How Is A Traumatic Brain Injury Diagnosed?

If you or a loved one has suffered a traumatic brain injury (TBI), understanding how it is diagnosed is important for both medical treatment and legal claims. A timely and correct diagnosis improves the chances of recovery and plays a key role in securing fair compensation for your injuries.  

Here are the steps involved in diagnosing a TBI and how they relate to your legal case.

Initial Assessment After a Brain Injury 

After an accident causing a potential TBI—whether it’s a car crash, slip and fall, or workplace incident, medical professionals will perform an initial evaluation to assess the severity of the injury. 

• History: Doctors ask about the cause of the injury, the events leading to it, and initial symptoms such as confusion, dizziness, or loss of consciousness.  It is important to know that you need not lose consciousness to have sustained a brain injury.  You may also be asked about what the last thing you remember before your accident and the first thing you remember after your accident.     
• Symptom Review: Medical professionals will ask about the signs and symptoms that are common following a traumatic brain injury including headaches, nausea, memory loss, sensitivity to sound or lights, and mood swings. These symptoms are critical for determining the extent of the injury. 
• Glasgow Coma Scale (GCS): This tool measures eye-opening, verbal response, and motor response to determine the immediate medical intervention you need in a hospital. The lower the GCS score, the more need for medical intervention including CT scans, MRI studies, neurology or neurosurgery consultations. 

Why is this legally important to your brain injury case? 

Accurate documentation of symptoms and severity can strengthen your claim and connect your injury to the accident and provide support for the diagnosis of concussion or brain injury.  A concussion is a brain injury. 

Neurological and Physical Exams 

Healthcare providers may conduct a neurological and physical examination to evaluate the brain's function and any physical damage to the head. 

• Physical Examination: An examination to look for signs of trauma like bruising, swelling, black and blue marks, or bleeding. 
• Neurological Testing: Assessment of balance, coordination, reflexes, and sensory responses. 

Why are brain injury attorneys interested in your initial physical and neurological examination?  

These exams provide essential medical evidence that details the injury’s immediate effects, which can serve as key proof of brain injury in personal injury claim. 

Brain Imaging Studies  

Imaging tests may identify structural damage to the brain. These tests provide information about skull fractures, bleeding and swelling within the brain and may also show damage to nerve fibers.   

• CT Scans (Computed Tomography): Often used in emergency settings to detect skull fractures, bleeding, or swelling. 
• MRI Scans (Magnetic Resonance Imaging): A more detailed computerized study which often can identify damage to nerve fibers, such as diffuse axonal injuries or brainstem damage. 

What is the legal significance of negative brain imaging findings:   

It is important to know that a normal skull x ray, CT scan, or MRI study does not mean a brain injury did not occur. These studies are often negative even when the brain is damaged.  If the study shows structural damage, your attorney can use this study to objectively show your injury, but often the studies are not sensitive enough to detect injury to microscopic brain fibers. Medical professionals have said, absence of proof, is not proof of absence.     

Cognitive and Psychological Assessments 

Cognitive impairments, such as memory loss, difficulty concentrating, or mood changes, are common in TBI cases. Neuropsychologists use specialized tests known as neuropsychological assessments to measure any impairments in how your brain is functioning. 

• Cognitive Testing: Evaluates memory, concentration, attention, processing speed, and problem-solving skills. 
• Emotional and Behavioral Testing: Identifies issues like depression, anxiety, or impulsivity, which are common after a TBI. 

How does a neuropsychological assessment help your brain injury attorney to establish your brain damage?  

These assessments document the long-term impact of the injury on your daily life, which is essential for calculating your pain and suffering, long term disability, earning damage and reduced quality of life in your lawsuit. 

Specialized Brain Injury Diagnostic Tools  

Here are additional diagnostic tools which may be used depending on a person’s medical condition: 

• Intracranial Pressure (ICP) Monitoring: Tracks swelling inside the skull often used if a patient is in a coma 
• EEG (Electroencephalogram): Measures electrical impulse within the brain if a seizure is suspected.  
• Blood Biomarkers: Tests that look for brain-specific proteins within blood plasma to determine if a patient sustained a concussion.  

Why is Ongoing Monitoring and Follow-Up Important following a brain injury? 

TBIs can evolve over time, with symptoms appearing days or weeks after the initial trauma. Follow-up visits help track changes, document new symptoms, and adjust treatment plans. 

Why is your brain injury attorney interested in reviewing your follow up medical records? 

Your attorney will want to review your medical progress records to show how your brain injury has progressed, which can prove the lasting effects on your quality of life. 

De Caro & Kaplen, LLP is a nationally recognized personal injury law firm with an emphasis on representing victims of brain trauma.  If you’ve suffered a traumatic brain injury due to someone else’s negligence, our experienced brain injury attorneys are here to help you understand your rights and build a strong case to secure the justice you deserve. 

De Caro & Kaplen, LLP is a Preferred Attorney Law Firm by The Brain Injury Association of America. 

Contact Us Today for a Free Consultation  Call us at  212 732 2262 or fill out our online form.

About The Author

Michael V. Kaplen represents victims of vehicle collisions, unsafe buildings and construction sites, and medical malpractice, and is a preferred attorney of The Brain Injury Association of America.

Michael is board certified as a Civil Trial Advocate and board certified in medical malpractice litigation. He is a Professorial Lecturer in Law, The George Washington University Law School, The Legal Aspects of Traumatic Brain Injury.

Michael is past chairman of the American Association for Justice (AAJ) Automobile, Highway and Premise Liability Section, past chairman of the AAJ Traumatic Brain Injury Litigation Group, three term president of the Brain Injury Association of New York State served two terms as chair of the New York State Traumatic Brain Injury Services Coordinating Council and vice-president, New York State Academy of Trial Lawyers.

He was invited by President Obama to participate in the White House Healthy Kids & Safe Sports Concussion Summit.

He is admitted to courts in New York, Florida, and Washington, DC. He has been selected as a New York Super Lawyer and recognized by Best Lawyers of America and U.S. News and World Report in personal injury law.