6 Stroke Abstraction

The Jackson Heart Study: Annual Follow-up with Third Party Respondents

Attach 17 -Stroke Abstraction (STR) Form

The Jackson Heart Study: Annual Follow-up with Third Party Respondents

OMB: 0925-0491

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OMB# 0925-0491

EXPIRATION DATE XX/XXXX

COHORT STROKE ABSTRACTION FORM


Form Code: STR

Version D: 04/0/2005

ID NUMBER Contact Year



Last Name: Initial:



Instructions: The Stroke Form is completed for each eligible Cohort hospitalization for stroke as determined by the Cohort Eligibility Form. Event ID must be entered above. Refer to this form's Q by Q instructions for information on entering numerical responses. For multiple choice and "yes/no" questions, circle the letter corresponding to the most appropriate response. If a letter is circled incorrectly, mark through it with an "X" and circle the correct response.


Cohort Stroke Abstraction Form (STRD Screen 1 of 27)

A. HOSPITAL INFORMATION

1.a. Hospital number:




[If code 96-99, specify

name and location]:





b. Medical record number:






2. Has the hospital chart

for this event been

located? ................. Yes Y


No N

Go to Item 56,

Screen 27.




3. ENTER ON CFDB FORM


a. Last Name:





b. Initials: .................



c. If name unavailable, SOUNDEX:


- -

4. ENTER ON CFDB FORM

Social Security/Medicare number:



- - -


5. ENTER ON CFDB FORM

Patient address:




City County State





Zip









Cohort Stroke Abstraction Form (STRD Screen 2 of 27)


6. List all discharge diagnosis and

procedure codes exactly as they

appear on the face sheet of the

medical record and/or on the

discharge summary.



a. .


b. .


c. .


d. .



e. .


f. .



g. .


h. .


i. .


j. .





k. .


l. .



m. .


n. .


o. .


p. .


q. .


r. .


s. .


t. .



u. .




Cohort Stroke Abstraction Form (STRD Screen 3 of 27)


7. Transcribe discharge diagnoses exactly as they appear on face sheet

and/or on discharge summary:


____________________________________________________________________________________________________


____________________________________________________________________________________________________

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Cohort Stroke Abstraction Form (STRD Screen 4 of 27)


8. ENTER ON CFDB FORM


Date of birth: / /

m m d d y y y y




9. Sex .................... Male M


Female F



10. Race or ethnic group:


White/Caucasian .......... W


Black/Negro .............. B


Asian/Pacific Islander ... A


American Indian/

Native Alaskan .......... I


Other .................... O


Unknown/not recorded ..... U




11. Was the patient transferred

from or to another

acute care hospital ..... Yes Y


Go to Item 12,

Screen 5.

No N




a. First Transfer

Hospital Code:


Name


City


State




b. Date of admission to that hospital:


/ /

m m d d y y y y


Cohort Stroke Abstraction Form (STRD Screen 5 of 27)

11.c. Second Transfer

Hospital Code:



Name


City


State



d. Date of admission to that hospital:



/ /

m m d d y y y y


12. Date of arrival at this hospital:



/ /

m m d d y y y y


13.a. Time of arrival at this hospital:

(24 hr clock)


:

h h m m



14. Date of discharge or death:




/ /

m m d d y y y y


15. Discharged ....... Alive A

Go to Item 17,

Screen 6.


Dead D


Cohort Stroke Abstraction Form (STRD Screen 6 of 27)

16. Length of time between onset

of new neurologic symptoms/

signs and death:


Less than 24 hours L

24-48 hours E

Greater than 48 hours G

Unknown U

Not Applicable N


Go to Item 19a.


17. Did the discharge diagnosis

include any 430, 431,

432, 433, 434, or

436 codes? ......... Yes Y

No N

Go to Item 19a.




18. Did any neurologic

symptoms/signs

last > 24 hours? ....... Yes Y


Go to Item 56,

Screen 27.

No N



19.a. Were there new neurological

symptoms/signs leading

to or present upon

admission to this

hospital? ........ Yes Y

No N

Go to Item 21,

Screen 7.



b. If no, what was the condition(s)

causing admission?






Cohort Stroke Abstraction Form (STRD Screen 7 of 27)


20. Did new neurological

symptoms/signs develop

during this

hospitalization? .... Yes Y


No N

Go to Item 56,

Screen 27.

Unknown U




21. Date of onset of current

neurological event:



/ /

m m d d y y y y


22. Was the onset of the

predominant neurologic

symptom(s)/sign(s)

either sudden or

rapid? ............. Yes Y


No N


Unknown U



23. History of previous

stroke (also review

previous discharge

diagnoses) .......... Yes Y

Go to Item 26.

No N


Unknown U


24. Month/year of first stroke:


/

m m y y y y


25. Month/year of most recent stroke:



/

m m y y y y



26. History of

previous TIA: ....... Yes Y

Go to Item 28,

Screen 8.

No N


Unknown U




Cohort Stroke Abstraction Form (STRD Screen 8 of 27)


27. Month/year of first and

most recent TIA:


  1. First: .......... /


m m y y y y


  1. Most Recent: .... /


m m y y y y



28. History of myocardial

infarction prior

to the onset of

this event: .......... Yes Y


No N


Unknown U




29. Are any of the following

conditions documented as

having been present within

four weeks prior to or

during this hospitalization?


a. Myocardial infarction

(IF YES, COMPLETE

HRA FORM) ....... Yes Y


No N


Unknown U



b. Intracardiac thrombus

or intracardiac

tumor (myxoma) ........ Yes Y


No N





Cohort Stroke Abstraction Form (STRD Screen 9 of 27)


29.c. Atrial fibrillation

or flutter ............ Yes Y


No N



d. Rheumatic heart

disease, valvular

heart disease (e.g.,

mitral stenosis,

artificial heart

valve) ................ Yes Y


No N



e. Subacute bacterial

endocarditis .......... Yes Y


No N



f. Systemic embolus

(including

angiographically

identified embolus) ... Yes Y


No N




29.g.1. Hematologic abnormality:

hypercoagulable state

e.g., DIC ........... Yes Y


No N



g.2. Hematologic abnormality:

hemorrhagic

e.g., leukemia,

thrombocytopenia,

DIC ................. Yes Y


No N



h. Brain tumor (benign or

malignant, primary

or metastatic) ........ Yes Y


No N






Cohort Stroke Abstraction Form (STRD Screen 10 of 27)


29.i. Major head trauma, e.g.,

subdural hematoma,

epidural hematoma,

skull fracture ........ Yes Y


No N



j. Another nonstroke

disease process

which likely caused

a focal neurologic

deficit or coma ....... Yes Y


Go to Item 30a.

No N





k. Specify:




30. Were any of the following performed

or present in the week prior to the

onset of acute neurologic symptoms?



a. Cardiac catheterization Yes Y


No N



b. Open heart surgery ..... Yes Y


No N



c. Cerebral angiography ... Yes Y


No N



d. Carotid endarterectomy . Yes Y


No N






Cohort Stroke Abstraction Form (STRD Screen 11 of 27)


30.e. Therapy with anticoagulants

(Heparin, Warfarin

(Coumadin)) ........... Yes Y


No N



f. Therapy with

thrombolytic agents

(streptokinase,

TPA, urokinase) ........ Yes Y


No N




B. PHYSICIAN DOCUMENTATION OF NEW

SYMPTOMS OR SIGNS PRESENT ON OR

LEADING TO THIS ADMISSION, OR

OCCURRING DURING HOSPITALIZATION:


31.a. Headache at onset

or admission .......... Yes Y


Go to Item 32a.

No N



31.b. Indicate severity:


Severe S

Mild/moderate M


Unspecified U



c. What was the duration?


Less than 24 hours L


24 hours or more M


Unknown U



32.a. Vertigo ................ Yes Y


Go to Item 33,

Screen 12.

No N


b. What was the duration?


Less than 24 hours L


24 hours or more M


Unknown U




Cohort Stroke Abstraction Form (STRD Screen 12 of 27)


33.a. Convulsions ............ Yes Y


Go to Item 34.

No N



b. Was this the first

neurologic symptom? ... Yes Y


No N



34. Meningeal signs:

Stiff neck (nuchal rigidity);

limitation on leg extension,

neck flexion (Kernig,

Brudzinski) ............. Yes Y


No N




35.a. Coma, unconsciousness,

stupor occurring within

12 hours after onset of

the neurologic event .. Yes Y

Go to Item 36, Screen 13.


No N



b. What was the duration?


Less than 24 hours L


24 hours or more M


Unknown U






Cohort Stroke Abstraction Form (STRD Screen 13 of 27)


36.a. Aphasia ................ Yes Y


Go to Item 37.

No N





b. What was the duration?


Less than 24 hours L


24 hours or more M


Unknown U



37. Pre-retinal (Subhyaloid)

Hemorrhages ............. Yes Y


No N





38.a. Hemianopia ............. Yes Y


Go to Item 39.

No N



b. What was the duration?


Less than 24 hours L


24 hours or more M


Unknown U


39.a. Diplopia ............... Yes Y


Go to Item 40, Screen 14.

No N




b. What was the duration?


Less than 24 hours L


24 hours or more M


Unknown U






Cohort Stroke Abstraction Form (STRD Screen 14 of 27)


40.a. Dysphagia (difficulty in

swallowing), dysarthria,

dysphonia, or tongue

deviation ............. Yes Y


No N

Go to Item 41.





b. What was the duration?


Less than 24 hours L


24 hours or more M


Unknown U



41.a. Weakness, paresis

or paralysis

affecting the face .... Yes Y


Go to Item 42, Screen 15.

No N



b. Indicate affected side(s):


Right side R


Left side L


Both sides B


Unknown U



c. What was the duration?


Less than 24 hours L


24 hours or more M


Unknown U







Cohort Stroke Abstraction Form (STRD Screen 15 of 27)


42.a. Weakness, paresis or

paralysis affecting

the extremities ....... Yes Y


No N

Go to Item 43, Screen 16.




b. Arm: (Circle one)


Affected, side unspecified U


Right Only R


Left Only L


Both B


Neither N




42.c. Leg: (Circle one)


Affected, side unspecified U


Right Only R


Left Only L


Both B


Neither N



d. What was the duration of the

weakness, paresis, or paralysis

affecting the extremities?


Less than 24 hours L


24 hours or more M


Unknown U








Cohort Stroke Abstraction Form (STRD Screen 16 of 27)


43.a. Loss of sensation,

tingling, paresthesias,

hemianesthesia

affecting the face .... Yes Y


Go to Item 44.

No N





b. Indicate affected side(s):


Right side R


Left side L


Both sides B


Unknown U



c. What was the duration?


Less than 24 hours L


24 hours or more M


Unknown U




44.a. Loss of sensation, tingling,

paresthesias, hemianesthesia

affecting the extremities


Go to Item 45, Screen 17.

Yes Y

No N


b. Arm: (Circle one)


Affected, side unspecified U


Right Only R


Left Only L


Both B


Neither N








Cohort Stroke Abstraction Form (STRD Screen 17 of 27)


44.c. Leg: (Circle one)


Affected, side unspecified U


Right Only R


Left Only L


Both B


Neither N



d. What was the total duration of the

loss of sensation, tingling,

paresthesias, hemianesthesia

affecting the extremities?


Less than 24 hours L


24 hours or more M

Unknown U




45.a. Gait disturbance ....... Yes Y


Go to Item 46.

No N



b. What was the duration?


Less than 24 hours .......... L


24 hours or more ............ M


Unknown ..................... U




46.a. Cranial Nerve III

Palsy: ................ Yes Y


No N







Cohort Stroke Abstraction Form (STRD Screen 18 of 27)


46.b. Other neurologic

symptom: .............. Yes Y


No N


If yes, specify:










c. Did any neurologic

sign/symptom last

> 24 hours or did

death occur < 24 hours

after onset of new

sign/symptom? .......... Yes Y


No N




C. LABORATORY TESTS PERFORMED THIS

ADMISSION:


47.a. Was lumbar puncture

performed? ............ Yes Y

Go to Item 48, Screen 20.

No N





Record for the first nontraumatic

LP after onset of symptoms or

first LP if all traumatic.


b. Date:

/ /


m m d d y y y y



c. Traumatic? ............. Yes Y


No N







Cohort Stroke Abstraction Form (STRD Screen 19 of 27)


47.d. Appearance: .. Clear fluid C


Xanthochromic X


Gross blood B


Unknown U



e. Microscopic RBCs (Tube 1):


Zero RBCs cu.mm. Z


1-999 RBC cu.mm. L


1000+ RBC cu.mm. G


Unknown U




47.f. Microscopic RBCs (Tube 2):


No tube N


Zero RBCs cu.mm. Z


1-999 RBC cu.mm. L


1000+ RBC cu.mm. G


Unknown U



g. Lumbar puncture diagnosis:


Normal Study A


Exclusionary pathology B


Unrelated pathology or

traumatic tap C


Bloody (non-traumatic)

or xanthochromic D




Cohort Stroke Abstraction Form (STRD Screen 20 of 27)


48.a. Was cerebral angiography

performed? ............ Yes Y

Go to Item 49, Screen 21.


No N






b. Date:

/ /

m m d d y y y y



c. Angiography diagnosis


Normal study A


Exclusionary pathology B


Unrelated pathology C


Ruptured aneurysm D


Avascular mass without

evidence ruptured

aneurysm/AVM E




48.d. Stenosis - Right internal carotid


Not studied A


0-29% stenosis B


30-69% stenosis C


70-89% stenosis D


> 90% stenosis E

If B, C, D, or E, specify percentage.


d.1. %


e. Stenosis - Left internal carotid


Not studied A


0-29% stenosis B


30-69% stenosis C


70-89% stenosis D


> 90% stenosis E

If B, C, D, or E, specify percentage.




e.1. %








Cohort Stroke Abstraction Form (STRD Screen 21 of 27)


49.a. Was at least one CT scan

performed during this

hospitalization? ...... Yes Y


Go to Item 51, Screen 23.

No N






b. What was approximate time

between symptom onset and the

first CT scan?


Less than 24 hours A


24-48 hours B


Greater than 48 hours C


Unknown U




49.c. Date of first

CT scan:

/ /

m m d d y y y y



d. First CT diagnosis

Normal study A


Exclusionary pathology B


Unrelated pathology C


Normal study, but done within

48 hours of symptom onset D


Subarachnoid hemorrhage E


Intracerebral hematoma F


Ischemic infarction, with

no evidence of hemorrhage G





Cohort Stroke Abstraction Form (STRD Screen 22 of 27)


50.a. Were two or more CT scans

performed during this

hospitalization? ....... Yes Y


No N

Go to Item 51, Screen 24.






b. What was approximate time

between symptom onset and the

last CT scan?


Less than 24 hours A


24-48 hours B


Greater than 48 hours C


Unknown U




50.c. Date of last CT scan during

this hospitalization:



/ /

m m d d y y y y



50.d. Last CT diagnosis


Normal study A


Exclusionary pathology B


Unrelated pathology C


Normal study, but done within

48 hours of symptom onset D


Subarachnoid hemorrhage E


Intracerebral hematoma F


Ischemic infarction, with

no evidence of hemorrhage G







Cohort Stroke Abstraction Form (STRD Screen 23 of 27)


51.a. Were any other CT scans performed

after the onset of acute

neurologic symptoms/signs,

but before admission to

this hospital? ........ Yes Y


No N

Go to Item 52, Screen 24.





b. What was approximate time

between symptom onset and the

first CT scan prior to this

hospitalization?


Less than 24 hours A


24-48 hours B


Greater than 48 hours C


Unknown U




51.c. Date of pre-admission

CT scan:


/ /

m m d d y y y y



d. Pre-admission CT diagnosis


Normal study A


Exclusionary pathology B


Unrelated pathology C


Normal study, but done within

48 hours of symptom onset D


Subarachnoid hemorrhage E


Intracerebral hematoma F


Ischemic infarction, with

no evidence of hemorrhage G






Cohort Stroke Abstraction Form (STRD Screen 24 of 27)


52.a. Was Magnetic Resonance

Imaging (MRI) including

the head performed? ... Yes Y


No N

Go to Item 53, Screen 25.





b. What was approximate time

between symptom onset and

the MRI? (If > 1 MRI, pick

the most meaningful.)


Less than 24 hours A


24-48 hours B


Greater than 48 hours C


Unknown U



  1. D ate:


/ /

m m d d y y y y




52.d. MRI diagnosis:


Normal study A


Exclusionary pathology B


Unrelated pathology C


Normal study, but done within

48 hours of symptom onset D


Subarachnoid hemorrhage E


Intracerebral hematoma F


Ischemic infarction, with

no evidence of hemorrhage G




Cohort Stroke Abstraction Form (STRD Screen 25 of 27)


53.a. Was B-Mode and/or Doppler

Ultrasound on carotid(s)

performed? ............ Yes Y


No N

Go to Item 54.




b. Date:

/ /

m m d d y y y y



53.c. Ultrasound diagnosis - Right

internal carotid


Not studied A


0-29% stenosis B


30-69% stenosis C


70-89% stenosis D


> 90% stenosis E


"Hemodynamically

significant lesion" F

If B, C, D, or E, specify percentage:





c.1. %




53.d. Ultrasound diagnosis - Left

internal carotid


Not studied A


0-29% stenosis B


30-69% stenosis C


70-89% stenosis D


> 90% stenosis E


"Hemodynamically

significant lesion" F

If B, C, D, or E, specify percentage:




d.1. %


54.a. Was a craniotomy performed

(post event)? ......... Yes Y


Go to Item 55, Screen 26.

No N




b. Date:

/ /

m m d d y y y y













Cohort Stroke Abstraction Form (STRD Screen 26 of 27)


54.c. Craniotomy diagnosis


No pathology A


Exclusionary pathology B


Unrelated pathology C


Ruptured aneurysm D


Intracerebral hematoma E


Infarction F






55.a. Was an autopsy

performed? ............ Yes Y

Go to Item 56, Screen 27.

No N




C. Autopsy diagnosis


b. Recent bleeding of

saccular aneurysm ..... Yes Y


No N



c. Intracerebral

hemorrhage ............ Yes Y


No N



d. Recent nonhemorrhagic

infarction of brain ... Yes Y


No N











Cohort Stroke Abstraction Form (STRD Screen 27 of 27)


55.e. Recent infarcted

area (bland or

hemorrhagic) .......... Yes Y


No N



f. Source of emboli in a

vessel of any organ,

or an embolus in

the brain ............. Yes Y


No N


D. ADMINISTRATIVE INFORMATION:


56. Abstractor Number: ......




57. Date

Abstracted:


/ /

m m d d y y y y




E. ADDITIONAL FORMS TO BE FILLED OUT:


Criteria based

Form on this form


58. STR(s) Item 11 = Y (If transfer

was from/to study hospital, be sure to cross-check

hospital discharge index to

avoid duplication.)


Yes Y


No N



59. DTH Item 15 = D .... Yes Y


No N



60. HRA Item 29a = Y ... Yes Y


No N



61. Xerox Item 55a = Y ... Yes Y

Autopsy

Report No N


62. CFD Item 2 = Y ... Yes Y

No N






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