DEMOGRAPHICS (Epidemiology Study)1999

Transcription

1 DEMOGRAPHICS (Epidemiology Study)1999 NOTE: All DATES will be recorded as MM / DD / YY and all TIMES will be recorded as MILITARY TIME. (D-1) Abstractor (D-2) / / Date of Initial Chart Review (D-3) : Time Abstraction Begun (D-4) : Time Ended (Codes for Type: 1=hospital 2=autopsy 3=outpatient clinic 4=physician 5=nursing home 6=squad record 9=N/A) (D-8) INSTITUTION Type Name: MR# (D-9) INSTITUTION Type Name: MR# (D-10) INSTITUTION Type Name: MR# (D-11) ICD-9-CM CODE (stroke related) (D-12) 1=primary 2=secondary 9=N/A (D-13) ICD Code, per Study Reviewer (D-14) NAME Enter 999 if no stroke-related code. Enter 999 if no stroke code. STUDY NO Last First Middle Initial (D-15) ADDRESS, Street City State Zip (D-16) PHONE ( ) - (D-17) SOCIAL SECURITY # - - (D-18) AGE (D-20) GENDER (D-21) ETHNIC GROUP (D-22) TYPE OF INSURANCE (D-23) MARITAL STATUS (D-19) DATE OF BIRTH / / 1=male 2=female (D-5) DATE OF STROKE (D-6) Date of Admission (D-7) Date of Discharge 1=Black 2=White 3=Hispanic 4=Asian 5=other (explain) 1=Medicare 2=Medicaid 3=HMO 4=other private /commercial 5=self pay / / / / / / If stroke happened at home when the subject was alone and was discovered later, enter the date discovered as the date of stroke. If unknown date but known month and year, enter month/15/year. If not a stroke or date not available, enter 06/15/88. 1=never married 2=married 3=living with partner 4=widowed 5=divorced 6=separated (D-24) EMPLOYMENT STATUS 1=currently employed 2=formerly employed 3=never employed 4=retired 7=homemaker (D-25) RESIDENCE AT TIME OF ADMISSION 1=home 2=nursing home 7=other (explain) (D-26) SITE WHERE STROKE OCCURRED 1=home 2=work 3=hospital 7=other (explain) (D-27) CASE 1=yes 2=no (D-28) Discussed with study PI 1=yes 2=no (D-29) Person determining status of case 1=abstractor 2=physician (D-30) TYPE OF CASE 1=infarct 2=TIA 3=ICH 4=SAH 5=IVH 6=unruptured cerebral aneurysm 7=other (explain) (D-31) REASON FOR EXCLUSION 1=out of time period 2=doesn t meet stroke criteria 3=residence out of geographic area 7=other (explain) 9=N/A (case) (D-32) INTERVIEWED 1=yes 2=no (D-33) Who was interviewed 1=patient only 2=proxy only 3=both patient and proxy 9=N/A (D-34) Reason interview not done 1=doctor refused permission 2=patient/family refused permission 3=non-case 4=not the interviewed case 5=greater than 60 days 6=patient expired 7=other (explain) (interview done) (D-35) Genetic material obtained using BUCCAL SWABS? 1=yes 2=no (D-36) Genetic material obtained using BLOOD? 1=yes 2=no (D-37) CASE PER PHYSICIAN REVIEW 1=yes 2=no (D-38) / / Date of physician review Enter 06/15/88 if N/A (D-39) Initials of MD (D-40) Type of Case, per Physician 1=infarct 2=TIA 3=ICH 4=SAH 5=IVH 6=unruptured cerebral aneurysm 7=other (explain) Date data entered Date Date completely into database incomplete / / revised, corrected / / entered into database / / 1

2 EMS RECORD (1) (EMS-1) Check here, if NO RECORD (EMS-2) EMS RUN 1=yes 2=no (EMS-3) TYPE OF RUN 1=ALS 2=BLS 8=unknown 9=not available (EMS-3a) Squad and Run Number INITIAL EVALUATION (EMS-4) / / (EMS-5) : Date Time (EMS-6) Awake prior to onset of stroke 1=yes 2=no TIMES (please use military time) 88:88=unk (EMS-7) : Dispatch (EMS-8) : At Scene (If no at scene time, use time of first vital signs.) (EMS-9) : To Hospital (EMS-10) : At Hospital (EMS-11) CHIEF 1=stroke/CVA 2=MI 3=seizure 4=fall /found down / unresponsive COMPLAINT 5=weakness / numbness 6=headache 7=other (explain) EVALUATION DONE (EMS-12) : Time (EMS-13) (EMS-14) (EMS-15) Blood Pressure Systolic Diastolic Pulse (EMS-16) Respirations For EMS-17 thru EMS-19, use (EMS-17) Eyes Glasgow Coma Scale (1-6) or (EMS-18) (EMS-19) Motor Verbal (EMS-20) Total 88=unk 99=N/A (EMS-21) Is GCS an estimate? 1=yes 2=no 2

3 EMS RECORD (2) LIFE SQUAD PROCEDURES (EMS-22) Check here, if NO RECORD (EMS-23) Monitor 1=yes 2=no (EMS-24) IV 1=yes 2=no (EMS-25) IV Fluid 1=NS 2=D5W 3=RL 4=hep lock (EMS-26) Rate (ml / hr or KVO, WO) 9=N/A 5=other 9=N/A (explain) (EMS-27) Oxygen 1=yes 2=no 9=N/A (EMS-28) L / min 9=N/A (EMS-29) D50 1=yes 2=no 9=N/A (EMS-30) Narcan 1=yes 2=no 9=N/A (EMS-31) Lidocaine 1=yes 2=no 9=N/A (EMS-32) B / P Medication 1=yes 2=no 9=N/A Type: (EMS-33) Intubation 1=yes 2=no 9=N/A (EMS-34) Glucose 1=yes 2=no 9=N/A (EMS-35) Pulse ox 1=yes 2=no 9=N/A (EMS-36) Other 1=yes 2=no (explain) 3

4 ED RECORD (1) (ED-1) Check here, if NO RECORD (ED-2) Hospital INITIAL EVALUATION (ED-3) Awake prior to onset 1=yes 2=no FIRST MEDICAL CONTACT (ED-4) Type (ED-5) / / Date (ED-6) : Time 1=911 2=PMD 3=NH 4=hospital 5=ED 6=coroner 7=other EVALUATION DATES / TIMES 06/15/88 for unknown dates, 88:88 for unknown times (ED-7) / / First Recorded ED (Arrival) Date (ED-8) : First Recorded ED (Arrival) Time (ED-9) : Time of 1st MD Order (ED-10) Sent to CT 1=yes 2=no (ED-11) / / Date Sent for CT (ED-12) : Time Sent for CT (ED-13) Disposition from ED 1=admit 2=discharged home 3=transfer to another hospital 4=coroner (ED-14) / / Date of Hospital Admit / Transfer (ED-15) : Time of Hospital Admit / Transfer (ED-16) / / Discharge Date Home (from ED) (ED-17) : Discharge Time Home (from ED) (ED-18) DIAGNOSIS FROM 1=stroke / CVA / TIA 2=MI 3=seizure 4=fall /found down / unresponsive ED CHART 5=weakness / numbness 6=headache / migraine 7=other (ED-19) CHIEF COMPLAINT, if other, above (ED-20) ADMITTING DIAGNOSIS, if other, above (ED-21) DISCHARGE DIAGNOSIS, if other, above 4

5 ED RECORD (2) SYMPTOMS (If not specified, chart 8=unk or 9=N/A) (ED-22) Weakness [if YES, answer ED-23, -24, -25] 1=yes 2=no 3=generalized (ED-23) Face 1=left 2=right 3=both (ED-24) Arm 1=left 2=right 3=both (ED-25) Leg 1=left 2=right 3=both (ED-26) Numbness [if YES, answer ED-27, -28, -29] 1=yes 2=no 3=generalized (ED-27) Face 1=left 2=right 3=both (ED-28) Arm 1=left 2=right 3=both (ED-29) Leg 1=left 2=right 3=both (ED-30) Headache 1=yes 2=no (ED-31) Mental Status 1=alert and oriented 2=drowsy / somnolent 3=dizzy 4=coma / unresponsive 5=posturing 6=alert but disoriented / confused 7=other (ED-32) Speech 1=normal 2=slurred 3=garbled 4=mute 7=other (ED-33) Fall / Cannot Walk 1=yes 2=no 9=N/A (ED-34) Vision 1=normal 2=blurred 3=double 4=partial loss 5=total blindness 6=photophobia 7=other (ED-35) Other (explain) 1=yes 2=no 9=N/A GLASGOW COMA SCORE (ED-36) Eyes (1 4) Glasgow Coma Scoring (1-6) or (ED-37) Motor (1 6) (ED-38) Verbal (1 5) (ED-39) Total 88=unk 99=N/A (ED-40) PU 1=yes 2=no 9=N/A (ED-41) Estimate? 1=yes 2=no 9=N/A (ED-42) NIH STROKE SCALE DONE? 1=yes 2=no (ED-43) If done, score (ED-44) ET PROCEDURES (ED-45) Arterial Line 99=N/A 1=yes 2=no 9=N/A 1=yes 2=no 9=N/A (ED-46) ANTIHYPERTENSIVE MEDICATION GIVEN (ED-47) (ED-48) Blood pressure Systolic Diastolic 1=yes 2=no 9=N/A If ED-46 is YES, answer ED-49 thru -54. If NO, slash mark blanks (ED-49) Medications Given (ED-50) : Time first dose administered (ED-51) Medications Given (ED-52) : Time first dose administered (ED-53) Medications Given (ED-54) : Time first dose administered 5

6 MEDICAL THERAPIES PRIOR TO ONSET OF STROKE (MED-0) Check here, if NO MEDICATIONS. List all medications. Their classification will be assigned at Stroke Research Center. MEDICATION (MED-1) (MED-2) (MED-3) (MED-4) (MED-5) (MED-6) (MED-7) (MED-8) (MED-9) (MED-10) (MED-11) (MED-12) (MED-13) (MED-14) (MED-15) (MED-16) (MED-17) (MED-18) (MED-19) (MED-20) (MED-21) (MED-22) (MED-23) (MED-24) (MED-25) (MED-26) (MED-27) (MED-28) CLASSIFICATION (MED-1a) (MED-2a) (MED-3a) (MED-4a) (MED-5a) (MED-6a) (MED-7a) (MED-8a) (MED-9a) (MED-10a) (MED-11a) (MED-12a) (MED-13a) (MED-14a) (MED-15a) (MED-16a) (MED-17a) (MED-18a) (MED-19a) (MED-20a) (MED-21a) (MED-22a) (MED-23a) (MED-24a) (MED-25a) (MED-26a) (MED-27a) (MED-28a) 6

7 STROKE EVALUATION (1) (SE-1) / / DATE OF STROKE If stroke happened at home when the subject was alone and was discovered later, enter the date discovered as the date of stroke. If unknown date but known month and year, enter month/15/year. (SE-2) : TIME OF STROKE 1=AM 2=PM 8=unk (SE-3) Was time of stroke estimated? 1=yes 2=no RULES FOR TIME OF STROKE ONSET: Enter exact time if given If reported as: Record as: After midnight 00:59 1=AM Morning 07:59 1=AM Afternoon 12:59 2=PM Evening 07:59 2=PM Don t know, Uncertain 88:88 8=unk (SE-4) EVALUATION DONE BY PHYSICIAN? 1=yes 2=no (SE-5) Place first of Evaluation 1=ER 2=OP setting 3=NH 4=ICU 5=floor 6=other (SE-6) / / Date (SE-7) : Time (SE-7a) / BP (if no ED record) (SE-8) CLINICAL CARDIAC EXAM 1=yes 2=no (SE-9) ER Physician Findings 1=normal 2=abnormal (SE-10) Admitting Physician Findings 1=normal 2=abnormal (SE-11) Arrhythmia 1=yes 2=no 8=unk If YES, explain (SE-12) Heart Murmur 1=yes 2=no If YES, type: 1=systolic 2=diastolic 3=both (SE-13) Neck Bruit 1=none 2=left 3=right 4=bilateral 7=other (SE-14) SEIZURE IN ACUTE SETTING OF STROKE 1=yes 2=no (SE-15) MODIFIED RANKIN SCALE PRIOR TO STROKE ONSET 0=no symptoms 1=no significant disability despite SXs; able to carry out usual activities 2=slight disabilities; unable to carry out all previous activities, but able to look after self without assistance 3=moderate disabilities; requiring some help; able to walk without assistance 4=moderately severe disabilities; unable to walk without assistance (includes cane, walker); unable to attend to body needs 5=severe disability; bedridden; incontinent; requiring constant nursing care 9=not available (SE-16) EVALUATED BY A NEUROLOGIST 1=yes 2=no (SE-17) Evaluated by someone other than a neurologist, identify: 1=neurosurgeon 2=PMD 3=ED MD (SE-18) NEUROLOGICAL FINDINGS 1=normal 2=abnormal (SE-19) Oriented to Person 1=yes 2=no (SE-20) Oriented to Place 1=yes 2=no (SE-21) Oriented to Time 1=yes 2=no 7

8 STROKE EVALUATION (2) (SE-22) NIH Stroke SCALE DONE? 1=yes 2=no (SE-23) If YES, total score. (SE-24) Abstracted stroke severity estimated below. 1=yes 2=no If unable to estimate, draw a slash thru SE-25 to SE-41. (SE-25) / / Date (SE-26) : Time NOTE: If not mentioned in record, code as normal. Use 8=unk and 9=N/A where applicable for the following: (SE-27) 1A Level of Consciousness 0=alert 1=drowsy 2=stuporous 3=coma (SE-28) 1B LOC Questions 0=answer both correctly 1=answers one correctly 2=answers neither correctly (SE-29) 1C LOC Commands 0=performs both correctly 1=performs one correctly 2=performs neither correctly (SE-30) 2 Best Gaze 0=normal 1=abnormal (SE-31) 3 Visual 0=normal 1=abnormal (SE-32) 4 Facial Palsy 0=normal 1=abnormal (SE-33) 5A Left Arm 0=normal 1=affected / weak 2=paralyzed / flaccid (SE-34) 5B Right Arm 0=normal 1=affected / weak 2=paralyzed / flaccid (SE-35) 6A Left Leg 0=normal 1=affected / weak 2=paralyzed / flaccid (SE-36) 6B Right Leg 0=normal 1=affected / weak 2=paralyzed / flaccid (SE-37) 7 Ataxia 0=normal 1=abnormal (SE-38) 8 Sensory 0=normal 1=abnormal (SE-39) 9 Best Language 0=normal 1=abnormal 2=mute (SE-40) 10 Dysarthria 0=normal 1=abnormal 2=speech incomprehensible (SE-41) 11 Neglect 0=normal 1=abnormal (SE-42) SHORT-TERM MEMORY PROBLEMS? 1=yes 2=no (SE-43) If YES, explain (SE-44) Did symptoms last more than 24 hours? 1=yes 2=no 3=wax and wane 4=Resolved PTA 5=intermittent (SE-44a) / Duration of Symptoms for TIA (hours / minutes) 7=other (SE-45) OTHER POSSIBLY PERTINENT NEUROLOGIC FINDINGS: (SE-46) NOTES: 8

9 STROKE (PRIOR) HISTORY (SH-1) PRIOR HISTORY OF STROKE 1=yes 2=no If NO, then draw a slash thru SH-2 to SH-7a. (SH-2) Number of prior strokes (SH-3) Significant impairment from prior strokes 1=yes 2=no PRIOR STROKES List most recent first Type of Stroke codes: 1=Cerebral Infarct 2=ICH 3=SAH 4=IVH (SH-4) Type of stroke (SH-5) Type of stroke (SH-6) Type of stroke (SH-7) Type of stroke (SH-4a) / / Date of Stroke (SH-5a) / / Date of Stroke (SH-6a) / / Date of Stroke (SH-7a) / / Date of Stroke PRIOR HISTORY OF: 1=yes 2=no (SH-8) Cerebral Aneurysm (SH-9) AVM (SH-10) TIA (SH-10a) / / Date of most recent TIA (SH-11) DEFICIT PRIOR TO STROKE NOT CAUSED BY A STROKE 1=yes 2=no (SH-12) If YES, specify 1=CVD 2=arthritis / bone disease 3=cancer 4=neurologic, other than stroke 5=respiratory 7=other FAMILY HISTORY Has any relative ever had: (SH-13) Ischemic Stroke 1=yes 2=no 8=unk (SH-14) Transient Ischemic Attack or mini Stroke 1=yes 2=no 8=unk (SH-15) Intracerebral Hemorrhage 1=yes 2=no 8=unk (SH-16) Subarachnoid Hemorrhage 1=yes 2=no 8=unk (SH-17) Stroke of unknown type 1=yes 2=no 8=unk (SH-18) Alzheimer s Disease or Dementia 1=yes 2=no 8=unk (SH-19) Brain Aneurysm 1=yes 2=no 8=unk (SH-20) Hypertension 1=yes 2=no 8=unk 9

10 BASELINE MEDICAL HISTORY (1) PRIOR TO STROKE ONSET Note: If no history of condition in record, then put 8=unk. (MHX-0) WEIGHT (LBS) / HEIGHT (FEET / INCHES) (MHX-1) HISTORY OF HYPERTENSION 1=yes 2=no 8=unk (MHX-2) Drug Treatment 1=yes 2=no 8=unk (MHX-3) DIABETES MELLITUS 1=yes 2=no 8=unk (MHX-4) Current or Past Treatment 1=yes 2=no 8=unk (MHX-5) If YES, type of treatment 1=diet only 2=oral med 3=insulin 8=unk (MHX-6) HISTORY OF ELEVATED CHOLESTEROL 1=yes 2=no 8=unk (MHX-7) If YES, type of treatment 1=diet 2=drug therapy 3=none 8=unk (MHX-8) HISTORY OF CORONARY ARTERY DISEASE 1=yes 2=no 8=unk (MHX-9) HISTORY OF MYOCARDIAL INFARCTION 1=yes 2=no 8=unk (MHX-10) / / If YES, date of most recent MI (MHX-11) ATRIAL FIBRILLATION BY EKG 1=yes 2=no 8=unk (MHX-12) HISTORY OF ANGINA 1=yes 2=no 8=unk (MHX-13) HISTORY OF CONGESTIVE HEART FAILURE 1=yes 2=no 8=unk (MHX-14) PROSTHETIC HEART VALVE 1=yes 2=no 8=unk (MHX-15) If YES, Type 1=mitral 2=aortic 3=both 8=unk (MHX-16) PRIOR CARDIAC BYPASS SURGERY 1=yes 2=no 8=unk (MHX-17) / / If YES, date of most recent surgery (MHX-18) CARDIAC VESSEL ANGIOPLASTY 1=yes 2=no 8=unk (MHX-19) / / If YES, date of most recent angioplasty (MHX-20) CARDIAC PACEMAKER 1=yes 2=no 8=unk (MHX-21) CARDIOMYOPATHY 1=yes 2=no 8=unk (MHX-22) HISTORY OF CAROTID ARTERY DISEASE 1=yes 2=no 8=unk (MHX-23) CAROTID ENDARTERECTOMY 1=yes 2=no 8=unk (MHX-24) / / If YES, date of most recent endarterectomy 10

11 BASELINE MEDICAL HISTORY (2) PRIOR TO STROKE ONSET (MHX-25) CEREBRAL ANGIOGRAM WITHIN 24 HRS PRIOR TO ONSET 1=yes 2=no 8=unk (MHX-26) CORONARY ANGIOGRAM WITHIN 24 HRS PRIOR TO ONSET 1=yes 2=no 8=unk (MHX-27) RECENT EMBOLI TO PERIPHERAL ARTERIES 1=yes 2=no 8=unk in last three months, to leg, arm, kidney, gut (MHX-28) DEMENTIA 1=yes 2=no 8=unk (MHX-28a) If YES, type 1=Alzheimer s 2=multi-infarct 7=other 8=unk (MHX-29) DEPRESSION 1=yes 2=no 8=unk (MHX-30) SICKLE CELL DISEASE 1=yes 2=no 8=unk (MHX-31) THALASSEMIA 1=yes 2=no 8=unk (MHX-32) HEMOPHILIA 1=yes 2=no 8=unk (MHX-33) HIV POSITIVE 1=yes 2=no 8=unk (MHX-34) HISTORY OF BRAIN TUMOR 1=yes 2=no 8=unk (MHX-35) If YES, type (MHX-36) HISTORY OF MALIGNANCY 1=yes 2=no 8=unk (MHX-37) If YES, type (MHX-38) HISTORY OF SEIZURE 1=yes 2=no 8=unk (MHX-39) OTHER SIGNIFICANT MEDICAL CONDITIONS 1=yes 2=no 8=unk If YES, list: (MHX-40) NOTES: 11

12 SUBSTANCE ABUSE (SA-1) SMOKING USE 1=yes 2=no 8=unk If NO or unknown, then draw a slash thru SA-2 to SA-5. (SA-2) Number of Years (SA-3) Number of Packs per Day 88=unk 99=N/A (SA-4) Current Smoker 1=yes 2=no (SA-5) How many years since last smoked? If current smoker, enter 99. If unknown, enter 88. (SA-6) RECENT ALCOHOL USE 1=yes 2=no 8=unk If NO or unknown, then draw a slash thru SA-7 and SA-8. (SA-7) Primary Type 1=beer 2=wine 3=hard liquor 7=other 8=unk (SA-8) Servings of Alcohol per Day or or Enter 0 servings if occasional use. Otherwise indicate the number of servings per day based on amounts below: 1 serving = 1 oz. hard liquor 1 serving = 4 oz. wine 1 serving = 12 oz. beer (SA-9) Patient noted on medical record as heavy drinker, defined as more than 2 servings per day 1=yes 2=no 8=unk STREET DRUG USE (SA-10) Marijuana 1=yes 2=no 8=unk (SA-11) Hashish 1=yes 2=no 8=unk (SA-12) Cocaine / Crack 1=yes 2=no 8=unk (SA-13) Speed 1=yes 2=no 8=unk (SA-14) LSD 1=yes 2=no 8=unk (SA-15) Ecstasy 1=yes 2=no 8=unk (SA-16) Heroin 1=yes 2=no 8=unk (SA-17) Methadone 1=yes 2=no 8=unk (SA-18) ICE 1=yes 2=no 8=unk (SA-19) PCP 1=yes 2=no 8=unk (SA-20) Inhalants 1=yes 2=no 8=unk (SA-21) Other 1=yes 2=no 8=unk Specify: (SA-22) ALCOHOL DETECTED IN URINE OR BLOOD 1=yes 2=no 8=unk (SA-23) DRUGS (other than alcohol) DETECTED IN URINE OR BLOOD 1=yes 2=no 8=unk (SA-24) STREET DRUG USE WITHIN 24 HOURS OF STROKE ONSET 1=yes 2=no 8=unk (SA-25) NOTES: 12

13 ADMISSION EKG, CHEST X-RAY (EKG-1) Check here, if NO RECORD (EKG-2) ADMISSION EKG 1=normal 2=abnormal If ABNORMAL, answer EKG-3 thru EKG-11 (EKG-3) Sinus Bradycardia < 60 1=yes 2=no (EKG-4) Sinus Tachycardia > 100 1=yes 2=no (EKG-5) PAC (Atrial Ectopics) 1=yes 2=no (EKG-6) PVC (Ventricular Ectopic) 1=yes 2=no (EKG-7) Atrial Fibrillation / Flutter 1=yes 2=no (EKG-8) 3rd Degree Heart Block 1=yes 2=no (EKG-9) LVH (Estes of 4+ on report) 1=yes 2=no (EKG-10) Old MI (listed on interpretation) 1=yes 2=no (EKG-11) Acute MI (must list acute MI, not just ischemic changes) 1=yes 2=no (EKG-12) ATRIAL FIBRILLATION DEVELOPED LATER IN STAY l=yes 2=no (EKG-13) CHEST X-RAY l=normal 2=abnormal (EKG-14) NOTES: 13

14 DIAGNOSTIC TESTS (DIA-1) CT OF HEAD DONE AFTER ONSET 1=yes 2=no (DIA-2) Location of Study Performed (DIA-3) / / Date of Study (DIA-4) : Time of Study (DIA-5) Primary Findings 1=normal 2=infarct 3=ICH 4=SAH 5=AVM 6=aneurysm 7=other (DIA-6) CT Notes: (DIA-7) SECOND CT DONE 1=yes 2=no (DIA-8) Location of Study Performed (DIA-9) / / Date of Study (DIA-10) : Time of Study (DIA-11) Primary Findings 1=normal 2=infarct 3=ICH 4=SAH 5=AVM 6=aneurysm 7=other (DIA-12) 2nd CT Notes: (DIA-13) MR DONE 1=yes 2=no (DIA-14) Location of Study Performed (DIA-15) / / Date of Study (DIA-16) : Time of Study (DIA-17) Primary Findings 1=normal 2=infarct 3=ICH 4=SAH 5=AVM 6=aneurysm 7=other (DIA-18) MR Notes: (DIA-19) SECOND MR DONE 1=yes 2=no (DIA-20) Location of Study Performed (DIA-21) / / Date of Study (DIA-22) : Time of Study (DIA-23) Primary Findings 1=normal 2=infarct 3=ICH 4=SAH 5=AVM 6=aneurysm 7=other (DIA-24) 2nd MR Notes: (DIA-25) NOTES: 14

15 LABORATORY (LAB-1) Check here, if NO RECORD (LAB-2) LOCATION OF LAB (LAB-3) / / DATE DRAWN (Put slash mark, if not available) (LAB-4). White Blood Cell Count (LAB-5). Hemoglobin (LAB-6) Platelet Count (in thousands) (LAB-7). Creatinine (LAB-8) Serum Blood Sugar Lipid Profile (LAB-9) LDL (LAB-10) HDL (LAB-11). LDL / HDL (LAB-12) Triglycerides (LAB-13) Total Cholesterol (LAB-14). Protime (LAB-15). INR (LAB-16). Partial Thromboplastin Time (LAB-17) Anticardiolipin Antibodies 1=normal 2=abnormal 8=unk (LAB-18) Lumbar Puncture 1=yes 2=no 8=unk If YES, answer LAB-19 and LAB-20 (LAB-19) LP RBCs (LAB-20) Xanthochromia 1=yes 2=no 8=unk (LAB-21) Positive RPR or VDRL 1=yes 2=no 8=unk (LAB-22) (LAB-23) (LAB-24) CK CKMB SED Rate (LAB-25) OTHER: 15

16 MR ANGIOGRAPHY (MR-1) Check here, if NO RECORD (MR-2) MR ANGIOGRAPHY DONE 1=yes 2=no (MR-3) (MR-4) LOCATION / / DATE (MR-5) : TIME (MR-6) FINDINGS 1=normal 2=abnormal TO BE COMPLETED BY PHYSICIAN (MR-7) Source of information 1=film 2=report 3=both (MR-8) (MR-9) If ABNORMAL, answer MR-8 thru MR-22 1=occluded / absent 2=severe stenosis 3=possible stenosis 8=not examined 9=N/A CCA right CCA left (MR-10) ICA neck right (MR-11) ICA neck left (MR-12) ICA siphon right (MR-13) ICA siphon left (MR-14) MCA right trunk (MR-15) MCA left trunk (MR-16) ACA right trunk (MR-17) ACA left trunk (MR-18) PCA right trunk (MR-19) PCA left trunk (MR-20) Vertebral right (MR-21) Vertebral left (MR-22) Basilar (MR-23) ANEURYSM 1=yes 2=no If YES, answer MR-24 thru MR-32 (MR-24) ICA 1=left 2=right 3=both 4=not seen 9=N/A (MR-25) ACOM 1=left 2=right 3=both 4=not seen 9=N/A (MR-26) Ophthalmic 1=left 2=right 3=both 4=not seen 9=N/A (MR-27) PCOM 1=left 2=right 3=both 4=not seen 9=N/A (MR-28) ACA 1=left 2=right 3=both 4=not seen 9=N/A (MR-29) MCA 1=left 2=right 3=both 4=not seen 9=N/A (MR-30) Vertebral 1=left 2=right 3=both 4=not seen 9=N/A (MR-31) Basilar 1=yes 4=not seen 9=N/A (MR-32) AVM 1=yes 4=not seen 9=N/A (MR-33) OTHER: 16

17 CEREBRAL ANGIOGRAPHY (CR-1) Check here, if NO RECORD (CR-2) CEREBRAL ANGIOGRAPHY DONE 1=yes 2=no (CR-3) (CR-4) LOCATION / / DATE (CR-5) : TIME (CR-6) FINDINGS 1=normal 2=abnormal TO BE COMPLETED BY PHYSICIAN (CR-7) Source of information 1=film 2=report 3=both (CR-8) (CR-9) If ABNORMAL, answer CR-8 thru CR-30 1=no lesion 2=mild, <50% 3=moderate, 50-79% 4=severe, 80-99% 5=occlusion 8=not examined 9=N/A CCA right CCA left (CR-10) ICA neck right (CR-11) ICA neck left (CR-12) ICA siphon right (CR-13) ICA siphon left (CR-14) MCA right trunk (CR-15) MCA left trunk (CR-16) MCA right branch (CR-17) MCA left branch (CR-18) ACA right trunk (CR-19) ACA left trunk (CR-31) ANEURYSM 1=yes 2=no If YES, answer CR-32 thru CR-40 (location and size of largest diameter) Codes for location: 1=left 2=right 3=both 4=not seen 9=N/A location size (mm) (CR-32) ICA (CR-33) ACOM (CR-34) Ophthalmic (CR-35) PCOM (CR-36) ACA (CR-37) MCA (CR-38) Vertebral (CR-39) PICA (CR-40) Basilar (1=yes) (CR-41) AVM 1=yes 4=not seen 9=N/A (CR-20) ACA right branch (CR-21) ACA left branch (CR-22) PCA right trunk (CR-23) PCA left trunk (CR-24) PCA right branch (CR-25) PCA left branch (CR-26) Vertebral right (CR-27) Vertebral left (CR-28) PICA right (CR-29) PICA left (CR-30) Basilar (CR-42) OTHER: 17

18 CAROTID ULTRA (CA-1) Check here, if NO RECORD (CA-2) Carotid ultrasound done after stroke 1=yes 2=no If YES, complete the rest of this form. (CA-3) / / DATE (CA-4) : TIME (CA-5) Carotid Findings 1=normal 2=abnormal If ABNORMAL, complete the following: RIGHT LEFT (CA-6) CCA 1=no lesion 2=mild <50% 3=mod 50-79% 4=severe 80-99% 5=occlusion 8=not VIS (CA-7) ICA 1=no lesion 2=mild <50% 3=mod 50-79% 4=severe 80-99% 5=occlusion 8=not VIS (CA-8) ECA 1=no lesion 2=mild <50% 3=mod 50-79% 4=severe 80-99% 5=occlusion 8=not VIS 9=N/A 9=N/A 9=N/A (CA-9) Ulceration 1=yes 2=no If YES, complete the following: RIGHT LEFT (CA-10) CCA 1=yes 2=no (CA-11) ICA 1=yes 2=no (CA-12) NOTES: 18

19 ECHO (EC-1) Check here, if NO RECORD (EC-2) Echocardiogram 1=yes 2=no 8=unk If YES, answer the following: (EC-3) / / Date of Echocardiogram (EC-4) Type of Echocardiogram 1=transthoracic (TTE) 2=transesophageal (TEE) 3= 1&2 8=unk If both TTE and TEE, use TEE data to complete rest of form. (EC-5) Quality of Study 1=adequate 2=poor 3= limited 8=unk (EC-6) Echocardiographic Findings 1=normal 2=abnormal 8=unk (EC-7) Left atrial enlargement 1=yes 2=no 8=unk (EC-8) LVH 1=yes 2=no 8=unk (EC-9) VALVULAR VEGETATION 1=yes 2=no 8=unk (EC-10) CARDIOMYOPATHY 1=yes 2=no 8=unk (EC-11) MURAL THROMBUS 1=yes 2=no 8=unk (EC-12) MVP 1=yes 2=no 8=unk (EC-13) AKINETIC WALL 1=yes 2=no 8=unk (EC-14) VENTRICULAR ANEURYSM 1=yes 2=no 8=unk (EC-15) LV EJECTION FRACTION 1=yes 2=no 8=unk If YES, % (EC-16) SPONTANEOUS LEFT ATRIAL CONTRAST OR SMOKE 1=yes 2=no 8=unk (EC-17) MITRAL VALVULAR DISEASE, NOT MVP 1=yes 2=no 8=unk (EC-18) AORTIC VALVE DISEASE 1=yes 2=no 8=unk (EC-19) PATENT FORAMEN OVALE 1=yes 2=no 8=unk (EC-20) ATRIAL SEPTAL ANEURYSM 1=yes 2=no 8=unk (EC-21) AORTIC ATHEROSCLEROTIC DEBRIS 1=yes 2=no 8=unk (Plaques of ascending aorta & aortic arch) (EC-22) OTHER 1=yes 2=no 8=unk If YES, specify: (EC-23) NOTES: 19

20 INTERVENTIONS (IT-1) Check here, if NO RECORD (IT-2) MAJOR OPERATIONS 1=yes 2=no If YES, answer IT-3 thru IT-5 (IT-3) / / Date of Operation (IT-4) : Time of Operation (IT-5) Type of Operation 1=aneurysm clipping 2=clot evacuation 3=AVM resection 5=other (IT-6) INTRACRANIAL PRESSURE MONITORING 1=yes 2=no (IT-7) INTUBATION 1=yes 2=no (IT-8) INTRAVENTRICULAR DRAIN or SHUNT PLACED 1=yes 2=no (IT-9) NIPRIDE FOR BLOOD PRESSURE CONTROL 1=yes 2=no (IT-10) OTHER MEDICATION FOR BLOOD PRESSURE CONTROL 1=yes 2=no (IT-11) If YES, specify: (IT-12) / BLOOD PRESSURE (closest to 24 hours after admission) (IT-13) MANNITOL FOR INCREASED ICP 1=yes 2=no (IT-14) HYPERVENTILATION FOR INCREASED ICP 1=yes 2=no (IT-15) THROMBOLYTIC THERAPY 1=yes 2=no (IT-16) HEPARIN FOLLOWING ISCHEMIC STROKE 1=yes 2=no (IT- 16a) if YES, date / / and time : of start (IT-17) NIMODIPINE FOLLOWING SAH 1=yes 2=no (IT-18) OTHER EXPERIMENTAL DRUG STUDY 1=yes 2=no (IT-19) If YES, specify: (IT-20) MEDICAL TREATMENT FOR STOKE PREVENTION AFTER STROKE 1=yes 2=no 9=N/A If YES, answer questions IT-21 thru IT-29 (IT-21) Aspirin, < 325 mg/day 1=yes 2=no (IT-22) Aspirin, = 325 mg/day 1=yes 2=no (IT-23) Aspirin, > 325 mg/day 1=yes 2=no (IT-24) Warfarin 1=yes 2=no (IT-25) Ticlopidine 1=yes 2=no (IT-26) Persantine 1=yes 2=no (IT-27) Clopidogrel (Plavix) 1=yes 2=no (IT-28) Other 1=yes 2=no (IT-29) If other, specify (IT-30) NOTES: 20

21 CLINICAL COURSE (CC-1) Check here, if NO RECORD NOTE: If there are questions regarding whether a subsequent event is a new event or a continuation of an old event, contact the physician. (CC-2) SUBSEQUENT STROKE OF SAME TYPE 1=yes 2=no (CC-3) If NO, draw a slash thru CC-3 and CC-4. / / Date (CC-4) Type 1=infarct 2=TIA 3=ICH 4=SAH (CC-5) SUBSEQUENT STROKE OF DIFFERENT TYPE 1=yes 2=no NOTE: IF YES (and stroke is not TIA), THIS STROKE MUST BE ABSTRACTED SEPARATELY. If NO, draw a slash thru CC-6 and CC-7. (CC-6) / / Date (CC-7) Type 1=infarct 2=TIA 3=ICH 4=SAH (CC-7a) HEMORRHAGIC TRANSFORMATION 1=yes 2=no Please describe in the NOTES field, below. (CC-7b) / / Date (CC-8) ANGIOGRAPHIC VASOSPASM 1=yes 2=no (as documented by angiogram) (CC-9) VASOSPASM BY ELEVATED VELOCITIES 1=yes 2=no on Transcranial Doppler, as noted on record (CC-10) REBLEEDING/HEMORRHAGE GROWTH BY CT 1=yes 2=no (CC-10a) INFARCT FOLLOWING HEM./SAME EVENT 1=yes 2=no (CC-11) HYDROCEPHALUS BY CT OR MR 1=yes 2=no (CC-12) NOTES: 21

22 OUTCOME (O-1) VITAL STATUS AT DISCHARGE 1=dead 2=alive (O-2) / / If DEAD, Date of Death (O-3) Cause of Death 1=herniation 2=rebleed 3=vasospasm 4=cardiac arrhythmia 5=MI 6=CHF 7=other 8=unk 9=N/A 10=sudden, unexplained 11=pneumonia 12=pulmonary embolism 13=not clear If ALIVE, answer O-4 to O-7: FUNCTIONAL STATUS at 30 days post stroke or discharge. (O-4) / / DATE MODIFIED RANKIN DONE (O-5) Modified Rankin 0=no symptoms 1=no significant disability despite SXs; able to carry out usual activities 2=slight disabilities; unable to carry out all previous activities, but able to look after self without assistance 3=moderate disabilities; requiring some help; able to walk without assistance 4=moderately severe disabilities; unable to walk without assistance (includes cane, walker); unable to attend to body needs 5=severe disability; bedridden; incontinent; requiring constant nursing care 9=not available (O-6) / / DATE OXFORD HANDICAP SCALE DONE (O-7) Oxford Handicap Scale 0=no symptoms 1=minor symptoms that do not interfere with lifestyle 2=minor handicap, symptoms that lead to some restriction in lifestyle, but do not interfere with the patient s capacity to look after himself 3=moderate handicap, symptoms that significantly restrict lifestyle and prevent totally independent existence 4=moderately severe handicap, symptoms that clearly prevent independent existence, though not needing constant attention 5=severe handicap, totally dependent patient requiring constant attention night and day 9=not available (O-8) / / DATE OF DISCHARGE (O-9) DISPOSITION AT DISCHARGE 1=Home (alone, or with others) 2=Relative or friend 3=Rehab Hospital 4=Skilled Nursing Facility 5=Extended care 6=Hospital 7 =other (specify) 8=unknown 9=N/A IF DISCHARGED TO PLACE OTHER THAN HOME: (O-10) Name: (O-11) Address: (O-12) City/ST/Zip: (O-13) Phone: ( ) - (O-14) / / DATE OF LAST VISIT / LAST TIME SEEN 22

23 AUTOPSY (AU-1) Check here, if patient is alive and has NO RECORD (AU-2) / / DATE OF DEATH (m/d/y) (AU-3) AUTOPSY DONE? 1=yes 2=no If YES, answer the following: (AU-4) / / Date of Autopsy (AU-5) Heart Weight (grams) (AU-6) Type of Stroke Causing Death 1=SAH 2=ICH 3=infarct 4=SAH & ICH 5=ICH & IVH 6=IVH 7=other (AU-7) IF SAH, CAUSE OF SAH 1=aneurysm 2=AVM 3=other (AU-8) IF ICH, CAUSE OF ICH 1=small vessel hypertension 2=amyloid 3=AVM 4=tumor 5=aneurysm 7=other 12=vasculitis 13=blood dyscrasia 14=anticoagulants 15=thrombolytic agents (AU-9) IF INFARCT, CAUSE OF INFARCT 1=small vessel disease 2=cardioembolism 3=atheroembolism 4= large vessel occlusion 5=vasculitis 7=other 8= unk 9=N/A (AU-10) OTHER PERTINENT FINDINGS (e.g., aneurysm, AVM, old strokes, atherosclerosis of intra- or extracranial vessels): 23

24 CTs and MRs CT #1 CT #2 MR #1 MR #2 (CTMR-1) DATE / / / / / / / / (CTMR-2) TIME : : : : (CTMR-3) (CTMR-4) Source of Data Number of Brain Lesions Seen FINDINGS 1=film only 2=report only 3=both 4=neither (CTMR-5) Edema } 1=yes (CTMR-6) Mass Effect } 2=no (CTMR-7) Midline Shift } 8=unk (CTMR-8) (CTMR-9) (CTMR-10) Hydrocephalus (not due to atrophy) Periventricular Leukomalacia Number of slices where white matter changes are visualized } 9=N/A 1=mild 2=mod 3=sev 4=none (CTMR-11) Slice Thickness (mm) (CTMR-12) SAH Present? 1=yes 2=no (CTMR-13) If YES, Fisher classification (range 1-4) (CTMR-14) IVH Present? 1=yes 2=no (CTMR-15) If YES, Petruk classification (range 0-3) (CTMR-16) Evidence of rebleeding since earliest scan 1=yes 2=no (CTMR-17) Notes for CT #1 (CTMR-18) Notes for CT #2 (CTMR-19) Notes for MR #1 (CTMR-20) Notes for MR #2 24

25 CT #1 LESIONS Complete the following for up to 4 lesions. #1 lesion should be that lesion most likely related to clinical history and neurological findings. (CTL1-1) Does this lesion explain the 1=yes 2=no 3=possible clinical findings? (CTL1-2) Lesion Type 1=infarct 2=ICH If INFARCT: (CTL1-3) Age 1 = 0-30 days 2 = >30 days (CTL1-4) Category 1=bland 2=hemorrhage 3=other Lesion #1 Lesion #2 Lesion #3 Lesion #4 (CTL1-5) If OTHER, specify (CTL1-6) Location 1=subcortical 2=watershed 3=cortical 4=1&3 5=brain stem 6=cerebellum If ICH: (CTL1-7) IVH also present 1=yes 2=no (CTL1-8) SAH also present 1=yes 2=no Anatomic Location: 1=right 2=left 3=midline (CTL1-9) Frontal.. (CTL1-10) Temporal.. (CTL1-11) Parietal.. (CTL1-12) Occipital.. (CTL1-13) Deep White Matter.. (CTL1-14) Putamen.. (CTL1-15) Globus Pallidus.. (CTL1-16) Internal Capsule.. (CTL1-17) Thalamus.. (CTL1-18) Caudate.. (CTL1-19) Pons.. (CTL1-20) Midbrain.. (CTL1-21) Cerebellum.. (CTL1-22) Vascular Distribution 1=ICA 2=MCA 3=ACA 4=PCA 5=MCA branch 6=ACA branch 7=PCA branch 8=leticullstriate 12=basilar artery 13=penetrating basilar 14=PICA 9=Art of Heubner 15=AICA 16=SCA (CTL1-30) Notes for Lesion # =thalamo-perf 17=cort medul art artery 11=anterior 88=unk choroidal 99=N/A Size of Infarct/Hemorrhage: (CTL1-23) Largest Diameter (cm)... (CTL1-24) Diameter 90 Degrees to Largest (cm) (CTL1-25) On Number of 10mm Slices... (CTL1-26) Ellipsoid Volume.. (CTL1-27) Notes for Lesion #1 (CTL1-28) Notes for Lesion #2 (CTL1-29) Notes for Lesion #3

26 CT #2 LESIONS Complete the following for up to 4 lesions. #1 lesion should be that lesion most likely related to clinical history and neurological findings. (CTL2-1) Does this lesion explain the 1=yes 2=no 3=possible clinical findings? (CTL2-2) Lesion Type 1=infarct 2=ICH If INFARCT: (CTL2-3) Age 1 = 0-30 days 2 = >30 days (CTL2-4) Category 1=bland 2=hemorrhage 3=other Lesion #1 Lesion #2 Lesion #3 Lesion #4 (CTL2-5) If OTHER, specify (CTL2-6) Location 1=subcortical 2=watershed 3=cortical 4=1&3 5=brain stem 6=cerebellum If ICH: (CTL2-7) IVH also present 1=yes 2=no (CTL2-8) SAH also present 1=yes 2=no Anatomic Location: 1=right 2=left 3=midline (CTL2-9) Frontal.. (CTL2-10) Temporal.. (CTL2-11) Parietal.. (CTL2-12) Occipital.. (CTL2-13) Deep White Matter.. (CTL2-14) Putamen.. (CTL2-15) Globus Pallidus.. (CTL2-16) Internal Capsule.. (CTL2-17) Thalamus.. (CTL2-18) Caudate.. (CTL2-19) Pons.. (CTL2-20) Midbrain.. (CTL2-21) Cerebellum.. (CTL2-22) Vascular Distribution 1=ICA 2=MCA 3=ACA 4=PCA 5=MCA branch 6=ACA branch 7=PCA branch 8=leticullstriate 12=basilar artery 13=penetrating basilar 14=PICA 9=Art of Heubner 15=AICA 16=SCA (CTL2-30) Notes for Lesion # =thalamo-perf 17=cort medul art artery 11=anterior 88=unk choroidal 99=N/A Size of Infarct/Hemorrhage: (CTL2-23) Largest Diameter (cm)... (CTL2-24) Diameter 90 Degrees to Largest (cm) (CTL2-25) On Number of 10mm Slices... (CTL2-26) Ellipsoid Volume.. (CTL2-27) Notes for Lesion #1 (CTL2-28) Notes for Lesion #2 (CTL2-29) Notes for Lesion #3

27 MR #1 LESIONS Complete the following for up to 4 lesions. #1 lesion should be that lesion most likely related to clinical history and neurological findings. (MRL1-1) Does this lesion explain the 1=yes 2=no 3=possible clinical findings? (MRL1-2) Lesion Type 1=infarct 2=ICH If INFARCT: (MRL1-3) Age 1 = 0-30 days 2 = >30 days (MRL1-4) Category 1=bland 2=hemorrhage 3=other Lesion #1 Lesion #2 Lesion #3 Lesion #4 (MRL1-5) If OTHER, specify (MRL1-6) Location 1=subcortical 2=watershed 3=cortical 4=1&3 5=brain stem 6=cerebellum If ICH: (MRL1-7) IVH also present 1=yes 2=no (MRL1-8) SAH also present 1=yes 2=no Anatomic Location: 1=right 2=left 3=midline (MRL1-9) Frontal.. (MRL1-10) Temporal.. (MRL1-11) Parietal.. (MRL1-12) Occipital.. (MRL1-13) Deep White Matter.. (MRL1-14) Putamen.. (MRL1-15) Globus Pallidus.. (MRL1-16) Internal Capsule.. (MRL1-17) Thalamus.. (MRL1-18) Caudate.. (MRL1-19) Pons.. (MRL1-20) Midbrain.. (MRL1-21) Cerebellum.. (MRL1-22) Vascular Distribution 1=ICA 2=MCA 3=ACA 4=PCA 5=MCA branch 6=ACA branch 7=PCA branch 8=leticullstriate 12=basilar artery 13=penetrating basilar 14=PICA 9=Art of Heubner 15=AICA 16=SCA (MRL1-30) Notes for Lesion # =thalamo-perf 17=cort medul art artery 11=anterior 88=unk choroidal 99=N/A Size of Infarct/Hemorrhage: (MRL1-23) Largest Diameter (cm)... (MRL1-24) Diameter 90 Degrees to Largest (cm) (MRL1-25) On Number of 10mm Slices... (MRL1-26) Ellipsoid Volume.. (MRL1-27) Notes for Lesion #1 (MRL1-28) Notes for Lesion #2 (MRL1-29) Notes for Lesion #3

28 MR #2 LESIONS Complete the following for up to 4 lesions. #1 lesion should be that lesion most likely related to clinical history and neurological findings. (MRL2-1) Does this lesion explain the 1=yes 2=no 3=possible clinical findings? (MRL2-2) Lesion Type 1=infarct 2=ICH If INFARCT: (MRL2-3) Age 1 = 0-30 days 2 = >30 days (MRL2-4) Category 1=bland 2=hemorrhage 3=other Lesion #1 Lesion #2 Lesion #3 Lesion #4 (MRL2-5) If OTHER, specify (MRL2-6) Location 1=subcortical 2=watershed 3=cortical 4=1&3 5=brain stem 6=cerebellum If ICH: (MRL2-7) IVH also present 1=yes 2=no (MRL2-8) SAH also present 1=yes 2=no Anatomic Location: 1=right 2=left 3=midline (MRL2-9) Frontal.. (MRL2-10) Temporal.. (MRL2-11) Parietal.. (MRL2-12) Occipital.. (MRL2-13) Deep White Matter.. (MRL2-14) Putamen.. (MRL2-15) Globus Pallidus.. (MRL2-16) Internal Capsule.. (MRL2-17) Thalamus.. (MRL2-18) Caudate.. (MRL2-19) Pons.. (MRL2-20) Midbrain.. (MRL2-21) Cerebellum.. (MRL2-22) Vascular Distribution 1=ICA 2=MCA 3=ACA 4=PCA 5=MCA branch 6=ACA branch 7=PCA branch 8=leticullstriate 12=basilar artery 13=penetrating basilar 14=PICA 9=Art of Heubner 15=AICA 16=SCA (MRL2-30) Notes for Lesion # =thalamo-perf 17=cort medul art artery 11=anterior 88=unk choroidal 99=N/A Size of Infarct/Hemorrhage: (MRL2-23) Largest Diameter (cm)... (MRL2-24) Diameter 90 Degrees to Largest (cm) (MRL2-25) On Number of 10mm Slices... (MRL2-26) Ellipsoid Volume.. (MRL2-27) Notes for Lesion #1 (MRL2-28) Notes for Lesion #2 (MRL2-29) Notes for Lesion #3

29 STROKE SUBTYPE (1) (STR-1) NURSE S IMPRESSION OF STROKE SUBTYPE 1=infarct 2=TIA 3=ICH 4=SAH 5=ICH SAH 6=IVH (STR-2) Notes: (STR-3) PHYSICIAN S FINAL IMPRESSION OF STROKE SUBTYPE 1=infarct 2=TIA 3=ICH 4=SAH 5=ICH+SAH 6=IVH If subtype is INFARCT or TIA, suspected cause: (STR-4) SMALL VESSEL OCCLUSIVE DISEASE 1=Brain images show deep infarct <= 1.5 cm appropriate to the clinical syndrome present, which is typical lacunar, e.g., pure motor hemiparesis face; arm & leg; or arm & leg relatively. 2=Clinical syndrome as above, but CT is negative for lesion that could explain the syndrome. 3=Brain images show deep infarct <= 1.5 cm that could explain the clinical syndrome, but it is other than the classically described lacunar strokes. 4=not seen 8=unk 9=N/A (STR-5) CARDIOEMBOLIC STROKE 1= yes 2=no If NO, unk, or N/A, then slash thru STR-6 to STR-15. (STR-6) Atrial fibrillation or flutter 1= yes 2=no (STR-7) MI within 2 months 1= yes 2=no (STR-8) Cardiac thrombus on testing 1= yes 2=no (STR-9) Valvular vegetation 1= yes 2=no (STR-10) Prosthetic heart valve 1= yes 2=no (STR-11) Acute congestive heart failure 1= yes 2=no (STR-12) Dilated cardiomyopathy 1= yes 2=no (STR-13) Right to left shunt with venous source 1= yes 2=no (STR-14) Systemic emboli related to cardiac source (within 3 months) 1= yes 2=no (STR-15) Akinetic segment on echo or other cardiac testing 1= yes 2=no 29

30 STROKE SUBTYPE (2) (STR-16) LARGE VESSEL ATHEROSCLEROSIS 1=Evidence from angiogram or non-invasive tests of > 50% area stenosis of occlusion consistent with atherosclerosis of an artery appropriate to the site of the infarct, e.g. common carotid, proximal internal carotid, carotid siphon, middle cerebral, basilar and distal vertebral arteries without evidence for distal emboli to explain infarct. 2=Same as (1), but with evidence for distal emboli to explain infarct. 3=Tandem Lesion Strokes Evidence of stenosis or distal occlusion of a large intracranial artery supplying the infarcted area with an ipsilateral proximal lesion of at least 50% stenosis or evidence for an ulcerated plaque. 4=not seen 8=unk 9=N/A (STR-17) STROKE WITH NORMAL ARTERIES (normal angiogram) 1= yes 2=no 3=no ANGIO (STR-18) OTHER IDENTIFIED CAUSE OF ISCHEMIC STROKE 1= yes 2=no (STR-19) If YES, specify: (STR-20) UNKNOWN CAUSE OF INFARCT 1= yes 2=no (STR-21) LIKELIEST CLINICAL CLASSIFICATION OF ISCHEMIC STROKE 1=small vessel 2=cardioembolic 3=large vessel 4=normal artery 5=other ident (STR-22) If subtype is ICH, most likely cause: 1=sm vessel HTN 2=amyloid 3=AVM 4=cavern hemang 5=aneurysm 6=tumor 7=thrombolytics 8=anticoagulants 9=cocaine 10=other 11=no clear cause 88=unk 99=N/A (STR-23) If OTHER, specify: (STR-24) Location 1=deep 2=lobar 3=brain stem 4=cerebellum (STR-25) If subtype is SAH, most likely cause: 1=aneurysm 2=AVM 3=vasculitis 4=no clear cause (STR-26) / / Date of Physician Review (STR-27) Reviewer Initials (STR-28) NOTES: 30