CTE found in teenage brains by B.U. team

WESTBROUGH, MA January 18, 2018 The scientists studying the damaged brains of older athletes have had the opportunity to study brain damage in athletes who died from other causes.  In 4 such cases, there was evidence of chronic traumatic encephalopathy (CTE) that was not commensurate with the degree of brain trauma that was observed during their athletic careers according to Felice Freyer of the Boston Globe. This recent study was published in the journal Brain illustrates that the onset of CTE may be closer to onset of brain injury than first thought not much later in life.
“The report, published Thursday in the journal Brain, also provides what Goldstein called “the best evidence to date” supporting the theory that CTE is caused not just by concussions, but rather by any blow to the head, including mild impacts. Instead of diagnosing and responding to concussions, he said, coaches would do better to protect children from all hits to the head.” Felice Freyer – Boston Globe 1-8-18
The possibility of younger athletes developing CTE and the symptoms associated with this progressive disease is quite worrisome especially to parents.  It was always thought that CTE would develop later in life if at all. With the prospects of the disease having a much earlier onset the cost of CTE over a lifetime is incalculable in terms of medical costs and neuropsychological sequelae that may evolve in time. The true impact of this and the consequence for repeated, subclinical blows to the head is only now becoming clear.
Like dementia of the Alzheimer’s type the build up of tau protein underlies the changes associated with CTE. “Chronic traumatic encephalopathy is a condition bringing forth progressive tauopathy that occurs as a consequence of repetitive mild traumatic brain injury. We analysed post-mortem brains obtained from a cohort of 85 subjects with histories of repetitive mild traumatic brain injury and found evidence of chronic traumatic encephalopathy in 68 subjects: all males, ranging in age from 17 to 98 years (mean 59.5 years), including 64 athletes, 21 military veterans (86% of whom were also athletes) and one individual who engaged in self-injurious head banging behavior” according to the journal Brain. McKee, A. et. al. 2017

McKee, A. et. al. (2017) The spectrum of disease in chronic traumatic encephalopathy. Brain, Volume 136, Issue 1, 1 January 2013, Pages 43–64, https://doi.org/10.1093/brain/aws307
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Once common treatment of concussion

Head injuries at the time were treated as mere nuisances. Players reacted to violent head blows by trying to blink away their blurred vision, shake the ringing from their skulls, and trundle back to their huddles, unless they were flagged by sideline doctors. Even then, they generally returned quickly to action.  Boston Globe October 2017

Clock of the Year – Vote for your favorite of 2017

WESTBOROUGH, MA It is time once again to select the “Clock of the Year”.  Voting will go on for the next week.   There are 10 clocks featured this year each one drawn by a patient undergoing rehabilitation at Whittier Rehabilitation Hospital in Westborough, MA.  The diagnoses of each patient may or may not be presented with the clock as it scrolls through.  Any clock with a measuring tape would be presented in millimeters-centimeters not inches.  The clocks shown in millimeters are tiny – micrographic in quality.  The first clock in the slideshow is drawn by a 93-year old – each one would then become a successive number through # 10.

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I have published many blogs about the use of the clock drawing in clinical practice.  Clock drawing was first introduced to me in my practice as a pre-doctoral student in psychology at the V.A. Medical Center in Boston by Dr. Edith Kaplan.  She taught us that
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Michael Sefton at MFA Boston

something as simple as a clock drawing can become a daunting task when faced with cognitive changes from brain injury, stroke, or dementia.  I carry on this tradition in honor of Dr. Kaplan and the role she played in my formative work as a neuropsychologist.  Today, every discipline it seems uses a clock to assess problem solving, organization, and following directions in patients with suspected decline in their thinking skill. Dr Kaplan died in September, 2009 and is missed even now.

Brain and Behavior: B.U. scientist says Aaron Hernandez had CTE

Westborough, MA November 18, 2017 The NFL has some explaining to do. Why are former athletes killing themselves and in some cases other people? As students studying the brain it was something special when you could make a correlation between an identified brain lesion and the behavior you are seeing.  I was in China in early November 2017 at a conference on RNA targeted therapy for cancer.  As the non-scientist in the group I was referred to as the clinician who saw the phenotype rather than the genotype – referring to the innumerable genetic underpinnings of cellular biology and changing science of modified nucleotides.  I understood this to have some meaningful interest to the faculty that consisted of 3 prior Nobel laureates and leading scientists in RNA targeted therapy.  So after sitting through hours of presentations I realize the importance of not making a rush to judgment about the cause of some predicted outcome. As a neuropsychologist we are asked to make assumptions about brain integrity after CNS infarcts and make educated predictions about the functional implication of focal lesions in brain.
Recently the scientists at Boston University announced the results of the post-mortem analysis of the brain of Aaron Hernandez, former N.E. Patriots receiver and convicted murderer.  Hernandez had his conviction expunged after he died while his case was on appeal. The 27-year old brain was highly suggestive of having the tell tale signs of chronic traumatic encephalopathy or CTE thought to be the result of repeated concussions and now realized as the result of hundreds – perhaps thousands of sub-concussive blows to the head that accumulate over time.  Hernandez’s brain was the youngest of the donated brains to be identified with advanced CTE. Hernandez played football for 17 years starting when he was a young boy. The question remains did the brain damage that was identified in the post-mortem analysis cause behavior change in Hernandez and could the murder of Odin Lloyd be attributed to the build up of dangerous tau protein in his brain?
“While no one can prove a causal link between Hernandez’s brain damage and his actions, there is little dispute that he displayed CTE symptoms associated with behavioral problems, such as aggressiveness, explosiveness, impulsivity, and suicide.”
Boston Globe Bob Hohler November 9, 2017
By history Aaron Hernandez was an angry, impulsive and violent teenager that his mother reported began when his father died suddenly. Coupled with this was a biological proclivity toward degenerative brain disorders such as Alzheimer’s Disease and CTE.  Both are diagnosed only after the death of the victim. We know that brain-behavior relationships exist from research in stroke and traumatic brain injury where focal injuries result in specific and expected changes in behavior.  These often result from a disconnection between functional centers of the brain including limbic structures that link centers for emotional regulation and the frontal system that exerts inhibitory control over those emotions. The athlete’s who have donated their brain’s upon their death have almost universally exhibited changes in behavior including poor impulse control, depression, and anger.

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BU Medical School and WCVB images 2017

Clock of the Week – September 25, 2017 Micrographia

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Clock of the week drawn by 79-Y/O male with bilateral embolic CVA (note size approximately 8 mm)
WESTBOROUGH, MA September 25, 2017 This clock is unique simply on the basis of it’s size.  The scale below the 3 clocks is used for measuring wounds.  It was given to me by the certified wound care specialist here at Whittier.  The top clock was the “finished” product.  One can see all the numbers were written and there was a series of hands drawn that appear as scribble moving from left to right.  The numbers fall outside of the circle – drawn by the patient.  You can appreciate what effort went into the clock as small as it was – only 8 millimeters across.  Micrographia is a term given to drawings that are tiny – a syndrome often assigned to dysfunction in the frontal lobe of the brain.  Just to be sure, I consulted with Lezak – 3rd Edition.  Micrographic written output is seen in patients with Parkinson’s Disease. In another blog published in 2016, I shared a similar clock and describe this interesting syndrome.

Clock of the Week

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Dr. Michael Sefton at Boston Museum of Fine Arts
WESTBOROUGH, MA September 15, 2017  Much has been published about the utility of the clock drawing in making preliminary assumptions about the cognitive health of an individual who may be referred for neuropsychological assessment.  I use it all the time and those of you who have submitted clocks for publication here agree with my assumptions.  The photograph at the left was taken at the Boston Museum of Fine Arts by a colleague Dr. David Kent, a neuropsychologist from Worcester, MA. There are several posts that identify some of the literature behind the assumptions I make about clock drawing and cognition.  Here is another link: Clocks and cognition

 

 

Click and see the interesting “Clock of the week

Construction and Self-monitoring

WESTBOROUGH, MA August 6, 2017 Self-monitoring refers to the capacity to observe one’s own behavior in real time. It is easy to see when someone lacks this important neurocognitive feature. Walk into any middle school and there will be hundreds of boys who act and behave without forethought.  Self-monitoring is a higher-order function that sets us apart from other species – even primates and is thought to mature in the second or third decade of life. It is possible to lose the ability to watch and adjust behavior such as with traumatic brain injury involving frontal lobe structures and in disorders of cognition such as dementia.  How is it possible to lose appreciation for the organization of the task (see drawing on left) and fail to notice one’s errors?
The bicycle task requires a rudimentary capacity to envision the bike and draw it from the image one has in his head.  It requires conceptualization, motor control and visual motor integration for success.  The task is age old – like the clocks frequently featured in these pages. Self-monitoring is a prerequisite for social pragmatics – a fancy term for acting your age. In some cases the failure in self-monitoring results in errors in behavior that can become socially debilitating – especially when the patient demonstrates an indifference to his limitations and does not respond to redirection and feedback.  The task of constructing a bicycle is a screening for higher order deficits.  Like the clock drawing it requires planning, organization, even mechanical awareness.  Muriel Lezak says that regardless of lesion the task requires judgment, organization, conceptual integration, and accurate self-appraisal.  Those with defective self-monitoring often miss important features and omit crucial parts of the bicycle’s mechanism like pedals, chain or both (Lezak, 1995)

 

 

“The capacity to self-monitor and modify one’s behavior is required in an open society or the lack of order would result in people being oblivious to each other and indifferent toward their personal effect on social and interpersonal relationships”    Michael Sefton 2017
In the first bike drawing the patient constructed the bicycle as asked but became confused very quickly.  the two objects extending out from the left and right are wheels that were drawn after I had asked “how does it work?” Interestingly one of the scoring criteria are the correct placement of spokes on the wheels. There are no spokes on the wheels of the second and third drawings. In some cases the concept of perseveration is revealing of decreased self-monitoring.  In a published blog the concept is described.  It is the process of repeating the same response over and over without awareness.

Lezak, M. Neuropsychological Assessment – Third Edition. Oxford Press, 1995.
Sefton, M. (2016) Perseveration, severation, eration, ation, blog post, taken August 8, 2017.