Between 10 and 20 per cent of professional boxers go on to develop a chronic traumatic encephalopathy,(63) the punch-drunk syndrome, with damage to the extrapyramidal system as well as cerebellar and pyramidal pathways. They are slow and ataxic. Cognitive impairment, in particular memory impairment, is a frequent accompaniment and dementia is present in about half of the cases.

Upper brainstem lesions may explain the neurological symptoms, while cerebral atrophy, white matter changes, and damage to diencephalic structures may account for cognitive changes. Perforation of the septum pellucidum, which separates the two lateral ventricles, is a characteristic finding in boxers' encephalopathy. APOE e4 status increases vulnerability to the punch-drunk syndrome,(64) and this is consistent with the finding that amyloid is present.

Professional footballers may show evidence of subtle impairments of thinking, raising the possibility that repeated blows to the head from heading the ball may be sufficient to cause slight brain injury.

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