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A Clinical Approach to the Diagnosis of Traumatic Encephalopathy Syndrome A Review

Nicole Reams, MD1; James T. Eckner, MD, MS2; Andrea A. Almeida, MD2; Andrea L. Aagesen, DO3; Bruno Giordani, PhD4; Hank Paulson, MD3; Matthew T. Lorincz, MD, PhD3; Jeffrey S. Kutcher, MD3
[+] Author Affiliations
1Department of Neurology, NorthShore University Health System, Glenview, Illinois
2Department of Physical Medicine and Rehabilitation, University of Michigan Health System, Ann Arbor
3Department of Psychiatry, University of Michigan Health System, Ann Arbor
4Department of Neurology, University of Michigan Health System, Ann Arbor
JAMA Neurol. 2016;73(6):743-749. doi:10.1001/jamaneurol.2015.5015.
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Importance  Chronic traumatic encephalopathy (CTE) refers to pathologic changes that have been found in some individuals with a history of repetitive traumatic impact to the head (hereinafter referred to as head trauma). These changes cannot be assessed during the clinical evaluation of a living patient.

Observations  The neuropathologic features, taxonomy, history, role of biomarkers in diagnosis, and existing criteria of CTE are reviewed. Previous criteria have been proposed to approach the living patient; however, a unified, specific approach is needed for the practicing clinician. We propose a new diagnostic construct for the clinical syndrome associated with repetitive exposure to head trauma: traumatic encephalopathy syndrome. This clinical paradigm will provide the framework for a diagnosis of probable, possible, and unlikely traumatic encephalopathy syndrome, with included discussion regarding the minimum exposure, nature of the clinical course, and additional clinical features needed for diagnosis.

Conclusions and Relevance  While prospective longitudinal studies are ongoing to further elucidate the association of exposure to head trauma, clinical features, and the development of pathologic changes, a corresponding clinical construct for diagnosis is necessary.

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Figure.
Initial Clinical Approach to the Patient With Neurocognitive Problems and Possible Traumatic Encephalopathy Syndrome (TES)

This model includes patients with a duration of neurocognitive problems for longer than 2 years. For a patient to be considered for a diagnosis of TES, the neurocognitive complaints or decline must be beyond the expected course given the individual’s age and other medical issues. This flowchart is intended to provide a framework for the practicing physician; clinical judgment and assessment remain a necessary aspect of the diagnostic pathway. NDD indicates neurodegenerative disease.

aIncludes obstructive sleep apnea, migraine, mood disorder, substance abuse, medication effect, and “worried well” (ie, individuals who do not have a medical disorder but may visit a physician owing to psychological distress or need for reassurance).

bInclude emotional dysregulation, behavioral change, or motor disturbance.

cConsider trauma-accelerated NDD vs typical NDD.

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