Protecting Athlete's Brains from Repetitive Head Impacts: An Evidence-Based Perspective

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Background. Repetitive head impacts (RHI) are increasingly recognized as a significant source of cumulative brain injury in contact and collision sports. Despite often being subclinical, repeated concussive and subconcussive events are associated with microstructural brain damage, neuroinflammation, and long-term neurodegenerative processes, including chronic traumatic encephalopathy (CTE). Material and methods. This narrative literature review synthesized 52 studies from PubMed database. Inclusion criteria comprised studies published between 2011-2026, emphasizing systematic reviews and clinical trials. Aim. Summary of current evidence on the pathophysiology of RHI, evaluation of the role of biomarkers and neuroimaging, and discussion of evidence-based prevention strategies in athletes. Results. RHI induce cumulative neuronal and glial damage through biomechanical forces, particularly rotational acceleration, leading to axonal injury and white matter disruption detectable with advanced imaging techniques. Among biomarkers, neurofilament light chain shows the most consistent association with axonal damage, while tau-related markers remain less reliable for clinical use. Preventive strategies, including exposure reduction, rule modifications, and technique optimization, demonstrate effectiveness but vary in strength and consistency of evidence. Conclusions. RHI represent a complex and multifactorial clinical problem with significant long-term neurological implications. Although emerging diagnostic tools offer promising insights, their routine clinical utility is still constrained by methodological limitations and lack of standardization. A multidimensional prevention approach and further large-scale, longitudinal research integrating biomechanical, imaging, and biomarker data are essential to improve risk assessment and reduce the burden of RHI-related brain injury.