Damage to women’s brains as a result of intimate partner violence takes a different form to that sustained by men as a result of sports-related head traumas, the largest autopsy study of its kind has revealed.
The study shows substantial medical comorbidity, including cardiovascular and cerebrovascular disease, suggesting a 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.
But importantly, it finds that the impact of repeated head traumas sustained through domestic violence manifest differently to the chronic traumatic encephalopathy (CTE) frequently seen in male sports players. The study found no evidence of CTE in these women.
Despite how common intimate partner violence is—it affects one in three women at some point in their lives—remarkably little is known about the neuropathology of partner violence.
The long-term consequences of traumatic brain injury include the risk of neurodegenerative disease, and there is an assumption that repeated head injuries sustained in the context of intimate partner violence are 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,” said Dr Kristen Dams-O’Connor, director of the Brain Injury Research Center of Mount Sinai and lead author of the paper.
“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.”
The clinical research team invited families of deceased women to participate in an interview so the team could learn more about the deceased’s health, brain trauma history, and any symptoms of clinical decline the relatives may have observed during life.
The postmortem protocol of the LETBI study includes ex vivo imaging, in which the whole brain specimen is scanned at high resolution. This allows 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.
For the prospective case series, 14 brains were obtained over two years from women with documented intimate partner violence (ages 20s-late 70s; median, 30s) and complex histories, including prior traumatic brain injury; nonfatal strangulation; cerebrovascular, neurological, and/or psychiatric conditions; and epilepsy.
At autopsy, all had old and/or recent traumatic brain injury stigmata (physical marks seen in the brain that are characteristic of the condition).
Substantial vascular and white matter pathology was seen in some. 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 hemorrhage) 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.
Findings from the initial prospective case series prompted similar exploration of an expanded case series of 70 archival intimate partner violence cases (ages late teen to late 80s; median 30s) 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 characterising 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 realise.
“Our research suggests that it is a frequently unmeasured and under-recognised contributor to the brain health decline experienced by many survivors.”
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