Understanding neurodegeneration after traumatic brain injury: from mechanisms to clinical trials in dementia
Neil Sn Graham, David J Sharp, Neil Sn Graham, David J Sharp
Abstract
Traumatic brain injury (TBI) leads to increased rates of dementia, including Alzheimer's disease. The mechanisms by which trauma can trigger neurodegeneration are increasingly understood. For example, diffuse axonal injury is implicated in disrupting microtubule function, providing the potential context for pathologies of tau and amyloid to develop. The neuropathology of post-traumatic dementias is increasingly well characterised, with recent work focusing on chronic traumatic encephalopathy (CTE). However, clinical diagnosis of post-traumatic dementia is problematic. It is often difficult to disentangle the direct effects of TBI from those produced by progressive neurodegeneration or other post-traumatic sequelae such as psychiatric impairment. CTE can only be confidently identified at postmortem and patients are often confused and anxious about the most likely cause of their post-traumatic problems. A new approach to the assessment of the long-term effects of TBI is needed. Accurate methods are available for the investigation of other neurodegenerative conditions. These should be systematically employed in TBI. MRI and positron emission tomography neuroimaging provide biomarkers of neurodegeneration which may be of particular use in the postinjury setting. Brain atrophy is a key measure of disease progression and can be used to accurately quantify neuronal loss. Fluid biomarkers such as neurofilament light can complement neuroimaging, representing sensitive potential methods to track neurodegenerative processes that develop after TBI. These biomarkers could characterise endophenotypes associated with distinct types of post-traumatic neurodegeneration. In addition, they might profitably be used in clinical trials of neuroprotective and disease-modifying treatments, improving trial design by providing precise and sensitive measures of neuronal loss.
Keywords: acquired brain injury; cognition; dementia; image analysis; traumatic brain injury.
Conflict of interest statement
Competing interests: None declared.
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.
Figures
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References
- Maas AIR, Menon DK, Adelson PD, et al. . Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017;16:987–1048. 10.1016/S1474-4422(17)30371-X
- McMillan TM, Teasdale GM, Weir CJ, et al. . Death after head injury: the 13 year outcome of a case control study. J Neurol Neurosurg Psychiatry 2011;82:931–5. 10.1136/jnnp.2010.222232
- Scheid R, Walther K, Guthke T, et al. . Cognitive sequelae of diffuse axonal injury. Arch Neurol 2006;63:418–24. 10.1001/archneur.63.3.418
- Sariaslan A, Sharp DJ, D’Onofrio BM, et al. . Long-Term outcomes associated with traumatic brain injury in childhood and adolescence: a nationwide Swedish cohort study of a wide range of medical and social outcomes. PLoS Med 2016;13:e1002103 10.1371/journal.pmed.1002103
- Li Y, Li Y, Li X, et al. . Head injury as a risk factor for dementia and Alzheimer's disease: a systematic review and meta-analysis of 32 observational studies. PLoS One 2017;12:e0169650 10.1371/journal.pone.0169650
- Nordström A, Nordström P. Traumatic brain injury and the risk of dementia diagnosis: a nationwide cohort study. PLoS Med 2018;15:e1002496 10.1371/journal.pmed.1002496
- Fann JR, Ribe AR, Pedersen HS, et al. . Long-Term risk of dementia among people with traumatic brain injury in Denmark: a population-based observational cohort study. Lancet Psychiatry 2018;5:424–31. 10.1016/S2215-0366(18)30065-8
- Shively S, Scher AI, Perl DP, et al. . Dementia resulting from traumatic brain injury: what is the pathology? Arch Neurol 2012;69:1245–51. 10.1001/archneurol.2011.3747
- World Health Organisation International classification of diseases 11th revision edn, 2018.
- American Psychiatric Association Diagnostic and statistical manual of mental disorders 5th edn APA, 2013.
- Raj R, Kaprio J, Korja M, et al. . Risk of hospitalization with neurodegenerative disease after moderate-to-severe traumatic brain injury in the working-age population: a retrospective cohort study using the Finnish National health registries. PLoS Med 2017;14:e1002316 10.1371/journal.pmed.1002316
- Barnes DE, Byers AL, Gardner RC, et al. . Association of mild traumatic brain injury with and without loss of consciousness with dementia in US military veterans. JAMA Neurol 2018;75:1055–61. 10.1001/jamaneurol.2018.0815
- Fleminger S, Oliver DL, Lovestone S, et al. . Head injury as a risk factor for Alzheimer's disease: the evidence 10 years on; a partial replication. J Neurol Neurosurg Psychiatry 2003;74:857–62. 10.1136/jnnp.74.7.857
- Mortimer JA, van Duijn CM, Chandra V, et al. . Head trauma as a risk factor for Alzheimer's disease: a collaborative Re-analysis of case-control studies. EURODEM risk factors Research Group. Int J Epidemiol 1991;20(Suppl 2):S28–35. 10.1093/ije/20.supplement_2.s28
- Abner EL, Nelson PT, Schmitt FA, et al. . Self-reported head injury and risk of late-life impairment and AD pathology in an AD center cohort. Dement Geriatr Cogn Disord 2014;37:294–306. 10.1159/000355478
- Schaffert J, LoBue C, White CL, et al. . Traumatic brain injury history is associated with an earlier age of dementia onset in autopsy-confirmed Alzheimer’s disease. Neuropsychology 2018;32:410–6. 10.1037/neu0000423
- Crane PK, Gibbons LE, Dams-O’Connor K, et al. . Association of traumatic brain injury with late-life neurodegenerative conditions and neuropathologic findings. JAMA Neurol 2016;73:1062–9. 10.1001/jamaneurol.2016.1948
- Jafari S, Etminan M, Aminzadeh F, et al. . Head injury and risk of Parkinson disease: a systematic review and meta-analysis. Mov Disord 2013;28:1222–9. 10.1002/mds.25458
- Gardner RC, Byers AL, Barnes DE, et al. . Mild TBI and risk of Parkinson disease: a chronic effects of neurotrauma Consortium study. Neurology 2018;90:e1771–9.
- Lolekha P, Phanthumchinda K, Bhidayasiri R. Prevalence and risk factors of Parkinson's disease in retired Thai traditional boxers. Mov Disord 2010;25:1895–901. 10.1002/mds.23210
- Watanabe Y, Watanabe T. Meta-analytic evaluation of the association between head injury and risk of amyotrophic lateral sclerosis. Eur J Epidemiol 2017;32:867–79. 10.1007/s10654-017-0327-y
- McKee AC, Stein TD, Nowinski CJ, et al. . The spectrum of disease in chronic traumatic encephalopathy. Brain 2013;136:43–64. 10.1093/brain/aws307
- Iverson GL, Keene CD, Perry G, et al. . The need to separate chronic traumatic encephalopathy neuropathology from clinical features. J Alzheimers Dis 2018;61:17–28. 10.3233/JAD-170654
- Stern RA, Daneshvar DH, Baugh CM, et al. . Clinical presentation of chronic traumatic encephalopathy. Neurology 2013;81:1122–9. 10.1212/WNL.0b013e3182a55f7f
- Malec JF, Brown AW, Leibson CL, et al. . The mayo classification system for traumatic brain injury severity. J Neurotrauma 2007;24:1417–24. 10.1089/neu.2006.0245
- Goldman SM, Kamel F, Ross GW, et al. . Head injury, alpha-synuclein Rep1, and Parkinson's disease. Ann Neurol 2012;71:40–8. 10.1002/ana.22499
- Li L, Bao Y, He S, et al. . The association between apolipoprotein E and functional outcome after traumatic brain injury: a meta-analysis. Medicine 2015;94:e2028 10.1097/MD.0000000000002028
- Johnson VE, Stewart JE, Begbie FD, et al. . Inflammation and white matter degeneration persist for years after a single traumatic brain injury. Brain 2013;136:28–42. 10.1093/brain/aws322
- Goldstein LE, Fisher AM, Tagge CA, et al. . Chronic traumatic encephalopathy in blast-exposed military veterans and a blast neurotrauma mouse model. Sci Transl Med 2012;4:134ra60 10.1126/scitranslmed.3003716
- Johnson VE, Stewart W, Smith DH. Widespread tau and amyloid-beta pathology many years after a single traumatic brain injury in humans. Brain Pathol 2012;22:142–9. 10.1111/j.1750-3639.2011.00513.x
- Tagge CA, Fisher AM, Minaeva OV, et al. . Concussion, microvascular injury, and early tauopathy in young athletes after impact head injury and an impact concussion mouse model. Brain 2018;141:422–58. 10.1093/brain/awx350
- Kondo A, Shahpasand K, Mannix R, et al. . Antibody against early driver of neurodegeneration cis P-tau blocks brain injury and tauopathy. Nature 2015;523:431–6. 10.1038/nature14658
- Gentleman SM, Nash MJ, Sweeting CJ, et al. . β-Amyloid precursor protein (βAPP) as a marker for axonal injury after head injury. Neurosci Lett 1993;160:139–44. 10.1016/0304-3940(93)90398-5
- Johnson VE, Stewart W, Smith DH. Axonal pathology in traumatic brain injury. Exp Neurol 2013;246:35–43. 10.1016/j.expneurol.2012.01.013
- Smith DH, Johnson VE, Stewart W. Chronic neuropathologies of single and repetitive TBI: substrates of dementia? Nat Rev Neurol 2013;9:211–21. 10.1038/nrneurol.2013.29
- Falcon B, Zivanov J, Zhang W, et al. . Novel tau filament fold in chronic traumatic encephalopathy encloses hydrophobic molecules. Nature 2019;568:420–3. 10.1038/s41586-019-1026-5
- Ghajari M, Hellyer PJ, Sharp DJ. Computational modelling of traumatic brain injury predicts the location of chronic traumatic encephalopathy pathology. Brain 2017;140:333–43. 10.1093/brain/aww317
- Smith DH, Chen X-HAN, Pierce JES, et al. . Progressive atrophy and neuron death for one year following brain trauma in the rat. J Neurotrauma 1997;14:715–27. 10.1089/neu.1997.14.715
- Ramlackhansingh AF, Brooks DJ, Greenwood RJ, et al. . Inflammation after trauma: microglial activation and traumatic brain injury. Ann Neurol 2011;70:374–83. 10.1002/ana.22455
- Scott G, Zetterberg H, Jolly A, et al. . Minocycline reduces chronic microglial activation after brain trauma but increases neurodegeneration. Brain 2018;141:459–71. 10.1093/brain/awx339
- Zanier ER, Bertani I, Sammali E, et al. . Induction of a transmissible tau pathology by traumatic brain injury. Brain 2018;127:2685–99. 10.1093/brain/awy193
- McKee AC, Cairns NJ, Dickson DW, et al. . The first NINDS/NIBIB consensus meeting to define neuropathological criteria for the diagnosis of chronic traumatic encephalopathy. Acta Neuropathol 2016;131:75–86. 10.1007/s00401-015-1515-z
- Cole JH, Jolly A, de Simoni S, et al. . Spatial patterns of progressive brain volume loss after moderate-severe traumatic brain injury. Brain 2018;141:822–36. 10.1093/brain/awx354
- Sidaros A, Skimminge A, Liptrot M, et al. . Long-term global and regional brain volume changes following severe traumatic brain injury: a longitudinal study with clinical correlates. Neuroimage 2009;44:1–8. 10.1016/j.neuroimage.2008.08.030
- Cole JH, Marioni RE, Harris SE, et al. . Brain age and other bodily 'ages': implications for neuropsychiatry. Mol Psychiatry 2019;24:266–81. 10.1038/s41380-018-0098-1
- Cole JH, Ritchie SJ, Bastin ME, et al. . Brain age predicts mortality. Mol Psychiatry 2018;23:1385–92. 10.1038/mp.2017.62
- Cole JH, Leech R, Sharp DJ, et al. . Prediction of brain age suggests accelerated atrophy after traumatic brain injury. Ann Neurol 2015;77:571–81. 10.1002/ana.24367
- Mac Donald CL, Dikranian K, Bayly P, et al. . Diffusion tensor imaging reliably detects experimental traumatic axonal injury and indicates approximate time of injury. J Neurosci 2007;27:11869–76. 10.1523/JNEUROSCI.3647-07.2007
- Johnson VE, Stewart W, Smith DH. Traumatic brain injury and amyloid-β pathology: a link to Alzheimer's disease? Nat Rev Neurosci 2010;11:361–70. 10.1038/nrn2808
- Hellyer PJ, Leech R, Ham TE, et al. . Individual prediction of white matter injury following traumatic brain injury. Ann Neurol 2013;73:489–99. 10.1002/ana.23824
- Bacioglu M, Maia LF, Preische O, et al. . Neurofilament light chain in blood and CSF as marker of disease progression in mouse models and in neurodegenerative diseases. Neuron 2016;91:56–66. 10.1016/j.neuron.2016.05.018
- Preische O, Schultz SA, Apel A, et al. . Serum neurofilament dynamics predicts neurodegeneration and clinical progression in presymptomatic Alzheimer’s disease. Nat Med 2019;25:277–83. 10.1038/s41591-018-0304-3
- Shahim P, Gren M, Liman V, et al. . Serum neurofilament light protein predicts clinical outcome in traumatic brain injury. Sci Rep 2016;6:36791 10.1038/srep36791
- Zetterberg H, Smith DH, Blennow K. Biomarkers of mild traumatic brain injury in cerebrospinal fluid and blood. Nat Rev Neurol 2013;9:201–10. 10.1038/nrneurol.2013.9
- Scott G, Ramlackhansingh AF, Edison P, et al. . Amyloid pathology and axonal injury after brain trauma. Neurology 2016;86:821–8. 10.1212/WNL.0000000000002413
- Stern RA, Adler CH, Chen K, et al. . Tau positron-emission tomography in former national football League players. N Engl J Med 2019;380:1716–25. 10.1056/NEJMoa1900757
- Bobinski M, de Leon MJ, Wegiel J, et al. . The histological validation of post mortem magnetic resonance imaging-determined hippocampal volume in Alzheimer's disease. Neuroscience 1999;95:721–5. 10.1016/S0306-4522(99)00476-5
- Schott JM, Bartlett JW, Barnes J, et al. . Reduced sample sizes for atrophy outcomes in Alzheimer's disease trials: baseline adjustment. Neurobiol Aging 2010;31:1452–62. 10.1016/j.neurobiolaging.2010.04.011
- Cash DM, Frost C, Iheme LO, et al. . Assessing atrophy measurement techniques in dementia: results from the MIRIAD atrophy challenge. Neuroimage 2015;123:149–64. 10.1016/j.neuroimage.2015.07.087
- US Food and Drug Administration Early Alzheimer’s Disease: Developing Drugs for Treatment Guidance for Industry (draft guidance) 2018.
Source: PubMed