3-month post-procedure mri

CRF #20

Site

Patient Number

Please enter in three digit format (e.g., 001, 002, ..., 025)

Is this an original or revised submission?

Original

Revised

Name of the Person Entering Data into this CRF

First Name

Last Name

MRI EXAMINATION

Date of MRI Evaluation

MM

DD

YYYY

Time of MRI Evaluation

Hour

Minute

Second

Image Quality

Satisfactory

Suboptimal

Non-Diagnostic

If the image quality was "suboptimal" or "non-diagnostic," please specify the limitations and/or recommendations:

UTERINE FINDINGS

Uterine Measurements Including the Cervix (Length X Width X Height)

Uterine Measurements Excluding the Cervix (Length X Width X Height()

Maximum Uterine Diameter >20 cm

Yes

No

Any areas of myometrial infarction?

Yes

No

If there are areas of myometrial infarction, please specify the image and series (or sequence and slice position).

Any areas worrisome for uterine infection?

Yes

No

If there are areas worrisome for uterine infection, please specify the image and series (or sequence and slice position).

Number of Fibroids

Number of Devascularized Fibroids Prior to UFE

Number of Vascularized Fibroids

Maximum Fibroid Diameter >12 cm

Yes

No

FIBROID #1

Check if you cannot see or assess fibroid #1 and add a comment in the box below

If applicable, state why you cannot see or assess fibroid #1

Size of Fibroid #1 (include measurements and the image and series or sequence and slice position)

Location of Fibroid #1

If fibroid #1 is submucosal, please specify the percentage of fibroid in an intracavitary position

100%

51-99%

25-50%

<25%

If fibroid #1 is subserosal, please specify the percentage of fibroid circumference beyond the serosal margin

100%

51-99%

25-50%

<25%

Signal Intensity of Fibroid #1 on T1-Weighted Images

Signal Intensity of Fibroid #1 on T1-Weighted Images Compared to Myometrium

Signal Intensity of Fibroid #1 on T2-Weighted Images

Signal Intensity of Fibroid #1 on T2-Weighted Images Compared to Myometrium

Enhancement Pattern of Fibroid #1 Compared to Myometrium

If there is a residual enhancing component, what are the measurements (length X width X height) and what is the image and series or sequence and slice position?

FIBROID #2

Check if you cannot see or assess fibroid #2 and add a comment in the box below

If applicable, state why you cannot see or assess fibroid #2

Size of Fibroid #2 (include measurements and the image and series or sequence and slice position)

Location of Fibroid #2

If fibroid #2 is submucosal, please specify the percentage of fibroid in an intracavitary position

100%

51-99%

25-50%

<25%

If fibroid #2 is subserosal, please specify the percentage of fibroid circumference beyond the serosal margin

100%

51-99%

25-50%

<25%

Signal Intensity of Fibroid #2 on T1-Weighted Images

Signal Intensity of Fibroid #2 on T1-Weighted Images Compared to Myometrium

Signal Intensity of Fibroid #2 on T2-Weighted Images

Signal Intensity of Fibroid #2 on T2-Weighted Images Compared to Myometrium

Enhancement Pattern of Fibroid #2 Compared to Myometrium

If there is a residual enhancing component, what are the measurements (length X width X height) and what is the image and series or sequence and slice position?

FIBROID #3

Check if you cannot see or assess fibroid #3 and add a comment in the box below

If applicable, state why you cannot see or assess fibroid #3

Size of Fibroid #3 (include measurements and the image and series or sequence and slice position)

Location of Fibroid #3

If fibroid #3 is submucosal, please specify the percentage of fibroid in an intracavitary position

100%

51-99%

25-50%

<25%

If fibroid #3 is subserosal, please specify the percentage of fibroid circumference beyond the serosal margin

100%

51-99%

25-50%

<25%

Signal Intensity of Fibroid #3 on T1-Weighted Images

Signal Intensity of Fibroid #3 on T1-Weighted Images Compared to Myometrium

Signal Intensity of Fibroid #3 on T2-Weighted Images

Signal Intensity of Fibroid #3 on T2-Weighted Images Compared to Myometrium

Enhancement Pattern of Fibroid #3 Compared to Myometrium

If there is a residual enhancing component, what are the measurements (length X width X height) and what is the image and series or sequence and slice position?

OTHER FINDINGS

Adenomyosis

Yes

No

Cannot Assess

If "yes" for adenomyosis, is it focal or diffuse?

Focal

Diffuse

Cannot Assess

If "yes" for adenomyosis, please specify the maximum junctional zone thickness (mm)

If "yes" for adenomyosis, please specify the image and series or sequence and slice position where the maximum junctional zone thickness measurement was obtained

Were there areas of infarction within the adenomyosis after UAE?

Yes

No

If "yes" for infarction within adenomyosis, please specify the image and series or sequence and slice position.

Endometrial Abnormalities

Yes

No

Cannot Assesss

If "yes" for endometrial abnormalities, please describe:

If "yes" for endometrial abnormalities, please state your recommendations:

Ovarian Abnormalities

Yes

No

Cannot Assess

If "yes" for ovarian abnormalities, please describe:

If "yes" for ovarian abnormalities, please state your recommendations:

Other Abnormalities

Yes

No

If "yes" for other abnormalities, please describe:

If "yes" for other abnormalities, please state your recommendations:

Were any clinical recommendations based on the core-lab interpretation of this study communicated to the PI?

Yes

No

If "yes" please specify the date and method of communication

Attestation *

I approve the data entered into this CRF and attest to its accuracy.

Date of Completion

MM

DD

YYYY

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