boston, Massachusetts.,Department of Neurosurgery, Emerson Hospital, Concord, Massachusetts
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McKee AC, Stein TD, Crary JF, Bieniek KF, Cantu RC, Kovacs GG. Practical Considerations in the Diagnosis of Mild Chronic Traumatic Encephalopathy and Distinction From Age-Related Tau Astrogliopathy. J Neuropathol Exp Neurol 2021; 79:921-924. [PMID: 32688381 DOI: 10.1093/jnen/nlaa047] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ann C McKee
- Department of Pathology and Laboratory Medicine, VA Boston Healthcare System, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Department of Pathology, Boston University School of Medicine, Boston, Massachusetts.,Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston, Massachusetts.,Bedford Veterans Affairs Medical Center, Bedford, Massachusetts
| | - Thor D Stein
- Department of Pathology and Laboratory Medicine, VA Boston Healthcare System, Boston, Massachusetts.,Department of Pathology, Boston University School of Medicine, Boston, Massachusetts.,Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston, Massachusetts.,Bedford Veterans Affairs Medical Center, Bedford, Massachusetts
| | - John F Crary
- Department of Pathology, Nash Family Department of Neuroscience, Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kevin F Bieniek
- Department of Pathology and Laboratory Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas.,Biggs Institute Brain Bank Core, Glenn Biggs Institute for Alzheimer's and Neurodegenerative Diseases, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Robert C Cantu
- Concussion Legacy Foundation, Boston, Massachusetts.,Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurosurgery, Emerson Hospital, Concord, Massachusetts
| | - Gabor G Kovacs
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Tanz Centre for Research in Neurodegenerative Disease, University of Toronto, Toronto, Ontario, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
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35
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Wu YN, Stark C, Gravel J, White M, Avery J, Enis T, Cantu RC. Effects of Interval-Training Exercise on People Who Have Had Persistent Post-Concussive Symptoms for Less Than One Year: A Pilot Study. J Neurotrauma 2020; 38:573-581. [PMID: 33096965 DOI: 10.1089/neu.2019.6915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study is to examine the effects of a 12-session moderate intensity-interval-training program with blood flow restriction (BFR) and body cooling (BC) on people who have had persistent post-concussive symptoms (PPCS) for <1 year. A single-blind randomized controlled trial of interval-training exercise with BFR and BC was conducted. Twenty-five adults with PPCS were assigned to the experimental group (n = 14) or the control group (n = 11). Both groups rode a recumbent elliptical machine for 21 min at moderate intensity (65% predicted maximum heart rate) twice a week for 6 weeks, but only the experimental group received BFR and BC while riding. The variances of overall PPCS scale scores and their sub-domain scores for individuals during the 6-week intervention and 6-week follow-up period were calculated. During the intervention, the fluctuation of overall symptom severity, severity in the cognitive domain and severity in the mood domain were significantly less in the experimental group (p = 0.03; p = 0.02; p = 0.02). During the follow-up period, the number of symptoms remained more stable in the experimental group (p = 0.02), and a trend toward less fluctuation of symptom severity (p = 0.05) was also observed. The reduced number of symptoms in the cognitive and sleep domains remained more stable in the experimental group following the intervention (p = 0.007; p = 0.02). The severity of mood and sleep symptoms also remained more stable during the follow-up period in the experimental group (p = 0.04). More stable recovery was found in individuals who exercised using BFR and BC than in those who underwent exercise without BFR and BC. Moderate intensity-interval-training exercise with BFR and BC alleviated post-concussive symptoms in people who have had PPCS <1 year.
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Affiliation(s)
- Yi-Ning Wu
- Department of Physical Therapy and Kinesiology, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Caroline Stark
- Department of Physical Therapy and Kinesiology, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Jessica Gravel
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Matthew White
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Josh Avery
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Terrie Enis
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Robert C Cantu
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
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36
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Wright MJ, Monti MM, Lutkenhoff ES, Hardy DJ, Litvin PY, Kelly DF, Guskiewicz K, Cantu RC, Vespa PM, Hovda DA, Lopez WD, Wang C, Swerdloff R, Fuster JM. Memory in repeat sports-related concussive injury and single-impact traumatic brain injury. Brain Inj 2020; 34:1666-1673. [PMID: 32990043 DOI: 10.1080/02699052.2020.1825806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Repeat sports-related concussive/subconcussive injury (RC/SCI) is related to memory impairment. Objective & Methods: We sought to determine memory differences between persons with RC/SCI, moderate-to-severe single-impact traumatic brain injury (SI-TBI), and healthy controls. MRI scans from a subsample of participants with SI-TBI were used to identify the neuroanatomical correlates of observed memory process differences between the brain injury groups. Results: Both brain injury groups evidenced worse learning and recall in contrast to controls, although SI-TBI group had poorer memory than the RC/SCI group. Regarding memory process differences, in contrast to controls, the SI-TBI group evidenced difficulties with encoding, consolidation, and retrieval, while the RC/SCI group showed deficits in consolidation and retrieval. Delayed recall was predicted by encoding, with consolidation as a secondary predictor in the SI-TBI group. In the RC/SCI group, delayed recall was only predicted by consolidation. MRI data showed that the consolidation index we used mapped onto hippocampal atrophy. Conclusions: RC/SCI is primarily associated with consolidation deficits, which differs from SI-TBI. Given the role of the hippocampus in memory consolidation and the fact that hyperphosphorylated tau tends to accumulate in the medial temporal lobe in RC/SCI, consolidation deficits may be a cognitive marker of chronic traumatic encephalopathy in athletes.
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Affiliation(s)
- Matthew J Wright
- Lundquist Institute at Harbor-UCLA Medical Center , Torrance, California, USA.,Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine , Los Angeles, California, USA
| | - Martin M Monti
- Department of Psychology, UCLA , Los Angeles, California, USA.,Department of Neurosurgery, UCLA School of Medicine , Los Angeles, California, USA
| | - Evan S Lutkenhoff
- Department of Psychology, UCLA , Los Angeles, California, USA.,Department of Neurosurgery, UCLA School of Medicine , Los Angeles, California, USA
| | - David J Hardy
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine , Los Angeles, California, USA.,Department of Psychology, Loyola Marymount University , Los Angeles, California, USA
| | - Pavel Y Litvin
- Lundquist Institute at Harbor-UCLA Medical Center , Torrance, California, USA
| | - Daniel F Kelly
- Department of Neurosurgery, Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center , Santa Monica, California, USA
| | - Kevin Guskiewicz
- Department of Exercise & Sports Science, Center for the Study of Retired Athletes at the University of North Carolina , Chapel Hill, North Carolina, USA
| | - Robert C Cantu
- Department of Neurosurgery, Boston University School of Medicine , Boston, Massachusetts, USA
| | - Paul M Vespa
- Department of Neurosurgery, UCLA School of Medicine , Los Angeles, California, USA.,Department of Neurology, UCLA School of Medicine , Los Angeles, California, USA
| | - David A Hovda
- Department of Neurosurgery, UCLA School of Medicine , Los Angeles, California, USA
| | - Walter D Lopez
- Lundquist Institute at Harbor-UCLA Medical Center , Torrance, California, USA
| | - Christina Wang
- Lundquist Institute at Harbor-UCLA Medical Center , Torrance, California, USA
| | - Ronald Swerdloff
- Lundquist Institute at Harbor-UCLA Medical Center , Torrance, California, USA
| | - Joaquín M Fuster
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine , Los Angeles, California, USA
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37
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Alosco ML, Cherry JD, Huber BR, Tripodis Y, Baucom Z, Kowall NW, Saltiel N, Goldstein LE, Katz DI, Dwyer B, Daneshvar DH, Palmisano JN, Martin B, Cantu RC, Stern RA, Alvarez VE, Mez J, Stein TD, McKee AC. Characterizing tau deposition in chronic traumatic encephalopathy (CTE): utility of the McKee CTE staging scheme. Acta Neuropathol 2020; 140:495-512. [PMID: 32778942 PMCID: PMC7914059 DOI: 10.1007/s00401-020-02197-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a tauopathy associated with repetitive head impacts (RHI) that has been neuropathologically diagnosed in American football players and other contact sport athletes. In 2013, McKee and colleagues proposed a staging scheme for characterizing the severity of the hyperphosphorylated tau (p-tau) pathology, the McKee CTE staging scheme. The staging scheme defined four pathological stages of CTE, stages I(mild)-IV(severe), based on the density and regional deposition of p-tau. The objective of this study was to test the utility of the McKee CTE staging scheme, and provide a detailed examination of the regional distribution of p-tau in CTE. We examined the relationship between the McKee CTE staging scheme and semi-quantitative and quantitative assessments of regional p-tau pathology, age at death, dementia, and years of American football play among 366 male brain donors neuropathologically diagnosed with CTE (mean age 61.86, SD 18.90). Spearman's rho correlations showed that higher CTE stage was associated with higher scores on all semi-quantitative and quantitative assessments of p-tau severity and density (p's < 0.001). The severity and distribution of CTE p-tau followed an age-dependent progression: older age was associated with increased odds for having a higher CTE stage (p < 0.001). CTE stage was independently associated with increased odds for dementia (p < 0.001). K-medoids cluster analysis of the semi-quantitative scales of p-tau across 14 regions identified 5 clusters of p-tau that conformed to increasing CTE stage (stage IV had 2 slightly different clusters), age at death, dementia, and years of American football play. There was a predilection for p-tau pathology in five regions: dorsolateral frontal cortex (DLF), superior temporal cortex, entorhinal cortex, amygdala, and locus coeruleus (LC), with CTE in the youngest brain donors and lowest CTE stage restricted to DLF and LC. These findings support the usefulness of the McKee CTE staging scheme and demonstrate the regional distribution of p-tau in CTE.
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Affiliation(s)
- Michael L Alosco
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
| | - Jonathan D Cherry
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
| | - Bertrand Russell Huber
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
- National Center for PTSD, VA Boston Healthcare, Boston, USA
| | - Yorghos Tripodis
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, USA
| | - Zachary Baucom
- Department of Biostatistics, Boston University School of Public Health, Boston, USA
| | - Neil W Kowall
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
| | - Nicole Saltiel
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
| | - Lee E Goldstein
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, USA
- Department of Ophthalmology, Boston University School of Medicine, Boston, USA
- Department of Biomedical Engineering, Boston University College of Engineering, Boston, USA
- Department of Electrical and Computer Engineering, Boston University College of Engineering, Boston, USA
| | - Douglas I Katz
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Brigid Dwyer
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Daniel H Daneshvar
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
| | - Joseph N Palmisano
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, USA
| | - Brett Martin
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, USA
| | - Robert C Cantu
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Department of Neurosurgery, Boston University School of Medicine, Boston, USA
- Concussion Legacy Foundation, Boston, MA, USA
- Department of Neurosurgery, Emerson Hospital, Concord, USA
| | - Robert A Stern
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Department of Neurosurgery, Boston University School of Medicine, Boston, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, USA
| | - Victor E Alvarez
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Jesse Mez
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
| | - Thor D Stein
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Ann C McKee
- Department of Neurology, Boston University Alzheimer's Disease and CTE Centers, Boston University School of Medicine, Boston, USA.
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, USA.
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, MA, USA.
- Department of Veterans Affairs Medical Center, Bedford, MA, USA.
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Alosco ML, Tripodis Y, Rowland B, Chua AS, Liao H, Martin B, Jarnagin J, Chaisson CE, Pasternak O, Karmacharya S, Koerte IK, Cantu RC, Kowall NW, McKee AC, Shenton ME, Greenwald R, McClean M, Stern RA, Lin A. A magnetic resonance spectroscopy investigation in symptomatic former NFL players. Brain Imaging Behav 2020; 14:1419-1429. [PMID: 30848432 PMCID: PMC6994233 DOI: 10.1007/s11682-019-00060-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The long-term neurologic consequences of exposure to repetitive head impacts (RHI) are not well understood. This study used magnetic resonance spectroscopy (MRS) to examine later-life neurochemistry and its association with RHI and clinical function in former National Football League (NFL) players. The sample included 77 symptomatic former NFL players and 23 asymptomatic individuals without a head trauma history. Participants completed cognitive, behavior, and mood measures. N-acetyl aspartate, glutamate/glutamine, choline, myo-inositol, creatine, and glutathione were measured in the posterior (PCG) and anterior (ACG) cingulate gyrus, and parietal white matter (PWM). A cumulative head impact index (CHII) estimated RHI. In former NFL players, a higher CHII correlated with lower PWM creatine (r = -0.23, p = 0.02). Multivariate mixed-effect models examined neurochemical differences between the former NFL players and asymptomatic individuals without a history of head trauma. PWM N-acetyl aspartate was lower among the former NFL players (mean diff. = 1.02, p = 0.03). Between-group analyses are preliminary as groups were recruited based on symptomatic status. The ACG was the only region associated with clinical function, including positive correlations between glutamate (r = 0.32, p = 0.004), glutathione (r = 0.29, p = 0.02), and myo-inositol (r = 0.26, p = 0.01) with behavioral/mood symptoms. Other positive correlations between ACG neurochemistry and clinical function emerged (i.e., behavioral/mood symptoms, cognition), but the positive directionality was unexpected. All analyses controlled for age, body mass index, and education (for analyses examining clinical function). In this sample of symptomatic former NFL players, there was a direct effect between RHI and reduced cellular energy metabolism (i.e., lower creatine). MRS neurochemicals associated with neuroinflammation also correlated with behavioral/mood symptoms.
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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, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Benjamin Rowland
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 4 Blackfan Street HIM-820, Boston, MA, 02115, USA
| | - Alicia S Chua
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Huijun Liao
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 4 Blackfan Street HIM-820, Boston, MA, 02115, USA
| | - Brett Martin
- Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston, MA, USA
- Biostatistics & Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Johnny Jarnagin
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Christine E Chaisson
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- Biostatistics & Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Ofer Pasternak
- Departments of Psychiatry and Radiology, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarina Karmacharya
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Inga K Koerte
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Child and Adolescent Psychiatry, Psychosomatic, and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
| | - Robert C Cantu
- Boston University Alzheimer's Disease and CTE Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, Boston, MA, USA
- Concussion Legacy Foundation, Boston, MA, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease and CTE Center, Departments of Neurology, and Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA
- Neurology Service, VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease and CTE Center, Departments of Neurology, and Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Martha E Shenton
- Departments of Psychiatry and Radiology, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
| | - Richard Greenwald
- Simbex, Lebanon, NH, USA
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Michael McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease and CTE Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA
| | - Alexander Lin
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 4 Blackfan Street HIM-820, Boston, MA, 02115, USA.
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39
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Lopez V, Ma R, Weinstein MG, Hume PA, Cantu RC, Victoria C, Queler SC, Webb KJA, Allen AA. United States Under-19 Rugby-7s: Incidence and Nature of Match Injuries During a 5-year Epidemiological Study. Sports Med Open 2020; 6:41. [PMID: 32852666 PMCID: PMC7452962 DOI: 10.1186/s40798-020-00261-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 07/10/2020] [Indexed: 11/10/2022]
Abstract
Background There is a lack of injury data for the new Olympic sport of Rugby-7s, particularly for involved youth. Objective To determine injury rates and characteristics for players participating in U.S. Rugby-7s U19 (under 19 years of age) tournaments. Methods Injury data were collected, using the Rugby Injury Survey & Evaluation report methodology, at 24 U.S. Rugby-7 s U19 tournaments over 30 tournament days (2010–2014). Tournament medical-attention injuries and time-loss injuries (days absent before return to training/competition including post tournament) were recorded. Results During the 2101 playing hours (3072 males, aged 17.2 ± 1.5 years; 732 females, 16.6 ± 1.3 years of age), there were 173 tournament injuries with an overall injury incidence of 82.4/1000 player-match-hours (ph) (CI 70.5–95.6). Acute injuries (79.5/1000 ph) occurred during tackling (56.2/1000 ph) and involved joints/ligaments (32.8/1000 ph) of lower extremities (31.9/1000 ph). Head and neck injuries, including concussions, were common (males 21.9/1000 ph; females 22.0/1000 ph). Medical-attention injury incidences (49.5/1000 ph; n = 104; 95% CI 40.5–60.0) were higher than time loss (32.8/1000 ph; n = 69; 95% CI 25.5–41.6). Overall, injury incidences found no difference between sex (RR 0.78; p = 0.369). Time-loss injuries resulted in an average of 35.5 d to return to sport. Discussion This study is the first to report match injury incidences for U19 participants in Rugby-7s. Overall, match injury incidence among U.S. U19 Rugby-7s tournaments was similar compared to adult U.S. community Rugby-7s. Recurrent injury risk was notable in this population. Community injury surveillance studies are essential to understand risk from participation in amateur sports. Knowledge of these injury patterns in U19 Rugby-7s will help identify areas to direct resources to enable growth of Rugby-7s in youths and emerging countries being exposed to Rugby-7 s. Age-based injury frequency and patterns in rugby and its various formats are needed for the development of evidence-based, sport-specific, and population-specific injury prevention initiatives. Conclusions The match injury incidence of U19 participants in U.S. Rugby-7s was similar to the incidence among adult participants. Recurrent match injury risk was high at 23%. There were no significant differences in injury incidences between males and females. The first three matches of a tournament day result in the most injuries.
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Affiliation(s)
- Victor Lopez
- Rugby Research and Injury Prevention Group, affiliate Hospital for Special Surgery, 118-17 Union Turnpike, Suite 3B, New York, NY, 11375, USA. .,Auckland University of Technology, Sports Performance Research Institute New Zealand, New Zealand, AUT Millennium, 17 Antares Place, Mairangi Bay, Private Bag 92006, Auckland, 1142, New Zealand. .,USA Rugby Empire Geographic Union RFUs, P.O. Box 488, Bowling Green Station, New York, NY, 10274, USA. .,USA Rugby New England Geographic Union RFU, 2193 Commonwealth Ave, Box 364, Brighton, MA, 02135, USA. .,Northeast Rugby Academy, USA Rugby Development Program and USOC-Community Olympic Development Program, New York, NY, USA.
| | - Richard Ma
- Rugby Research and Injury Prevention Group, affiliate Hospital for Special Surgery, 118-17 Union Turnpike, Suite 3B, New York, NY, 11375, USA.,Auckland University of Technology, Sports Performance Research Institute New Zealand, New Zealand, AUT Millennium, 17 Antares Place, Mairangi Bay, Private Bag 92006, Auckland, 1142, New Zealand.,Northeast Rugby Academy, USA Rugby Development Program and USOC-Community Olympic Development Program, New York, NY, USA.,University of Missouri, Missouri Orthopaedic Institute & Thompson Laboratory for Regenerative Orthopaedics, Columbia, MO, USA
| | - Meryle G Weinstein
- Rugby Research and Injury Prevention Group, affiliate Hospital for Special Surgery, 118-17 Union Turnpike, Suite 3B, New York, NY, 11375, USA.,New York University, Department of Applied Statistics, Social Sciences, and Humanities, New York, NY, USA
| | - Patria A Hume
- Auckland University of Technology, Sports Performance Research Institute New Zealand, New Zealand, AUT Millennium, 17 Antares Place, Mairangi Bay, Private Bag 92006, Auckland, 1142, New Zealand
| | - Robert C Cantu
- Center for the Study of Traumatic Encephalopathy, Boston University School of Medicine, Boston, MA, USA.,Cantu Concussion Center, Department of Neurosurgery and Sports Medicine, Emerson Hospital, Concord, MA, USA.,Neurologic Sports Injury Center, Brigham and Women's Hospital, Boston, MA, USA.,Concussion Legacy Foundation, Waltham, MA, USA.,World Rugby, Independent Concussion Group, Dublin, Ireland
| | - Christian Victoria
- Rugby Research and Injury Prevention Group, affiliate Hospital for Special Surgery, 118-17 Union Turnpike, Suite 3B, New York, NY, 11375, USA.,New York University, College of Global Public Health, New York, NY, USA
| | - Sophie C Queler
- Rugby Research and Injury Prevention Group, affiliate Hospital for Special Surgery, 118-17 Union Turnpike, Suite 3B, New York, NY, 11375, USA.,Tulane University, New Orleans, LA, USA
| | - Khalil J A Webb
- Rugby Research and Injury Prevention Group, affiliate Hospital for Special Surgery, 118-17 Union Turnpike, Suite 3B, New York, NY, 11375, USA.,University of Arizona, Tucson, AZ, USA
| | - Answorth A Allen
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA.,National Basketball Association, New York Knickerbockers, New York, NY, USA.,USA Basketball, Colorado Springs, CO, USA
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Abstract
The long-term effects of repetitive head impacts have been recognized for close to a century. What is now referred to as chronic traumatic encephalopathy (CTE) was first described by Martland in 1928 in a series of boxers. Over the years, several important articles were published, including Critchley's 1957 report where he introduced the term "chronic traumatic encephalopathy," Robert's study in 1969 which provided evidence of the prevalence of neurological impairment in retired fighters, and Corsellis' initial description of the pathology of CTE. However, what brought public attention to the issue of CTE in sports were the postmortem findings of CTE pathology in professional American football players, initially reported by Omalu and subsequently in a large series by McKee. There is now standardization of pathological criteria for CTE and recognition that it can be seen across all activities that involve repetitive head impacts.
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Affiliation(s)
- Robert C Cantu
- Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, Massachusetts
| | - Charles Bernick
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, Nevada
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41
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Mez J, Daneshvar DH, Abdolmohammadi B, Chua AS, Alosco ML, Kiernan PT, Evers L, Marshall L, Martin BM, Palmisano JN, Nowinski CJ, Mahar I, Cherry JD, Alvarez VE, Dwyer B, Huber BR, Stein TD, Goldstein LE, Katz DI, Cantu RC, Au R, Kowall NW, Stern RA, McClean MD, Weuve J, Tripodis Y, McKee AC. Duration of American Football Play and Chronic Traumatic Encephalopathy. Ann Neurol 2020; 87:116-131. [PMID: 31589352 PMCID: PMC6973077 DOI: 10.1002/ana.25611] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 08/27/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with exposure to contact and collision sports, including American football. We hypothesized a dose-response relationship between duration of football played and CTE risk and severity. METHODS In a convenience sample of 266 deceased American football players from the Veterans Affairs-Boston University-Concussion Legacy Foundation and Framingham Heart Study Brain Banks, we estimated the association of years of football played with CTE pathological status and severity. We evaluated the ability of years played to classify CTE status using receiver operating characteristic curve analysis. Simulation analyses quantified conditions that might lead to selection bias. RESULTS In total, 223 of 266 participants met neuropathological diagnostic criteria for CTE. More years of football played were associated with having CTE (odds ratio [OR] = 1.30 per year played, 95% confidence interval [CI] = 1.19-1.41; p = 3.8 × 10-9 ) and with CTE severity (severe vs mild; OR = 1.14 per year played, 95% CI = 1.07-1.22; p = 3.1 × 10-4 ). Participants with CTE were 1/10th as likely to have played <4.5 years (negative likelihood ratio [LR] = 0.102, 95% CI = 0.100-0.105) and were 10 times as likely to have played >14.5 years (positive LR = 10.2, 95% CI = 9.8-10.7) compared with participants without CTE. Sensitivity and specificity were maximized at 11 years played. Simulation demonstrated that years played remained adversely associated with CTE status when years played and CTE status were both related to brain bank selection across widely ranging scenarios. INTERPRETATION The odds of CTE double every 2.6 years of football played. After accounting for brain bank selection, the magnitude of the relationship between years played and CTE status remained consistent. ANN NEUROL 2020;87:116-131.
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Alosco ML, Tripodis Y, Koerte IK, Jackson JD, Chua AS, Mariani M, Haller O, Foley ÉM, Martin BM, Palmisano J, Singh B, Green K, Lepage C, Muehlmann M, Makris N, Cantu RC, Lin AP, Coleman M, Pasternak O, Mez J, Bouix S, Shenton ME, Stern RA. Interactive Effects of Racial Identity and Repetitive Head Impacts on Cognitive Function, Structural MRI-Derived Volumetric Measures, and Cerebrospinal Fluid Tau and Aβ. Front Hum Neurosci 2019; 13:440. [PMID: 31920598 PMCID: PMC6933867 DOI: 10.3389/fnhum.2019.00440] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 12/02/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Factors of increased prevalence among individuals with Black racial identity (e.g., cardiovascular disease, CVD) may influence the association between exposure to repetitive head impacts (RHI) from American football and later-life neurological outcomes. Here, we tested the interaction between racial identity and RHI on neurobehavioral outcomes, brain volumetric measures, and cerebrospinal fluid (CSF) total tau (t-tau), phosphorylated tau (p-tau181), and Aβ1 - 42 in symptomatic former National Football League (NFL) players. METHODS 68 symptomatic male former NFL players (ages 40-69; n = 27 Black, n = 41 White) underwent neuropsychological testing, structural MRI, and lumbar puncture. FreeSurfer derived estimated intracranial volume (eICV), gray matter volume (GMV), white matter volume (WMV), subcortical GMV, hippocampal volume, and white matter (WM) hypointensities. Multivariate generalized linear models examined the main effects of racial identity and its interaction with a cumulative head impact index (CHII) on all outcomes. Age, years of education, Wide Range Achievement Test, Fourth Edition (WRAT-4) scores, CVD risk factors, and APOEε4 were included as covariates; eICV was included for MRI models. P-values were false discovery rate adjusted. RESULTS Compared to White former NFL players, Black participants were 4 years younger (p = 0.04), had lower WRAT-4 scores (mean difference = 8.03, p = 0.002), and a higher BMI (mean difference = 3.09, p = 0.01) and systolic blood pressure (mean difference = 8.15, p = 0.03). With regards to group differences on the basis of racial identity, compared to White former NFL players, Black participants had lower GMV (mean adjusted difference = 45649.00, p = 0.001), lower right hippocampal volume (mean adjusted difference = 271.96, p = 0.02), and higher p-tau181/t-tau ratio (mean adjusted difference = -0.25, p = 0.01). There was not a statistically significant association between the CHII with GMV, right hippocampal volume, or p-tau181/t-tau ratio. However, there was a statistically significant Race x CHII interaction for GMV (b = 2206.29, p = 0.001), right hippocampal volume (b = 12.07, p = 0.04), and p-tau181/t-tau ratio concentrations (b = -0.01, p = 0.004). CONCLUSION Continued research on racial neurological disparities could provide insight into risk factors for long-term neurological disorders associated with American football play.
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Affiliation(s)
- Michael L. Alosco
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Yorghos Tripodis
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Inga K. Koerte
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatic, and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
| | - Jonathan D. Jackson
- CARE Research Center, Massachusetts General Hospital, Boston, MA, United States
| | - Alicia S. Chua
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Megan Mariani
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Olivia Haller
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Éimear M. Foley
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
| | - Brett M. Martin
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, United States
| | - Joseph Palmisano
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, United States
| | - Bhupinder Singh
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Katie Green
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Christian Lepage
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Marc Muehlmann
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Nikos Makris
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Center for Morphometric Analysis, Massachusetts General Hospital, Boston, MA, United States
- Center for Neural Systems Investigations, Massachusetts General Hospital, Boston, MA, United States
| | - Robert C. Cantu
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
- Concussion Legacy Foundation, Boston, MA, United States
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA, United States
- Department of Neurosurgery, Emerson Hospital, Concord, MA, United States
| | - Alexander P. Lin
- Department of Radiology, Center for Clinical Spectroscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael Coleman
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Ofer Pasternak
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Jesse Mez
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
| | - Sylvain Bouix
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Martha E. Shenton
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Brockton, MA, United States
| | - Robert A. Stern
- Boston University Alzheimer’s Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA, United States
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, United States
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Davis GA, Ellenbogen RG, Bailes J, Cantu RC, Johnston KM, Manley GT, Nagahiro S, Sills A, Tator CH, McCrory P. The Berlin International Consensus Meeting on Concussion in Sport. Neurosurgery 2019; 82:232-236. [PMID: 29106653 DOI: 10.1093/neuros/nyx344] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 05/19/2017] [Indexed: 11/14/2022] Open
Abstract
The Fifth International Conference on Concussion in Sport was held in Berlin in October 2016. A series of 12 questions and subquestions was developed and the expert panel members were required to perform a systematic review to answer each question. Following presentation at the Berlin meeting of the systematic review, poster abstracts and audience discussion, the summary Consensus Statement was produced. Further, a series of tools for the management of sport-related concussion was developed, including the Sport Concussion Assessment Tool Fifth edition (SCAT5), the Child SCAT5, and the Concussion Recognition Tool Fifth edition. This paper elaborates on this process, the outcomes, and explores the implications for neurosurgeons in the management of sport-related concussion.
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Affiliation(s)
- Gavin A Davis
- Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health-Austin Campus, Heidelberg, Australia.,Murdoch Childrens Research Institute, Melbourne; Cabrini Medical Centre, Malvern, Victoria and Austin Health, Heidelberg, Australia
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Julian Bailes
- Department of Neurosurgery, North Shore University Health System, Evanston, Illinois
| | - Robert C Cantu
- Centre for the Study of Traumatic Encephalopathy, Boston University School of Medicine, Boston, Massachusetts
| | - Karen M Johnston
- Division of Neurosurgery, University of Toronto; Concussion Management Program AESM, Toronto, Ontario, Canada
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, California
| | - Shinji Nagahiro
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Allen Sills
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Charles H Tator
- Division of Neurosurgery and Canadian Concussion Centre, Toronto Western Hospital and University of Toronto, Toronto, Canada
| | - Paul McCrory
- Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health-Austin Campus, Heidelberg, Australia
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Standring OJ, Friedberg J, Tripodis Y, Chua AS, Cherry JD, Alvarez VE, Huber BR, Xia W, Mez J, Alosco ML, Nicks R, Mahar I, Pothast MJ, Gardner HM, Meng G, Palmisano JN, Martin BM, Dwyer B, Kowall NW, Cantu RC, Goldstein LE, Katz DI, Stern RA, McKee AC, Stein TD. Contact sport participation and chronic traumatic encephalopathy are associated with altered severity and distribution of cerebral amyloid angiopathy. Acta Neuropathol 2019; 138:401-413. [PMID: 31183671 DOI: 10.1007/s00401-019-02031-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 05/24/2019] [Accepted: 05/26/2019] [Indexed: 12/14/2022]
Abstract
Cerebral amyloid angiopathy (CAA) consists of beta-amyloid deposition in the walls of the cerebrovasculature and is commonly associated with Alzheimer's disease (AD). However, the association of CAA with repetitive head impacts (RHI) and with chronic traumatic encephalopathy (CTE) is unknown. We evaluated the relationship between RHI from contact sport participation, CTE, and CAA within a group of deceased contact sport athletes (n = 357), a community-based cohort (n = 209), and an AD cohort from Boston University AD Center (n = 241). Unsupervised hierarchal cluster analysis demonstrated a unique cluster (n = 11) with increased CAA in the leptomeningeal vessels compared to the intracortical vessels (p < 0.001) comprised of participants with significantly greater frequencies of CTE (7/11) and history of RHI. Overall, participants with CTE (n = 251) had more prevalent (p < 0.001) and severe (p = 0.010) CAA within the frontal leptomeningeal vessels compared to intracortical vessels. Compared to those with AD, participants with CTE had more severe CAA in frontal than parietal lobes (p < 0.001) and more severe CAA in leptomeningeal than intracortical vessels (p = 0.002). The overall frequency of CAA in participants with CTE was low, and there was no significant association between contact sport participation and the presence of CAA. However, in those with CAA, a history of contact sports was associated with increased CAA severity in the frontal leptomeningeal vessels (OR = 4.01, 95% CI 2.52-6.38, p < 0.001) adjusting for AD, APOE ε4 status, and age. Participants with CAA had increased levels of sulcal tau pathology and decreased levels of the synaptic marker PSD-95 (p's < 0.05), and CAA was a predictor of dementia (OR = 1.75, 95% CI 1.02-2.99, p = 0.043) adjusting for age, sex, and comorbid pathology. Overall, contact sport participation and CTE were associated with more severe frontal and leptomeningeal CAA, and CAA was independently associated with worse pathological and clinical outcomes.
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Affiliation(s)
- Oliver J Standring
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
| | - Jacob Friedberg
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
| | - Yorghos Tripodis
- Department of Biostatistics, School of Public Health, Boston University, Boston, MA, 20118, USA
| | - Alicia S Chua
- Department of Biostatistics, School of Public Health, Boston University, Boston, MA, 20118, USA
| | - Jonathan D Cherry
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Victor E Alvarez
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
- Department of Veterans Affairs Medical Centers, Bedford, MA, 01730, USA
| | - Bertrand R Huber
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Weiming Xia
- Department of Veterans Affairs Medical Centers, Bedford, MA, 01730, USA
| | - Jesse Mez
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Michael L Alosco
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Raymond Nicks
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- Department of Veterans Affairs Medical Centers, Bedford, MA, 01730, USA
| | - Ian Mahar
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Morgan J Pothast
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Veterans Affairs Medical Centers, Bedford, MA, 01730, USA
| | - Hannah M Gardner
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
| | - Gaoyuan Meng
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Veterans Affairs Medical Centers, Bedford, MA, 01730, USA
| | - Joseph N Palmisano
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, USA
| | - Brett M Martin
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, USA
| | - Brigid Dwyer
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
- Braintree Rehabilitation Hospital, Braintree, MA, 02118, USA
| | - Neil W Kowall
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
| | - Robert C Cantu
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, 20119, USA
- Concussion Legacy Foundation, Boston, MA, 02115, USA
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA, 02118, USA
- Department of Neurosurgery, Emerson Hospital, Concord, MA, 01742, USA
| | - Lee E Goldstein
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- Departments of Psychiatry, Ophthalmology, Boston University School of Medicine, Boston, USA
- Departments of Biomedical, Electrical and Computer Engineering, Boston University College of Engineering, Boston, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Douglas I Katz
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
- Braintree Rehabilitation Hospital, Braintree, MA, 02118, USA
| | - Robert A Stern
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, 20119, USA
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Ann C McKee
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, 20118, USA
- Department of Veterans Affairs Medical Centers, Bedford, MA, 01730, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Thor D Stein
- Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston University, Boston, MA, 02118, USA.
- VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA.
- Department of Veterans Affairs Medical Centers, Bedford, MA, 01730, USA.
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.
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Alosco ML, Mez J, Tripodis Y, Kiernan PT, Abdolmohammadi B, Murphy L, Kowall NW, Stein TD, Huber BR, Goldstein LE, Cantu RC, Katz DI, Chaisson CE, Martin B, Solomon TM, McClean MD, Daneshvar DH, Nowinski CJ, Stern RA, McKee AC. Age of first exposure to tackle football and chronic traumatic encephalopathy. Ann Neurol 2019; 83:886-901. [PMID: 29710395 DOI: 10.1002/ana.25245] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 04/09/2018] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To examine the effect of age of first exposure to tackle football on chronic traumatic encephalopathy (CTE) pathological severity and age of neurobehavioral symptom onset in tackle football players with neuropathologically confirmed CTE. METHODS The sample included 246 tackle football players who donated their brains for neuropathological examination. Two hundred eleven were diagnosed with CTE (126 of 211 were without comorbid neurodegenerative diseases), and 35 were without CTE. Informant interviews ascertained age of first exposure and age of cognitive and behavioral/mood symptom onset. RESULTS Analyses accounted for decade and duration of play. Age of exposure was not associated with CTE pathological severity, or Alzheimer's disease or Lewy body pathology. In the 211 participants with CTE, every 1 year younger participants began to play tackle football predicted earlier reported cognitive symptom onset by 2.44 years (p < 0.0001) and behavioral/mood symptoms by 2.50 years (p < 0.0001). Age of exposure before 12 predicted earlier cognitive (p < 0.0001) and behavioral/mood (p < 0.0001) symptom onset by 13.39 and 13.28 years, respectively. In participants with dementia, younger age of exposure corresponded to earlier functional impairment onset. Similar effects were observed in the 126 CTE-only participants. Effect sizes were comparable in participants without CTE. INTERPRETATION In this sample of deceased tackle football players, younger age of exposure to tackle football was not associated with CTE pathological severity, but predicted earlier neurobehavioral symptom onset. Youth exposure to tackle football may reduce resiliency to late-life neuropathology. These findings may not generalize to the broader tackle football population, and informant-report may have affected the accuracy of the estimated effects. Ann Neurol 2018;83:886-901.
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Affiliation(s)
- Michael L Alosco
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Jesse Mez
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Patrick T Kiernan
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ
| | - Bobak Abdolmohammadi
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Lauren Murphy
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Neil W Kowall
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Departments of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA.,VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA
| | - Thor D Stein
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Departments of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA.,VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA.,Department of Veterans Affairs Medical Center, Bedford, MA
| | - Bertrand Russell Huber
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA
| | - Lee E Goldstein
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Departments of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA.,Departments of Psychiatry, Ophthalmology, Boston University School of Medicine, Boston, MA.,Departments of Biomedical, Electrical & Computer Engineering, Boston University College of Engineering, Boston, MA
| | - Robert C Cantu
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Department of Neurosurgery, Boston University School of Medicine, Boston, MA.,Concussion Legacy Foundation, Boston, MA.,Department of Neurosurgery, Emerson Hospital, Boston, MA
| | - Douglas I Katz
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Braintree Rehabilitation Hospital, Braintree, MA
| | - Christine E Chaisson
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Data Coordinating Center, Boston University School of Public Health, Boston, MA
| | - Brett Martin
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Data Coordinating Center, Boston University School of Public Health, Boston, MA
| | - Todd M Solomon
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Michael D McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | - Daniel H Daneshvar
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Department of Orthopaedics, Stanford University, Stanford, CA
| | - Christopher J Nowinski
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Concussion Legacy Foundation, Boston, MA
| | - Robert A Stern
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Department of Neurosurgery, Boston University School of Medicine, Boston, MA.,Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA
| | - Ann C McKee
- Boston University Alzheimer's Disease and CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA.,Departments of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA.,VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA.,Department of Veterans Affairs Medical Center, Bedford, MA
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Abstract
While even today there is no uniformly agreed upon "gold standard" definition of concussion, concussion research dates back to the late 19th century. Historically, most researchers have believed that it does not matter where, how, or why the brain was injured, the only fact that mattered was that the brain was injured. The dangers of repeated concussions were chronicled as far back as 1870 by James Crighton Brown who warned that anyone suffering such an injury should avoid another forever after. In 1952, Harvard Physician Augustus Thorndike proposed that 3 concussions in a collision sport were sufficient to advise retirement from the sport. And in 1975, Gronwall and Wrightson suggested medical authorities had a duty to convince sporting authorities that the effects of concussions were cumulative. While most definitions of concussion prior to the 1970s involved a loss of consciousness or amnesia, there are numerous examples that physicians and surgeons knew concussions could occur without the loss of consciousness prior to Trotter's 1924 publication. It was the decade of the 1940s that seminal work on concussion and subconcussive brain trauma was carried out at Boston City Hospital, a Boston University Hospital. This chapter will not only focus on the history of concussion dating to the 18th Century, but also the wonderful research carried out at Boston City Hospital by Derek Denny-Brown, Donald Munro, Houston Merritt and others.
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Affiliation(s)
- Robert C Cantu
- Boston University of Medicine, Boston, MA; Robert C. Cantu Concussion Center, Emerson Hospital, MA; Emerson Hospital, MA; Department of Exercise and Sport Science, UNC at Chapel Hill, Chapel Hill, NC.
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Swartz EE, Myers JL, Cook SB, Guskiewicz KM, Ferrara MS, Cantu RC, Chang H, Broglio SP. A helmetless-tackling intervention in American football for decreasing head impact exposure: A randomized controlled trial. J Sci Med Sport 2019; 22:1102-1107. [PMID: 31204104 DOI: 10.1016/j.jsams.2019.05.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 04/01/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate a behavioral intervention to reduce head impact exposure in youth playing American football. DESIGN Nested randomized controlled trial. METHODS Participants, ages 14-17 years, wore head impact sensors (SIM-G™) during two seasons of play. Those randomized to the intervention group underwent weekly tackling/blocking drills performed without helmets (WoH) and shoulder pads while the control group trained as normal, matching frequency and duration. Research personnel provided daily oversight to maintain fidelity. Head impact frequency (≥10g) per athlete exposure (ImpAE) was analyzed over time (two 11-week seasons) using mixed effect models or ANCOVA. Secondary outcomes included exposure-type (training, game) and participation level (entry-level versus upper-level secondary education). RESULTS One-hundred fifteen participants (59 WoH, 56 control) met compliance criteria, contributing 47,382 head impacts and 10,751 athlete exposures for analysis. WoH had fewer ImpAE during games compared to control participants at weeks 4 (p=0.0001 season 1, p=0.0005 season 2) and 7 (p=0.0001 both seasons). Upper-level WoH participants had less ImpAE during games than their matched controls at weeks 4 (p=0.017 and p=0.026) and 7 (p=0.037 and p=0.014) in both seasons, respectively. Upper-level WoH also had fewer ImpAE during training at week 7 (p=0.015) in season one. CONCLUSIONS Tackling and blocking drills performed without a helmet during training reduced the frequency of head impacts during play, especially during games. However, these differences disappeared by the end of the season. Future research should explore the frequency of behavioral intervention and a dose-response relationship considering years of player experience. TRIAL REGISTRATION ClinicalTrials.gov # NCT02519478.
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Affiliation(s)
- Erik E Swartz
- University of Massachusetts - Lowell, Department of Physical Therapy and Kinesiology, United States; University of New Hampshire, Department of Kinesiology, United States.
| | - Jay L Myers
- University of Massachusetts - Lowell, Department of Physical Therapy and Kinesiology, United States; University of New Hampshire, Department of Kinesiology, United States
| | - Summer B Cook
- University of New Hampshire, Department of Kinesiology, United States
| | | | - Michael S Ferrara
- University of New Hampshire, Department of Kinesiology, United States
| | - Robert C Cantu
- Emerson Hospital, Department of Neurosurgery, United States
| | - Hong Chang
- Clinical and Translational Sciences Institute, Tufts University, United States
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Wu YN, Gravel J, White M, Avery J, Enis T, Stark C, Cantu RC. Moderate Intensity-interval-training With Blood Flow Restriction And Body Cooling For People With Post-concussion Syndrome. Med Sci Sports Exerc 2019. [DOI: 10.1249/01.mss.0000562714.28560.a9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Victoria C, Lopez V, Ompad DC, Ma R, Weinstein MG, Allen AA, Cantu RC. Gender Differences In The Risk Of Head, Neck & Face Injuries In US Rugby-7s. Med Sci Sports Exerc 2019. [DOI: 10.1249/01.mss.0000562787.79835.e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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