Chronic Traumatic Encephalopathy

Monday, May 14, 2012

Getting your bell rung was once a badge of honor in sports. The ability to shake it off and not miss a play was accepted and routine. But it had been known for almost a hundred years that repeated hits to the head had long term consequences and “dementia pugilista” was the term used for a punch drunk old fighter who had been hit in the head one too many times. The realization was slow in coming that the same injury to the brain could occur in football players and that the most popular sport in the country could be a potential cause of psychiatric disturbances and early dementia.

A new term was born, chronic traumatic encephalopathy (CTE) that described a brain that had gradual degeneration in function because of repeated head injuries causing both concussions with symptoms and those that were asymptomatic. The symptoms of concussion had faded, but months and years later, new symptoms would occur. CTE symptoms start slowly and creep up on the patient. Initially, there may be concentration and memory issues with episodes of disorientation and confusion, dizziness and headache. It was as if the concussion symptom were starting to return even without a new head injury. Emotions would get labile and the patient could become aggressive and psychotic. As CTE progresses, behavior becomes even more erratic, with aggression and Parkinson-like symptoms. Finally, thought processes decrease even further into dementia with more Parkinson symptoms including speech and walking abnormalities. The symptoms are progressive and cannot be stopped.

The diagnosis of CTE is tough to make clinically. There are no bleeding or major abnormalities on CT scan and it appears to act like other diseases that attack brain function. It can be confirmed by autopsy and dissection of the brain but that doesn’t particularly help the patient. An abnormal protein called tau builds up in the brain and causes abnormal nerve fibers and cell tangles in the brain…and it looks different than an Alzheimer brain where loss of brain tissue was routinely seen.

Victims of CTE seem to may be more prone to death because of alcohol or drug overdose and suicide. The recent suicide deaths of NFL football players Junior Seau, Ray Easterling and Dave Duerson and NHL hockey players Derek Boogard, Wade Belak and Rick Rypien have brought the specter of CTE and chronic head injury to the front page but it isn’t just these athletes who may be at risk. The correlation between boxing and CTE should be expected because the goal of the sport is to inflict a concussion upon the opponent, but what about soccer players or non-athletes who are unlucky enough to sustained repeated concussions?

The CTE diagnosis is difficult since there is only supportive treatment and the consequences of the brain injury include early death. It would seem that prevention is the best and only option at the present time, but that may be difficult when society approves of the violence on the football field and boxing ring. Young athletes see themselves as invincible and indestructible. The pursuit of near term athletic glory overshadows the specter of long term disability, especially when the symptoms may be delayed by decades. People may have righteous indignation about the situation, but for now it stops on Saturday when they cheer for their alma mater’s colors and on Sunday when their favorite NFL team takes the field.

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