1. MISTIE III Surgical Summary & Lessons Learned
Issam Awad, MD
Lynn Money
M. Delour Fam
Agnieszka Stadnik
MISTIE III Surgical Center

2. Surgical summary to date

3. Surgical Summary to Date –Cont’d
Catheter Category
Trajectory A
Trajectory B
Trajectory C
Surgical cases that didn’t go to surgery
115 SURGICAL CASES 54 26 33
2 (1 pt herniated overnight before surgery, taken for crani;
1 pt improved overnight so surgeon didn’t take to surgery)
64 GOOD INITIAL
34 (63.0% of 54)
9 (34.6% of 26)
21 (63.6% of 33)
38 SUBOPTIMAL INITIAL
18 (34.6% of 54)
(16 dosed; 1 replaced and dosed; 1 replaced & reached endpoint)
10 (38.5% of 26)
(5 dosed;
4 replaced & dosed;
1 replaced & reached endpoint)
10 (30.3% of 33)
(10 dosed)
11 POOR INITIAL
2 (3.7% of 54) (replaced and dosed)
7 (26.9% of 26)*
(6 replaced & dosed)
2 (6.1% of 33)
(replaced & dosed)
26 CATHETERS REPOSITIONED AFTER DOSING OR REPLACED
6 (1 replaced d/t dislodging by pt) 16
(includes 5 repositioned after dosing and 1 replaced after dosing d/t dislodging)
5 (includes 1 new catheter placed during dosing to better target remaining clot)
% Evacuated
74.6
71.1
68.4
*One case, the site exhausted their resources and did not attempt to retarget the clot. One case, site did not obtain permission from family for second procedure to retarget clot.

4. Surgical Summary to Date- Cont’d
Good
Suboptimal
Poor
% Evacuated
Pre-qualified (n=63)
37 (58.7% of 63)
18 (28.6% of 63)
8 (12.7% of 63)
71.8
Qualified w/ probation (n=26)
13 (50% of 26)
12 (46.2% of 26)
1(3.8% of 26)
68.3
Fully qualified
(n=24)
14 (58.3% of 24)
9 (37.5% of 24)
1 (4.2% of 24)
76.4
Note: 2 cases did not go to surgery so not counted here

5. Trajectory pitfalls

6. Given location of ICH, determine optimal trajectory.B C

7. Trajectory A

8. Catheter too deep: can be due to image guidance issues or a new shape of clot after aspiration
Too deep better than too shallow… Can always simply withdraw

9. Too shallow
Be careful about pulling back too much when repositioning the catheter
- Too deep is always better than too shallow

10. Too medial May be prevented by more lateral and larger burr holes
May reflect post-aspiration clot
May still be suitable for dosing if catheter perforations in contact with clot

11. Trajectory b

12. Too medial
Image guidance by anterior surface landmarks often inaccurate for posterior trajectories
Consider burr hole and angle of approach

13. Burr hole vs twist drill: Burr hole allows greater maneuverability and angles of freedom. Especially important for Trajectory B clots

14. Mode of insertion - Larger and more lateral burr holes
Twist Drill
Burr hole

15. Mode of insertion - Angles
Twist drill
Burr hole

16. Trajectory c

17. Too shallow

18. Trajectory C is often used with complex clot shapes and may complete dosing with multiple small satellite bleeds remaining

19. Good placement generally leads to good clearance

20. Image Guidance is Mandatory For both cannula and catheter20
Image Guidance is Mandatory For both cannula and catheter
Stereotactic CT Guided Navigation
(passive catheter introducer or equivalent device)
Real Time Image Guidance
(Procedural CT, intraop imaging, etc)

21. Image guidance
Use image guidance with the cannula (when used) AND with the catheter insertion
Avoid errors due to “wiggle” and depth estimates

22. Real time image guidance
Using real time image guidance, site was able to immediately retarget clot remaining after aspiration for optimal catheter placement and dosing

23. Summary of Safety Lessons
Mentoring and guidance can help achieve good results despite initial technical errors
Image guidance is mandatory for catheter and cannula
Use fiducials for posterior approaches, to avoid navigation mishaps
Larger (and more lateral) burr holes often allow more accurate placement
Real time image guidance and intraoperative imaging can save the day

24. Additional considerations

25. Importance of etiology screening
54 y/o male
History included HTN, diabetes, prior smoker, BP up to 250/115 on admission
CTA done, read as negative
PI stated CTA suggested suspicious etiology so scheduled cath angio
Found AVM, pt screen failed
Risk factors alone are not enough to exclude vascular etiology
Dural Arteriovenous Fistula

26. Preoperative (craniectomy) CT
ICP monitoring
48 y/o female
Expansion of ICH from 47-59ml, stabilized
Young patient with tight cranial vault, comatose, intubated. No ICP monitoring.
CTA negative, cath angio not done
3 day delay in randomization d/t stabilization, etiology screening, team availability
Herniation before going to surgery, taken to open surgery
ICP monitoring was indicated if operation delayed, or if case randomized to medical. All patients should receive best medical therapy
Stability CT 1
Stability CT 3
Preoperative (craniectomy) CT

27. Drainage issues Post-2 doses 76 y/o male
History of HTN, hyperlipidemia, afib
CTA, MRI negative
Trajectory B approved, C was used
suboptimal but acceptable placement
2nd catheter placed after 4 doses; further doses given
Dosing issues throughout: catheter left clamped twice, not allowed to drain
Scant drainage reported with last few doses
Expansion of ICH after 8 doses
Final doses should not have been given with scant drainage. Always troubleshoot catheter drainage/dosing configuration and restore drainage before dosing.
Post-2nd catheter
Post-8 doses

28. Consent for multiprocess intervention
78 y/o female
Site had poor initial catheter placement
Procedure done late at night in procedure room, decided to wait to replace until morning when would be in own OR
In the morning, family refused repositioning
Consent should be obtained upfront for multiprocess intervention and not a single catheter placement

29. IVH Considerations
IVH, even when EVD placed, does not necessarily represent an exclusion
Proceed with evaluation
Send CT scans
Case will be adjudicated by SC and CC
Cases with IVH and more than one EVD cannot be included
If your patient has more than one catheter, they should be clearly labeled to ensure the study rt-PA is injected only into the ICH
Concern about increased risk of infection with multiple drains. We will monitor this and inform sites if we see any trends.
Cases with casting, mass effect or shift from IVH are not included
Cases with IVH and more than one EVD cannot be included

30. M3 EVD Placement and Eligibility Determination

31. MISTIE-3 Patient 6074: EVD for ICP Management
ICH: cc LLV: 2.16 cc RLV: 6.68 cc
Total Ventricular Volume: 8.84 cc

32. EVD with IVH Mass Effect
Screen Failure
ICH Volume: 42 cc

33. Thank you!