Can diffusion tensor imaging (DTI) detect brain changes after a concussion when a standard MRI or CT scan is normal? In this episode of Life After Impact, I sit down with board-certified neurologist Dr. Rebecca Romero to explore how DTI is moving from the world of concussion and traumatic brain injury research into clinical practice.
Dr. Romero explains how DTI brain imaging can evaluate microscopic changes in the brain's white matter pathways following mild traumatic brain injury (mTBI), including changes that may not be visible on conventional MRI. We discuss fractional anisotropy, white matter tract integrity, susceptibility-weighted imaging (SWI), hemosiderin deposition, and brain-volume measurements—and why DTI must still be interpreted alongside the patient's symptoms, history, neurological examination, and other objective testing rather than used as a stand-alone concussion test.
But DTI is only one part of this conversation.
What particularly impressed me about Dr. Romero's approach is how comprehensive and integrative her concussion evaluations are.
Rather than relying on a single scan or a brief neurological examination, her clinical network begins gathering objective information before the patient even sits down with her. This can include symptom questionnaires, eye-movement testing, balance and postural stability assessment, EEG/event-related potentials, and cognitive screening. Dr. Romero then spends considerable time reviewing the patient's history, symptoms, test results, and neurological findings to begin putting the pieces together.
We discuss why this matters when someone has been told:
“Your MRI was normal.”
Standard CT and MRI scans are often normal after concussion because they were designed primarily to identify larger structural abnormalities—not necessarily the microscopic changes associated with mild traumatic brain injury.
DTI provides another way of looking at the brain by examining the diffusion of water through white matter tracts—the communication highways connecting different regions of the brain. Dr. Romero explains how abnormalities in measures such as fractional anisotropy can contribute additional objective information when interpreted within the larger clinical picture.
Importantly, she also explains why DTI isn't appropriate for everyone. Age, previous concussions, hypertension, diabetes, and other medical conditions can complicate interpretation and potentially contribute to false-positive findings. This is not simply a scan that should be ordered for every person who experiences a concussion.
Our conversation then expands well beyond imaging.
We explore post-concussion brain fog, cognitive impairment, headaches, dizziness and autonomic dysfunction, neuroinflammation, sleep problems, medication-overuse headaches, exercise, nutrition, and women's hormones during perimenopause and menopause.
Dr. Romero also explains how rehabilitation is incorporated into her model of care, including oculomotor and balance rehabilitation and emerging cognitive-motor approaches based on the specific deficits identified during testing.
In this episode, we discuss:
- What diffusion tensor imaging (DTI) is
- How DTI differs from a conventional MRI
- Why CT and MRI scans are often normal after concussion
- White matter tracts and fractional anisotropy
- Microscopic changes associated with mild traumatic brain injury
- Susceptibility-weighted imaging and hemosiderin deposition
- When DTI may—and may not—be appropriate
- EEG/event-related potentials and the P300 response
- Eye-movement and balance testing after concussion
- Cognitive testing and executive-function problems
- Autonomic dysfunction, dizziness, and orthostatic symptoms
- Post-traumatic headaches and medication-overuse headache
- Neuroinflammation after traumatic brain injury
- Sleep and concussion recovery
- Perimenopause, hormones, and female concussion recovery
- The importance of coordinated, comprehensive concussion care
One of the most important messages from this episode is that better concussion diagnosis isn't necessarily about finding one perfect test.
It's about combining emerging technologies such as DTI with a careful history, neurological examination, objective functional testing, and thoughtful clinical reasoning to create a more complete picture of what happened to the brain—and what that individual patient may need next.
Dr. Romero & ProCare: Website
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