Anda di halaman 1dari 2

ID ___________

PLAIN CT BRAIN Date of CT: __________

Acute Hemmorhage: Yes□ No □ Unknown □

Number of Acute Hemmorhage: _________________

Location of Acute Hemmorhage: _________________

Previous Hemmorhage: Yes□ No □ Unknown □

Number of Previous Hemmorhage: _________________

Location of Previous Hemmorhage: _________________

Is there any Acute infarct on CT: Yes□ No □ Unknown □

Number of Acute infarct on CT: _________________

Location of Acute infarct: _________________

Widest Diameter of infarct (mm): _________________

Previous Infarct on CT: Yes□ No □ Unknown □

Number of previous infarct on CT: ______________

Location of previous infarct: ______________

Widest Diameter of previous infarct (______mm)

Severe White matter disease: Yes□ No □ Unknown □

AETIOLOGICAL CLASSIFICATION OF INFARCT

Large artery atherosclerosis: Yes□ No □ Unknown □

Cardio-aortic embolism: Yes□ No □ Unknown □

Small artery occlusion: Yes□ No □ Unknown □

Other : Yes□ No □ Unknown □

If other, what cause? __________________


Undetermined?: Yes□ No □ Unknown □

Level of Confidence: Possible □ Probable □ Evident □

CAROTID DUPLEX

Right ICA Stenosis: Yes□ No □ Unknown □

Degree of Right ICA Stenosis (%): Yes□ No □ Unknown □

Is Right ICA Stenosis relevant to acute stroke?: Yes□ No □ Unknown □

Left ICA Stenosis: Yes□ No □ Unknown □

Degree of Left ICA Stenosis (%)? Yes□ No □ Unknown □

Is Left ICA Stenosis relevant to acute stroke?: Yes□ No □ Unknown □

Is thrombus present? Yes□ No □ Unknown □

Is thrombus relevant to acute stroke?: Yes□ No □ Unknown □

Anda mungkin juga menyukai