Anatomic High-Risk Conditions
Indicate if the patient had previous radiation therapy to the neck before the current admission or procedure.
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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.
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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
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Previous vertebral intervention Yes or no. If yes, within <30 d, 31–180 d, or >180 d? Note: ● Left ● Right ● Proximal ● Distal
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Previous ipsilateral Carotid EndArterectomy (CEA) Yes or no
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Indicate if the patient has an open tracheostomy at the time of the current procedure.
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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
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Comorbid Cardiopulmonary Conditions
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.
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Indicate if, before the current procedure, the patient has been receiving home oxygen therapy for treatment of chronic lung disease.
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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.
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Patient assessment
Indicate if carotid bruits are present. Choose 1 of the following: ● Yes — Left — Right — Bilateral ● No ● Not assessed
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Indicate if supraclavicular bruits are present. Choose 1 of the following: ● Yes — Left — Right — Bilateral ● No ● Not assessed
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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
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Modified Rankin Stroke Scale score Indicate the patient’s score
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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
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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
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