Covid-19 and brain injury (7/9/20 newsletter)

Jul 23

We are excited to announce that Concussion Alliance is hosting a 10-week summer internship for undergraduates; the interns and one of our volunteers have written this newsletter! All of the writers are students or alumni from Carleton College.

Contributors this week:

Editors: Conor Gormally and Malayka Gormally.
Contributors: Will Altaweel, Cassidy Bins, Trevor Hughes, Elena Morales-Grahl, Caroline Saksena, Srishti (Shelly) Seth, Trinh Tieu, and Elliot Yim.

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Covid-19

Moderately ill COVID-19 patients show increase in brain injury biomarkers

A study published in Neurology found evidence of an increase in biomarkers associated with brain injury in COVID-19 patients. The University of Gothenburg reported in a press release that the researchers compared blood samples from 47 mild, moderately, or severely ill COVID-19 patients with a healthy control group of 33 people matched by age and sex. Results showed that patients with moderate COVID-19 (admitted to a hospital but not requiring ventilator support) had increased levels of GFAP (glial fibrillary acidic protein). GFAP leaks out of the brain in the event of neuronal injury and is in research as a potential biomarker for TBI.

Additionally, most patients requiring ventilator treatment had elevated concentrations of plasma NfL (neurofilament light chain protein), another potential brain injury biomarker, and there was a significant correlation between NfL levels and the severity of the virus.

"The increase in NfL levels, in particular, over time is greater than we've seen previously in studies connected with intensive care, and this suggests that COVID-19 can in fact directly bring about a brain injury," stated study co-author Henrik Zetterberg in the university press release. He says more research is needed to determine whether the increase in biomarkers is due to the virus or the immune system. Co-author Magnus Glissén stated that these blood tests for biomarkers associated with brain injury could help monitor patients with moderate to severe COVID-19 and reduce brain injury risk.

For updated information on COVID-19 and various resources to stay safe, visit Concussion Alliance's COVID-19 page.

Education

Cleveland Clinic provides informational resource for parents

A recent article from the Cleveland Clinic website highlights what parents need to know about concussions: concussion symptoms, statistics regarding concussion demographics, the riskiest sports, and “the recipe for recovery.” The article distills information into ten key points and is geared towards a general audience.

Webinars:

Concussion Legacy Foundation (CLF) is presenting part 2 of their Q&A webinar “20 Questions on Concussion with Dr. Robert Cantu.” The webinar is today (July 9) at 4 pm EST. Register to receive a webinar link.
Upcoming CLF webinars:

“The Impact of Concussion on Vision,” July 16, register here.
“Neuroendocrine Dysfunction After Concussions: What Patients & Families Should Know,” July 22, register here.

Sports

Athletic trainers reduce their use of sideline assessment tools the longer they practice

The Journal of Athletic Training published a study from the University of Georgia that measured athletic trainers' (ATs) knowledge of concussion symptoms and their response to athletes in different scenarios. Landon B. Lempke et al. randomly surveyed 8725 athletic trainers from the National Athletic Trainers' Association membership to evaluate signs and symptom recognition as well as patient-clinician scenarios.

The athletic trainers who responded correctly identified 78% of concussion signs and symptoms. However, their odds of using standardized sideline assessment tools decreased by 3% for each additional year of clinical experience. The authors highlight that athletic trainers need to "frequently review and implement current consensus guidelines into clinical practice to improve concussion recognition and prevent improper management."

They also wanted to investigate why “When asked whether an athlete would be allowed to RTP [return to play], ATs more frequently responded yes than in identical scenarios asking whether the AT would feel comfortable with the athlete returning to play.” The researchers theorized that stakeholders (the player, a parent, or coach) involved in the RTP decision could “negatively influence an AT’s decision.” They recommend that "future researchers should explore why ATs' behaviors differ from expert consensus guidelines to identify the barriers to appropriate health care and improve athlete safety."

Cannabis

Cannabidiol (CBD) proves to be a promising treatment for neurological conditions associated with concussions

Cannabidiol (CBD) is a non-psychoactive, non-toxic compound found in cannabis that may improve concussion symptoms. A review by Dr. Brian Fiani et al. in Neurological Sciences found that CBD can help treat neurological conditions such as anxiety, chronic pain, PTSD, and epilepsy; these conditions are part of the range of persistent post-concussion symptoms. Dr. Fiani concludes that CBD has “remarkable potential to become a supplemental therapy in many healthcare domains.”

With only one FDA-approved CBD prescription drug currently available (for epilepsy), more of the ongoing clinical trials and pharmaceutical research must be completed before CBD therapy for neurological and psychiatric conditions can be implemented on that scale. The University of Miami Miller School of Medicine has two clinical trials underway, studying CBD combined with dexanabinol for concussion, and CBD combined with psilocybin for concussion and PTSD.

Diagnostics

MRI a promising tool for determining long-term effects of repetitive mild traumatic brain injury

In a study recently published in Brain: A Journal of Neurology, Ronel Veksler et al. found that repetitive mild traumatic brain injury (mTBI) is associated with blood-brain barrier dysfunction (BBBD) in athletes. BBBD may provide insight into the long-term consequences of repetitive mTBI.

The study is the first to “distinguish between fast and slow leakage through the pathological blood-brain barrier (BBB)” using “modified dynamic contrast-enhanced MRI.” Researchers took MRIs of the brains of Israeli amateur American football players, non-contact athletes, and non-athletes. Results found “slow blood-to-brain transport” and an “increase in permeability” of the BBB in specific regions of the football players’ brains compared to the control groups’.

“Since a leaky BBB is also found in CTE [chronic traumatic encephalopathy] and causes brain dysfunction and degeneration, it now seems that this test could provide the first (and so far the only) evidence for brain injury in the players we studied on the Israel football team,” says study co-author Alon Friedman. The study hopes that identifying leaky BBB in younger athletes may allow for the earlier detection of long-term complications associated with repetitive mTBI, though further research is necessary.

Therapies

Wearable tech to help patients and clinicians track exertion and recovery

The health-tech startup Neurovine is using wearable technology and artificial intelligence to collect data on concussion patients' physical and mental exertion. An article by Ottawa Business Journal shares how the company and its tech can monitor patients' exertion. This new tool aims to eventually empower patients, caregivers, and doctors in crafting personalized concussion recovery paths. Neurovine has raised $750,000 in preliminary funding and is currently conducting clinical trials at Bruyere Research Institute. Ten athletes at Carleton University are participating in "virtual trials," with plans to “find up to 150 patients.” The COVID-19 pandemic is accelerating the company's virtual platform plans and highlights the importance of telehealth technology, especially in remote healthcare delivery.

Veterans and Service Members

Tulane University receives $12.5 million to treat TBI and PTSD in veterans

Tulane University announced in a recent press release that it received a $12.5 million gift from the Avalon Fund to create the Tulane University Center for Brain Health. Opening in the fall of 2020, the center will specialize in treating traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) in U.S. military veterans. Given Tulane’s reputation as a top university for veterans, Tulane President Michael Fitts expressed enthusiasm for the new center, stating that “This gift from the Avalon Fund will allow us to serve our veterans in another capacity, helping them heal from the wounds of war.” The grant will fund diagnostic evaluation, an outpatient program, discharge planning, and patient follow-up for at least one year.

Mental Health

Patients with a history of repeated head impacts and TBI could have more depression symptoms later in life

New research published in Neurology sheds light on the detrimental long-term effects of repetitive head impacts and TBI on mental health. Researchers Michael L. Alosco et al. found that patients with a history of traumatic brain injury (TBI) and repetitive head impacts (RHI) exhibited more depression symptoms than patients with only TBI history or neither. The researchers examined 13,323 participants over 40 years old; 725 subjects reported having RHI, and 7,277 reported TBI history, with and without loss of consciousness (LOC).

The study used online assessment tools that measured depressive symptoms and cognitive performance. RHI and TBI, regardless of LOC, had a synergistic effect that negatively impacted performance on neuropsychological tests. In addition to worse cognitive function, “the group that had a history of repetitive head impacts and TBI with loss of consciousness reported the most depressive symptoms,” according to a press release by Boston University School of Medicine.

The study is limited by its lack of information regarding the individual intensity and frequency of participants' RHI and TBI. However, its results indicate that repetitive head impacts, commonly seen in contact sports and abusive relationships, may be contributing to “mid- to later-life neuropsychiatric and cognitive functioning” observed in individuals with a history of either mTBI and TBI.

Statistics

Migraine history may negatively impact recovery from concussion

A study conducted by Laura Langer et al. found that concussion patients with a history of migraines may be more likely to experience slow recovery from a concussion. The study, presented at the American Headache Society's annual meeting and reported on in a Neurology Today blog post, included 302 participants, 116 of whom had a history of migraines before sustaining a concussion.

Among participants who experienced migraines more than once per month, 42% reported continuous post-traumatic headache a week after sustaining the concussion, compared to 18% of those who experienced migraines less than once per month. However, this difference was not statistically significant in later follow-ups.

The researchers found persistent differences between the two groups in other measures. Participants who experienced migraines more than once per month had higher Sports Concussion Assessment Tool (SCAT-3) scores and more symptoms than those who experienced migraines less frequently. These differences remained statistically significant during all weeks of the 16-week trial.

Co-investigator Jonathan Gladstone noted that "when evaluating patients with concussion in the early post-concussion interval, inquiring about pre-injury migraine history would appear prudent to identify those at potential increased risk of slower recovery and more intense symptoms."

Youth

Study investigates how parents of middle schoolers find, evaluate concussion resources

The Journal of Sport and Health Science published a study investigating how middle school children's parents obtain sports-related concussion (SRC)-related information. Zachary Y. Kerr et al. sampled 1083 parents of children aged 10-15, who completed an online questionnaire. This survey gauged parental and child characteristics, and their utilization and perceived trustworthiness of various sources of SRC-related information.

The survey participants looked to many information sources, including doctors/health professionals, national and local news, friends and family, blogs/social media, sport-specific media, and other health-related resources. However, the trustworthiness of each source varied greatly. This study urges all SRC-related information sources to include up-to-date, accurate, reliable, and trustworthy information to ensure that parents understand their children's SRC-related risk and how to prevent and manage such injuries. The researchers acknowledged that their sample was limited to parents in the U.S. only.

Women's Health

More research needed on the prevalence of brain trauma as a result of intimate partner violence

The Ohio Domestic Violence Network (ODVN) has been working to determine the effects of intimate partner violence (IPV) on brain injuries in survivors.

Educational materials from ODVN are included in a June report released by the U.S. Government Accountability Office, highlighting the need for improved data collection on the prevalence of brain injuries resulting from IPV. A better understanding of IPV-related brain trauma puts nonprofit organizations and clinicians in a position to better address the ongoing cognitive issues many survivors face.

Culture

'Less lethal' weapons police use on protesters can cause brain injury directly and indirectly

Many police officers carry "less lethal" weapons, the use of which has been highlighted in the wake of George Floyd's death. Though slower speeds and blunter tips may deem some projectiles "less lethal" than bullets, these weapons can still cause severe injury and death. A USA Today article describes the most common "less lethal" weapons used by police, categorized into projectiles and aerosols. The article also profiles protestors who have suffered brain injuries, facial injuries, and the loss of an eye.

"Less lethal" projectiles include pepper-balls, bean bag rounds, and sponge grenades, shot from a machine similar to a firearm. Both bean bag rounds and sponge grenades can cause serious injury if fired at the head or neck or in close range. Concussion Alliance has documented cases of protestors suffering brain injuries from "less lethal" projectiles aimed at the head and neck.

The most common aerosols are pepper spray and tear gas, which will both stimulate tears. Additionally, tear gas is a pain receptor activating nerve agent that causes intense burning pain. These aerosols do not directly cause impacts to the head. However, a crowd in pain and suffering vision impairment is an environment conducive to falls, collisions, and other potential sources of concussion and brain injury.

CTE and Neurodegeneration Issues

A discussion of dementia-causing neurodegeneration following traumatic brain injury

In an article published in the Journal of Neurology, Neurosurgery, & Psychiatry, Neil SN Graham et al. discuss the link between traumatic brain injury (TBI) and dementia-causing neurodegeneration. The authors point to multiple meta-analyses that have shown a significant increase in risk for dementia and Alzheimer's after a brain injury.

When a TBI occurs, the axons in the brain's neurons tear. This tear causes the proteins that form the cell's structure to disassociate. One of these proteins is called Tau, which can lead to cell death or disruption when dissociated. This tearing also leads to the accumulation of amyloid-beta and TDP-43, which also cause injury to brain cells. These proteins are also present in brains with dementia, demonstrating how neurodegeneration caused by TBI may lead to this form of chronic neurodegeneration.

The authors explain the methods of identification for this type of neurodegeneration, including MRI, PET imaging, and biomarkers. The article also recognizes the "therapeutic opportunity to intervene after TBI before significant neurodegeneration takes place." Difficulties in interpretation can stem from differences in the way dementia is defined, high reliance on self-reported TBI, separating the direct effects of TBI from progressive neurodegeneration or psychiatric impairment, and the lack of a standardized assessment for the long-term effects of TBI.