Extracranial Cerebrovascular Testing Section (Add On)

This form is to be used for add on testing sections for accreditedIACVascular Testing facilities only. If your facility is not currently accredited by the IAC 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 vascularfacility:

Hospital

Private office

Free-standing imaging center

Independent facility

Other (please specify):

Indications

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

Yes No

If no, please explain:

Equipment

Does the equipment used in the performance of extracranialcerebrovascular 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

Protocol

Submit a detailed copy of the technical protocol for extracranial cerebrovascular examinations.

Attached

Diagnostic Criteria(Applicable Standard –3.4A)

Submit a detailed copy of the referenced diagnostic criteria for extracranial cerebrovascular examinations.

Attached

Extracranial 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 cases must be submitted in digital format (CD, DVD, flash drive) including the embedded image-specific reader (DICOM viewer).
  • 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 three representative patient examinations; all must be abnormal demonstrating >50% internal carotid artery (ICA) stenosis and include bilateral testing.

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

  • Primary Examination |Submit one abnormal casestudy demonstrating >50% ICA stenosis.

1

Reviewed 4/2016

Extracranial Cerebrovascular Testing Section (Add On)