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J Mocco

Bio: J Mocco is an academic researcher from Vanderbilt University. The author has contributed to research in topics: Medicine & Aneurysm. The author has an hindex of 47, co-authored 144 publications receiving 8040 citations. Previous affiliations of J Mocco include McKnight Brain Institute & State University of New York System.


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Journal ArticleDOI
01 Sep 2013-Stroke
TL;DR: A multidisciplinary panel of neurointerventionalists, neuroradiologists, and stroke neurologists with extensive experience in neuroimaging and IAT, convened at the “Consensus Meeting on Revascularization Grading Following Endovascular Therapy” with the goal of addressing heterogeneity in cerebral angiographic revascularization grading.
Abstract: See related article, p 2509 Intra-arterial therapy (IAT) for acute ischemic stroke (AIS) has dramatically evolved during the past decade to include aspiration and stent-retriever devices. Recent randomized controlled trials have demonstrated the superior revascularization efficacy of stent-retrievers compared with the first-generation Merci device.1,2 Additionally, the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) 2, the Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), and the Interventional Management of Stroke (IMS) III trials have confirmed the importance of early revascularization for achieving better clinical outcome.3–5 Despite these data, the current heterogeneity in cerebral angiographic revascularization grading (CARG) poses a major obstacle to further advances in stroke therapy. To date, several CARG scales have been used to measure the success of IAT.6–14 Even when the same scale is used in different studies, it is applied using varying operational criteria, which further confounds the interpretation of this key metric.10 The lack of a uniform grading approach limits comparison of revascularization rates across clinical trials and hinders the translation of promising, early phase angiographic results into proven, clinically effective treatments.6–14 For these reasons, it is critical that CARG scales be standardized and end points for successful revascularization be refined.6 This will lead to a greater understanding of the aspects of revascularization that are strongly predictive of clinical response. The optimal grading scale must demonstrate (1) a strong correlation with clinical outcome, (2) simplicity and feasibility of scale interpretation while ensuring characterization of relevant angiographic findings, and (3) high inter-rater reproducibility. To address these issues, a multidisciplinary panel of neurointerventionalists, neuroradiologists, and stroke neurologists with extensive experience in neuroimaging and IAT, convened at the “Consensus Meeting on Revascularization Grading Following Endovascular Therapy” with the goal …

1,162 citations

Journal ArticleDOI
01 Jan 2011-Stroke
TL;DR: Hemodynamics is as important as morphology in discriminating aneurysm rupture status with high AUC values, and all 3 models—morphological only, hemodynamic only, and combined—discriminate intracranial aneurYSm rupturestatus with highAUC values.
Abstract: Background and purpose the purpose of this study was to identify significant morphological and hemodynamic parameters that discriminate intracranial aneurysm rupture status using 3-dimensional angiography and computational fluid dynamics. Methods one hundred nineteen intracranial aneurysms (38 ruptured, 81 unruptured) were analyzed from 3-dimensional angiographic images and computational fluid dynamics. Six morphological and 7 hemodynamic parameters were evaluated for significance with respect to rupture. Receiver operating characteristic analysis identified area under the curve (AUC) and optimal thresholds separating ruptured from unruptured aneurysms for each parameter. Significant parameters were examined by multivariate logistic regression analysis in 3 predictive models-morphology only, hemodynamics only, and combined-to identify independent discriminants, and the AUC receiver operating characteristic of the predicted probability of rupture status was compared among these models. Results morphological parameters (size ratio, undulation index, ellipticity index, and nonsphericity index) and hemodynamic parameters (average wall shear stress [WSS], maximum intra-aneurysmal WSS, low WSS area, average oscillatory shear index, number of vortices, and relative resident time) achieved statistical significance (P Conclusions all 3 models-morphological (based on size ratio), hemodynamic (based on WSS and oscillatory shear index), and combined-discriminate intracranial aneurysm rupture status with high AUC values. Hemodynamics is as important as morphology in discriminating aneurysm rupture status.

628 citations

Journal ArticleDOI
TL;DR: Size ratio and aneurysm angle are promising new morphological metrics for IA rupture risk assessment because these parameters account for vessel geometry and may bridge the gap between morphological studies and more qualitative location-based studies.
Abstract: Intracranial aneurysms (IA) affect approximately 2 to 5% of the entire population (23, 25) Ruptured IAs typically cause subarachnoid hemorrhage (SAH) and its sequelae, resulting in significant morbidity and mortality Among patients who have SAH, 50 to 60% will die from the initial hemorrhage and a further 20 to 25% will experience complications (30) However, despite their expected common occurrence, only 1% of all IAs actually rupture (25) Although the morbidity and mortality associated with rupture may suggest that an incidentally detected aneurysm should be treated to forestall the catastrophic event of SAH, the two current methods of treatment (open microsurgical aneurysm clip ligation or endovascular aneurysm coil embolization) are not without some risk of major morbidity and mortality (8, 31) Therefore, an accurate metric (or several metrics) to judge the risk of rupture of an aneurysm is critical to aid in generating the best possible treatment algorithm Hemodynamics has been shown to play an important role in IA pathophysiology and rupture Using computational fluid dynamics, Hassan et al (11) suggested that high wall shear stress (WSS) may be responsible for IA growth and rupture in high-flow aneurysms, whereas the predominant factors causing rupture in low-flow aneurysms are high intra-aneurysmal pressure and flow stasis Cebral et al (6) demonstrated that ruptured IAs have unstable flow patterns, smaller impinging jet diameters, and smaller impingement zones Shojima et al (24) found that ruptured IAs have a higher average WSS in the aneurysm sac than unruptured IAs They observed recirculation zones and blood stasis at the apex of ruptured IAs It is important to realize that IA hemodynamics are strongly dependent on the geometry of the aneurysmal sac and its feeding vessel (11, 13, 26) For a given geometry, Cebral et al (5) showed that hemodynamics do not vary significantly with physiological variations of flow rate, blood pressure, and waveform Therefore, suitable parameters characterizing IA geometry can capture the characteristic hemodynamics and potentially predict rupture risk Several past studies have investigated such parameters The most ubiquitous parameter is IA size Although aneurysms exceeding 10 mm in size are considered to be dangerous, several studies have shown that a large percentage of ruptured aneurysms are, in fact, smaller than 10 mm (2, 9, 22, 23, 26, 27, 30) The relationship between IA rupture risk and IA size has yet to be completely elucidated Aneurysm shape has been studied as well, and certain shape parameters show stronger correlation with rupture than IA size Aspect ratio (AR), defined as IA height divided by neck diameter, is the most commonly studied shape parameter Although most findings affirm its importance, they do not converge on a common threshold value (2, 22, 26, 27, 29) Other, more sophisticated, shape parameters such as undulation index (UI), nonsphericity index (NSI), and ellipticity index (EI) have been proposed (22) in an attempt to account for the three-dimensional (3D) nature of IA Such 3D parameters show promise to be better predictors than lower-dimensional parameters such as size or AR, and they are further examined in the current study Previous studies have also investigated additional factors that correlate with IA rupture risk, such as familial preponderance, smoking, hypertension, female sex, connective tissue disorder, aneurysm growth rate, and presence of multiple IAs (15-17, 32) However, these studies have not yielded quantifiable metrics that can be readily integrated into the clinical decision-making process Adding complexity from such diverse variables into our current study would make risk assessment analysis unwieldy Currently, morphometric evaluation, typically using size alone, is the mainstay of applied aneurysm rupture risk assessment in day-to-day clinical practice Our aim is to improve such morphological evaluation and better the accuracy of aneurysm rupture risk assessment, something that is fundamental to the current practice of cerebrovascular neurosurgery A limitation of previous morphology-based rupture risk studies, including those investigating 3D parameters, is that the geometry of the parent artery is typically ignored Parent artery geometry has a significant influence on the resultant IA hemodynamics and, consequently, the rupture risk Castro et al (4) have demonstrated that upstream vessel tortuosity can critically influence intra-aneurysmal hemodynamics Hassan et al (11) observed that a greater parent vessel incidence angle shifts the high WSS area toward the aneurysm dome, where rupture-prone blebs often are present, whereas Hoi et al (13) noted that highly curved parent vessels subject IAs to higher hemodynamic stresses at the inflow zone that might promote growth or rupture Thus, parent vessel geometry should be accounted for when defining morphological parameters for IA rupture risk prediction Furthermore, numerous studies have observed a connection between IA rupture risk and vessel location (3, 4, 9, 21, 26, 30) Because vessel location is strongly related to vessel geometry, this finding affirms the importance of vessel geometry for IA rupture risk Incorporating parent vessel geometry in morphology parameters can, at least to some extent, capture the influence of IA location as well In the current study, we address the above-mentioned issues and define three new morphology parameters that incorporate IA parent vessel geometry We analyze a group of 45 IAs (20 ruptured, 25 unruptured) to evaluate new IA rupture parameters, in comparison with five “traditional” parameters that have been described in earlier studies

448 citations

Journal ArticleDOI
TL;DR: The ADAPT technique is a fast, safe, simple, and effective method that has facilitated the approach to acute ischemic stroke thrombectomy by utilizing the latest generation of large bore aspiration catheters to achieve previously unparalleled angiographic outcomes.
Abstract: Background The development of new revascularization devices has improved recanalization rates and time, but not clinical outcomes. We report a prospectively collected clinical experience with a new technique utilizing a direct aspiration first pass technique with large bore aspiration catheter as the primary method for vessel recanalization. Methods 98 prospectively identified acute ischemic stroke patients with 100 occluded large cerebral vessels at six institutions were included in the study. The ADAPT technique was utilized in all patients. Procedural and clinical data were captured for analysis. Results The aspiration component of the ADAPT technique alone was successful in achieving Thrombolysis in Cerebral Infarction (TICI) 2b or 3 revascularization in 78% of cases. The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 95%. The average time from groin puncture to at least TICI 2b recanalization was 37 min. A 5MAX demonstrated similar success to a 5MAX ACE in achieving TICI 2b/3 revascularization alone (75% vs 82%, p=0.43). Patients presented with an admitting median National Institutes of Health Stroke Scale (NIHSS) score of 17.0 (12.0–21.0) and improved to a median NIHSS score at discharge of 7.3 (1.0–11.0). Ninety day functional outcomes were 40% (modified Rankin Scale (mRS) 0–2) and 20% (mRS 6). There were two procedural complications and no symptomatic intracerebral hemorrhages. Discussion The ADAPT technique is a fast, safe, simple, and effective method that has facilitated our approach to acute ischemic stroke thrombectomy by utilizing the latest generation of large bore aspiration catheters to achieve previously unparalleled angiographic outcomes.

424 citations

Journal ArticleDOI
TL;DR: The ADAPT technique is a simple and effective approach to acute ischemic stroke thrombectomy and Utilizing the latest generation of large bore aspiration catheters in this fashion has allowed us to achieve excellent clinical and angiographic outcomes.
Abstract: Background The development of new revascularization devices has improved recanalization rates and time but not clinical outcomes. We report our initial results with a new technique utilizing a direct aspiration first pass technique with a large bore aspiration catheter as the primary method for vessel recanalization. Methods A retrospective evaluation of a prospectively captured database of 37 patients at six institutions was performed on patients where the ADAPT technique was utilized. The data represent the initial experience with this technique. Results The ADAPT technique alone was successful in 28 of 37 (75%) cases although six cases had large downstream emboli that required additional aspiration. Nine cases required the additional use of a stent retriever and one case required the addition of a Penumbra aspiration separator to achieve recanalization. The average time from groin puncture to at least Thrombolysis in Cerebral Ischemia (TICI) 2b recanalization was 28.1 min, and all cases were successfully revascularized. TICI 3 recanalization was achieved 65% of the time. On average, patients presented with an admitting National Institutes of Health Stroke Scale (NIHSS) score of 16.3 and improved to an NIHSS score of 4.2 by the time of hospital discharge. There was one procedural complication. Discussion This initial experience highlights the fact that the importance of the technique with which new stroke thrombectomy devices are used may be as crucial as the device itself. The ADAPT technique is a simple and effective approach to acute ischemic stroke thrombectomy. Utilizing the latest generation of large bore aspiration catheters in this fashion has allowed us to achieve excellent clinical and angiographic outcomes.

312 citations


Cited by
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Journal ArticleDOI
01 Mar 2013-Stroke
TL;DR: These guidelines supersede the prior 2007 guidelines and 2009 updates and support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit.
Abstract: Background and Purpose—The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audienc...

7,214 citations

01 Feb 2009
TL;DR: This Secret History documentary follows experts as they pick through the evidence and reveal why the plague killed on such a scale, and what might be coming next.
Abstract: Secret History: Return of the Black Death Channel 4, 7-8pm In 1348 the Black Death swept through London, killing people within days of the appearance of their first symptoms. Exactly how many died, and why, has long been a mystery. This Secret History documentary follows experts as they pick through the evidence and reveal why the plague killed on such a scale. And they ask, what might be coming next?

5,234 citations

Journal ArticleDOI
TL;DR: In patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation, intraarterial treatment administered within 6 hours after stroke onset was effective and safe.
Abstract: Methods We randomly assigned eligible patients to either intraarterial treatment plus usual care or usual care alone. Eligible patients had a proximal arterial occlusion in the anterior cerebral circulation that was confirmed on vessel imaging and that could be treated intraarterially within 6 hours after symptom onset. The primary outcome was the modified Rankin scale score at 90 days; this categorical scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death). The treatment effect was estimated with ordinal logistic regression as a common odds ratio, adjusted for prespecified prognostic factors. The adjusted common odds ratio measured the likelihood that intraarterial treatment would lead to lower modified Rankin scores, as compared with usual care alone (shift analysis). Results We enrolled 500 patients at 16 medical centers in the Netherlands (233 assigned to intraarterial treatment and 267 to usual care alone). The mean age was 65 years (range, 23 to 96), and 445 patients (89.0%) were treated with intravenous alteplase before randomization. Retrievable stents were used in 190 of the 233 patients (81.5%) assigned to intraarterial treatment. The adjusted common odds ratio was 1.67 (95% confidence interval [CI], 1.21 to 2.30). There was an absolute difference of 13.5 percentage points (95% CI, 5.9 to 21.2) in the rate of functional independence (modified Rankin score, 0 to 2) in favor of the intervention (32.6% vs. 19.1%). There were no significant differences in mortality or the occurrence of symptomatic intracerebral hemorrhage. Conclusions In patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation, intraarterial treatment administered within 6 hours after stroke onset was effective and safe. (Funded by the Dutch Heart Foundation and others; MR CLEAN Netherlands Trial Registry number, NTR1804, and Current Controlled Trials number, ISRCTN10888758.)

5,230 citations

Journal ArticleDOI
TL;DR: In this paper, the authors evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation.
Abstract: Among patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation. Methods We randomly assigned participants to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds model was used to calculate the common odds ratio as a measure of the likelihood that the intervention would lead to lower scores on the modified Rankin scale than would control care (shift analysis). Results The trial was stopped early because of efficacy. At 22 centers worldwide, 316 participants were enrolled, of whom 238 received intravenous alteplase (120 in the intervention group and 118 in the control group). In the intervention group, the median time from study CT of the head to first reperfusion was 84 minutes. The rate of functional independence (90-day modified Rankin score of 0 to 2) was increased with the intervention (53.0%, vs. 29.3% in the control group; P<0.001). The primary outcome favored the intervention (common odds ratio, 2.6; 95% confidence interval, 1.7 to 3.8; P<0.001), and the intervention was associated with reduced mortality (10.4%, vs. 19.0% in the control group; P = 0.04). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in intervention group and 2.7% of participants in control group (P = 0.75). Conclusions Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality. (Funded by Covidien and others; ESCAPE ClinicalTrials.gov number, NCT01778335.)

4,739 citations

Journal ArticleDOI
TL;DR: In patients with ischemic stroke with a proximal cerebral arterial occlusion and salvageable tissue on CT perfusion imaging, early thrombectomy with the Solitaire FR stent retriever, as compared with alteplase alone, improved reperfusion, early neurologic recovery, and functional outcome.
Abstract: Background Trials of endovascular therapy for ischemic stroke have produced variable results. We conducted this study to test whether more advanced imaging selection, recently developed devices, and earlier intervention improve outcomes. Methods We randomly assigned patients with ischemic stroke who were receiving 0.9 mg of alteplase per kilogram of body weight less than 4.5 hours after the onset of ischemic stroke either to undergo endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or to continue receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging. The coprimary outcomes were reperfusion at 24 hours and early neurologic improvement (≥8-point reduction on the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3). Secondary outcomes included the functional score on the modified Rankin scale at 90 days. Results The trial was stopped early because of efficacy after 70 patients had undergone randomization (35 patients in each group). The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group (median, 100% vs. 37%; P<0.001). Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early neurologic improvement at 3 days (80% vs. 37%, P = 0.002) and improved the functional outcome at 90 days, with more patients achieving functional independence (score of 0 to 2 on the modified Rankin scale, 71% vs. 40%; P = 0.01). There were no significant differences in rates of death or symptomatic intracerebral hemorrhage. Conclusions In patients with ischemic stroke with a proximal cerebral arterial occlusion and salvageable tissue on CT perfusion imaging, early thrombectomy with the Solitaire FR stent retriever, as compared with alteplase alone, improved reperfusion, early neurologic recovery, and functional outcome. (Funded by the Australian National Health and Medical Research Council and others; EXTEND-IA ClinicalTrials.gov number, NCT01492725, and Australian New Zealand Clinical Trials Registry number, ACTRN12611000969965.)

4,562 citations