Pta data form

ICSS Surgery Technical and Discharge Data
Centre . Operating Surgeon.
ICSS No. __ __ __ __

Patient’s Family Name. Forename . D O B __ __/__ __/__ __
Date of Admission __ __ /__ __ /__ __
Date of Discharge __ __ /__ __/__ __


SURGICAL DETAILS: Please complete this section as soon as possible after carotid surgery
Was the procedure proctored/supervised by another surgeon Yes† No† If Yes give name of
supervising/proctoring surgeon……………………………………………………………………………
Date of operation:
Carotid artery treated:

Type of reconstruction:
Standard endarterectomy † Eversion endarterectomy † Vein interposition † Local anaesthetic
† † If yes give type………………………………. General anaesthetic
Combined (GA + LA)
Shunt used
Distal intimal flap sutured
Carotid plication
Patch used
monitoring
Other monitoring
Occlusion time (do not include shunt time, if used) …………………
Start Time (24 hr)
Finish Time (24 hr)
__ __.__ __


ANTIPLATELET/ ANTICOAGULANT THERAPY
Pre-procedure
During procedure
Postprocedure
Surgery technical and discharge data
PERISURGERY & POSTSURGERY COMPLICATIONS:
NEUROLOGICAL
Date of onset
Time of onset Duration of symptoms
Yes No (Day Month Year) (24hr)
(Days Hours Minutes)
Left carotid ischaemic stroke (symptoms >24hrs)* Right carotid ischaemic stroke (symptoms >24hrs)* † † __ __/__ __/__ __ __ __.__ __ __ __.__ __.__ __ Vertebrobasilar ischaemic stroke (symptoms >24hrs)* † † __ __/__ __/__ __ __ __.__ __ __ __.__ __.__ __ Left retinal infarction (symptoms >24hrs) * Right retinal infarction (symptoms >24hrs) * Intracerebral haemorrhage (symptoms >24hrs) * Subarachnoid haemorrhage (symptoms >24hrs) * Left carotid amaurosis fugax (symptoms<24hrs) Right carotid amaurosis fugax (symptoms<24hrs) If “yes” for hyperperfusion: Symptoms: < Please complete Death Report *Please complete Major Event Form
OTHER COMPLICATIONS:
<If yes, complete Death Report
*If yes, complete Major Event Form
If symptomatic, complete Major Event Form
If symptomatic, complete Major Event Form
If symptomatic, complete Major Event Form
Loss of consciousness (if awake during procedure) ……………………………………………. Chest infection needing antibiotics/prolonging stay † Details………………………………………… † Details………………………………………… † Details…………………………….…………. † Details………………………………………… † Details………………………………………… 1 If yes for wound infection please specify if this required: Surgery † 2If Yes for cranial nerve palsy please specify type: Glossopharyngeal † Facial nerve † Spinal accessory † Other † (please state site)………… Other complications and management (if any):………………………………………………………………………….

Blood pressure on discharge: __ __ __/__ __ __ (complete value closest to discharge)
Form completed by (PRINT).
Date __ __/__ __ /__ __
(Day Month Year)
PLEASE COPY FOR YOUR FILES THEN POST OR FAX THIS FORM TO THE ICSS OFFICE
PLEASE ALSO RETURN COPIES OF ANY RELEVANT IMAGING FILMS AND/OR REPORTS.
Fax 020 7837 9632 (+44 20 7837 9632 outside UK)
ICSS Office, Stroke Research Group,
Box 6, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
Page 2 of 2
Version 2.00- 030703
Surgery technical and discharge data

Source: http://s489637516.websitehome.co.uk/ICSS/downloads/SurgeryForm2_0.pdf