Chronic Traumatic Encephalopathy in Soccer Players: Review of 14 Cases.

OBJECTIVE: Exposure to repetitive sports-related concussions or (sub)concussive head trauma may lead to chronic traumatic encephalopathy (CTE). Which impact (heading or concussion) poses the greatest risk of CTE development in soccer players? DESIGN: Narrative review. SETTING: Teaching hospital and University of Applied sciences. PATIENTS: A literature search (PubMed) was conducted for neuropathologic studies in the period 2005-December 2022, investigating soccer players with dementia and a CTE diagnosis, limited to English language publications. 210 papers were selected for final inclusion, of which 7 papers described 14 soccer players. ASSESSMENT: Magnetic resonance imaging studies in soccer players show that lifetime estimates of heading numbers are inversely correlated with cortical thickness, grey matter volume, and density of the anterior temporal cortex. Using diffusion tensor imaging-magnetic resonance imaging, higher frequency of headings-particularly with rotational accelerations-are associated with impaired white matter integrity. Serum neurofilament light protein is elevated after heading. MAIN OUTCOME MEASURES: Chronic traumatic encephalopathy pathology, history of concussion, heading frequency. RESULTS: In 10 of 14 soccer players, CTE was the primary diagnosis. In 4 cases, other dementia types formed the primary diagnosis and CTE pathology was a concomitant finding. Remarkably, 6 of the 14 cases had no history of concussion, suggesting that frequent heading may be a risk for CTE in patients without symptomatic concussion. Rule changes in heading duels, management of concussion during the game, and limiting the number of high force headers during training are discussed. CONCLUSIONS: Data suggest that heading frequency and concussions are associated with higher risk of developing CTE in (retired) soccer players. However based on this review of only 14 players, questions persist as to whether or not heading is a risk factor for CTE or long-term cognitive decline.

A Child Presenting with a Glasgow Coma Scale Score of 13: Mild or Moderate Traumatic Brain Injury? A Narrative Review.

OBJECTIVE: The objective of this article was to compare children with traumatic brain injury (TBI) and Glasgow Coma Scale score (GCS) 13 with children presenting with GCS 14 and 15 and GCS 9 to 12. DATA SOURCE: We searched PubMed for clinical studies of children of 0 to 18 years of age with mild TBI (mTBI) and moderate TBI, published in English language in the period of 2000 to 2020. STUDY SELECTION: We selected studies sub-classifying children with GCS 13 in comparison with GCS 14 and 15 and 9 to 12. We excluded reviews, meta-analyses, non-U.S./European population studies, studies of abusive head trauma, and severe TBI. DATA SYNTHESIS: Most children (>85%) with an mTBI present at the emergency department with an initial GCS 15. A minority of only 5% present with GCS 13, 40% of which sustain a high-energy trauma. Compared with GCS 15, they present with a longer duration of unconsciousness and of post-traumatic amnesia. More often head computerized tomography scans show abnormalities (in 9-16%), leading to neurosurgical intervention in 3 to 8%. Also, higher rates of severe extracranial injury are reported. Admission is indicated in more than 90%, with a median length of hospitalization of more than 4 days and 28% requiring intensive care unit level care. These data are more consistent with children with GCS 9 to 12. In children with GCS 15, all these numbers are much lower. CONCLUSION: We advocate classifying children with GCS 13 as moderate TBI and treat them accordingly.

Susceptibility-Weighted MRI and Microbleeds in Mild Traumatic Brain Injury: Prediction of Posttraumatic Complaints?

BACKGROUND: Only in 7-15% of patients with mild traumatic brain injury (mTBI), traumatic CT-abnormalities are found. Nevertheless, 40% of mTBI patients suffer from posttraumatic complaints not resolving after 6 months. We discuss the ability of susceptibility-weighted imaging (SWI), sensitive for microbleeds, to detect more subtle brain abnormalities. SUMMARY: After a search on PubMed, we selected 15 studies on SWI in adult mTBI patients; 11 studies on 3T MRI, and 4 studies on 1.5T MRI. All 1.5T studies showed that, compared to T2, gradient echo, diffusion-weighted imaging, or fluid-attenuated inversion recovery sequences, SWI is more sensitive for microbleeds. Only two 1.5T studies described the association between SWI findings and outcome. In 3 of the 4 studies, no control group was present. The mean number of microbleeds varied from 3.2 to 6.4 per patient. In the 3T studies, the percentage of patients with traumatic microbleeds varied from 5.7 to 28.8%, compared to 0-13.3% in normal controls. Microbleeds were particularly located subcortical or juxtacortical. The number of microbleeds in mTBI varied from 1 to 10 per patient. mTBI patients with microbleeds appeared to have higher symptom severity at 12 months and perform worse on tests of psychomotor speed and speed of information processing after 3 and 12 months, compared to mTBI patients without microbleeds. KEY MESSAGES: There is some evidence that traumatic microbleeds predict cognitive outcome and persistent posttraumatic complaints in patients with mTBI.

[Flying and COVID-19: options to reduce the risk of transmission]. / Vliegverkeer en covid-19.

With air travel continuing after the SARS-CoV-2 pandemic as before, is there a risk of in-flight-transmission? We found 18 papers describing a total number of 306 index patients on 150 flights, 79 infected passengers and four infected cabin crew. Infection transmission within the aircraft cabin depends on flight occupancy, proximity to the index patient, duration of flight and the prevailing virus variant. A negative PCR-test has a sensitivity of 95 %, around 5 % of travelers will get a false negative result. Airborne transmission of virus-containing saliva droplets (aerosols) is considered the most important infection mechanism; infection via contaminated surfaces is less common. Strict distancing, with an empty middle seat, is essential. The risk of in-flight transmission can be further minimized by mandatory masking, restricting passenger movements, restricting meals and beverages, frequent hand sanitizing and complying to rules while boarding or at disembarkation.

Aerotoxic syndrome, discussion of possible diagnostic criteria.

Introduction: The term aerotoxic syndrome (ATS) was proposed 20 years ago to describe a constellation of symptoms reported by pilots and cabin crew following exposure to hydraulic fluids, engine oil, and pyrolysis products during flight. Hydraulic fluids and engine oil contain a large number of potentially toxic chemicals, including various organophosphate compounds (OPCs). However, ATS is not yet recognised as a valid diagnosis in aviation or general medicine, because the incidence and aetiology continues to be debated.Discussion: Early studies report findings from symptom surveys or cognitive assessments of small samples of self-selected aircrew, but objective measures of exposure were lacking. Over the last decade, researchers have used more sophisticated techniques to measure exposure, such as on board monitoring studies and biomarkers of exposure (e.g., reduced levels of serum butyrylcholinesterases [BChE]) and more sophisticated techniques to detect nervous system injuries such as fMRI and autoantibody testing. Consideration has also been given to inter-individual differences in the ability to metabolise certain chemical compounds as a result of genetic polymorphisms and exclusion of other potential causes of ill health.Conclusions: We discuss factors which suggest a diagnosis of probable ATS; recommend an assessment protocol which incorporates the aforementioned techniques; and propose diagnostic criteria for probable ATS, based on our previously reported findings in aircrew and the results of recent studies.

[An abnormal CT scan following a mild traumatic brain injury; what then?] / Een afwijkende CT-scan bij licht traumatisch hoofdletsel, en dan?

CT scan reveals traumatic intracranial abnormalities in fewer than 10% of patients following mild traumatic brain injury (mTBI). Management policy in these patients is not clear. Clinical or radiological deterioration occurs in 10-20% of this risk group, usually within 24 hours and often without neurosurgical consequences. Patients with mTBI and subarachnoid blood or small foci of contusion do not need to be admitted to medium/high care or to the ICU. This is warranted in patients fulfilling the following criteria: age > 65 years; a Glasgow Coma Scale (GCS) score < 15; anticoagulant use; or multiple trauma. It is also warranted by fulfilment of one or more of the following CT-criteria: shift of the midline; subdural or epidural haematoma; a temporal or subfrontal focus of contusion; or intraparenchymatous bleeding > 10 ml. Repeated CT-scan is only indicated in case of clinical deterioration. Transfer to a neurosurgical centre is not necessary in the majority of patients with mTBI and CT abnormalities.