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. 2022 Aug 1;79(8):787-796.
doi: 10.1001/jamaneurol.2022.1634.

Association of APOE Genotypes and Chronic Traumatic Encephalopathy

Affiliations

Association of APOE Genotypes and Chronic Traumatic Encephalopathy

Kathryn Atherton et al. JAMA Neurol. .

Erratum in

  • Error in Open Access Status.
    [No authors listed] [No authors listed] JAMA Neurol. 2023 Feb 1;80(2):215. doi: 10.1001/jamaneurol.2022.3673. JAMA Neurol. 2023. PMID: 36251311 Free PMC article. No abstract available.

Abstract

Importance: Repetitive head impact (RHI) exposure is the chief risk factor for chronic traumatic encephalopathy (CTE). However, the occurrence and severity of CTE varies widely among those with similar RHI exposure. Limited evidence suggests that the APOEε4 allele may confer risk for CTE, but previous studies were small with limited scope.

Objective: To test the association between APOE genotype and CTE neuropathology and related endophenotypes.

Design, setting, and participants: This cross-sectional genetic association study analyzed brain donors from February 2008 to August 2019 from the Veterans Affairs-Boston University-Concussion Legacy Foundation Brain Bank. All donors had exposure to RHI from contact sports or military service. All eligible donors were included. Analysis took place between June 2020 and April 2022.

Exposures: One or more APOEε4 or APOEε2 alleles.

Main outcomes and measures: CTE neuropathological status, CTE stage (0-IV), semiquantitative phosphorylated tau (p-tau) burden in 11 brain regions (0-3), quantitative p-tau burden in the dorsolateral frontal lobe (log-transformed AT8+ pixel count per mm2), and dementia.

Results: Of 364 consecutive brain donors (100% male; 53 [14.6%] self-identified as Black and 311 [85.4%] as White; median [IQR] age, 65 [47-77] years) 20 years or older, there were 294 individuals with CTE and 70 controls. Among donors older than 65 years, APOEε4 status was significantly associated with CTE stage (odds ratio [OR], 2.34 [95% CI, 1.30-4.20]; false discovery rate [FDR]-corrected P = .01) and quantitative p-tau burden in the dorsolateral frontal lobe (β, 1.39 [95% CI, 0.83-1.94]; FDR-corrected P = 2.37 × 10-5). There was a nonsignificant association between APOEε4 status and dementia (OR, 2.64 [95% CI, 1.06-6.61]; FDR-corrected P = .08). Across 11 brain regions, significant associations were observed for semiquantitative p-tau burden in the frontal and parietal cortices, amygdala, and entorhinal cortex (OR range, 2.45-3.26). Among football players, the APOEε4 association size for CTE stage was similar to playing more than 7 years of football. Associations were significantly larger in the older half of the sample. There was no significant association for CTE status. Association sizes were similar when donors with an Alzheimer disease neuropathological diagnosis were excluded and were reduced but remained significant after adjusting for neuritic and diffuse amyloid plaques. No associations were observed for APOEε2 status. Models were adjusted for age at death and race.

Conclusions and relevance: APOEε4 may confer increased risk for CTE-related neuropathological and clinical outcomes among older individuals with RHI exposure. Further work is required to validate these findings in an independent sample.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Atherton reported nonfinancial support from Concussion Legacy Foundation during the conduct of the study. Dr Farrell reported grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Nowinski is the cofounder and chief executive officer of the Concussion Legacy Foundation; reported nonfinancial support (travel reimbursement) from the NFL Players Association as a member of the Mackey-White Health & Safety Committee, WWE, and AEW (All Elite Wrestling); personal fees (stock options) from Oxeia Biopharmaceuticals, PreCon Health, and Aurora CTS; and serves as an advisor for Oxeia Biopharmaceuticals and PreCon Health outside the submitted work. Dr Katz reported grants from National Institute of Neurological Disorders and Stroke and Boston University School of Medicine Department of Neurology during the conduct of the study; royalties from Springer/Demos Publishing for a textbook on brain injury; serves as an expert witness in legal cases involving brain injury and concussion; receives a stipend from Encompass Health as program medical director for brain injury and chair of the annual Neurorehabilitation conference; and has received honoraria for a keynote address for the HealthSouth Annual Medical Directors Meeting. Dr Goldstein is a paid consultant to Johnson & Johnson, Janssen Research & Development LLC, and Rebiscan Inc and has received funding from the WWE and Ivivi Health Sciences. Dr Cantu reported royalties from Houghton Mifflin Harcourt; compensation for expert legal opinion to the National Collegiate Athletic Association and National Hockey League; consults for the Concussion Legacy Foundation; is senior advisor and paid consultant to the NFL Head Neck & Spine Committee; is a member of the Mackey-White Committee of the National Football League Players Association; is vice president of National Operating Committee on Standards for Athletic Equipment and chair scientific advisory committee and cofounder of Medical Director Concussion Legacy Foundation; and is on the Medical Science Committee for the National Collegiate Athletic Association Student-Athlete Concussion Injury Litigation. Dr Alosco reported grants from NIH during the conduct of the study and receives royalties from Oxford University Press for a textbook outside the submitted work. Dr Stern reported grants from NIH during the conduct of the study; personal fees from Biogen and Lundbeck outside the submitted work; member of the Mackey-White Committee of the National Football League Players Association; receives royalties for published neuropsychological tests from Psychological Assessment Resources Inc; and is a member of the Board of Directors of King-Devick Technologies. Dr McKee is a member of the Mackey-White Committee of the National Football League Players Association and reports other funding from Buoniconti Foundation during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Brain Heat Map of Estimated Associations of APOEε4 Status With Semiquantitative Tau Burden in Brain Regions Commonly Affected in Chronic Traumatic Encephalopathy Among Donors Older Than 65 Years
Only regions with at least nominally significant associations shown. Odds ratio (OR) is the odds of increasing 1 level (scale of 0-3) for APOEε4 carriers compared with noncarriers. Generated with cerebroViz. AMY indicates amygdala; DLF, dorsal lateral frontal; EC, entorhinal cortex; IOF, inferior orbital frontal; IP, inferior parietal; ST, superior temporal.
Figure 2.
Figure 2.. Estimated Associations of APOEε4 Status With Quantitative Tau Burden in the Dorsolateral Frontal Lobe When Adjusting for Amyloid-β Pathology
A, Association sizes unadjusted and adjusted for neuritic and diffuse amyloid plaques. β Value is the increase in log tau + pixels/mm2 in the dorsolateral frontal lobe for ε4 carriers compared with noncarriers. The whiskers represent 95% CIs. B, Akaike information criterion (AIC) for unadjusted and adjusted models. Smaller AIC indicates better model fit. C, Variance explained (r2) for unadjusted and adjusted models.

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