Mild Traumatic Brain Injuries (mTBIs) are non-penetrating brain injuries that do not result in gross pathological lesions, yet they may cause a spectrum of cognitive and behavioral deficits. mTBI has been placed in the spotlight because of increased awareness of blast induced and sports-related concussions, but the underlying pathophysiological mechanisms are poorly understood. Several studies have implicated neuronal membrane poration and ion channel dysfunction as the primary mechanism of injury. We hypothesized that injury forces utilize mechanically-sensitive, transmembrane integrin proteins, which are coupled to the neuronal cytoskeleton (CSK) and distribute injury forces within the intracellular space, disrupting CSK organization and reducing intercellular neuronal functionality. To test this, magnetic beads were coated with adhesive protein, allowing them to bind to integrins in the neuronal membrane in vitro. To apply forces to the neurons via the bound beads, we built custom magnetic tweezers and demonstrated that focal adhesions (FACs) formed at the site of bead binding. We showed that the beads were coupled to the CSK via integrins by measuring the disparate adhesion of the soma and neurite to their underlying substrate. The soma also required more force to detach than neurites, correlating with the FAC density between each neuronal microcompartment and substrate. We then utilized the magnetic tweezers to test whether beads bound to integrins injured neurons more than beads that bound to neurons nonspecifically. Integrin-bound beads injured neurons more often and the injury was characterized by the formation of focal swellings along axons, reminiscent of Diffuse Axonal Injury. While integrin-bound beads initiated swellings throughout neurons, beads bound nonspecifically only caused local injury where beads were attached to neurons. To demonstrate the electrical dysfunction of integrin-mediated injury forces, we adapted Magnetic Twisting Cytometry to simultaneously apply injury forces to beads bound to multiple cells within neuronal networks in vitro. The formation of focal swellings resulted in reduced axonal electrical activity and decreased coordinated network activity. These data demonstrate that the mechanical insult associated with mTBI is propagated into neurons via integrins, initiating maladaptive CSK remodeling that is linked to impaired electrical function, providing novel insight into the underlying mechanisms of mTBI. / Engineering and Applied Sciences

Traumatic Brain Injury (TBI) is linked to a diverse range of diffuse pathological damage for which there is a severe lack of therapeutic options. A major limitation to drug development is the inability to identify causal mechanisms that link head trauma to the multitude of secondary injury cascades that underlie neuropathology. To elucidate these relationships, it is important to consider how physical forces are transmitted through the brain across multiple spatial scales ranging from the whole head to the sub-cellular level. In doing so, the mechanical behavior of the brain is typically characterized solely by its material properties and biological structure. Alternatively, forces transmitted through distinct cellular and extracellular structures have been shown to influence physiological processes in multiple cell types through the transduction of mechanical forces into cellular chemical responses. As an essential component of various biological processes, these mechanotransduction events are regulated by mechanical cues directed through extracellular matrix (ECM) and cell adhesion molecules (CAM) to mechanosensitive intra-cellular structures such as focal adhesions (FAs). Using a series of in vitro models, we have implicated FAs in the cellular mechanism of traumatic axonal injury by showing that forces directed through these structures potentiate injury levels and, moreover, that inhibition of FA-mediated signaling pathways may be neuroprotective. In addition, we show that localizing trauma forces through specific brain ECM results in differential injury rates, further implicating mechanosensitive cell-ECM linkages in the mechanism of TBI. Therefore, we show that FAs play a major role in axonal injury at low strain magnitudes indicating that cellular mechanotransduction may be an important mechanism underlying the initiation of cell and sub-cellular injuries ultimately responsible for the diffuse pathological damage and clinical symptoms observed in diffuse axonal injury. Furthermore, since these mechanisms may present the earliest events in the complex sequelae associated with TBI, they also represent potential therapeutic opportunities. / Engineering and Applied Sciences

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24797号 / 医博第4989号 / 新制||医||1066(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 花川 隆, 教授 髙橋 良輔, 教授 高橋 淳 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24512号 / 医博第4954号 / 新制||医||1064(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 花川 隆, 教授 古川 壽亮, 教授 中本 裕士 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

In an average year more than 1.7 million people will experience a traumatic brain injury (TBI) in the United States. It is known that atrophy occurs across a spectrum for TBI patients, ranging from mild to severe. Current conventional magnetic resonance imaging (MRI) methods are inconsistent in detecting this atrophy on the milder end of the spectrum. Also more contemporary imaging tools, although efficient, are too time consuming for clinical applicability. It is for these reasons that a quick and efficient measurement for detecting this atrophy is needed by clinicians. The measuring of third ventricle width had the potential to be this measurement, since it is known that ventricular dilation is an indirect measure of brain atrophy. This study used two different data sets acquired at multiple sites. A total of 152 TBI patients' MRI scans were analyzed with diagnosis ranging from mild to severe. They have been age matched with 97 orthopedic injury controls. All scans were analyzed using Freesurfer® auto-segmentation software to acquire cortical, subcortical, and ventricular volumes. These metrics were then used as a standard of efficacy which we tested the new third ventricle width protocol against. There was no statistically significant difference between the overall TBI group and OI group (Welch's F(1,238.435) = 1.091, p= .267). The complicated mild injury subgroup was significantly increased from the mild subgroup (p= .001, d= .87). The grand average third ventricle width measurement was the best prognosticator of all measures analyzed despite only predicting 35.1% of cases correctly. The findings suggest that the third ventricle width measurement is insensitive to atrophy between all groups as hypothesized.

Les commotions cérébrales ont longtemps été considérées comme une blessure ne comportant que peu ou pas de conséquences. Cependant, la mise à la retraite forcée de plusieurs athlètes de haut niveau, liée au fait d'avoir subi des commotions cérébrales multiples, a porté cette question au premier plan de la culture scientifique et sportive. Malgré la sensibilisation croissante du public et la compréhension scientifique accrue des commotions cérébrales, il reste encore beaucoup d’inconnus au sujet de ces blessures. En effet, il est difficile de comprendre comment cette atteinte peut avoir des effets si profonds malgré le fait qu’elle n’entraîne apparemment pas de conséquences physiques apparentes lorsque les techniques traditionnelles d’imagerie cérébrale sont utilisées. Les techniques de neuroimagerie fonctionnelle ont cependant contribué à répondre aux nombreuses questions entourant les conséquences des commotions cérébrales ainsi qu'à accroître la compréhension générale de la physiopathologie de commotions cérébrales. Bien que les techniques de base telles que l'imagerie structurelle comme les scans TC et IRM soient incapables de détecter des changements structurels dans la grande majorité des cas (Ellemberg, Henry, Macciocchi, Guskiewicz, & Broglio, 2009; Johnston, Ptito, Chankowsky, & Chen, 2001), d'autres techniques plus précises et plus sensibles ont été en mesure de détecter avec succès des changements dans le cerveau commotionné. Des études d’IRM fonctionelle ont entre autres établi une solide relation entre les altérations fonctionnelles et les symptômes post-commotionels (Chen, Johnston, Collie, McCrory, & Ptito, 2007; Chen et al., 2004; Chen, Johnston, Petrides, & Ptito, 2008; Fazio, Lovell, Pardini, & Collins, 2007). Les mesures électrophysiologiques telles que les potentiels évoqués cognitifs (ERP) (Gaetz, Goodman, & Weinberg, 2000; Gaetz & Weinberg, 2000; Theriault, De Beaumont, Gosselin, Filipinni, & Lassonde, 2009; Theriault, De Beaumont, Tremblay, Lassonde, & Jolicoeur, 2010) et la stimulation magnétique transcrânienne ou SMT (De Beaumont, Brisson, Lassonde, & Jolicoeur, 2007; De Beaumont, Lassonde, Leclerc, & Theoret, 2007; De Beaumont et al., 2009) ont systématiquement démontré des altérations fonctionnelles chez les athlètes commotionnés. Cependant, très peu de recherches ont tenté d'explorer davantage certaines conséquences spécifiques des commotions cérébrales, entre autres sur les plans structural et métabolique. La première étude de cette thèse a évalué les changements structurels chez les athlètes commotionnés à l’aide de l'imagerie en tenseur de diffusion (DTI) qui mesure la diffusion de l'eau dans la matière blanche, permettant ainsi de visualiser des altérations des fibres nerveuses. Nous avons comparé les athlètes commotionnés à des athlètes de contrôle non-commotionnés quelques jours après la commotion et de nouveau six mois plus tard. Nos résultats indiquent un patron constant de diffusion accrue le long des voies cortico-spinales et dans la partie du corps calleux reliant les régions motrices. De plus, ces changements étaient encore présents six mois après la commotion, ce qui suggère que les effets de la commotion cérébrale persistent bien après la phase aiguë. Les deuxième et troisième études ont employé la spectroscopie par résonance magnétique afin d'étudier les changements neurométaboliques qui se produisent dans le cerveau commotionné. La première de ces études a évalué les changements neurométaboliques, les aspects neuropsychologiques, et la symptomatologie dans la phase aiguë post-commotion. Bien que les tests neuropsychologiques aient été incapables de démontrer des différences entre les athlètes commotionnés et non-commotionnés, des altérations neurométaboliques ont été notées dans le cortex préfrontal dorsolatéral ainsi que dans le cortex moteur primaire, lesquelles se sont avérées corréler avec les symptômes rapportés. La deuxième de ces études a comparé les changements neurométaboliques immédiatement après une commotion cérébrale et de nouveau six mois après l’atteinte. Les résultats ont démontré des altérations dans le cortex préfrontal dorsolatéral et moteur primaire dans la phase aiguë post-traumatique, mais seules les altérations du cortex moteur primaire ont persisté six mois après la commotion. Ces résultats indiquent que les commotions cérébrales peuvent affecter les propriétés physiques du cerveau, spécialement au niveau moteur. Il importe donc de mener davantage de recherches afin de mieux caractériser les effets moteurs des commotions cérébrales sur le plan fonctionnel. / Concussions had long been considered an injury of little to no consequence. However, the forced retirement of several high profile athletes due to the impact of having suffered multiple concussions has pushed the issue to the forefront of scientific and sports culture alike. Despite the growing public awareness and the ever-expanding scientific understanding of concussions there is still much that remains unknown about these injuries. Indeed, understanding how an injury can have such profound effects, though mostly transient, without any apparent physical consequence continues to confound how concussions are conceptualized in research. Neuroimaging techniques have helped answer many of the questions surrounding the physical consequences of concussions on the brain as well as increasing the general understanding of the pathophysiology of concussions. While basic structural imaging techniques such as CT scans and MRI are unable to detect any structural changes in the vast majority of cases (Ellemberg, et al., 2009; Johnston, et al., 2001), other more precise and sensitive techniques have been able to successfully detect changes in the concussed brain. Functional MRI studies have further established a strong relationship between functional alterations and post-concussion symptoms (Chen, et al., 2007; Chen, et al., 2004; Chen, et al., 2008; Fazio, et al., 2007). Electrophysiological measures such as ERP (Gaetz, et al., 2000; Gaetz & Weinberg, 2000; Theriault, et al., 2009; Theriault, et al., 2010) and TMS (De Beaumont, Brisson, et al., 2007; De Beaumont, Lassonde, et al., 2007; De Beaumont, et al., 2009) have consistently demonstrated alterations in concussed athletes. However, there has been very little research that has attempted to further explore the specific structural and metabolic aspects of concussion. The first study assessed structural changes in concussed athletes using diffusion tensor imaging which measures water diffusion in white matter. We compared concussed athletes with non-concussed control athletes in the days immediately after injury and again six months later. Our results indicated a consistent pattern of increased diffusion along neural tracts of the cortical spinal tract and in the corpus callosum underlying motor cortex. Furthermore, these changes were still present six months after injury suggesting that the effects of concussion are persistent past the acute phase. The second and third studies employed magnetic resonance spectroscopy as a means of investigating the neurometabolic changes that occur in the concussed brain. The first of these studies investigated the neurometabolic changes, neuropsychological aspects, and symptomatology in the acute post-injury phase. While neuropsychological testing was unable to show differences between concussed and non-concussed athletes, neurometabolic alterations were noted in the dorsal lateral prefrontal cortex as well as in primary motor cortex which correlated with reported symptoms. The second study investigated neurometabolic changes immediately after concussion and again six months after injury. Results indicated alterations in the dorsolateral prefrontal and primary motor cortices in the acute post-injury phase, but only those in primary motor cortex persisted to the six month time point.

Traumatic brain injury is a major health problem with much of its morbidity associated with traumatic axonal injury (TAI). To date, significant insight has been gained into the initiating pathogenesis of TAI. However, the specific anterograde and retrograde sequelae of TAI are poorly understood because the diffuse nature of TAI complicates data analysis. To overcome this limitation, we subjected transgenic mice expressing yellow fluorescent protein (YFP) within the visual system to central fluid percussion injury, and consistently generated diffuse TAI within the optic nerve that could easily be followed in the organized YFP positive fibers. We demonstrated progressive axonal swelling, disconnection and proximal and distal axonal dieback, with regression and reorganization of the proximal swellings, and the persistence of the distal disconnected and degenerating swellings. Antibodies targeting the C-terminus of amyloid precursor protein, a marker of TAI, mapped to the proximal axonal segments without distal targeting. Antibodies targeting microglia/macrophages, revealed activated microglia/ macrophages closely encompassing the distal disconnected, degenerating axonal segments at 7 - 28 days post injury, suggesting their role in the delayed axonal degeneration. In contrast, in the proximal reorganizing axonal segments, microglia/macrophages appeared less reactive with their processes paralleling preserved axonal profiles. Concomitant with these events, YFP fluorescence quenching also occurred, complicating data analysis. This quenching mapped to Texas-Red-conjugated-IgG immunoreactive loci, suggesting that blood–brain barrier disruption and its attendant edema participated in fluorescence quenching. This was confirmed through antibodies targeting endogenous YFP, which identified the retention of intact axons despite YFP fluorescent loss. Paralleling these events, TAI was not accompanied by retrograde retinal ganglion cell (RGC) death. Specifically, no TUNEL+ or cleaved caspase-3 immunoreactive RGCs were observed from 2 days to 3 months post-TBI. Further, Brn3a immunoreactive RGC quantification revealed no significant RGC loss. This RGC preservation was accompanied by the persistent phospho-c-Jun expression for up to 3 months post-TBI, a finding linked to neuronal survival and potential axonal repair. Parallel ultrastructural study again failed to identify RGC death. Collectively, this study provides unprecedented insight into the evolving pathobiology associated with TAI, and offers advantages for future studies focusing on its therapeutic management and neuronal reorganization.

Les commotions cérébrales ont longtemps été considérées comme une blessure ne comportant que peu ou pas de conséquences. Cependant, la mise à la retraite forcée de plusieurs athlètes de haut niveau, liée au fait d'avoir subi des commotions cérébrales multiples, a porté cette question au premier plan de la culture scientifique et sportive. Malgré la sensibilisation croissante du public et la compréhension scientifique accrue des commotions cérébrales, il reste encore beaucoup d’inconnus au sujet de ces blessures. En effet, il est difficile de comprendre comment cette atteinte peut avoir des effets si profonds malgré le fait qu’elle n’entraîne apparemment pas de conséquences physiques apparentes lorsque les techniques traditionnelles d’imagerie cérébrale sont utilisées. Les techniques de neuroimagerie fonctionnelle ont cependant contribué à répondre aux nombreuses questions entourant les conséquences des commotions cérébrales ainsi qu'à accroître la compréhension générale de la physiopathologie de commotions cérébrales. Bien que les techniques de base telles que l'imagerie structurelle comme les scans TC et IRM soient incapables de détecter des changements structurels dans la grande majorité des cas (Ellemberg, Henry, Macciocchi, Guskiewicz, & Broglio, 2009; Johnston, Ptito, Chankowsky, & Chen, 2001), d'autres techniques plus précises et plus sensibles ont été en mesure de détecter avec succès des changements dans le cerveau commotionné. Des études d’IRM fonctionelle ont entre autres établi une solide relation entre les altérations fonctionnelles et les symptômes post-commotionels (Chen, Johnston, Collie, McCrory, & Ptito, 2007; Chen et al., 2004; Chen, Johnston, Petrides, & Ptito, 2008; Fazio, Lovell, Pardini, & Collins, 2007). Les mesures électrophysiologiques telles que les potentiels évoqués cognitifs (ERP) (Gaetz, Goodman, & Weinberg, 2000; Gaetz & Weinberg, 2000; Theriault, De Beaumont, Gosselin, Filipinni, & Lassonde, 2009; Theriault, De Beaumont, Tremblay, Lassonde, & Jolicoeur, 2010) et la stimulation magnétique transcrânienne ou SMT (De Beaumont, Brisson, Lassonde, & Jolicoeur, 2007; De Beaumont, Lassonde, Leclerc, & Theoret, 2007; De Beaumont et al., 2009) ont systématiquement démontré des altérations fonctionnelles chez les athlètes commotionnés. Cependant, très peu de recherches ont tenté d'explorer davantage certaines conséquences spécifiques des commotions cérébrales, entre autres sur les plans structural et métabolique. La première étude de cette thèse a évalué les changements structurels chez les athlètes commotionnés à l’aide de l'imagerie en tenseur de diffusion (DTI) qui mesure la diffusion de l'eau dans la matière blanche, permettant ainsi de visualiser des altérations des fibres nerveuses. Nous avons comparé les athlètes commotionnés à des athlètes de contrôle non-commotionnés quelques jours après la commotion et de nouveau six mois plus tard. Nos résultats indiquent un patron constant de diffusion accrue le long des voies cortico-spinales et dans la partie du corps calleux reliant les régions motrices. De plus, ces changements étaient encore présents six mois après la commotion, ce qui suggère que les effets de la commotion cérébrale persistent bien après la phase aiguë. Les deuxième et troisième études ont employé la spectroscopie par résonance magnétique afin d'étudier les changements neurométaboliques qui se produisent dans le cerveau commotionné. La première de ces études a évalué les changements neurométaboliques, les aspects neuropsychologiques, et la symptomatologie dans la phase aiguë post-commotion. Bien que les tests neuropsychologiques aient été incapables de démontrer des différences entre les athlètes commotionnés et non-commotionnés, des altérations neurométaboliques ont été notées dans le cortex préfrontal dorsolatéral ainsi que dans le cortex moteur primaire, lesquelles se sont avérées corréler avec les symptômes rapportés. La deuxième de ces études a comparé les changements neurométaboliques immédiatement après une commotion cérébrale et de nouveau six mois après l’atteinte. Les résultats ont démontré des altérations dans le cortex préfrontal dorsolatéral et moteur primaire dans la phase aiguë post-traumatique, mais seules les altérations du cortex moteur primaire ont persisté six mois après la commotion. Ces résultats indiquent que les commotions cérébrales peuvent affecter les propriétés physiques du cerveau, spécialement au niveau moteur. Il importe donc de mener davantage de recherches afin de mieux caractériser les effets moteurs des commotions cérébrales sur le plan fonctionnel. / Concussions had long been considered an injury of little to no consequence. However, the forced retirement of several high profile athletes due to the impact of having suffered multiple concussions has pushed the issue to the forefront of scientific and sports culture alike. Despite the growing public awareness and the ever-expanding scientific understanding of concussions there is still much that remains unknown about these injuries. Indeed, understanding how an injury can have such profound effects, though mostly transient, without any apparent physical consequence continues to confound how concussions are conceptualized in research. Neuroimaging techniques have helped answer many of the questions surrounding the physical consequences of concussions on the brain as well as increasing the general understanding of the pathophysiology of concussions. While basic structural imaging techniques such as CT scans and MRI are unable to detect any structural changes in the vast majority of cases (Ellemberg, et al., 2009; Johnston, et al., 2001), other more precise and sensitive techniques have been able to successfully detect changes in the concussed brain. Functional MRI studies have further established a strong relationship between functional alterations and post-concussion symptoms (Chen, et al., 2007; Chen, et al., 2004; Chen, et al., 2008; Fazio, et al., 2007). Electrophysiological measures such as ERP (Gaetz, et al., 2000; Gaetz & Weinberg, 2000; Theriault, et al., 2009; Theriault, et al., 2010) and TMS (De Beaumont, Brisson, et al., 2007; De Beaumont, Lassonde, et al., 2007; De Beaumont, et al., 2009) have consistently demonstrated alterations in concussed athletes. However, there has been very little research that has attempted to further explore the specific structural and metabolic aspects of concussion. The first study assessed structural changes in concussed athletes using diffusion tensor imaging which measures water diffusion in white matter. We compared concussed athletes with non-concussed control athletes in the days immediately after injury and again six months later. Our results indicated a consistent pattern of increased diffusion along neural tracts of the cortical spinal tract and in the corpus callosum underlying motor cortex. Furthermore, these changes were still present six months after injury suggesting that the effects of concussion are persistent past the acute phase. The second and third studies employed magnetic resonance spectroscopy as a means of investigating the neurometabolic changes that occur in the concussed brain. The first of these studies investigated the neurometabolic changes, neuropsychological aspects, and symptomatology in the acute post-injury phase. While neuropsychological testing was unable to show differences between concussed and non-concussed athletes, neurometabolic alterations were noted in the dorsal lateral prefrontal cortex as well as in primary motor cortex which correlated with reported symptoms. The second study investigated neurometabolic changes immediately after concussion and again six months after injury. Results indicated alterations in the dorsolateral prefrontal and primary motor cortices in the acute post-injury phase, but only those in primary motor cortex persisted to the six month time point.

Traumatic brain injury is a topic that in recent years has received increased scrutiny by the media and is viewed as a cause for public health concern in athletes that are participating in contact sports. There has been an apparent rise in the reported number of traumatic brain injuries over the last decade possibly due to a number of factors such as an increase in enrollment of sports and suspected better understanding of brain injury in the sports world. Direct or indirect impact forces applied involving acceleration/deceleration and linear/angular forces primarily cause trauma to the brain. This insult results in evident diffuse axonal and focal injuries to varying degrees in brain tissue. The spectrum of pathophysiology in traumatic brain injury involves structural, neurochemical, metabolic, vascular, inflammatory, immunologic, and ultimately cell death, which plays a hand directly in the nonspecific presentation of symptoms reported by athletes as well as the progression of recovery. Traumatic brain injury is typically associated with short- and long-term sequelae, however, inducing repetitive episodes of trauma over a career, as may happen in sports, may lead to a progressive neurodegenerative disease known as chronic traumatic encephalopathy. Chronic traumatic encephalopathy has been known to affect boxers previously, but in recent years the attention has shifted and found this disease in athletes from other sports. The spectrum of disease in chronic traumatic encephalopathy involves a progressive tauopathy that spreads across different regions of the brain in a classified four staged grading system. Several risk factors have been identified in placing athletes at risk for traumatic brain episodes, however no risk factors have been directly linked to chronic traumatic encephalopathy. Much information is lacking in a complete understanding of traumatic brain injury and chronic traumatic encephalopathy, therefore emphasizing the importance of further research and consistently improving modifications in the protocols for assessment, recognition, management, and return to play criteria for injured athletes. Furthermore, despite the gaps in knowledge, preventative measures should serve a particular role in reducing the incidence of detected traumatic brain injuries, which should include policy changes, sport rule changes, and especially changes to the accepted sports culture through mandatory education.

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