| Demographic Data |
| Relation to Proband |
granddaughter |
| Age at Sampling |
6 YR |
| Gender |
Female |
| Age of Onset(If not a control) |
4 YR |
| Age at Diagnosis(If not a control) |
6 YR |
| Hispanic or Latino/Not Hispanic or Latino |
Hispanic/Latino |
| Racial Category |
White |
| Country |
USA |
| Diagnosed By |
No Data |
| |
| Data Elements |
| Clinical Element Type: Cerebrovascular Disease |
| (Baseline) |
| Longitudinal Data |
| Is this data Longitudinal (Follow-Up) Data? |
yes no |
| Smoking History |
| smoking history |
never former smoker current smoker |
| years smoking |
No Data |
| Family History |
| Family history of Cerebrovascular Disease |
present absent Unknown
Notes: CCM (GREAT GRANDMOTHER, AUNT, MOTHER, GREAT GREAT AUNT, FIRST COUSIN TWICE REMOVED) |
| Family History of Aneurysm |
present absent Unknown |
| Aneurysm Location of affected Family Member |
No Data |
| Specific diagnosis |
| Cerebrovascular diagnosis |
silent cerebral infarction
transient ischemic attack
unruptured intracranial aneurysm
symptomatic ischemic stroke
symptomatic intracerebral hemorrhage
aneurysmal subarachnoid hemorrhage
vascular cognitive impairment
arteriovenous malformations (AVM)
other
Unaffected primary blood relative of proband
Cerebral Cavernous Malformation (CCM)
Hereditary Hemorrhagic Telangiectasia (HHT)
|
| Prior Medical History |
| Pre-existing history of dementia |
Present Absent |
| Pre-hemorrhage history of ischemic stroke |
Present Absent Not Applicable |
| TOAST criteria |
| ischemic stroke subtype based on TOAST |
not applicable |
| AVM subtype criteria |
| AVM type |
unruptured ruptured not applicable |
| Spetzler-Martin score |
No Data |
| Size |
No Data |
| AVM Location |
No Data |
| Venous drainage |
No Data |
| Drainage Location |
cortical
subcortical/deep
posterior fossa
|
| Confirmation of diagnosis |
| did a neurologist confirm the cerebrovascular diagnosis |
yes no |
| Medical History |
| hypertension |
yes no |
| diabetes mellitus |
yes no |
| atrial fibrillation |
yes no |
| myocardial infarction |
yes no |
| Other risk factors |
yes no |
| Genetic Data of Subject |
| Mutation/s in subject's DNA (if present, describe) |
present absent unknown
Notes: CCM1-CHM |
| Medical History |
| Hypertension treated with medication |
yes no |
| Blood pressure (at time of blood draw) |
85/58 |
| Other diagnosis |
| Parkinson's disease |
yes no |
| Alzheimer's disease |
yes no |
| Epilepsy |
yes no |
| Amyotrophic lateral sclerosis |
yes no |
| Dementia |
yes no |
| Other Neurological Diagnosis(es) |
yes no |
| Optional data |
| State Examination (MMSE) score |
No Data |
| Neurological examination |
yes no |
| Handedness |
Right Left Ambidextrous |
| Montreal Cognitive Assessment(MoCA) score |
No Data |
| Clinical Element Type: Cerebral Cavernous Malformation (CCM) |
| (Baseline) |
| Family History |
| Family History of CCM: |
Present Absent Unknown |
| If present, list family members: |
GREAT GRANDMOTHER, GREAT GREAT AUNT, FIRST COUSIN TWICE REMOVED, AUNT, MOTHER |
| Known Genetic Syndrome: |
Present Absent Unknown |
| Please Specify, if applicable: |
No Data |
| Known Mutation(s) in DNA: |
Present Absent Unknown |
| Please specify, if applicable: |
CCM1-CHM |
| Diagnostic Criteria |
| Number of CCM lesions on MRI: |
Single Multiple |
| Age at MRI: |
6 YEARS |
| Presentation at symptom onset: |
Seizure
Headache
Clinical Stroke
Asymptomatic
|
| Modified Rankin Score: |
0 1 2 3 4 5 6 |
| Optional Data |
| Smoking History: |
Never Previous Current |
| Years Smoking, if applicable: |
No Data |
| Handedness: |
Left Right Ambidextrous |