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Prevention and Treatment of the Effecfs of Repetitive Brain Trauma Concussion, PCS, CTE

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Prevention and Treatment of the Effecfs of Repetitive Brain Trauma Concussion, PCS, CTE Prevention and Treatment of the Effecfs of Repetitive Brain Trauma Concussion, PCS, CTE Robert C. Cantu, MA, MD, FACS, FACSM, FAANS Clinical Professor of Neurosurgery and Neurology Co-Founder, Medical Director Co-Founder-Clinical Diagnostics and Therapeutics Concussion Legacy Foundation Leader CTE-AD Center Boston University School of Medicine Member Independent Concussion Advisory Group World Rugby Medical Director and Director of Clinical Research Dr. Robert C. Cantu Concussion Center Senior Advisor, NFL Head Neck & Spine Committee Assoc. Chairman, Dept. of Surgery, Member, NFLPA Mackey-White TBI Committee Chief, Neurosurgery Service Director of Sports Medicine Senior Advisor Brain Injury Center Emerson Hospital, Concord, MA Children’s Hospital, Boston MA Medical Director VP and Chair Scientific Advisory Committee National Center for Catastrophic Sports Injury Research National Operating Committee on Standards for Adjunct Professor Athletic Equipment ( NOCSAE ) Dept. of Exercise and Sports Science, UNC Chapel Hill Disclosures • Senior Advisor NFL Head Neck & Spine Committee • VP NOCSAE and Chair Scientific Advisory Committee • Co-Founder, Medical Director Concussion Legacy Foundation • Royalties Houghton Mifflin Harcourt • Legal Expert Opinion (NCAA, NHL etc.) Historical Definitions of concussion • Persian physician Rhazes 10th century AD • before 1974: LOC • 1980’s - ~2000: altered brain function • Currently: any symptom Theories of Concussion • Vascular; brief ischemia, decreased cerebral blood flow • Reticular: brainstem site, effect on the ARAS produces loss of consciousness • Centripetal: Stresses and strains maximal at the brains surface but when severe would make them way to the center of the brain and to the brainstem. • Pontine cholinergic system: activation of the inhibitory system in the dorsal pons • Convulsive: symptoms like those of a seizure but is a brainstem reflex Strain in the Brain: a restating of CTC •The direction, type, rapidity and magnitude of head motions will determine the strains in the brain •A particular set of input variables will produce a particular and unique “strain field/time profile” •Certain “strain-field/time profiles” will result in clinically apparent symptoms (phenotypic presentation) and pathological alterations Visualizing a Concussion • The brain is the consistency of custard or Jell-O • A concussion can occur due to linear acceleration where the brain slams into the rough interior of the skull Visualizing a Concussion • A concussion can be caused by rotational forces, which twist the brain • Most concussions are caused by a combination of both forces Common Concussion Symptoms From SCAT 3 POST-CONCUSSION SYNDROME Physical • Up to 30% of concussive patients have persistent symptoms past the typical healing time-frame, including Vestibulo Emotion -ocular al physical, cognitive, and emotional symptoms, which can last for weeks to months. (Baker, et al, 2012; Mittenberg et al, 2001) Cognitive Sleep Learning with Purpose Diagnosis of Concussion Balance Symptom Assessment Check List Eye(BESS EYE) Eye Cognitive Tracking Assessment Smooth Persuit Saccadic Take away message 1: When diagnosing a concussion the more tools you use the more accurate you will be- there is no golden bullet except LOC Concussion was thought to be a Structural Injury as far Back as the Mid-Nineteenth Century • James Crichton-Brown who was to found the Journal Brain in 1871 wrote: “Concussion is, of course, the most important element in the vast majority of cranial injuries, in relation to subsequent mental infirmity. ….Everything points to the conclusion that the evil of concussion really consists on what may be called dynamical changes in the nerve cells and their connecting fibrils.” Crighton-Browne J. Cranial Injuries and Mental Disease. W Rid Lun Asy Med Rep.1:30-21;1871. Concussion was Thought to be a Structural Injury Mott linked repetitive head trauma with structural changes. Other pathologists including Charles Cassasa, Michael Osnato and Vincent Giliberti and Harrison Martland talked of concussion hemorrhages. • Mott FW. The Lettsomian Lectures on the Effect of High Explosives Upon the Central Nervous System: Lecture II. • Lancet.441-448;1916. • Cassasa CSB. Multiple Traumatic Cerebral Hemorrhages. Proc NY Path Soc.24:101-106;1924. • Osnato M, Giliberti V. Postconcussion Neurosis Traumatic Encephalitis. A Conception of Postconcussion • Phenomena. Arch Neurol Psych. 18:181-214;1927. • Martland HS. Punch Drunk. Jama.91:1103-1107;1928. ion hemorrhages. Take away message 2: Concussion is both a pathophysiologic metabolic as well as a structural injury In the early 1930’s concussion was discussed in a text entitled The Injured Workman by G F Walker. He stated concussions were common enough that “mental impairment of post traumatic origin is surely well-known to every practitioner in industrial districts.” Walker GF. The Injured Workman. Bristol: John Wright & Sons Ltd; quotes on 41-47;1933. Take away message 3: Concussion in a small percent of cases can have permanent effects (prolonged PCS) Fixed Head vs Head That Can Move • Tedeschi reported when 68 animals were divided into two groups in which half a moving head struck a stationary object and the other half a moving object struck a stationary head by a force of exactly the same momentum, it was clear the group in which the head was not able to move had less loss of consciousness (40% vs 73%) and less percentage chance of death (7% vs 17%). Tedeschi CG. Cerebral Injury by Blunt Mechanical Trauma. Special Reference to the Effects of Repeated Impacts of Minimal Intensity; Observations on Experiment Animals. Arch of Neurol. And Psychiatry. 53:333- 354;1945. Take away message 4: Concussion risk is reduced by decreasing the rapid movement of the head (head restraint, neck strength) It was also of interest in a group of animals that received sub concussive trauma that some animals that received repetitive sub concussive trauma (defined as head trauma of such minimal strength as to be insufficient to cause a loss of consciousness or delayed effect in a normal animal) had loss of consciousness as the number of sub concussive insults increased and that some had persistent deficits and some died. Those that received sub concussive repetitive head trauma in close approximation in time unconsciousness began to be seen as soon as the fifth sub concussive blow. It was also concluded that "when the repeated sub concussive blows were delivered in a short period, there was a somewhat higher incidence of ill effects then when the trauma was delivered at longer intervals”. Tedeschi CG. Cerebral Injury by Blunt Mechanical Trauma. Special Reference to the Effects of Repeated Impacts of Minimal Intensity; Observations on Experiment Animals. Arch of Neurol. And Psychiatry. 53:333-354;1945. Evidence Based Cantu Revised Concussion Grading Guidelines Grade 1 No LOC* PTA‡/PCSS‡‡ < 30 min (Mild) Grade 2 LOC <1 min or PTA/PCSS > 30 min (Moderate) Grade 3 LOC > 1 min or PTA > 24 hrs, PCSS > 7 days (Severe) *Loss of consciousness ‡Post-traumatic amnesia (antrograde/retrograde) ‡‡Post-concussion sign/symptoms Cantu RC Post-tramatic (retrograde and anterograde) amnesia: pathophysiology and implications in grading and safe return to play. J of Athletic Training 36(3),2001 Concussion Definitions: Why we are seeing more concussions? Take away message 5: Concussions are not created equally, the duration of symptoms is > important than > proximity of concussions > than number NFL Funded UPMC Hosted Michael “Micky” Collins, PhD Meeting Chair Anthony P. Kontos, PhD David Okonkwo, MD, PhD Co-Organizer Co-Organizer Meeting Chairman Anthony P. Kontos, PhD Anthony P. Kont s Cantu Concussion Center Speech/ Physical Occupational Therapy Language Therapy Pathology Neuropsychology Support Group/Yoga Medical Provider Other: Psychiatry/ Optometry/ Ophthalmology ENT, Endocrinology Psychology Take away message 6: Concussion is treatable with therapies/pharmacology 1995 “I’ve found a disease that no one has ever seen before” Andre Waters Commits Suicide • November 20, 2006 • “I think I lost count at 15.” He later added: “I just wouldn’t say anything. I’d sniff some smelling salts, then go back in there.” 37 HISTORY OF CTE Journal of the American Medical Association 1928 ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF Babinski Cushing Neurology Neurosurgery Critchley Vincent Establishes Neurosurgery in Europe. Martland Parker Millspaugh Courville Jordan 1928 1934 1937 1962 1997 Psychopathic Chronic Punch Traumatic Dementia Located Deterioration Traumatic Drunk Encephalopathy Pugilistica In Holland of the Pugilist Brain Injury • Recently, we uncovered case reports of Punch-drunk football players (aka “stumblebacks”) in the early medical literature (1930s). • Notably, the clinical presentation in those cases was consistent with recent pathologically confirmed cases. The Milwaukee Journal circa 1937 Part of the CTE Archive.org (CTEarchive.com) Impact Growth Time VA-BU-CLF BRAIN BANK • Founded in September 2008, the first center in the world dedicated to CTE research • Pathological, clinical, and basic science research • 500 brains donated, over 350 confirmed with CTE ConcussionFoundation ConcussionFoundation ConcussionFoundation.orgConcussionFoundation.org @ChrisNowinski1@ConcussionLF Christopher Nowinski, a former professional Robert Cantu wrote the original, and wrestler and Harvard defensive tackle, was largely ignored, return-to-play
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