Diffusion Tensor Imaging in Athletes Sustaining Repetitive Head Impacts: A Systematic Review of Prospective Studies

Competitive sport participation, in contact and collision sports, exposes athletes to repetitive head impacts. Although these impacts do not always result in overt symptomology or a diagnosed "concussion," evidence indicates that cumulative repetitive impacts affect brain pathophysiology. The purpose of this study was to perform a systematic review of prospective, longitudinal trials evaluating repetitive head impact exposure on white matter (WM) microstructure in collision and contact sport athletes to inform clinical care and treatment strategies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to determine studies that met predetermined inclusion and exclusion criteria. Initially, 2498 abstracts were identified, and 20 studies were critically evaluated herein. The majority of studies demonstrated significant longitudinal changes in anisotropy and/or diffusivity metrics that were associated with the quantity and/or the magnitude of head impact exposure, highlighting the utility of diffusion tensor imaging (DTI) for measuring changes in WM microstructure. Our review also comments on study methodology and describes how age, sex, sport, and time between sport cessation and DTI measures contribute to divergent findings within the literature. Suggestions for future research are also provided to overcome previous study limitations and maximize our understanding of the role of repetitive head impact exposure on WM integrity and long-term neurological sequela.