Feb. 26, 2011 -- When Dave Duerson, former member of the Chicago Bears who was a four-time Pro-Bowl safety, died of a self-inflicted gunshot wound at age 50 on Feb. 17, he made sure his brain was intact -- or as intact as it could be after a head-banging career in professional football.
He shot himself in the abdomen, after requesting that his brain be studied for evidence of chronic traumatic encephalopathy, a condition that has become an increasing source of concern among professional athletes. Around 20 football players who died relatively young have been found to have the brain changes associated with this condition, and some critics are now calling for a ban on the game for youth younger than 18.
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Neuropathologist Bennet Omalu, MD, who was the first to identify the condition, told MedPage Today, "There is no reason, no medical justification, for any child younger than 18 to play football, period."
A Death in Pittsburgh
It has been known since the 1920s that the repetitive brain trauma experienced by boxers sometimes led to neurologic and cognitive deterioration -- a condition that initially was termed "dementia pugilistica."
But in 2002, after the death of Pittsburgh Steelers former star center Mike Webster, known as "Iron Mike," Omalu, who then worked in the medical examiner's office in Pittsburgh, performed an autopsy on the player, whose life ended with a heart attack after years of homelessness and destitution -- he had even sold his Super Bowl rings -- as well as depression and multiple suicide attempts.
On first examining Webster's brain, Omalu was startled to find that it appeared perfectly normal. He had been expecting visible evidence of repeated damage that could cause the player's deterioration.
But he persevered, and in special analyses of brain tissue samples, he found large deposits of tau, a protein which is part of the microskeleton of brain cells. With repeated axonal injury, tau loses its self-repairing ability, becomes hyperphosphorylated, and begins to accumulate, forming neurofibrillary tangles and neuritic threads in areas of the neocortex.
"People said then, and still are saying today, that when former athletes deteriorate into depression, drug abuse, and even violence and criminality, it's because they don't compete well on the field of life after competing well on the field of football," Omalu said in an interview with MedPage Today.
"I did not think that was a correct assumption. I think football was a high impact sport that could result in repeated blows to the head and brain damage," he said.
Omalu, who is now chief medical examiner in San Joaquin County, Calif., named the condition chronic traumatic encephalopathy, and published his findings in Neurosurgery in 2005, recommending "comprehensive clinical and forensic approaches to understand and further elucidate this emergent professional sport hazard."
The National Football League reacted with outrage, demanding a retraction of the paper. "They said I was Nigerian -- what I was doing wasn't science, I was practicing voodoo medicine," he recalled.
But within a year he had identified a similar case, and then a third, a 44-year-old former football player who experienced depression, insomnia, paranoia, and memory loss before shooting himself in the head.
When he published the third case, he recommended that full autopsies and comprehensive neuropathological examinations of the brain be performed on every retired NFL player who dies with a history of psychiatric, emotional, or physical problems.
More Cases Seen
Cases among football players and other athletes continued to be reported, raising sufficient attention that a research institute was initiated at Boston University in conjunction with the Sports Legacy Institute. This initiative, known as the Center for the Study of Encephalopathy, was to more fully investigate the effects of repetitive concussive and subconcussive head injuries in athletes.
In a report published in the Journal of Neuropathology and Experimental Neurology in 2009, the Boston researchers described five cases in football players as well as more than 30 in boxers. They noted that gridiron players appeared to die at younger ages, around 44, than boxers, who typically died at 60. The football players also died after shorter symptom duration -- six years rather than 20.
As with the earlier patients, symptoms included severe mood disorders, memory loss, aggressiveness, and four of the five had died tragically -- two from suicide, one during a high-speed chase by police, and another of an accidental gunshot wound.
Echoing the earlier observations of Omalu, the Boston researchers explained that they found neurofibrillary and astrocytic tangles, as well as other abnormalities, in numerous areas of the players' brains, including the dorsolateral frontal and parietal and inferior occipital cortices.
"The patchy, irregular location of the cortical [neurofibrillary tangles] and astrocytic tangles suggests that the distribution is related to direct mechanical injury from blows to the side or top of the head," they wrote.
A Player Unraveling
Between 1985 and 1989, Duerson's time with the Chicago team, he was involved in more than 550 tackles.
He was a team member when the Bears defeated the New England Patriots by 46 to 10 in Super Bowl XX, and was playing for the New York Giants when they triumphed over the Buffalo Bills in Super Bowl XXV.
After retirement, he served on a panel that evaluates players' disability claims, as more former players sought support for psychiatric, emotional, and physical problems they believed related to injuries on the field.
Duerson also ran successful fast-food franchises for a while, but his life gradually deteriorated -- divorcing after being charged with battery toward his wife, selling his business at auction, and losing his home to foreclosure.
In the months before his death he confided to friends that he was experiencing depression and other symptoms, and feared that he might have chronic traumatic encephalopathy.
This possibility will be investigated by the researchers at the Boston institute, where a "brain bank" has been set up, with some 100 living NFL players offering to donate their brains for research purposes when they die.
In a note he left behind, Duerson wrote, "Please, see that my brain is given to the NFL's brain bank."
Looking for Answers
Today researchers from the Boston University institute and elsewhere are evaluating possible preventive strategies, including the use of neuroprotective substances such as omega-3 fatty acids and the experimental Alzheimer's drug Posiphen.
Risk factors also are being considered.
"We need to continue the research that we and others are doing looking at causes of chronic traumatic encephalopathy, seeing who is at risk, and to see if there is possibly a genetic predisposition," Julian Bailes, MD, told MedPage Today in a telephone interview.
Bailes, who is co-director along with Omalu of the Brain Injury Research Institute in Morgantown, W. Va., explained that he and his colleagues have now examined about 30 brains looking for evidence of chronic traumatic encephalopathy, not only in football players, but in boxers, wrestlers, and military veterans.
"We would love one day to be able to diagnose it earlier before it's full blown and ends catastrophically as it did in [Duerson's] case," he said in a phone interview.
Omalu believes stronger measures may be needed.
"The brain is not fully developed until about age 18. Impact to the head in younger people may not cause any obvious damage that could be seen on CT or MRI, but on the cellular, epigenetic level there is damage," he said.
"Iron Man" Mike Webster's son Garrett, who is an administrator at the Brain Injury Research Institute, wrote of his father's last years, "He grew increasingly violent and angry with those around him. In the end he died broke, alone, and with only a few loyal friends still looking out for him."
On the institute's website, Garrett Webster continued, "I cannot tell you how much of a relief it was to learn that my father was not wholly responsible for his behavior and actions."