Brain imaging study of youth hockey players shows early markers for concussion damage.

A brain imaging study of youth hockey players shows early markers for concussion damage.

James Hudziak, M.D., has two children who love ice hockey. His son skates for his college team and one of his daughters plays in high school.

As a pediatric neuropsychiatrist and director of the Vermont Center for Children, Youth and Families at the University of Vermont (UVM) College of Medicine, Hudziak believes in the benefits of ice hockey and other sports for kids. Athletic activities help a young person build organizational skills, improve motor and emotional control, reduce anxiety and boost confidence.

Now, though, Hudziak is looking into the potential dangers of ice hockey for young athletes. He and UVM colleagues Matthew Albaugh, Ph.D., Catherine Orr, Ph.D., and Richard Watts, Ph.D., have published a groundbreaking study in the February issue of TheJournal of Pediatrics that shows a relationship between concussions sustained by young ice hockey players and subtle changes in the cortex, the outer layer of the brain that controls higher-level reasoning and behavior.

Each year, more than 300,000 sports-related concussions (SRC) occur across all sports and all levels in the United States, according to a 2013 "Ice Hockey Summit II" report to which Hudziak and Boston University (BU) School of Medicine's Ann McKee, M.D., contributed. The report's authors advised the elimination of head hits from all levels of hockey, a change in body-checking policies and the elimination of fighting in all amateur and professional hockey. "Ice hockey SRC prevalence is high," the report states. "Hockey players compete at high speeds as they mature, risking injury from intentional and accidental collisions, body checks, illegal on-ice activity and fighting."

The UVM team used advanced imaging technology and cognitive testing to assess 29 Vermont ice hockey players between ages 14 and 23, some diagnosed with a sports-related concussion. As the severity of the athletes' concussion symptoms increased, the researchers found, the cortex got thinner in areas where it should be dense at those players' ages -- areas that relate to attention control, memory, and emotion regulation.

"We believe that injury to a developing brain may be more severe than injury to an adult brain," Hudziak says.

What the study indicates for the future health and function of an ice hockey player is unclear. The researchers hope to do further studies, ideally following the brains of these athletes over a couple of decades and factoring for their involvement and time in the sport as well as other influences, such as smoking and alcohol use.

"The concern is that what we are finding may be an early marker of brain damage," Albaugh says. "Years of playing contact sports and repeatedly getting your head knocked around probably isn't good for the brain, especially in young children whose brains are still maturing" he adds.

Their findings contribute to research into the consequences of brain injury in other sports, including the brain damage discovered in older professional football players by McKee, a neurology and pathology professor at BU and director of the "brain banks" in various centers of study for the university and the Veterans Administration. Her work was a cornerstone of "League of Denial: The NFL's Concussion Crisis," an investigative report by the public television program "Frontline" on the National Football League's response to players' brain trauma.

"It just adds to our information base about young athletes playing contact sports," McKee says of Hudziak's study. "It's a first step. It needs to be looked at longitudinally. We need to know if these athletes recover."

McKee says she wouldn't necessarily expect the brain changes in young hockey players to lead to chronic traumatic encephalopathy (CTE), a serious but uncommon disease that she found prevalent in retired NFL players. Instead, she expects that further study in the ice hockey arena will show that young players' brains can recover from early blows. Brains have a chance for rehabilitation after injury, she says.

"We're hopeful that these changes can be reversed," she says of the cortex thinning observed in Hudziak's study. "I would look at this as an opportunity to make a difference, and not a cause of irrevocable damage in these players."

Hudziak and his UVM colleagues would like to help the organizations running professional, collegiate, junior and youth hockey leagues make better decisions about how best to treat players' head injuries; how and when to return players to the ice after an injury; when to pull them from the sport entirely; and how to prevent injuries from occurring. Players and coaches at the national, college and youth levels of hockey have talked to Hudziak about his findings, he says.

In Hudziak's study, he and his colleagues cite research indicating "that cerebral concussion accounts for 15 to 22.2 percent of all reported injuries" in hockey.

The key challenges for them, says Hudziak, are that the definition of "concussion" is so slippery and reports of the incidence of concussions are inconsistent. Some people think a concussion happens when someone is hit in the head or gets dizzy; others think a person has to be "knocked out" to have a concussion.

His study focuses on the symptoms recorded after a diagnosed concussion. But Hudziak wonders whether lesser head injuries, what he calls sub-concussive events, could have as many or more consequences for the brain over time as a single major blow.

On the computer in his office, Hudziak shows a video of a professional hockey game during which a player gets body checked. It doesn't look like a very serious hit, though he's carried off the ice.

Then, the video reverses to just a few minutes earlier in the game, when that same player collides with another and flips violently backwards, throwing off his helmet before his head hits the ice. That suggests the potential harm inside a person's skull that can occur from cumulative assault.

As Hudziak puts it, "The sum is greater than the individual parts."

That player flew into Burlington, Vt. to meet with Hudziak and his team, so they can learn more from his brain.

Ideally, Hudziak says, they want to apply their current study to female and male ice hockey players ages 8 to 14, then to college-age skaters of both genders and finally to retired professional hockey players. They'd like to compare their findings at each age group to nonathletes and to the same groups in soccer -- a sport typically involving less-severe head injuries.

"We don't have any sense that hockey's going to be worse than soccer," Hudziak points out.

Already, in a follow-up study, Hudziak's team has found more evidence of increased problems in the brains of athletes, compared with nonathletes. This work focuses on "hyperintensities," which look like little bright white spots on a brain image. His research suggests a higher volume of these bright spots may correlate with decreased thickness in the cortex.

"As a general rule of thumb, you're allowed one of these bright spots every 10 years of your life," Albaugh says.

So a 50-year-old should have about five of these bright spots. One of the college-age athletes in the study has 18 spots, Albaugh says. Hudziak now has to call some parents to tell them of the "clinically concerning findings" in their children's brain images.

Hudziak doesn't want to warn parents to keep their kids out of hockey or other team play. As the founder of the unique Vermont Family-Based Approach, which incorporates all aspects of a child's life to address emotional and behavioral problems, he prescribes hockey, soccer and other sports to help eliminate behavior, attention and psychological disorders. It is his hope that through brain training and health promotion the brain may recover.

"My goal is not to rid the world of these sports," Hudziak says. "My goal is to make these sports safer, so that more people can play them."

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Brain damage from mild concussions

This article explains how football players can have brain damage from milder concussions.

A new, enhanced MRI diagnostic approach was, for the first time, able to identify significant damage to the blood-brain barrier (BBB) of professional football players following "unreported" trauma or mild concussions. Published in the current issue of JAMA Neurology, this study could improve decision making on when an athlete should "return to play."

According to Prof. Alon Friedman, from the Ben-Gurion University Brain Imaging Research Center and discoverer of the new diagnostic, "until now, there wasn't a diagnostic capability to identify mild brain injury early after the trauma. In the NFL, other professional sports and especially school sports, concern has grown about the long-term neuropsychiatric consequences of repeated mild Traumatic Brain Injury (mTBI) and specifically sports-related concussive and sub-concussive head impacts."

The paper, published by researchers at Ben-Gurion University of the Negev (BGU) and Soroka University Medical Center, describes a new diagnostic approach using Magnetic Resonance Imaging (MRI) for detection and localization of vascular pathology and blood-brain barrier breakdown in football players.

The images from the Ben-Gurion University of the Negev JAMA Neurology study represent Blood-Brain Barrier (BBB) Permeability in Football Players (A) vs. a control group (B). The players in the pathological-BBB group (B) presented focal BBB lesions in different cortical regions including the temporal (player 4), frontal (player 5), and parietal (player 6) lobes. Both gray and white matter were involved.

"The goal of our study was to use our new method to visualize the extent and location of BBB dysfunction in football players using Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI) on a Phillips 3-T Ingenia. Specifically, it generates more detailed brain maps showing brain regions with abnormal vasculature, or a 'leaky BBB.' "

Study participants included 16 football players from Israel's professional football team, Black Swarm, as well as 13 track and field athletes from Ben-Gurion University who served as controls. All underwent the newly developed MRI-based diagnostic.

The DCE-MRIs were given between games during the season and revealed significant damage.

Forty percent of the examined football players with unreported concussions had evidence of "leaky BBB" compared to 8.3 percent of the control athletes.

"The group of 29 volunteers was clearly differentiated into an intact-BBB group and a pathological-BBB group," Friedman explains. "This showed a clear association between football and increased risk for BBB pathology that we couldn't see before. In addition, high-BBB permeability was found in six players and in only one athlete from the control group."

Friedman also explains that not all the players showed pathology. This indicates that repeated, mild concussive events might impact some players differently than others. This level of diagnosis of individual players can provide the basis of more rational decision making on "return to play" for professionals as well amateurs of any age.

"Generally, players return to the game long before the brain's physical healing is complete, which could exacerbate the possibility of brain damage later in life," says Friedman.

A decade of research in the BGU Laboratory for Experimental Neurosurgery has shown that vascular pathology, and specifically dysfunction of the blood-brain barrier (BBB), plays a key role in brain dysfunction and degeneration, and may be an underlying cause of neurodegenerative complications after brain injuries.

The BBB is a highly selective permeable membrane that separates circulating blood from extracellular fluid. It protects the brain by preventing many dangerous substances from penetrating, and therefore is not meant to be damaged.

Medical researchers, including Friedman's group at BGU, are working to find ways to find drugs that will target the BBB and facilitate its repair, allowing for the prevention of Alzheimer's disease and other brain-related disease.

"Prof. Friedman has been able to conduct this breakthrough brain research using the state-of-the-art MRI machine donated as a result of contributions from American Associates, Ben-Gurion University of the Negev (AABGU)," explains Doron Krakow, AABGU executive vice president. "We believe that with continued support, Prof. Friedman and the DCE-MRI can help render more accurate and informed decisions by athletes and others exposed to mild concussions about when to resume activities."

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Brain damage can occur even in mild brain injuries

A study shows that even a mild brain injury can cause lasting brain damage.

Even mild traumatic brain injury may cause brain damage and thinking and memory problems, according to a study published in the July 16, 2014, online issue of Neurology®, the medical journal of the American Academy of Neurology.

For the study, 44 people with a mild traumatic brain injury and nine people with a moderate traumatic brain injury were compared to 33 people with no brain injury. All of the participants took tests of their thinking and memory skills. At the same time, they had diffusion tensor imaging scans, a type of MRI scan that is more sensitive than traditional MRI for detecting damage to brain cells and helps map fiber tracts that connect brain regions. The people with brain injuries had their scans an average of six days after the injury. A year later, 23 of those with injuries had another scan and took the cognitive tests again.

Compared to the people with no brain injury, those with injuries had brain damage in brain white matter consisting of disruption to nerve axons, those parts of nerve cells that make up white matter and that allow brain cells to transmit messages to each other.

The study found that patient scores on the verbal letter fluency task, a test of thinking and memory skills, were 25 percent lower than in the healthy people. This was strongly related to the imaging measures of white matter damage.

“Most of the studies thus far have focused on people with severe and chronic traumatic brain injury,” said study author Andrew Blamire, PhD, of Newcastle University in the United Kingdom. “We studied patients who had suffered clinically mild injuries often from common accidents such as falling from a bicycle, or slow speed car accidents. This finding is especially important, as 90 percent of all traumatic brain injuries are mild to moderate.”

One year after the injury, the scores on thinking and memory tests were the same for people with brain injuries and those with no injuries, but there were still areas of brain damage in people with injuries. “These results show that thinking skills were recovering over time,” Blamire said. “The areas of brain damage were not as widespread across the brain as previously, but focused in certain areas of the brain, which could indicate that the brain was compensating for the injuries.”

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In rats, brain damage occurs with no signs of concussion

Brain damage is seen in rats after repeated "subconcussive" brain trauma, or a head injury that shows no concussion symptoms.

A standard experimental model of concussion in rats causes substantial brain damage -- but no behavioral changes comparable to those seen in patients with concussion, reports a study in the April issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The results highlight the "disconnect" between preclinical and clinical studies of concussion, according to the report by Dr. Charles L. Rosen of West Virginia University, Morgantown, and colleagues. The study also adds to concerns over the possible long-term effects of repeated, "subconcussive" brain trauma -- causing no concussion symptoms -- in humans.

Despite Diffuse Brain Damage, No Signs of 'Concussion' in Rats

Concussions are thought to be a form of "mild traumatic brain injury." However, there is no definitive diagnostic test to determine when a concussion has occurred. Instead, concussion is diagnosed on the basis of symptoms such as headache, nausea, dizziness, and confusion.

In contrast, animal studies of concussion have focused on directly observed injury to brain tissues, with little attention to the possible behavioral and functional consequences of the brain trauma. Thus there is a "clear disconnect" between experimental and clinical studies of concussion, according to Dr. Rosen and colleagues.

To address this discrepancy, they used a standard technique, called the "impact-acceleration model," to induce brain injury in rats. As reported by previous studies, this technique caused "diffuse axonal injury" to the brain, with visible evidence of damage on the cellular level.

The researchers also compared injured and uninjured animals on a wide range of functional and behavioral tests. The tests were chosen to reflect symptoms and functions similar to those used to diagnose concussion in humans -- for example, locomotor activity, coordination/balance, cognitive function, and anxiety- and depression-like behaviors.

But despite a rather extensive pattern of brain injury, the rats had no significant abnormalities on any of the tests. That was so on the day after brain injury as well as up to one week afterward. "The lack of functional deficits is in sharp contrast to neuropathological findings indicating neural degeneration, astrocyte reactivity, and microglial activation." Dr. Rosen and colleagues write.

Findings Support Concerns about 'Subconcussive Injury'

The new study comes at a time when new researchers are finding evidence of long-term neurodegenerative changes in the brains of people who have never been diagnosed with a concussion. One key study in high school football players found changes in neurological function and health in athletes who never had concussion symptoms, but had sustained "repetitive subconcussive blows."

Traditionally, concussion has been regarded as a temporary problem that resolves with no long-term effects. But that view has changed in recent years, with studies in athletes and others showing chronic traumatic encephalopathy linked to repetitive head injury -- both the concussive and subconcussive types.

The new experiments support the concept that significant brain damage may be present in individuals who have completely normal results on symptom-based assessments currently used to diagnose concussions. Dr. Rosen and coauthors write, "It appears that even subconcussive injury, or injury below the current clinical threshold for detection using standard measures, may have lasting neurological effects."

The researchers emphasize that their short-term study in rats provides no direct evidence of long-term changes caused by "mild" traumatic brain injury in humans. They discuss the need for further research to clarify the effects of traumatic brain injury over time, and to develop new models for understanding the long-term impact of repeated head trauma.

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Study: Brain damage from concussion stays after symptoms subside

A study shows that after symptoms from a concussion go away, the brain damage from the concussion persists.

Months after concussion symptoms such as dizziness, headaches and memory loss fade, the brain continues to show signs of injury, a new study suggests.

Comparing 50 concussion patients with the same number of healthy people, researchers found that the brains of those suffering concussions showed abnormalities four months later. This happened despite the fact that their symptoms had already eased to some degree.

The findings may sway conventional thinking about when it's safe to resume physical activities that could produce another concussion, the study authors said.

"This is a very different population than professional athletes going out and having concussions on a fairly [frequent] basis, as well as jostling their brain around their skull on a regular basis in practice," said study author Andrew Mayer, an associate professor of translational neuroscience at the Mind Research Network in Albuquerque, N.M. It's hard to predict an outcome based on these findings, he said, "but just because you feel you're healed doesn't mean you are."

The study, which was funded by the U.S. National Institutes of Health, is published in the Nov. 20 online edition of the journal Neurology.

Considered a mild traumatic brain injury that occurs from a sudden blow to the head or body, a concussion has symptoms that range from headache and blurry vision to difficulties in sleeping or thinking clearly. Most occur without losing consciousness, according to the U.S. Centers for Disease Control and Prevention.

Mayer and his team matched 50 patients with mild concussions to 50 healthy people of similar age and education levels. They tested all participants in memory and thinking skills, as well as other symptoms such as anxiety and depression.

Special brain scans using technology that is not available in standard brain scans were also given. All tests and scans were repeated two weeks after the concussion, and again four months later.

While concussion symptoms were reduced by up to 27 percent four months after injury, brain scans of those with concussions showed abnormalities in the frontal cortex area of both sides of the brain. These abnormalities may have resulted from changes in location of fluid around brain cells or changes in the shape of certain brain cells in response to damage, Mayer explained.

The findings, he noted, suggest that the recommendation that athletes suffering concussions should refrain from play for one to two weeks may not be sufficient.

"In one or two weeks, most people typically report feeling better," he said. "But when we start talking about it in an analogy of a burn or knee injury, it becomes a little more clear when the doctor says we need to wait a bit longer [to return to prior activities]. It makes sense that the brain would be similar to those tissue types," added Mayer.

Kenneth Podell, co-director of the Houston Methodist Concussion Center, said the study strengthens the understanding that physical changes within the brain after concussion are separate from mental symptoms. But Podell, who was not involved in the research, added that the study couldn't offer implications for potential long-term concussion effects such as depression or dementia.

"Everyone seen at four months should be followed in another four, six or eight months and then re-scanned," he said. "One of the biggest problems we have looking at concussions is we try to predict long-term effects from short-term findings. This injury is very difficult to commit the type of resources needed to do that kind of very expensive and time-consuming study."

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Football players without concussions still risk brain damage

A study shows that both concussive hits and sub-concussive hits that do not result in a concussion can cause brain damage in football players. - JR

Concussions are the leading cause of brain damage in sports, particularly in football. However, researchers at Cleveland Clinic and the University of Rochester have found that football players may suffer long-term brain changes even in the absence of concussion.

In a study of 67 college football players, researchers found that the more hits to the head a player absorbed, the higher the levels of a particular brain protein that's known to leak into the bloodstream after a head injury. Even though none of the football players in the study suffered a concussion during the season, four of them showed signs of an autoimmune response that has been associated with brain disorders.

"Much attention is being paid to concussions among football players and the big hits that cause them, but this research shows that more common, 'sub-concussive' hits appear to cause damage too," said Damir Janigro, Ph.D., the director of cerebrovascular research in Cleveland Clinic's Lerner Research Institute, who led the study in collaboration with Nicola Marchi, Ph.D., of Cleveland Clinic and Jeffrey Bazarian, M.D., M.P.H., of the Clinical and Translational Science Institute at the University of Rochester Medical Center.

The study -- published March 6, 2013, in the online journal PLOS ONE and sponsored by the National Institute of Neurological Disorders and Stroke (NINDS) -- incorporated several methods to assess brain injury, including blood tests, brain scans, and tests to measure memory, motor control, reaction time, impulse control and balance, in addition to extensive review of game video to assess head hits among the players in the study.

For the blood test, researchers drew blood from football players at Baldwin Wallace University, John Carroll University and the University of Rochester before and after games, in order to search for the S100B protein in the blood. (Of the 67 players in the study, 57 underwent blood tests. Pre-season baseline levels of S100B were measured in 27 players.)

Typically, S100B is found only in the brain; finding S100B in the blood indicates damage to the blood-brain barrier. While the exact function of S100B is not known, it is used in many countries to diagnose mild traumatic brain injury when other typical signs or symptoms are absent. Studies in Janigro's lab revealed that once in the bloodstream, S100B is seen by the immune system as a foreign invader, triggering an autoimmune response that releases auto-antibodies against S100B. Those antibodies then seep back into the brain through the damaged blood-brain barrier, attacking brain tissue and leading to long-term brain damage.

Four players -- out of the 27 for whom pre-season S100B blood levels were measured -- showed signs of an autoimmune response to S100B, which has also been associated with other brain disorders, such as epilepsy and dementia. Brain scans (using diffusion tensor imaging) confirmed that the presence of S100B antibodies in the players' blood correlated with brain tissue damage, comparable to what one typically observes in the scan of a whiplash victim.

"Think of the blood-brain barrier disruption as opening a door to the brain that shouldn't be open," Janigro said. "Proteins like S100B that normally stay inside the brain get out where they aren't supposed to be -- and get attacked. In addition, the door is open for things that don't belong in the brain to get in."

Estimates suggest that up to 40 percent of football players experience a concussion annually, the majority of these going unreported. Overall, the U.S. Centers for Disease Control and Prevention estimates that 3.8 million Americans suffer concussions each year.

Concussions can be difficult to diagnose, relying on player symptoms, cognitive tests or CT scans or MRIs that cost thousands of dollars. The S100B blood test offers an objective measure of whether a player has endured head trauma, as the researchers found that elevated S100B levels directly correlate to the number and severity of head hits. Body contact or simply playing in a football game did not affect S100B levels in the players.

A blood test will be much less expensive (about $40) and could be performed anywhere, such as locker rooms or doctors' offices. More importantly, though, the blood test could offer a yes-or-no determination of whether an athlete requires medical intervention as a result of in-game collisions.

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Single concussion can cause long-term brain damage

Studies show that one concussion can cause lasting brain damage.

A single concussion may cause lasting structural damage to the brain, according to a new study published online in the journalRadiology.

"This is the first study that shows brain areas undergo measureable volume loss after concussion," said Yvonne W. Lui, M.D., Neuroradiology section chief and assistant professor of radiology at NYU Langone School of Medicine. "In some patients, there are structural changes to the brain after a single concussive episode."

According to the Centers for Disease Control and Prevention, each year in the U.S., 1.7 million people sustain traumatic brain injuries, resulting from sudden trauma to the brain. Mild traumatic brain injury (MTBI), or concussion, accounts for at least 75 percent of all traumatic brain injuries.

Following a concussion, some patients experience a brief loss of consciousness. Other symptoms include headache, dizziness, memory loss, attention deficit, depression and anxiety. Some of these conditions may persist for months or even years.

Studies show that 10 to 20 percent of MTBI patients continue to experience neurological and psychological symptoms more than one year following trauma. Brain atrophy has long been known to occur after moderate and severe head trauma, but less is known about the lasting effects of a single concussion.

Dr. Lui and colleagues set out to investigate changes in global and regional brain volume in patients one year after MTBI. Twenty-eight MTBI patients (with 19 followed at one year) with post-traumatic symptoms after injury and 22 matched controls (with 12 followed at one year) were enrolled in the study. The researchers used three-dimensional magnetic resonance imaging (MRI) to determine regional gray matter and white matter volumes and correlated these findings with other clinical and cognitive measurements.

The researchers found that at one year after concussion, there was measurable global and regional brain atrophy in the MTBI patients. These findings show that brain atrophy is not exclusive to more severe brain injuries but can occur after a single concussion.

"This study confirms what we have long suspected," Dr. Lui said. "After MTBI, there is true structural injury to the brain, even though we don't see much on routine clinical imaging. This means that patients who are symptomatic in the long-term after a concussion may have a biologic underpinning of their symptoms."

Certain brain regions showed a significant decrease in regional volume in patients with MTBI over the first year after injury, compared to controls. These volume changes correlated with cognitive changes in memory, attention and anxiety.

"Two of the brain regions affected were the anterior cingulate and the precuneal region," Dr. Lui said. "The anterior cingulate has been implicated in mood disorders including depression, and the precuneal region has a lot of different connections to areas of the brain responsible for executive function or higher order thinking."

According to Dr. Lui, researchers are still investigating the long-term effects of concussion, and she advises caution in generalizing the results of this study to any particular individual.

"It is important for patients who have had a concussion to be evaluated by a physician," she said. "If patients continue to have symptoms after concussion, they should follow-up with their physician before engaging in high-risk activities such as contact sports."

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Identifying conditions contributing to concussions and brain damage

A new computer model claims to help reduce concussions and brain injury in athletes and soldiers.

Concussions can occur in sports and in combat, but health experts do not know precisely which jolts, collisions and awkward head movements during these activities pose the greatest risks to the brain. To find out, Johns Hopkins engineers have developed a powerful new computer-based process that helps identify the dangerous conditions that lead to concussion-related brain injuries. This approach could lead to new medical treatment options and some sports rule changes to reduce brain trauma among players.

The research comes at a time when greater attention is being paid to assessing and preventing the head injuries sustained by both soldiers and athletes. Some kinds of head injuries are difficult to see with standard diagnostic imaging but can have serious long-term consequences. Concussions, once dismissed as a short-term nuisance, have more recently been linked to serious brain disorders.

"Concussion-related injuries can develop even when nothing has physically touched the head, and no damage is apparent on the skin," said K. T. Ramesh, the Alonzo G. Decker Jr. Professor of Science and Engineering who led the research at Johns Hopkins. "Think about a soldier who is knocked down by the blast wave of an explosion, or a football player reeling after a major collision. The person may show some loss of cognitive function, but you may not immediately see anything in a CT-scan or MRI that tells you exactly where and how much damage has been done to the brain. You don't know what happened to the brain, so how do you figure out how to treat the patient?"

To help doctors answer this question, Ramesh led a team that used a powerful technique called diffusion tensor imaging, together with a computer model of the head, to identify injured axons, which are tiny but important fibers that carry information from one brain cell to another. These axons are concentrated in a kind of brain tissue known as "white matter," and they appear to be injured during the so-called mild traumatic brain injury associated with concussions. Ramesh's team has shown that the axons are injured most easily by strong rotations of the head, and the researchers' process can calculate which parts of the brain are most likely to be injured during a specific event.

The team described its new technique in the Jan. 8 edition of the Journal of Neurotrauma. The lead author, Rika M. Wright, played a major role in the research while completing her doctoral studies in Johns Hopkins' Whiting School of Engineering, supervised by Ramesh. Wright is now a postdoctoral research fellow at Carnegie Mellon University. Ramesh is continuing to conduct research using the technique at Johns Hopkins with support from the National Institutes of Health.

Beyond its use in evaluating combat and sports-related injuries, the work could have wider applications, such as detecting axonal damage among patients who have received head injuries in vehicle accidents or serious falls. "This is the kind of injury that may take weeks to manifest," Ramesh said. "By the time you assess the symptoms, it may be too late for some kinds of treatment to be helpful. But if you can tell right away what happened to the brain and where the injury is likely to have occurred, you may be able to get a crucial head-start on the treatment."

Armed with this knowledge, Ramesh and his colleagues want to use their new technology to examine athletes, particularly football and hockey players, who are tackled or struck during games in ways that inflict that violent side-to-side motion on the head. In the recent journal article, the authors point out that many professional sports games are recorded in high-definition video from multiple angles. This, they write, could allow researchers to reconstruct the motions involved in sport collisions that lead to the most serious head injuries.

The authors also noted that some sports teams equip their players' helmets or mouth guards with instruments that can measure the acceleration of the head during an impact. Such data, entered into the researchers' computer model, could help determine the likely location of brain damage. These results, combined with neuropsychological tests, could be used to guide the athlete's treatment and rehabilitation, the authors said, and to help a sports team decide when an athlete should be allowed to resume playing. This strategy also may help reduce the risk to athletes arising from a degenerative disease linked to repeated concussions.

More research, testing and validation must be conducted before the computer model can become useful in a clinical setting. This will include animal experiments and the correlation of data from event reconstruction to make sure the model accurately identifies brain injuries.

Ideally, Ramesh would like to collect digital brain images from soldiers and athletes before they enter combat or join highly physical sports activities. "We would then be able to track a high-risk population and keep records detailing what types of head injuries they experience," he said. "Then, we could look at how their brains may have changed since the original images were collected. This will also help guide the physicians and health professionals who provide treatment after critical events."

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Brain Damage Differences in Men and Women with Sleep Apnea

A study shows that of people with sleep apnea, women have a higher degree of brain damage than men do.

Women suffering from sleep apnea have, on the whole, a higher degree of brain damage than men with the disorder, according to a first-of-its-kind study conducted by researchers at the UCLA School of Nursing. The findings are reported in the December issue of the peer-reviewed journal Sleep.

Obstructive sleep apnea is a serious disorder that occurs when a person's breathing is repeatedly interrupted during sleep, sometimes hundreds of times. Each time, the oxygen level in the blood drops, eventually resulting in damage to many cells in the body. If left untreated, it can lead to high blood pressure, stroke, heart failure, diabetes, depression and other serious health problems.

Approximately 10 years ago, this UCLA research team was the first to show that men with obstructive sleep apnea have damage to their brain cells.

For this latest, multi-year study, "Sex Differences in White Matter Alterations Accompanying Obstructive Sleep Apnea," the researchers looked at patients who were diagnosed with obstructive sleep apnea at the UCLA Sleep Laboratory. They compared the nerve fibers in these patients' brains -- known as white matter -- to fibers of individuals without sleep problems and focused on unearthing the difference in brain damage between men and women with sleep apnea.

"While there are a great many brain studies done on sleep apnea and the impact on one's health, they have typically focused on men or combined groups of men and women, but we know that obstructive sleep apnea affects women very differently than men," said chief investigator Paul Macey, assistant professor and associate dean of information technology and innovations at the UCLA School of Nursing. "This study revealed that, in fact, women are more affected by sleep apnea than are men and that women with obstructive sleep apnea have more severe brain damage than men suffering from a similar condition."

In particular, the study found that women were impacted in the cingulum bundle and the anterior cingulate cortex, areas in the front of the brain involved in decision-making and mood regulation. The women with sleep apnea also showed higher levels of depression and anxiety symptoms, the researchers said.

"This tells us that doctors should consider that the sleep disorder may be more problematic and therefore need earlier treatment in women than men," Macey said.

With this finding as a foundation, Macey said that the next step is for researchers to "untangle the timing of the brain changes" and find out if treating sleep apnea can help the brain.

"What we don't yet know," he said, "is, did sleep apnea cause the brain damage, did the brain damage lead to the sleep disorders, or do the common comorbidities, such as depression, dementia or cardiovascular issues, cause the brain damage, which in turn leads to sleep apnea."

Co-investigators on the study included Rajesh Kumar, Ronald Harper and Dr. Frisca Yan-Go of UCLA's Brain Research Institute and the departments of neurobiology and neurology at the David Geffen School of Medicine at UCLA, and Mary Woo of the UCLA School of Nursing. All of the work for the study was performed at UCLA, with financial support provided by a grant from the National Institute of Nursing Research.

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