CT - ARCHIVE

Definition

CT diagnoses based on a combination of reports taken from radio-graphic CT scan results within 7 days of injury.

“CT Data” form: See SOP 0. Current Forms

Code CTStatus as 99-unknown if CT scans/reports done, but unavailable

Form

[X] Form 1
[ ] Form 2

Source

To be coded by a CT certified individual from all CT reports of the head and/or neck dated within 7 days of injury.

Details

A properly trained person at the facility who has been certified following TBIMS procedures may code this variable.

Do not use MRI findings to code this variable.

If CT reports are not available from a system acute hospital, CT reports from non-system hospitals may be used if available.

CTA (CT angiography) reports should not be included.

Findings, including old infarcts and midline shift, should be coded as ‘present’ regardless of cause.

Characteristics

All CT variables were removed from data collection on 6/30/2025.

Training

Testing and certification of collectors of this variable is required. It is available from the National Data and Statistical Center.

A score of 80% or greater is required for certification.

Variables

Form Type

Variable

ID

Question

History

Form 1

CTStatus

429

CT status

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CTComp

425

Extent of compression

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CTIntracrain

427

1. Intracranial hemorrhage and/or contusions, extra-axial collections

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CTPunctate

428

2. Punctate/petechial hemorrhages

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CTSubarachnioid

428

3. Subarachnoid hemorrhage

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CTIntraventricular

428

4. Intraventricular hemorrhage

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5a1CorticalLFront

422

5a1. Left frontal

1989-10-01 - Variable Added
2025-06-30 - Variable REMOVED

Form 1

CT5a2CorticalRFront

422

5a2. Right frontal

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5a3CorticalNFront

422

5a3. Laterality N/S frontal

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5b1CorticalLTemp

422

5b1. Left temporal

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5b2CorticalRTemp

422

5b2. Right temporal

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5b3CorticalNTemp

422

5b3. Lat. N/S temporal

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5c1CorticalLPar

422

5c1. Left parietal

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5c2CorticalRPar

422

5c2. Right parietal

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5c3CorticalNPar

422

5c3. Lat. N/S parietal

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5d1CorticalLOcc

422

5d1. Left occipital

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5d2CorticalROcc

422

5d2. Right occipital

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5d3CorticalNOcc

422

5d3. Lat. N/S occipital:

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5e1CorticalLUnk

422

5e1. Left location N/S

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5e2CorticalRUnk

422

5e2. Right location N/S

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT5e3CorticalNUnk

422

5e3. Lat. N/S location N/S

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT6aNonCortL

423

6a1. Left

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT6aNonCortR

423

6a2. Right

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT6aNonCortN

423

6a3. Lat. N/S

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7a1AxialLEpi

424

7a1. Left epidural

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7a2AxialREpi

424

7a2. Right epidural

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7a3AxialNEpi

424

7a3. Lat. N/S epidural

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7b1AxialLSub

424

7b1. Left subdural (non-falcine)

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7b2AxialRSub

424

7b2. Right subdural (non-falcine)

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7b3AxialNSub

424

7b3. Lat. N/S subdural (non-falcine)

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7c1AxialLNS

424

7c1. Left location N/S

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7c2AxialRNS

424

7c2. Right location N/S

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7c3AxialNNS

424

7c3. Lat. N/S location N/S

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7d1FalcineSub

424

7d1. Falcine/tentorial subdural hemorrhage

2015-01-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7d2FalcineSAH

424

7d2. Falcine/tentorial subarachnoid hemorrhage

2015-01-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CT7d3FalcineUnk

424

7d3. Falcine/tentorial hemorrhage unspecified

2015-01-01 - Variable Added
2025-06-30 - Variable Removed

Form 1

CTFrag

426

Intraparenchymal fragments

1989-10-01 - Variable Added
2025-06-30 - Variable Removed

Codes and Values

ID 422

For Form: [Form 1]
For Variables: [CT5a1CorticalLFront, CT5a2CorticalRFront, CT5a3CorticalNFront, CT5b1CorticalLTemp, CT5b2CorticalRTemp, CT5b3CorticalNTemp, CT5c1CorticalLPar, CT5c2CorticalRPar, CT5c3CorticalNPar, CT5d1CorticalLOcc, CT5d2CorticalROcc, CT5d3CorticalNOcc, CT5e1CorticalLUnk, CT5e2CorticalRUnk, CT5e3CorticalNUnk]

Code

Description

0

No

1

Yes

66

Variable Did Not Exist

88

CT Not Done

99

Unknown

ID 423

For Form: [Form 1]
For Variables: [CT6aNonCortL, CT6aNonCortR, CT6aNonCortN]

Code

Description

0

No

1

Yes

66

Variable Did Not Exist

88

CT Not Done

99

Unknown

ID 424

For Form: [Form 1]
For Variables: [CT7a1AxialLEpi, CT7a2AxialREpi, CT7a3AxialNEpi, CT7b1AxialLSub, CT7b2AxialRSub, CT7b3AxialNSub, CT7c1AxialLNS, CT7c2AxialRNS, CT7c3AxialNNS, CT7d1FalcineSub, CT7d2FalcineSAH, CT7d3FalcineUnk]

Code

Description

0

No

1

Yes

66

Variable Did Not Exist

88

CT Not Done

99

Unknown

ID 425

For Form: [Form 1]
For Variables: [CTComp]

Code

Description

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

66

Variable Did Not Exist

88

CT Not Done

99

Unknown

ID 426

For Form: [Form 1]
For Variables: [CTFrag]

Code

Description

0

No Fragment(s)

1

Yes Fragment(s)

66

Variable Did Not Exist

88

No CT done

99

Unknown

ID 427

For Form: [Form 1]
For Variables: [CTIntracrain]

Code

Description

0

No Visible Pathology

1

Yes, Pathology Exists

66

Variable Did Not Exist

88

CT Not Done

99

Unknown

ID 428

For Form: [Form 1]
For Variables: [CTPunctate, CTSubarachnioid, CTIntraventricular]

Code

Description

0

No

1

Yes

66

Variable Did Not Exist

88

CT Not Done

99

Unknown

ID 429

For Form: [Form 1]
For Variables: [CTStatus]

Code

Description

0

CT Not Done

1

CT Done

66

Variable Did Not Exist

99

Unknown ( CT scans/reports done, but unavailable )

History

Date

Description

1996-05-15

Changed DEFINITION : dropped laterality for punctate, subarachnoid and intraventricular hemorrhages; dropped location for noncortical contusions. Retrospective coding to be done for all cases with system admissions as of 1/1/94. Use code 0 for all cases prior to that date if data was not collected.

1997-01-01

Added CODE : 0 for variable not in existence.

1998-09-01

Changed NOTE : regarding coding no fragments.

1999-04-01

Changed DEFINITION : substituted "non-hemorrhagic" for "bland" for description of contusion.

1999-04-01

Added NOTE : regarding not using MRI data.

2004-01-01

Added NOTE : that a trained person who is TBIMS certified may code this variable.

2005-01-01

Added CODE : '8 (CT not done)' to items B2-7.

2005-04-01

Added CODE : '9 - unknown' to all items in sections B2 through B6.

2007-04-01


Added NOTE : to code tentorial collections as SAH.

2013-01-01

Added NOTE : contact NDSC (instead of Santa Clara)

2014-10-01

Added NOTE: "If CT reports are not available from a system acute hospital, CT reports from non-system hospitals may be used if available."

2016-01-01

Changed DEFINITION : to include items 7d, 1,2 and 3 Falcine or Tentorial items.

2017-10-01

Added NOTE : CTA (CT angiography) reports should not be included.

2022-10-01

Added to TRAINING : "A score of 80% or greater is required for certification".

2024-07-01

Added NOTE: Findings, including old infarcts and midline shift, should be coded as 'present' regardless of cause.

2025-06-30

All CT variables were removed from data collection on 6/30/2025.