TBI is classified as mild, moderate, or severe at, or close to, the time of the original injury. While this classification will often correspond to the future level of functional disability that may not always be the case. It is recognized that serial assessments of the patient's cognitive, emotional, behavioral and social functioning is required over time. The trauma may cause structural damage or may produce more subtle damage that manifests itself by altered brain function without structural damage that can be detected by traditional diagnostic studies. The veteran is classified as having mild, moderate or severe injury if he or she meets any of the criteria within a particular severity level. If a patient meets criteria in more than one category of severity, the higher severity level is assigned.

What tests are used to diagnose residuals of mild, moderate or severe TBI?

Acute brain injuries are classified as focal, diffuse (widespread), or mixed depending on the mechanism of injury and the body's response to the injury. Focal damage, such as a contusion or hematoma, is diagnosed through neuroimaging studies such as a computerized tomography scan (CT) or magnetic resonance imaging (MRI). The trauma may cause structural damage or may produce more subtle damage that manifests itself by altered brain function that can be detected by traditional imaging studies, such as MRI or CT scanning. In addition to traditional imaging studies, other imaging techniques, such as functional magnetic resonance imaging (fMRI), diffusion tensor imaging, positron emission tomography (PET) scanning and electrophysiological testing such as electroencephalography may be used to detect damage to or physiological alteration of brain function. A skull X-ray can reveal skull deformities as a result of the TBI.

If it is not clinically possible to determine the brain injury level of severity because of medical complications (e.g., medically-induced coma), other types of blood tests for specific proteins and enzymes present in a TBI patient are required to make a determination of the severity of the brain injury.

Altered brain function may manifest itself by diminished performance on neuropsychological testing or other standardized testing. Dysfunction does not necessarily reflect the patient's ultimate level of functioning. It is recognized that serial assessments of the patient's cognitive, emotional, behavioral and social functioning are required.

The potential residuals of traumatic brain injury necessitate a comprehensive examination to document all disabling effects. Specialist examinations, such as eye and audio examinations, mental disorder examinations, and others may also be needed in some cases.

There are no widely accepted single tools for assessing cognitive impairment. However, medical records may include the results of a Mini-Mental State Examination (MMSE) or Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), or other neuropsychological tests.

What is the treatment for TBI?

Treatment is focused on restoring oxygen to the brain as quickly as possible and stabilizing the TBI combat soldier. In the days and weeks immediately following brain injury, the function of surviving brain tissue often is affected by swelling, bleeding and/or changes in the complex chemistry of the brain. Sometimes blood accumulation must be removed surgically to reduce swelling and pressure within the brain. Controlling swelling and giving the blood flow and chemical systems of the brain time to recover usually lead to improvement in function.

Long-term, multi-faceted rehabilitation services are needed to help individuals rebuild their lives after a brain injury. Although the total number of brain cells does not change, it is believed that cells have the ability to gradually learn how to carry out some functions of destroyed cells. Recovery can take weeks, months and years and slows over time. The effects of brain injury are often long lasting and recovery, despite treatment, may be incomplete. Although some people with severe brain injury experience only mild long-term difficulties, other people may require care or special services for the rest of their lives. Treatment is based on an evolving understanding of how a damaged brain recovers.

What is the treatment for TBI?

Delayed or late effects are likely to occur in more severe forms of TBI; however, progressive cognitive, physical and behavioral impairments can evolve over time. Some residuals will require evaluation under other diagnostic criteria if they involve the neurologic system, mental disorders such as PTSD, eye and audio systems, and other body systems. There may be an overlap of signs, symptoms, or both of a co-morbid mental or neurologic or other physical disorder.

The effects of TBI can have a profound impact on an individual's ordinary activities of daily living and employment. The degree of disability may involve sensory organs, loss of use of an extremity, loss of bladder and/or bowel control, or the need for aid and attendance or housebound benefits. Residuals may include injury to the face, jaw, mouth and teeth, and scars to the head, neck and face.

Subjective complaints such as headache, dizziness, and insomnia may persist or become permanent.

Additional Information about Residuals of Traumatic Brain Injury

• The designation of TBI as mild, moderate, or severe is made at or close to the time of the initial injury and is a determination of acute injury severity. Once this acute level of severity is determined, it does not change, regardless of the veteran's course of residuals. While this classification has a rough correlation with prognosis, it is not a strict correlation, so that TBI classified as mild, for example, does not necessarily equate to mild disability or mean that residuals will be mild. Classification of the level of severity has no bearing on C&P evaluations.

• Regarding the requirements for clinical signs immediately following the traumatic event, note that only one of the five listed items under the definition of TBI is needed for the diagnosis. Any one of the five items is sufficient for the diagnosis.

• While discussions of the evaluation of residuals of TBI into mild versus moderate or severe TBI, it is the actual findings in each case that determine what types of conditions will need evaluation and therefore which set of guidelines are most appropriate to follow.

• Avoid pyramiding. Evaluate each residual disability separately as long as the same signs and symptoms are not used to support more than one evaluation. Then, combine the evaluations. Symptoms of cognitive impairment and mental disorders such as depression and PTSD often overlap. In such cases, a single evaluation taking into account both conditions may be the most appropriate way to evaluate them.

• When there is no diagnosis of a mental disorder, or when there is a diagnosis of a mental disorder but there are behavioral/emotional symptoms that are reported to be residuals of TBI, and not attributed to a mental disorder, evaluate them under "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." In that case, do not also assign an evaluation based on the same behavioral/emotional symptoms.

• Do not overlook the additional injuries that may also be present in a veteran with TBI - burns, shrapnel wounds, fractures, amputations, spine injuries, etc. Please request separate examinations to determine the residuals of these injuries and base your evaluation on the examiners' findings. (Also note the new changes in the rating schedule dealing with scars.)

• May be entitled to special monthly compensation where the Veteran has a single service-connected disability rated as 100% with additional service-connected disability or disabilities independently ratable at 60% or more, which are separate and distinct from the 100% service-connected disability and involves different anatomical segments or bodily systems. See  38 CFR 3.350(i)(1) – Special Monthly Compensation (SMC).

• Consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc.

• Reference 38 CFR 3.310(d) for information on disabilities considered to be the proximate result of a service-connected traumatic brain injury (TBI).

• Reference 38 CFR 3.350(j) for information on special aid and attendance benefit for residuals of traumatic brain injury (38 U.S.C. 1114(t)).

• Reference 38 CFR 3.352(b)(2) for information on higher level aid and attendance allowance as a result of service-connected residuals of traumatic brain injury.

Notes

• There may be an overlap of manifestations of conditions evaluated under the table titled “Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified” with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition.

• Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation.

• “Instrumental activities of daily living” refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from “Activities of daily living,” which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet.

• The terms “mild,” “moderate,” and “severe” TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under diagnostic code 8045.

• A veteran whose residuals of TBI are rated under a version of 38 CFR 4.124a, diagnostic code 8045, in effect before October 23, 2008 may request review under diagnostic code 8045, irrespective of whether his or her disability has worsened since the last review. VA will review that veteran's disability rating to determine whether the veteran may be entitled to a higher disability rating under diagnostic code 8045. A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however, in no case will the award be effective before October 23, 2008. For the purposes of determining the effective date of an increased rating awarded as a result of such review, VA will apply 38 CFR 3.114, if applicable.