INTRACRANIAL CT DIAGNOSIS
Variable 135
date of last revision: 04/01/05
DEFINITION:
CT diagnoses based on a combination of reports taken from radiographic CT scan results within 7 days of injury. See: 27a.Guidelines for Completing Variable 135 in Appendix N.

CT diagnosis data collection form: 27b.Intracranial CT Diagnosis Data Collection Form.
CODE:
[It is not possible to display information in columns in the live syllabus, which is important for displaying the codes for V135. A more neatly formated display of the codes than below is available at: Codes for v135.]


A. EXTENT OF INTRACRANIAL COMPRESSION - use only one of the following codes:
0 Variable did not exist when data collected for this case
1 No visible intracranial compression
2 Cisterns are present but midline shift is noted of 1-5 mm.
3 Cisterns compressed or absent with midline shift of 0-5 mm. compression
4 Midline shift of greater than 5 mm.
5 Extent not specified
8 CT not done
9 Unknown if intracranial

B. PATHOLOGY:
0 Variable did not exist when data collected for this case
1 No visible pathology
2 Yes, pathology exists
8 CT not done
9 Unknown if pathology

2. Punctate/petechial hemorrhages, with/without cerebral swelling:
1=No 2=Yes 8=CT not done *9 Unknown if pathology

3. Subarachnoid hemorrhage:
1=No 2=Yes 8=CT not done *9 Unknown if pathology

4. Intraventricular hemorrhage:
1=No 2=Yes 8=CT not done *9 Unknown if pathology

5. Focal cortical parenchymal contusions (non-hemorrhagic/hemorrhagic) or hemorrhage in cerebral cortex; indicate all by laterality and location:
a1. Left, Frontal: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
a2. Right, Frontal: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
a3. Laterality not specified, Frontal: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
b1. Left, Temporal: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
b2. Right, Temporal: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
b3. Laterality not specified, Temporal: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
c1. Left, Parietal: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
c2. Right, Parietal: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
c3. Laterality not specified, Parietal: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
d1. Left, Occipital: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
d2. Right, Occipital: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
d3. Laterality not specified, Occipital: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
e1. Left, Location not specified: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
e2. Right, Location not specified: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
e3. Laterality and Location not specified: 1=No 2=Yes 8=CT not done *9 Unknown if pathology

6. Focal noncortical parenchymal contusions (non-hemorrhagic/hemorrhagic) or hemorrhage; includes cerebellum, brainstem, pons, thalamus, basal ganglion and internal capsule: indicate laterality.
a. Left: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
b. Right: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
c. Laterality not specified: 1=No 2=Yes 8=CT not done *9 Unknown if pathology

7. Presence of any extra-axial collection
a1. Left, Epidural: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
a2. Right, Epidural: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
a3. Laterality not specified, Epidural: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
b1. Left, Subdural: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
b2. Right, Subdural: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
b3. Laterality not specified, Subdural: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
c1. Left, location not specified: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
c2. Right, location not specified: 1=No 2=Yes 8=CT not done *9 Unknown if pathology
c3. Laterality and location not specified: 1=No 2=Yes 8=CT not done *9 Unknown if pathology

C. INTRAPARENCHYMAL FRAGMENTS:

1 No fragment(s)
2 Yes fragment(s)
8 No CT done
9 Unknown if fragments
0 Variable did not exist when data collected for this case
CHARACTERS:
1 numeric
NOTE:
Do not use MRI findings to code this variable.

A properly trained person at the facility who has been certfied by TBIMS procedures may code this variable (see syllabus section 27a).
TRAINING:
Testing and certification of collectors of this variable is required. It is available from the Northern California TBI Model System (contact Jerry Wright at Jerry.Wright@hhs.co.santa-clara.ca.us.)
EXAMPLE:
Patient had a CT scan demonstrating no intracranial compression. There was a right subarachnoid hemorrhage and bone fragments present in the right temporal area.

A. EXTENT OF COMPRESSION: 1

B. PATHOLOGY:
1. 2
2. 1
3. 2
4. 1
5a1. 1
5a2. 1
5a3. 1
5b1. 1
5b2. 1
5b3. 1
5c1. 1
5c2. 1
5c3. 1
5d1. 1
5d2. 1
5d3. 1
5e1. 1
5e2. 1
5e3. 1
6a. 1
6b. 1
6c. 1
7a1. 1
7a2. 1
7a3. 1
7b1. 1
7b2. 1
7b3. 1
7c1. 1
7c2. 1
7c3. 1

C. INTRAPARENCHYMAL FRAGMENTS: 2

Traumatic Brain Injury Model System National Database Live Syllabus V10.3
Monday, September 25, 2006 10:34am  .   comments/questions?
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