Measure IVH: GRAEB Scale CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Measure IVH: GRAEB Scale Quantitative analysis of blood in the ventricular system Prediction of outcome1 Track clot resolution for dosing decisions Monitor for new blood (re-bleed) vs. clot migration 1 Graeb DA, Robertson WD, Lapointe JS, Nugent RA, Harrison PB. Computed tomographic diagnosis of intraventricular hemorrhage. Etiology and prognosis. Radiology. 1982 pr;143(1):91-6. Baltimore, MD

Modified Graeb Scoring CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Modified Graeb Scoring R Temporal Tip L Temporal Tip Scores: Enter “1” if Expanded R Temporal Tip: ____ _____ R Lateral: ____ _____ R Posterior Tip: ____ _____ L Temporal Tip: ____ _____ L Lateral: ____ _____ L Posterior Tip: ____ _____ IIIrd: ____ _____ IVth: ____ _____ Sum each column: ____ _____ Total Score: _____ IIIrd R Lat L Lat IVth R Posterior Tip L Posterior Tip This is a summary of the scoring system. The diagram on the top represents the ventricular system. Using the table below it, you can see that based on the percentage that the ventricle is filled with blood, it is assigned a score of 1-4. I want to point out here that the 3rd and 4th ventricles either get a score of 0 for no blood present, 2 for some to half full, or 4 for half to totally full. Baltimore, MD

Anatomy of the ventricular system CLEAR III Meeting - Thurs Morning (2) Anatomy of the ventricular system Sept 29 - Oct 1, 2010 Lateral Ventricle Posterior Tip Trigone Third Ventricle Fourth Ventricle We use the trigone as the division between temporal tip, posterior tip, and lateral ventricles. Temporal Tip Baltimore, MD

The Graeb score from a CT, the old way CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 The Graeb score from a CT, the old way Back before we had the Vision database and electronic CRFs, a GRAEB score would be calculated by shading in a paper ventricle diagram to correspond with the amount and location of blood observed on the CT. Then, using that table, you would determine the score for each region and add to get a total score. Here we have some screen shots of a CT and the corresponding shaded GRAEB diagram. Baltimore, MD

The Graeb score from a CT (using the eCRF) CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 The Graeb score from a CT (using the eCRF) Fill out ventricle diagram to correspond with the amount and location of blood observed in the CT scan by clicking on the online form. In CLEAR III, we have made it much easier. Using the electronic case report form, you now simply click on the diagram where you see blood and the system will automatically calculate the GRAEB for you. You may notices the little green box next to each ventricular region. This is to be selected only if the ventricle is completely full of blood and expanded as result of that blood. Selecting this box assigns an extra point for the expanded region to increase the GRAEB score and reflect the fact that not only is the entire ventricle full, but there is even more blood present causing it to appear expanded. Baltimore, MD

Rules for standardization CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Rules for standardization IVH GRADING SCALE Add one point for each ventricle that is expanded beyond normal anatomic limits. This only applies to ventricles filled with blood. Use the trigone as the boundary to differentiate the lateral ventricle, posterior tip, and temporal tip. Round upwards – for example, if you believe that 40 - 60% of a ventricle is occupied by blood, the ventricle is graded as >50% occupied. The minimum point total is 0 (i.e., no blood); the maximum point total is 32 (i.e., completely full of blood with maximum expansion). To help standardize the GRAEB system between readers and patients, please use the following guidelines: Add one point for each ventricle that is filled with blood and expanded beyond normal anatomic limits. Use the trigone as the boundary to differentiate the lateral ventricle, posterior tip, and temporal tip. Round upwards – for example, if you believe that 40 - 60% of a ventricle is occupied by blood, the ventricle is graded as >50% occupied. You will see that the minimum point total is 0 (i.e., no blood); the maximum point total is 32 (i.e., completely full of blood with maximum expansion. Baltimore, MD

Example Subject, Stability Scan CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Example Subject, Stability Scan Fourth Ventricle (corresponding score) Scores: Enter “1” if Expanded R Temporal Tip: ____ _____ R Lat: ____ _____ R Posterior Tip: ____ _____ L Temporal Tip: ____ _____ L Lat: ____ _____ L Posterior Tip: ____ _____ IIIrd: ____ _____ IVth: ____ _____ Sum each column: ____ _____ Total Score: _____ We will now go through an example subject. Here we have a slice that gives a good look at the fourth ventricle. We can see that the fourth ventricle is full, and appears to be dilated. This corresponds to a score of 4 (out of a possible 4) for a full forth ventricle, plus one in the column for expansion. 4 1 Baltimore, MD

Example Subject, Stability Scan CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Example Subject, Stability Scan Left Temporal Tip (corresponding score) Scores: Enter “1” if Expanded R Temporal Tip: ____ _____ R Lat: ____ _____ R Posterior Tip: ____ _____ L Temporal Tip: ____ _____ L Lat: ____ _____ L Posterior Tip: ____ _____ IIIrd: ____ _____ IVth: ____ _____ Sum each column: ____ _____ Total Score: _____ 1 Next we find the a slice that gives a good look at the left temporal horn. We can see that the anterior portion of the left temporal tip is empty of blood (we can see CSF on this slice), but there is a grey boundary as we approach the posterior tip. Likely some of this blood mixture is part of the left temporal horn, thus we give the left temporal horn a score of 1 (out of a possible 2). This is one of the challenges when scoring: determining the location of blood when boundaries are grey. The most important part is to be consistent from scan to scan, and compare two scans side by side to evaluate whether the blood has migrated or been resolved from a particular anatomic region when scoring. The temporal horn does not appear to be expanded due to blood, so the expanded column is completed with a zero. 4 1 Baltimore, MD

Example Subject, Stability Scan CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Example Subject, Stability Scan Right Temporal Tip (corresponding score) Scores: Enter “1” if Expanded R Temporal Tip: ____ _____ R Lat: ____ _____ R Posterior Tip: ____ _____ L Temporal Tip: ____ _____ L Lat: ____ _____ L Posterior Tip: ____ _____ IIIrd: ____ _____ IVth: ____ _____ Sum each column: ____ _____ Total Score: _____ 1 1 As we find in this slice, the right temporal horn is easier to interpret, as we see a much clearer blood/CSF boundary. This blood denoted by the red arrow is clearly further anterior, and inferior to what we should consider the posterior tip. There is, however, considerable CSF space in the temporal tip, and as such we should score the right temporal tip with a score of 1 (out of a possible 2), with zero points in the expanded column. 4 1 Baltimore, MD

Example Subject, Stability Scan CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Example Subject, Stability Scan Left Posterior Tip (corresponding score) Scores: Enter “1” if Expanded R Temporal Tip: ____ _____ R Lat: ____ _____ R Posterior Tip: ____ _____ L Temporal Tip: ____ _____ L Lat: ____ _____ L Posterior Tip: ____ _____ IIIrd: ____ _____ IVth: ____ _____ Sum each column: ____ _____ Total Score: _____ 1 1 2 We now are looking at slice showing the blood in the right posterior tip. We see that the tip is full, so it gets a first-column score of 2 (out a possible 2). This does not appear to be expanded so a 0 is entered in the expanded column. 4 1 Baltimore, MD

Example Subject, Stability Scan CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Example Subject, Stability Scan Right Posterior Tip (corresponding score) Scores: Enter “1” if Expanded R Temporal Tip: ____ _____ R Lat: ____ _____ R Posterior Tip: ____ _____ L Temporal Tip: ____ _____ L Lat: ____ _____ L Posterior Tip: ____ _____ IIIrd: ____ _____ IVth: ____ _____ Sum each column: ____ _____ Total Score: _____ 1 2 1 2 We also find that the right posterior tip is full, so it too gets a score of 2 (out of a possible 2), but without expansion. 4 1 Baltimore, MD

Example Subject, Stability Scan CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Example Subject, Stability Scan Third Ventricle (corresponding score) Scores: Enter “1” if Expanded R Temporal Tip: ____ _____ R Lat: ____ _____ R Posterior Tip: ____ _____ L Temporal Tip: ____ _____ L Lat: ____ _____ L Posterior Tip: ____ _____ IIIrd: ____ _____ IVth: ____ _____ Sum each column: ____ _____ Total Score: _____ 1 2 1 2 This slice shows the catheter tip in the third ventricle. The third ventricle is full of blood, so it gets a score of 4 (out of a possible 4). It is also distended as a result of the clot, and as such receives a “1” in the column for expansion. 4 1 4 1 Baltimore, MD

Example Subject, Stability Scan CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Example Subject, Stability Scan Right, Left Laterals (corresponding score) Scores: Enter “1” if Expanded R Temporal Tip: ____ _____ R Lat: ____ _____ R Posterior Tip: ____ _____ L Temporal Tip: ____ _____ L Lat: ____ _____ L Posterior Tip: ____ _____ IIIrd: ____ _____ IVth: ____ _____ Sum each column: ____ _____ Total Score: _____ 1 4 2 1 3 2 This slices shows the two lateral ventricles. Note that the lateral ventricles are the largest parts of the ventricle system. For the sake of the presentation, we will only examine this one slice but keep in mind that it’s important to look at all slices that contain the laterals to fully evaluate for blood. Here we see that the right lateral is full, so it gets a score of 4 (out of a possible four). The left lateral ventricle contains mostly blood, but there is evidence of CSF on this slices, as well as other slices not pictured. For this reason we decided to give this ventricle a score of 3 (out of a possible 4). Both lateral ventricles were determined to not be expanded, and as such have been score with a zero in the expansion column fields. 4 1 4 1 Baltimore, MD

Example Subject, Stability Scan CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 Example Subject, Stability Scan 3D Reconstruction (IVH only) (corresponding score) Scores: Enter “1” if Expanded R Temporal Tip: ____ _____ R Lat: ____ _____ R Posterior Tip: ____ _____ L Temporal Tip: ____ _____ L Lat: ____ _____ L Posterior Tip: ____ _____ IIIrd: ____ _____ IVth: ____ _____ Sum each column: ____ _____ Total Score: _____ 1 4 2 1 3 2 We have summed each column, and found the total score for this subject for this scan to be 23. The picture on the left shows a 3D reconstruction of this hemorrhage. 4 1 4 1 21 2 23 Baltimore, MD

CLEAR III Meeting - Thurs Morning (2) Sept 29 - Oct 1, 2010 GRAEB Best Practices Use scores in dosing decision making. Complete your scores in real-time. Have PI and coordinator complete paper forms together. Then make every attempt to make the numbers reflect the actual score when clicking the online form. Be consistent with your boundaries from scan to scan, patient to patient. Compare your subject’s current scan with their most recent previous scan to evaluate changes. To summarize, when completed in real-time, the Graeb system is a helpful tool for dosing decision making. The many regions of the ventricular system can make it difficult to determine when you have reached 80% reduction of the clot. Comparing Graeb scores on the daily CTs is a good way to assess this endpoint. You will be most accurate if you are consistent with your boundaries from scan to scan and patient to patient. We will provide you will pink pocket CT cards and bedside worksheets to complete in real time when examining a CT. Then, later when you have time to sit down and complete the data entry, they can be easily transcribed into the eCRF. Take care to ensure the numbers reflect the actual score when clicking on the online form. As always, call us in the Reading Center (410-502-2949) if you have any questions or would like more training! Baltimore, MD