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Chronic Traumatic Encephalopathy in the Brains of Military Personnel

List of authors.
  • David S. Priemer, M.D.,
  • Diego Iacono, M.D., Ph.D.,
  • C. Harker Rhodes, M.D., Ph.D.,
  • Cara H. Olsen, Dr.P.H.,
  • and Daniel P. Perl, M.D.

Abstract

Background

Persistent neuropsychiatric sequelae may develop in military personnel who are exposed to combat; such sequelae have been attributed in some cases to chronic traumatic encephalopathy (CTE). Only limited data regarding CTE in the brains of military service members are available.

Methods

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We performed neuropathological examinations for the presence of CTE in 225 consecutive brains from a brain bank dedicated to the study of deceased service members. In addition, we reviewed information obtained retrospectively regarding the decedents’ histories of blast exposure, contact sports, other types of traumatic brain injury (TBI), and neuropsychiatric disorders.

Results

Neuropathological findings of CTE were present in 10 of the 225 brains (4.4%) we examined; half the CTE cases had only a single pathognomonic lesion. Of the 45 brains from decedents who had a history of blast exposure, 3 had CTE, as compared with 7 of 180 brains from those without a history of blast exposure (relative risk, 1.71; 95% confidence interval [CI], 0.46 to 6.37); 3 of 21 brains from decedents with TBI from an injury during military service caused by the head striking a physical object without associated blast exposure (military impact TBI) had CTE, as compared with 7 of 204 without this exposure (relative risk, 4.16; 95% CI, 1.16 to 14.91). All brains with CTE were from decedents who had participated in contact sports; 10 of 60 contact-sports participants had CTE, as compared with 0 of 165 who had not participated in contact sports (point estimate of relative risk not computable; 95% CI, 6.16 to infinity). CTE was present in 8 of 44 brains from decedents with non–sports-related TBI in civilian life, as compared with 2 of 181 brains from those without such exposure in civilian life (relative risk, 16.45; 95% CI, 3.62 to 74.79).

Conclusions

Evidence of CTE was infrequently found in a series of brains from military personnel and was usually reflected by minimal neuropathologic changes. Risk ratios for CTE were numerically higher among decedents who had contact-sports exposure and other exposures to TBI in civilian life than among those who had blast exposure or other military TBI, but the small number of CTE cases and wide confidence intervals preclude causal conclusions. (Funded by the Department of Defense–Uniformed Services University Brain Tissue Repository and Neuropathology Program and the Henry M. Jackson Foundation for the Advancement of Military Medicine.)

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CTE in Military Personnel
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Funding and Disclosures

Supported by the Department of Defense–Uniformed Services University Brain Tissue Repository and Neuropathology Program, by an award (HU00012120007) from the Uniformed Services University, and by an award (312159-1.00-66531) from the Henry M. Jackson Foundation for the Advancement of Military Medicine.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

The views expressed in this article are those of the authors and do not necessarily reflect the views or policies of the Uniformed Services University, the Department of Defense, the U.S. government, or the Henry M. Jackson Foundation for the Advancement of Military Medicine.

We thank the families (or their legal representatives) who consented to donations of brain specimens on behalf of their loved ones to the Department of Defense–Uniformed Services University Brain Tissue Repository for military traumatic brain injury research; Ms. Patricia Lee and her histology team; Ms. Stacey Gentile, Ms. Deona Cooper, Mr. Harold Kramer Anderson, Ms. Leslie Sawyers, and Mr. Paul Gegbeh for providing logistic support; and Dr. Charles Rice and Vice Admiral (Ret.) Timothy Szymanski for their advice and support of our program.

Author Affiliations

From the Department of Defense–Uniformed Services University Brain Tissue Repository (D.S.P., D.I., C.H.R., D.P.P.), the Departments of Neurology (D.I.), Pathology (D.S.P., D.I., D.P.P.), and Preventative Medicine and Biostatistics (C.H.O.), and the Neuroscience Graduate Program, Department of Anatomy, Physiology, and Genetics (D.I.), F. Edward Hébert School of Medicine, Uniformed Services University, and the Henry M. Jackson Foundation for the Advancement of Military Medicine (D.S.P., D.I., C.H.R.) — both in Bethesda, MD.

Dr. Perl can be contacted at or at the Department of Pathology, F. Edward Hébert School of Medicine, Uniformed Services University, 4301 Jones Bridge Rd., Bethesda, MD 20814.

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