INTRODUCTION: After traumatic brain injury (TBI), cognitive, behavioral alterations and seizures frequently occur. Beside instrumental examinations, neuropsychological testing is the common clinical practice for detecting cognitive deficits. However, in highly skilled individuals, subtle changes with a large impact on fitness to fly may be neglected.CASE REPORT: A 28-yr-old Italian Air Force pilot with almost 700 flying hours suffered a TBI. After 2 yr of cognitive retraining programs, as the neuropsychological evaluation executed in a public hospital was within the standards and repeated EEGs had all been normal, the pilot was allowed to resume flying duties. During the refresh flight training, he was not considered proficient for solo flight and was again referred to the Institute of Aerospace Medicine (IMAS), where, due to the absence of a neuropsychologist, the pilot was referred to a public hospital. Again, he was within the normal range and received a fitness to fly with limitations. Nevertheless, the flight instructors noticed the presence of cyclic errors. Consequently, he was sent for a third time to the IMAS, where the cooperation between a neuropsychologist and a flight surgeon allowed a tailored testing.DISCUSSION: With a proper evaluation, the subject showed deficits in topographic visuospatial learning and in prospective memory. After 5 yr, he was finally declared permanently unfit to fly. Specific neuropsychological batteries, simulated flight tests, and aeromedical evaluations are described here.Verde P, Guadagno AG, D'Angelo A, Vitalone R, Di Vita A, Piccardi L. A controversial assessment of fitness to fly after a traumatic brain injury. Aerosp Med Hum Perform. 2022; 93(2):116-122.