SMART INDIA STUDY CRF

Basic Demographics
1. Hospital Name
2. Name
3. Smart India Id
4. Hospital Id
5. Current Status Impatient Outpatient

Demographic Details
1. Sex
2. Age
3. Height(Cm)
4. Weight(Kg)
5. Phone Number
6. Email Address
7. House Address
8. Pin Code
Admission Details

1. Symptom Onset Date: Time:

2. First Hospital Admission Date: Time:
3. Duration: Symptom To First Hospital (Hours/Days) Hours: Days:
4. Mode Of Transport To First Hospital Ambulance/Car/Other
5. Smart India Study Centre Hospital Admission Date: Time:
6. Duration: Symptom To Smart India Study Centre Hospital Hours: Days:
(Hours/Days)
7. Mode Of Transport To Smart India Study Centre Hospital Ambulance/Car/Other
8. Diagnosis Ischemic Stroke
Hemorrhagic Stroke (ICH)
CVT
TIA
Others(Mention)
IF Hemorrhagic stroke : (ICH SCORE - ) ANY SURGICAL INTERVENTION OPTED-------
9. Past History (If Any)
10. Stroke Territory Anterior Posterior
11. Toast Classification Large Artery Atherosclerosis
Cardio-Embolism
Small Vessel Occlusion
Stroke Of Undetermined Etiology
12. Wake Up Stroke Yes No
If Yes Last Known Well Date/Time:
13. Prior Rx: Antiplatelet Yes No
If Yes Details
14. Prior Rx: Anticoagulant Yes No
If Yes Details
15. Prior Rx: Anti Hypertensives Yes No
If Yes Details
16. Prior Rx: Statins Yes No
If Yes Details
17. Prior Rx: OHA Or Insulin Yes No
If Yes Details
Risk Factors
1. Hypertension Yes No
If Yes: Duration Of Hypertension:
Hypertension Detected During Stroke Admission
Rx Of Hypertension: Prior To Stroke
Hypertension: Compliance To Rx
Other Details:
2. Diabetes Mellitus Yes No
If Yes: Duration Of Dm
Dm Detected During Stroke Admission
Rx Of Dm: Prior To Stroke
Dm: Compliance To Rx
Other Details:
3. Atrial Fibrillation Yes No
If Yes: Duration Of AF
Other Details:
4. Coronary Artery Disease Yes No
If Yes: Duration Of CAD
Other Details:
5. Dyslipidemia Yes No
If Yes: Duration Of Dyslipidemia
Other Details:
6. Rheumatic Heart Disease Yes No
If Yes: Duration Of RHD
Other Details:
7. Prior Stroke Yes No
If Yes: Duration Of Prior Stroke
Other Details:
8. Dementia Yes No
If Yes: Duration Of Dementia
Other Details:
9. Alcohol Yes No
If Yes: Duration Of Alcohol Consumption
Other Details
10. Substance Abuse Yes No
If Yes: Duration Of Substance Abuse
Other Details
11. Tobacco/ Smoking Yes No
If Yes: Duration Of Tobacco/ Smoking
Other Details
12. Prior TIA Yes No
13. Family H/O Stroke Yes No
14. Family H/O CAD Yes No
15. Moya Moya Disease Yes No
16. SLE Yes No
17. Takayasu Artheritis Yes No
18. Fibromuscular Dysplasia Yes No
19. Intermittent Claudication Yes No
20. Other Risk Factores
Symptoms And Signs
1. Right Hemiparesis Yes No
2. Left Hemiparesis Yes No
3. Aphasia Yes No
4. Right UMN Palsy Yes No
5. Left UMN Palsy Yes No
6. Dysarthria Yes No
7. Right Cerebellar Ataxia Yes No
8. Left Cerebellar Ataxia Yes No
9. Left Hemisensory Loss Yes No
10. Right Hemisensory Loss Yes No
11. Vision Loss Yes No
12. Diplopia Yes No
13. Hearing Loss Yes No
14. Bladder Dysfunction Yes No
15. Headache Yes No
16. Neck Pain Yes No
17. Right Vision Loss Yes No
18. Left Vision Loss Yes No
19. Right Hemineglect Yes No
20. Left Hemineglect Yes No
21. Angina/ Chest Pain Yes No
22. Neck Stiffness Yes No
23. Vomiting Yes No
24. Seizure At Stroke Onset Yes No
If Yes: Seizure Type Focal
Generalised
Partial
25. Seizure Within 01 Week Of Stroke Onset Yes No
If Yes: Seizure Type Focal
Generalised
Partial
26. Seizure After 01 Week Of Stroke Onset Yes No
If Yes: Seizure Type Focal
Generalised
Partial
27. Other Symptoms
Other Neurological Findings
1. Tone
2. Power
3. Sensory Examination
4. Cerebellar System
5. Gait Pattern
6. Misc Findings

EXAMINATION SCALES

GCS ON ADMISSION :DONE/NOT DONE DATE/TIME...........................................................................

S.No Command Score

1. Eye Opening (1 Point Each) Opens Spontaneously
Opens To Verbal Commands
Opens To Pain
No Eye Opening
2. Best Verbal Response (1 Oriented
Point Each) Confused
Inappropriate Words
Incomprehensible Words
No Verbal Response
3. Best Motor Response (1 Obeys Commands
Point Each) Localising Pain
Withdrawl From Pain
Flexion To Pain
Extension To Pain
No Motor Response
GCS Score
NIHSS ON ADMISSION: DONE/NOT DONE DATE/TIME:............................................................................................

Instructions Scale Definition Score

1a. Loc 0=Alert
1=Drowsy
2=Stuporous
3=Coma
1b.Loc Questions-Month And Age 0=Answer Both Correctly
1= Answer One Correctly
2=Incorrect On Both
1c. Loc Commands-Open, Close 0=Obeys Both Correctly
Eyes & Show Thumb 1=Obeys One Correctly
2=Incorrect
2.Best Gaze (Follow Finger) 0=Normal
1=Partial Gaze Palsy
2=Forced Deviation
3.Visual Fields 0=No Visual Loss
1=Partial Hemianopia
2=Complete Hemianopia
3=Bilateral Hemianopia
4.Facial Palsy (Show Teeth, 0= Normal
Eyebrows, Squeeze Eye) 1=Minor
2=Partial
3=Complete
5a. Motor Arm (Left) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
5b. Motor Arm (Right) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
6a. Motor Leg(Left) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
6b. Motor Leg (Right) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
7. Limb Ataxia 0=Absent
1=Present In One Limb
2=Present In Two Limbs
8. Sensory 0= Normal
1=Partial Loss
3=Severe Loss
9.Best Language (Name Items, 0=No Aphasia
Describe Pictures) 1=Mild To Moderate Aphasia
2=Severe Aphasia
3=Mute
10.Dysarthria (Speech Clarity To 0=Normal Articulation
Mama Baba, Amritsar, Tip Top, 1=Mild To Moderate Slurring Of Speech
Fifty Fifty) 2=Near To Unintelligable Or Worse
X=Intubated Or Other Physical Barriers
11.Extinction/Neglect (Double 0=No Neglect
Simultaneous Testing) 1=Partial Neglect
2=Complete Neglect
Total Score
NIHSS AT 24 Hours: DONE/NOT DONE DATE/TIME:............................................................................................

Instructions Scale Definition Score

1a. Loc 0=Alert
1=Drowsy
2=Stuporous
3=Coma
1b.Loc Questions-Month And Age 0=Answer Both Correctly
1= Answer One Correctly
2=Incorrect On Both
1c. Loc Commands-Open, Close Eyes 0=Obeys Both Correctly
& Show Thumb 1=Obeys One Correctly
2=Incorrect
2.Best Gaze (Follow Finger) 0=Normal
1=Partial Gaze Palsy
2=Forced Deviation
3.Visual Fields 0=No Visual Loss
1=Partial Hemianopia
2=Complete Hemianopia
3=Bilateral Hemianopia
4.Facial Palsy (Show Teeth, 0= Normal
Eyebrows, Squeeze Eye) 1=Minor
2=Partial
3=Complete
5a. Motor Arm (Left) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
5b. Motor Arm (Right) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
6a. Motor Leg(Left) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
6b. Motor Leg (Right) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
7. Limb Ataxia 0=Absent
1=Present In One Limb
2=Present In Two Limbs
8. Sensory 0= Normal
1=Partial Loss
3=Severe Loss
9.Best Language (Name Items, 0=No Aphasia
Describe Pictures) 1=Mild To Moderate Aphasia
2=Severe Aphasia
3=Mute
10.Dysarthria (Speech Clarity To 0=Normal Articulation
Mama Baba, Amritsar, Tip Top, Fifty 1=Mild To Moderate Slurring Of Speech
Fifty) 2=Near To Unintelligable Or Worse
X=Intubated Or Other Physical Barriers
11.Extinction/Neglect (Double 0=No Neglect
Simultaneous Testing) 1=Partial Neglect
2=Complete Neglect
Total Score
GCS AT 24 HOURS: DONE/NOT DONE DATE/TIME:..........................................................

S.No Command Score

1. Eye Opening (1 Point Opens Spontaneously
Each) Opens To Verbal Commands
Opens To Pain
No Eye Opening
2. Best Verbal Response (1 Oriented
Point Each) Confused
Inappropriate Words
Incomprehensible Words
No Verbal Response
3. Best Motor Response (1 Obeys Commands
Point Each) Localising Pain
Withdrawl From Pain
Flexion To Pain
Extension To Pain
No Motor Response
GCS Score
NIHSS AT DISCHARGE: DONE/NOT DONE DATE/TIME:............................................................................................

Instructions Scale Definition Score

1a. Loc 0=Alert
1=Drowsy
2=Stuporous
3=Coma
1b.Loc Questions-Month And Age 0=Answer Both Correctly
1= Answer One Correctly
2=Incorrect On Both
1c. Loc Commands-Open, Close Eyes 0=Obeys Both Correctly
& Show Thumb 1=Obeys One Correctly
2=Incorrect
2.Best Gaze (Follow Finger) 0=Normal
1=Partial Gaze Palsy
2=Forced Deviation
3.Visual Fields 0=No Visual Loss
1=Partial Hemianopia
2=Complete Hemianopia
3=Bilateral Hemianopia
4.Facial Palsy (Show Teeth, 0= Normal
Eyebrows, Squeeze Eye) 1=Minor
2=Partial
3=Complete
5a. Motor Arm (Left) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
5b. Motor Arm (Right) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
6a. Motor Leg(Left) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
6b. Motor Leg (Right) 0=No Drift
1=Drift
2=Can’t Resist Gravity
3=No Effort Against Gravity
4=No Movement
X=Untestable
7. Limb Ataxia 0=Absent
1=Present In One Limb
2=Present In Two Limbs
8. Sensory 0= Normal
1=Partial Loss
3=Severe Loss
9.Best Language (Name Items, 0=No Aphasia
Describe Pictures) 1=Mild To Moderate Aphasia
2=Severe Aphasia
3=Mute
10.Dysarthria (Speech Clarity To 0=Normal Articulation
Mama Baba, Amritsar, Tip Top, Fifty 1=Mild To Moderate Slurring Of Speech
Fifty) 2=Near To Unintelligable Or Worse
X=Intubated Or Other Physical Barriers
11.Extinction/Neglect (Double 0=No Neglect
Simultaneous Testing) 1=Partial Neglect
2=Complete Neglect
Total Score
GCS AT DISCHARGE: DONE/NOT DONE DATE/TIME:..........................................................

S.No Command Score

1. Eye Opening (1 Point Opens Spontaneously
Each) Opens To Verbal Commands
Opens To Pain
No Eye Opening
2. Best Verbal Response (1 Oriented
Point Each) Confused
Inappropriate Words
Incomprehensible Words
No Verbal Response
3. Best Motor Response (1 Obeys Commands
Point Each) Localising Pain
Withdrawl From Pain
Flexion To Pain
Extension To Pain
No Motor Response
GCS Score

EMERGENCY AND CASUALITY

1. HEART RATE /MIN

2. SYSTOLIC BP
3. DIASTOLIC BP
4. RESPIRATORY RATE
5. BLOOD SUGAR

BLOOD INVESTIGATIONS

S.NO NAME VALUE

1. TOTAL CHOLESTROL (mg/dl)
2. LDL (mg/dl)
3. HDL (mg/dl)
4. VLDL (mg/dl)
5. TRIGLYCERIDES (mg/dl)
6. FASTING BS (mg/dl)
7. PP BS (mg/dl)
8. SODIUM (mg/dl)
9. INR
10. HEMOGLOBIN (g/dl)
11. TOTAL LEUCOCYTE COUNT (TLC)

12. PLATELETES (LACS/µl)

13. ESR
14. UREA (mg%)
15. CREATININE (mg%)
16. HbA1C (%)
17. C-reactive Proteins (CRP)
18. Homocysteine Positive
Negative
Not done
19. BLOOD HOMOCYSTINE (mcmol/L)

20. SERUM B12 (ng/ml)

21. T3 (ng/dl)
22. T4 (ug/dl)
23. FREE T3 (pg/ml)
24. FREE T4 (pg/dl)
25. TSH (mIU/ml)
26. POTASSIUM (mEq/L)
27. SERUM TOTAL PROTEIN (g/dl)
28. SERUM ALBUMIN (g/dl)
29. SGOT (IU/L)
30. SGPT (IU/L)
31. TROPONIN T POSITIVE
NEGATIVE
NOT DONE
32. TROPONIN T (ng/ml)

STROKE IN YOUNG

S.NO TEST VALUE

1. ANA
2. DsDNA
3. APLA
4. Prt S def
5. Prt C def
6. FACTOR V LEIDEN MUTATION
7. HIV
8. ELEVATED ACE LEVELS

MANAGEMENT

S.No
1. Thrombolysis Done Yes
No
2. Thrombolysis Agent Alteplase
Tenecteplase
3. Dose Of Thrombolytic Agent
4. Window Period (Minutes)
5. Symptoms To Emergency (Minutes)
6. Arrival To Physician Contact (Minutes)
7. Arrival To Ct Scan (Minutes)
8. Arrival To Thrombolysis (Minutes)

Post Thrombolysis Complications

1. Documented Thrombolytic Complications Yes
No
If Yes Please Select Symptomatic Hemorrhage
Asymptomatic Hemorrhage
Systemic Hemorrhage
2. Complication Description
3. Mechanical Thrombectomy Done Yes
No
4. Door To Puncture (Minutes)
5. Door To Recanalisation (Minutes)
6. Ct Post Thrombectomy Date:
Time:
7. Post Intervention Complications Symptomatic Hemorrhage
Asymptomatic Hemorrhage
Systemic Hemorrhage
8. Complication Description

1. Antiplatelets Started Yes

No
2. Antiplatelets Aspirin 75mgod
Aspirin 150 Mg Od
Clopidogrel 75 Mg Od
Aspirin/ Dipyridamole 25 Mg /200
Mg Bd
Ticagrelor 90 Mg Bd
3. Antiplatelets Started Date:
Time:
4. Other Antiplatelets
5. Anticoagulants Started Yes
 No
6. Anticoagulants Warfarin
Dabigatran
Epixaban
Edoxaban
Enoxaparin
Dalteparin
Fondaparinux
Acitrom
7. Anticoagulants Used
8. Anticoagulants Dose
9. Anticoagulants Started Date:
Time:
10. Other Anticoagulants
1. Statins Started Yes
No
Date:
Time:
2. Statins (Name & Dose)

1. Anti-Hypertensives Yes
No
Date:
Time:
2. Anti-Hypertensives 1
Anti-Hypertensives 2
Anti-Hypertensives 3

3. Other Prescribed Drugs

DVT Prophylaxis
1. DVT Prophylaxis Yes
No
Date:
Time:
2. Prophylactic Agent Pneumatic Compression
Unfractionated Heparin
Fondaparinux
Enoxaparin
Dalteparin

Supportive Treatment
1. Ryles Tube Feeding Yes
No
2. Mobilisation Started Yes
No
Date:
Time:
3. Air Water Mattress Yes
No
4. Physiotherapy Yes
No
Date:
Time:
5. Discharge Advice
Guss(Gugging Swallowing Screen) : DONE/ NOT DONE
Preliminaryinvestigation/Indirect Swallowing Test
1. Vigilance No
Yes
2. Cough And /Or Throat Clearing No
Yes

Saliva Swallow
1. Swallowing Successful No
Yes
2. Drooling Yes
No
3. Voice Change (Hoarse, Gurgly, Coated, Yes
Weak) No

Direct Swallowing Test

1. Deglutition
Semisolid Swallowing Not Possible
Swallowing Delayed (>2 Sec) (Solid
Textures>10 Sec)
Swallowing Succesful
Liquid Swallowing Not Possible
Swallowing Delayed (>2 Sec) (Solid
Textures>10 Sec)
Swallowing Succesful
Solid Swallowing Not Possible
Swallowing Delayed (>2 Sec) (Solid
Textures>10 Sec)
Swallowing Succesful
2. Cough (Involuntary)
Semisolid Yes
No
Liquid Yes
No
Solid Yes
No
3. Drooling
Semisolid Yes
No
Liquid Yes
No
Solid Yes
No
4. Voice Change
Semisolid Yes
No
Liquid Yes
No
Solid Yes
No
Sum
SHOW COMPLICATIONS

S.No Complication
1. Tracheostomy Yes
No
2. VAP (Ventilator Associated Pneumonia) Yes
No
3. UTI (Urinary Tract Infection) Yes
No
4. Sepsis Yes
No
5. Meningitis Yes
No
6. Ventriculitis Yes
No
7. Prolonged Ventilation Yes
No
8. Mechanical Ventilation Yes
No
9. Bed Sores Yes
No
10. DVT (Deep Vein Thrombosis) Yes
No
11. Re-Bleed Yes
No
12. Redo Surgery Yes
No
13. Other Complication

DISCHARGE & FOLLOW UP

S.No
1. Show Discharge/Outcome Yes
No
2. Patient Discharge Yes
No
Date:
Time:
3. Patient Expired Yes
No
Date:
Time:
4. mRS(On Admission) 0=No Symptoms
1=Usual Activities Possible With
Symptoms
2=Usual Activities Not Possible But Looks
After Own Affairs
3=Help Required But Walking Without
Assistance
4= Requires Help For Walking &Own
Bodily Needs
5= Bedridden, Inconsistent Requiring
Constant Nursing
6= Death
5. mRS (At Discharge) Date:
Time:
6. mRS(3 Months) Date:
Time:

SCANS

S.NO SCAN REPORT ATTACHED

1. CT SCAN : YES/NO
2. CT ANGIOGRAPHY : YES/NO
3. MRI : YES/NO
4. MRA : YES/NO
5. ECG
6. HOLTER
7. ANY OTHER INVESTIGATION