title: Is There Chronic Brain Damage in Retired NFL Players? Neuroradiology, Neuropsychology, and Neurology Examinations of 45 Retired Players.
abstract: BACKGROUND
  Neuropathology and surveys of retired National Football League (NFL) players suggest that chronic brain damage is a frequent result of a career in football. There is limited information on the neurological statuses of living retired players. This study aimed to fill the gap in knowledge by conducting in-depth neurological examinations of 30- to 60-year-old retired NFL players.
  
  
  OBJECTIVE
  In-depth neurological examinations of 30- to 60-year-old retired players are unlikely to detect objective clinical abnormalities in the majority of subjects.
  
  
  METHODS
  A day-long medical examination was conducted on 45 retired NFL players, including state-of-the-art magnetic resonance imaging (MRI; susceptibility weighted imaging [SWI], diffusion tensor imaging [DTI]), comprehensive neuropsychological and neurological examinations, interviews, blood tests, and APOE (apolipoprotein E) genotyping.
  
  
  METHODS
  Level 3.
  
  
  METHODS
  Participants' histories focused on neurological and depression symptoms, exposure to football, and other factors that could affect brain function. The neurological examination included Mini-Mental State Examination (MMSE) evaluation of cognitive function and a comprehensive search for signs of dysarthria, pyramidal system dysfunction, extrapyramidal system dysfunction, and cerebellar dysfunction. The Beck Depression Inventory (BDI) and Patient Health Questionnaire (PHQ) measured depression. Neuropsychological tests included pen-and-paper and ImPACT evaluation of cognitive function. Anatomical examination SWI and DTI MRI searched for brain injuries. The results were statistically analyzed for associations with markers of exposure to football and related factors, such as body mass index (BMI), ethanol use, and APOE4 status.
  
  
  RESULTS
  The retired players' ages averaged 45.6 ± 8.9 years (range, 30-60 years), and they had 6.8 ± 3.2 years (maximum, 14 years) of NFL play. They reported 6.9 ± 6.2 concussions (maximum, 25) in the NFL. The majority of retired players had normal clinical mental status and central nervous system (CNS) neurological examinations. Four players (9%) had microbleeds in brain parenchyma identified in SWI, and 3 (7%) had a large cavum septum pellucidum with brain atrophy. The number of concussions/dings was associated with abnormal results in SWI and DTI. Neuropsychological testing revealed isolated impairments in 11 players (24%), but none had dementia. Nine players (20%) endorsed symptoms of moderate or severe depression on the BDI and/or met criteria for depression on PHQ; however, none had dementia, dysarthria, parkinsonism, or cerebellar dysfunction. The number of football-related concussions was associated with isolated abnormalities on the clinical neurological examination, suggesting CNS dysfunction. The APOE4 allele was present in 38% of the players, a larger number than would be expected in the general male population (23%-26%).
  
  
  CONCLUSIONS
  MRI lesions and neuropsychological impairments were found in some players; however, the majority of retired NFL players had no clinical signs of chronic brain damage.
  
  
  CONCLUSIONS
  These results need to be reconciled with the prevailing view that a career in football frequently results in chronic brain damage.
authors.affiliation: Department of Neurology, Long Island Jewish Medical Center, New Hyde Park, New York ; Department of Neurology, Hofstra North Shore-LIJ School of Medicine, Hempstead, New York.
authors.forename: Ira R
authors.initials: IR
authors.lastname: Casson
authors.affiliation: ProBiomechanics LLC, Bloomfield Hills, Michigan ; Department of Biomedical Engineering, Bioengineering Center, Wayne State University, Detroit, Michigan.
authors.forename: David C
authors.initials: DC
authors.lastname: Viano
authors.affiliation: Departments of Radiology and Biomedical Engineering, Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: E Mark
authors.initials: EM
authors.lastname: Haacke
authors.affiliation: Departments of Radiology and Biomedical Engineering, Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Zhifeng
authors.initials: Z
authors.lastname: Kou
authors.affiliation: Emergency Nursing and Clinical Outreach, Lawrence Hospital Center, Bronxville, New York.
authors.forename: Danielle G
authors.initials: DG
authors.lastname: LeStrange
keywords: brain injury; chronic traumatic encephalopathy (CTE); clinical neurology; concussion; neuropsychology; neuroradiology