Extracranial Carotid and Vertebral Artery Disease data elements

Description

Indicate if the patient is asymptomatic. No prior stroke or TIA

Data type

boolean

Alias

UMLS CUI-1

C0231221

Description

Indicate the onset and duration of symptoms.

Data type

text

Alias

UMLS CUI-1

C0231220

Description

Previous stroke is defined as an acute loss of neurological function caused by an ischemic or hemorrhagic event with residual symptoms for at least 24 h or symptoms for <24 h with evidence of acute infarction (eg, by CT or MRI). If present, record stroke type: ● Ischemic ● Intracerebral hemorrhage ● Subarachnoid hemorrhage ● Unknown If ischemic, list the most likely etiologies: ● Large-artery atherosclerosis of the extracranial vessels (eg, carotid) ● Large-artery atherosclerosis of the intracranial vessels (eg, middle cerebral artery stenosis) ● Cardioembolism ● Small-vessel occlusion (lacunar) ● Ischemic stroke of other determined etiology (eg, arterial dissection) ● Ischemic stroke of undetermined etiology

Data type

text

Alias

UMLS CUI-1

C0205156

UMLS CUI-2

C0038454

Description

Documented history of TIA consisting of a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction Note the following: ● Right retinal ● Right hemispheric ● Left retinal ● Left hemispheric ● Vertebrobasilar ● Unknown distribution Date of first and most recent episode

Data type

text

Alias

UMLS CUI-1

C0455536

Description

ASA grade

Data type

integer

Alias

UMLS CUI-1

C1531480

Description

History of dementia, Alzheimer’s disease, chronic confusion (at least 1 mo in duration), or senility Year of onset (first diagnosis) may be helpful.

Data type

text

Alias

UMLS CUI-1

C0455499

Description

Indicate if the patient has a documented history of epilepsy.

Data type

boolean

Alias

UMLS CUI-1

C0455511

Description

Indicate if the patient has a hemorrhage. Choose all that apply: ● Intraparenchymal ● Intraventricular ● Subarachnoid ● Subdural

Data type

text

Alias

UMLS CUI-1

C0019080

Description

Select any of the following that apply ● Atherosclerosis ● FMD ● Dissection ● Vasculitis (Takayasu’s or giant cell arteritis) ● Irradiation ● Restenosis following CEA ● Restenosis following CAS ● Restenosis following vertebral angioplasty/stenting

Data type

text

Description

Indicate if the patient had previous radiation therapy to the neck before the current admission or procedure.

Data type

boolean

Alias

UMLS CUI-1

C0205156

UMLS CUI-2

C0746818

Description

Previous neck surgery (other than CEA) Indicate if the patient had a previous extensive (ie, radical) neck dissection (other than CEA) before the current admission or procedure.

Data type

boolean

Alias

UMLS CUI-1

C0205156

UMLS CUI-2

C0185773

Description

Previous carotid intervention Yes or no. If yes, within <30 d, 31–180 d, or >180 d? Note: ● Right CEA ● Right CAS ● Left CEA ● Left CAS

Data type

text

Description

Previous vertebral intervention Yes or no. If yes, within <30 d, 31–180 d, or >180 d? Note: ● Left ● Right ● Proximal ● Distal

Data type

text

Description

Previous ipsilateral Carotid EndArterectomy (CEA) Yes or no

Data type

boolean

Description

Indicate if the patient has an open tracheostomy at the time of the current procedure.

Data type

boolean

Alias

UMLS CUI-1

C0040590

Description

Indicate if patient has a history of cranial nerve palsy/palsies. Choose 1 of the following: ● Yes — If yes, indicate all nerves involved: X Recurrent laryngeal or its parent nerve, the vagus nerve X Hypoglossal X Facial X Other ● No

Data type

text

Alias

UMLS CUI-1

C0151311

Description

History of chronic lung disease (eg, chronic obstructive pulmonary disease, chronic bronchitis, emphysema, restrictive lung disease) or currently receiving long-term treatment with inhaled or oral pharmacological therapy (eg,beta-adrenergic agonist, anti-inflammatory agent, leukotriene receptor antagonist, or steroid) Year of onset (first diagnosis) may be helpful.

Data type

text

Alias

UMLS CUI-1

C1533075

Description

Indicate if, before the current procedure, the patient has been receiving home oxygen therapy for treatment of chronic lung disease.

Data type

text

Alias

UMLS CUI-1

C0421203

Description

Indicate if the patient’s highest NYHA cardiac functional class has been class III or IV at any time within 6 wk before the current procedure. Patients in NYHA classes III and IV have anginal or heart failure symptoms at rest and/or resulting in marked limitation of physical activity. NYHA classes III and IV are formally defined as follows: ● Class III: Patient has cardiac disease resulting in marked limitation of physical activity. Patient is comfortable at rest. However, less than ordinary physical activity (eg, walking 1 to 2 level blocks or climbing 1 flight of stairs) causes fatigue, palpitations, dyspnea, or anginal pain. ● Class IV: Patient has dyspnea at rest that increases with any physical activity. Patient has cardiac disease resulting in inability to perform any physical activity without discomfort. Symptoms may be present even at rest. If any physical activity is undertaken, discomfort is increased. Note: For patients without cardiac disease or patients with NYHA class I or II, code No.

Data type

text

Description

Indicate if carotid bruits are present. Choose 1 of the following: ● Yes — Left — Right — Bilateral ● No ● Not assessed

Data type

text

Alias

UMLS CUI-1

C0007280

Description

Indicate if supraclavicular bruits are present. Choose 1 of the following: ● Yes — Left — Right — Bilateral ● No ● Not assessed

Data type

text

Description

Indicate if the NIHSS was used. Choose 1 of the following: ● Yes — Indicate scores done before the procedure, immediately after the procedure, before discharge, and other. ● No

Data type

text

Alias

UMLS CUI-1

C1697238

Description

Modified Rankin Stroke Scale score Indicate the patient’s score

Data type

text

Alias

UMLS CUI-1

C2984908

Description

Indicate if the Barthel Index was measured. Choose 1 of the following: ● Yes — Indicate scores done before the procedure, immediately after the procedure, before discharge, and other. ● No

Data type

text

Alias

UMLS CUI-1

C0451019

Description

Indicate the presence or absence of the following: ● Hemiparesis ● Upper motor neuron facial weakness ● Lower motor neuron facial weakness ● Dysphasia ● Hemisensory loss ● Visuospatial neglect ● Branch retinal artery occlusion ● Central retinal artery occlusion ● Dysarthria ● Gait ataxia ● Disconjugate gaze ● Tongue deviation ● Nystagmus

Data type

text

Description

Carotid Duplex Ultrasound Date of procedure Location of measurement: Measure each of the following in the right CCA, right ICA, left CCA, and left ICA. Plaque characteristics: ● No plaque ● Homogeneous plaque (stable) ● Heterogeneous plaque (unstable) ● Surface irregularity Intima-media thickness [mm] CCA systolic velocity: Measure systolic velocity in proximal, mid, and distal segments of CCA. Measure velocity in centimeters per second. CCA diastolic velocity: Measure diastolic velocity in proximal, mid, and distal segments of CCA. Measure velocity in centimeters per second. ICA systolic velocity: Measure systolic velocity in proximal, mid, and distal segments of ICA. Measure velocity in centimeters per second. ICA diastolic velocity: Measure diastolic velocity in proximal, mid, and distal segments of ICA. Measure velocity in centimeters per second. Peak ICA: distal CCA systolic velocity ratio Indicate systolic velocity radio measured in centimeters per second. Choose 1 of the following: ● <2.0 ● 2.0–4.0 ● >4.0 Degree of stenosis Indicate range of stenosis: ● Normal ● 1%–49% ● 50%–69% ● 70%–99% ● Complete occlusion Carotid stent stenosis Indicate the range of stenosis after carotid stenting: ● Normal ● 1%–49% ● 50%–69% ● 70%–99% ● Complete occlusion Carotid bifurcation location Indicate the location of carotid bifurcation. Choose 1 of the following: ● Normal ● High Vertebral artery flow direction Indicate the direction of artery flow for the right and left vertebral artery. Choose 1 of the following: ● Forward ● Reversed ● No flow detected

Data type

text

Alias

UMLS CUI-1

C0741989

Description

CT Angiography Date of procedure Radiologist name Location of measurement Measure each of the following in the right CCA, right ICA, left CCA, and left ICA. Luminal diameter of CCA Measure diameter in millimeters. Luminal diameter of ICA Measure diameter in millimeters. Degree of stenosis Use the NASCET method for measurement of stenosis defined by the formula % stenosis=100x(1-minimum luminal diameter at the lesion site)/diameter of nontapering segment of distal ICA Nonobstructed diameter of ICA [mm] Plaque characteristics: ● Calcifications ● Ulceration ● Tandem lesion Intracranial atherosclerotic disease Indicate if intracranial atherosclerotic disease (>50% stenosis) is present in the distribution in either the right or left ICAs: Yes or no. Other vascular abnormality: Indicate if another vascular abnormality is present, including aneurysm, AVM, etc.

Data type

text

Alias

UMLS CUI-1

C1536105

Description

Magnetic Resonance Angiography Date of procedure Location of measurement: Measure each of the following in the right CCA, right ICA, left CCA, and left ICA. Diameter of CCA Measure diameter in millimeters. Diameter of ICA Measure diameter in millimeters. Degree of stenosis Use the NASCET method for measurement of stenosis defined by the formula % stenosis=100x(1-minimum luminal diameter at the lesion site)/diameter of nontapering segment of distal ICA Nonobstructed diameter of ICA [mm] Plaque: Indicate if any of the following are present and describe: ● Fibrous cap thickness in millimeters ● Fibrous cap disruption ● Intraplaque lipid content ● Intraplaque hemorrhage Tandem lesion: yes or no. Other vascular abnormality: Indicate if another vascular abnormality is present, including aneurysm, AVM, etc. Intracranial atherosclerotic disease Indicate if intracranial atherosclerotic disease (>50% stenosis) is present in the distribution of either the right or left ICA: Yes or no.

Data type

text

Alias

UMLS CUI-1

C0243032

Description

Date of procedure Target carotid vessel: Indicate whether the target vessel is the right or left carotid artery for the current procedure: Right or left. Target vertebral artery: Indicate whether the target vessel is the right or left vertebral artery for the current procedure: Right or left. Is the current procedure part of a clinical trial? Yes or no. If yes, note trial type: ● Postmarket surveillance ● Premarket approval ● IDE ● Other (specify) Anesthesia: Indicate if the patient received general anesthesia, local anesthesia, or no anesthesia during the current procedure. If >1 method was used, code it General. Procedure Indications and Anatomic Variables Target lesion symptomatic within past 6 mo: yes/no Restenosis in target vessel after prior CAS Note if the indication for the current procedure is restenosis in the target carotid artery that was previously treated with angioplasty and/or a stent. Carotid artery restenosis is defined as >50% diameter stenosis at or adjacent to the site previously treated with balloon angioplasty or a stent. Restenosis of target vessel after prior CEA Note if the indication for the current procedure is restenosis in the target carotid artery that was previously treated with carotid artery endarterectomy. Restenosis is defined as renarrowing within or adjacent to a prior endarterectomy site, evidenced by >50% diameter stenosis. Carotid lesion difficult to access surgically: yes/no Note: Lesions that are difficult to access include those that are high in the neck (eg, at or above the level of C2) and those that are within the proximal one half or one third of the CCA, at or below the clavicle, rendering endarterectomy either difficult or impossible. Vertebral lesion difficult to access surgically: Yes or no Indicate if the lesion is difficult to access surgically Aortic arch type Indicate the patient’s aortic arch type configuration. The 3 types of aortic arch are based on the relationship of the innominate artery to the aortic arch. The more inferior the origin of the target artery (ie, type II or III aortic arch), the greater the difficulty in gaining access to the carotid artery. Category: ● Type I ● Type II ● Type III Contrast volume [ml] Fluoroscopy time:Indicate the total fluoroscopy time recorded during the procedure to the nearest 0.10 min. The time recorded should include the total time for the procedure. Contralateral carotid occlusion:Indicate if there is known 100% occlusion of the patient’s contralateral carotid artery. Contralateral vertebral occlusion:Indicate if there is known 100% occlusion of the patient’s contralateral vertebral artery. Bovine arch: Indicate if the patient’s aortic arch is bovine, in which the right brachiocephalic and left carotid arteries share a common trunk from the aortic arch. Procedure arterial access site: Indicate the primary arterial access site used to perform the CAS procedure. Note the location: ● Femoral ● Direct carotid puncture ● Direct vertebral puncture ● Brachial ● Radial ● Axillary exposure ● Carotid cut down ● Vertebral cut down Arterial access closure method: List methods and devices in chronological order of closure. Indicate the method used to achieve hemostasis. Methods should include devices and nondevices such as manual compression. Tandem lesions Indicate if there is evidence of tandem lesions. Choose 1 of the following: ● Yes — Specify location(s) ● No Intracranial stenosis Indicate if there is evidence of intracranial lesions. Choose 1 of the following: ● Yes — Specify location(s) ● No Other intracranial pathology Indicate if there is evidence of other intracranial pathology. Choose 1 of the following: ● Yes — Specify type ● No Lesions and Devices Target lesion location List the following: ● Isolated CCA ● Isolated ICA ● Bifurcation ● Vertebral ostia ● Vertebral artery ostia ● Midcervical vertebral Visible thrombus present Indicate if the target lesion contains thrombus as assessed by baseline angiography and implied by the presence of filling defect. Ulceration Indicate if the target lesion is ulcerated as assessed by baseline angiography. Calcification Indicate if calcification is present. If present, specify the location. Choose 1 of the following: ● None ● Mild ● Moderate ● Severe Lesion length Indicate the length of the target lesion in millimeters as assessed by baseline angiography. Minimal luminal diameter Indicate the MLD of the target lesion in millimeters as assessed by baseline angiography. The MLD is defined as the minimum luminal diameter derived from the angiographic view that shows the tightest point of the stenosis. Diameter of distal ICA Indicate the diameter of the nontapering distal segment of the ICA for NASCET measurement at the intended landing zone of the distal edge of the stent (where the vessel is no longer tapered and the walls become parallel). Note: NASCET was a randomized clinical trial that compared the safety and efficacy of CEA to medical therapy for the prevention of stroke in symptomatic patients. Preprocedure percent stenosis of the carotid artery Indicate the percent stenosis preprocedure, which is calculated as follows: 1. When the tightest stenosis is in the ICA or at the carotid bifurcation, use the NASCET method. Percent diameter stenosis is calculated as: 1-(minimum luminal diameter at the lesion site/diameter of nontapering segment of the distal ICA). The nontapering site is where the walls of the ICA become parallel. 2. Do not use the NASCET method if the distal lumen collapses from a low-flow situation. In such cases, enter 99% because the stenosis may be graded as a near-occlusion. 3. For stenosis localized to the CCA, percent diameter stenosis is calculated as 1-(minimum luminal diameter/diameter of the adjacent normal segment of the CCA). Preprocedure percent stenosis of the vertebral artery Indicate preprocedure percent stenosis calculated as follows: When the tightest stenosis is in the cervical vertebral artery (origin to dural entry), percent diameter stenosis is calculated as 1-(minimum luminal diameter of the nontapering segment of the distal vertebral artery). The nontapering site is where the walls of the vertebral artery become parallel. Lesion treatment incomplete or aborted Indicate if the lesion treatment was incomplete or aborted: Yes or no. If yes, note the reason(s): ● Failure to gain vascular access ● Unable to cross with guidewire ● Unable to cross with balloon ● Unable to deploy stent ● Arrhythmia ● Failure to confirm significant stenosis ● Difficult to access because of tortuosity ● Cardiac ischemia ● Hypotension ● Hypertension ● Unable to deliver stent ● Acute neurological event ● Other Embolic protection attempted Indicate if the operator tried to use an EPD: ● Yes — Indicate if predilatation was done before balloon or stent. — List EPD devices in chronological order. — Note if successfully deployed. ● No If yes, indicate if predilatation was done before balloon or stent. ● Yes ● No If yes, list EPD devices in chronological order. Predilatation Indicate if predilatation was performed before the attempted stent implantation or after EPD: Yes or no Stents implanted Were stents implanted? Yes or no. If yes, list stents in chronological order with the following information: ● Stent ● Brand ● Model ● Manufacturer Stents tapered Yes or no Stent(s) diameter Indicate the diameter of the stent. If a tapered stent was used, indicate the smallest diameter of the tapered stent in millimeters. Stent(s) length Indicate the length of the stent in millimeters. Stent(s) malposition Indicate if the stent was deployed in a location or position other than that for which it was intended. Postdilatation performed Was postdilatation performed? Yes or no. If yes, note the following: ● Nominal balloon diameter in millimeters ● Maximum inflation pressure in atmospheres Final MLD Indicate the final residual lumen diameter in millimeters. Final percent stenosis for carotid artery Indicate percent stenosis postprocedure, calculated as follows: 1. For an ICA site, use NASCET methodology. Percent diameter stenosis is calculated as 1-(minimum residual luminal diameter within the treated site/diameter of the nontapering segment of the distal ICA). The nontapering site is where the walls of the ICA become parallel. 2. For a lesion and interventional site localized to the CCA, percent diameter stenosis is calculated as 1-(minimum residual luminal diameter/diameter of the adjacent normal segment of the CCA). Final percent stenosis for vertebral artery Value is dependent on the largest stenosis using essentially similar NASCET criteria for vertebral disease.

Data type

text

Description

Carotid Endarterectomy Date of procedure Operator name Is the current procedure part of a carotid trial? Yes or no. If yes, note the type of trial: ● Postmarket surveillance ● Premarket approval ● IDE ● Other (specify) Target carotid vessel: Indicate whether the target vessel is the right or left carotid artery for the current procedure: ● Right ● Left ● Common ● Bifurcation ● Distal internal Anesthesia: Indicate if the patient received general anesthesia, local anesthesia, or no anesthesia during the current procedure. If >1 method of anesthesia was given, code it General. Endarterectomy technique Standard or eversion Procedure Indications and Anatomic Variables Target lesion symptomatic within past 6 mo Indicate if the patient has had neurologic symptoms related to the target lesion in the past 6 mo. Target lesion symptomatic within past 3 mo: Yes or no Target lesion symptomatic within past 6 wk: Yes or no Restenosis in target vessel after prior CEA Note if the indication for the current procedure is restenosis in the target carotid artery that was previously treated with CEA. Restenosis is defined as renarrowing within or adjacent to a prior endarterectomy site, evidenced by >50% diameter stenosis. Contralateral carotid artery occlusion Indicate if there is known 100% occlusion of the patient’s contralateral carotid artery. Contralateral carotid artery stenosis: Yes or no Spontaneous carotid artery dissection Indicate if the patient has had a spontaneous carotid artery dissection before the current procedure: Yes or no. If yes, note the location: ● Common carotid ● Carotid bifurcation ● Distal internal Tandem lesions Yes or no. If yes, note the location. Intracranial stenosis Yes or no. If yes, note the location. Other intracranial pathology: Yes or no. If yes, note the type. Intraprocedural Information Patch utilization Standard technique? ● Yes — If yes, indicate the type of patch (eg, Dacron, PTFE, bovine pericardium, vein). ● No Thrombus present on direct visual inspection Indicate if a thrombus (blood clot) was present on direct visual inspection intraoperatively during the CEA procedure. Monitoring technique used Note the following: ● Awake monitoring ● Selective monitoring based on EEG, stump pressure, SSEP, motor-evoked potential, anatomic, or other factor (describe). Shunting used: Indicate if a shunt was used. If yes, note the following: ● Selective shunt based on EEG, stump pressure, SSEP, motor-evoked potential, anatomic, or other factor (describe) ● Was a shunt indicated but not technically possible? Surgical procedure terminated Indicate if the CEA procedure was terminated: Yes or no. If yes, note the reason(s): ● Hypotension ● Hypertension ● Nerve compromise ● Excessive scar tissue ● Carotid artery thrombosis ● Difficulty with anesthesia ● Difficulty with suction ● ICA string sign or atresia ● Cardiac instability ● Inability to implement shunting ● Excessive bleeding ● Inability to access lesion because of anatomical lesions ● Other (specify) Intraoperative completion evaluation Check all that apply: ● None ● Standard Doppler ● Arteriogram (include findings) ● Duplex scan (include findings) Intraoperative complications Indicate any of the following: ● Reopening of carotid artery (note indication and findings) ● Technical difficulties (describe) Patient outcome ● Normal neurologic exam ● Deficit (describe) Medications Antiplatelet therapy, aspirin Yes or no. If yes, note type. Contraindicated clopidogrel Yes or no Contraindicated ticlopidine Yes or no Contraindicated other Yes or no Intraoperative anticoagulation Indicate the drug and dose used

Data type

text

Alias

UMLS CUI-1

C0014099

Description

Indicate adverse event(s) that occurred during or after the procedure. Specify time of occurrence relative to procedure: ● Abrupt closure ● Spasm requiring treatment ● Loss of external carotid ● Distal intracranial embolization ● Embolization (systemic) ● Embolization (carotid) ● Thrombosis ● Occlusive untreated dissection ● Arrhythmia requiring treatment ● Hypotension requiring treatment ● Hypertension requiring treatment ● Stroke (ischemic, hemorrhagic, unknown type) ● TIA ● Amaurosis fugax ● Seizure ● Puncture site complications ● Death (or death in lab) ● Intubation or resuscitation ● Stent malposition ● Embolic protection retrieval ● Intracranial hemorrhage ● Other (specify)

Data type

text

Alias

UMLS CUI-1

C0021890

Description

Results ● Procedure technical failure—unable to deploy stent ● Procedure terminated for stenosis <70% ● Procedure terminated because of complication before deployment ● Procedure technical success without complications ● Procedure technical success with complications

Data type

text

Description

Indicate if there is acute occlusion <24 h after the procedure.

Data type

boolean

Alias

UMLS CUI-1

C2062866

Description

Residual stenosis Note: ● Right ● Left ● Bilateral

Data type

text

Description

Right-side percent stenosis Indicate right-side percent stenosis.

Data type

float

Measurement units

• %

Alias

UMLS CUI-1

C1261287

UMLS CUI-2

C0205090

Description

Left-side percent stenosis Indicate left-side percent stenosis.

Data type

float

Measurement units

• %

Alias

UMLS CUI-1

C1261287

UMLS CUI-2

C0205091

Description

Stent migration/deformation Stent located in planned landing zone with complete lesion coverage

Data type

text

Description

Occlusion of cerebral arteries or periprocedural neurologic deficit resulting from dislodgment of atheromatous debris or thrombus from the procedural site

Data type

text

Description

Postprocedural complications in hospital Indicate if any of the following occurred: ● None ● Arrhythmia requiring treatment ● Hypotension requiring treatment ● Hypertension requiring treatment ● MI ● New unstable angina ● Electrocardiographic changes ● Cardiac enzyme elevations ● Pulmonary embolism ● Stroke (ischemic, hemorrhagic, unknown type) ● Deterioration in Modified Rankin Scale score ● TIA ● Amaurosis fugax ● Seizure ● Intracranial hemorrhage ● Hyperperfusion syndrome ● Other neurologic complication (specify) ● Secondary carotid intervention (specify) ● Vessel thrombosis or ischemia of extremity ● Puncture site complications ● Pseudoaneurysm ● Pseudoaneurysm vascular repair ● Hematoma (local or retroperitoneal) (indicate if transfusion required) ● Other bleeding (indicate if transfusion required) ● Access site infection ● Creatinine increase >1.0 mg/dL ● Hemodialysis ● Pneumonia ● Urinary tract infection ● Sepsis ● Death ● Other (specify)

Data type

text

Alias

UMLS CUI-1

C0032787

Description

Medication instruction Verbal and written medication instructions provided to patient and/or family

Data type

text

Alias

UMLS CUI-1

C2064717

Description

Verbal and written instructions provided to patient and/or family (by physician or nurse) regarding new or worsening symptoms and when to call the physician

Data type

text

Description

Advice given or discussion held with the patient and/or family about diet counseling related to lowering cardiovascular risk. May include ● Sodium restriction ● Fluid restriction ● Other (specify)

Data type

text

Alias

UMLS CUI-1

C0204932

Description

Referral to dietitian for weight management and/or advanced nutritional instruction

Data type

text

Description

Advice given or discussion held with the patient and/or family about activity level and restrictions in activity and/or exercise recommendations.

Data type

text

Description

Advice given or discussion held with the patient (by physician, nurse, or other personnel) about the importance of stopping smoking. May include ● Counseling (may be basic or advanced) ● Written materials ● Referral to smoking cessation program ● Drugs to assist for smoking cessation

Data type

text

Alias

UMLS CUI-1

C1095963

Description

Documentation of plan for follow-up care with physician and/or nurse Should include date of follow-up

Data type

text

Description

Patient referred to other care such as neurology, neurosurgery, vascular surgery, cardiology clinic/office. Transitional care (specify duration): ● Home health care ● Nurse case manager ● Hospice or palliative care ● Home telemonitoring ● Ambulatory cardiac telemetric monitoring (eg, mobile cardiac outpatient telemetry) ● Period of time enrolled in the program and/or qualitative characterization of the level of the patient’s success/participation in the program(s) may be specified.

Data type

text

Alias

UMLS CUI-1

C0034927

Description

Discharge status Indicate the following: ● Discharge NIHSS score ● Discharge Modified Rankin Scale score ● Discharge Barthel Index ● Cranial nerve injury ● Technical defects requiring revision ● Stroke (ischemic, hemorrhagic, unknown type)—note date ● TIA (single or multiple)—note date ● Amaurosis fugax ● MI (Q wave or non–Q wave)—note date

Data type

text

Alias

UMLS CUI-1

C0586514

Description

Indicate the period at which outcome measures are assessed. Choose all that apply: ● 1 mo ● 3 mo ● 6 mo ● 1 y

Data type

text

Alias

UMLS CUI-1

C2986292

Description

Documentation of follow-up evaluation for patients with established carotid/vertebral arterial disease should include ● Patient history ● Functional status ● Physical examination ● Laboratory or other tests Follow-Up NIHSS indicate date of visit Right-side percent stenosis Indicate right-side percent stenosis. Left-side percent stenosis Indicate left-side percent stenosis. MRA or CTA performed Indicate if MRA or CTA was performed in any of the following time frames: ● Before discharge — Yes — No ● 3 mo — Yes — No ● 6 mo — Yes — No ● Annually — Yes — No Right-side percent stenosis Indicate right-side percent stenosis. Left-side percent stenosis Indicate left-side percent stenosis. Follow-up Modified Rankin Scale score (See scale above.) Follow-up Barthel Index (See scale above.) Stroke Indicate stroke type: ● Ischemic ● Hemorrhagic ● Unknown Indicate whether or not the patient was hospitalized. Reason for termination Indicate the reason for termination. Death Note the following: ● Date ● Cause ● Date of the last visit in which the patient was evaluated ● Death within 30 d of last visit ● Death 30 d after last visit

Data type

text

Alias

UMLS CUI-1

C0589121

Description

Indicate if repeat duplex ultrasound was performed in any of the following time frames: ● Before discharge — Yes — No ● 3 mo — Yes — No ● 6 mo — Yes — No ● Annually — Yes — No

Data type

text

Description

Repeat Hospitalization Date of admission Primary reason for readmission Stroke, TIA, MI, other Repeat duplex ultrasound performed: Yes or no Right-side percent stenosis Left-side percent stenosis Was repeated MRA, CTA, or conventional angiogram performed: Yes or no Target lesion revascularization: Indicate whether CAS was performed. Target vessel revascularization: Indicate whether CEA or CAS was performed. Stent patency: Indicate whether the stent is patent and if restenosis is present: ● Right-side percent stenosis ● Left-side percent stenosis

Data type

text