Diagnosing brain injury in absence of a continuing loss of consciousness, is a matter of triangulating behavioral observations, scientific test results and objective measuring tools for the change in function correlated with brain injury. The most important piece of the diagnostic puzzle is the clinical judgment of a doctor experienced with brain injured people. In today’s world, medical science has a severe prejudice in terms of basing a diagnosis on imaging studies, to the exclusion of all other things. But most non-coma brain damage is microscopic and ruling out a brain injury based primarily on absence of abnormal imaging, is wrong. Yet far too often, even though physicians will admit that in theory a negative scan doesn’t mean no brain injury, they will base their diagnostic judgments upon that alone.
Yet, as many as 50% of those in coma have normal CT scans. MRI’s, while they are getting better, still have significant false negatives even with comatose patients. Neuropsychological tests results can provide a major portion of the diagnostic process, but again, if only the tests themselves are read in a vacuum, wrong conclusions are virtually guaranteed. Only if all testing, imaging, neuropsychological, EEG results are interpreted with a clear understanding that someone can have a significant brain injury without clear cut evidence on any one of these tests, can a reliable rule out diagnosis be made.
The most troubling area of brain damage to diagnose relates to frontal lobe deficits. The reason is that these deficits manifest themselves in real world behavioral changes, not abnormal neuropsychological tests. While numerous neuropsychological test instruments address certain frontal lobe issues, such instruments only measure particular aspects of frontal lobe function, not the synergistic interplay of the various deficits. One of the most significant frontal lobe deficits -deficits in terms of initiating activity – is virtually unmeasurable thru neuropsychological testing, because it is the test administrator who directs activity. Only thru a detailed evaluation of the pattern of activity (or lack thereof) in the real world, can an assessment of this most disabling of symptoms be assessed.
Brain injury symptomotology scans all types of cognitive, emotional and behavioral aspects. Anything that can go wrong with the human body can start in the brain. Yet, traumatic injury will follow certain patterns. If the change in function, particularly function in the real world, fits those patterns, then the diagnosis needs to be made, and treatment and adaptive strategies implemented. No test or MRI can substitute for the subjective judgments of someone who has worked with brain injured survivors for years.
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