Chronic neurodegeneration after traumatic brain injury: Alzheimer disease, chronic traumatic encephalopathy, or persistent neuroinflammation?

Abstract

It has long been suggested that prior traumatic brain injury (TBI) increases the subsequent incidence of chronic neurodegenerative disorders, including Alzheimer disease, Parkinson disease, and amyotrophic lateral sclerosis. Among these, the association with Alzheimer disease has the strongest support. There is also a long-recognized association between repeated concussive insults and progressive cognitive decline or other neuropsychiatric abnormalities. The latter was first described in boxers as dementia pugilistica, and has received widespread recent attention in contact sports such as professional American football. The term chronic traumatic encephalopathy was coined to attempt to define a "specific" entity marked by neurobehavioral changes and the extensive deposition of phosphorylated tau protein. Nearly lost in the discussions of post-traumatic neurodegeneration after traumatic brain injury has been the role of sustained neuroinflammation, even though this association has been well established pathologically since the 1950s, and is strongly supported by subsequent preclinical and clinical studies. Manifested by extensive microglial and astroglial activation, such chronic traumatic brain inflammation may be the most important cause of post-traumatic neurodegeneration in terms of prevalence. Critically, emerging preclinical studies indicate that persistent neuroinflammation and associated neurodegeneration may be treatable long after the initiating insult(s).

Fig. 1

Chronic neurodegeneration after traumatic brain injury (TBI)—a complex and multifactorial pathobiology. Single or repeated TBI initiates complex biochemical mechanisms that lead to chronic neurodegeneration and delayed chronic neuropsychiatric changes. The biochemical and pathological features of Alzheimer’s disease, chronic traumatic brain inflammation, and chronic traumatic encephalopathy following TBI are shown. Aβ = β-amyloid; APP = amyloid precursor protein; PS-1 = presenilin-1; BACE = β-amyloid converting enzyme; TDP-43 = TAR DNA-binding protein 43; NFTs = neurofibrillary tangles; NOX2 = NADPH oxidase