RSNA: Soccer Players at Risk for Brain Injury

I'm pretty sure none of us will be heading a soccer ball any time soon but just to let you know in case any of your young relatives is taking up competitive soccer. Be careful out there.
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Soccer players who use their head to work the ball may be at risk for white matter abnormalities similar to those seen in traumatic brain injury (TBI) -- but only beyond a certain threshold, researchers said here.

In a small study of amateur soccer players, those who headed the ball more than 1,320 times per year had a greater likelihood of tiny changes in white matter as measured on diffusion tensor imaging, Michael Lipton, MD, PhD, of the Albert Einstein College of Medicine in Bronx, N.Y., reported at the Radiological Society of North America meeting here.

"These are changes in the brain that are similar to those we see with a concussion or TBI," Lipton said during a press briefing. "I'm not advocating banning heading, but there may be a threshold level, which we defined, that indicates a safe range of heading."

Lipton explained that after heading the ball, patients have reported symptoms such as headache and feeling dazed or confused, and some studies have shown that cognitive performance may also be affected.

Still, there have not been many imaging studies of its potential neurological consequences, he said.

So he and his colleagues used diffusion tensor MRI to look at tiny changes in white matter -- the fibers that make up the brain's network wiring, he said -- in 38 amateur soccer players in the New York City area who've been playing the game their whole lives.

Over the preceding year, the number of times the patients headed the ball ranged from none to 5,600, and Lipton said the upper quartile was 1,320.

Compared with the other soccer players, those in the upper quartile of heading had lower fractional anisotropy -- uniform diffusion of water across white matter -- in six regions of the brain.

That included five regions in temporooccipital white matter and one in frontal white matter.

The researchers noted that the relationship between heading and fractional anisotropy followed a reverse "S" shape, indicating that white matter abnormalities rise as the frequency of heading rises.

Although further study is needed -- particularly to assess whether these changes in white matter correspond with changes in cognitive performance -- Lipton said the findings suggest there may be room for public health intervention, given that more than 250 million people worldwide play soccer regularly. In the U.S. alone, that estimate is 18 million people, he said.

Lipton noted that more soccer players need to be assessed over a longer period of time to see if their threshold stands up, but still, he said, players should try to minimize heading, especially during practice drills, when balls are repeatedly headed back and forth.

According to guidelines from the American Academy of Pediatrics, there are not enough data to recommend against heading altogether, but the organization similarly encourages children to minimize the number of times they do so.

Max Wintermark, MD, of the University of Virginia in Charlottesville, who was not involved in the study, cautioned that the results are preliminary and that given the small number of participants, "we have to be careful not to generalize findings that have been obtained in just a few patients."

Still, he said it's "worth more study," particularly among children -- although such a study would involve practical limitations, such as the need for sedation.