Vessel Imaging



Patient InformationStudy ID number:Date and time of study (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):NIH Stroke Scale (NIHSS) at time of study (0-42):Scan purpose (Select all that apply): FORMCHECKBOX Initial FORMCHECKBOX Monitoring Technical InformationUltrasound Type: FORMCHECKBOX Transcranial Color-coded Real-time Sonography (TCCS) FORMCHECKBOX Transcranial Doppler (TCD)Probe:Type: Frequency (Hz):Patient type: FORMCHECKBOX Asymptomatic FORMCHECKBOX Acute StrokeIf Acute Stroke, indicate study type: FORMCHECKBOX Initial FORMCHECKBOX Follow-up 1 FORMCHECKBOX Follow-up 2 FORMCHECKBOX Chronici. FORMCHECKBOX Stroke: FORMCHECKBOX Hemisphere FORMCHECKBOX Eye FORMCHECKBOX Vertebrobasilarii. FORMCHECKBOX TIA: FORMCHECKBOX Hemisphere FORMCHECKBOX Eye FORMCHECKBOX Vertebrobasilariii. Laterality: FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Brain Edema FORMCHECKBOX Brain Death FORMCHECKBOX Sickle Cell FORMCHECKBOX Arteriovenous Malformation FORMCHECKBOX Monitoring FORMCHECKBOX Right Shunt FORMCHECKBOX Left Shunt FORMCHECKBOX VasospasmInterpretation site: FORMCHECKBOX Onsite FORMCHECKBOX OffsiteIf Offsite, indicate type: FORMCHECKBOX Video FORMCHECKBOX Print FORMCHECKBOX DigitalContrast Agent: FORMCHECKBOX YesType: FORMCHECKBOX Bolus FORMCHECKBOX Infusion FORMCHECKBOX Other, specify: FORMCHECKBOX NoInsonation plane: FORMCHECKBOX Free FORMCHECKBOX Coronal FORMCHECKBOX Axial mesencephalicInsonation window: FORMCHECKBOX Orbital FORMCHECKBOX Excellent FORMCHECKBOX Fair FORMCHECKBOX Poor FORMCHECKBOX Temporal FORMCHECKBOX Excellent FORMCHECKBOX Fair FORMCHECKBOX Poor FORMCHECKBOX Posterior FORMCHECKBOX Excellent FORMCHECKBOX Fair FORMCHECKBOX PoorVesselsM1 SEQ Table \* ARABIC 1 Vessels M1 TableSideRightLeftB-mode FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX OcclusionColor flow FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpectrumDepth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Depth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Symptomatic? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoDepth (mm):(mm):Findings: (select all that apply) FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility Index FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility Index Flow Direction: FORMCHECKBOX Towards FORMCHECKBOX Away from FORMCHECKBOX Towards FORMCHECKBOX Away fromInsular M2 SEQ Table \* ARABIC 2 Vessels Insular M2 TableSideRightLeftB-mode FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX OcclusionColor flow FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpectrumDepth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Depth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Symptomatic? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoDepth (mm):(mm):Findings: (select all that apply) FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility Index FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility Index Flow Direction: FORMCHECKBOX Towards FORMCHECKBOX Away from FORMCHECKBOX Towards FORMCHECKBOX Away fromA1 SEQ Table \* ARABIC 3 Vessels A1 TableSideRightLeftB-mode FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX OcclusionColor flow FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpectrumDepth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Depth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Symptomatic? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoDepth (mm):(mm):Findings: (select all that apply) FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility Index FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility IndexFlow Direction: FORMCHECKBOX Towards FORMCHECKBOX Away from FORMCHECKBOX Towards FORMCHECKBOX Away fromInternal Carotid Artery (ICA) SEQ Table \* ARABIC 4: Vessels ICA TableSideRightLeftB-mode FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX OcclusionColor flow FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpectrumDepth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Depth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Symptomatic? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoDepth (mm):(mm):Findings: (select all that apply) FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility Index FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility IndexFlow Direction: FORMCHECKBOX Towards FORMCHECKBOX Away from FORMCHECKBOX Towards FORMCHECKBOX Away fromP1 SEQ Table \* ARABIC 5: Vessels P1 TableSideRightLeftB-mode FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX OcclusionColor flow FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpectrumDepth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Depth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Symptomatic? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoDepth (mm):(mm):Findings: (select all that apply) FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility Index FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility IndexFlow Direction: FORMCHECKBOX Towards FORMCHECKBOX Away from FORMCHECKBOX Towards FORMCHECKBOX Away fromP2 SEQ Table \* ARABIC 6: Vessels P2 TableSideRightLeftB-mode FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX OcclusionColor flow FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpectrumDepth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Depth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Symptomatic? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoDepth (mm):(mm):Findings: (select all that apply) FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility Index FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility IndexFlow Direction: FORMCHECKBOX Towards FORMCHECKBOX Away from FORMCHECKBOX Towards FORMCHECKBOX Away fromVertebral7: Vertebral Vessels TableSideRightLeftB-mode FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX OcclusionColor flow FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpectrumDepth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Depth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Symptomatic? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoDepth (mm):(mm):Findings: (select all that apply) FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility Index FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility IndexFlow Direction: FORMCHECKBOX Towards FORMCHECKBOX Away from FORMCHECKBOX Towards FORMCHECKBOX Away fromBasilar8: Basilar Vessels TableSideRightLeftB-mode FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX OcclusionColor flow FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpectrumDepth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Depth (mm):Angle correction: FORMCHECKBOX Yes FORMCHECKBOX NoPeak velocity (cm/sec):Mean velocity (cm/sec):Direction to Probe: FORMCHECKBOX Towards FORMCHECKBOX Away fromAsymmetry index:End diastolic ratio:COGIF score: FORMCHECKBOX No flow FORMCHECKBOX Low flow/No diastolic flow FORMCHECKBOX Low flow/diastolic flow FORMCHECKBOX Established perfusionCOGIF Follow-up: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Date (M M/D D/Y Y Y Y):(HH:MM, 24 hr clock):Symptomatic? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoDepth (mm):(mm):Findings: (select all that apply) FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility Index FORMCHECKBOX No Signal FORMCHECKBOX Systolic Spike FORMCHECKBOX Reversed Diastolic Flow FORMCHECKBOX Reduced upstroke/ Pulsatility IndexFlow Direction: FORMCHECKBOX Towards FORMCHECKBOX Away from FORMCHECKBOX Towards FORMCHECKBOX Away fromEC ICA9: Vessels EC ICA TableSideRightLeftB-mode FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX OcclusionPower M ModeLeft MCA: FORMCHECKBOX Absent FORMCHECKBOX High Resistance FORMCHECKBOX Low ResistanceRight MCA: FORMCHECKBOX Absent FORMCHECKBOX High Resistance FORMCHECKBOX Low ResistanceHigh Intensity Transient Signal HitsDuration time (msec):Intensity (dB):A1: RightLeft FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No Number:Number:Start Time:(hh:mm, 24 hr clock)Start Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)Siphon:RightLeft FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No Number:Number:Start Time:(hh:mm, 24 hr clock)Start Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)P1:RightLeft FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No Number:Number:Start Time:(hh:mm, 24 hr clock)Start Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)M1:RightLeft FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No Number:Number:Start Time:(hh:mm, 24 hr clock)Start Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)Ophthalmic:RightLeft FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No Number:Number:Start Time:(hh:mm, 24 hr clock)Start Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)Vert:RightLeft FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No Number:Number:Start Time:(hh:mm, 24 hr clock)Start Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)Basilar: FORMCHECKBOX Yes FORMCHECKBOX No Number:Start Time:(hh:mm, 24 hr clock)End Time:(hh:mm, 24 hr clock)Vasomotor Response (VMR)Vessel(s): FORMCHECKBOX MCA FORMCHECKBOX Other, specify:VMR: FORMCHECKBOX Normal (Skip to Diagnosis) FORMCHECKBOX Abnormal Breath-holding index (BHI): DiagnosisExtracranial stenosis: FORMCHECKBOX Yes (Select all that apply) FORMCHECKBOX Collateral: FORMCHECKBOX OA FORMCHECKBOX ACA FORMCHECKBOX VA FORMCHECKBOX Reduced upstroke FORMCHECKBOX Reduced Pulsatility Index (PI) FORMCHECKBOX VMR FORMCHECKBOX Reduced velocity FORMCHECKBOX No Intracranial stenosis: FORMCHECKBOX YesVessel(s): FORMCHECKBOX MCA FORMCHECKBOX ICA FORMCHECKBOX VA FORMCHECKBOX Basilar FORMCHECKBOX Other, specify:% Stenosis:Peak Systolic Velocity (PSV) criterion:Mean velocity criterion:Other: FORMCHECKBOX No Vasospasm: FORMCHECKBOX YesSeverity: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereVessel(s): FORMCHECKBOX MCA FORMCHECKBOX ICA FORMCHECKBOX VA FORMCHECKBOX Basilar Criterion:Lindegaard ratio:Posterior ratio:Intracranial pressure (ICP):Resistive Index (RI):Partial pressure of carbon dioxide (PCO2):Hemoglobin: FORMCHECKBOX No Brain Death: FORMCHECKBOX Yes (Select all that apply) FORMCHECKBOX Reversed diastolic flow FORMCHECKBOX Systolic spike FORMCHECKBOX No signals FORMCHECKBOX No Sickle Cell (indication for study): FORMCHECKBOX Normal FORMCHECKBOX ConditionalVessel(s): FORMCHECKBOX MCA FORMCHECKBOX Other, specify Velocity: FORMCHECKBOX AbnormalVessel(s): FORMCHECKBOX MCA FORMCHECKBOX Other, specify Velocity:General InstructionsThis CRF contains data that would be collected when a transcranial vessel imaging study is performed to examine brain vessels and evaluate cerebral hemodynamics. The data elements are Supplemental and should only be collected if the research team considers them appropriate for their study.Specific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module. ................
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