THE PHRASE THAT CAN MISLEAD A CASE
In litigation involving head trauma, few chart phrases are more likely to be overinterpreted than “CT head: no acute intracranial abnormality.”
To an attorney, adjuster, juror, or patient, the phrase may sound like a definitive finding that the brain was not injured. Medically, that is not what the study establishes.
A normal acute CT can be very reassuring about the absence of CT-detectable structural emergencies, particularly intracranial hemorrhage, but mild traumatic brain injury (mTBI), commonly called concussion, remains primarily a clinical diagnosis.
The Centers for Disease Control and Prevention specifically notes that a brain scan such as CT is not needed to identify a mild TBI or concussion, although imaging may be used when there is concern for bleeding or another structural injury.
This distinction is not semantic. It affects causation analysis, case valuation, deposition strategy, the interpretation of emergency records, and the selection of experts.
The question is not simply whether a scan was “normal.”
The correct question is: what was the scan designed to detect, what did it actually exclude or make less likely, and what clinical diagnosis was being evaluated?
WHAT CT IS – AND IS NOT – DESIGNED TO DO
In acute head trauma, noncontrast CT is the principal imaging examination when clinical decision rules indicate that imaging is warranted.
The American College of Radiology rates noncontrast CT as “usually appropriate” for acute mild head trauma when imaging is indicated by a clinical decision rule.
Conversely, when such a rule does not indicate imaging, CT and MRI are generally not appropriate as routine initial studies.
That framework itself demonstrates an important point: clinicians do not diagnose or exclude concussion simply by ordering a scan.
CT is particularly valuable for identifying acute structural pathology that can change emergency management: intracranial hemorrhage, mass effect, certain fractures, and other traumatic abnormalities.
A negative CT therefore carries real clinical meaning.
What it does not do is establish that the patient experienced no physiologic brain disturbance, no cognitive symptoms, no post-concussive syndrome, or no functional impairment.
A lawyer reviewing the phrase “negative CT” should therefore resist two opposite errors.
The first is treating the negative study as proof that no concussion occurred.
The second is treating the negative study as irrelevant.
It is neither.
It is evidence that must be interpreted according to the diagnostic question the test was capable of answering.
WHAT ABOUT MRI?
MRI provides greater soft-tissue contrast and can become useful in selected patients, particularly when neurologic deficits persist and are unexplained by CT or when the clinical scenario has moved beyond the immediate acute phase.
However, conventional MRI is not a universal concussion detector.
A normal conventional MRI does not, standing alone, exclude mTBI.
Likewise, an abnormal MRI obtained after trauma does not automatically prove that every abnormality was caused by the traumatic event.
This is where record review becomes critical.
The radiology report must be integrated with the mechanism, acute history, neurologic examination, prior medical history, symptom evolution, and competing explanations.
Imaging is one component of the causation analysis, not the causation analysis itself.
CONCUSSION IS A CLINICAL DIAGNOSIS
The CDC describes mild TBI or concussion as resulting from a bump, blow, or jolt to the head, or a hit to the body that causes rapid movement of the head and brain.
Symptoms may affect how a person feels, thinks, acts, and sleeps.
Common complaints include headache, dizziness or balance problems, nausea, sensitivity to light or noise, fatigue, concentration difficulty, cognitive slowing, memory problems, irritability, anxiety, emotional change, and sleep disturbance.
Loss of consciousness is not required for mTBI.
Neither is post-traumatic amnesia required in every definition used clinically.
The 2023 American College of Emergency Physicians clinical policy expressly addresses mild traumatic brain injury in patients with or without loss of consciousness, amnesia, or disorientation, depending on the clinical definition being applied.
For litigation, the practical implication is straightforward: the absence of loss of consciousness, a normal Glasgow Coma Scale score, or a normal CT does not by itself resolve whether mTBI occurred.
Those facts remain important, but they must be placed within the full clinical picture.
SYMPTOMS MAY EVOLVE AFTER THE EVENT
Another recurrent litigation problem is the assumption that every concussion symptom must be documented at the moment of injury.
The CDC states that some mild TBI and concussion symptoms appear immediately while others may not appear for hours or days.
A patient may initially focus on headache or nausea and later recognize concentration difficulty, sleep disturbance, irritability, dizziness, or cognitive fatigue.
That does not mean that any symptom reported days later should automatically be attributed to trauma.
A physician reviewing the record should ask whether the timing is medically coherent, whether there is longitudinal consistency, whether the symptom pattern fits the alleged injury, and whether competing causes are present.
Migraine, medication effects, intoxication, sleep deprivation, anxiety, depression, vestibular disorders, prior head injury, and other conditions can produce overlapping symptoms.
THE RECORD STILL HAS TO MAKE MEDICAL SENSE
A defensible mTBI analysis is not built around a single phrase in a radiology report.
It is built from the entire record.
Important questions include:
- The nature of the mechanism
- Whether the patient struck the head or experienced rapid acceleration-deceleration
- Immediate symptoms
- Documented alteration of awareness, confusion, amnesia, disequilibrium, headache, nausea, or cognitive complaints
- Serial neurologic examinations
- The timing and evolution of symptoms
- Prior concussions
- Baseline headaches or psychiatric conditions
- Medications or substances
- The consistency of later histories with contemporaneous documentation
The timing of the diagnosis also matters.
A diagnosis documented contemporaneously by an emergency physician, neurologist, sports-medicine physician, or primary-care clinician may carry different evidentiary significance from a diagnosis introduced months later without a clear clinical bridge.
That does not make the later diagnosis invalid, but it changes the questions that must be answered.
WHY THE WORDING OF A MEDICAL OPINION MATTERS
Compare these two statements:
“The CT was normal, therefore the patient did not sustain a traumatic brain injury.”
and
“The CT showed no acute CT-detectable intracranial structural injury; whether the patient sustained a mild traumatic brain injury requires clinical assessment.”
The first overstates what the imaging can prove.
The second accurately separates radiologic evidence from clinical diagnosis.
For counsel, that distinction may affect how a radiologist, emergency physician, neurologist, neuropsychologist, or retained expert should be questioned.
It may also reveal whether an opposing opinion rests on an appropriate medical foundation or on an assumption that exceeds the capability of the test being cited.
THE LEGALMDS PERSPECTIVE
Medical records contain observations, diagnoses, test results, and treatment decisions.
They do not always explain the limits of those observations.
In head-injury litigation, a short radiology phrase can acquire a meaning in the legal file that it never had in the clinical encounter.
LegalMDs can help counsel determine what a negative study actually establishes, whether the clinical history supports or undermines an mTBI diagnosis, what alternative explanations require consideration, and which questions should be asked before settlement, deposition, mediation, or trial.
The objective is not to make a normal scan “abnormal.”
It is to interpret the scan accurately and in context.
In a head-injury case, “normal imaging” and “no injury” are not synonymous – and understanding the difference can materially change the medical analysis of the case.
REFERENCES
- Centers for Disease Control and Prevention. About Mild TBI and Concussion. Updated Sept. 15, 2025. https://www.cdc.gov/traumatic-brain-injury/about/index.html
- Centers for Disease Control and Prevention. Symptoms of Mild TBI and Concussion. Updated Sept. 15, 2025. https://www.cdc.gov/traumatic-brain-injury/signs-symptoms/index.html
- American College of Emergency Physicians. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury. Ann Emerg Med. 2023;81(5):e63-e105.
- American College of Radiology. ACR Appropriateness Criteria: Head Trauma. https://acsearch.acr.org/docs/69481/Narrative/
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