Analytical Monitoring of Brain Metabolism: Not a Research Tool for Elite Academy but an Essential Issue for Return to Play Following Concussion

Sports contexts are accountable for up to one-third of all TBIs, the majority of which are concussive sports-related brain injuries. Post-concussion symptoms recover spontaneously within days to weeks but may also last for a much longer time. At the time of impact, the mechanical forces transmitted to the brain initiate a complex series of chained biochemical pathways, modifying proteins and gene expressions, mitochondrial functions, energy metabolism, and oxidative/nitrosative stress. During a scarcely predictable post-trauma period, brain cells must be defined as biochemically, metabolically, and genetically vulnerable. This “window of vulnerability” might last longer than symptom clearance, and it is probably involved in the occurrence of both fatal and non-fatal second impact syndrome (SIS). Proton magnetic resonance spectroscopy (1H-MRS) can monitor brain biochemistry by identifying and quantifying various metabolites connected to nervous cell energetics. Growing clinical evidence, from either 1H-MRS or other advanced neuroimaging techniques, has clearly established that metabolic and ultrastructural concussion-mediated brain alteration persists beyond clinical and neuropsychological clearance. Data from these examinations represent a significant step toward objectively quantifying brain disturbances in post-concussed patients. SIS aside, the combination of longitudinal 1H-MRS information with macro- and micro-structural data from advanced, dedicated neuroimaging can be crucial to minimize the risk that recurrent injuries (causing cumulative biochemical network impairment) may develop into chronic traumatic encephalopathy. These high-tech tools should not be considered just for sophisticated, research-related aims, but as valid, complementary, decisive diagnostic and, above all, prognostic instruments for a safer return of athletes to play.