Vessel Imaging Angiography - NINDS Common Data Elements



Patient Information**Study 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 Diagnostic FORMCHECKBOX Treatment FORMCHECKBOX Post-treatment FORMCHECKBOX Monitoring FORMCHECKBOX Other, specifyTechnical Information**Imaging modality (Select all that apply): FORMCHECKBOX DSA FORMCHECKBOX MRA/MRV FORMCHECKBOX CTA/CTV FORMCHECKBOX Cone Beam Computed Tomography (CBCT)Digital Subtraction Angiography (DSA)Site of access: FORMCHECKBOX Brachial FORMCHECKBOX Femoral FORMCHECKBOX Radial FORMCHECKBOX OtherSelective injections (Select all that apply in table below and side): SEQ Table \* ARABIC 1 Technical Information TableInjection SiteSideArch FORMCHECKBOX N/A – Not presentCommon Carotid FORMCHECKBOX Right FORMCHECKBOX Left FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not presentInternal Carotid FORMCHECKBOX Right FORMCHECKBOX Left FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not presentVertebral FORMCHECKBOX Right FORMCHECKBOX Left FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not presentSubclavian FORMCHECKBOX Right FORMCHECKBOX Left FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not presentMagnetic Resonance Angiography (MRA): (Select all that apply) FORMCHECKBOX Head (Time of Flight - TOF) FORMCHECKBOX Neck (TOF) FORMCHECKBOX Contrast enhanced Head and Neck FORMCHECKBOX Magnetic Resonance Venography (MRV) with contrast FORMCHECKBOX Magnetic Resonance Venography (MRV) without contrastComputer Tomography Angiography (Select all that apply): FORMCHECKBOX Head FORMCHECKBOX Neck FORMCHECKBOX Computer Tomography Venography (CTV)FindingsArterial findings:Location: FORMCHECKBOX CCA origin FORMCHECKBOX M3 multiple FORMCHECKBOX CCA to bifurcation FORMCHECKBOX M4 single FORMCHECKBOX ICA at origin FORMCHECKBOX M4 multiple FORMCHECKBOX C1 cervical FORMCHECKBOX Vertebral origin FORMCHECKBOX C2 petrous FORMCHECKBOX Vertebral – cervical FORMCHECKBOX C3 lacerum FORMCHECKBOX Vertebral – intracranial proximal to PICA FORMCHECKBOX C4 cavernous FORMCHECKBOX Vertebral – distal to PICA FORMCHECKBOX C5 clinoidal FORMCHECKBOX Basilar – proximal FORMCHECKBOX C6 – ophthalmic to PCOM FORMCHECKBOX Basilar – mid FORMCHECKBOX C6 – PCOM to terminus FORMCHECKBOX Basilar – distal FORMCHECKBOX A1 FORMCHECKBOX PCOM FORMCHECKBOX A2 FORMCHECKBOX P1 FORMCHECKBOX M1 proximal to striate FORMCHECKBOX P2 FORMCHECKBOX M1 distal to striate FORMCHECKBOX P3 FORMCHECKBOX M2 single FORMCHECKBOX SCA FORMCHECKBOX M2 multiple FORMCHECKBOX AICA FORMCHECKBOX M3 single FORMCHECKBOX PICAFindings:1 Findings TableSideRightLeftFindings FORMCHECKBOX Normal FORMCHECKBOX Occlusion FORMCHECKBOX Aneurysm FORMCHECKBOX Stenosis FORMCHECKBOX AVM FORMCHECKBOX Other FORMCHECKBOX Not visualized FORMCHECKBOX Normal FORMCHECKBOX Occlusion FORMCHECKBOX Aneurysm FORMCHECKBOX Stenosis FORMCHECKBOX AVM FORMCHECKBOX Other FORMCHECKBOX Not visualized***Qureshi Angiographic Occlusions Scale (Scores listed and defined directly below): SEQ Table \* ARABIC 2 Occlusions Scale TableScoreDescription0No Occlusion1 – MCAMCA occlusion M3 segment1 – ACAACA occlusion A2 or distal segments1 – BA/VAOne BA/VA branch occlusion2 – MCAMCA occlusion M2 segment2 – ACAACA occlusion A1 and A2 segments2 – BA/VATwo or more BA/VA branch occlusions3AMCA occlusion M1 segment with lentriculostriate arteries spared and/or leptomeningeal collaterals visualized3BMCA occlusion M1 segment with no sparing of lentriculostriate arteries nor leptomeningeal collaterals visualized4A – ICAICA occlusion with collaterals filling MCA4A – BABA occlusion with partial anterograde filling4B – ICAICA occlusion with collaterals filling ACA4B – BABA occlusion with partial retrograde filling5 – ICAICA occlusion with no collaterals5 – BABA occlusion with no filling either directly or via collateralsExpanded Thrombolysis in Cerebral Infarction (eTICI) Perfusion Scale-Grade (Scores listed and defined directly below): 3 Perfusion Scale Cause and Symptomology TableScoreDescriptionGrade 0No reperfusion or 0% filling of downstream territory.Grade 1Thrombus reduction without any reperfusion of distal arteries.Grade 2aReperfusion in less than half or 1-49% of the territory.Grade 2b5050-66% reperfusion, exceeding the modified TICI (mTICI) 2B threshold but below the original TICI 2B cut-off point.Grade 2b6767-89% reperfusion, exceeding TICI but below TICI 2C.Grade 2cEquivalent to TICI 2C or 90-99% reperfusion.Grade 3Complete or 100% reperfusion, tantamount to TICI 3.Arterial Occlusion Lesion (AOL) Recanalization Scale for DSA; Modified Arterial Occlusion Lesion (mAOL) Recanalization Scale for CTA and MRA (Scores listed and defined directly below):4 Recanalization Scale TableScoreDescription0No recanalization of the primary occlusive lesion1Incomplete or partial recanalization of the primary occlusive lesion with no distal flow2Incomplete or partial recanalization of the primary occlusive lesion with any distal flow3Complete recanalization of the primary occlusion with any distal flowIntracranial collateral segment status:5 Intracranial collateral segment status TableLocationSideECA/OA - ICA FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not PresentECA/Other - ICA FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not PresentAComA - A1 - MCA FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not PresentAComA – A2 – MCA pial FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not PresentPComA – ICA FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not PresentPCA – ACA pial FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not PresentPCA – MCA pial FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not PresentICA to MCA/ACA Moyamoya FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not PresentOther: FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral FORMCHECKBOX N/A – Not PresentCollateral grade (Grades listed and defined directly below): 6a ASITN Collateral Grade TableScoreDescriptionGrade 0No collaterals visible to the ischemic siteGrade 1Slow collaterals to the periphery of the ischemic site with persistence of some of the defectGrade 2Rapid collaterals to the periphery of ischemic site with persistence of some of the defect and to only a portion of the ischemic territoryGrade 3Collaterals with slow but complete angiographic blood flow of the ischemic bed by the late venous phaseGrade 4Complete and rapid collateral blood flow to the vascular bed in the entire ischemic territory by retrograde perfusion6b Tan Collateral Score TableScoreDescription0Absence of vessels on CTA source images (CTA-SI)1Collateral supply filling ≤50% but >0% of the occluded MCA territory2Collateral supply filling >50% but <100% of the occluded MCA territory3100% collateral supply of the occluded MCA territoryVenous findings:Superior Sagittal Sinus findings:7 Findings TableOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherInferior Sagittal Sinus findings: 8 Findings TableOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherStraight Sinus findings:9 Findings TableOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherTransverse Sinus findings:10 Findings TableSideRightLeftOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Other FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherSigmoid Sinus findings:11 Findings TableSideRightLeftOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Other FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherJugular Bulb findings:12 Findings TableSideRightLeftOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Other FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherCavernous Sinus findings:13 Findings TableSideRightLeftOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Other FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherInternal Cerebral Vein findings:14 Findings TableSideRightLeftOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Other FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Othera. Vein of Galen findings:15a Findings TableOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherFrontal Cortical Vein findings:15b Findings TableSideRightLeftOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Other FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherParietal Cortical Vein findings:16 Findings TableSideRightLeftOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Other FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherTemporal Cortical Vein findings:17 Findings TableSideRightLeftOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Other FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherOccipital Cortical Vein findings:18 Findings TableSideRightLeftOverall Assessment FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX Other FORMCHECKBOX Normal FORMCHECKBOX Small Caliber/Congenital Hypoplasia FORMCHECKBOX Stenosis FORMCHECKBOX Occlusion FORMCHECKBOX OtherAneurysm DetailsShape/pathology of aneurysm: FORMCHECKBOX Saccular FORMCHECKBOX Fusiform FORMCHECKBOX DissectingAnatomic location: FORMCHECKBOX C1 cervical FORMCHECKBOX M4 FORMCHECKBOX C2 petrous FORMCHECKBOX M4 single FORMCHECKBOX C3 lacerum FORMCHECKBOX M4 multiple FORMCHECKBOX C4 cavernous FORMCHECKBOX Vertebral origin FORMCHECKBOX C5 clinoidal FORMCHECKBOX Vertebral-cervical FORMCHECKBOX C6 - ophthalmic to PCOM FORMCHECKBOX Vertebral-intracranial proximal to PICA FORMCHECKBOX C6 - PCOM to terminus FORMCHECKBOX Vertebral-distal to PICA FORMCHECKBOX A1 FORMCHECKBOX Basilar-distal to AICA FORMCHECKBOX ACOM FORMCHECKBOX Basilar-mid FORMCHECKBOX A2 FORMCHECKBOX Basilar-proximal to AICA FORMCHECKBOX M1 proximal to striate FORMCHECKBOX PCOM FORMCHECKBOX M1 distal to striate FORMCHECKBOX P1 FORMCHECKBOX M2 FORMCHECKBOX P2 FORMCHECKBOX M2 single FORMCHECKBOX P3 FORMCHECKBOX M2 multiple FORMCHECKBOX SCA FORMCHECKBOX M3 FORMCHECKBOX AICA FORMCHECKBOX M3 single FORMCHECKBOX PICA FORMCHECKBOX M3 multipleLocation of aneurysm: FORMCHECKBOX Cavernous FORMCHECKBOX Persistent trigeminal FORMCHECKBOX Medial paraclinoid FORMCHECKBOX Lateral paraclinoid FORMCHECKBOX Ophthalmic FORMCHECKBOX Superior hypophyseal FORMCHECKBOX Posterior communicating FORMCHECKBOX Anterior choroidal FORMCHECKBOX Internal carotid artery bifurcation FORMCHECKBOX Middle cerebral artery bifurcation FORMCHECKBOX Anterior communicating FORMCHECKBOX Pericallosal FORMCHECKBOX Posterior inferior cerebellar artery FORMCHECKBOX Superior cerebellar FORMCHECKBOX Basilar apex FORMCHECKBOX OtherDome size of aneurysm (mm):Neck size of aneurysm (mm):Aneurysm irregularity: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownLargest height/largest neck diameter for each aneurysm:Presence of mural thrombus or partial thrombosis in aneurysm: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Presence of 3D reconstruction of aneurysm: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownEndovascular Aneurysm Treatment***Wall opposition for stents or flow diverters: FORMCHECKBOX Good FORMCHECKBOX Poor FORMCHECKBOX Unknown***Occlusion percentage of aneurysm:Raymond-Roy Occlusion Classification: FORMCHECKBOX Complete occlusion FORMCHECKBOX Dog ear FORMCHECKBOX Residual neck FORMCHECKBOX Residual aneurysmOcclusion of parent or branch vessel related to aneurysm: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***CFD: Volumetric***Mean kinetic energy measurement of aneurysm:***Mean velocity measurement of aneurysm (cm/sec):***Mean aneurysm shear rate:***Mean aneurysm vorticity:***Mean viscous dissipation:***Vortex coreline length (cm):***CFD: Surface Factors***Mean wall shear stress of aneurysm (dyne/cm2):***Maximum wall shear stress (dyne/cm2):***Minimum wall shear stress (dyne/cm2):***Shear concentration index:***Percentage of aneurysm under low WSS:***Mean oscillatory shear stress:***CFD: Hemodynamic Factors***Mean inflow rate of aneurysm (ml/sec):***Inflow concentration index:Additional Supplemental ElementsVascular dissection extent type (Choose one): FORMCHECKBOX Luminal narrowing greater than 50% (including "string sign") FORMCHECKBOX Vessel occlusion FORMCHECKBOX Luminal narrowing less than 50%Vascular dissection findings type (Choose one): FORMCHECKBOX Watershed or embolic infarction in the territory of the dissected vessel with SAH FORMCHECKBOX Watershed or embolic infarction in the territory of the dissected vessel without SAH FORMCHECKBOX Adjacent skull fracture (e.g. carotid canal)Traumatic aneurysm (Choose one): FORMCHECKBOX Present FORMCHECKBOX Absent FORMCHECKBOX IndeterminateTraumatic aneurysm anatomic site (Choose all that apply):Carotid FORMCHECKBOX R FORMCHECKBOX LVertebral FORMCHECKBOX R FORMCHECKBOX LACA FORMCHECKBOX R FORMCHECKBOX LMCA FORMCHECKBOX R FORMCHECKBOX LPCA FORMCHECKBOX R FORMCHECKBOX LBasilar FORMCHECKBOX Other (Describe): FORMCHECKBOX R FORMCHECKBOX LTraumatic aneurysm volume measurement:mm3Traumatic aneurysm findings type (Choose one): FORMCHECKBOX Intraluminal thrombus FORMCHECKBOX Cavernous (intradural) FORMCHECKBOX Skull fracture, with penetrating injury FORMCHECKBOX Skull fracture, without penetrating injuryVenous sinus injury (Choose one): FORMCHECKBOX Present FORMCHECKBOX Absent FORMCHECKBOX IndeterminateVenous sinus injury morphology type (Choose all that apply): FORMCHECKBOX Compression FORMCHECKBOX Occlusion FORMCHECKBOX LacerationVenous sinus injury anatomic site (Choose all that apply):Sagittal sinus FORMCHECKBOX Posterior (occipital) FORMCHECKBOX Anterior (frontoparietal)Transverse sinus FORMCHECKBOX R FORMCHECKBOX LSigmoid sinus FORMCHECKBOX R FORMCHECKBOX LGeneral InstructionsThis CRF contains data that would be collected when an imaging study is performed using angiography to examine the blood vessels of the body. There are separate sections to record arterial findings and venous findings.** Element is classified as Supplemental – Highly Recommended***Element is classified as ExploratoryThe remaining 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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