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• Posted August 29, 2023

Autopsy Study of Athletes Who Died Young Shows Many Had Signs of CTE

The degenerative brain disease known as chronic traumatic encephalopathy (CTE) may be striking some at much younger ages than thought possible: New research has uncovered early signs of the condition in amateur athletes who died young after playing contact sports.

The troubling finding was discovered during the brain autopsies of 152 athletes. All had engaged in the type of sports, such as football, where head impacts are routine. And all had died before turning 30.

Investigators determined that roughly 4 in 10 had developed early signs of CTE while still in their teens and 20s. And the vast majority of those with CTE — more than 70% — were just young amateurs, not professional players.

“CTE is a neurodegenerative disease caused by repetitive hits to the head that has been found most often in contact sport athletes,” explained study author Dr. Ann McKee. She is a professor of neurology and pathology at Boston University and director of neuropathology care with the Veterans Affairs Boston Healthcare System.

But while most research has focused on the risk of brain damage among professional athletes, the latest analysis reveals “that CTE can begin very early, as early as 17 years, and that it can develop in amateur soccer, rugby, ice hockey and football players, and amateur wrestlers,” McKee stressed.

That comes as little surprise to Dr. Daniel Daneshvar, chief of the division of brain injury rehabilitation at Harvard Medical School in Boston.

“The findings are striking, because evidence of other neurodegenerative diseases is not found in individuals this young,” noted Daneshvar, who was not part of the study team.

But “a hit to the head has the same risk of damage, whether or not you're getting paid,” he added.

Because CTE can only be definitively diagnosed during a brain autopsy, McKee's analysis focused on deceased athletes who had donated their brains to BU's “UNITE Brain Bank.” The bank holds the world's largest collection of nervous system tissue samples, drawn from deceased athletes for the express purpose of studying traumatic brain injury and CTE.

Most of the athletes (93%) were male and about three-quarters were white. All had died at some point between 2008 and 2022 before turning 30, at an average age of 23.

The vast majority (nearly 6 in 10) had died by suicide. Almost 15% had died due to an accidental overdose, while about 1 in 10 had succumbed to an injury.

Roughly 84% of the brain donors had been amateur athletes. Among that pool, about 60% had played football as their main sport, while about 15% had played soccer. Most of the other amateurs were either hockey players or wrestlers.

The donors also included the first American female athlete to be diagnosed with CTE, a 28-year-old collegiate soccer player. Her identity remains private, the researchers said.

In the study, published online Aug. 28 in JAMA Neurology, the researchers evaluated all donor brain tissue for telltale signs of neurodegenerative damage, including CTE. Tissue was also examined for indications of stroke; arterial hardening, blockage or stiffness; and damage to white matter tissue responsible for memory, balance and mobility.

Donor families were also asked to provide their own recollections as to each athlete's behavior, moods and thinking issues prior to their death.

Based on brain analyses alone, the investigators concluded that just over 40% of the athletes — including both amateurs and professionals — had CTE. Roughly 7 in 10 of those diagnosed with CTE were amateur football, hockey, soccer, rugby players or wrestlers.

Athletes diagnosed with CTE tended to be a bit older than those with healthy brains (25 versus 21 years), and had spent more time playing their sport (nearly 12 years versus under 9 years). Most of those with CTE had developed what the team characterized as “mild” disease.

But even among the 60% of athletes with no indications of CTE, there were signs of trouble brewing.

According to family reports, about 70% of the athletes had struggled with depression and apathy. Nearly 6 in 10 were said to have exhibited behavioral control problems, while nearly as many had trouble making decisions. About 4 in 10 battled alcohol abuse, while a similar number reportedly struggled with drug abuse.

These patients may not have had CTE, acknowledged McKee. Other types of injuries stemming from repetitive head impacts might have been in play, as well as physical or mental health issues unrelated to sports. Or it could be that family member recollections were not entirely accurate, she cautioned.

McKee also stressed that her team's analysis “is a brain donation case series… not a study of the general population.”

Brain donors, she noted, are a highly selective group, often with more brain injury symptoms than the average athlete.

Daneshvar concurred, noting that “someone with depression who dies tragically at a young age due to suicide is more likely to have their brain donated by their loved ones [who are] understandably looking for answers, compared to someone without that clinical history.”

Even so, McKee called for broad changes to the way high-impact sports are played, with an eye “to limit how many times, and how hard, athletes who play contact sports are hit in the head.”

Specifically, she advised eliminating practice drills that involve head impacts; eliminating heading in soccer and checking in hockey; reducing game length and frequency; starting contact sports later in life; and increased monitoring of athletes' health.

“And it is imperative that these changes be made at all levels,” including amateur and youth sports, McKee added.

More information

There's more on CTE and sports at Boston University CTE Center.

SOURCES: Ann McKee, MD, professor, neurology and pathology, and director, neuropathology care, Veterans Affairs Boston Healthcare System, U.S. Department of Veteran Affairs, Boston; Daniel Hamed Daneshvar, MD, PhD, chief, division of brain injury rehabilitation, and assistant professor, Harvard Medical School, Boston; JAMA Neurology, Aug. 28, 2023, online