Surgery and Pathology



Date of Surgery (MM/DD/YYYY):Suspected pathology (Choose all that apply): FORMCHECKBOX Mesial temporal sclerosis FORMCHECKBOX Neoplasm FORMCHECKBOX Cortical dysplasia FORMCHECKBOX Tuberous sclerosis FORMCHECKBOX Cavernous malformation FORMCHECKBOX Arteriovenous malformation FORMCHECKBOX Malformation of cortical development FORMCHECKBOX Hemorrhage FORMCHECKBOX Stroke FORMCHECKBOX Infection FORMCHECKBOX Gliosis, traumatic FORMCHECKBOX Gliosis, unknown FORMCHECKBOX Unknown FORMCHECKBOX Other, specify:Surgical Data Details Table ProcedureDetails FORMCHECKBOX Diagnostic (If applicable)ElectrodesElectrode Location FORMCHECKBOX Depth FORMCHECKBOX Hippocampus FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Insula FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Amygdala FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Other, specify:___________ FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Subdural FORMCHECKBOX Hippocampus FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Insula FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Amygdala FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Other, specify:___________ FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Epidural FORMCHECKBOX Hippocampus FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Insula FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Amygdala FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Other, specify:___________ FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Foramen ovale FORMCHECKBOX Hippocampus FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Insula FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Amygdala FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Other, specify:___________ FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Interhemispheric FORMCHECKBOX Hippocampus FORMCHECKBOX Frontal FORMCHECKBOX Temporal FORMCHECKBOX Parietal FORMCHECKBOX Occipital FORMCHECKBOX Insula FORMCHECKBOX Amygdala FORMCHECKBOX Other, specify: ___________ FORMCHECKBOX Other, specify: FORMCHECKBOX Hippocampus FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Insula FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Amygdala FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Other, specify: ___________ FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX Anterior Temporal Lobectomy (ATL)Laterality FORMCHECKBOX Left FORMCHECKBOX RightEstimate of size of resection based on (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingSuperior temporal gyrus (cm): ___Middle temporal gyrus (cm): ___Inferior temporal gyrus (cm): ___Parahippocampal gyrus (cm): ___Amygdala (% of total): ___Hippocampus (cm): ___ FORMCHECKBOX Anterior Temporal Lobectomy plus (ATL+)(Complete in addition to ATL section above, if applicable.)Adjacent resection: FORMCHECKBOX Yes FORMCHECKBOX NoLocation of resection beyond ATL (Choose all that apply): FORMCHECKBOX Lateral temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Orbitofrontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Dorsolateral frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Medial frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Central cortex FORMCHECKBOX Left FORMCHECKBOX RightEstimate of size of resection beyond ATL based on (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingLargest Dimension: AP (cm): ___ Largest Dimension: LAT (cm): ___Largest Dimension: Depth (cm): ___ Volume of resected tissue (cm3): ___ FORMCHECKBOX AmygdalohippocampectomyLaterality: FORMCHECKBOX Left FORMCHECKBOX RightApproach to hippocampus: FORMCHECKBOX Sylvian Fissure FORMCHECKBOX Superior temporal gyrus/sulcus FORMCHECKBOX Middle temporal gyrus/sulcus FORMCHECKBOX Sub-temporal FORMCHECKBOX Other, specify:Estimate of size of resection based on (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingParahippocampal gyrus (cm): ___Amygdala (% of total): ___Hippocampus (cm): ___ FORMCHECKBOX LesionectomyLocation of lesion (Choose all that apply): FORMCHECKBOX Lateral temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Medial temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Hypothalamus FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Orbitofrontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Dorsolateral frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Medial frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Central cortex FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Insula FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Multifocal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Other, specify: FORMCHECKBOX Left FORMCHECKBOX RightExtent of resection (Choose all that apply): FORMCHECKBOX Incomplete lesion removal FORMCHECKBOX Complete lesion removal FORMCHECKBOX Removal of one lesion, others remain FORMCHECKBOX Unknown FORMCHECKBOX Other, specify:Extent of size of resection based on (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imaging FORMCHECKBOX Lesionectomy+(Complete in addition to Lesionectomy section above, if applicable.)Adjacent resection: FORMCHECKBOX Yes FORMCHECKBOX NoExtent of resection (Choose all that apply): FORMCHECKBOX Lesion + anatomically abnormal adjacent brain FORMCHECKBOX Lesion + electrically abnormal adjacent brainEstimate of size of resection beyond lesionectomy based on (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingLargest Dimension: AP (cm): ___Largest Dimension: LAT (cm): ___Largest Dimension: Depth (cm): ___Volume of resected tissue (cm3): ___ FORMCHECKBOX Neocortical resection (Topectomy)Location (Choose all that apply): FORMCHECKBOX Lateral temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Orbitofrontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Dorsolateral frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Medial frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Central cortex FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Insula FORMCHECKBOX Left FORMCHECKBOX RightEstimate of size of resection based on (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingLargest Dimension: AP (cm): ___Largest Dimension: LAT (cm): ___Largest Dimension: Depth (cm): ___Volume of resected tissue (cm3): ___ FORMCHECKBOX Multi-lobar resectionLesion: FORMCHECKBOX Yes FORMCHECKBOX NoLobe: Temporal Lobe resected? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes:Laterality (Choose all that apply): FORMCHECKBOX Left FORMCHECKBOX RightBasis for estimated percentage of lobe removed (Check all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingEstimated percentage of lobe removed: FORMCHECKBOX 0-25 FORMCHECKBOX 26-50 FORMCHECKBOX 51-75 FORMCHECKBOX 76-100Lobe: OccipitalLobe resected? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes:Laterality (Choose all that apply): FORMCHECKBOX Left FORMCHECKBOX RightBasis for estimated percentage of lobe removed (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingEstimated percentage of lobe removed: FORMCHECKBOX 0-25 FORMCHECKBOX 26-50 FORMCHECKBOX 51-75 FORMCHECKBOX 76-100Lobe: ParietalLobe resected? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes:Laterality (Choose all that apply): FORMCHECKBOX Left FORMCHECKBOX RightBasis for estimated percentage of lobe removed (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingEstimated percentage of lobe removed: FORMCHECKBOX 0-25 FORMCHECKBOX 26-50 FORMCHECKBOX 51-75 FORMCHECKBOX 76-100Lobe: FrontalLobe resected? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes:Laterality (Choose all that apply): FORMCHECKBOX Left FORMCHECKBOX RightBasis for estimated percentage of lobe removed (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingEstimated percentage of lobe removed: FORMCHECKBOX 0-25 FORMCHECKBOX 26-50 FORMCHECKBOX 51-75 FORMCHECKBOX 76-100InsulaInsula resected? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes: Laterality (Choose all that apply): FORMCHECKBOX Left FORMCHECKBOX RightBasis for estimated percentage of insula removed (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingEstimated percentage of insula removed: FORMCHECKBOX 0-25 FORMCHECKBOX 26-50 FORMCHECKBOX 51-75 FORMCHECKBOX 76-100 FORMCHECKBOX HemispherectomyLaterality: FORMCHECKBOX Left FORMCHECKBOX RightType: FORMCHECKBOX Anatomical hemispherectomy FORMCHECKBOX Functional hemispherectomy FORMCHECKBOX Other, specify: FORMCHECKBOX Vagus nerve stimulation (VNS)Laterality: FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Corpus callosotomyExtent of disconnection based on (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingExtent of disconnection: FORMCHECKBOX Complete (1st stage) FORMCHECKBOX Anterior two-thirds FORMCHECKBOX Anterior half FORMCHECKBOX Completion of callosotomy (2nd stage) FORMCHECKBOX Posterior callosotomy FORMCHECKBOX Multiple subpial transectionLocation (Choose all that apply): FORMCHECKBOX Lateral temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Medial temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Orbitofrontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Dorsolateral frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Medial frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Central cortex FORMCHECKBOX Left FORMCHECKBOX RightEstimate of size based on (Choose all that apply): FORMCHECKBOX Surgical estimation FORMCHECKBOX Post-operative imagingLargest Dimension: AP(cm):Largest Dimension: LAT(cm):Was resection performed in conjunction with MST? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, complete the section appropriate for the resection. FORMCHECKBOX Stereotactic lesioningLesion found on MRI? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, type (Choose all that apply): FORMCHECKBOX Laser FORMCHECKBOX Radiofrequency FORMCHECKBOX Focused ultrasound FORMCHECKBOX RadiosurgeryIf radiosurgery, marginal dose (Gy): ___ Lobe/location (Check all that apply): FORMCHECKBOX Medial temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Lateral temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Orbitofrontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Dorsolateral frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Medial frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Central cortex FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Insula FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Hypothalamus FORMCHECKBOX Periventricular FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Therapeutic brain stimulation: FORMCHECKBOX Responsive (Closed-loop) FORMCHECKBOX Open-loopNumber of electrodes placed: ____Target of electrode(s) (Choose all that apply): FORMCHECKBOX Cortical: FORMCHECKBOX Hippocampus FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Lateral temporal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Occipital FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Parietal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Orbitofrontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Dorsolateral frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Medial frontal FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Central cortex FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Insula FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Subcortical: FORMCHECKBOX Anterior thalamus FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Centromedian thalamus FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Cerebellum FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Subthalamic nucleus FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Brainstem FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Other, specify: _________Stereotactic coordinates, (Write in values, if available):Anterior-posterior: ____Lateral: ____Depth: ____Method of placement (Choose all that apply): FORMCHECKBOX Local anesthesia FORMCHECKBOX General anesthesia FORMCHECKBOX Frameless stereotaxy FORMCHECKBOX Framed stereotaxy FORMCHECKBOX Other, specify: _______Method of verifying placement (Choose all that apply): FORMCHECKBOX Neuroimaging FORMCHECKBOX EEG FORMCHECKBOX Unit recording FORMCHECKBOX None FORMCHECKBOX Other, specify:Stimulus parameters (write in values or range) Frequency (per second): ____Voltage (V if constant volt stimulator): ____Current (mA if constant current stimulator): ____Polarity: FORMCHECKBOX Bipolar FORMCHECKBOX Referential FORMCHECKBOX Other, specify:Pulse width(microseconds): ___Stimulus type:(Choose below) FORMCHECKBOX Continuous FORMCHECKBOX Intermittent FORMCHECKBOX Responsive stimulationOn cycle time (seconds): ___Off cycle time (seconds): ___Postoperative MRI verification? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownOther Surgical Procedure (enter details): Additional Surgical DetailsLanguage Laterality: FORMCHECKBOX Language(dominant) FORMCHECKBOX Language(non-dominant) FORMCHECKBOX UnknownIntraoperative ECoG: FORMCHECKBOX Pre-resection FORMCHECKBOX Post-resection FORMCHECKBOX NoneIntraoperative cortical stimulation mapping: FORMCHECKBOX Yes FORMCHECKBOX NoStereotaxis?: FORMCHECKBOX Frame FORMCHECKBOX Frameless FORMCHECKBOX NonePathology DataPathology Data Details (Choose all that apply):Hippocampus (Choose all that apply): FORMCHECKBOX Classic hippocampal sclerosis FORMCHECKBOX End folium sclerosis FORMCHECKBOX Dispersion of dentate granule cell layer FORMCHECKBOX Other hippocampal damageTemporal lobe(describe):Vascular: FORMCHECKBOX Cavernous malformation FORMCHECKBOX Sturge Weber malformation FORMCHECKBOX Arteriovenous malformation (AVM) FORMCHECKBOX Stroke(ischemic/hemorrhagic)Tumor: FORMCHECKBOX Astrocytoma (include grade) FORMCHECKBOX Grade I FORMCHECKBOX Grade II FORMCHECKBOX Grade III FORMCHECKBOX Grade IV FORMCHECKBOX Grade Unidentifiable FORMCHECKBOX Dysembryoplastic neuroepithelial tumor (DNET) FORMCHECKBOX Mixed glioma (include grade) FORMCHECKBOX Grade I FORMCHECKBOX Grade II FORMCHECKBOX Grade III FORMCHECKBOX Grade IV FORMCHECKBOX Grade Unidentifiable FORMCHECKBOX Metastatic FORMCHECKBOX Oligodendroglioma (include grade) FORMCHECKBOX Grade I FORMCHECKBOX Grade II FORMCHECKBOX Grade III FORMCHECKBOX Grade IV FORMCHECKBOX Grade Unidentifiable FORMCHECKBOX Ganglioglioma FORMCHECKBOX Other, specify:Other Low Grade Developmental Tumor Grade (if known): FORMCHECKBOX Grade I FORMCHECKBOX Grade II FORMCHECKBOX Grade III FORMCHECKBOX Grade IV FORMCHECKBOX Grade UnidentifiableAssociated cortical dysplasia? FORMCHECKBOX Yes FORMCHECKBOX NoInfectious/inflammatory: FORMCHECKBOX Abscess FORMCHECKBOX Cysticercosis FORMCHECKBOX Rasmussen’s encephalitis FORMCHECKBOX Other, specify:Developmental: FORMCHECKBOX Focal cortical dysplasia - ILAE Type Ia FORMCHECKBOX Focal cortical dysplasia - ILAE Type Ib FORMCHECKBOX Focal cortical dysplasia - ILAE Type IIa FORMCHECKBOX Focal cortical dysplasia - ILAE Type IIb FORMCHECKBOX Focal cortical dysplasia - ILAE Type IIIa FORMCHECKBOX Focal cortical dysplasia - ILAE Type IIIb FORMCHECKBOX Focal cortical dysplasia - ILAE Type IIIc FORMCHECKBOX Focal cortical dysplasia - ILAE Type IIId FORMCHECKBOX Polymicrogyria FORMCHECKBOX Tuber (documented TS) FORMCHECKBOX Agyria/pachygyria FORMCHECKBOX Heterotopic gray matter FORMCHECKBOX Hemimegalencephaly FORMCHECKBOX Other low grade developmental tumorTraumatic(describe):Postoperative CourseHospital-stay (days):Post-operative seizures?: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how many?:Post-operative complications, neurological (new or worsened deficit-check all that apply): FORMCHECKBOX Aphasia – if Yes, specify: FORMCHECKBOX Anomia FORMCHECKBOX Visual field deficit: FORMCHECKBOX Quadrantanopia FORMCHECKBOX Hemianopsia FORMCHECKBOX Hemiparesis FORMCHECKBOX Memory deficit – if Yes, specify: FORMCHECKBOX Cranial nerve deficit – if Yes, specify: FORMCHECKBOX Altered mental status – if Yes, specify: FORMCHECKBOX Herniation syndrome FORMCHECKBOX Stroke FORMCHECKBOX Psychiatric – if Yes, specify:Post-Operative Complications (Choose all that apply) FORMCHECKBOX Wound infection: FORMCHECKBOX Superficial FORMCHECKBOX Deep FORMCHECKBOX Post-operative hematoma FORMCHECKBOX UTI FORMCHECKBOX DVT/PE FORMCHECKBOX Pneumonia FORMCHECKBOX Stroke FORMCHECKBOX Hemorrhage FORMCHECKBOX Respiratory, other – if Yes, specify: FORMCHECKBOX Nausea/vomiting FORMCHECKBOX GI, other – if Yes, specify: FORMCHECKBOX MI FORMCHECKBOX Death FORMCHECKBOX Other, specify:Re-admission within 30 days?: FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, list the reason for re-admission:Return to Operating Room?: FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, list the reason for return:Resolution (please complete for all applicable complications):Postoperative complication (specify):largely resolved by (date):Postoperative complication(specify):largely resolved by (date):Postoperative complication (specify):largely resolved by (date):Postoperative complication (specify):largely resolved by (date):Postoperative complication (specify):largely resolved by (date):General InstructionsSurgery and pathology information is collected to verify the inclusion and exclusion criteria and to describe the study population. The CDEs on this form are classified as Supplemental – Highly Recommended for any study that involves surgery. Typically, the Surgery and Pathology form captures surgeries that EVER occurred at some point in time within a protocol-defined period (e.g., the last 12 months). The form should focus on any clinically relevant surgical or invasive interventions (i.e., surgeries/interventions related to the protocol treatment, to the disease being studied, etc.)REFERENCESBlümcke I, Thom M, Aronica E, Armstrong DD, Vinters HV, Palmini A, Jacques TS, Avanzini G, Barkovich AJ, Battaglia G, Becker A, Cepeda C, Cendes F, Colombo N, Crino P, Cross JH, Delalande O, Dubeau F, Duncan J, Guerrini R, Kahane P, Mathern G, Najm I, Ozkara C, Raybaud C, Represa A, Roper SN, Salamon N, Schulze-Bonhage A, Tassi L, Vezzani A, Spreafico R. The clinicopathologic spectrum of focal cortical dysplasias: a consensus classification proposed by an ad hoc Task Force of the ILAE Diagnostic Methods Commission. Epilepsia. 2011 Jan;52(1):158-74.Blümcke I, Thom M, Aronica E, Armstrong DD, Bartolomei F, Bernasconi A, Bernasconi N, Bien CG, Cendes F, Coras R, Cross JH, Jacques TS, Kahane P, Mathern GW, Miyata H, Moshé SL, Oz B, ?zkara ?, Perucca E, Sisodiya S, Wiebe S, Spreafico R. International consensus classification of hippocampal sclerosis in temporal lobe epilepsy: a Task Force report from the ILAE Commission on Diagnostic Methods. Epilepsia. 2013 Jul;54(7):1315-29. ................
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