Clinical diagnosis and risk factors for chronic traumatic encephalopathy
Montenigro, Philip Homes
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Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease characterized by a pathognomonic distribution of hyperphosphorylated tau accumulations in neurons, astrocytes, and cell processes, situated around vessels at the depths of cortical sulci. Case reports of CTE pathology exhibit a common exposure to repetitive head impacts (RHI), suggesting that RHI are a necessary factor in the disease’s etiology. Currently, it is only possible to definitively diagnose CTE after death using histopathological techniques and consensus-based neuropathological diagnostic criteria recently established by the National Institute of Health and National Institute of Neurological Disorders and Stroke. Though considerable progress has been made in characterizing the neuropathology of CTE, less is known about the clinical aspects of the disease. Specifically, additional research is needed to identify disease-specific clinical manifestations, clinicopathological correlations, and a means of diagnosis during life, all of which are critical to developing future epidemiological studies, preventative measures, and treatment trials. Moreover, it is not yet known which specific aspects of RHI exposure (type, frequency, duration) are causally linked to developing clinically meaningful neurological impairments or CTE neuropathology, nor have studies identified risk-modifying factors, such as genotype (e.g. APOE). The objective of this dissertation’s published works was to systematically address these gaps in knowledge. First, to define a common clinical presentation of CTE, we conducted a retrospective analysis of medical records and semi-structured next-of-kin reports of 36 former athletes with autopsy-confirmed CTE without comorbid neurodegenerative disease. We then published clinical diagnostic criteria for CTE based on a systematic review of clinical features exhibited in 202 former athlete cases and a pooled analysis of 83 neuropathologically confirmed CTE cases. In subsequent analyses, we operationalized clinical criteria to investigate specific clinicopathological associations between tau, amyloid beta, age, APOE genotype, and clinical outcomes and utilized the clinical criteria to explore potential risk-factors related to RHI from boxing and football. Lastly, we developed a metric to quantify cumulative RHI exposure in retired, living, football players. Using this metric, our study was the first to indicate a causal relationship between cumulative RHI exposure and risk of later life cognitive, mood, and behavioral impairment. These studies are preliminary, and our results require replication and validation in larger, longitudinal prospective studies.