Vessel Caotid Ultransound



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 Post-treatment FORMCHECKBOX MonitoringTechnical InformationProbe: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 Chronic StrokeInterpretation site: FORMCHECKBOX Onsite FORMCHECKBOX OffsiteIf Offsite, indicate type: FORMCHECKBOX Video FORMCHECKBOX Print FORMCHECKBOX Digital Contrast Agent: FORMCHECKBOX Yes FORMCHECKBOX No (Skip to 5)Agent:Type: FORMCHECKBOX Bolus FORMCHECKBOX Infusion FORMCHECKBOX Other, specify: Read type (Select all that apply): FORMCHECKBOX Local read FORMCHECKBOX Local report FORMCHECKBOX Central read Reader blinded to clinical data: FORMCHECKBOX Yes FORMCHECKBOX No Study technically satisfactory: FORMCHECKBOX Yes FORMCHECKBOX No FindingsB-mode:CCA SEQ Table \* ARABIC 1 Findings TableSideRightLeft*Finding FORMCHECKBOX Normal (Skip to B) FORMCHECKBOX Plaque FORMCHECKBOX Normal (Skip to B) FORMCHECKBOX Plaque*Echo pattern FORMCHECKBOX Homogeneous FORMCHECKBOX Heterogeneous FORMCHECKBOX Homogeneous FORMCHECKBOX Heterogeneous*Surface FORMCHECKBOX Smooth FORMCHECKBOX Irregular FORMCHECKBOX Smooth FORMCHECKBOX Irregular*Severity of plaque FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereTexture of plaque:Data to be entered by site: Data to be entered by siteComposition of plaque: Data to be entered by site: Data to be entered by siteMotion of plaque: Data to be entered by site: Data to be entered by siteICA SEQ Table \* ARABIC 2 Findings TableSideRightLeft*Finding FORMCHECKBOX Normal (Skip to C) FORMCHECKBOX Plaque FORMCHECKBOX Normal (Skip to B) FORMCHECKBOX Plaque*Echo pattern FORMCHECKBOX Homogeneous FORMCHECKBOX Heterogeneous FORMCHECKBOX Homogeneous FORMCHECKBOX Heterogeneous*Surface FORMCHECKBOX Smooth FORMCHECKBOX Irregular FORMCHECKBOX Smooth FORMCHECKBOX IrregularTexture of plaqueData to be entered by siteData to be entered by siteComposition of plaqueData to be entered by siteData to be entered by siteMotion of plaqueData to be entered by siteData to be entered by siteResidual lumenData to be entered by siteData to be entered by siteThickness of plaqueData to be entered by siteData to be entered by siteECA SEQ Table \* ARABIC 3: Findings TableSideRightLeft*Finding FORMCHECKBOX Normal (Skip to 2) FORMCHECKBOX Plaque FORMCHECKBOX Normal (Skip to B) FORMCHECKBOX Plaque*Echo pattern FORMCHECKBOX Homogeneous FORMCHECKBOX Heterogeneous FORMCHECKBOX Homogeneous FORMCHECKBOX Heterogeneous*Surface FORMCHECKBOX Smooth FORMCHECKBOX Irregular FORMCHECKBOX Smooth FORMCHECKBOX IrregularTexture of plaqueData to be entered by siteData to be entered by siteComposition of plaqueData to be entered by siteData to be entered by siteMotion of plaqueData to be entered by siteData to be entered by siteResidual lumenData to be entered by siteData to be entered by siteThickness of plaqueData to be entered by siteData to be entered by siteColor flow:CCA SEQ Table \* ARABIC 4 Color flow TableSideRightLeft*Angle(degrees):(degrees):*Peak velocity(cm/sec):(cm/sec):*End diastolic velocity(cm/sec):(cm/sec):*No signal? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No*% Stenosis criterion FORMCHECKBOX PSV FORMCHECKBOX PSV/EDV FORMCHECKBOX Other, specify: FORMCHECKBOX PSV FORMCHECKBOX PSV/EDV FORMCHECKBOX Other, specify:*% Stenosis(%):(%):Volume flow rate {CDE# C13920}(ml/m):(ml/m):Other findings FORMCHECKBOX Turbulence FORMCHECKBOX Spectral broadening FORMCHECKBOX Turbulence FORMCHECKBOX Spectral broadeningICA SEQ Table \* ARABIC 5 Color flow TableSideRightLeft*Angle(degrees):(degrees):*Peak velocity(cm/sec):(cm/sec):*End diastolic velocity(cm/sec):(cm/sec):*No signal? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No*% Stenosis criterion FORMCHECKBOX PSV FORMCHECKBOX PSV/EDV FORMCHECKBOX Other, specify: FORMCHECKBOX PSV FORMCHECKBOX PSV/EDV FORMCHECKBOX Other, specify:*% Stenosis(%):(%):CCA externalization FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoPower Doppler FORMCHECKBOX Flow FORMCHECKBOX No flow FORMCHECKBOX Flow FORMCHECKBOX No flowOther findings FORMCHECKBOX Turbulence FORMCHECKBOX Spectral broadening FORMCHECKBOX Turbulence FORMCHECKBOX Spectral broadeningECA SEQ Table \* ARABIC 6 Color flow TableSideRightLeft*Angle(degrees):(degrees):*Peak velocity(cm/sec):(cm/sec):*End diastolic velocity(cm/sec):(cm/sec):*No signal? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No*% Stenosis criterion FORMCHECKBOX PSV FORMCHECKBOX PSV/EDV FORMCHECKBOX Other, specify: FORMCHECKBOX PSV FORMCHECKBOX PSV/EDV FORMCHECKBOX Other, specify:*% Stenosis(%):(%):Other findings FORMCHECKBOX Turbulence FORMCHECKBOX Spectral broadening FORMCHECKBOX Turbulence FORMCHECKBOX Spectral broadeningVertebral – origin: FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occluded Vertebral – interosseous: FORMCHECKBOX Normal FORMCHECKBOX Stenosis FORMCHECKBOX Occluded Intima Media Thickness (IMT):B-mode: FORMCHECKBOX Yes FORMCHECKBOX No B-mode guided M mode: FORMCHECKBOX Yes FORMCHECKBOX No Electronic caliper: FORMCHECKBOX Yes FORMCHECKBOX No Edge detection algorithm: FORMCHECKBOX Yes, type: FORMCHECKBOX No (Skip to 5)Timing: FORMCHECKBOX ECG Gating FORMCHECKBOX End Diastolic FORMCHECKBOX Peak SystolicFindings:Mean and Max IMT: SEQ Table \* ARABIC 7 Mean and Max IMT TableArtery and sideMean IMT Near-wallMean IMT Far-wallMax IMTNear-wallMax IMTFar-wallCCA – right(mm):(mm):(mm):(mm):CCA – left(mm):(mm):(mm):(mm):Bulb – right(mm):(mm):(mm):(mm):Bulb – left(mm):(mm):(mm):(mm):ICA – right(mm):(mm):(mm):(mm):ICA – left(mm):(mm):(mm):(mm):Diameters: SEQ Table \* ARABIC 8 Diameters TableArtery and sideMean IMT Near-wallMean IMT Far-wallMax IMTNear-wallMax IMTFar-wallCCA – right(mm):(mm):(mm):(mm):CCA – left(mm):(mm):(mm):(mm):* Recommended as a Core Stroke CDE if protocol includes imagingGeneral InstructionsThis CRF contains data that would be collected when an imaging study is performed using carotid ultrasound to examine the two large arteries in the neck. There are separate sections to record findings from B-mode and color flow imaging.Important note: A subset of the data elements included on this CRF Module is considered Core (i.e., strongly recommended for stroke clinical studies to collect if imaging studies are performed). The remaining data elements (i.e., non Core) 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. There is actually a single Data Dictionary for all of the imaging CDEs as the six different CRF Modules for stroke imaging share many elements.The CRF includes all instructions available for the data elements at this time. More detailed instructions will be added in Version 3.0 of this CRF Module. ................
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