Multi-Modal Biomarkers of Repetitive Head Impacts and Traumatic Encephalopathy Syndrome: A Clinicopathological Case Series

Breton M. Asken, Jeremy A. Tanner, Lawren Vandevrede, Kaitlin B. Casaletto, Adam M. Staffaroni, Nidhi Mundada, Corrina Fonseca, Leonardo Iaccarino, Renaud La Joie, Torie Tsuei, Miho Mladinov, Harli Grant, Ranjani Shankar, Kevin K.W. Wang, Haiyan Xu, Yann Cobigo, Howie Rosen, Raquel C. Gardner, David C. Perry, Bruce L. MillerSalvatore Spina, William W. Seeley, Joel H. Kramer, Lea T. Grinberg, Gil D. Rabinovici

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


Traumatic encephalopathy syndrome (TES) criteria were developed to aid diagnosis of chronic traumatic encephalopathy (CTE) pathology during life. Interpreting clinical and biomarker findings in patients with TES during life necessitates autopsy-based determination of the neuropathological profile. We report a clinicopathological series of nine patients with previous repetitive head impacts (RHI) classified retrospectively using the recent TES research framework (100% male and white/Caucasian, age at death 49-84) who completed antemortem neuropsychological evaluations, T1-weighted magnetic resonance imaging, diffusion tensor imaging (n = 6), (18)F-fluorodeoxyglucose-positron emission tomography (n = 5), and plasma measurement of neurofilament light (NfL), glial fibrillary acidic protein (GFAP), and total tau (n = 8). Autopsies were performed on all patients. Cognitively, low test scores and longitudinal decline were relatively consistent for memory and executive function. Medial temporal lobe atrophy was observed in all nine patients. Poor white matter integrity was consistently found in the fornix. Glucose hypometabolism was most common in the medial temporal lobe and thalamus. Most patients had elevated plasma GFAP, NfL, and total tau at their initial visit and a subset showed longitudinally increasing concentrations. Neuropathologically, five of the nine patients had CTE pathology (n = 4 "High CTE"/McKee Stage III-IV, n = 1 "Low CTE"/McKee Stage I). Primary neuropathological diagnoses (i.e., the disease considered most responsible for observed symptoms) were frontotemporal lobar degeneration (n = 2 FTLD-TDP, n = 1 FTLD-Tau), Alzheimer disease (n = 3), CTE (n = 2), and primary age-related tauopathy (n = 1). In addition, hippocampal sclerosis was a common neuropathological comorbidity (n = 5) and associated with limbic-predominant TDP-43 proteinopathy (n = 4) or FTLD-TDP (n = 1). Memory and executive function decline, limbic system brain changes (atrophy, decreased white matter integrity, hypometabolism), and plasma biomarker alterations are common in RHI and TES but may reflect multiple neuropathologies. In particular, the neuropathological differential for patients with RHI or TES presenting with medial temporal atrophy and memory loss should include limbic TDP-43. Researchers and clinicians should be cautious in attributing cognitive, neuroimaging, or other biomarker changes solely to CTE tau pathology based on previous RHI or a TES diagnosis alone.

Original languageEnglish (US)
Pages (from-to)1195-1213
Number of pages19
JournalJournal of Neurotrauma
Issue number17-18
StatePublished - Sep 1 2022


  • Biomarker
  • Chronic traumatic encephalopathy
  • Concussion
  • Hippocampal sclerosis
  • Limbic-predominant age-related tdp-43 encephalopathy
  • Traumatic encephalopathy syndrome

ASJC Scopus subject areas

  • Clinical Neurology


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