Why TBI Documentation Is Uniquely Challenging
Traumatic brain injury — particularly mild TBI (concussion) and post-concussion syndrome — presents a documentation challenge unlike any other personal injury condition. The symptoms of TBI are often primarily subjective: headaches, cognitive fog, memory problems, sleep disturbance, mood changes, light and sound sensitivity. Standard MRI, which can clearly demonstrate disc herniation and rotator cuff tears, is frequently normal in mild to moderate TBI cases.
This creates a dangerous documentation gap. Defense IME physicians exploit normal MRI findings to argue that TBI is not present or not significant. Without objective neuropsychological testing and careful clinical documentation, even a genuinely disabling TBI can be minimized in litigation.
The MAIC TBI Evaluation Protocol
At MAIC, TBI evaluation begins with a comprehensive neurological examination by a board-certified neurologist, including cranial nerve testing, cognitive screening using validated instruments (MoCA, MMSE, Trail Making Test), balance and coordination assessment, and a structured symptom inventory. The neurologist's report documents the pattern of symptoms, their onset and progression, and their correlation with the reported mechanism of head impact.
Where indicated, formal neuropsychological testing is ordered to provide quantitative assessment of memory, attention, processing speed, and executive function — the cognitive domains most frequently affected by TBI. These test results provide objective data that is far more resistant to defense challenge than symptom reports alone.
Imaging in TBI Cases
While standard MRI is frequently normal in mild TBI, advanced imaging techniques can demonstrate TBI-related pathology that standard sequences miss. MAIC's 3T MRI — with its superior resolution compared to 1.5T — can identify subtle findings including microhemorrhages, white matter changes, and diffuse axonal injury patterns that support the TBI diagnosis.
For more severe TBI cases, advanced MRI sequences including diffusion tensor imaging (DTI) and susceptibility-weighted imaging (SWI) may be indicated to demonstrate axonal injury and microbleeds, respectively. MAIC's radiology team can coordinate these advanced sequences when clinically indicated.
Building the Complete TBI Case
A defensible TBI claim requires neurological evaluation, cognitive testing, advanced imaging where indicated, functional impact documentation from physical therapy and occupational therapy, and — for cases involving significant functional impairment — vocational rehabilitation assessment. MAIC coordinates all of these elements within our 60,000 sq ft Bronx facility. To refer a TBI patient, call (888) 991-5290.