Neurocentro della Svizzera Italiana
Clinical follow-up SwissGlioma Network
Examination interval

6 Weeks

7 years

3 months
6 months

8 years
9 years
12 months
18 months
2 years

3 years
4 years

5 years
6 years






Follow-up Data:
GCS:

NIHSS:


Karnofsky:
Mini Mental Score:





Carbamazepin
Levetiracetam (Keppra)
Epilepsy class II
Epilepsy class III


Phenytoin
Vaproat
Epilepsy class IV
Epilepsy not reported

Other: ________________________________________

Treatment complications
none


Same occupation, but reduction in work
load
New occupation

Pulmonary embolism (PE)
Myocardial infarction
No occupation
retired



student/child
Other _________________________

Not reported




Pneumonia
Wound infection
Other infection _____________________________
Thrombosis of cerebral sinus
Deep vein thrombosis (DVT)
Other _____________________________________
Not reported
Specify wound infection
yes
no

Abscess
Subdural empyema

Subcutaneous infection

not reported
If yes, Dosage of Dexamethason: ______ mg

Antiplatelet agent

yes

no

not reported


Use of steroids

15 years
> 15 years
none




Same occupation compared to before
diagnosis


13 years
14 years




10 years
11 years
12 years
No epilepsy
Epilepsy class I
Type of occupation


Type of antiepileptic drugs
Epilepsy according to Engel`s classification


Heparin



Marcoumar

yes

no

not reported
yes
no
not reported
Other relevant medication

yes

no

not reported
Specify relevant medication:
________________________________________
 Epidural empyema
 none
Other anticoagulant

yes

no

not reported
Relevant comorbidities











none
Diabetes
Arterial Hypertension
Cardiac illness
Nephrological illness
Pulmonary illness
Oncological illness (other than brain tumor)
Immunological illness
Under immuno-suppresive therapy
Other relevant comorbidities _____________________
Not reported
Lasciare formulario compilato a Jane Frangi
Neurocentro della Svizzera Italiana
Clinical follow-up SwissGlioma Network
Post-operative residual tumor on MRI_ 3 months after surgery
Remnant of tumor
 complet resection
 residual tumor
Maximum diameter axial
T1 contrast-enhanced
Maximum diameter coronal
T1 contrast-enhanced
Maximum diameter sagittal
T1 contrast-enhanced
____________ mm
____________ mm
____________ mm
not performed/available
not performed/available
not performed/available
<=0.175 cm3 (GTR)
 residual tumor
>0.175 cm3
 biopsy only
Firma medico:
____________________________
Lasciare formulario compilato a Jane Frangi