Traumatic brain injury (TBI) is a significant health issue, with ~2 million cases in Canada and the United States every year1,2. TBI affects all age groups and genders and has an incidence rate greater than any other disease, notably including breast cancer, AIDS, Parkinson's disease, and multiple sclerosis3. Despite the prevalence of TBI, its pathophysiology remains poorly understood, and treatment options are limited. In part, this is because 85% of all TBIs are classified as mild (mTBI), and mTBI has previously been thought to produce only limited and transient behavioral changes with no long-term neuropsychiatric consequences4,5. It is now recognized that mTBI recovery can take weeks to years5,6, precipitate more serious neurological conditions4, and that even repeated "sub-concussive" impacts affect the brain7. This is alarming as athletes in sports such as hockey/football have >10 head sub-concussive impacts per game/practice session7,8,9,10.
Adolescents have the highest incidence of mTBI, and in Canada, roughly one in 10 teens will seek medical care for a sport-related concussion annually11,12. In reality, any sub-concussive head impact or mTBI can cause diffuse damage to the brain, and this could also create a more vulnerable state for subsequent injuries and/or more serious neurological conditions13,14,15,16,17. In Canada, it is recognized legally via Rowan's law that prior injury can increase the vulnerability of the brain to further injury18, but mechanistic understanding of r-mTBI remains woefully inadequate. It is clear, however, that single and r-mTBI can impact learning capacity during school years19,20, have sex-specific outcomes21,22,23,24, and impair cognitive capacity later in life16,25,26. Indeed, cohort analyses strongly associate r-mTBI early in life with dementia later on27,28. r-mTBI is also potentially associated with chronic traumatic encephalopathy (CTE), which is characterized by the accumulation of hyperphosphorylated tau protein and progressive cortical atrophy and precipitated by significant inflammation27,29,30,31. Although the links between r-mTBI and CTE are currently controversial32, this model will allow them to be explored in greater detail in a preclinical setting.
An mTBI is often described as an "unseen injury," as it occurs within a closed skull and is difficult to detect even with modern imaging techniques33,34. An accurate experimental model of mTBI should adhere to two tenets. First, it should recapitulate the biomechanical forces normally observed in the clinical population35. Second, the model should induce heterogeneous behavioral outcomes, something that is also highly prevalent in clinical populations36,37,38. Currently, the majority of preclinical models tend to be more severe, involving craniotomy, stereotaxic head restraint, anesthesia, and controlled cortical impacts (CCI) that produce significant structural damage and more extensive behavioral deficits than normally observed clinically33. Another concern with many preclinical models of concussion that involve craniotomies is that this procedure itself creates inflammation in the brain, and this can exacerbate mTBI symptoms and neuropathology from any subsequent injury39,40. Anesthesia also introduces several complex confounds, including reducing inflammation41,42,43, modulating microglial function44, glutamate release45, Ca2+ entry through NMDA receptors46, intracranial pressure, and cerebral metabolism47. Anesthesia further introduces confounds by increasing blood-brain barrier (BBB) permeability, tau hyperphosphorylation, and corticosteroid levels, while reducing cognitive function48,49,50,51. Additionally, diffuse, closed-headed injuries represent the vast majority of clinical mTBIs52. They also allow one to better study the multitude of factors that can influence behavioral outcomes, including sex21, age53, inter-injury-interval15, severity54, and the number of injuries23.
The direction of the accelerative/decelerative forces (vertical or horizontal) is also an important consideration for behavioral and molecular outcomes. Research from Mychasiuk and colleagues have compared two models of diffuse closed-headed mTBI: weight-drop (vertical forces) and lateral impact (horizontal forces)55. Both the behavioral and molecular analyses revealed heterogeneous model- and sex-dependent outcomes following mTBI. Thus, animal models that help avoid surgical procedures, while incorporating linear and rotational forces, are more representative of the physiological conditions under which these injuries normally occur33,56. The ACHI model was created in response to this need, allowing for the rapid and reproducible induction of mTBI in rats while avoiding procedures (i.e., anesthesia) that are known to bias sex differences57.