The largest brain autopsy study of female victims of intimate partner violence has revealed a unique brain injury pathology unlike that seen among male contact sports athletes.
The largest brain autopsy study of women who had experienced intimate partner violence reveals substantial vascular and white matter damage in the brain, but no evidence of chronic traumatic encephalopathy (CTE), the neurodegenerative disease recognized among male contact sports athletes who sustain repeated head trauma or traumatic brain injury (TBI).
The international collaboration, led by a team from the Brain Injury Research Centre of Mount Sinai in collaboration with the New York City Office of the Chief Medical Examiner, and published this week in Acta Neuropathologica, also found substantial medical comorbidity, including cardiovascular and cerebrovascular disease.
The authors highlighted the need to consider a broad scope of pathology that underlies intimate partner violence-related brain injury, as well as the medical and psychiatric comorbidities that contribute to brain health during life, pointing out that despite intimate partner violence impacting one in three women at some point in their live, remarkably little was known about the neuropathology of partner violence.
Dr Kristen Dams-O’Connor, Director of the Brain Injury Research Centre of Mount Sinai and lead author of the paper, noted that in the popular press and even in scientific discussions, there was an assumption that repeated head injuries sustained in the context of intimate partner violence were comparable to those sustained by male contact sports athletes.
“Because our team has been conducting research and clinical care with survivors of partner violence for years, we strongly suspected that the neuropathology of brain injury may be far more complex than assumed,” Dr Dams-O’Connor said.
“Through our unique collaboration with the Office of the Chief Medical Examiner here in New York and international colleagues, we were able to shed light on this group that has been nearly absent from the medical literature and reveal that the long-term consequences of include the risk of neurodegenerative disease.”
For the study, 14 brains were obtained over two years from women with documented intimate partner violence (aged in their 20s to late 70s) and complex histories, including prior traumatic brain injury; nonfatal strangulation; cerebrovascular, neurological, and/or psychiatric conditions; and epilepsy.
The postmortem protocol of the LETBI study included ex vivo imaging, in which the whole brain specimen was scanned at high resolution, allowing the researchers to identify lesions that are invisible to the human eye and that would be missed in a standard brain autopsy, permitting an examination of unparalleled comprehensiveness.
“At autopsy, all had old and/or recent traumatic brain injury stigmata (physical marks seen in the brain that are characteristic of the condition) and substantial vascular and white matter pathology was seen in some,” the authors said.
“Evidence of cerebrovascular disease from lacunes (small cystic cavities in the brain that usually result from an ischemic infarction and much more rarely from a small, deep cerebral haemorrhage) and/or from chronic infarcts (localized areas of dead tissue resulting from failure of blood supply).
“Alzheimer’s disease neuropathologic change was present only in the oldest case in the series (in the 70-79 age range), and no CTE neuropathologic change was identified in any participants.”
The findings from the initial case series prompted similar exploration of an expanded case series of 70 archival intimate partner violence cases (aged from late teens to late 80s) accrued from multiple international institutions.
In this archival series, the research team again found evidence of vascular and white matter pathologies: only limited neurodegenerative proteinopathies were encountered in the oldest subjects, with none meeting the consensus criteria for CTE neuropathologic change.
“We were astounded by the burden of health comorbidity carried by the women in this series. Approximately half had epilepsy, and chronic diseases such as diabetes, hypertension, substance use, and HIV were common,” said Dr. Dams-O’Connor.
“The findings clearly indicate that we should be casting a much wider net when it comes to characterizing the neuropathology of partner violence-related brain injury and post-traumatic neurodegeneration.”
“The consequences for intimate partner violence are enormous both on an individual and societal level, and it’s more common than most people realize,” she added. “Our research suggests that it is a frequently unmeasured and under-recognized contributor to the brain health decline experienced by many survivors.”
The researchers advised any GP who encountered someone with a history of intimate partner violence to be aware that the individual may have a neurological injury that affected their brain health and function, with research consistently demonstrating that people living with brain injury may not be able to benefit from standard interventions that were not tailored to address their deficits.
They noted that such people may require difference accommodations, more reminders, and more support to benefit from available assistance.
“If someone with a brain injury misses an appointment, it may not be because they’re ungrateful for the help or they don’t care about the service being offered. If they lose their temper, it may be a manifestation of neurobehavioral dysregulation attributable to the traumatic brain injury,” Dr. Dams-O’Connor explained.
“If they remain in a violent relationship, it may be that they don’t have the cognitive and executive function skills, or resources, required to orchestrate a safe and successful path to safety – this is not something the survivor should be blamed for.
“The results of this case series represent an unprecedented advancement in the understanding of partner violence-related brain injury, and the investigators believe there is a message of hope in our findings.
“Vascular contributors to cognitive impairment and decline may be treatable in some cases, and given the high burden of vascular brain injury, together with the extensive disease comorbidity observed in this cohort, it is possible that some symptoms experienced by people living with partner violence-related brain injury may be treatable, or even preventable.”