MEDICAL 
RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate In A Clinical Research Study 
NIH 2514-2, Minor Patient's Assent to Participate In A Clinical 
Research Study 
m 
STUDY NUMBER CONTINUATION: page^of pages. 
Risks 
Risks of MRI 
Patients at risk for injury from MRI are those with pacemakers, aneurysm clips (metal clips on 
the wall of a large artery), or shrapnel fragments. Welders and metal workers are also at risk for 
injury because of possible metallic foreign bodies in the eye. The study is done with you lying flat in 
a long metal cylinder. You will feel no pain. This may be frightening if you fear closed spaces. 
Patients can be observed at all times by the operators and can be assisted if necessary. You will be 
moved out of the machine if requested. The thumping sound you will hear is the radio waves 
forming the images. 
A small proportion of people develop short-lived reactions during the gadolinium 
administration including nausea, headache, hot flashes, and heart palpitations. These symptoms 
usually resolve spontaneously within minutes. A smaller group of patients are actually allergic to the 
dye and may develop a rash, hives, respiratory difficulty, and in extreme cases pulmonary and 
cardiac arrest and death. You will be closely monitored and if an allergic reaction develops, you will 
be promptly treated with epinephrine and breathing assistance if necessary. Both therapies are 
immediately available in the MRI scan suite. 
Risks from Stereotaxic Procedures 
The surgical risks depend on the preoperative condition of the patient, the location, and size 
of the tumor. Known risks associated with stereotaxic brain surgery include hemorrhage, 
deterioration of neurological functions (such as motor - weakness in the arm and/or leg, sensory - 
loss of sensation over parts of your body, and cognitive functions - partial or complete loss of 
functions related to communication such as speech and comprehension, and other functions related 
to intellectual capacity, memory etc.), infection and death. The relative risks will be discussed with 
you in accordance with your condition, specific findings and planned surgical procedures. 
PATIENT 
IDENTIFICATION 
CONTINUATION SHEET for either 
NIH-2514-1 (10-84) 
Recombinant DNA Research, Volume 15 
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