Intracranial Cerebrovascular Testing Section (Add On)

This form is to be used for add on testing sections for accredited IACVascular Testing facilities only. If your facility is not currently accredited or in the review process, please contact the IAC office before filling out this form.

Please answer all questions. Required attachments will be indicated by the  symbol.

Name of institution (as listed in the IAC Accreditation Agreement):

(This institution name will be tracked in the IAC database and will receive all IAC correspondence)

Application #:

Department:

Street address 1:

Street address 2:

City:State: Zip code:

Location of vascular facility:

Hospital

Private office

Free-standing imaging center

Independent facility

Other (please specify):

In the initial evaluation for intracranial cerebrovascular disease which of the following are routinely performed as your primary examination?

Transcranial Doppler

Transcranial Duplex Imaging

Indications

Are appropriate indications for examination documented prior to performing the examination?

Yes No

If no, please explain:

Equipment

Imaging equipment:Does the equipment used in the performance of intracranial cerebrovascular examination include:

  1. Color flow Doppler capability?

Yes No

  1. A range of imaging frequencies appropriate for the structures to be evaluated?

Yes No

  1. Doppler frequencies appropriate for the vessels evaluated?

Yes No

  1. Range-gated spectral Doppler with the ability to adjust the depth and position?

Yes No

  1. A measureable and adjustable Doppler angle?

Yes No

  1. A visual display, audible output, and permanent recording capabilities?

Yes No

Non-imagingequipment: Does the equipment used in performance of intracranial cerebrovascular exam:

  1. Have a direction sensitive Doppler blood flow meter?

Yes No

  1. Have Doppler transducer frequencies appropriate for the vessels evaluated?

Yes No

  1. Have waveform display demonstrating bidirectional flow and signal intensity?

Yes No

  1. Have an audible output, and permanent recording of the waveform capabilities?

Yes No

Automated software:(If used for testing such as automatic emboli detection or calculators of hemodynamic indices):

Evidence of validation for the intended application
Yes No N/A

Protocols and Diagnostic Criteria

Submit a detailed technical protocolandreferenced diagnostic criterion for the primary testing.

Protocol: Attached

Criteria: Attached

Intracranial Cerebrovascular Case Study Instructions

Case study submissions are required in order to assess the interpretative and technical quality of the facility.

  • The IAC is HIPAA compliant; do not remove identifying information from the case study materials.
  • Cases must represent best work.
  • All cases must be selected from within the past 12 months from the date of application filing.
  • All cases must be abnormal of varying degrees of pathology.
  • The Technical Director and Medical Director must be represented.
  • Cases must represent as many staff as possible. When selecting and submitting case studies, do not duplicate staff members (medical and technical) until all staff have been represented at least once.
  • All duplex case studies must be submitted in digital format (CD, DVD, flash drive) including the embedded image-specific reader (DICOM viewer).
  • Non-imaging case studies can be submitted as jpeg/pdf or other diagnostic hard copy.
  • Label all media with patients’ names or identification, and testing section.
  • Submit one copy of the application, all documents, case study images/worksheets and the final reports to the IAC office.

Case Study Submission Requirements

Primary Site Case Study Submission Requirements(if an application includes only one site):

  • Primary Examination | Submit a total of threerepresentative patient examinations; all must be abnormal of varying degrees of pathology.

*Two primary testing case studies must be submitted and if performed, the third case study must be chosen from the list below:

Emboli detection

Vasomotor reactivity

Right-to-left shunt

Assessment of cerebral circulatory arrest

Peri-procedural or intra-operative monitoring

Monitoring of reperfusion therapies in acute stroke

Monitoring in the neuro-intensive care setting

If no additional testing is performed, submit a third primary case study

Additional Testing: If performed, submit a detailed technical protocolandreferenced diagnostic criteria for the third case study chosen above.

Protocol:Attached N/A

Criteria: Attached N/A

Multiple Site Case Study Submission Requirements(if an application includes one or more multiple sites):

  • Primary Examination | Submit one abnormal casestudy as noted for primary testing above.

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Reviewed 4/2016

Intracranial Cerebrovascular Testing Section (Add On)