Diffusion Tensor Imaging (DTI)

  • Diffusion Tensor Imaging (DTI) allows direct in vivo examination of the brain microstructure, white matter tracts, and diffuse axonal injury after suspected Traumatic Brain Injury.
  • DTI is superior to CT and MRI for characterizing Traumatic Brain Injury.  With mild to moderate TBI, CTs and MRIs of the brain will often be reported as “negative/normal.”  This does not necessarily mean that TBI has not occurred. This is where DTI plays an important role.
  • We will arrange for a DTI scan to be performed at a local TBI Imaging Associates-affiliated neuro-imaging facility.
  • The study will then be interpreted by TBI Imaging Associates’ own specialist Neuroradiologist, who is amongst the nation’s leaders in TBI imaging and DTI expert witness work.
  • A detailed report will be issued, either refuting or confirming Traumatic Brain Injury, and characterizing the areas of the brain that are affected.
  • Turnaround time:  Within 4 weeks of receiving referral. Please refer here.

The use of DTI for Traumatic Brain Injury – A Review of the Evidence

The evidence for the use of DTI to support, quantify, localize, target neurorebilitation for, and render a prognosis for TBI has mounted over time, and is now widely accepted both in medical and legal arenas. Please contact us for detailed source references.

Click + below to expand.

Legal References

National Law Review - "Another Win for Diffusion Tensor Imaging (DTI)" Peach v. RLI Insurance Company, No. 17-2-16348-1 SEA


1. “This Court finds that the science and methodology underlined in diffusion tensor imaging (DTI) is well accepted in the medical and scientific community”
2. “The Court further finds any difference of opinion among the experts, with regards to the application of DTI or ASL to determine whether a patient has mild traumatic brain injury (mTBI), is a matter of weight rather than admissibility;”

Traumatic Brain Injury Law Blog - "Federal Court Upholds the Admissibility of Diffusion Tensor Imaging in TBI Case" Marsch v Celebrity Cruises, Inc., Case No. 1(17-CV-21097-UU)


1. “The United States District Court for the Southern District of Florida has ruled that diffusion tensor imaging (DTI) satisfies the Daubert standard for admissibility.”
2. “…court rejected Celebrity’s argument, finding that DTI findings and testimony has been deemed reliable and admitted by numerous courts across the country for almost a decade.”

National Law Review - "New York Court Upholds Validity of DTI" Siracusa v. City Ice Pavilion, 2017 NY Slip Op 27254


1. “…the court had found that DTI was acceptable as a reliable means of diagnosing traumatic brain injury and accepted in the medical community.”

National Law Review - "Connecticut Court Upholds Admissibility of Diffusion Tensor Imaging" Vizzo v. Fairfield Bedfort, FST-CV12-6015703-S


1. “…while plaintiff did have preexisting medical conditions, the location of the abnormality on DTI was more consistent with traumatic brain injury (TBI) than plaintiff’s preexisting medical conditions.”
2. “The court rejected the defendants’ argument that diffusion tensor imaging should be barred in this case, finding that the grounds for defendants’ motion went more to the weight of the evidence rather than admissibility of it. The court denied defendants’ motion.”

National Law Review - "Federal Trial Court Once Again Upholds Introduction of Diffusion Tensor Imagining into Evidence" White v. Deere and Co., et al, Civil Case No. 13-cv-02173


1. “A federal judge has once again upheld the introduction of diffusion tensor imagining (DTI) in an mTBI case, rejecting defendant’s motion to exclude the DTI findings.”
2. “The trial court noted, one of the papers submitted was a peer-reviewed article that reviewed the last decade of research conducted on DTI, which found ‘a unifying theme can be deduced from this large body of research; DTI is an extremely useful and robust tool for the detection of TBI-related brain abnormalities. The overwhelming consensus of these studies is that low white matter FA is characteristic of TBI.'”

National Law Review - "Federal Court in Louisiana Admits DTI into Evidence" Andrew v Patterson Motor Freight, Inc., Civil Action No. 6:13CV814


1. “Plaintiff retained Dr. Eduardo Gonzalez-Toledo who administered Diffusion Tensor Imaging, which according to Dr. Gonzalez-Toledo demonstrated evidence of traumatic brain injury pathology”
2. “…the Court finds plaintiff has submitted sufficient evidence to show the reliability of DTI. In sum, the evidence submitted shows DTI has been tested and has a low error rate; DTI has been subject to peer review and publication; and DTI is a generally accepted method for detecting TBI. Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 593-94. The Court additionally notes DTI testimony has been admitted by several courts. See e.g. Ruppel v. Kucanin, 2011 WL 2470621 (N.D.Ind.); Hammar v. Sentinel Ins. Co., Ltd., No. 08-019984 (Fla.Cir.Ct.2010);Booth v. Kit, 2009 WL 4544743 (D.N.M.). Accordingly, the Court denies defendants’ motion to the extent it seeks to exclude evidence and testimony regarding DTI”

Written Testimony of Dr. Randall Benson before the House Judiciary Committee


1. “I would like share with you some observations from eight years of evaluating traumatic brain injury cases, the vast majority of which I obtain neuropsychological testing and advanced MR imaging: 1) people with TBI are frequently misdiagnosed, often by multiple physicians; 2) the most frequent diagnostic category given is psychiatric—anxiety, depression, conversion disorder; 3) two neuropsychologists studying the same patient may differ considerably regarding existence of TBI; 4) TBI symptoms overlap considerably with those of “primary” psychiatric disorders; 5) without the ability to “see” the brain injury with imaging, there is no completely objective way to determine what is TBI and what is something else, e.g., post-traumatic stress, conversion, malingering; 6) people with brain injury seem to vary considerably in severity of symptoms and recovery in the face of similar falls, crashes, etc.”
2. “In summary, DTI is able to “visualize” diffuse axonal injury from TBI. In some cases location of lesions appears to correlate with specific symptoms but generally the severity of DAI as indicated by DTI is strongly predictive of general neurocognitive disability.

Medical Journal Articles, Papers, and Textbook References

Brain Injury - "Mild traumatic brain injury in the United States: demographics, brain imaging procedures, health-care utilization and costs"


1. “Mild TBI…is estimated to account for at least 75% of all TBI cases in the USA, and is a significant public health concern due to its association with long-term cognitive delcine and neurodegenerative disorders.”
2. “Although TBI may be accompanied by apparent and indisputable signs such as momentary loss of consciousness or memory loss, symptoms of mTBI tend to be more subtle and less likely to be reported by patients with limited symptomatology.”
3. “The most common locations for mTBI diagnosis were in a non-ED outpatient/physician office setting only (39%)…”

Excerpt from textbook entitled Concussion and Traumatic Encephalopathy


“Numerous MR techniques currently identify trauma-related neuropathology, with potential candidate biomarkers of CBI listed in Table 6.1. The MRI method known as diffusion tensor imaging (DTI) has become the most frequently employed MRI metric in CBI research. DTI is an established neuroimaging procedure used diagnostically…”

American Journal of Neuroradiology - "Imaging Evidence and Recommendations for Traumatic Brain Injury: Advanced Neuro- and Neurovascular Imaging Techniques"


1. “The incidence of TBI, especially mild TBI, is understimated because patients frequently dismiss their symptoms and never present to the emergency department or they believe that the admisson of symptoms may compromise their work situation.”
2. “Currently, there is evidence from group analyses that DTI can identify TBI-associated changes in the brain across a range of injury severity, from mild to severe TBI.”

American Journal of Bioethics Neuroscience - "Daubert, Frye and DTI: Hijacking the Right to Trail by Jury"


1. “Diffusion tensor imaging (DTI) has evolved into the best diagnostic imaging modality used to detect and prove evidence in the brain in the event of a traumatic brain injury (TBI) or mild traumatic brain injury (mTBI) in individuals.”
2. “DTI is the first objective eveidence that a jury can and should consider if appropriate accompanying evidence and expert testimony support such evidence.”

American Academy of Neurology - "White matter correlates of cognitive dysfunction after mild traumatic brain injury"


1. “Conclusions: Acute mild/moderate traumatic brain injury is characterized by increased tissue FA, which represents a clear neurobiological link between cognitive dysfunction and white matter injury after mild/moderate injury”
2. “Our study in a large cohort of patients with mild and moderate TBI has shown extensive increases in MD but these were accompanied by increased FA at the acute time point. These changes were strongly correlated with underperformance on cognitive testing and show a clear neurobiological basis for dysfunction postinjury.”

American Journal of Bioethics Neuroscience - "Clarifying the Robust Foundation for and Appropriate Use of DTI in mTBI Patients"


1. “The misleading and often entirely unsubstantiated opinions and positions ofWortzel, Tsiouris, and Filippi (2014), in opposition to diffusion tensor imaging (DTI) as a useful measure in mTBI, are at odds with the clear consensus of the scientific literature regarding mild traumatic brain injury (mTBI), its clinical assessment, and its natural history.”
2. “…the overwhelming consensus of a substantial body of scientific inquiry supports DTI for detecting pathology in mTBI patients.

American Journal of Neuroradiology - "Decreased Fractional Anisotropy Evaluated Using Tract-Based Spatial Statistics and Correlated with Cognitive Dysfunction in Patients with Mild Traumatic Brain Injury in the Chronic Stage"


“DTI is sensitive to the diffusion characteristics of water (such as the principal diffusion direction and diffusion anisotropy)
and has been developed as a tool to investigate the integrity of brain tissues such as white matter tracts8 and to uncover discrete axonal injury”

Journal of Neurology, Neurosurgery & Psychiatry - "Diffusion tensor imaging studies of mild traumatic brain injury: a meta-analysis"


1. “Mild traumatic brain injury is one of the most controversial neurologic injuries, as there is no obvious biological marker. Diffusion tensor imaging has been considered as a potential biomarker in mTBI patient with other normal neuro-imaging, as it can detect white matter micro-structure changes.”
2. “The results provide strong evidence that DTI can detect microstructureal damage in the white matter of mTBI patients…”

Neuropsychology Review - "MR Diffusion Tensor Imaging: A Window into White Matter Integrity of the Working Brain"


1. “DTI permits the interrogation of the brain’s microstructure, allowing for a more refined characterization of white matter and the complex network of nerve fibers connecting different brain areas.”
2. “Whereas conventional MRI has failed to correctly estimate the extent of damage following head injury, DTI provided information regarding injury severity as well as markers predictive of outcome and may therefore serve as a potential biomarker of recovery (Mayer et al. 2010).”
3. “In a recent study, whole-brain analysis of head injury survivors at least 6 months after the injury revealed significant bilateral decreases in anisotropy in the major of white matter bundles evaluated and increases in diffusivity in most of the cortex, likely reflecting secondary damage. In the same cohort, impairment of learning and memory correlated with diffusivity in the left posterior cingulate, left hippocampal formation, and left temporal, frontal, and occipital cortices (Salmond et al. 2006).
4. “Even in children, DTI has proved sensitive to white matter injury at 3 months following moderate to severe head injury, even in brain regions appearing normal on conventional MRI. Thus, DTI measures, especially those derived from fiber tracking analysis, can be good markers of outcome as they were related, in the same patients, to global outcome and cognitive processing speed (Levin et al. 2008).”

Neurotherapeutics - "Diffusion Tensor Imaging of the Brain"


“…the applications of DTI are rapidly increasing because the technique is highly sensitive to changes at the cellular and microstructural level.”

Journal of Neuroscience - "Diffusion Tensor Imaging Reliably Detects Experimental Traumatic Axonal Injury and Indicates Approximate Time of Injury"


1. “At every time point, DTI was more sensitive to injury than conventional magnetic resonance imaging, and relative anisotropy distinguished injured from control mice with no overlap between groups. Remarkably, DTI changes strongly predicted the approximate time since trauma. These results provide an important validation of DTI for pericontusional TAI and suggest novel clinical and forensic applications.”
2. “In summary, we have demonstrated that DTI is capable of detecting pericontusional white matter injury in a mouse model of TBI at a range of acute to subacute time points. DTI appears more sensitive than conventional MRI for this purpose at all of the time points studied. Furthermore, DTI offers information on the timing of injury such that subacute injuries (7 d to 1 month old) can be differentiated from acute injuries (4 d old) with a high degree of accuracy at the level of the individual scan.”
3. “…DTI has tremendous potential as a clinical tool in the assessment of TBI”

Journal of Neurology, Neurosurgery, and Psychiatry - "Evidence for white matter disruption in traumatic brain injury without macroscopic lesions"


1. “Conclusions: Disruption of the corpus callosum and fornix in patients with nmTBI without macroscopically detectable lesions is shown. DTI is sensitive enough to detect abnormal neural fibres related to cognitive dysfunction after nmTBI.”
2. “Our results suggest that DTI was able to objectively show abnormalities in patients with nmTBI with cognitive impairments but without macroscopically detectable lesions.”

Americal Journal of Neuroradiology - "Diffusion Tensor Imaging as Potential Biomarker of White Matter Injury in Diffuse Axonal Injury"


1. “CONCLUSION: DTI reveals changes in the white matter that are correlated with both acute GCS and Rankin scores at discharge. DTI may be a valuable biomarker for the severity of tissue injury and a predictor for outcome.’
2. “Our data demonstrate that DTI is feasible in the setting of TBI…”

Out-of-Town Patients

  • We offer multiple options for clients/patients who do not reside within driving distance of one of our affiliated imaging facilities:
  1. New ad hoc local affiliate – Once we receive a referral and are made aware of where the patient resides, in most cases, we can establish a relationship with a local neuro-imaging facility in a short period of time.
  2. Travel to our imaging facility in Dallas, TX – We welcome out-of-town patients to drive/fly to Dallas to obtain their DTI scan, and we facilitate the logistics for this.
  3. Turnaround time:  Typically within 6 weeks of receiving a referral. Please refer here.

Depositions and Trial Services

  • The Neuroradiologist we work with is a TBI imaging specialist and a highly sought-after DTI expert witness.  He is available for depositions and trial services on a case-by-case basis.