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Data Collection Sheet for Brain AVM (2016)MRN:Date of Birth:Last Name:Gender:MaleFemaleFirst Name:Date of presentation:Clinical Presentation:IncidentalHemorrhageSeizureFocal neurological deficitHeadacheOtherHandedness:RightLeftAmbidextrousImaging source and date:AVM CHARACTERISTICS:AVM Size:AVM Location:CorticalFrontalTemporalParietalOccipital SubcorticalBasal ganglia Internal capsuleCorpus callosum VentricularIntraventricularCerebellar hemisphereVermian (paramedian)Deep cerebellar nucleiBrainstem Lesion sideRightLeft MidlineAVM border with adjacent brainCompactDiffuseEloquence:Not eloquentSensorimotor Visual cortexLanguage cortexThalamus / hypothalamus / basal gangliaInternal capsuleCerebellar peduncleDeep cerebellar nucleiBrainstemOther eloquenceAVM HEMORRHAGE:Evidence of NEW hemorrhage:YesNoEvidence of OLD hemorrhage: YesNoAge of new hemorrhageAge of old hemorrhageIs new hemorrhage symptomatic?YesNoWas old hemorrhage symptomatic?YesNoHemorrhage location:VentricularParenchymalSubarachnoidHemorrhage location:VentricularParenchymalSubarachnoidHemorrhage Size:Hemorrhage Size:VENOUS DRAINAGE:Venous DrainageSuperficial Deep BothNo. drains leaving nidus:Venous stenosis / occlusions (%)Periventricular drainage:YesNoNo. veins reaching sinus:Sinus thrombosis / occlusions (%)Venous ectasia:YeNoVenous reflux:YesNoARTERIAL SUPPLY:Feeding arteries:ACA cortical branchesACA penetratorsMCA cortical branchesMCA penetratorsPCA cortical branchesPCA penetratorsOther ICA branchesICA penetratorsECA branchesAnterior choroidal a.Posterior choroidal a.Superior cerebellar a.AICAPICAVA branchesVA penetratorsBasilar artery penetratorsOther arteriesNo. of arterial aneurysms:Location of aneurysms:Flow-relatedNot flow-relatedNidalProximalDistalAneurysms with hemorrhagic history?YesNoArterial aneurysms hemorrhagic (date):OTHERS:Number of vessels to be embolized:Pial-to-pial collateralizationSame territory Between territories NoneIntravascular pressure measurementsMoya-moya –type changesYesNo?Heustein Sy 2016Reference: "Reporting Terminology For Brain Arteriovenous Malformation Clinical And Radiographic Features For Use In Clinical Trials". Stroke 32.6 (2001): 1430-1442. Web.Describing AVMs:GeneralClinical presentationIncidentalHemorrhageSeizureFocal neurological deficitHeadacheOtherDate of presentationImaging source and dateLocation and SizeLesion sideRightLeft MidlineHandednessRightLeftAmbidextrousAVM sizeAVM locationCorticalSubcorticalVentricularCorpus callosumFrontalTemporalParietalOccipital Basal gangliaInternal capsuleIntraventricularCerebellar hemisphereVermian (paramedian)Deep cerebellar nucleiBrainstem EloquenceNot eloquentSensorimotor cortexVisual cortexLanguage cortexThalamus / hypothalamus / basal gangliaInternal capsuleCerebellar peduncleDeep cerebellar nucleiBrainstemOther eloquenceAVM border with adjacent brainCompactDiffuseAVM hemorrhageEvidence of new hemorrhage (y/n)Age of new hemorrhageIs new hemorrhage symptomaticEvidence of old hemorrhage (y/n)Age of old hemorrhageWas old hemorrhage symptomatic?Hemorrhage locationVentricularParenchymalSubarachnoidHemorrhage sizeVenous drainageSuperficial vs deep venous drainageBoth superficial and deepSuperficial onlyDeep onlyPeriventricular drainage (y/n)Number of draining veins leaving nidusNumber of veins reaching sinusVenous stenosis / occlusion (%)Venous ectasia (y/n)Venous reflux (y/n)Sinus thrombosis / occlusions (%)Arterial supplyFeeding arteriesAnterior choroidal a.ACA cortical branchesACA penetratorsMCA cortical branchesMCA penetratorsOther ICA branchesICA penetratorsPCA cortical branchesPCA penetratorsPosterior choroidalSuperior cerebellarAICAPICAECA branchesBasilar artery penetratorsVA branchesVA penetratorsOther arteriesArterial aneurysmsNumber of aneurysmsLocationFlow-relatedNot flow-relatedNidalProximalDistalArterial aneurysms hemorrhagic history (y/n)Arterial aneurysms hemorrhagic (date)Number of vessels to be embolizedMoya-moya –type changes (y/n)Pial-to-pial collateralization Same territoryBetween territoriesNoneIntravascular pressure measurements ................
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