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Albany IR
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pre-procedure mri
CRF #8
Site
Albany Medical Center (01)
UCSF (02)
LIJ/Northwell (03)
U Penn (04)
Yale (05)
Charlotte Radiology (06)
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
AM
PM
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 slide position).
Number of Fibroids
1
2-5
6-10
>10
Cannot Assess
Number of Devascularized Fibroids Prior to UFE
0
1
2-5
6-10
>10
Cannot Assess
Maximum Fibroid Diameter >12 cm
Yes
No
FIBROID #1
Size of Fibroid #1 (Include the measurements and the image and series or sequence and slice position)
Location of Fibroid #1
Submucosal
Intramural
Subserosal
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
Heterogeneous
Homogeneous
Signal Intensity of Fibroid #1 on T1-Weighted Images Compared to Myometrium
Increased
Decreased
Isointense
Signal Intensity of Fibroid #1 on T2-Weighted Images
Heterogeneous
Homogeneous
Signal Intensity of Fibroid #1 on T2-Weighted Images Compared to Myometrium
Increased
Decreased
Isointense
Enhancement Pattern of Fibroid #1 Compared to Myometrium
Hyperenhancing
Isoenhancing
Hypoenhancing
Devascularized
If partially devascularized, specify the size of any enhancing component in three planes (length X width X height) and specify the image and series or sequence and slice position.
FIBROID #2
Size of Fibroid #2 (Include the measurements and the image and series or sequence and slice position)
Location of Fibroid #2
Submucosal
Intramural
Subserosal
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
Heterogeneous
Homogeneous
Signal Intensity of Fibroid #2 on T1-Weighted Images Compared to Myometrium
Increased
Decreased
Isointense
Signal Intensity of Fibroid #2 on T2-Weighted Images
Heterogeneous
Homogeneous
Signal Intensity of Fibroid #2 on T2-Weighted Images Compared to Myometrium
Increased
Decreased
Isointense
Enhancement Pattern of Fibroid #2 Compared to Myometrium
Hyperenhancing
Isoenhancing
Hypoenhancing
Devascularized
If partially devascularized, specify the size of any enhancing component in three planes (length X width X height) and specify the image and series or sequence and slice position.
FIBROID #3
Size of Fibroid #3 (Include the measurements and the image and series or sequence and slice position)
Location of Fibroid #3
Submucosal
Intramural
Subserosal
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
Heterogeneous
Homogeneous
Signal Intensity of Fibroid #3 on T1-Weighted Images Compared to Myometrium
Increased
Decreased
Isointense
Signal Intensity of Fibroid #3 on T2-Weighted Images
Heterogeneous
Homogeneous
Signal Intensity of Fibroid #3 on T2-Weighted Images Compared to Myometrium
Increased
Decreased
Isointense
Enhancement Pattern of Fibroid #3 Compared to Myometrium
Hyperenhancing
Isoenhancing
Hypoenhancing
Devascularized
If partially devascularized, specify the size of any enhancing component in three planes (length X width X height) and specify the image and series or sequence and slice position.
OTHER FINDINGS
Adenomyosis
Yes
No
Cannot Assess
If "yes" for adenomyosis, please specify if it is 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
Endometrial Abnormalities
Yes
No
Cannot Assess
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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