Brain Magnetic Resonance Imaging (MRI)



Has brain MRI been performed? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, have multiple brain MRIs been performed? FORMCHECKBOX Yes FORMCHECKBOX No, single brain MRIIf yes, how many have been performed? FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX >6Table for recording MRI resultsBrain MRIDate Performed (yyyy-mm-dd)Age of affectedWhere Performed1stData to be entered by site[derived field]Data to be entered by site2ndData to be entered by site[derived field]Data to be entered by site3rdData to be entered by site[derived field]Data to be entered by siteWas sedation used? FORMCHECKBOX Yes FORMCHECKBOX NoGeneral description of field of view/ anatomical positioning:Magnetic field strength of scanner used: FORMCHECKBOX 1.5 T FORMCHECKBOX 3.0 T FORMCHECKBOX 4.0 T FORMCHECKBOX 7.0 T FORMCHECKBOX Other: TBody part scanned: FORMCHECKBOX Brain FORMCHECKBOX Cervial spine FORMCHECKBOX Thoracic spine FORMCHECKBOX Lumbar spineHead circumference at time of scan: cmTotal time in scanner (include all studies done within each particular session): :HH:MMRF receiver coil(s) and number of channels: (check all that apply) FORMCHECKBOX Head coil, FORMCHECKBOX Neck coil, FORMCHECKBOX Spine Array, FORMCHECKBOX Body coil (transmit)Sequences used: FORMCHECKBOX T1-weighted FORMCHECKBOX T2-weighted FORMCHECKBOX FLAIR FORMCHECKBOX Other:Specify sequence name of T1 or T2 used:Contrast used: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, name of the contracts: dosage:T1-MRI sequence parametersSlice orientation: FORMCHECKBOX Axial FORMCHECKBOX Coronal FORMCHECKBOX Sagittal FORMCHECKBOX ObliqueField of view: x mm2In-plane resolution: x mm2Slice thickness: mmGap between slices: mm or % (for 2D acquisition)Number of slices:Repetition time (TR): msEcho time (TE): msAcquisition time: minutes FORMCHECKBOX Check box if items #7a-f are the same for all sequences.T2 sequence parameters (copy the following sections if parameters are different for the 2 sequences)Slice orientation: FORMCHECKBOX Axial FORMCHECKBOX Coronal FORMCHECKBOX Sagittal FORMCHECKBOX ObliqueField of view: x mm2In-plane resolution: x mm2Slice thickness: mmGap between slices: mm or %Number of slices:Repetition time (TR): msEcho time (TE): msAcquisition time: minutesFLAIR sequence parameters (copy the following sections if parameters are different for the 2 sequences)Slice orientation: FORMCHECKBOX Axial FORMCHECKBOX Coronal FORMCHECKBOX Sagittal FORMCHECKBOX ObliqueField of view: x mm2In-plane resolution: x mm2Slice thickness: mmGap between slices: mm or %Number of slices:Repetition time (TR): msEcho time (TE): msAcquisition time: minutesInversion time (TI): msName of the scanner manufacturer: FORMCHECKBOX GE FORMCHECKBOX Siemens FORMCHECKBOX Philips FORMCHECKBOX Toshiba FORMCHECKBOX Other:Clinical read of MRIsRead type: FORMCHECKBOX Local FORMCHECKBOX CentralReader blinded to clinical data? FORMCHECKBOX Yes FORMCHECKBOX NoQuality of images technically satisfactory? FORMCHECKBOX Yes FORMCHECKBOX NoLesions found FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, type of lesion(s): FORMCHECKBOX Malformation FORMCHECKBOX WM hyperintensity FORMCHECKBOX Grey matter hyperinsity FORMCHECKBOX Infarct FORMCHECKBOX Other, specify:If infarct or other abnormalities, specify:Other incidental findings FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, indicate Type(s): FORMCHECKBOX PVL FORMCHECKBOX Other white matter intensities FORMCHECKBOX Venous malformations FORMCHECKBOX Vascular malformations FORMCHECKBOX Other, specifyMalformationsCortex – Pachygyria (includes cobblestone lissencephaly): FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, indicate location(s): FORMCHECKBOX Frontoparietal FORMCHECKBOX Temporal FORMCHECKBOX OccipitalIf Yes, indicate thickness of the cortex:Cortex Lissencephaly (LIS type 1): FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, indicate thickness of the cortex:Cortex – Polymicrogyria: FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, indicate location(s): FORMCHECKBOX Frontoparietal FORMCHECKBOX Temporal FORMCHECKBOX OccipitalOther cortical abnormality: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, specify: FORMCHECKBOX Schizencephaly FORMCHECKBOX Porencephaly FORMCHECKBOX Other, specify:If yes, indicate location (s): FORMCHECKBOX Frontoparietal FORMCHECKBOX Temporal FORMCHECKBOX OccipitalSubcortical cysts: FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, indicate location(s): FORMCHECKBOX Frontoparietal FORMCHECKBOX Temporal FORMCHECKBOX OccipitalVentricles: FORMCHECKBOX Normal FORMCHECKBOX AbnormalIf Abnormal, specify: FORMCHECKBOX Dilation FORMCHECKBOX Other, specify:Brainstem: FORMCHECKBOX Normal FORMCHECKBOX AbnormalIf Abnormal, specify: FORMCHECKBOX Hypoplasia FORMCHECKBOX Anterior concavity FORMCHECKBOX Posterior concavity FORMCHECKBOX OtherPons: FORMCHECKBOX Normal FORMCHECKBOX AbnormalIf Abnormal, specify: FORMCHECKBOX Hypoplasia FORMCHECKBOX Cleft FORMCHECKBOX OtherCerebellum: FORMCHECKBOX Normal FORMCHECKBOX AbnormalIf Abnormal, specify: FORMCHECKBOX Vermal hypoplasia FORMCHECKBOX Hemispheric hypoplasia FORMCHECKBOX Vermal dysplasia FORMCHECKBOX Hemispheric dysplasia FORMCHECKBOX Cysts FORMCHECKBOX Cleft FORMCHECKBOX Other, specifyWhite matter hyperintensityWhite matter on T2 weighted images: FORMCHECKBOX Normal FORMCHECKBOX AbnormalIf Abnormal, indicate location(s): FORMCHECKBOX Frontal FORMCHECKBOX Parietal FORMCHECKBOX Temporal FORMCHECKBOX Occipital FORMCHECKBOX Periventricular FORMCHECKBOX Deep WM FORMCHECKBOX Cerebellar WM FORMCHECKBOX DiffuseCompacted white matter tracts:Corpus Callosum FORMCHECKBOX Involved FORMCHECKBOX SparedInternal capsule FORMCHECKBOX Involved FORMCHECKBOX SparedAnterior commissure FORMCHECKBOX Involved FORMCHECKBOX SparedGrey matter hyperintensityGrey matter hyperintensity on T2/FLAIR images: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, specify: FORMCHECKBOX Caudate FORMCHECKBOX Putamen FORMCHECKBOX Pallidum FORMCHECKBOX Thalamus FORMCHECKBOX Subthalamic nucleus FORMCHECKBOX Mammillary body FORMCHECKBOX Substantia nigra FORMCHECKBOX Red Nucleus FORMCHECKBOX Periaqueductal Grey FORMCHECKBOX Cerebellar Nuclei FORMCHECKBOX Floor of the Fourth Ventricle FORMCHECKBOX Colliculi FORMCHECKBOX OtherEye abnormalities: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, specify: FORMCHECKBOX Optic Nerve Abnormalities FORMCHECKBOX Microphthalmia FORMCHECKBOX CataractGeneral InstructionsThis form contains data elements that are collected for Brain Magnetic Resonance Imaging. Responses to categories are obtained from health professionals performing the procedure. CMD-specific Instructions:The elements on this CRF are Supplemental – Highly Recommended for dystroglycanopathies; Supplemental for MDC1A; and Exploratory for all other congenital muscular dystrophies.Specific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module.Multiple MRIs performed – Answer, only if brain MRI was performed.Brain MRI date performed - Date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.) and in the format acceptable to the study database.Brain MRI age of affected – This is recorded for each brain MRI performed. This is a derived element based on Date of Birth and Visit Date.Scanner strength – Choose one.Body part scanner – Choose one.Head circumference - Record the head circumference of the participant/subject as well as the units for the measurement. Answer should be recorded in centimeters (cm)RF receiver coil(s) and number of channels – Choose all that applyT2 sequence parameters – If the sequences are different for T1 and T2 sequence parameters, record the T2 parameters as indicated. If they are the same, leave the T2 parameters section blank.FLAIR sequence parameters – If the sequences are different for T1 and FLAIR sequence parameters, record the FLAIR parameters as indicated. If they are the same, leave the FLAIR parameters section blank.Contrast used - Choose one. If yes, record the name of the contrast agent and its dosage.Field of view - Answer should be recorded as a dimension (AAxAA) and in millimeters squared (mm2).Plane resolution - Answer should be recorded as a dimension (AAxAA) and in millimeters squared (mm2)Slice thickness - Answer should be recorded in millimeters squared (mm2)Gap between slices - Answer should be recorded in millimeters squared (mm2) or % (for 2D acquisition)Repetition time – Answer should be recorded in milliseconds (ms)Acquisition time – Answer should be recorded in minutes ................
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