6 survey

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: First: .......... / m m y y y y 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 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