Chronic Traumatic Encephalopathy - Risk to Athletes and Veterans Post-Concussion

In 2009, Ann C. McKee, MD, Robert C. Cantu, MD, Christopher J. Nowinski, AB, E. Tessa Hedley-Whyte, MD, Brandon E. Gavett, PhD, Andrew E. Budson, MD, Veronica E. Santini, MD, Hyo-Soon Lee, MD, Caroline A. Kubilus, and Robert A. Stern, PhD, published a landmark article on Chronic Traumatic Encephalopathy (CTE) in the Journal of Neuropathology and Experimental Neurology [J Neuropathol Exp Neurol. 2009 July; 68(7): 709-735]. While 'Dementia Pugilistica' or the repeated brain trauma caused by boxing had been well established, this article raised attention to highlight other repeat concussion sports such as football. The researchers further identified and defined CTE, as a syndrome with specific pathology and symptoms. The symptoms of CTE reported include memory disturbances, behavioral and personality changes, Parkinsonism, speech and gait abnormalities and is now noted to include impulsive behavior, mood instability, increased suicide risk and eventual dementia in some instances. The neuropathology reported in CTE was characterized by, 'atrophy of the cerebral hemispheres, medial temporal lobe, thalamus, mammillary bodies, and brainstem, with ventricular dilatation and a fenestrated cavum septum pellucidum. Microscopically, there are extensive tau-immunoreactive neurofibrillary tangles, astrocytic tangles, and spindle-shaped and threadlike neurites throughout the brain. The neurofibrillary degeneration of CTE is distinguished from other tauopathies by preferential involvement of the superficial cortical layers, irregular, patchy distribution in the frontal and temporal cortices, propensity for sulcal depths, prominent perivascular, periventricular and subpial distribution, and marked accumulation of tau-immunoreactive astrocytes. Deposition of beta amyloid, most commonly as diffuse plaques, occurs in fewer than half the cases. CTE is a neuropathologically distinct, slowly progressive tauopathy with a clear environmental etiology.' This complex neuropathological definition essentially indicates a progressive, chronic degeneration of brain tissue involving the abnormal build-up of tau protein.

Now, a concern has been raised that military service members and veterans exposed to multiple blast-related concussions could also be at risk for CTE.  With the wars in Iraq in Afghanistan marked by blast related traumatic brain injury (TBI) as the signature injury, an estimated 200,000 military service members have been affected – many with repeat concussion from Improvised Explosive Devices (IEDs).  Clear data regarding the exact number of injured veterans and the number who have sustained repeat injury is not available, but the number and implications appear significant, affecting thousands.  At present, there are not agreed upon guidelines for clinically assessing CTE, and there is no identified treatment to prevent its occurrence.  Evaluation, timely treatment and support for those with brain injury (at risk for CTE) is critical to minimize its effect on service members and their families.  Lakeview is serving this population as a Tricare provider and through our participation in the Assisted Living for Veterans with TBI pilot project funded by the VA.   In the attached video, Josh Zepps, David Wood and Rick Collins are joined by veterans Matt Zeller, Joshua Flashman, Bernadette Beckwell to discuss CTE and the risk veterans with a history of TBI may face from this degenerative brain disease