What is the impression of a computed tomography (CT) scan of the head that shows no focal findings, no intracranial hemorrhage, mass, or infarct, and normal gray-white differentiation?

From the Guidelines

The patient can be safely discharged with no need for further imaging or observation, given the normal CT head findings and no evidence of neurologic deterioration, as the risk of deterioration with a normal CT and neurologic examination is very low (0.006%) 1. The CT scan of the head shows normal findings with no evidence of any abnormalities, such as intracranial hemorrhage, mass, or infarct. The brain tissue appears healthy with no signs of bleeding, tumors, or stroke. The ventricles (fluid-filled spaces) and surrounding structures are normal in size and position.

• Key findings include:
  • No mass effect or midline shift
  • Preserved gray-white differentiation
  • Normal caliber of the ventricles and basal cisterns
  • Intact calvaria and skull base with no aggressive bone lesion There is a retention cyst or mucosal polyp in the sphenoid sinus, which was also present on a previous CT scan from April 9,2025, indicating this is a stable finding and not concerning, as supported by the low rate of intracranial complications within 72 hours in patients with a negative head CT 1.
• The presence of this cyst/polyp is common and typically asymptomatic, requiring no treatment unless it causes symptoms. Overall, this is a completely normal CT scan of the head with no findings that require medical intervention or follow-up, and the patient can be managed based on their clinical presentation and neurologic examination, with consideration for further imaging or observation only if there is evidence of neurologic deterioration 1.

From the Research

CT Head Scan Findings

• The brain parenchyma demonstrates no focal finding, with no intracranial hemorrhage, mass, or infarct 2
• The gray-white differentiation is preserved, and the ventricles and basal cisterns are normal in caliber, with no mass effect or midline shift
• The calvaria and skull base are intact, with no aggressive bone lesion

Mucous Retention Cysts

• A retention cyst/mucosal polyps in the sphenoid sinus was found, similar to a CT performed on April 9,2025
• Studies have shown that cone-beam computed tomography (CBCT) scans can detect mucous retention cysts more accurately than panoramic radiography 3, 4
• The presence of mucous retention cysts has been correlated with potential influencing factors, including age, sex, and dentoalveolar pathology 4

Clinical Implications

• Routine follow-up CT scans may be beneficial in patients with minimal brain injury, as they can lead to higher levels of medical management or neurosurgical intervention in patients with worsening CT findings 5
• The detection of mucous retention cysts can be important for diagnosis and treatment, particularly in cases where they may be associated with obstructive sinus phenomena 6
• A normal CT head scan, as in this case, can help rule out certain conditions, such as intracranial hemorrhage or mass effect, and guide further management and treatment 2