Are You Ready for Some Football? Maybe Not
Sports-related chronic traumatic encephalopathy presents a new challenge to radiology researchers hoping to identify this condition early in its course.
Football season is well underway in the United States. The college football playoffs are right around the corner — semifinal games on December 31 and championship game on January 9 — with remaining tickets for the latter starting at $910 (as of November 20). Of course, on February 5, 2017, there's America's most-watched annual sporting event, the Super Bowl, where I've seen nosebleed section tickets going for just under $4,000 on popular online ticket-selling sites. If prices like that (along with travel and other associated costs) are not a deterrent to attendance, it's no wonder that the passion of many football fans is often compared to religious devotion.
In recent years, though, the faith of (some) football aficionados has been (slightly) shaken. Autopsy studies of former football players who suffered from dementia reveal a pattern of tau protein deposition in the cerebral cortex. These deposits possess a unique distribution pattern compared to other tauopathies, such as age-related brain changes and a variety of neurodegenerative disorders. Named "chronic traumatic encephalopathy" (CTE), this repetitive traumatic brain injury can only be definitively diagnosed at this time by a histopathologic and immunohistochemical analysis of the post-mortem brain tissue.
News of CTE set off a wave of concern in some football parents who now see the risk of CTE (or milder sequelae of traumatic brain injury) as outweighing the benefits of this sport. Pop Warner, the largest youth football program in the country, enacted rule changes in the 2012 season aimed at concussion prevention, but this didn't prevent a recent class-action lawsuit from being filed. The Boston University ( BU) CTE center (which has evaluated the brains of several former NFL players with CTE and which banks deceased athlete brain tissue) reported the youngest player ever diagnosed with CTE on autopsy: an 18-year-old who suffered multiple concussions while playing high school football. As CTE can be found in other impact sports, such as hockey and soccer, CTE awareness will probably increase over time as will calls for enhanced prevention efforts and earlier diagnosis.
CTE cannot currently be diagnosed with certainty during a person's lifetime, not only because of a lack of sign and symptom specificity (resembling other neurodegenerative disorders) but also, because of a lack of an in vivo test for it. Robert A. Stern, a BU CTE Center scientist, believes that a test will "be developed within a decade that will be able to diagnose CTE in living people." Radiologists are among those trying to find a way to achieve that goal. Mild traumatic brain injury is occult on CT and MR imaging, so CTE neuroimaging research — to detect structural brain changes and more subtle findings related to axonal integrity — is in its infancy.
Jeffrey B. Ware, MD, a radiology resident at the University of Pennsylvania, who engages in imaging research of traumatic brain injury, joins Radiology Firing Line podcast host Saurabh (Harry) Jha, MD, for a discussion of the role imaging may play in CTE patients.
Dr. Ware suggests that one approach to clinical imaging research is to selectively evaluate patients who have on-going problems due to post-concussive syndrome lasting beyond the expected recovery period, such as difficulty returning to activities of daily living. This sub-group of traumatic brain injury patients may be the best candidates for baseline and serial imaging to search for sentinel changes of CTE, to assess outcomes, and to potentially intervene early to mitigate downstream effects.
Until more is understood about CTE, the most die-hard football players and fans will stay faithful to their beloved sport, with an agnostic stance toward sports-related brain trauma. Declining youth participation in football will likely not be enough to eliminate so big a sport in a generation or even two. In the meantime, better prevention strategies and an in vivo diagnostic test may be developed, so that ultimately, 200 years after the first college football game between Rutgers and Princeton in 1869, people will still be playing the game but without paying the heavy price of CTE.