10/20/2018 Current Evidence of Chronic Traumatic Grant funding, salary/employment, consulting fee, Encephalopathy Disclosures honorarium or equity Abbott Diagnostic Laboratories Continuing Legal Education in MN, NY Hennepin County Medical Center Hennepin Health Foundation Integra Corporation Intellectual Property Islamic Medical Association of North America related to concussion Medtronic Corporation and brain injury Minnesota Brain Injury Alliance assessment National Football League Intellectual Property National Neurotrauma Society Uzma Samadani MD PhD FACS related to assessment of North American Brain Injury Society dementia after brain Oculogica Inc Rockswold Kaplan Endowed Chair Traumatic Brain Injury Research injury Steven and Alexandra Cohen Foundation for Veteran Post Intellectual Property Traumatic Stress and Traumatic Brain Injury Hennepin County Medical Center related to treatment of Texas, Minnesota, and Wisconsin High School Coaches intracranial hemorrhage Associations Associate Professor Neurosurgery, University of Minnesota United States Veterans Administration and Office of Research and Development Staff Neurosurgeon, Minneapolis VAMC USA Football What Do These Men Have In Common? Franklin D. Roosevelt in Groton Dwight D. Eisenhower John F. Kennedy enjoyed playing Nixon (top center) seen Gerald Ford played on two national Jimmy Carter played under- School’s 1899 football team, sitting kicking a football at West touch football with family and here as a member of the championship football teams at 140 lb. football at second from left, first row. Point. 1912. friends. He also played football at Whittier (California) squad, Michigan. He played center for the Annapolis.He was a sprint the Dexter School in Brookline, also played college football University of Michigan Wolverines . football played for the Navy Mass. and at the Choate Hall prep Midshipmen. Franklin D. Roosevelt Dwight D. Eisenhower John F. Kennedy Richard Nixon Gerald Ford Jimmy Carter school in Wallingford. Reagan poses as Notre Dame George H. W. Bush pictured Pictured above, Bill Clinton George W. Bush went to the Obama was a star basketball player, Trump , who attended the New football star George Gipp, whom above, playing football in 1980. reaching for the ball at a game Phillips Academy in Andover, winning the state championship in York Military Academy, was a George W. Bush Barack Obama Donald Trump Ronald Reagan George H. W. Bush Bill Clinton Reagan played in the 1940 film He also captained the football in South Carolina. He played Massachusetts, where he was an 1979. Also, in the White House member of the varsity soccer, Knute Rockne All American. team at Yale from 1964-68). touch football when growing all-around athlete, playing Concussion Summit, he recounts his baseball and football teams. up. baseball, basketball and football. early days when he played football. Why is concussion/brain injury so hard to diagnose and define? How do we diagnose and classify these? No two recoveries are the same (functional plasticity, resilience) What are the long-term consequences? Scalp Injury Prognosis Best Skull Injury Compressive Lesions Epidural / Subdural Spinal Cord Injury = Paralysis Inner Ear Injury - Dizziness Subarachnoid Hemorrhage/IVH Diffuse Axonal Injury=CTE Anoxic Brain Injury= Permanent Neuro Deficit Endocrine Dysfunction= Cortical Spreading Depression= Depression, Suicidality Headache, Seizures, Stroke Worst Genetic and environmental contributors to recovery (COMT, BDNF, ApoE, RAR) 1 10/20/2018 Why is concussion/injury so hard to diagnose and Neither imaging nor loss of consciousness tell the whole story define? Some people with brain injury were never “hit” in the head… Inflammation/edema •Primary blast injury: transmission of the blast Diffuse axonal injury pressure wave to the brain. Endocrine dysfunction •Secondary blast injury: penetration of Spreading depolarization (CSD) projectiles through the skull and into the Iron toxicity brain. Physiologic Hypoxic/anoxic Injury •Tertiary blast injury: acceleration and TBI Astroglial scarring (blast) deceleration effects, for example, if the casualty is thrown against fixed surfaces. •Quaternary blast injury: thermal, chemical, and other injuries to the head, including the Structural TBI face, scalp, and respiratory tract. Loss of Schematic diagram of the mechanisms of blast-related traumatic brain injury. Figure shows local effects (1–7) consciousness and systemic effects (8, 9) of primary blast injury, secondary blast injury (10–12), tertiary blast injury (13), quaternary blast injury (14), and portals for blast wave transmission to the brain (15, 16). (1) Acoustic impedance mismatch causes spallation. (2) Shock–bubble interaction. (3) Shear stress causing diffuse axonal injury. (4) Cavitation. (5) Skull deformation with elastic rebound. (6) Reflection of the blast wave within the skull. (7) Bobblehead effect of acceleration–deceleration. (8) Blood surge from the torso damages the microvasculature. (9) Air embolism from blast lung injury.(10) Penetrating fragments. (11) Compound fractured skull. (12) Intracerebral haemorrhage. (13) Contrecoup contusion. (14) Burns. (15) Blast wave transmitted through the orbits. (16) Blast wave transmitted through the nasal sinuses. Rosenfeld et al. Lancet Neurology Blast-related traumatic brain injury, 2013-09-01Z, Volume 12, Issue 9, Pages 882-893 Suicide Risk Is Increased After Concussion 235000 pts followed for 9 years: 31/100,000 >109,000 Swedes under age 25 with TBI compared to their siblings Increased risk: pension disability, psychiatric hospitalization and premature death Severity and number of injuries correlates with outcome Lehman et al 2016 3439 NFL players from 1959-1988 seasons were studied (minimum of 5 Drugs are assessed by standardized mortality ratio (the seasons per player) Followed for 28.9 years after increase or decrease in mortality of a study cohort with retirement respect to the general population If playing in the NFL (for a mimimum of 5 seasons) was Players retired-since 1987 treated like taking a drug: 6.1/100,000 Players retired- since 2005 It reduces standardized mortality 12.5/100,000 (measured 30 years later) by half! Take daily Average American man- since 2014 20.1/100,000 Saving 296 lives at the cost of 17 deaths Since 2005, NFL players are 48% less likely to commit suicide than the general population Since 1987, NFL players are 70% less likely to commit suicide than general population! 2 10/20/2018 Suicide in the general population and Decrease in Youth Athletics NCAA athletes Compared to Youth Suicide Rate NUMBER OF ATHLETIC PARTICPANTS (AGE 6-17) COMPARED TO NUMBER OF SUICIDES IN TOTAL US POPULATION 44,000 100000000 90000000 42,000 80000000 40,000 70000000 General Population 12.6 per 100,000 Published Oct 2015 60000000 38,000 50000000 18-22 year old non-college 12 per 100,000 40000000 9 year study 36,000 30000000 College students 7.5 per 100,000 of Number Suicides 3,773,309 participant seasons 34,000 20000000 10000000 NCAA Athlete 0.93/100,000 32,000 0 2009 2010 2011 2012 2013 2014 Number of Athletic Participants NCAA Football (male only) 2.25/100,000 Number of Suicides Athletic Participants Linear (Athletic Participants ) What is the Relationship Between Concussion and Dementia? 1/3 of Americans have had a concussion in their lifetime, 2/3 of these concussions are in males Dementia occurs about 63.5 per 1000 persons in the US 32 Alzheimer’s twice as common in women vs men 5 Million have Alzheimer’s – no reliable diagnostic, unknown An increase in sports participation (grades 7-12) leads to a cause decrease in depression by 25% Other common types: vascular dementia, frontotemporal Suicidal ideation decreases by 12% with an increase in sports dementia, normal pressure hydrocephalus participation What are the risk factors for dementia? Smoking High blood pressure 4265 older adults followed Diabetes Atrial fibrillation for 45190 years Sedentary lifestyle Genetics High fat diet / obesity Decreased level of education No association between a Frequent alcohol use (women) single brain injury Female gender Mild brain injury if over 65 years Low socioeconomic status (women) of age (men) and mild cognitive Sleep apnea Moderate or severe brain injury impairment, Alzheimers Hearing loss if over 55 (men) or other types of dementia Depression Decreased social contact 3 10/20/2018 What is Chronic Traumatic Omalu et al and McKee et al. presented Encephalopathy (CTE) new definitions for CTE in the 2000s: , First discovered in 1928 in NJ boxers published in JAMA Found in 17% of living professional boxers in England, named CTE in 1969 Motor deficits, Dementia Pathology described in 1960’s and 1970’s at Queen’s Square, England “CTE, as defined in America, is not a neurological entity, but Current Sports Medicine Reports: is a culture-specific social phenomenon.” Jim January/February 2014 - Volume 13 - Issue 1 - p 33–37 Andrikopoulos, British Medical Journal February 2015: The feds step in to help define CTE: decide on 4 types but the condition may be clinically asymptomatic 4 10/20/2018 “the pathognomic “a substantial lesion consists of number of p-tau aggregates neurologically in neurons, unimpaired astrocytes and subjects even at a cell processes very old age around small display only sparse vessels in an to modest extent of irregular pattern neurodegenerative at the depths of pathology” the cortical sulci ” Contact sport athletes, regardless of injury, are CTE is equally common in people with and at increased