1

Summary

Neuroimaging is not recommended as part of a routine evaluation for all service members following mTBI. A physical 

exam, individual history and provider judgment should be combined to develop the best evaluation and treatment plan 

for each individual. Neuroimaging is recommended for the evaluation of service members with clinical red flags (Table 

1.0, page 2), new onset or persistent or worsening symptoms, and individuals whose recovery is not progressing as 

anticipated. The specific recommendations described here for those individuals with acute, sub-acute and chronic 

mTBI. The clinical diagnosis of mTBI is based on a history of a traumatic injury in the context of a change in alteration 

in consciousness. Neuroimaging findings are not typically included in the diagnosis of mTBI. Current literature reports 

that 10-15% of individuals who sustain trauma, are alert and have grossly normal neurological function including a 

Glasgow Coma Scale score of 15 will have an acute brain lesion on CT, while fewer than 1% will have a lesion that 

requires neurosurgical intervention.7

 The lack of positive imaging findings does not invalidate a diagnosis of mTBI; 

nor do symptoms reported. In addition, the lack of neuroimaging findings should not deter the need for specialty 

referral should this be clinically indicated. Standardized recommendations of testing parameters can aid care across 

the MHS by creating the capability to compare similar studies regardless of their origin as well as decrease repeated 

neuroimaging when not indicated.

More than 273,000 service members have sustained a 

traumatic brain injury (TBI) between 2000 and the first 

quarter of 2013.1

 The majority of these (approximately 

85%) occurred in the non-deployed environment and 

82.4% were classified as mild TBI (mTBI), also known as 

concussion.1,2 Neuroimaging following mTBI has been 

addressed in the deployed setting by the Joint Theater 

Trauma Systems (JTTS) Clinical Practice Guideline, “Use 

of Magnetic Resonance Imaging in the Management 

of Mild Traumatic Brain Injury (mTBI) Concussion in 

the Deployed Setting”, the “Department of Defense 

Guidance for Management of Mild traumatic Brain 

Injury/ Concussion in the Deployed Setting” (Department 

of Defense Instruction DoDI 6490.11) as well as the 

“Concussion Management Algorithms” (CMA).3,4,5 The 

Veterans Affairs and Department of Defense clinical 

practice guideline, “Management of Concussion/ 

mTBI” provides guidance for imaging after seven days, 

(the acute stage).6

 This clinical recommendation (CR), 

“Neuroimaging following mTBI in the Non-Deployed 

Setting” and companion clinical support tool (CST) offer 

guidance for Military Health System (MHS) providers as 

a standard approach for imaging from the acute through 

chronic stages following mTBI. Additionally, an appendix 

(Appendix A) containing expert recommended minimum 

technical parameters and sequencing is provided 

to promote standardization amongst the radiology 

community.

The guidance contained in this CR represents a review 

of currently published literature and expert contributions 

obtained by the Defense Centers of Excellence for 

Psychological Health and Traumatic Brain Injury (DCoE) 

in collaboration with clinical subject matter experts 

representing the Services, Department of Veterans 

Affairs (VA), academic, research and civilian sectors. The 

TBI Quad Service group, an inter-agency, multi Service 

collaborative effort organized by TBI subject matter 

experts, which includes representatives from the Army, 

Navy, Marine Corps, Air Force, Defense and Veterans 

Brain Injury Center (DVBIC), Army Medical Research and 

Material Command (MRMC), Joint Trauma Analysis and 

Prevention of Injury in Combat program(JTAPIC), National 

Intrepid Center of Excellence, U.S. Central Command, 

Force Health Protection and Readiness, the United States 

Coast Guard and the Department of Veterans Affairs 

(VA) have reviewed this recommendation. Current clinical 

imaging modalities included in this recommendation 

are: computed tomography (CT), magnetic resonance 

imaging (MRI), positron emission tomography (PET) and 

single photon emission computed tomography (SPECT). 

The individual’s history of concussion, clinical expertise, 

provider judgment and operational requirements may 

supersede any recommendation for each individual case, 

as service member safety is always paramount.

Neuroimaging following 

Mild Traumatic Brain Injury 

in the Non-Deployed Setting

 DCoE Clinical Recommendation | July 2013

Introduction and Background
2

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting

Clinical Recommendation

General Considerations

Red Flags

Current guidance of DODI 6490.11 and the CMA for management of concussion in deployed setting includes careful 

examination for red flags (clinical symptoms or signs that may indicate more severe injury).4,5 Neuroimaging is important 

in the evaluation of service members with clinical red flags and can be completed with CT or MRI (see Table 4.0) if 

available and not contraindicated. Clinical Red Flags are reflected in Table 1.0 and combine the provider red flags 

indicated in the CMA and the recommended CT indications from the New Orleans Criteria.5, 8

Common mTBI Pathophysiology

The purpose or goal of neuroimaging determines the modality and techniques employed. There is increasing evidence 

that specific MRI imaging techniques correspond, at least in a general way, with specific posttraumatic histopathology. 

For example, diffusion tensor imaging (DTI) abnormalities are thought to correspond to axonal injury and susceptibility 

weighted imaging (SWI) abnormalities to microhemorrhages.9

 Table 2.0 provides information on the specific mTBI 

pathophysiology that may be identified for each imaging technique.

Table 1.0 RED FLAGS

(CMA and New Orleans Criteria for CT Scan5, 8)

Table 2.0 Relationship Between Neuroimaging Techniques 

and Common mTBI Pathophysiology

Progressive declining level 

of consciousness (LOC)

Progressive declining, 

neurological exam

Focal neurological deficit: 

motor or sensory, slurred 

speech

Cannot recognize people 

or disoriented to place

Pupillary asymmetry GCS < 15 Double vision LOC > 5 minutes 

Seizures Worsening headache Visible physical injury 

above clavicle

Repeated vomiting

Drug or Alcohol 

intoxication

Coagulopathy Unusual behavior Age > 60

mTBI Pathophysiology MRI imaging Technique

Axonal Injury/White matter injury Fluid Attenuated Inversion Recovery (FLAIR)

Diffusion Weighted Imaging (DWI)

2D/3D T2

Traumatic Sub-Arachnoid Hemorrhage (tSAH) FLAIR

3D T1 weighted imaging

Susceptibility Weighted Imaging (SWI)/Gradient Echo (GRE)

Cortical contusions / microhemorrhages FLAIR

3D T1-weighted imaging

SWI/GRE

Vascular injury SWI/GRE

Volume loss 3D T1-weighted imaging
3

Neuroimaging in the Service Member who sustains mTBI: 

Acute, Sub-acute and Chronic Stages

Acute Stage

The acute stage is defined as time of injury to seven days.6 Most patients who sustain an mTBI complain of common 

symptoms such as headache or dizziness. In the absence of red flags or CT criteria (Table 1.0, page 2), no imaging 

is recommended. The goal of imaging in the acute stage of mTBI is to identify surgical masses or lesions in a service 

member with signs or symptoms of significant injury, such as the previously listed clinical red flags.10, 11, 12 CT scan is 

the recommended acute imaging modality for persons with head injury and suspected intracranial pathology. CT is 

readily available, highly sensitive and is the least expensive test for the rapid detection of intracranial injury requiring 

urgent neurosurgical intervention and a standard imaging study in acute trauma protocols. CT does not include the 

risk of MRI with ferromagnetic materials such as in fragments which can be common in improvised explosive devices. 

Imaging studies for the individual with acute mTBI should be obtained within 48 hours.13 CT exam is the recommended 

standard to determine trauma and/or focal neurological changes in the acute time period.14 If clinically indicated, a CT 

exam is the first line for imaging in the acute stage. If symptoms are improving no imaging is recommended.

If new onset, persistent or worsening symptoms are observed, providers may consider obtaining an MRI after 72 hours 

when available and not contraindicated. An MRI should be considered in the acute stage if the service member:3

1. Sustained a concussion with alteration of consciousness (AOC) to include any 

memory loss greater than 15 minutes and has persisting or worsening symptoms after 72 hours. 

2. Sustained concussion with loss of consciousness (LOC) <30 minutes and has 

persisting or worsening symptoms after 72 hours despite a normal CT.

3. Sustained three or more concussions in past 12 months.

4. Has a documented diagnosis of concussion and has a Military Acute 

Concussion Evaluation (MACE) Cognitive Score <25 after 72 hours post-injury.

In cases of contraindications, the primary care provider (PCP) may consider consult with specialists in nuclear 

medicine, radiology or neurology. It is recommended that PCPs consult a specialist if the clinical presentation is 

unusual or if their level of clinical experience or confidence may require additional expertise. Cervical spine (c-spine) 

imaging is recommended if there is point tenderness, pain with flexion or extension, focal neurological findings or 

mechanism of injury that is likely to affect the cervical spine (e.g., fall greater than three feet, motor vehicle crash, etc.). 

MRI studies can reveal incidental findings unrelated to patient-reported symptoms that may require unnecessary 

follow-up on irrelevant artifacts. 

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting

Sub-acute Stage

The sub-acute stage of mTBI is defined as 8 days to 89 days post-injury.6 In the absence of red flags, new, persistent 

or worsening symptoms or if symptoms are improving, no imaging is recommended. The goal of imaging in the subacute stage of mTBI is to evaluate the service member, enhance understanding of symptoms, provide education 

and identify the need for specialist referral. Treatment of mTBI in the sub-acute stage includes addressing symptoms 

obtained by history. An accurate history aids in standardization and results in providing recommendations in the subacute stage as well as reducing unnecessary imaging in the mTBI population. The key pieces of information for the 

PCP to collect to better understand the service member’s injury are reflected in Table 3.0.
4

In the sub-acute stage of mTBI, there is a need to consider two possible presentations: those persons who have not 

received a previous imaging assessment and those who have received an imaging assessment and are currently 

receiving follow-up care. For both presentations, however, MRI is recommended as the imaging modality of choice in 

the sub-acute stage of mTBI.10, 15, 16, 17 In a service member who has persistent or worsening symptoms, MRI may be 

50% more sensitive than CT alone in detecting chronic lesions in white matter.18 Additional considerations in sub-acute 

stage of mTBI as reflected in Table 4.0 in the sub-acute column include:

• In cases where the PCP refers to a specialist, it is recommended that a detailed individual history include history of 

injury and course of mTBI including past imaging studies and treatments.

• If MRI is unavailable or contraindications are present, CT is the modality of choice.

• Preferred MRI sequences are listed in Table 4.0; Appendix A

• MRI should be completed prior to referral to a specialist.

• If there are no structural abnormalities identified on MRI or CT and/or abnormalities do not explain persistent 

symptoms, PET Hexamethylpropyleneamine Oxime (HMPAO) or Ethylcysteinate Dimer (ECD) SPECT may offer 

additional information in the understanding of sequelae following mTBI.19, 20

• If an individual has normal c-spine results during the acute stage, repetition of c-spine imaging is not 

recommended.

Key Consideration Example

Trajectory of symptoms Is the individual seeing improvement or worsening of 

symptoms?

Functional impact on patient. Consideration of the 

societal, occupational and familial function impacts on 

patient

Does the service member have the ability to rest or 

is there a requirement to return to normal activities 

immediately?

Service member’s history of concussions Has the service member experienced more than one 

concussion? If so, how many and over what period of 

time?

Service member’s history of examinations and 

assessments

How many visits to medical care has the service 

member had since time of injury?

Symptom tracking and documentation How are symptoms being documented and what 

is being used to track symptoms? (Example, 

Neurobehavioral Symptom Inventory).

Service member’s history of imaging after injury If indicated, has c-spine imaging been completed?

Table 3.0 Comprehensive History

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting

Chronic Stage

The chronic stage of mTBI is defined as 90 days or greater post-injury.6 Imaging is not recommended unless the 

service member presents with, new, persistent or worsening symptoms. The goal of imaging in the chronic stage of 

mTBI is to further evaluate the individual’s injury, enhance understanding of persistent symptoms, provide education 

and identify the need for specialist referral. Conventional MRI is the imaging modality of choice for the evaluation of 

new, persistent or worsening symptoms in individuals with chronic mTBI. If MRI is unavailable or contraindications are 

present, then non-contrast CT is the alternative modality. Additional considerations reflected in Table 4.0 in chronic 

stage mTBI include:

• A repeat of subsequent imaging is recommended if the previous exam was a CT.

• A repeat MRI is also suggested if a previous MRI indicates need for follow-up, or if it did not meet the minimum 

recommendations (see Table 4.0 and Appendix A).

• If there are no structural abnormalities identified on MRI or CT and/or abnormalities do not explain persistent 

symptoms, PET Hexamethylpropyleneamine Oxime (HMPAO) or Ethylcysteinate Dimer (ECD) SPECT may offer 

additional information in understanding sequelae following mTBI.19, 20
5

Table 4.0 Neuroimaging Recommendations following mTBI

No imaging is recommended if symptoms are improving

Modality Clinical indications 

in mTBI 

Acute (injury-7 days post injury)

GOAL of IMAGING: Identify surgical 

mass or lesions via Clinical red 

Flags

Sub-Acute (8-89 Days post injury)

GOAL of IMAGING: Evaluate, 

enhance counseling, identify need 

for referral

Chronic (90 days or greater post injury)

GOAL of IMAGING: Evaluate, 

enhance counseling, identify need for 

referral

CT Utility varies based upon length of 

time between injury and 

presentation

Modality of choice if clinical evaluation 

indicates Use only if MRI is contraindicated Use only if MRI is contraindicated

MRI

Minimum requirements of a 

mTBI exam includes:

1.5 tesla or above with 3D T1/T2, 

FLAIR, DWI/ DTI, SWI/GRE SWI/ 

GRE SWI may identify areas of 

prior DAI or prior 

microhemorrhage. GRE may be 

substituted if SWI not available or 

run as a complimentary exam 

DWI trace maps calculated from 

DTI data may be substituted for 

conventional DWI

If symptoms are worsening after 72 hours Modality of choice

Modality of choice

DWI has low yield for individuals with chronic 

mTBI and persistent symptoms

PET 18 FDG-PET No clinical indication

If there are no structural abnormalities identified 

on MRI or CT and/or abnormalities do not explain 

persistent symptoms, PET may offer additional 

information in the understanding of sequelae 

following mTBI

If there are no structural abnormalities identified 

on MRI or CT and/or abnormalities do not explain 

persistent symptoms, PET may offer additional 

information in the understanding of sequelae 

following mTBI

SPECT If PET not available, consider 

HMPAO or ECD SPECT No clinical indication

If there are no structural abnormalities identified 

on MRI or CT and/or abnormalities do not explain 

persistent symptoms, SPECT may offer 

additional information in the understanding of 

sequelae following mTBI

If there are no structural abnormalities identified 

on MRI or CT and/or abnormalities do not explain 

persistent symptoms, SPECT may offer 

additional information in the understanding of 

sequelae following mTBI

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting

Special Considerations

Service Member Education

In the mTBI population, delivering consistent and comprehensive education provides the individual who has 

sustained an mTBI with a better understanding of evidence-based outcomes with a focus on recovery. In instances 

where imaging tests are not indicated, service members should be educated on the potentially harmful effects from 

unnecessary testing. The service member’s education may also include information about imaging modalities and 

expectations of imaging procedures if clinically indicated.

Pregnancy

Women of reproductive age should be screened for pregnancy prior to imaging, when CT or other x-rays are needed, 

as well as prior to accessing neuroimaging environments.21 Potential harm to the fetus or embryo may be caused by 

exposure to ionizing radiation.21 Only the head is directly irradiated when conducting a head CT; therefore the risk is 

estimated to be lower, due to indirect scattered radiation as compared to exposure due to background radiation during 

the entire gestation period.22 There is no conclusive evidence of harmful effects of MRI exposure to the developing 

fetus. However, if pregnancy is established, a risk- benefit analysis of the MRI should be conducted.22 Pregnant women 

undergoing an MRI should provide written informed consent as documentation of their understanding of the potential 

risks and benefits, and the desire to proceed with the study.21, 22 It is further recommended that the radiologist consult 

with the referring physician and provide documentation of the following information:22

• The information requested from the MR study cannot be acquired via other nonionizing radiation means 

(e.g., ultrasonography). 

• The referring physician does not feel it is sensible to wait for the end of pregnancy to obtain data.

• The data are needed to potentially affect the care of the individual or fetus during the pregnancy. 

Contrast agents, such as those that contain gadolinium, should not be administered during pregnancy. The decision 

to use contrast agents should be made on a case-by-case basis by the referring provider and should include a 

supervising radiologist. In addition, the information should be well documented and the referring provider should be 

able to defend the decision to administer contrast agent.21, 22
6

Recommended Standards for MRI

The quality of imaging may be affected by the consistency of approach and order of sequences. Poor quality or 

substandard testing may result in unnecessary repeated testing of the service member. The recommended standards 

per the American College of Radiology (ACR) for CT of the head or brain include the following:13

• Sequential single-slice technique, multislice helical (spiral) protocol, or multidetector multislice algorithm. 

• Contiguous or overlapping axial slices should be acquired with a slice thickness of no greater than 5 mm. 

• In the setting of trauma, images should be obtained and/or reviewed at window settings appropriate for 

demonstrating brain and bone abnormalities as well as small subdural hematomas and soft tissue lesions (subdural 

windows). 

• For imaging of the cranial base, an axial slice thickness as thin as possible, but no greater than 3 mm with spiral 

techniques and 2 mm with multi-detector and non-spiral techniques, should be used for 2D reformatting or for 3D 

reconstruction.

MRI offers a higher contrast resolution image of the brain and is generally more sensitive for detecting subtle 

intracranial pathology. MRI at 1.5 T has been reported to detect different markers of cerebral injury in up to 30% of 

individuals that have a normal head CT.23 The sensitivity of MRI may make it an informative imaging tool for concussion 

in certain circumstances (see Table 4.0). The recommended mTBI MRI protocols preferred and alternate protocols for 

1.5T and 3.0T are outlined in Appendix A. The minimum recommended magnet strength is 1.5T. The recommended 

protocols in Appendix A are meant as a guideline for radiologists and technologists who are imaging individuals 

who sustain a TBI. The goal of the standard protocol is to maintain reproducibility and comparability across the 

Military Health System as well as individuals in the VA system. These standard protocols reflect the recommended 

minimum standard and are not meant to supersede the clinician or radiologists’ clinical judgment. Several variables 

may contraindicate the recommended standards resulting in the necessity to use a lower strength machines (such 

as open MRI) or an alternative method of imaging such as CT. Such variables may include an individual’s body size, 

claustrophobia or a service member with implanted hardware or with retained metal fragments.

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting
7

References

1. Defense Veterans Brain Injury Center, 2012, DoD worldwide numbers for TBI worldwide totals. 

Retrieved from: http://www.dvbic.org/sites/default/files/uploads/dod-tbi-2000-2012.pdf

2. Armed Forces Health Surveillance Center. (2013). Deployment-Related Conditions of Special Surveillance Interest, U.S. Armed Forces, by Month 

and Service, January 2003-December 2012 (data as of 22 January 2013) Traumatic brain injury. 

Retrieved from: http://www.afhsc.mil/viewMSMR?file=2013/v20_n01.pdf#Page=17

3. Joint Theater Trauma System Clinical Practice Guideline (2011). Use of magnetic resonance imaging (MRI) in the managaement of mild traumatic 

brain injury (mTBI) concussion in the deployed setting. 

Retrieved from: http://www.usaisr.amedd.army.mil/assets/cpgs/Use_of_MRI_in_Mgmt_of_mTBI_in_the_Deployed_Setting_11_Jun_12.pdf

4. Department of Defense Instruction 6490.11: DoD Policy Guidance for Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting, September 18, 2012. Retrieved from: https://www.hsdl.org/?search&collection=public&fct&so=date&submitted=Search&o

ffset=0&tabsection=US+Depts%2C+Agencies+%26+Offices&page=1&publisher=United+States.+Dept.+of+Defense

5. Concussion Management in Deployed Settings version 4.0 (2012). 

Retrieved from: http://www.dcoe.health.mil/Content/Navigation/Documents/DCoE_Concussion_Management_Algorithm_Cards.pdf

6. Management of Concussion/mTBI Working Group. (2009). VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. Journal of Rehabilitation Research and Development, 46(6), CP1–68.

7. Levine, Z. (2010). Mild traumatic brain injury. Canadian Family Physician, 56(4), 346-349. 

8. Haydel, M., Preston, C., Mills, T., Luber, S., Blaudeau, E., & DeBlieux, P. (2000). Indications for computed tomography in patients with 

minor head injury. New England Journal of Medicine, 343(2), 100-105.

9. Shenton, M., Hamoda, H., Schneiderman, J., Bouix, S., Pasternak, O., Rathi, Y., ... Zafonte, R. (2012). A review of magnetic resonance 

imaging and diffusion tensor imaging findings in mild traumatic brain injury. Brain Imaging and Behavior, 6, 137-192.

10. Haacke, E.M., Duhaime, A.C., Gean, A.D., Riedy, G., Wintermark, M., Mukherjee, P., ... Smith, D.H. (2010). Common Data Elements in 

Radiologic Imaging of Traumatic Brain Injury. Journal of Magnetic Resonance Imaging, 32(3), 516-43.

11. Jagoda, A.S., Bazarian, J.J., Bruns, J.J. Jr, Cantrill, S.V., Gean, A.D., Howard, P.K., ... Whitson, R.R. (2009). Clinical policy: neuroimaging 

and decision making in adult mild traumatic brain injury in the acute setting. Annals of Emergency Medicine, 52(6), 714-748. 

12. McAllister, T.W., Sparling, M.B., Flashman, L.A., & Saykin, A.J. (2001). Neuroimaging findings in mild traumatic brain injury. Journal of 

Clinical and Experimental Neuropsychology, 23(6), 775-791.

13. American College of Radiology–American Society of NeuroRadiology. (2010). Practice guideline for the performance of computed tomography 

(CT) of the brain. Retrieved from: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/CT_Brain.pdf

14. Le, T.H., & Gean, A.D. (2009). Neuroimaging of traumatic brain injury. Mt. Sinai Journal of Medicine, 76(2),145-62.

15. Duhaime, A.C., Gean, A.D., Haacke, E.M., Hicks, R., Wintermark, M., Mukherjee, P., ... Riedy, G. (2010). Common Data Elements Neuroimaging Working Group Members, Pediatric Working Group Members. Common data elements in radiologic imaging of traumatic brain 

injury. Archives of Physical Medicine and Rehabilitation, 91(11), 1661-6. 

16. Toth, A., Kovacs, N., Perlaki, G., Orsi, G., Aradi, M., Komaromy, H.,... Schwarcz, A. (2012). Multi-modal magnetic resonance imaging 

in the acute and sub-acute phase of mild traumatic brain injury: Can we see the difference? Journal of Neurotrauma, 30(1), 2-10.

17. Yuh, E., Mukherjee, P., Lingsma, H., Yue, J., Ferguson, A., Gordon, W. ... Manley, G. (2013). Magnetic resonance imaging improves 

3-month outcome prediction in mild traumatic brain injury. Annals of Neurology, 73(2), 224-35.

18. Benzinger, T., Brody, D., Cardin, S., Curley, K., Mintun, M., Mun, S., Wong, K., & Wrathall, J. (2009). Blast related brain injury: Imaging 

for clinical and research applications: Report of the 2008 St. Louis workshop. Journal of Neurotrauma, 26 (12), 2127-2144.

19. Lin A., Liao, H., Merugumala, S., Prabhu, S., Meehan, W., & Ross, B. (2012). Metabolic imaging of mild traumatic brain injury. 

Brain Imaging and Behavior, 6, 208-223.

20. Bigler. E., & Maxwell, W., (2012). Neuropathology of mild traumatic brain injury: Relationship to neuroimaging findings. Brain Imaging and 

Behavior, 6, 108-136.

21. American College of Radiology. (2008) ACR Practice guideline for imaging pregnant or potentially pregnant adolescents and women 

with ionizing radiation. Retrieved from: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Pregnant_Patients.pdf

22. Wang, P., Chong, S., Kelly, A., Knoepp, U., Mazza, M., & Goo, M. (2012). Imaging of the Pregnant and Lactating Patients: Part I, 

evidence –based review and recommendations. American Journal of Radiology, 198, 778-784.

23. Mittl, R., Grossman, R., Hiehl, J., Hurst, R., Kauder, D., Gennarelli, T., & Alburger, G. (1994). Prevelance of MR evidence of diffuse axonal 

injury in patients with mild head injury and normal CT findings. American Journal of Neuroradiology, 15(8), 1583-1589.

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting
8

Appendix A

The following protocols (Minimum preferred 1.5T; Alternate 1.5 T; Preferred 3.0T; Alternate 3.0T) are meant as 

guidelines for radiologists and technologists who are imaging service members who sustain a TBI. The goal of the 

standard protocol is to maintain reproducibility and comparability across both the Military Health System as well as 

extending into the care of these individuals into the VA system. The standard protocols reflect the recommended 

minimum standard and are not meant to supersede the clinician or radiologists’ individual clinical judgment. The 

following is recommended:

• Keep all fields of vision (FOVs) the same as noted in the table if at all possible.

• Higher resolution can be used if desired but it will be at the expense of time and signal-to-noise ratio (SNR).

• Do not change, flip angles or echo times significantly. There is some variability between manufacturers, but 

changing these parameters extensively will result in unintended artifact and signal characteristics.

• If SWI is not available, run the same parameters as shown in the tables and save the phase data. (It will then be 

possible to reconstruct SWI data prospectively using appropriate software). 

• When limited to using a 2D GRE scan, the alternate protocol is recommended.

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting
9

Sequence Order #1 #2 #3 #4 #5 #6 #7

3D FLAIR 3D SWI DWI T1 MPRAGE 3D T2 T2* GRE

*optional

DTI*

*optional

Sequence tse_vfl swiIPAT ep2d_diff tfl tse_vfl gre_r ep2d_diff

Orientation Sagittal Axial Axial Sagittal Sagittal Axial Axial

TR (ms) 6000 50 5400 2000 3500 1110 6500

TE (ms) 353 40 100 3.22 355 26 100

TI (ms) 2200 - - 1000 - - -

FA (degree) - 15 8 - 20 -

FOV (mm2) 256x208 256x192 256x256 256x256 256x208 256x192 256x256

Matrix size 256x256 512x256 128x128 512x256 256x256 256x256 128x128

Nz/TH (mm)/slab 160/1 64/2 32/4 120/2 160/1 32/4 32/2

Voxel size (mm3) 1x1x1 0.5x1x2 2x2x4 0.5x1x2 1x1x1 1x1x4 2x2x2

Ave./Meas. 1/1 1/1 3/1 1/1 1/1 1/1 10/1

Concatenations 1 1 1 1 1 1 1

Phase oversmpl. 0% 0% 0% 0% 0% 0% 0%

Dist. factor - - 0% - - 0% 0%

Phase Enc. Dir A>>P R>>L A>>P A>>P A>>P R>>L A>>P

iPAT None 2/24 2/24 None None None 2/24

BW (Hz/pixel) 888 80 1502 160 751 78 1502

Flow Comp - Yes - - - Yes -

Phase partial 

Fourier

Off Off 6/8 Off Off Off 6/8

Slice partial Fourier 6/8 Off Off Off 6/8 Off Off

Filter Elliptical - - Elliptical - Elliptical -

Saturation Band None None None - None None None

Gap/Thickness 

(mm)

- - - - - - -

Diffusion Mode - - 3-Scan Trace - - - MDDW

Diff. Weightings - - 3 - - - 2

Noise level/Diff 

Directions

- - 40/3 - - - 40/6

b-values - - 0, 500, 1000 - - - 0, 1000

Echo spacing (ms) 3.3 - 0.75 10 3.38 - 0.75

Turbo factor 213 - - - 209 - -

Echo trains per 

slice

- - - - - - -

Coils 8 Channel 

Head

8 Channel 

Head

8 Channel 

Head

8 Channel 

Head

8 Channel 

Head

8 Channel 

Head

8 Channel 

Head

Time 8:50 5:47 2:27 8:32 7:05 3:35* 8:16

Total Time 41:02

(44:37*)

Preferred -TBI MRI 1.5T Protocol 

Head (Center at the orbital ridge)

Note

Please follow the sequence order

• FLAIR, SWI, 3D T2, T2 GRE sequences are acquired with a rectangular FOV. 

• Elliptical filter is ON in FLAIR, T1 MPRAGE, and T2 GRE sequences. 

• All other filters are OFF

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting
10

Sequence Order #1 #2 #3 #4 #5 #6 #7

2D FLAIR 3D SWI DWI T1 MPRAGE T2 TSE T2* GRE

*optional

DTI*

*optional

Sequence tse swiIPAT ep2d_diff tfl tse gre_r ep2d_diff

Orientation Axial Axial Axial Sagittal Axial Axial Axial

TR (ms) 9540 50 5400 2000 7000 1110 6500

TE (ms) 114 40 100 3.22 106 26 100

TI (ms) 2500 - - 1000 - - -

FA (degree) 150 15 8 160 20 -

FOV (mm2) 256x192 256x192 256x256 256x256 256x192 256x192 256x256

Matrix size 256x256 512x256 128x128 512x256 256x256 256x256 128x128

Nz/TH (mm)/slab 32/4 64/2 32/4 120/2 32/4 32/4 32/2

Voxel size (mm3) 1x1x4 0.5x1x2 2x2x4 0.5x1x2 1x1x4 1x1x4 2x2x2

Ave./Meas. 2/1 1/1 3/1 1/1 1/1 1/1 10/1

Concatenations 2 1 1 1 1 1 1

Phase oversmpl. 0% 0% 0% 0% 0% 0% 0%

Dist. factor 0% - 0% - 0% 0% 0%

Phase Enc. Dir R>>L R>>L A>>P A>>P R>>L R>>L A>>P

iPAT 2/30 2/24 2/24 None None None 2/24

BW (Hz/pixel) 201 80 1502 160 130 78 1502

Flow Comp No Yes - - No Yes -

Phase partial 

Fourier

Off Off 6/8 Off Off Off 6/8

Slice partial Fourier Off Off Off Off Off Off Off

Filter Elliptical - - Elliptical Elliptical Elliptical -

Saturation Band None None None - None None None

Gap/Thickness 

(mm)

- - - - - - -

Diffusion Mode - - 3-Scan Trace - - - MDDW

Diff. Weightings - - 3 - - - 2

Noise level/Diff 

Directions

- - 40/3 - - - 40/6

b-values - - 0, 500, 1000 - - - 0, 1000

Echo spacing (ms) 9.5 - 0.75 10 11.8 - 0.75

Turbo factor 29 - - - 17 - -

Echo trains per 

slice

- - - - - - -

Coils 8 Channel 

Head

8 Channel 

Head

8 Channel 

Head

8 Channel 

Head

8 Channel 

Head

8 Channel 

Head

8 Channel 

Head

Time 2:53 5:47 2:27 8:32 2:55 3:35* 8:16

Total Time 30:50

(34:25*)

Alternate -TBI MRI 1.5T Protocol 

Head (Center at the orbital ridge)

Note

Please follow the sequence order:

• FLAIR, SWI, T2 TSE, T2 GRE sequences are acquired with a rectangular FOV. 

• Elliptical filter is ON in FLAIR, T1 MPRAGE, T2 TSE and T2 GRE sequences. 

• All other filters are OFF.

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting
11

Sequence Order #1 #2 #3 #4 #5 #6 #7

3D FLAIR 3D SWI DWI T1 MPRAGE 3D T2 T2* GRE

*optional

DTI*

*optional

Sequence tse_vfl gre ep2d_diff tfl tse_vfl gre ep2d_diff

Orientation Sagittal Axial Axial Axial Sagittal Axial Axial

TR (ms) 6000 29 5000 1750 2500 818 818

TE (ms) 397 20 92 2.98 2.98 20 93

TI (ms) 2200 - - 900 - - -

FA (degree) - 15 90 9 - 20 -

FOV (mm2) 256x256 256x192 256x256 256x256 256x256 256x192 256x256

Matrix size 256x256 512x256 128x128 512x256 256x256 256x256 128x128

Nz/TH (mm)/slab 160/1 72/2 32/4 192/1 192/1 32/4 46/2

Voxel size (mm3) 1x1x1 0.5x1x2 2x2x4 0.5x1x1 1x1x1 1x1x4 2x2x2

Ave./Meas. 1 1/1 2 1 1/1 1/1 10/1

Concatenations 1 1 1 1 2 1

Slice oversmpl. 0% 22.2% 0% 0% 0% 0% 0%

Dist. factor 0% 0% 25% 0% 0% 0% 0%

Phase Enc. Dir A>>P R>>L A>>P R>>L A>>P R>>L A>>P

iPAT 2/24 2/24 2/24 2/24 2/24 2/24 2/24

BW (Hz/pixel) 2/24 120 1346 180 751 180 1346

Flow Comp No Yes - No No Slice/Read -

Phase partial 

Fourier

Allowed Off 6/8 Off Allowed Off 6/8

Slice partial Fourier 7/8 Off Off Off - -

Saturation Band

Gap/Thickness 

(mm)

Diffusion Mode 3-Scan Trace MDDW

Diff. Weightings 2

Noise level/Diff 

Directions

40 40/30

b-values 0, 500, 1000 0, 1000

Echo spacing (ms) 3.32 3.32 3.42

Turbo factor 141 128 141

Echo trains per 

slice

1 1

Coils Head+Neck Head Head Head Head Head Head

Time 05:20 04:35 1:27 04:03 04:02 2:58* 07:50

Total Time 27:52

(30:50*)

Preferred TBI MRI 3T Protocol 

Head (Center at the orbital ridge)

Note

Please follow the sequence order:

• 3D SWI sequence is acquired with a rectangular FOV. 

• Distortion Correction filters are OFF in all sequences.

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting
12

Sequence Order #1 #2 #3 #4 #5 #6 #7

2D FLAIR 3D SWI DWI T1 MPRAGE 2D T2 T2* GRE

*optional

DTI*

*optional

Sequence tse gre ep2d_diff tfl tse gre ep2d_diff

Orientation Axial Axial Axial Axial Axial Axial Axial

TR (ms) 8000 29 5000 1750 6000 818 7200

TE (ms) 129 20 92 2.98 94 20 93

TI (ms) 2500 - - 900 - - -

FA (degree) 150 15 90 90 120 20 -

FOV (mm2) 256x192 256x192 256x256 256x256 256x192 256x192 256x256

Matrix size 256x256 512x256 128x128 512x256 256x256 256x256 128x128

Nz/TH (mm)/slab 64/2 64/2 32/4 192/1 64/2 32/4 46/2

Voxel size (mm3) 1x1x2 0.5x1x2 2x2x4 0.5x1x2 1x1x2 1x1x4 2x2x2

Ave./Meas. 1/1 1/1 2 1 2/1 1/1 2

Concatenations 3 1 1 2 2 1

Slice oversmpl. 0% 22.2% 0% 0% 0% 0% 0%

Dist. factor 0% 0% 25% 0% 0% 0% 0%

Phase Enc. Dir R>>L R>>L A>>P R>>L R>>L R>>L A>>P

iPAT 2/46 2/24 2/24 2/24 2/32 2/24 2/24

BW (Hz/pixel) 296 120 1346 180 222 180 1346

Flow Comp Slice Yes - No Slice Slice/Read -

Phase partial 

Fourier

Off Off 6/8 Off Off Off 6/8

Slice partial Fourier Off Off Off Off

Saturation Band

Gap/Thickness 

(mm)

Diffusion Mode - - 3-Scan Trace - - - MDDW

Diff. Weightings - - - - - 2

Noise level/Diff 

Directions

- - 40 - - - 40/30

b-values - - 0, 500, 1000 - - - 0, 1000

Echo spacing (ms) 11.7 - 7.6 11.7 -

Turbo factor 17 128 15

Echo trains per 

slice

7 7

Coils Head+Neck Head Head Head Head Head Head

Time 03:14 04:35 1:27 04:03 03:02 2:58* 07:50

Total Time 23:54

(26:52*)

Alternate TBI MRI 3T Protocol 

Head (Center at the orbital ridge)

Note

Please follow the sequence order:

• 2D FLAIR, 2D T2 sequences are acquired with a rectangular FOV. 

• Distortion Correction filters are OFF in all sequences

1335 East West Highway, Suite 6-100, Silver Spring, Maryland 20910 

www.DVBIC.org

DCoE Clinical Recommendation | July 2013

Neuroimaging following Mild Traumatic Brain Injury in the Non-Deployed Setting