Elsevier

World Neurosurgery

Volume 86, February 2016, Pages 515.e11-515.e16
World Neurosurgery

Case Report
Junior Seau: An Illustrative Case of Chronic Traumatic Encephalopathy and Update on Chronic Sports-Related Head Injury

https://doi.org/10.1016/j.wneu.2015.10.032Get rights and content

Background

Few neurologic diseases have captured the nation's attention more completely than chronic traumatic encephalopathy (CTE), which has been discovered in the autopsies of professional athletes, most notably professional football players. The tragic case of Junior Seau, a Hall of Fame, National Football League linebacker, has been the most high-profile confirmed case of CTE. Here we describe Seau's case, which concludes an autopsy conducted at the National Institutes of Health that confirmed the diagnosis.

Case Description

Since 1990, Junior Seau had a highly distinguished 20-year career playing for the National Football League as a linebacker, from which he sustained multiple concussions. He committed suicide on May 2, 2012, at age 43, after which an autopsy confirmed a diagnosis of CTE. His clinical history was significant for a series of behavioral disturbances. Seau's history and neuropathologic findings were used to better understand the pathophysiology, diagnosis, and possible risk factors for CTE.

Conclusions

This high-profile case reflects an increasing awareness of CTE as a long-term consequence of multiple traumatic brain injuries. The previously unforeseen neurologic risks of American football have begun to cast doubt on the safety of the sport.

Introduction

The likelihood of suffering mild traumatic brain injuries (TBIs) from participation in sports is quite high, with estimates of 1.6–3.8 million occurring each year in the United States.1 Mild TBI results from a traumatic disruption of brain function with cognitive sequelae that range in severity from transient focal neurologic deficits to a loss of consciousness.2, 3 Concussion is related to mild TBI, although its definition is more elusive. Participants of the 4th International Conference on Concussion in Sport, held in Zurich in 2012, agreed to define concussion as “a complex pathophysiological process affecting the brain, induced by biomechanical force.”4 Features of a concussion include a rapid onset of neurologic impairment that can resolve spontaneously within minutes to hours and a functional (rather than structural) disturbance of the brain.4 Concussion is a subset of mild TBI, although mild TBI can include subconcussive impacts as well. Sports-related mild TBI occurs most commonly in collision-heavy contact sports such as boxing, American football, rugby, ice hockey, soccer, and martial arts.2, 5 In American football, for example, players can sustain hundreds of repetitive mild TBI in practices and games that may be concussive (symptomatic) or subconcussive (asymptomatic but still may lead to increased risk over time).6, 7, 8

Repetitive mild TBI is thought to contribute to the development of chronic traumatic encephalopathy (CTE), a neurodegenerative disease pathologically confirmed by the presence of a unique pattern of hyperphosphorylated tau neurofibrillary and astrocytic tangles in the brain.9, 10, 11 This disease has received national media attention because of several famous former National Football League (NFL) players who committed suicide and were afterwards diagnosed with CTE. Postmortem analyses of early clinical symptoms associated with CTE have identified headaches and behavioral changes that include aggression, mood swings, and suicidality; CTE is also associated with a range of cognitive impairment and motor deficits that can manifest after a period of latency after mild TBI.2, 12, 13

Currently, the diagnosis of CTE can only be confirmed posthumously with an autopsy.14 Given this diagnostic limitation, the incidence of CTE is unknown, along with the number and severity of mild TBI required for the development of CTE. True causation of CTE after mild TBI also is still lacking, but the association has been postulated in several players. We describe the case of Junior Seau, one of the greatest linebackers in NFL history and the recipient of national media attention after his suicide by a gunshot wound to the chest in May 2012; Seau was diagnosed with CTE after his death. We further examine the historical origins, clinical characteristics, and pathophysiology of CTE.

Section snippets

Patient History

Born January 19, 1969, Junior Seau played American football competitively in high school and college before being drafted to play for the NFL professionally in 1990 (Figure 1). After a highly distinguished 20-year career playing for the NFL as a linebacker, he was posthumously inducted into the Class of 2015 Pro Football Hall of Fame. Seau had never self-reported any head injuries, but both his family friend and ex-wife later revealed to the press that Seau had experienced multiple concussions

History of CTE

The conceptualization of CTE is attributed to Dr. Harrison Martland, who described a constellation of symptoms that appeared to be the result of repeated blows to the head, using the term “punch drunk,” in 1928. Such symptoms included acute gait unsteadiness, mental deterioration, and Parkinsonian-like symptoms.21 Since Martland's report, a variety of terms have been used to refer to this syndrome. Because initial reports had described the symptoms in professional boxers, Parker characterized

Conclusions

The increasing public awareness of CTE, especially among high-profile NFL players such as Junior Seau, has impacted the sports community substantially. In 2014, the NFL Players Association received lawsuits from former NFL players alleging that the NFL did not adequately inform them about the high risk of recurrent mild TBI on their long-term health and that the organization should have done more to protect its players.43 The NFL has published a protocol detailing the protective measures a

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      The increasing public awareness of concussions and its sequelae, propelled by contributions in popular and social media from media and athletics, may increase the influence and reach of these articles when analyzed using altmetrics.26,27 In particular, the 2 sports most frequently mentioned in our analysis were hockey and football, both of which have had notable media coverage surrounding concussions, with the widely publicized release of the Concussion movie starring Will Smith, suicides by notable retired players such as Junior Seau, head injuries experienced by Sidney Crosby, the debate surrounding fighting in hockey, and the like.28-31 The second most popular field in our study was neuro-oncology.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    Tej D. Azad and Amy Li are co–first authors.

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