MISTIE Catheter Placement Analysis. Qian Qian Liu
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1 MISTIE Catheter Placement Analysis Qian Qian Liu
2 Objectives Determine various factors that may affect catheter placement score and percentage clot volume reduction Location of the clots ICH designation of the clots ICH stability volume Age of Patient Surgeon Experience ICH longest length How many sides of the catheter port is touching the clot at the EOT scan? Would an additional dose be beneficial?
3 ICH Designation: Location and Trajectory Type A Anterior 1/3 of the basal ganglia Entry point in the anterior frontal area Catheter trajectory along the longitudinal axis of clot Type B Posterior 1/3 of the basal ganglia Entry point in the posterior parietal-occipital area Catheter trajectory along the longitudinal axis of clot Type C Superficial (lobar) Entry point at the superficial area closest to clot at the widest equatorial point of a spherical-shaped clot
4 Description of Catheter Placement Score (5 points) (5 points) Catheter Placement Score (5 points) % Clot Reduction Coeffficient Std Err. t P> t Catheter Placement Score
5 Type A Clot: Type A Trajectory Stability CT 3/1/1 12:2:21 PM CP Score: 135 % Clot volume reduction: 89.18% Catheter CT 3/12/1 12:1:46 AM EOT CT 3/15/1 5:3 AM
6 Type A Clot: Type A Trajectory Stability CT 2/1/9 6:2:29 AM CP Score: 45 % Clot volume reduction: 24.99% Catheter CT 2/11/9 7:15:2 PM EOT CT 2/14/9 1:2: AM
7 Type B Clot: Type B Trajectory CP Score: 126 % Clot volume reduction: 74.14% Stability CT 9/14/1 12:2:35 PM Catheter CT 9/14/1 9::28 PM EOT CT 9/16/1 3:59:2 PM
8 Type B Clot: Type B Trajectory Stability CT 2/28/11 4:52: AM CP Score: 28 % Clot volume reduction: 14.7% Catheter CT 3/2/11 2:38 PM EOT CT 3/3/11 8:52: AM
9 Type C Clot: Type C Trajectory Stability CT 2/6/1 3:24:33 AM CP Score: 118 % Clot volume reduction: 74.67% Catheter CT 2/7/1 9:2:14 PM EOT CT 2/9/1 2:57:21 PM
10 Type C Clot: Type C Trajectory Stability CT 1/4/1 11:53:33 AM CP Score: 29 % Clot volume reduction: 44.83% Catheter CT 1/4/1 6:51:27 PM EOT CT 1/6/1 5:19:7 PM
11 Number of Patients Number of Patients ICH Designation for Clot Locations: Surgical and Medical Patients 5 1% 45 9% 4 8% 35 7% 3 6% 25 5% 2 4% 15 3% 1 2% 5 1% Caudate Thalamus Globus Pallidus Putamen Lobar % Caudate Thalamus Globus Pallidus Putamen Lobar A A B B C C Most clot locations were designated as Type A, except for thalamus and lobar clots. As can be expected, the majority of lobar clots were designated as type C.
12 Number of Patients Number of Patients ICH Designation for Clot Locations: Surgical Patients 35 1% % 8% 7% 2 6% % 4% 3% 5 2% Caudate Thalamus Glo Pal Putamen Lobar A B C % % Caudate Thalamus Glo Pal Putamen Lobar A B C Most clot locations were designated as Type A, except for thalamus and lobar clots. As can be expected, the majority of lobar clots were designated as type C.
13 Effects of Age and Stability Clot Volume Catheter Placement Score Coeffficient Std Err. t P> t Age Stability volume % Clot Reduction Coeffficient Std Err. t P> t Age Stability volume
14 Average Catheter Placement Score Average catheter placement score higher for Type A ICH designation and basal ganglia clots Average Catheter Placement Score vs. Clot Location Stage 1 Avg CP Score Stage 2 Avg CP Score 2 N Mean N Mean Catheter Placement Score Coeffficient Std Err. t P> t ICH designation Type B to Type A ICH designation Type C to Type A Clot Location Average catheter placement score is higher for Type A ICH designation compared to those of type B and C designations Average catheter placement score is higher when the clot is located in the basal ganglia compared to when is lobar
15 Multivariate Regression of Catheter Placement Score Catheter Placement Score Coeffficient Std Err. t P> t Patient Number ICH Designation Patient Number ICH Designation ICH Stability clot volume Type B-A Type C-A Type B-A Type C-A When regress catheter placement score with patient number and ICH designation, do see significance in the placement score between type B compared to type A and between type C and type A.
16 Average % Clot Volume Reduction No Significant Difference in Average % Clot Volume Reduction Average % Clot Volume Reduction vs. Clot Location Stage 1 Stage 2-1 % Clot Volume Reduction Coeffficient Std Err. t P> t ICH designation Type B to Type A ICH designation Type C to Type A Clot Location
17 Age distribution of clot location and ICH designation BG = 8 patients Lobar = 37 patients Age Coeff Std Err. t P> t ICH Designation Type B compared to Type A ICH Designation Type C compared to Type A ICH Designation Type C compared to Type B Clot Location
18 Number of Patients Catheter Placement Score by Age and Clot Location <65 >= 65 Age N= 36 N= 19 N= 3 N= 22 Lobar Basal Ganglia Catheter Placement Score Coeff Std Err. t P> t Age
19 Evaluating Surgeon Experience Effects of training, location, # subjects
20 Average Catheter Placement Score by Surgeon Experience
21 Number of Patients Location of Clots (Deep or Lobar) per Surgeon Experience Basal Ganglia Lobar Patient Number for Surgeon (Surgeon Experience)
22 % Clot Volume Reduction % Clot Volume Reduction % Clot Volume Reduction Catheter Placement Score Catheter Placement Score Catheter Placement Score Surgeon s catheter placement score by individual patients Dr. Aldrich Dr. Awad Dr. Broaddus Stage 1 Stage Patient Number Patient Number Patient Number Dr. Aldrich Dr. Awad Dr. Broaddus Stage 1 Stage Patient Number Patient Number Patient Number
23 % Clot Volume Reduction Catheter Placement SCore Surgeon s catheter placement score by individual patients Dr. Camarata Dr. Dodd Dr. Huang Dr. Zucarello Stage 1 Stage Dr. Camarata Patient Number Dr. Dodd Patient Number Dr. Huang Patient Number Dr. Zucarello 5 1 Patient Number Stage 1 Stage 2 Catheter placement score increased on average in stage 2 for each neurosurgeon Don t see a general increase in placement score after each subsequent patient
24 Average Catheter Placement Score % Clot Volume Reduction 16 Average Catheter Placement Score and % Clot Reduction for each Surgeon Average Catheter Placement Score for Each Surgeon Separated by ICH Designation 1. Average % Clot Volume Reduction for Each Surgeon Separated by ICH Designation Type A Type B Type C Type A Type B Type C Average Catheter Placement Score for each type for each surgeon Average % clot volume reduction for each type for each surgeon Aldrich Awad Broaddus Camarata Dodd Huang Zuccarello Aldrich Awad Broaddus Camarata Dodd Huang Zuccarello
25 Number of Patients Number of Patients Effects of ICH length on Catheter Placement Basal Ganglia Clot A-C Length Distribution A-C length (cm) 4 Lobar Clot A-C Length Distribution A-C length (cm) Basal Ganglia Lobar Less than Greater than 4 13
26 A-C Length Distribution by ICH Designation Basal Ganglia Clot A-C Length Distribution by ICH Designation Type C Type B Type A Lobar Clot A-C Length Distribution by ICH Designation Type C Type B Type A
27 Number of Patients Number of Patients A-C Length Distribution by Actual Catheter Trajectory Basal Ganglia Clot A-C Length Distribution by Actual Trajectory Freq of Type C- Vertical Freq of Type C- Horizontal Freq of Type B Freq of Type A A-C Length (cm) Lobar Clot A-C Length Distribution by Actual Trajectory Freq of Type C- Vertical Freq of Type C- Horizontal Freq of Type B Freq of Type A A-C Length (cm)
28 Summary Most basal ganglia clots were designated as Type A, while most lobar clots were designated as Type C; however, the longest axis of the clots may not always follow the catheter track axis. The average catheter placement score is higher for type A designation and for basal ganglia clots, although the difference is not significant. However, when we account for surgeon experience, the ICH designation does significantly impact the catheter placement score (Type C to Type A P>.23; Type B to Type A P>.32). Type C designation tends to occur in older patients. Catheter placement score did not increase with surgeon experience. Catheter placement score did increase in stage 2 compared to stage 1. When planning trajectories, the surgeon may want to look at the longest axis to inform the trajectory designation.
29 Number of catheter side ports touching clot on the EOT CT scan Problem Will an additional dose of r-tpa at the EOT CT scan be beneficial in reducing the ICH volume? Methods: Determined number of sides of the catheter ports touching the clot by looking at anterior, posterior, right, and left sides of the catheter. Looked at the EOT scans and the scans after catheter placement. Maximum of 4 sides touching = clot surrounds the catheter side ports Minimum of sides touching = clot does not touch any of the side ports
30 Observations CP Score: 58 Sides touching: CP Score: 112 Sides touching: CP Score: 45 Sides touching: CP Score: 134 Sides touching: 3
31 Number of Patients Number of Patients Number of Patients Number of Patients Catheter Position in Relation to the Clot Scans after Catheter Placement EOT Catheter Position in relation to the clot Stage 1: Number of catheter sides touching clot for 3 categories of catheter placement scores Stage 1: Number of catheter sides touching clot for 3 categories of catheter placement scores Sides 1 Side 2 Sides 3 Sides 4 Sides < = 7 >7 and < =1 > Sides 1 Side 2 Sides 3 Sides 4 Sides <= 7 >7 and < =1 >1 Stage 2: Number of catheter sides touching clot for 3 categories of catheter placement scores Stage 2: Number of catheter sides touching clot for 3 categories of catheter placement scores < =7 >7 and < =1 > <= 7 >7 and < =1 >1 Sides 1 Side 2 Sides 3 Sides 4 Sides Sides 1 Side 2 Sides 3 Sides 4 Sides
32 Number of catheter side ports touching clot on the EOT CT scan Sides after Catheter Placement Coeffficient Std Err. t P> t Catheter Placement Score Sides at EOT Coeffficient Std Err. t P> t Catheter Placement Score Total Doses Given Catheter Placement Score Total Doses Given Sides Reduced Coeffficient Std Err. t P> t Catheter Placement Score Total Doses Given Sides touching after catheter placement
33 EOT Catheter Position in relation to the clot Observations of scans A number of the patients who had good catheter placements still had clot surrounding the catheter side ports and would appear to benefit from an additional dose before catheter removal. Patients with poor catheter placements had catheter side ports that were already located outside the clot, so by the EOT scan, not as much clot was touching the catheter ports. Analysis sides touching does not correlate with catheter placement score because a lower score would indicate that the catheter is placed more to the side of the clot. More sides touching could indicate that the catheter was placed well, and more doses could be given before catheter removal. When regress sides touching to catheter placement score and total doses given, find a significance between both variables in determining the number of sides touching. Future Direction: Look at the Superior and Inferior Sides of the Catheter Give different weights to different sides of the catheter touching the clot
34 Acknowledgements Natalie Ullman Andrew Mould Katie Smith Sam Nekoovaght-Tak Carol Thompson Shane Thorp Ryan Fisico Dr. Dan Hanley
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