# TBI imaging and records: CT, MRI, DTI and diffuse axonal injury > TBI imaging in court: why a normal CT does not rule out brain injury, how SWI and DTI get challenged, and the first 72 hours of records that set severity. Canonical page: https://medrecords.ai/guides/tbi-imaging-diffuse-axonal-injury-dti/ --- New — **Missing Records Detection:** flags every visit, provider, and date missing from the file. [See how →](https://medrecords.ai/product/missing-records-identification/) Field guide, September 2026. 14 chapters. ## TBI imaging, diffuse axonal injury and DTI: the records that decide severity For brain injury plaintiff and defense attorneys, legal nurse consultants and neuropsychology IME evaluators. You walk away with the severity criteria mapped to the records that prove them, an imaging modality table, a DTI admissibility decision path, a records request and a first 72 hours worksheet. By [Ahmed Jemaa](https://medrecords.ai/authors/ahmed-jemaa/), Co-Founder and CEO, Medrecords AI. Published 26 September 2026. TBI imaging in litigation means the CT, MRI, susceptibility-weighted and diffusion tensor studies used to prove or dispute a brain injury. They are read together with the first 72 hours of records: EMS and emergency Glasgow Coma Scale scores, loss of consciousness, post-traumatic amnesia and any blood biomarker result. A normal CT does not rule out mild TBI, and DTI findings face admissibility challenges under Rule 702. Most brain injury cases turn on a severity label, and that label comes from records written by paramedics and emergency staff in the first hours, long before anyone orders an MRI or a neuropsychological test. A normal head CT gets read as proof that nothing happened. A DTI report gets offered as proof that something did. Neither side wins the imaging fight without first winning the fight over the first 72 hours. This guide is built from the 2021 VA/DoD mild TBI guideline, the 2023 ACRM diagnostic criteria for mild TBI and the 1993 ACRM definition reprinted with them, the FDA De Novo decision summary for the first cleared GFAP and UCH-L1 blood test, the ACR Appropriateness Criteria for head trauma, the Glasgow Coma Scale guidance published by its developers, Federal Rule of Evidence 702, the AACN 2021 validity consensus and peer-reviewed papers on MRI outcome prediction and DTI in litigation. Full citations are in chapter 14. Every case example is a labeled hypothetical. No court opinion is cited because none was reviewed. Nothing here is legal or medical advice. Diagnosis, severity and causation are questions for qualified experts, and admissibility rules vary by state. 9 numbers ### TBI imaging and severity in 9 numbers 13 to 15 Glasgow Coma Scale range for mild TBI, using the best available score in the first 24 hours VA/DoD mTBI guideline, 2021, table 1 30 minutes loss of consciousness ceiling for mild TBI in both the VA/DoD table and the ACRM criteria VA/DoD 2021, table 1; ACRM 2023, box 1 24 hours of post-traumatic amnesia: past this, ACRM 2023 drops the "mild" qualifier ACRM 2023, box 1 72 hours window in which acute symptoms "nearly always appear," per the ACRM criteria ACRM 2023, criterion 3 27% of mild TBI patients with a normal admission CT had an abnormal early MRI (study of 135 patients) Yuh and colleagues, Ann Neurol 2013 12 hours from suspected head injury: the serum draw window for the first cleared GFAP and UCH-L1 test FDA DEN170045, indications for use 97.5% sensitivity of that test for acute lesions on CT (117 of 120 CT-positive patients) FDA DEN170045, clinical study 36.5% specificity: most patients with a normal CT still tested positive FDA DEN170045, 2x2 table 10 of 10 head trauma scenarios in which the ACR rates MRI with DTI "usually not appropriate" ACR Appropriateness Criteria, head trauma Chapter 1 Everyone ### How the first records set TBI severity Traumatic brain injury is graded mild, moderate or severe. The grade drives the guideline that applies, the recovery curve an expert describes, the life care plan and how a jury hears the word "mild." It is assigned from 4 measures, all recorded in the acute chart, not the imaging suite. - **Glasgow Coma Scale (GCS).** A 3 to 15 score from eye, verbal and motor responses. - **Loss of consciousness (LOC).** Whether, and how long, the person was unconscious. - **Alteration of consciousness (AOC).** Confusion or feeling dazed without full unconsciousness. - **Post-traumatic amnesia (PTA).** The period after the injury the person cannot remember. The VA/DoD guideline adds a fifth row for structural imaging. It is the only row where a mild injury and a severe injury can look the same: the table allows normal imaging in all 3 grades. | Criterion | Mild | Moderate | Severe | | --- | --- | --- | --- | | Structural imaging | Normal | Normal or abnormal | Normal or abnormal | | Loss of consciousness | 0 to 30 minutes | Over 30 minutes and under 24 hours | Over 24 hours | | Alteration of consciousness | Up to 24 hours | Over 24 hours; severity based on other criteria | | | Post-traumatic amnesia | 0 to 1 day | Over 1 and under 7 days | Over 7 days | | GCS, best available score in first 24 hours | 13 to 15 | 9 to 12 | Under 9 | Source: VA/DoD Clinical Practice Guideline, Management and Rehabilitation of Post-Acute Mild TBI, version 3.0, 2021, table 1. Its footnote: a patient who meets criteria in more than 1 category is assigned the higher severity. #### The highest category wins That footnote is the plaintiff's most useful sentence in the table. A GCS of 15 on arrival does not make an injury mild if the chart documents 3 days of amnesia; under the table, that is moderate. The defense check runs the other way: does a "moderate" label rest on 1 criterion the records do not support, such as an amnesia estimate written weeks later from the patient's own account? #### The Glasgow Coma Scale in the chart The GCS was described in 1974 by Graham Teasdale and Bryan Jennett. Its developers publish the current structure and guidance at glasgowcomascale.org. Each component is scored on the best response observed: ##### Eye opening (E, 1 to 4) Highest4, spontaneousMiddle3, to sound; 2, to pressureLowest1, noneUntestableRecord NT, for example eyes swollen shut ##### Verbal response (V, 1 to 5) Highest5, orientatedMiddle4, confused; 3, words; 2, soundsLowest1, noneUntestableRecord NT, for example intubated ##### Motor response (M, 1 to 6) Highest6, obeys commandsMiddle5, localising; 4, normal flexion; 3, abnormal flexion; 2, extensionLowest1, noneUntestableRecord NT, for example paralysed or sedated The components add to a sum score from 3 to 15. The developers' guidance is specific about 1 trap that shows up in almost every trauma chart: when a component cannot be tested, it should be recorded as "NT" (not testable), not assigned a score of 1, and no total should be reported. A GCS of "3T" or "7T" on an intubated patient is an artifact of that problem. It means the verbal score was not testable. It does not mean the patient scored 1 on speech. The guidance also lists factors that interfere with the assessment: sedation, paralysis, intubation, language barriers, hearing loss and orbital fractures. Alcohol and drugs are the other big confounder in the emergency department, and the ACRM criteria say a clinical sign counts only when it is not better explained by intoxication, pain, psychological trauma or other confounders. #### Why both sides read the GCS twice - **Which score counts.** VA/DoD uses the best available score in the first 24 hours; ACRM uses the score after 30 minutes. A 12 at the scene and a 15 at triage read differently under each rule, so the time of each score is evidence. - **Components or only a total.** A 14 can be E4 V4 M6 (confused) or E3 V5 M6 (eyes open only to voice). Charts that record only the total lose that detail. - **Who scored it.** Paramedics, triage nurses and physicians score it minutes apart. The developers report good agreement between observers in most studies, and lower agreement in moderate impairment, where most disputes sit. - **What else was in the blood.** The defense will attribute a low verbal score to a charted blood alcohol level. The plaintiff's answer is a repeat score after it would have cleared, if anyone recorded 1. **A caution on GCS and diagnosis.** The VA/DoD guideline notes that in April 2015 the Department of Defense issued a memo recommending against using GCS scores to diagnose TBI. The GCS still appears in its severity table. The distinction is that a GCS helps grade an injury once one is established. It does not by itself prove or disprove that a brain injury happened. If you remember one thing Severity is set by the worst supported criterion, not the best. Pull every GCS, every LOC note and every amnesia estimate from the first 24 hours, with the time and the author of each, before anyone argues about imaging. Chapter 2 Deciding ### ACRM 1993 and 2023: what counts as a mild TBI For 30 years, a widely used definition of mild TBI was the 1993 ACRM definition, a 2-page statement in the Journal of Head Trauma Rehabilitation. In 2023 the ACRM published new diagnostic criteria, built from an evidence review and a 3-round Delphi vote. The final agreement rate among the panel was 90.7%. Expect both sides to use whichever version suits their records, and expect older expert reports to cite only the 1993 text. ##### ACRM 1993 definition Core testAt least 1 of: any LOC; any memory loss for events just before or after the accident; any alteration in mental state; focal neurological deficitsSeverity ceilingLOC of about 30 minutes or less; after 30 minutes, an initial GCS of 13 to 15; PTA not over 24 hoursSymptoms aloneNot a route in the definitionImagingNo imaging qualifier in the definitionConfoundersNot listed in the definitionTerminologyMild traumatic brain injury ##### ACRM 2023 diagnostic criteria Core testA plausible mechanism, plus 1 or more clinical signs; or 2 or more acute symptoms plus 1 or more exam or lab findings; or neuroimaging evidenceSeverity ceilingMild is dropped if LOC is over 30 minutes, GCS is under 13 after 30 minutes, or PTA is over 24 hoursSymptoms aloneNot enough; they can support a "suspected mild TBI" labelImaging"With" or "without neuroimaging evidence of structural intracranial injury"ConfoundersCriterion 6: findings must not be better explained by intoxication, other injuries, psychological conditions, pre-existing conditions or symptom exaggerationTerminology"Concussion" may be used interchangeably with mild TBI when imaging is normal or not indicated #### How the 2023 criteria work **ACRM 2023 diagnostic path for mild TBI** — 4 steps — ACRM 2023, box 1 Step 1 — **Mechanism** — A biomechanically plausible mechanism of injury (criterion 1), shown by witness report, video, acute care records or the person's account. Step 2 — **Evidence of brain injury** — Any 1 of: a clinical sign (criterion 2); 2 or more acute symptoms plus an exam or lab finding (criteria 3 and 4); or trauma-related imaging abnormality (criterion 5). Step 3 — **Not better explained** — The signs, symptoms and findings are not fully accounted for by confounders such as intoxication, pain, stress reaction or symptom exaggeration (criterion 6). Step 4 — **Qualifiers** — Check the 3 severity indicators that remove "mild." Add the neuroimaging qualifier if imaging was done. Step 2 has 3 doors. The second door, symptoms plus a finding, lets a person with no documented LOC and a normal CT meet the criteria, which is the scenario most mild TBI cases are fought over. The criteria tie each element to a record. Criterion 2 signs include LOC, altered mental status such as slowed or inappropriate responses, and amnesia around the injury. Criterion 3 symptoms may be delayed a few hours but "nearly always appear less than 72 hours from injury," and can be shown by acute care documentation or an interview about the first days. Criterion 4 covers cognitive, balance and eye movement findings on an acute exam, and elevated blood biomarkers, and notes that most of those tests lose sensitivity over the first 72 hours. MythNo loss of consciousness means no brain injury. RuleBoth definitions accept an alteration of mental state or amnesia without LOC. ACRM 2023 also accepts 2 acute symptoms plus 1 exam or lab finding. MythA normal CT rules out a TBI. RuleACRM 2023: "Neuroimaging is not necessary to diagnose mild TBI." Its main acute role is to find injuries that need intervention. MythSymptoms reported months later prove the diagnosis. RuleACRM 2023 treats post-acute symptoms as non-specific. They should not alone be used to diagnose a mild TBI. Myth"Concussion" is a lesser injury than "mild TBI." Rule30 of 32 ACRM experts (93.8%) agreed the terms may be used interchangeably when imaging is normal or not clinically indicated. The VA/DoD guideline also uses them interchangeably. The 2023 criteria help plaintiffs whose acute chart shows symptoms and a positive exam finding but no clear LOC. They help defendants through criterion 6, which makes confounders part of the diagnosis. A diagnosis that ignores a charted blood alcohol level or a painful neck injury is open to attack under the very criteria the plaintiff's expert may cite. If you remember one thing Ask every expert which definition they applied and when it was published. A 2026 report that cites only the 1993 definition has skipped the confounder criterion and the "suspected mild TBI" category, and the other side will say so. Chapter 3 Building ### The first 72 hours: EMS, emergency and trauma records Every severity measure in chapter 1 decays fast. Confusion clears, amnesia is only measurable while it lasts, and the ACRM notes that most exam and lab findings lose sensitivity over the first 72 hours. So the records written in that window are the primary evidence, and their gaps are the battleground. An MRI 3 weeks later can show a lesion. It cannot show confusion at the scene. The measures are spread across at least 6 sources: the 911 call and dispatch log, the police report, the EMS run sheet, ED triage and physician notes, nursing neuro checks, and the first follow-up visits. The EMS run sheet belongs to the ambulance agency, not the hospital, so a hospital request will not produce it. Nursing neuro checks sit in flowsheets that some chart exports leave out. Between them they hold the serial GCS readings that show change over time. #### A worked hypothetical: 1 crash, 3 stories The timeline below is a labeled hypothetical, built to show how a normal CT and a "mild" discharge can sit on top of records that support a more serious grade, and how the same records give the defense its best arguments. **Hypothetical rear-end collision, first 72 hours** — hypothetical — Illustration 1. 17:42 **911 call** Caller: "The driver isn't answering me, now he's moving." Dispatch log time-stamps the call. CAD log p. 1 2. 17:51 **EMS on scene** "Bystander states pt out approx 1 min." GCS E3 V4 M6 = 13. "Repetitive questioning, asks what happened x4." Neck pain. EMS run sheet p. 2 3. 18:09 **EMS repeat** GCS 14 (V4). Oriented to person and place only. EMS run sheet p. 3 4. 18:22 **ED triage** GCS 15. "Denies LOC." Pain 7 of 10 neck. No components recorded. ED triage note p. 1 5. 18:48 **ED physician** "Amnestic to event, last memory is stopping at light, next memory is ambulance." CT head and cervical spine ordered. ED provider note p. 4 6. 19:31 **CT head without contrast** "No acute intracranial abnormality." Radiology report p. 7 7. 21:05 **Discharge** "Concussion. GCS 15, neuro intact." Head injury instructions. No documented reassessment of amnesia or orientation after 18:48. ED discharge p. 9 8. Day 2 **No record** No call, portal message or visit. Symptoms on this day rest on testimony alone. Nothing produced 9. Hour 64 **Urgent care** Headache, light sensitivity, nausea, "feels foggy," trouble finding words at work. Referred to a concussion clinic. Urgent care note p. 2 Plaintiff reads: witnessed LOC, confusion at the scene, documented amnesia and new symptoms inside 72 hours. Defense reads: brief LOC, GCS 15 within an hour, normal CT, neck pain as a competing source of symptoms, and a day with no record. #### How each side works this timeline ##### Plaintiff Build the grade from the worst supported criterion - Anchor LOC to the 911 call and a named bystander, not the patient's memory. - Use the EMS V4 and repetitive questioning as altered mental status under ACRM criterion 2. - Quote the physician's amnesia note word for word; it is the only contemporaneous PTA evidence. - Show that "denies LOC" came from a patient who could not remember the crash. - Place the hour 64 symptoms inside the 72-hour window of criterion 3. ##### Defense Test every criterion against its source and its confounders - Ask whether "approx 1 min" came from someone who saw the impact. - Note GCS 15 within 40 minutes, the best score in the first 24 hours under VA/DoD. - Weigh neck pain and acute stress as sources of headache and fogginess under criterion 6. - Point to the day with no record. - Check whether later PTA figures trace to a record or to a later interview. #### 5 conflicts to look for in every acute chart 1. **"Denies LOC" against a witnessed LOC.** A patient with amnesia for the event cannot reliably deny LOC. Set both entries side by side with times and authors. 2. **A total GCS without components.** Look for the components in the EMS report or a nursing flowsheet for the same period. 3. **Templated "neuro intact" text.** Compare discharge templates with the free text the same clinician wrote. 4. **Clock drift.** EMS software, dispatch, the EHR and the scanner keep separate clocks. A 6-minute offset can move a GCS past the 30-minute mark. 5. **Amnesia estimated later.** PTA durations in expert reports often come from an interview months later. Trace each figure to its first appearance. If you remember one thing Put every GCS, LOC, confusion and amnesia entry from the first 72 hours on 1 timeline with its time, author and page. Most severity disputes are settled by that page before any expert opens a scan. Chapter 4 Everyone ### CT versus MRI, and why a normal CT does not end the case A noncontrast head CT is the emergency test for head trauma. It answers the first hour question: is there bleeding, swelling or a fracture that needs a neurosurgeon. It was never designed to prove the absence of a brain injury. The ACRM 2023 criteria say neuroimaging "is not necessary to diagnose mild TBI" and that its main clinical role is to rule out injuries that might need neurosurgical or other medical intervention. #### What the ACR recommends, and when The ACR Appropriateness Criteria for head trauma rate each imaging test by clinical scenario. For acute mild head trauma, the ACR splits patients by whether a clinical decision rule calls for imaging; its references include the Canadian CT Head Rule and the New Orleans Criteria. | Scenario | CT head without contrast | MRI head without contrast | MRI head with DTI | | --- | --- | --- | --- | | Acute mild (GCS 13 to 15), decision rule says no imaging | Usually not appropriate | Usually not appropriate | Usually not appropriate | | Acute mild, decision rule says image | Usually appropriate | Usually not appropriate | Usually not appropriate | | Acute moderate (GCS 9 to 12), severe (3 to 8) or penetrating | Usually appropriate | Usually not appropriate | Usually not appropriate | | Acute, unchanged exam, normal first imaging: short-term follow-up | May be appropriate | May be appropriate | Usually not appropriate | | Acute, unchanged exam, positive first imaging such as a subdural hematoma: follow-up | Usually appropriate | May be appropriate | Usually not appropriate | | Acute, new or worsening neurological deficit: follow-up | Usually appropriate | May be appropriate | Usually not appropriate | | Subacute or chronic, unexplained cognitive or neurological deficits | Usually appropriate | Usually appropriate | Usually not appropriate | Source: ACR Appropriateness Criteria, Head Trauma, rating tables for variants 1 to 7. The same tables rate functional MRI, SPECT brain perfusion and FDG-PET/CT "usually not appropriate" in each of those scenarios. 2 points carry weight in litigation. A normal ED CT and no early MRI is the expected pattern for acute mild head trauma, so a missing early MRI proves nothing by itself. And MRI becomes "usually appropriate" once a patient has unexplained cognitive or neurological deficits in the subacute or chronic phase, which is where most litigated mild TBI claims sit. #### How often MRI finds what CT missed About 3 of 10 — 27% 27% of mild TBI patients with a normal admission CT had an abnormal early MRI, done a mean of 12 days after injury. Prospective study of 135 patients at 3 Level I trauma centers. Yuh and colleagues, Annals of Neurology, 2013. Both sides cite this study. For plaintiffs it shows a normal CT does not mean a normal brain. For defendants it sets limits: trauma center patients, MRI at about 12 days rather than months later, and 73% of CT-negative patients still had a normal MRI. #### The imaging modalities at a glance | Modality | What it shows well | Limits in a TBI case | | --- | --- | --- | | CT head without contrast | Acute bleeding, fractures, swelling; fast | Misses small contusions and microscopic axonal injury | | Conventional MRI (T1, T2, FLAIR) | Contusions, small bleeds, white matter lesions | Often done weeks or months later; lesions must be tied to trauma | | SWI or gradient echo | Blood products, including microbleeds from axonal injury | A sequence within an MRI; the report should say if it ran | | Diffusion tensor imaging (DTI) | Group differences in white matter, as values such as fractional anisotropy | No large normative database; not specific to TBI; ACR "usually not appropriate" | | Functional MRI, SPECT, FDG-PET | Activity, blood flow or metabolism | ACR "usually not appropriate" for head trauma | If you remember one thing A normal CT answers 1 question: did the patient need emergency intervention. It does not answer whether a brain injury happened. That answer comes from the first 72 hours of records, and sometimes from a later MRI. Chapter 5 Everyone ### Diffuse axonal injury and microbleeds on MRI Diffuse axonal injury (DAI) is damage to the brain's long nerve fibers, the axons, caused by rapid acceleration, deceleration or rotation of the head. Much of it is microscopic. When small blood vessels tear along with the axons, the injury leaves tiny bleeds, and those bleeds are what imaging can see. The Yuh study calls them foci of hemorrhagic axonal injury. Conventional sequences miss many of them. Susceptibility-weighted imaging (SWI) is an MRI sequence built to pick up blood products. A 2006 review in Archives of Physical Medicine and Rehabilitation by Ashwal and colleagues describes SWI as "more sensitive in detecting hemorrhagic lesions seen with diffuse axonal injury (DAI) than conventional imaging," and reports that in children with TBI the number and volume of hemorrhagic DAI lesions correlated with neurologic disability and with impairments of intelligence, memory and attention. #### Which MRI findings predicted a worse 3-month outcome **Imaging findings and poorer 3-month outcome after mild TBI** — n = 135 — Yuh and colleagues, Ann Neurol, 2013 Adjusted odds ratios for a poorer Extended Glasgow Outcome Scale score at 3 months. MRI findings kept their predictive value after adjusting for the CT findings and for demographic, clinical and socioeconomic factors. That is the strongest peer-reviewed support for the claim that early MRI findings in mild TBI mean something for outcome. It is also narrower than it is sometimes presented. The finding was 4 or more foci, not 1. The outcome was measured at 3 months, not years. And odds ratios describe groups; they do not tell an expert how a specific person with 2 microbleeds will do. #### Questions to ask about any reported microbleed - **Was SWI or gradient echo run?** If not, "no hemorrhage" means none visible on the sequences used. - **How many foci, and where?** Yuh's threshold was 4 or more. "Scattered foci" without a count needs clarification. - **Is each focus trauma-related?** ACRM criterion 5 counts only trauma-related abnormalities, and small foci of blood products can have other causes. The neuroradiologist should say why the pattern fits injury. - **Is there an earlier scan?** A pre-injury MRI, even 1 done for headaches years before, is the best test of whether a finding is new. If you remember one thing Microbleeds on SWI are real, visible evidence of hemorrhagic axonal injury, and the outcome data behind them is group data with a threshold. Get the count, the location, the sequence and any prior scan before either side builds an argument on them. Chapter 6 Deciding ### DTI in court: the Rule 702 fight over white matter Diffusion tensor imaging is an MRI technique that measures how water moves through brain tissue. In healthy white matter, water moves more easily along the fibers than across them. Software turns that into values per region, most often fractional anisotropy (FA), from 0 to 1. Lower FA is read as a sign of disrupted white matter. With a normal CT and a normal conventional MRI, a DTI report showing low FA is often the plaintiff's only imaging evidence, which is why it draws so many challenges. #### The rule the challenge is brought under "A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if the proponent demonstrates to the court that it is more likely than not that: (a) the expert's scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue; (b) the testimony is based on sufficient facts or data; (c) the testimony is the product of reliable principles and methods; and (d) the expert's opinion reflects a reliable application of the principles and methods to the facts of the case." The 2023 amendment, adopted by the Supreme Court in April 2023, took effect on December 1, 2023. It made 2 changes. It spelled out that the proponent must show each requirement is met more likely than not, and it amended (d) to emphasize, in the committee note's words, that each expert opinion "must stay within the bounds of what can be concluded from a reliable application of the expert's basis and methodology." The note also says many courts had treated the sufficiency of an expert's basis and the application of the method as questions of weight for the jury, and calls those rulings "an incorrect application of Rules 702 and 104(a)." For DTI, that matters most at step (d), where group research meets 1 patient. A lab can use a reliable method in general and still apply it unreliably to 1 patient. State courts apply their own versions of the rule, and some still use a general acceptance test, so check the standard in your jurisdiction before building a challenge or a defense of 1. #### The published critique A widely cited critique is a 2011 article in the Journal of the American Academy of Psychiatry and the Law by Wortzel and colleagues, which anchored a review of the DTI literature to the Daubert factors. Its main points: - "Alterations in white matter integrity are not specific to TBI." Other conditions can lower FA, so a low value does not by itself confirm a mild TBI. - There is no large normative database for each make and model of scanner and each software version. Each institution builds its own, which makes interpreting a single patient's result against local norms "preliminary at best." - Group-level findings, where mild TBI patients as a group differ from controls, are not validated at the single-patient level. - The authors concluded that expert testimony on DTI findings "will seldom be appropriate" in mild TBI litigation. The same article gives the plaintiff something too. On whether the technique can be tested, the authors wrote that DTI as applied to mild TBI "fares well." They said their analysis "does not dictate the admissibility of DTI evidence in any given instance," and that with experienced labs and clinically unambiguous mild TBI, DTI may add a quantifiable measure of white matter integrity, though in those cases, they added, it would be superfluous evidence for an otherwise well-established mild TBI. The article is 15 years old. Expect the plaintiff's expert to say the field has moved on, and the defense to answer with the current ACR and VA/DoD positions. #### What the current guidelines say - **ACR.** MRI with DTI is rated "usually not appropriate" in all 10 head trauma scenarios in the Appropriateness Criteria, including subacute or chronic head trauma with unexplained cognitive deficits. - **VA/DoD.** Recommendation 4 of the 2021 guideline: "We suggest against using the following tests to establish the diagnosis of mild traumatic brain injury or direct the care of patients with symptoms attributed to mild traumatic brain injury: a. Neuroimaging b. Serum biomarkers c. Electroencephalogram." It is a weak recommendation. The discussion says mild TBI "continues to be a clinical diagnosis" and that the associations found between DTI and symptom severity or return to work were weak. ##### Arguments for admitting DTI What a proponent usually has to show - DTI is an established MRI technique with a large literature, and even its critics call it testable. - It corroborates a diagnosis the acute records and exam already support. - The normative database is documented: size, ages, scanner and software match. - Acquisition and analysis followed a written protocol with quality control. - The regions reported fit the mechanism and the deficits. ##### Arguments for excluding or limiting DTI What an opponent usually tests - Low FA is not specific to trauma, and the report ignores other causes. - The normative data is small, unpublished or from a different scanner or software version. - Group research is being used to diagnose 1 person. - The ACR and VA/DoD do not recommend DTI to diagnose mild TBI. - Without a documented, reproducible pipeline, the application fails Rule 702(d). #### A decision path for a DTI report 1 **Do the acute records support a TBI without the DTI?** YesDTI is corroboration. The fight narrows to whether it adds reliable information. NoDTI carries the diagnosis alone. Expect the full specificity and group-to-individual critique. 2 **Is the normative database documented?** YesCheck size, age and sex match, and same scanner and software version. NoRequest it. Without it, "abnormal" has no stated reference point. 3 **Were the raw diffusion data and pipeline produced?** YesThe other side's expert can rerun the analysis and test region selection. NoThe results cannot be reproduced, which goes to Rule 702(b) and (d). 4 **Does the report address other causes of low FA?** YesTest its reasoning against the prior history and any pre-injury imaging. NoCross-examination starts with non-specificity. **No case law here.** Courts have gone both ways on DTI, and outcomes turn on the record and the jurisdiction. This guide cites no rulings because none was reviewed for it. Pull the opinions in your own jurisdiction and read them in full before relying on any summary. If you remember one thing A DTI fight is won on documentation: the raw data, the scanner and software versions, the normative database and the analysis steps. Request all of it early, whichever side you are on. Chapter 7 Everyone ### GFAP and UCH-L1 blood tests: what a result can and cannot show Glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) are proteins found in brain cells, GFAP in glial cells and UCH-L1 in neurons. After a brain injury they appear in the blood. The FDA granted De Novo authorization to the first test that measures both, the Banyan Brain Trauma Indicator, under decision number DEN170045. When a GFAP or UCH-L1 result appears in an ED chart, both sides will read it. #### What the FDA authorized it to do The indication is narrow. The test uses serum drawn within 12 hours of a suspected head injury, in patients 18 and older with a GCS of 13 to 15, "along with other available clinical information." A negative result "is associated with the absence of acute intracranial lesions visualized on a head CT." In other words, it helps decide whether a CT is needed. It was not authorized to diagnose a concussion or to measure how bad a brain injury is. #### The clinical study in 1 table Result against head CT — Patients — What it means Test positive, CT positive — 117 — true positive Test negative, CT positive — 3 — false negative, 2.5% of CT-positive Test negative, CT negative — 666 — true negative, 36.5% of CT-negative Test positive, CT negative — 1,161 — false positive for a CT lesion Evaluable patients — 1,947 — 120 CT-positive, 1,827 CT-negative 97.5% — sensitivity for acute lesions on CT (117 of 120) 99.6% — negative predictive value (666 of 669 negative results had a normal CT) 9.2% — positive predictive value: fewer than 1 in 10 positive results had a CT lesion 5 of 5 — patients with a lesion needing surgery tested positive The FDA summary estimated that the test could avoid about one third of unnecessary CT scans. Its required labeling includes this limitation: "A negative result is generally associated with the absence of acute intracranial lesions. An appropriate neuroimaging method is required for diagnosis of acute intracranial lesions." #### Reading a biomarker result in a case file Plaintiff overreachA positive test proves a brain injury. Record1,161 of 1,278 positive results in the FDA study came from patients with a normal CT. A positive result says a CT is warranted. Defense overreachA negative test proves no brain injury. RecordA negative result is associated with no acute CT lesion. Most mild TBIs have none, so it is consistent with mild TBI. Timing errorThe draw time does not matter. RecordThe authorized window is 12 hours. The ACRM says collection timing "strongly influences" a biomarker's value. ACRM 2023 counts "elevated blood biomarker(s) indicative of intracranial injury" as a criterion 4 finding. The evidence it cites: in 1 study, GFAP was detectable within 1 hour, peaked at about 20 hours and kept its accuracy beyond 72 hours, though it may track CT findings less well in older adults. The VA/DoD guideline's recommendation 4 suggests against serum biomarkers to establish a mild TBI diagnosis in the post-acute phase. If you remember one thing A GFAP and UCH-L1 result answers a CT question for a specific window. Pull the lab report with the draw time, the device, the cutoff and the injury time, and treat anything read beyond that as an expert argument, not a lab fact. Chapter 8 Deciding ### Neuropsychological testing and performance validity Imaging and biomarkers answer whether there was structural injury. Neuropsychological testing answers a different question: how the person thinks, remembers and processes information now, compared with norms or with their own earlier performance. In most mild TBI cases with normal imaging, the neuropsychologist's report is the main evidence of lasting deficits, and the defense's IME neuropsychologist is the main rebuttal. #### Timing The VA/DoD guideline's recommendation 6 suggests against comprehensive neuropsychological testing during the first 30 days after a mild TBI. A full battery done in the first weeks may be challenged as premature. Screening tests done in the ED or at a concussion clinic are a different thing, and they can supply the criterion 4 cognitive finding under ACRM 2023. #### Validity testing is expected, not optional Performance validity tests (PVTs) check whether a person's test scores reflect their true ability, for example whether they gave full effort. Symptom validity tests check whether symptom reports are credible. The American Academy of Clinical Neuropsychology updated its consensus statement on validity assessment in 2021, with 20 experts reaching agreement in January of that year. Its conclusion is direct: "All clinical and forensic evaluations must proactively address the degree to which results of neuropsychological and psychological testing are valid." This lines up with ACRM criterion 6, which says criterion 4 test findings must not be better explained by "factors influencing the validity of the symptom reporting or test results." A neuropsychology report in a TBI case that has no validity measures, or that reports failed validity measures and then interprets the scores anyway, is open to attack from both directions. ##### Plaintiff checks on the defense IME Where the rebuttal report is weakest - Was 1 borderline validity result used to discard the whole battery? - Were pain, sleep, medication and mood ruled out before calling low effort exaggeration? - Did the examiner review the acute records or only later complaints? ##### Defense checks on the treating or retained report Where the deficit report is weakest - Were validity measures given, and reported in full? - Are deficits measured against age norms only, or against pre-injury school, work or military testing? - Were depression, PTSD, chronic pain and prior injuries weighed under criterion 6? - Was a full battery given inside the first 30 days? #### Getting the raw data Many psychologists will release test materials and raw scores only to another psychologist, citing test security and their professional ethics obligations. Plan early for a psychologist-to-psychologist exchange or a protective order. A report without raw data is hard to test, and a request made late in discovery will be fought on those grounds. If you remember one thing In a mild TBI case with normal imaging, the neuropsychology reports usually decide the damages. Their validity sections decide the neuropsychology reports. Read those first. Chapter 9 Building ### Reading a brain MRI report line by line Lawyers and nurse consultants rarely read the images. They read the report, and the report has a structure that tells you more than its impression line. The mock report below is a hypothetical, built from the fields every radiology report carries. The numbered notes say what to check in each. MRI brain without contrast Hypothetical report Exam Exam date — Day 22 after the collision1 Indication — MVC 3 wks ago. Persistent HA, memory complaints. R/O DAI. Referred by counsel.2 Technique — 3T. Sag T1, ax T2, FLAIR, DWI, SWI. No DTI.3 Comparison — CT head from ED, day 0. No prior MRI available.4 Findings Hemorrhage — 4 punctate foci of susceptibility at the right frontal gray-white junction; 1 in the splenium of the corpus callosum.5 Parenchyma — No contusion. Few nonspecific FLAIR foci in frontal white matter.6 Impression Impression — Findings may represent sequelae of hemorrhagic axonal injury in the appropriate clinical setting. Clinical correlation recommended.7 Signature — Electronically signed. Addendum day 24.8 PL 000412 1. 1 **Interval from injury** Yuh's MRIs averaged 12 days. Litigation MRIs often come months later, and experts will argue about what changed. 2. 2 **Indication field** What the radiologist was told. "Referred by counsel" will be read aloud at deposition. 3. 3 **Technique** Which sequences ran. SWI makes the microbleed count meaningful. DTI raw data is a separate request. 4. 4 **Comparison** No prior MRI, no baseline. Search pre-injury records for earlier brain imaging. 5. 5 **Count and location** 5 foci. Experts compare number, location and sequence with the literature, including Yuh's 4-or-more threshold. 6. 6 **Nonspecific findings** Findings with more than 1 possible cause. The defense quotes the word; the plaintiff's expert has to explain it. 7. 7 **Hedged impression** "May represent" leaves the link to trauma to the clinicians. Neither side should quote it as a diagnosis. 8. 8 **Addendum** Get every version with timestamps. Changes between them are often the key lines. #### Preliminary and final reads Overnight emergency CTs are often read first by an on-call or remote radiologist, then finalized later. The 2 versions do not always match. The hypothetical below shows the kind of change that can move a case from "normal CT" to mild TBI "with neuroimaging evidence of structural intracranial injury" under ACRM 2023. **ED head CT, preliminary and final report** — hypothetical — Illustration **Preliminary** — day 0, 19:48 CT head without contrast — No acute intracranial hemorrhage. No mass effect or midline shift. No acute intracranial abnormality. **Final** — day 1, 07:15 CT head without contrast — Trace hyperdensity in a left frontal sulcus, possibly a small amount of subarachnoid hemorrhage versus volume averaging. No mass effect or midline shift. Follow-up imaging could be considered if clinically indicated. If the patient was discharged at 21:05 on day 0, the treating team saw only the preliminary read. Whether anyone acted on the final read, and whether it was communicated, is its own line of inquiry. If you remember one thing Read a radiology report from the top: interval, indication, technique, comparison. The impression line is the radiologist's summary; the fields above it tell you what the summary is worth. Chapter 10 Everyone ### Where AI helps and where it fails on brain injury records A TBI file suits AI medical record review in 1 way and not another. The severity fight lives in text: EMS narratives, triage notes, neuro checks and discharge templates spread across thousands of pages and 6 or more providers. A large language model (LLM) can read, sort and cite those entries faster than a person. But the imaging is pixels, the neuropsychology is raw data held by a psychologist, and every judgment about severity and cause belongs to an expert. By hand Find every GCS and LOC entry — Page by page through EMS, ED, trauma and nursing records Spot "denies LOC" against a witnessed LOC — Only if the reviewer remembers both pages Missing records — Noticed when an expert asks for the run sheet Imaging on the timeline — Report dates typed in; images on a separate disc With AI and a human reviewer Find every GCS and LOC entry — Draft AI medical chronology of every entry, each with a page-level citation Spot "denies LOC" against a witnessed LOC — Conflicting entries surfaced side by side for a person to resolve Missing records — Records the file refers to but does not contain, flagged with the line that implies them Imaging on the timeline — Studies placed by date next to the clinical entries, for the expert to read #### Where it fails - **Images and DTI numbers.** A language model sees the report text. It cannot read an MRI, count microbleeds or judge an FA value. That is a neuroradiologist's job. - **OCR on EMS records.** Run sheets are often scans or photos, with handwritten notes. Optical character recognition (OCR) can read "13" as "15," and a misread GCS changes the grade. Low-confidence pages need a human read. - **Templated text.** "Neuro intact, GCS 15" can be carried forward by EHR templates or drafted by ambient scribe tools. Clinical natural language processing that trusts the text records an exam no one performed. - **Hallucination.** Generative AI can state a fact no page supports, such as an undocumented PTA duration. Where 30 minutes and 24 hours are thresholds, 1 invented figure can decide the grade. The fixes are the ones courts now expect. Ground every line in a retrieval-augmented, page-level citation so a person can check it in 1 click. Keep a human-in-the-loop reviewer who checks the cites before anything leaves the firm. Lawyers have been sanctioned under Rule 11 for filing briefs with fabricated AI-generated citations, and an invented clinical fact in an expert disclosure is the same failure in a different document. #### What to ask a vendor before uploading a TBI file 1 — ##### A citation on every line Every GCS, LOC and amnesia entry links to its source page. No citation, no use. 2 — ##### A signed BAA, SOC 2, no training on your data Brain injury files hold PHI, psychiatric history and sometimes substance use records. Get the business associate agreement before the first upload. 3 — ##### Handles scans and handwriting EMS and scene records must go through OCR with low-confidence pages flagged, not smoothed over. 4 — ##### Opens DICOM without interpreting it Imaging should sit on the timeline for the expert to read. A tool that claims to diagnose from DTI is a liability at deposition. 5 — ##### Says what it will not do No severity grade, no causation opinion, no admissibility call. Legal AI that claims those shifts risk onto you. For a wider look at AI document review tools for neuropsychologists and IME evaluators, see the [comparison for neuropsychology IME work](https://medrecords.ai/best/ai-tools-for-neuropsychology-ime-evaluators/). For the imaging question on its own, see [can AI read DICOM imaging](https://medrecords.ai/guides/can-ai-read-dicom-imaging/), and for the court question, [is AI accurate enough for court](https://medrecords.ai/guides/is-ai-accurate-enough-for-court/). If you remember one thing Use AI for the text of the first 72 hours: every GCS, every LOC note, every conflict and every missing record. Keep the images, the test data and every judgment about severity with the experts, and check every cited line. Chapter 11 Building ### Templates: the records request and the first 72 hours worksheet Copy these into your own forms. Adjust the legal basis line to your jurisdiction and to whether you are sending a HIPAA authorization, a subpoena or a discovery request. For the mechanics of each route, see [how to get medical records for a lawsuit](https://medrecords.ai/guides/how-to-get-medical-records-for-a-lawsuit/). ##### 1. Brain injury records request Send to each provider in the first 72 hours chain and to every imaging facility. Ask for each item by name; a general "medical records" request often misses the run sheet, the flowsheets and the images. RE: [PATIENT NAME], DOB [DATE] Date of injury: [DATE] Dates of service requested: [DATE] to [DATE] Legal basis: [HIPAA AUTHORIZATION / SUBPOENA / REQUEST FOR PRODUCTION] Please produce the complete record, including: SCENE AND TRANSPORT [ ] 911 call audio and dispatch (CAD) event log with timestamps [ ] EMS patient care report, all pages, including narrative, every Glasgow Coma Scale entry with components, and times [ ] EMS cardiac monitor or device data, if retained EMERGENCY AND TRAUMA CARE [ ] ED triage note and triage flowsheet [ ] ED physician and trauma team notes, including addenda [ ] Nursing flowsheets and neuro checks (GCS, pupils, orientation) for the full stay [ ] Laboratory results with collection and result times, including blood alcohol, drug screen, and any GFAP or UCH-L1 test (device name and reference cutoff) [ ] Discharge instructions and discharge summary IMAGING [ ] Every radiology report version: preliminary, final and each addendum, with timestamps and reader names [ ] Images in native DICOM format for every CT and MRI, all series, not screenshots or a viewer-only disc [ ] For any DTI study: raw diffusion series, scanner make, model and software version, acquisition parameters, analysis software and version, region selection method, and a description of the normative comparison data [ ] Any prior brain imaging on file for this patient FOLLOW-UP [ ] Urgent care, primary care and concussion clinic notes for the first 30 days, including symptom scales and any cognitive, balance or eye movement screening Please produce electronic records in native electronic format where available, and certify completeness. [NAME] [FIRM] [CONTACT] ##### 2. First 72 hours severity worksheet Fill in 1 row per entry, in time order. The last 2 columns are the ones experts read first. Fill them in as you go. CASE: [NAME] INJURY TIME: [DATE, HH:MM, SOURCE] CLOCK OFFSETS NOTED: EMS [+/- MIN] ED [+/- MIN] CT [+/- MIN] TIME | HOURS FROM INJURY | SOURCE, PAGE | AUTHOR ROLE | GCS (E/V/M or NT) | LOC | CONFUSION / AOC | AMNESIA (PTA) | SYMPTOMS | EXAM FINDING | CONFOUNDER NOTED | CONFLICT WITH | GAP BEFORE NEXT ENTRY SEVERITY CHECK (VA/DoD table: highest category met wins) Best GCS, first 24 hours: [ ] at [TIME], page [ ] LOC duration: [ ] source: [WITNESS / PATIENT / NONE] AOC duration: [ ] source: [ ] PTA duration: [ ] first documented: [DATE, PAGE] Imaging: CT [NORMAL/ABNORMAL, PAGE] MRI [ ] SWI run [Y/N] ACRM 2023 CHECK Criterion 1 mechanism: [ ] Criterion 2 signs: [ ] Criterion 3 symptoms under 72 hours: [ ] Criterion 4 exam or lab findings: [ ] Criterion 5 imaging: [ ] Criterion 6 confounders to address: [ ] Mild qualifier removed? LOC over 30 min [ ] GCS under 13 after 30 min [ ] PTA over 24 hours [ ] If you remember one thing Ask for images in native DICOM and for every report version. A viewer-only disc and a final report are what most productions contain, and they are not enough for an imaging expert on either side. Chapter 12 Publisher ### What Medrecords AI does with a brain injury file Medrecords AI is medical chronology software. It works on the records you upload; it does not request or retrieve records from providers. On a TBI file it does 5 things: - Builds a [cited chronology](https://medrecords.ai/product/chronology/) that pulls every entry on consciousness, amnesia, GCS, imaging and symptom onset from the first days, then follows the injury through neurology and neuropsychology, with [a citation on every line](https://medrecords.ai/product/citations/) back to the source page. The worksheet in chapter 11 starts as a draft instead of a blank sheet. - Suggests the [date of injury as a key date](https://medrecords.ai/product/key-date-auto-suggestion/), with the pages that support it, for a reviewer to confirm before it anchors the timeline. - [Flags missing records](https://medrecords.ai/product/missing-records-identification/) the file implies, such as an ED note that says "per EMS" with no run sheet in the production, or a report that mentions a prior MRI nobody produced. Each flag cites the line that implies it. - Routes scanned run sheets and handwritten pages through [OCR](https://medrecords.ai/product/ocr/) and flags low-confidence pages for a human read. - Loads CT and MRI studies as DICOM in a browser viewer and places them on the timeline through [imaging review](https://medrecords.ai/product/imaging/), so your neuroradiologist can cite a slice like a page. What it does not do: it does not read or interpret CT, MRI, SWI or DTI images, does not grade severity, does not decide causation or admissibility, and does not score a case. Flags are signals, not verdicts. It runs under SOC 2 and HIPAA with a signed BAA (see [security](https://medrecords.ai/security/) and [HIPAA](https://medrecords.ai/hipaa/) ). Self-Service bills 10 cents a deduplicated page, down to 5 cents at volume, duplicates free; Enterprise On-Prem is an annual license. More on the use case: [traumatic brain injury record review](https://medrecords.ai/solutions/traumatic-brain-injury-record-review/). For what happens after severity is settled, see the companion guide on [TBI causation and long-term impact](https://medrecords.ai/guides/tbi-causation-long-term-impact/). The offer #### See the first 72 hours of your own TBI file on 1 cited timeline. Book a demo on a brain injury file you are working, then run your first case free on us. Every line comes back cited to its source page. You review, you revise, you sign. [Book a demo](https://medrecords.ai/demo/) [See imaging review](https://medrecords.ai/product/imaging/) Scheduling only. No records move from a public page. Chapter 13 Everyone ### Frequently asked questions Does a normal CT scan rule out a traumatic brain injury?No. CT finds bleeding, swelling and fractures that may need treatment. The ACRM 2023 criteria say neuroimaging is not necessary to diagnose mild TBI. In 1 multicenter study, 27% of mild TBI patients with a normal CT had an abnormal MRI about 12 days later. What GCS score counts as a mild TBI?13 to 15. The VA/DoD guideline uses the best available score in the first 24 hours; the ACRM uses the score after 30 minutes. Moderate is 9 to 12 and severe is under 9. If another criterion, such as PTA, points to a higher grade, the higher grade applies. What is diffuse axonal injury?Damage to the brain's long nerve fibers from rapid acceleration, deceleration or rotation of the head. Much of it is microscopic, but tiny bleeds that come with it can show on MRI, especially on SWI. Is DTI admissible to prove a mild TBI?It depends on the court, the rule applied and the documentation behind the study. Critics point to non-specific findings, missing normative databases and group data applied to 1 person. Read the opinions in your jurisdiction. What does a GFAP and UCH-L1 blood test show?For the first FDA-cleared test, a negative result in an adult with GCS 13 to 15, drawn within 12 hours, is associated with no acute lesion on head CT. It helps decide whether a CT is needed. It does not diagnose concussion; fewer than 1 in 10 positive results in the FDA study had a CT lesion. When should neuropsychological testing be done after a mild TBI?The VA/DoD guideline suggests against comprehensive neuropsychological testing in the first 30 days. Any forensic evaluation should include validity testing; the AACN 2021 consensus says all clinical and forensic evaluations must address whether results are valid. Can AI read a brain MRI or a DTI scan for a lawsuit?Not for litigation. AI tools can open DICOM studies, place them on a timeline and cite what the radiology report says, but reading the images, counting microbleeds and judging DTI values are tasks for a neuroradiologist. Can AI software find every GCS and loss of consciousness entry in a TBI file?AI medical record review can pull those entries from EMS, ED and nursing records and cite each to its page. A person should check every cite, especially on scanned run sheets where OCR can misread a 13 as a 15. Is it HIPAA compliant to upload brain injury records to an AI tool?It can be, with a vendor that signs a business associate agreement, holds SOC 2, does not train on your data and controls access. Consumer chatbots without a BAA are the wrong place for a file with psychiatric and substance use history. Can ChatGPT build a TBI medical chronology?A general chatbot can summarize pasted text, but it gives no page citations and can invent a GCS or a duration. For a chronology an expert will rely on, use a tool that cites every line to its page, and check each cite. Chapter 14 Everyone ### Sources and method Every figure, cutoff and criterion here was checked against the primary source in September 2026. Quotes are verbatim. The crash timeline, the MRI report and the CT report versions are hypothetical. No court opinion is cited because none was reviewed. Nothing here is legal or medical advice. - [VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of Post-Acute Mild Traumatic Brain Injury, version 3.0, 2021](https://www.healthquality.va.gov/guidelines/Rehab/mtbi/VADoDmTBICPGFinal508.pdf): severity table 1 and its footnotes, recommendations 4 and 6 and their discussion. - [Silverberg ND, Iverson GL and colleagues, American Congress of Rehabilitation Medicine diagnostic criteria for mild traumatic brain injury, Arch Phys Med Rehabil 2023;104(8):1343 to 1355](https://pubmed.ncbi.nlm.nih.gov/37211140/), read in the [author version](https://repository.uantwerpen.be/docstore/d:irua:19767) with its supplement, which reprints the 1993 ACRM definition (Kay and colleagues, J Head Trauma Rehabil 1993;8(3):86 to 87). - [FDA De Novo decision summary DEN170045, Banyan Brain Trauma Indicator](https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN170045.pdf): indications for use, clinical performance and labeling limitations. - [American College of Radiology Appropriateness Criteria, Head Trauma](https://acsearch.acr.org/docs/69481/Narrative/): rating tables for variants 1 to 10. - [Glasgow Coma Scale, official site](https://www.glasgowcomascale.org/what-is-gcs/): components, sum score, the NT rule for untestable components, interfering factors and reliability. - [Federal Rule of Evidence 702 and the 2023 committee note](https://www.law.cornell.edu/rules/fre/rule_702); [Supreme Court order of April 24, 2023](https://www.supremecourt.gov/orders/courtorders/frev23_5468.pdf) setting the December 1, 2023 effective date. - [Yuh EL and colleagues, Magnetic resonance imaging improves 3-month outcome prediction in mild traumatic brain injury, Ann Neurol 2013;73(2):224 to 235](https://europepmc.org/article/MED/23224915). - [Wortzel HS and colleagues, Diffusion tensor imaging in mild traumatic brain injury litigation, J Am Acad Psychiatry Law 2011;39(4):511](https://jaapl.org/content/39/4/511). - [Sweet JJ and colleagues, AACN 2021 consensus statement on validity assessment, The Clinical Neuropsychologist 2021](https://europepmc.org/article/MED/33823750). - [Ashwal S and colleagues, Susceptibility-weighted imaging and proton magnetic resonance spectroscopy in assessment of outcome after pediatric traumatic brain injury, Arch Phys Med Rehabil 2006](https://europepmc.org/article/MED/17140880). Related guides: [TBI causation and long-term impact](https://medrecords.ai/guides/tbi-causation-long-term-impact/), [blunt force trauma medical records](https://medrecords.ai/guides/blunt-force-trauma-medical-records/), [eggshell plaintiff and pre-existing conditions](https://medrecords.ai/guides/eggshell-plaintiff-pre-existing-conditions/), [how to write a medical chronology](https://medrecords.ai/guides/how-to-write-a-medical-chronology/). Related solutions: [sports concussion and CTE record review](https://medrecords.ai/solutions/sports-concussion-cte-record-review/), [motor vehicle accident record review](https://medrecords.ai/solutions/motor-vehicle-accident-record-review/), [personal injury defense](https://medrecords.ai/solutions/personal-injury-defense/), [legal nurse consultants](https://medrecords.ai/solutions/legal-nurse-consultants/). ### More guides - [**The eggshell plaintiff rule and pre-existing conditions: how prior records decide the case** — The eggshell plaintiff rule, aggravation and apportionment explained, what the defense looks for in prior…](https://medrecords.ai/guides/eggshell-plaintiff-pre-existing-conditions/) - [**Toxicology reports in litigation: how to read clinical and postmortem results without losing the case** — How to read a toxicology report for litigation: immunoassay screens versus GC-MS confirmation, serum alcohol…](https://medrecords.ai/guides/toxicology-report-litigation/) - [**Traumatic brain injury lawsuits: causation, long-term impact and the evidence that survives cross** — How a traumatic brain injury lawsuit is proven or defended from the records: causation attacks, post-concussion…](https://medrecords.ai/guides/tbi-causation-long-term-impact/) - [**UB-04 and CMS-1500: how to read the claim forms behind a medical bill** — What each box on a UB-04 and a CMS-1500 claim form means, the codes on them, a worked bill-to-record match…](https://medrecords.ai/guides/ub-04-and-cms-1500/) - [**What is a medical chronology?** — What a medical chronology is, what a good one includes, how it differs from a summary or narrative, who uses…](https://medrecords.ai/guides/what-is-a-medical-chronology/) - [**What is an attending physician statement (APS)? A field guide for underwriting and disability claims** — What an attending physician statement contains, how underwriters and LTD claims teams read one, the ERISA and…](https://medrecords.ai/guides/attending-physician-statement/)