Chronic traumatic encephalopathy (CTE) is a degenerative brain disorder that has been linked to repeated head trauma. CTE is a poorly understood condition that can be difficult to diagnose.
CTE is frequently associated with head injuries related to contact sports and military service but can affect anyone with a history of repeated head trauma. It is rare but can profoundly impact the quality of life and brain health. This article delves into the ways CTE affects the brain and preventative measures.
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What is Chronic Traumatic Encephalitis (CTE)?
Chronic traumatic encephalitis (CTE) is a chronic neurodegenerative disease that has been linked to repeated head trauma. Not everyone with a history of head trauma develops CTE.
History and Background of CTE
In the 1920s, a link between boxing and progressive neurological decline was established. At that time, the disease was known as dementia pugilistica or "punch drunk syndrome." Recently, there has been an increased focus on the condition, now known as CTE, and its association with athletes in other contact sports.
Pathophysiology: How CTE Affects the Brain
CTE is believed to be related to a buildup of tau proteins causing neurofibrillary tangles in the brain. Tau protein buildup also occurs in other neurodegenerative conditions such as Alzheimer's disease. Still, in CTE, the proteins develop more in the superficial levels of the brain than in the deeper areas. CTE can also be distinguished from Alzheimer's disease by the relative absence of beta-amyloid plaques.
The buildup of protein in the brain leads to enlargement of the ventricles and loss of brain volume in the cerebral tissues. Additionally, loss of pigment in the substantia nigra and enlargement of the cavum septum pellucidum also occur.
Causes and Risk Factors for CTE
CTE is unlikely to occur after a single head trauma; it's the accumulation of multiple traumas to the brain that seem to be associated with the risk of the condition.
Common Causes and Mechanisms
Repeated head trauma doesn't have to be severe to cause CTE; even mild repetitive trauma can contribute. Other types of repetitive trauma that have been linked to CTE include physical abuse, soccer, football, rugby, baseball, and hockey.
If the repeated trauma occurs before the first head injury has resolved, the risk of CTE may be higher. This is called second-impact syndrome.
High-Risk Groups and Activities
CTE has been seen in athletes participating in contact sports at all levels. It has also been reported in veterans who suffered from traumatic brain injury due to explosive blast injuries and circus performers who had repetitive head injuries from their profession. The groups at highest risk for CTE are those in combat sports, contact sports, and military personnel exposed to explosions.
Symptoms and Stages of CTE
As a degenerative condition, the symptoms of CTE occur gradually over time. The symptoms of CTE can be divided into four stages based on the symptoms.
Early Symptoms of CTE
Early symptoms of CTE include:
- Headaches
- Irritability
- Slurring of speech
- Unsteadiness on the feet
- Mild memory loss
- Executive function difficulty (trouble concentrating, difficulty organizing or planning)
These symptoms are similar to what is seen with other medical conditions, including Alzheimer's disease, other forms of dementia, vitamin b12 deficiency, and neurosyphilis.
Advanced Stages of CTE
In the advanced stages, people with CTE have increasing problems with memory as well as behavior, mood, and speech problems. Mental health symptoms increase, including depression and anxiety, and patients may become more aggressive and inappropriate in social settings. Advanced CTE is also associated with increasing problems with walking and increased falls. The risk of suicidal thoughts also increases.
Stages of CTE Progression
Researchers propose 4 stages of CTE.
- Stage I: this stage is generally asymptomatic. Some people may experience mild short-term memory problems and mild depression.
- Stage II: Mood and behavioral symptoms become more pronounced in this stage. Symptoms may include mild behavioral outbursts and increased depression symptoms.
- Stage III: Patients usually have more significant problems with memory and cognition at this stage. They also have less interest in things they typically enjoy and have executive function deficits.
- Stage IV: At this stage, patients have more language deficits, tremors and parkinsonism symptoms, and psychotic symptoms such as paranoia.
Diagnosis and Detection of CTE
Diagnosing CTE can be challenging for several reasons. The symptoms are similar to other conditions, and the diagnosis cannot be confirmed until death.
Challenges in Diagnosing CTE During Life
Currently, the diagnosis of CTE requires a brain biopsy and microscopic exam and cannot be confirmed until death. However, a presumptive diagnosis of CTE can be made based on the symptoms, history of head injuries, and physical and neurologic exam.
Researchers are evaluating neurological and cognitive testing to assess and diagnose CTE. These tests may include list-learning tests, story-learning tests, visual memory testing, and other neuropsychiatric tests.
Emerging Diagnostic Tools and Research
Researchers are evaluating whether magnetic resonance imaging (MRI) and other imaging modalities can be used to assess and diagnose CTE. Functional MRI (fMRI) has shown some benefit in differentiating different types of dementia and may help evaluate CTE.
Other modalities that are being evaluated include susceptibility-weighted imaging (SWI), diffusion tensor imaging (DTI), magnetic resonance spectroscopy (MRS), positron emission tomography (PET), event-related potentials (ERP), and single photon emission computed tomography (SPECT).
Another area of research for CTE is blood and cerebrospinal fluid biomarkers. Since CTE and Alzheimer’s disease share similarities, such as abnormal protein buildup (though the location in the brain varies), the biomarkers being evaluated for diagnosing Alzheimer's disease may also have utility in predicting and diagnosing CTE.
Treatment Options and Support for CTE
CTE treatment options currently focus on prevention and symptom management, though other symptoms are being researched.
Current Treatment Approaches for CTE Symptoms
There is no current treatment for CTE that will stop or cure the disease, but there are therapeutic options that may help reduce symptoms. These include:
- Speech therapy for language, memory, and swallowing may be helpful.
- Occupational therapy helps with activities of daily living, such as getting dressed or making accommodations in your home.
- Physical therapy can help with movement issues.
- Medications may help with depression, pain control, and some of the behavioral problems associated with CTE.
Experimental Treatments and Research Advances
As of 2020, there were no clinical trials specifically for CTE, but several trials for Alzheimer's disease are examining medications targeting the tau proteins. If investigational treatments and medications are effective for Alzheimer's, they may also help with the tau protein buildup for CTE.
Resources for Patients and Families
Resources and support for CTE patients and their families include:
- Concussion Legacy Foundation
- Boston University Center for Traumatic Brain Injury
- The Patrick Risha CTE Awareness Foundation
- Alzheimer's Association
- Family Caregiver Alliance
Preventing CTE and Protecting Brain Health
The best way to treat CTE is to protect the brain and prevent concussions.
Guidelines for Reducing Head Injury Risks
The Centers for Disease Control recommends several tips for preventing traumatic brain injury.
- Wear your seatbelt
- Don't drive or ride with someone under the influence of drugs or alcohol
- Wear a helmet for activities such as riding a bicycle, motorcycle, ATV, snowmobile, skateboard, or skates or for riding a horse, skiing or snowboarding
- Choose sports programs that have drills and safety programs for head injury prevention, and wear a helmet for contact sports
- Take steps to prevent falls
- Use safety gates and window guards to prevent falls in young children
Taking steps to prevent the brain injuries that can lead to CTE is the best way to avoid it.
Technological Advancements in Helmet Design and Equipment
Several new technologies are being developed to make helmets and equipment safer and to try to prevent concussions. The goal is to have the equipment absorb the shock of the impact rather than the head.
Promoting Education and Awareness
Avoiding the second-impact injury requires knowledge of the symptoms of concussion and the impacts concussion can have on long-term brain health. Since brain injuries and concussions can happen at any age or level of sports participation, educating coaches, parents, and athletes on the signs of concussions and the protocols for managing symptoms is essential.
There are several resources available to help educate you on concussions and concussion management.
- Nationwide Children's guide to concussions
- HEADS UP resources from the CDC
- Concussion.org
Common Misconceptions About CTE
There are several common misconceptions about CTE, which we will address.
CTE is Only a Concern for Professional Athletes
CTE can happen as a result of concussion at any age. Even amateur and young athletes can be at risk for concussion. Coaches, parents, and athletes at all levels must be aware of the symptoms of concussion and the need for medical care and early intervention.
CTE is Inevitable if You Play Contact Sports
Preventing concussions is the most essential step in preventing CTE. There are many preventative measures to help with avoiding concussion, including wearing protective gear. Advancements in equipment and concussion protocols may offer further protection.
CTE is Solely Diagnosed Based on Symptoms
CTE can be suspected based on symptoms, but currently, the only way to formally diagnose CTE is through the post-mortem exam. CTE is a complex disease with a complex diagnostic process.
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Key Takeaways
- CTE is an uncommon but serious chronic neurodegenerative condition.
- CTE diagnosis is complex and can only be definitively made after death.
- There is no cure for CTE, but symptom-based treatment may improve quality of life.
- Treatments in development for Alzheimer’s disease may have benefits for CTE as well due to similarities between the two diseases.
- Prevention of head injuries is the best way to prevent CTE.
- Athletes, coaches, and parents should be educated about concussion prevention, recognition, and treatment.
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