ARIC V5 / NCS Code Book I, S.4. Section 4: Central Agency Forms
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1 MRI Report and Referral Form - Vascular (MRV) ARIC V5 / NCS Code Book I, S.4 Page 1 of 15 MRI Report and Referral Form - Vascular: FORM CODE=MRV VERSION=1.0 Instructions: This form is completed by the MRI Reading Center to document pathology notification. Vers Vers EventName EventName 1979 Reading Centers Occurrence Occurrence MRV0a MRI-V read date 1959 Range 01/12/ /13/ Missing MRV0b Reader ID Missing
2 Page 2 of 15 MRV0c Acrostic 1959 Present Text suppressed 20 Missing MRV1 MRI-V scan date 1959 Range 10/18/ /13/ Missing MRV2 immediate MRI-V alert 1949 N No 8 Y Yes 22 Missing MRV2a MRI-V Giant Aneurysm 7 N No 1947 ~ Legitimately skipped MRV2b MRI-V Luminal thrombus 6 N No 1 Y Yes 1947 ~ Legitimately skipped MRV2c MRI-V Dissection or pseudoaneurysm 1 N No 6 Y Yes 1947 ~ Legitimately skipped
3 Page 3 of 15 MRV2d Location of alert problem MRI-V 3 LC1X Cervical segment of LICA 1 PBAX Proximal third of basilar artery 2 RC1X Cervical segment of RICA 1 RICA Right internal carotid artery 1947 ~ Legitimately skipped MRV2e Alert problem found on MRI-V in multiple locations 6 N No 1 Y Yes 1947 ~ Legitimately skipped MRV2f Other location 1 of alert problem MRI-V 1 LC1X Cervical segment of LICA 1954 ~ Legitimately skipped MRV2g Other location 2 of alert problem MRI-V 1954 ~ Legitimately skipped MRV2h Describe MRI-V alert 1955 Present Text suppressed MRV3 Physician notification recommended of MRI-V result 1554 N No 400 Y Yes
4 Page 4 of 15 MRV3a MRI-V aneurysm 176 N No 220 Y Yes 1556 ~ Legitimately skipped 27 Missing MRV3a1 MRI-V aneurysm: Location 6 ACOM Anterior communicating artery 6 DBAX Distal third of basilar artery 1 LA1X A1 segment of LACA 1 LACA Left anterior cerebral artery 2 LC2X Petrous segment of LICA 32 LC3X Cavernous segment of LICA 44 LC4X Supraclinoid segment of LICA 4 LM1X M1 segment of LMCA 5 LM2X M2 segment of LMCA 3 LOAX Left ophthalmic artery 1 LP1X P1 segment of LPCA 7 LPCM Left posterior communicating artery 1 LSCA Left superior cerebellar artery 1 RA1X A1 segment of RACA 1 RA2X A2 segment of RACA 45 RC3X Cavernous segment of RICA 36 RC4X Supraclinoid segment of RICA 7 RM1X M1 segment of RMCA 5 RM2X M2 segment of RMCA 1 RMCA Right middle cerebral artery 2 RMCB Right MCA bifurcation 7 RPCM Right posterior communicating artery 1 RPIC Right posterior inferior cerebellar artery 1 RSHA Right superior hypophysial artery 1735 ~ Legitimately skipped
5 Page 5 of 15 MRV3a2 MRI-V aneurysm: Multiple Locations 182 N No 37 Y Yes 1735 ~ Legitimately skipped MRV3a3 MRI-V aneurysm: Other Location1 10 LC3X Cavernous segment of LICA 13 LC4X Supraclinoid segment of LICA 1 LMCB Left MCA bifurcation 1 LMCT Left MCA trifurcation 2 RA2X A2 segment of RACA 5 RC3X Cavernous segment of RICA 4 RC4X Supraclinoid segment of RICA 1 RSCA Right superior cerebellar artery 1918 ~ Legitimately skipped MRV3a4 MRI-V aneurysm: Other Location2 1 DBAX Distal third of basilar artery 2 LC3X Cavernous segment of LICA 1 LC4X Supraclinoid segment of LICA 1 LM1X M1 segment of LMCA 10 NA No other location 1 RM2X M2 segment of RMCA 1 RMCB Right MCA bifurcation 1918 ~ Legitimately skipped 44 Missing MRV3a5 MRI-V aneurysm: Describe Alert 1953 Present Text suppressed 26 Missing
6 Page 6 of 15 MRV3b MRI-V AV malformation 398 N No 1556 ~ Legitimately skipped MRV3b1 MRI-V AV Malformation: Location 1955 ~ Legitimately skipped MRV3b2 MRI-V AV Malformation: Multiple Locations 1955 ~ Legitimately skipped MRV3b3 MRI-V AV Malformation: Other Location ~ Legitimately skipped MRV3b4 MRI-V AV Malformation: Other Location ~ Legitimately skipped MRV3b5 MRI-V AV Malformation: Describe Alert 1955 ~ Legitimately skipped MRV3c MRI-V critical stenosis 221 N No 177 Y Yes 1556 ~ Legitimately skipped
7 Page 7 of 15 MRV3c1 MRI-V Critical Stenosis: Location 2 BAXX Basilar artery 1 DBAX Distal third of basilar artery 2 LA1X A1 segment of LACA 2 LA2X A2 segment of LACA 1 LA3X A3 segment of LACA 1 LC2X Petrous segment of LICA 7 LC3X Cavernous segment of LICA 2 LC4X Supraclinoid segment of LICA 4 LM1X M1 segment of LMCA 10 LM2X M2 segment of LMCA 4 LP1X P1 segment of LPCA 14 LP2X P2 segment of LPCA 5 LP3X P3 segment of LPCA 1 LPCM Left posterior communicating artery 5 LV3X V3 segment of LVA 10 LV4X V4 segment of LVA 7 MBAX Middle third of basilar artery 6 PBAX Proximal third of basilar artery 3 RA1X A1 segment of RACA 3 RA2X A2 segment of RACA 1 RC2X Petrous segment of RICA 5 RC3X Cavernous segment of RICA 7 RC4X Supraclinoid segment of RICA 10 RM1X M1 segment of RMCA 9 RM2X M2 segment of RMCA 2 RP1X P1 segment of RPCA 35 RP2X P2 segment of RPCA 4 RP3X P3 segment of RPCA 1 RPCM Right posterior communicating artery 1 RPIC Right posterior inferior cerebellar artery 1 RV3X V3 segment of RVA 11 RV4X V4 segment of RVA 1779 ~ Legitimately skipped 23 Missing
8 Page 8 of 15 MRV3c2 MRI-V Critical Stenosis: Multiple Location 116 N No 60 Y Yes 1779 ~ Legitimately skipped MRV3c3 MRI-V Critical Stenosis: Other Location1 1 DBAX Distal third of basilar artery 4 LA1X A1 segment of LACA 1 LA2X A2 segment of LACA 1 LC3X Cavernous segment of LICA 2 LC4X Supraclinoid segment of LICA 2 LM1X M1 segment of LMCA 3 LM2X M2 segment of LMCA 1 LOAX Left ophthalmic artery 1 LP1X P1 segment of LPCA 8 LP2X P2 segment of LPCA 2 LP3X P3 segment of LPCA 1 LSCA Left superior cerebellar artery 1 LV3X V3 segment of LVA 3 LV4X V4 segment of LVA 1 MBAX Middle third of basilar artery 1 RA1X A1 segment of RACA 2 RA2X A2 segment of RACA 1 RA3X A3 segment of RACA 1 RM1X M1 segment of RMCA 3 RP1X P1 segment of RPCA 8 RP2X P2 segment of RPCA 7 RP3X P3 segment of RPCA 1 RV3X V3 segment of RVA 4 RV4X V4 segment of RVA 1895 ~ Legitimately skipped
9 Page 9 of 15 MRV3c4 MRI-V Critical Stenosis: Other Location2 2 LA2X A2 segment of LACA 1 LC3X Cavernous segment of LICA 1 LM1X M1 segment of LMCA 2 LM2X M2 segment of LMCA 1 LMCA Left middle cerebral artery 2 LP1X P1 segment of LPCA 5 LP2X P2 segment of LPCA 2 LP3X P3 segment of LPCA 1 LP4X P4 segment of LPCA 2 LV4X V4 segment of LVA 9 NA No other location 1 RA1X A1 segment of RACA 1 RC3X Cavernous segment of RICA 1 RP1X P1 segment of RPCA 8 RP2X P2 segment of RPCA 2 RP3X P3 segment of RPCA 3 RV4X V4 segment of RVA 1895 ~ Legitimately skipped 40 Missing MRV3c5 MRI-V Critical Stenosis: Describe Alert 1955 Present Text suppressed MRV3d MRI-V Vascular Occlusion 362 N No 36 Y Yes 1556 ~ Legitimately skipped
10 Page 10 of 15 MRV3d1 MRI-V Vascular Occlusion: Location 1 LC1X Cervical segment of LICA 3 LICA Left internal carotid artery 1 LMCA Left middle cerebral artery 1 LP1X P1 segment of LPCA 1 LV3X V3 segment of LVA 11 LV4X V4 segment of LVA 1 RA2X A2 segment of RACA 1 RC3X Cavernous segment of RICA 3 RICA Right internal carotid artery 2 RM1X M1 segment of RMCA 1 RP1X P1 segment of RPCA 1 RP2X P2 segment of RPCA 9 RV4X V4 segment of RVA 1919 ~ Legitimately skipped MRV3d2 MRI-V Vascular Occlusion: Multiple Locations 34 N No 2 Y Yes 1919 ~ Legitimately skipped MRV3d3 MRI-V Vascular Occlusion: Other Location1 1 LV4X V4 segment of LVA 1 MBAX Middle third of basilar artery 1953 ~ Legitimately skipped MRV3d4 MRI-V Vascular Occlusion: Other Location2 1 RP1X P1 segment of RPCA 1953 ~ Legitimately skipped
11 Page 11 of 15 MRV3d5 MRI-V Vascular Occlusion: Describe Alert 1955 Present Text suppressed MRV4 MRI-V Other vascular lesion 1940 N No 16 Y Yes 23 Missing MRV4a MRI-V Other vascular lesion: Immediate Alert 15 N No 1 Y Yes 1939 ~ Legitimately skipped MRV4b MRI-V Other vascular lesion: Physician Notification 15 Y Yes 1940 ~ Legitimately skipped MRV4c MRI-V Other vascular lesion description 1955 Present Text suppressed MRV5 MRI-V verified 14 N No 1944 Y Yes 21 Missing
12 Page 12 of 15 MRV6 MRI-V evaluation date 1 2 Range 07/12/ /22/ Missing MRV6a MRI-V evaluation ID Missing MRV6b MRI-V evaluation Notes 1 2 Present Text suppressed 1977 Missing MRV7 MRI-V evaluation date 2 MRV7a MRI-V evaluation ID 2 MRV7b MRI-V evaluation Notes 2 MRV8 MRI-V evaluation date 3 MRV8a MRI-V evaluation ID 3
13 Page 13 of 15 MRV8b MRI-V evaluation Notes 3 MRV9 MRI-V evaluation date 4 MRV9a MRI-V evaluation ID 4 MRV9b MRI-V evaluation Notes 4 MRV10 MRI-V evaluation date 5 MRV10a MRI-V evaluation ID 5 MRV10b MRI-V evaluation Notes 5 MRV11 MRI-V evaluation date 6 MRV11a MRI-V evaluation ID 6
14 Page 14 of 15 MRV11b MRI-V evaluation Notes 6 MRV12 MRI-V evaluation date 7 MRV12a MRI-V evaluation ID 7 MRV12b MRI-V evaluation Notes 7 MRV13 MRI-V evaluation date 8 MRV13a MRI-V evaluation ID 8 MRV13b MRI-V evaluation Notes 8 MRV14 MRI-V evaluation date 9 MRV14a MRI-V evaluation ID 9
15 Page 15 of 15 MRV14b MRI-V evaluation Notes 9
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