Objectives: To describe the prevalence of sensory dysfunction (i.e. auditory, visual, vestibular, chemosensory and multiple sensory problems) and explore associations with traumatic brain injury (TBI) severity and injury mechanism among deployed Post-9/11 Veterans. Methods: This retrospective cohort analysis used Departments of Defense and Veterans Affairs diagnostic codes and administrative data. Results:Among the 570,248 Veterans in this cohort, almost 23% had at least one diagnosis of sensory dysfunction. In the multinomial regression analysis, the odds of all types of sensory dysfunction were greater among those with any TBI relative to those with no TBI. The odds for auditory or multisensory problems were higher among those that indicated exposure to blast. In particular, exposure to quaternary blast injury (e.g. crush, respiratory and burn injuries) was associated with increased odds for auditory, visual, vestibular and multisensory problems. Conclusions:Sensory problems affect a substantial number of deployed Post-9/11 Veterans and are more common among those with TBI or with exposure to deployment-related blast exposure. Because sensory problems profoundly impact quality of life, their identification and enhanced education and therapy are vital tools to improve prognosis for these relatively young Veterans.

Psychosocial problems are exceedingly common following moderate-to-severe traumatic brain injury (TBI), and are thought to be the major predictor of long-term functional outcome. However, current rehabilitation protocols have shown little success in improving interpersonal and social abilities of individuals with TBI, revealing a critical need for new and more effective treatments. Recent research has shown that neuro-modulatory treatments (e.g., non-invasive brain stimulation, lifestyle interventions) targeting the functionality of specific brain systems—as opposed to focusing on re-teaching individuals with TBI the impaired behaviors— hold the potential to succeed where past behavioral protocols have failed. However, in order to implement such treatments it is crucial to gain a better knowledge of the neural systems underlying social functioning secondary to TBI. It is well established that in TBI populations the inability to identify and interpret social cues, and in particular to engage in successful recognition of facial affects, is one of the factors driving impaired social functioning following TBI. The aims of the work here described were threefold: (1) to determine the degree of impairment in individuals with moderate-to-severe TBI on tasks measuring different sub-types of facial affect recognition skills, (2) to determine the relationship between white matter integrity and different facial affect recognition ability in individuals with TBI by using diffusion tensor imaging, and (3) to determine the patterns of brain activation associated with facial affect recognition ability in individuals with TBI by using task-related functional magnetic resonance imaging (MRI). Our results revealed that individuals with TBI are impaired at both perceptual and verbal categorization facial affect recognition tasks, although they are significantly more impaired in the latter. Moreover, performance on tasks tapping into different types of emotion recognition abilities showed different white-matter neural correlates, with more individuals with TBI showing more extensive damage in the left inferior fronto-occipital fasciculus, uncinate fasciculus and inferior longitudinal fasciculus more likely to perform poorly on verbal categorization tasks. Lastly, our functional MRI study suggests an involvement of left dorsolateral prefrontal regions in the disruption of more perceptual emotion recognition skills, and involvement on the fusiform gyrus and of the ventromedial prefrontal cortex in more interpretative facial affect recognition deficits. The findings here presented further out understanding of the neurobiological mechanisms underlying facial affect impairment following TBI, and have the potential to inform the development of new and more effective treatments.

Mitochondrial dysfunction is a phenomenon observed in models of Traumatic Brain Injury (TBI). Loss of mitochondrial bioenergetics can result in diminished cellular homeostasis leading to cellular dysfunction and possible cellular death. Consequently, the resultant tissue damage can manifest as functional deficits and/or disease states. Therapeutic strategies to target this mitochondrial dysfunction have been investigated for models TBI and have shown promising effects. For this project, we tested the hypothesis that mitoNEET, a novel mitochondrial membrane protein, is a target for pioglitazone mediated neuroprotection. To test this, we used a severe Controlled Cortical Impact (CCI) injury model in mitoNEET null and wild-type mice. We then dosed these animals with pioglitazone or NL-1, which is a compound that has a similar structure to pioglitazone allowing us to hone in one the importance of mitoNEET binding. Wild-type animals treated with the mitoNEET ligands, both pioglitazone and NL-1, had improved mitochondrial function, tissue sparing and functional recovery, compared to mitoNEET null animals. In addition to this specific hypothesis tested, our experiments provided insight casting doubt on the central dogma that mitochondrial dysfunction following TBI is the result of vast oxidative damage and consequential irreversible mitochondrial loss. The data from these studies show that when mitoNEET is targeted with pioglitazone at 12 hours’ post-injury, mitochondrial dysfunction can be reversed. Additionally, when bypassing proteins upstream of Complex I with an alternative biofuel, such as beta-hydroxybuterate (BHB), TBI related mitochondrial dysfunction is once again reversed. This leads to novel hypothesis for future work which posits mitoNEET as a redox sensitive switch; when mitoNEET senses changes in redox, as seen in TBI, it inhibits mitochondrial respiration. When targeted with an agonist/ligand or bypassed with a biofuel TBI mitochondrial dysfunction can be reversed. These studies support the role of mitoNEET in the neuropathological sequelae of brain injury, supporting mitoNEET as a crucial target for pioglitazone mediated neuroprotection following TBI. Lastly, these studies propose a mechanism of TBI related mitochondrial dysfunction which can reversed with pharmacological agents.

Tauopathies are a group of neurodegenerative diseases characterized by the abnormal deposition of the protein tau, a microtubule stabilizing protein. Under normal physiological conditions tau is a highly soluble protein that is not prone to aggregation. In disease states alterations to tau lead to enhanced fibril formation and aggregation, eventually forming neurofibrillary tangles (NFTs). The exact cause for NFT deposition is unknown, but increased post-translational modifications and mutations to the tau gene can increase tangle formation. Tauopathic brains are stuck in a detrimental cycle, with cellular dysfunction contributing to the development of tau pathology and the development of tau pathology contributing to cellular dysfunction. The exact mechanisms by which each part of the cycle contributes to the other are still being explored. To investigate the unique contributions of each part of this cycle we utilized two separate models of tauopathy: one chronic and one acute. Overall this project provides novel insight into the role of pathological tau as both a cause, and a consequence, of cellular dysfunction. To understand how development of tau pathology contributes to cellular dysfunction we studied chronic disease models. Using human brain tissue we found that under normal conditions tau associates with ribosomes but that this interaction is enhanced in Alzheimer’s disease brains. We then used in vitro and in vivo models of tauopathy to show that this association causes a decrease in protein synthesis. Finally, we show that wild type tau and mutant tau reduce protein translation to similar levels. To understand how general cellular dysfunction contributes to development of pathology we used an acute model of tauopathy through traumatic brain injury (TBI). We injured rTg4510 tau transgenic mice at different ages to investigate the effect of TBI on tau fibrillization (2 month old) and the effect of TBI on tau already in NFTs (4.5 month old). In 2 month old mice, we found that tau hyperphosphorylation was decreased at 24 hours and increased at 7 days post injury, and that tau oligomerization was decreased at 24 hours post injury. We also found that tau fibrillization was not increased after 24 hours or 7 days post injury. In 4.5 month old mice, we found that TBI did not increase or decrease tangle counts in the brain, but we did qualitatively observe decreased variability within groups. Overall these studies contribute novel understanding of tau’s role in different disease states. We identified a functional consequence of the interaction between tau and ribosomes, and demonstrated that a single head impact did not increase tau fibril formation within 7 days of injury. While human diseases associated with TBI show neurofibrillary tangle deposition, we have yet to recreate that aspect of the disease in research models of TBI. Our findings support the need for further investigation into the nuances of tau in disease, especially following TBI.

Traumatic Brain Injury (TBI) is an increasingly diagnosed constellation of injuries derived from acute mechanical trauma to the brain. With the rise of advanced neuroimaging techniques recent focus has oriented primarily towards the mild-moderate range of TBI which previously was missed diagnostically. Characteristically, these advances have shown increasing areas of micro-hemorrhage in susceptible areas of the brain and to date there are no treatment modalities targeting micro-hemorrhages or their sequelae. This dissertation explores the effects of the resulting heme processing response in the days following injury with a particular focus on inducing early heme clearance from the parenchyma using a rat central fluid percussion injury model in the mild-moderate injury range. Since heme is released ~24-48 hours post-injury and is known to be cytotoxic we observed there may be a critical window for treatment to clear heme before it is spontaneously released and to increase the buffering capacity of the tissue. We targeted heme clearance by using drugs known to increased expression of Nrf2, an upstream transcriptional regulator of the canonical heme processing protein heme oxygenase 1 (HO-1), and tracking expression of HO-1, the iron sequestration/storage proteins Lipocalin 2 (LCN2) and Ferritin (FTL), as well as the activity of matrix metalloproteinases 2 and 9 (MMP2, MMP9). We examined both tissue known to be frankly hemorrhagic (the neocortex) as well as tissue lacking any identifiable bleed (the hippocampus). We demonstrated that using the HO-1 inducers Hemin and Sulforaphane in a single dose paradigm given 1 hour post-injury heme clearance was accelerated in the neocortex with the majority of heme pigment processed by 24 hours post-injury. Further there was significant attenuation of protein expression in HO-1 and ferritin as well as the enzyme activity of MMP2 and MMP9 in both the neocortex and the hippocampus. Behavioral attenuation was also seen in both rotarod and Morris water maze tests. While we intended to target hemorrhagic processing after injury, and indeed demonstrated improved clearance of heme from post-injury hemorrhagic regions of the brain, in both tissues studied we observed remarkably similar responses to the drugs utilized in protein expression, enzyme activity, and behavioral improvement which may suggest a globally improved pathologic state or that there are unidentified pathologic micro-hemorrhages or leaky vessels which extend further into the brain parenchyma than currently identified.

A growing body of evidence implicates the importance of the endogenous cannabinoid 2-arachidonyl glycerol (2-AG) in memory regulation. The biosynthesis of 2-AG occurs primarily through the diacylglycerol lipases (DAGL-α and -β), with 2-AG serving as a bioactive lipid to both activate cannabinoid receptors and as a rate limiting precursor for the production of arachidonic acid and subsequent pro-inflammatory mediators. Gene deletion of DAGL-α shows decrements in synaptic plasticity and hippocampal neurogenesis suggesting this biosynthetic enzyme may be important for processes of normal spatial memory. Additionally, 2-AG is elevated in response to pathogenic events such as traumatic brain injury (TBI), suggesting its regulatory role may extend to conditions of neuropathology. As such, this dissertation investigates the in vivo role of DAGL-α and -β to regulate spatial learning and memory in the healthy brain and following neuropathology (TBI). The first part of this dissertation developed a mouse model of learning and memory impairment following TBI, using hippocampal-dependent tasks of the Morris water maze (MWM). We found modest, but distinct differences in MWM performance between left and right unilateral TBI despite similar motor deficits, histological damage, and glial reactivity. These findings suggest that laterality in mouse MWM deficit might be an important consideration when modeling TBI-induced functional consequences. The second part of this dissertation work evaluated DAGL-β as a target to protect against TBI-induced learning and memory deficit given its selective expression on microglia and the role of 2-AG as a precursor for eicosanoid production. The gene deletion of DAGL-β did not protect against TBI-induced MWM or motor deficits, but unexpectedly produced a survival protective phenotype. These findings suggest that while DAGL-β does not contribute to injury-induced memory deficit, it may contribute to TBI-induced mortality. The third and final set of experiments investigated the role of DAGL-α in mouse spatial learning and memory under physiological conditions (given the predominantly neuronal expression of DAGL-α). Complementary pharmacological and genetic manipulations produced task specific impaired MWM performance, as well as impaired long-term potentiation and alterations to endocannabinoid lipid levels. These results suggest that DAGL-α may play a selective role in the integration of new spatial information in the normal mouse brain. Overall, these data point to DAGL-α, but not DAGL-β, as an important contributor to hippocampal-dependent learning and memory. In contrast, DAGL-β may contribute to TBI-induced mortality.

According to the Center for Disease Control’s (CDC) report to the Congress, there are 2.2 million emergency department visits; 80,000 hospitalizations; and 50,000 deaths each year due to traumatic brain injury. Adults 65 years and older account substantially for the majority of the hospitalization and deaths. Over 70% of the traumatic brain injuries of the older adults are classified as mild to moderate; however, even with these milder injuries, older adults present with a significantly higher morbidity and mortality compared to all other age groups (LeBlanc et al., 2006). With that in mind, it seems essential to develop a deeper understanding of the causes behind higher mortality and morbidity of traumatic brain injury in the elder population. It is well documented that increased age is accompanied by increased CNS inflammation. Recently, our laboratory showed that inflammation drives brain pathology. Specifically, we reported that the axon initial segment of cortical neurons was structurally and functionally compromised in an inflamed CNS environment. With this in mind, we proposed that age-related inflammation predisposes that brain to exacerbated pathologic consequence. To test this hypothesis, we administered a mild to moderate central fluid percussion brain injury in aged and young adult mice. Using immunocytochemical labeling against the axon initial segment protein ankyrinG combined with laser scanning confocal microscopy, we quantitatively compared axon initial segment number and length between age groups and within age groups with and without injury. Additionally, we also quantified global axonal pathology by immunolabeling for amyloid precursor protein (APP) positive swelling as an indicator of compromised axonal transport. We proposed that ankyrinG labeling will be both reduced in the aged injured mice compared against aged uninjured, young adult injured and young adult non-injured. We observed a significant increase in APP accumulations due to injury independent of aging, and due to aging independent of injury. No significant changes in the effect of injury between young and aged injured mice were observed. Although AIS length was not altered between age groups following injury, our results demonstrate that the elderly population presents with significantly shorter initial segments. The consequence of this shortening is not clear but may reflect compensatory changes in the brain to maintain homeostasis.

2.5 million people sustain a traumatic brain injury (TBI) annually in the United States. Although there is potential for functional recovery following TBI, there is no definitive treatment to improve recovery after TBI. Our lab has shown that TBI enhances an endogenous neurogenic response in the subventricular zone and hippocampus. TBI-induced neural stem cells (NSCs) can integrate into regions such as the hippocampus and olfactory bulb. Although the mechanism behind TBI-enhanced neurogenesis remains unknown, the Notch signaling pathway has been implicated as a regulator in the maintenance and survival of NSCs. This thesis explores the effects of Notch pathway manipulation on functional recovery following TBI. We hypothesize that Notch signaling plays a critical role in recovery after TBI. Activation of this pathway via a Notch agonist (Notch1) will facilitate post-injury recovery while inhibition of this pathway via a Notch antagonist (recombinant Jagged-1 Fc) will deter post-injury recovery. Functional recovery was assessed within 30 days or 60 days post-injury in two different cohorts of animals. The behavior assays conducted in this study included motor, cognitive, and olfactory assessment. In the 30-day phase, Notch pathway manipulation following TBI did not affect functional performance. In the 60-day study, significant group differences were found. While the FPI+Vehicle animals exhibited a functional recovery in Morris water maze, injured animals with Notch inhibition failed to show this cognitive recovery, indicating the involvement of the Notch pathway in cognitive recovery at the chronic stage following TBI. Motor and olfaction were not significantly affected by Notch pathway manipulation.

Severe traumatic brain injury (TBI) is a pervasive and devastating condition, often resulting in permanent alterations in cognition, behavior, and personality. As such, survivors of severe TBI usually rely on the assistance of caregivers to navigate situations of daily living throughout their life span. Spouses of individuals with TBI have been shown to experience greater levels of burden than parental caregivers of TBI survivors (Kreutzer et al., 1994; Mauss-Clum & Ryan, 1981) and subsequently rates of divorce and separation have been documented within the research literature to be high (Thomsen, 1984; Wood et al., 2005). Although marital breakdown has been frequently studied, research on marital satisfaction and coping within long-term marriages where one spouse has survived a severe TBI remains insufficient. The purpose of this study was to provide a descriptive analysis of long-term spousal caregivers of individuals with severe TBI. First, demographic variables of caregiving spouses of individuals with severe TBI, who remained married at least 10 years post injury, were described and comparisons to other spousal caregiver samples were addressed. Second, the relationship between marital adjustment and demographic variables, coping, and quality of life was examined. Finally, an analysis of primary stressors was conducted to better understand the caregiving spouses' continued experience of stressors. Twenty-one spousal caregivers who remained married for at least 10 years post injury to their spouse who sustained a severe TBI participated in the study. Analyses revealed that spouses had remained married an average of 19 years post-injury and in general were mildly dissatisfied within their marriages. Furthermore, marital adjustment (Dyadic Adjustment Scale total score) of long-term spousal caregivers of severe TBI was not significantly different than spousal caregivers of individuals with chronic illness. Higher marital satisfaction scores were associated with higher endorsement of emotion-focused coping strategies and greater mental health quality of life. In addition, marital satisfaction was positively associated with the longevity of the marital relationship, the age of the spouse at the time of the injury, and the length of the marriage at the time when the injury was sustained. As expected, higher scores of marital satisfaction were associated with higher levels of mental health quality of life. There were no significant relationships between physical health quality of life and marital satisfaction. An analysis of primary stressors show that long-term caregiving spouses continue to report similar types of stressors as indicated in the research literature from caregiving spouses during the first 5 to 8 years post injury. Findings were discussed in relation to implications for practice and additional research.

The degree of academic achievement following early onset brain injury is poorly understood. Furthermore, it is unclear if academic success can be predicted by age of onset or other lesion variables (e.g., size, laterality). The purpose of the current study was to describe patterns of academic achievement in individuals with childhood-onset focal brain lesions and to determine the role of variables in the plasticity or vulnerability of the developing brain with regard to achievement. Academic achievement data were collected from 58 individuals with childhood-onset focal brain lesions. The participants' reading, spelling, and arithmetic scores, as measured by the Wide Range Achievement Test, were analyzed in relation to several neuroanatomical variables, including lesion laterality, lesion site, and lesion size. The relationship between achievement and gender, age of onset, etiology, age at testing, and time since lesion onset was also identified. As a group, achievement scores did not differ from normative data, and the majority of the sample demonstrated adequate skills in each domain. However, the frequency of deficits was larger than expected when compared to base rates, suggesting vulnerability to early insult. Achievement scores were correlated with intelligence scores, but did not differ based on lesion laterality, lesion site, age of onset, or etiology. Size of lesion was significantly correlated with reading and spelling but not with arithmetic outcomes. Gender differences were identified, with males performing significantly better on the arithmetic measure than females. The age of onset, age at testing, and time since lesion onset were not correlated with achievement scores in any domain. No interactions were found between lesion laterality and gender or lesion site and lesion laterality. An interaction between gender and lesion site was found, but the significance of the finding is unclear. The current findings provide mixed evidence for the plasticity-vulnerability debate, as many individuals were able to achieve adequate academic skills whereas others demonstrated significant impairments. Further research is needed to elucidate factors that may predict achievement outcomes in individuals with childhood-onset focal brain injury.