Looking inside the injured brain
Doctors can analyze the brains of dead athletes to confirm football-linked brain injuries, said Patrick Hruby in The Washington Post Magazine. But what about a test for the living?
RED AND YELLOW were bad. Blue and green were good. The rest, Sam Gandy explained, remains unclear. It was December 2015, and Gandy, a neurologist at Mount Sinai Hospital in New York, was showing a former National Football League player named Sean Morey scans of his brain. A professional athlete for 10 seasons, Morey retired from the NFL in 2010 after doctors told him he had suffered too many concussions. At 39 years old, he also was suffering debilitating headaches, memory lapses, angry outbursts, and other symptoms associated with chronic traumatic encephalopathy (CTE), a neurodegenerative disease linked to repeated blows to the head. While CTE had been found in the brains of dozens of former players, including Pro Football Hall of Fame members Mike Webster and Junior Seau, there was no way to know whether Morey had it. The disease could be diagnosed only posthumously.
Gandy was working to change that. To try to identify CTE, he was using an experimental technique to scan the brains of retired football players and soldiers. The scans were color-coded. Healthy brains appeared mostly blue and green, like grassy islands surrounded by sea. By contrast, probable areas of damage looked yellow and red, as if fires were burning on those same islands. The images Gandy was showing Morey were the results of brain scans done seven months earlier using a positron-emission tomography (PET) machine. Much of Morey’s brain was green. But some areas were red. Bright, flaming red. And those areas corresponded to the damaged areas found in the autopsied brains of Seau, Webster, and others with CTE. “I knew they would find something,” Morey said later. “The question was, What was the extent of it?”
Suppose you’re a football player. Here’s what happens when doctors suspect that you’ve torn a knee ligament: They use a magnetic resonance imaging (MRI) machine to look at the tissues in your leg, determine whether and how they’ve been damaged, and use that information to prescribe a course of treatment and recovery. Here’s what happens when doctors suspect you’re suffering from CTE: They wait for you to die. After that, they carefully remove your brain from your skull, slice portions of it into small, thin pieces, stain those pieces with special chemicals, and place them under microscopes to look for the disease’s biological signature: tangles of a toxic, abnormal variation of a protein called tau in the depths of the sulci, which are the crevasses between the brain’s many wrinkles. Then, and only then, can it be said conclusively that you had CTE and not some other neurodegenerative disease or type of brain injury.
Linked to aggression, depression, suicidal thoughts, impaired judgment, impulse control problems, and dementia, CTE was found in the brain of Tyler Hilinski, a 21-year-old Washington State University quarterback who died of suicide in 2018, and in the brain of Aaron Hernandez, a 27-year-old former NFL player who in 2017 hanged himself in prison while serving a life sentence for murder.
Last year, Boston University researchers found that for football players, both the risk of developing the disease and its severity increase with the number of years playing the sport; athletes whose youth-to-pro careers lasted more than 14½ years were 10 times as likely to have CTE as those who played fewer. Yet because there’s no way to identify the disease in the living, many basic and important questions remain unanswered. Researchers do not know why some people who suffer repeated head hits develop CTE while others do not. They do not know how many hits are too many. They do not know exactly how the disease first arises, or how and why it spreads across the brain over time. They do not know why individuals develop different symptoms with different levels of severity.
Moreover, the inability to detect the disease in people such as Morey makes developing effective therapies almost impossible. But with detection, “we’d be able to begin clinical trials for new compounds to be able to treat the disease once it starts—and hopefully even prevent it if we can detect it early on,” says Robert Stern, the director of clinical research for Boston University’s CTE Center and an expert on the disease. “So the next critical step is to diagnose it during life.”
OREY NEVER PLANNED on becoming a medical case study. Undersize at 5-foot-11 and 193 pounds, he played his way from practice squads to the 2008 Pro Bowl as a special teams standout for the Arizona Cardinals. After football, Morey figured, he would put his Brown University degree to use and become an athletic director. Or perhaps go into politics. Brain injuries derailed those ambitions. Morey estimates that he suffered more than 20 concussions over his career, most of them undiagnosed, and countless other blows to the head. After the 2009 season, he began having blind spots in his vision and excruciating headaches that would leave him immobilized for hours at a time. When two doctors advised Morey to retire in the summer of 2010, he knew enough to take their advice. Two years earlier at the Super Bowl, he’d had a long conversation with Chris Nowinski, a former Harvard University football player and professional wrestler who was trying to warn the sports world about the potential dangers of concussions and repetitive brain trauma, including CTE.
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fering from symptoms associated with CTE and 31 people with no history of head injuries or symptoms was similarly suggestive— and similarly inconclusive. Stern, the Boston University researcher and one of the study’s co-authors, believes that the tracer used to detect p-tau, a compound called flortaucipir, may prove inadequate for a reliable CTE test. If a better test is developed, doctors still will need to scan a large number of suspected CTE patients, track them over time, and examine them after death to validate that the yellow and red areas seen in scans correspond to what’s actually inside their brains. That process probably will take years.
“Let’s do it one more time!” someone yelled.
What Morey loved most about football was community: the relationships with teammates and coaches, the shared sense of sacrifice, the pursuit of a common goal. Brain injuries often have left him isolated. Over time and by himself, Morey has shuffled through doctors and medications, searching for relief. Today, brain injury specialists have prescribed him a stimulant for focus, an antidepressant that he says “lengthens the fuse” on his blowups, and a blood pressure medication that softens his migraines. He spends roughly $20,000 a year on treatment.
Maybe the hardest thing about his condition, Morey says, is its invisibility. When you have a bum knee, others can see the swelling in the joint, the brace around your leg, the crutches you’re using to get around. Nobody says that you’re faking a limp, or that your inability to climb stairs is all in your head. Not so with a battered brain.
After Morey retired from football, a neurologist who examined him in 2012 for a workers’ compensation claim concluded that Morey’s problems were “substantially if not completely the result of his psychological state”—and not the result of brain damage from getting hit in the head. The neurologist based that conclusion, in part, on MRI and electroencephalogram (EEG) scans of Morey’s brain that did not “confirm the presence of a structural brain injury.” But those types of scans are less sensitive than the ones used by Gandy and Stern.
Similarly, the league’s concussion settlement, which covers about 20,500 retired players, only pays CTE claims to the families of players posthumously diagnosed with the disease between 2006 and April 2015. It also does not compensate mood and behavior disorders associated with CTE. Lawyers who negotiated the deal said it was the best they could do given that the disease cannot be diagnosed in the living.
“So much of the imaging that was discussed or debated or referenced for years and years was simply not sensitive enough to identify the damage that players had been sustaining,” Morey says. “Doctors and lawyers could point to that and suggest there were no long-term outcomes from football, even though guys were suffering. There must have been so many people experiencing these issues who were painted as bulls---ting or crazy. Don’t f---ing call us crazy. We’re not crazy. We’re hurting, and we need help.”