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Form Structure: Imaging Functional MR

This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
Imaging Functional MR
Short Name:
ImagingFunctionalMR
Description:
Functional magnetic resonance imaging (fMRI) specific imaging information.
Disease:
General (For all diseases)
Organization:
NIH
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Imaging
Publication Date:
2016-05-05
Version:
1.1
Date Created:
2016-04-08
Owner:
Number of Data Elements:
162
eForms:
N
Logically grouped data elements with defined frequency at which they repeat.

# Title Short Description Variable Name Required? Type
1 GUID   Global Unique ID which uniquely identifies a subject GUID Required CDE
2 Subject identifier number   An identification number assigned to the participant/subject within a given protocol or a study. SubjectIDNum Optional CDE
3 Age in years   Value for participant's subject age recorded in years. AgeYrs Optional CDE
4 Vital status   Status of participant/subject as alive or dead VitStatus Optional CDE
5 Visit date   Actual interview or visit date VisitDate Recommended CDE
6 Site name   The name of the site for the study SiteName Recommended CDE
7 Days since baseline   The number of days since baseline DaysSinceBaseline Optional CDE
8 Case control indicator   Indicator of whether subject is in the case or control arm of the study. CaseContrlInd Optional CDE
9 General notes text   General notes GeneralNotesTxt Optional CDE

Additional Element Groups

Listed below are your additional element groups.

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Form Administration (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Context type  The context to which the questions were answered ContextType Recommended CDE
2 Context type other text  The free-text related to ContextType specifying other text ContextTypeOTH Recommended CDE
3 Data source  Source of the data provided on the case report form DataSource Recommended CDE
4 Data source other text  The free-text field related to Data source specifying other text. Source of the data provided on the case report form DataSourceOTH Recommended CDE

Image Information (Appears At Least 1 Time)

# Title Short Description Variable Name Required? Type
1 Imaging study date and time  Date (and time, if applicable and known) the radiologic study was obtained. ImgStdyDateTime Recommended CDE
2 Imaging file  Image data file ImgFile Required CDE
3 Imaging file format type  Format of the imaging file ImgFileFormatTyp Required CDE
4 Imaging file format type other text  Format of the imaging file other text ImgFileFormatTypOTH Optional CDE
5 Imaging modality type  Type of radiologic study performed on the participant/subject ImgModltyTyp Required CDE
6 Imaging modality other text  The free-text field related to 'Imaging modality type' specifying other text. Type of radiologic study performed on the participant/subject ImgModltyOTH Optional CDE
7 Imaging preview file  Imaging preview file ImgPreviewFile Recommended CDE
8 Imaging file hash code  Hash code of the imaging file (SHA256). SHA256 produces hashes that are 256 bits long. ImgFileHashCode Optional CDE
9 Imaging acquisition duration  The duration of the imaging acquisition, in minutes ImgAcquisitionDur Recommended CDE
10 Imaging anatomic site  Type of body part or anatomy scanned in the imaging study ImgAntmicSite Recommended CDE
11 Imaging anatomic site other text  The free-text field related to 'Imaging anatomic site' specifying other text. Type of body part or anatomy scanned in the imaging study ImgAntmicSitOTH Optional CDE
12 Imaging head position text  Text describing head position relative to AC-PC coordinates, the line from the outer corner of the subjects eye to the ear tragus ImgHeadPostnTxt Recommended CDE
13 Imaging contrast agent used indicator  Indicator as to whether or not an imaging contrast agent was used for the scan. ImgContrastAgentUsedInd Optional CDE
14 Imaging contrast agent name  Name of imaging contrast agent used ImgContrastAgentName Optional CDE
15 Imaging contrast agent dose  Dosage of the contrast agent used ImgContrastAgentDose Optional CDE
16 Imaging contrast agent injection time  Time contrast medium was administered ImgContrastAgentInjctnTime Optional CDE
17 Imaging contrast agent injection rate  Rate of injection, in milliliters per minute (mL/min), of imaging contrast agent used, if any, for the perfusion magnetic resonance imaging (PMRI) scan ImgContrastAgentInjctnRate Optional CDE
18 Imaging contrast agent method type  Type of imaging contrast agent used for the scan. ImgContrastAgentMethodTyp Optional CDE
19 Imaging contrast agent method other text  The free-text field related to 'Imaging contrast agent method type' specifying other text. Indicates imaging contrast agent method of administration ImgContrastAgentMethodOTH Optional CDE
20 Sedation used indicator  Whether the participant/subject was administered any sedation SedationUsedInd Optional CDE
21 Imaging pre-scan procedure type  Type(s) of pre-scan action(s) administered to the participant/subject ImgPrescnProcdrTyp Optional CDE
22 Imaging pre-scan procedure other text  The free-text field related to 'Imaging pre-scan procedure type' specifying other text. Type(s) of pre-scan procedures administered to the participant/subject ImgPrescnProcdrOTH Optional CDE
23 Imaging scanner manufacturer name  Imaging scanner manufacturer name ImgScannerManufName Recommended CDE
24 Imaging scanner manufacturer other text  The free-text field related to 'Imaging scanner manufacturer name' specifying other text. Name of manufacturer of imaging scanner ImgScannerManufOTH Optional CDE
25 Imaging scanner model name  Name of model of imaging scanner ImgScannerModelName Recommended CDE
26 Imaging scanner model other text  The free-text field related to 'Imaging scanner model name' specifying other text. Name of model of imaging scanner ImgScannerModelOTH Optional CDE
27 Imaging scanner software name  Name of the scanner software that runs the imaging camera ImgScannerSftwrName Optional CDE
28 Imaging scanner software version number  Version number of the imaging scanner software ImgScannerSftwrVrsnNum Recommended CDE
29 Imaging provenance text  Imaging provenance ImgProvenanceTxt Optional CDE
30 Imaging analysis software name  Name of the software used for data processing or analysis of the imaging study. ImgAnlysisSftwrName Optional CDE
31 Imaging analysis software other text  The free-text field related to 'Imaging analysis software name' specifying other text. Name of the software used for data processing or analysis of the imaging study. ImgAnlysisSftwrOTH Optional CDE
32 Imaging analysis software version number  The version number of the software used for quantitative analysis of the imaging study ImgAnlysisSftwrVrsnNum Optional CDE
33 Imaging notes text  General imaging notes ImgNotesTxt Recommended CDE
34 Imaging skull stripping performed indicator  Skull stripping performed for anatomical and functional images ImgSklStrpPerfInd Optional CDE

Image pixel information and dimensions (Appears At Least 1 Time)

# Title Short Description Variable Name Required? Type
1 Imaging dimension type  Type of imaging dimension used ImgDimensionTyp Required CDE
2 Imaging dimension other text  The free-text field related to 'Imaging dimension type' specifying other text. Type of imaging dimension used ImgDimensionOTH Optional CDE
3 Imaging 1st dimension extent value  Image extent in first dimension (X) ImgDim1ExtentVal Required CDE
4 Imaging 1st dimension resolution value  Resolution in first dimension (X) ImgDim1ResolVal Required CDE
5 Imaging 1st dimension unit of measure value  Units of measure for image extent in first dimension (X) ImgDim1UoMVal Recommended CDE
6 Imaging 1st dimension unit of measure value other text  Units of measure for image extent in first dimension (X) other text ImgDim1UoMValOTH Optional CDE
7 Imaging 2nd dimension extent value  Image extent in second dimension (Y) ImgDim2ExtentVal Required CDE
8 Imaging 2nd dimension resolution value  Resolution in second dimension (Y) ImgDim2ResolVal Required CDE
9 Imaging 2nd dimension unit of measure value  Units of measure for image extent in second dimension (Y) ImgDim2UoMVal Recommended CDE
10 Imaging 2nd dimension unit of measure value other text  Units of measure for image extent in second dimension (Y) other text ImgDim2UoMValOTH Optional CDE
11 Imaging 3rd dimension extent value  Image extent in third dimension (Z) ImgDim3ExtentVal Recommended CDE
12 Imaging 3rd dimension resolution value  Resolution in third dimension (Z) ImgDim3ResolVal Recommended CDE
13 Imaging 3rd dimension unit of measure value  Units of measure for image extent in third dimension (Z) ImgDim3UoMVal Optional CDE
14 Imaging 3rd dimension unit of measure value other text  Units of measure for image extent in third dimension (Z) other text ImgDim3UoMValOTH Optional CDE
15 Imaging 4th dimension extent value  Image extent in forth dimension ImgDim4ExtentVal Optional CDE
16 Imaging 4th dimension extent type  Description of image extent in forth dimension ImgDim4ExtentTyp Optional CDE
17 Imaging 4th dimension extent type other text  Description of image extent in forth dimension other text ImgDim4ExtentTypOTH Optional CDE
18 Imaging 4th dimension resolution value  Resolution in forth dimension ImgDim4ResolVal Optional CDE
19 Imaging 4th dimension unit of measure value  Units of measure for image extent in forth dimension ImgDim4UoMVal Optional CDE
20 Imaging 4th dimension unit of measure value other text  Units of measure for image extent in forth dimension other text ImgDim4UoMValOTH Optional CDE
21 Imaging 5th dimension extent value  Image extent in fifth dimension ImgDim5ExtentVal Optional CDE
22 Imaging 5th dimension extent type  Description of image extent in fifth dimension ImgDim5ExtentTyp Optional CDE
23 Imaging 5th dimension extent type other text  Description of image extent in fifth dimension other text ImgDim5ExtentTypOTH Optional CDE
24 Imaging 5th dimension resolution value  Resolution in fifth dimension ImgDim5ResolVal Optional CDE
25 Imaging 5th dimension unit of measure value  Units of measure for image extent in fifth dimension ImgDim5UoMVal Optional CDE
26 Imaging 5th dimension unit of measure value other text  Units of measure for image extent in fifth dimension other text ImgDim5UoMValOTH Optional CDE
27 Imaging field of view measurement description text  The general description of field of view (FOV) or anatomical positioning ImgFOVMeasrDescTxt Recommended CDE
28 Imaging bandwidth value  Value, in Hertz per pixel, of bandwidth used in imaging acquisition. ImgBandwidthVal Optional CDE
29 Imaging slice orientation type  The slice orientation used in imaging acquisition ImgSliceOrientTyp Recommended CDE
30 Imaging slice orientation other text  The free-text field related to 'Imaging slice orientation type' specifying other text. The slice orientation used in imaging acquisition ImgSliceOrientOTH Optional CDE
31 Imaging slice over sampling value  Value of the slice over sampling (as a percentage) used in imaging acquisition ImgSliceOverSampVal Recommended CDE
32 Imaging slice thickness value  Value of the thickness of the optical slice measured in millimeters (mm) ImgSliceThicknessVal Recommended CDE
33 Imaging gap between slices measurement  Measurement of the gap between slices used in imaging acquisition ImgGapBetwnSlicesMeasr Optional CDE
34 Imaging registration technique used indicator  Indicator of whether a registration technique used to calculate the transformation to a standard average brain space ImgRegistTechUsedInd Recommended CDE
35 Imaging registration technique type  Type of registration technique used ImgRegistTechTyp Optional CDE
36 Imaging registration technique other text  The free-text field related to 'Imaging registration technique type' specifying other text. Type of registration technique used ImgRegistTechOTH Optional CDE

Image QA & QC (Appears At Least 1 Time)

# Title Short Description Variable Name Required? Type
1 Imaging QA/QC performed indicator  Was image-based QA/QC performed? ImgQAQCPerfInd Required CDE
2 Imaging QA/QC result  Results of image-based QA/QC ImgQAQCReslt Optional CDE
3 Imaging quality assurance/quality control (QA/QC) implemented techniques text  Free text field to describe the quality assurance techniques implemented. ImgQAQCImplentTxt Optional CDE
4 Imaging scan aborted reason  Reason the imaging was aborted ImgAbortRsn Optional CDE
5 Imaging artifacts indicator  Indicator of any obvious artifacts in the image ImgArtifactInd Optional CDE
6 Imaging artifact type  The artifacts present on the scan ImgArtifactTyp Optional CDE
7 Imaging artifact other text  The free-text field related to 'Imaging artifact type' specifying other text. The artifacts present on the scan ImgArtifactOTH Optional CDE
8 Imaging acquisition entire brain coverage indicator  Indicator of whether the imaging acquisition covered the entire brain ImgAcqEntireBrnCoverageInd Recommended CDE
9 Imaging visual analysis blinded indicator  Indicator of whether the visual analysis was performed blinded to clinical data ImgVisAnlysisBlindInd Optional CDE
10 Imaging visual analysis location performed type  Location where visual analysis of the imaging data are performed ImgVisAnlysisLocPerfTyp Optional CDE
11 Imaging visual analysis location performed other text  The free-text field related to 'Imaging visual analysis location performed type' specifying other text. Location where visual analysis of the imaging data are performed ImgVisAnlysisLocPerfOTH Optional CDE
12 Imaging visual analysis status  Status of findings from subjective review of image data ImgVisAnlysisStatus Optional CDE
13 Imaging visual analysis other text  The free-text field related to 'Imaging visual analysis status' specifying other text. Status of findings from subjective review of image data ImgVisAnlysisOTH Optional CDE
14 Imaging quality of images technically satisfactory indicator  Indicator of whether the quality of the images were technically satisfactory. ImgQualImgTechnSatisInd Optional CDE

Medication Pre-treatment (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Imaging medication pre-treatment status  Status of the medication(s) taken by the participant/subject pre-treatment for the imaging scan ImgMedctnPretrtmntStatus Optional CDE
2 Imaging medication pre-treatment withheld duration  Duration of time medication(s) were withheld from the participant/subject pre-treatment for the imaging scan ImgMedctnPretrtmntWithldDur Optional CDE
3 Imaging medication pre-treatment withheld duration unit of measure  Unit of measure (UOM) used to specify the length of time medication(s) were withheld from the participant/subject pre-treatment for the imaging scan ImgMedctnPrtrtmntWithhldDurUOM Optional CDE
4 Imaging medication pre-treatment withheld name  Medication pre-treatment withheld name ImgMedctnPrtrtmntWithhldName Optional CDE

Magnetic Resonance Information (Appears At Least 1 Time)

# Title Short Description Variable Name Required? Type
1 Imaging pulse sequence type  Type of imaging pulse sequence used ImgPulseSeqTyp Required CDE
2 Imaging pulse sequence other text  The free-text field related to 'Imaging pulse sequence type' specifying other text. Type of imaging pulse sequence used ImgPulseSeqOTH Optional CDE
3 Imaging scanner strength value  Value, in Tesla (T), of the scanner's magnetic field strength used for the scan being reported ImgScannerStrgthVal Required CDE
4 Imaging scanner strength other text  The free-text field related to 'Imaging scanner strength value' specifying other text. Value, in Tesla (T), of the scanner's magnetic field strength used for the scan being reported ImgScannerStrgthOTH Optional CDE
5 Imaging magnetic resonance imaging T1 T2 sequence name  The name of the T1 or T2 sequences used for MRI ImgMRIT1T2SeqName Optional CDE
6 Imaging fast indicator  Indicator of whether or not fast imaging was used ImgFastInd Recommended CDE
7 Imaging parallel acquisition used indicator  Indicator of whether a parallel acquisition method is used in imaging acquisition ImgParallelAcquistionUsedInd Recommended CDE
8 Imaging parallel acquisition used type  Type of the parallel acquisition method used in imaging acquisition. ImgParallelAcquistionMethodTyp Optional CDE
9 Imaging parallel acquisition used other text  The free-text field related to 'Imaging parallel acquisition used type' specifying other text. Type of the parallel acquisition method used in imaging acquisition. ImgParallelAcquistionMethodOth Optional CDE
10 Imaging repetition gap value  Duration between successive pulse sequences, in milliseconds, applied to the same slice during imaging acquisition ImgRepetitionGapVal Recommended CDE
11 Imaging inversion time  The time period between the 180� inversion pulse and the 90� excitation pulse in an Inversion Recovery pulse sequence. ImgInversionTime Recommended CDE
12 Imaging flip angle measurement  Measurement of the angle, in degrees, over which the radio frequency changes proton spin angle ImgFlipAngleMeasr Recommended CDE
13 Imaging echo duration  Duration between the application of the 90 degree pulse and the peak of the echo signal, in milliseconds, during the spin echo and inversion recovery pulse sequences in imaging acquisition ImgEchoDur Recommended CDE
14 Imaging echo spacing value  Value, in milliseconds, of the echo spacing used in imaging acquisition as part of Diffusion Tensor Imaging (DTI). ImgEchoSpcVal Optional CDE
15 Imaging echo train length measurement  Measurement of the echo train length used in imaging acquisition ImgEchoTrainLngthMeasr Optional CDE
16 Imaging fat signal suppressed indicator  Indicator as to whether or not fat signal was suppressed in imaging acquisition ImgFatSignalSuppressedInd Optional CDE
17 Imaging fat signal suppressor used method type  Type of method used to suppress fat signal in imaging acquisition ImgFatSignalSupprsUseMethdTyp Optional CDE
18 Imaging fat signal suppressor used method other text  The free-text field related to 'Imaging fat signal suppressor used method type' specifying other text. Type of method used to suppress fat signal in imaging acquisition ImgFatSignalSupprsUseMethdOTH Optional CDE
19 Imaging flow compensation indicator  Indicator of whether flow compensation was used in imaging acquisition ImgFlowCompnsatnInd Optional CDE
20 Imaging interpolation indicator  Indicator as to whether or not the k-space data were interpolated before applying Fourier transform. ImgInterpolationInd Optional CDE
21 Imaging field maps acquisition indicator  Indicator of whether field maps were acquired during the acquisition ImgFildMapsAcqInd Optional CDE
22 Imaging excitation number  Number of times each line of k-space data is acquired during the scan ImgExcitationNum Optional CDE
23 Imaging phase encode direction text  Text description of the phase encode direction used in imaging technique acquisition ImgPhasEncdeDirctTxt Optional CDE
24 Imaging phase partial Fourier indicator  Indicator of whether phase partial Fourier was used ImgPhasPartialFourierInd Optional CDE
25 Imaging phase partial Fourier value  Value of the phase partial Fourier ratio, if used in imaging acquisition ImgPhasPartialFourierVal Optional CDE
26 Imaging phase resolution percentage value  The value in percent of the phase resolution used in imaging acquisition ImgPhasResltnPercentVal Optional CDE
27 Imaging base resolution value  Value in points of the base resolution used in imaging acquisition as part of Diffusion Tensor Imaging (DTI). ImgBaseResolutionVal Optional CDE
28 Imaging shot count  The number of shots used in the imaging echo-planner acquisition ImgShotCt Optional CDE
29 Imaging signal averages number  Number of signal acquisitions averaged ImgSignalAvgNum Optional CDE

Magnetic Resonance RF Coil (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Imaging radio frequency coil name  Name of the RF coil(s) used for the body part scanned ImgRFCoilName Optional CDE
2 Imaging radio frequency coil channel count  Number of the coil channels in the radio frequency (RF) coil used for the imaging scan ImgRFCoilChannelCt Optional CDE
3 Imaging radio frequency coil channel other text  The free-text field related to 'Imaging radio frequency coil channel count' specifying other text. Number of the coil channels in the radio frequency (RF) coil used for the imaging scan ImgRFCoilChannelOTH Optional CDE
4 Imaging radio frequency coil function type  The function of the RF coil used ImgRFCoilFunctTyp Optional CDE
5 Imaging radio frequency coil type  Type of RF coil(s) used for the body part scanned ImgRFCoilTyp Optional CDE
6 Imaging radio frequency coil other text  The free-text field related to 'Imaging radio frequency coil type' specifying other text. Type of radio frequency (RF) coil(s) used for the body part scanned ImgRFCoilOTH Optional CDE
7 Imaging radio frequency coil category  Type of RF coil(s) category used for the body part scanned ImgRFCoilCat Optional CDE

fMRI Information (Appears At Least 1 Time)

# Title Short Description Variable Name Required? Type
1 Imaging fMRI experiment name  A free text field for the name of the fMRI experiment ImgFMRIExperName Recommended CDE
2 Imaging fMRI experiment description  A free text field for the description of the fMRI experiment ImgFMRIExperDescriptionTxt Recommended CDE
3 Imaging fMRI experiment notes  A free-text field for fMRI experiment notes to capture additional information ImgFMRINotesTxt Recommended CDE
4 Imaging functional magnetic resonance imaging task type  Tasks performed during a functional magnetic resonance imaging (fMRI) scan ImgFMRITaskTyp Required CDE
5 Imaging functional magnetic resonance imaging task other text  The free-text field related to 'Imaging functional magnetic resonance imaging task type' specifying other text. Tasks performed during a functional magnetic resonance imaging (fMRI) scan ImgFMRITaskOTH Optional CDE
6 Imaging functional task type  The functional status of the participant/subject when tasks are of a certain type ImgFunctionTaskTyp Optional CDE
7 Imaging rest duration  The rest duration between multiple evoked functional acquistions ImgRestDur Optional CDE
8 Imaging resting eye state status  The position of eyes at resting state during the imaging study ImgRestEyeStateStatus Optional CDE
9 Imaging complicating factor type  Factors that may hinder proper data acquisition and interpretation ImgComplicatingFactorTyp Optional CDE
10 Imaging complicating factor other text  The free-text field related to 'Imaging complicating factor type' specifying other text. Factors that may hinder proper data acquisition and interpretation ImgComplicatingFactorOTH Optional CDE
11 Imaging domain tested type  Cognitive Area or brain function tested during scan ImgDomainTestedTyp Optional CDE
12 Imaging domain tested other text  The free-text field related to 'Imaging domain tested type' specifying other text. Cognitive Area or brain function tested during scan ImgDomainTestedOTH Optional CDE
13 Imaging multiple evoked functional acquisitions indicator  Multiple evoked functional acquisitions ImgMultEvokFuncAcqInd Optional CDE
14 Imaging area language anatomic site  Imaging location on brain area for language ImgAreaLanguageAntmicSite Optional CDE
15 Laterality type  Laterality type relative to the anatomic site of the body examined or affected LatTyp Optional CDE
16 Language memory paradigms description text  A description of the language or memory paradigm that was used. LangMemoryParadigmDescTxt Optional CDE
17 Imaging behavioral monitoring indicator  Responses to paradigm items recorded or not ImgBehavioralMonitoringInd Optional CDE
18 Imaging anatomical functional skull stripping text  Type of skull stripping employed for anatomical and functional images ImgAntmicFuncSklStrpTxt Optional CDE
19 Imaging functional magnetic resonance imaging analysis type  Types of functional magnetic resonance imaging (fMRI) analytic methods ImgFMRIAnlysisTyp Optional CDE
20 Imaging functional magnetic resonance imaging analysis other text  The free-text field related to 'Imaging functional magnetic resonance imaging analysis type' specifying other text. Types of functional magnetic resonance imaging (fMRI) analytic methods ImgFMRIAnlysisOTH Optional CDE
21 Functional MRI data processing software additional detail text  Additional details regarding the fMRI data processing software used FMRIDatPrcssSftwrAddtnlDetlTxt Optional CDE

fMRI Auxiliary Files (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Imaging fMRI experiment auxiliary file  Imaging fMRI experiment auxiliary file ImgFMRIAuxFile Optional CDE
2 Imaging fMRI experiment auxiliary file type  Imaging fMRI experiment auxiliary file type ImgFMRIAuxFileTyp Optional CDE
3 Imaging fMRI experiment auxiliary file type other text  The free-text field related to 'Imaging fMRI experiment auxiliary file type' specifying other text. ImgFMRIAuxFileTypOTH Optional CDE
4 Imaging fMRI experiment auxiliary file notes text  A free-text field for notes on the attached fMRI experiment auxiliary file ImgFMRIAuxFileNotesTxt Optional CDE
Keywords

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