title: Too good to treat? ischemic stroke patients with small computed tomography perfusion lesions may not benefit from thrombolysis.
abstract: OBJECTIVE
  Although commonly used in clinical practice, there remains much uncertainty about whether perfusion computed tomography (CTP) should be used to select stroke patients for acute reperfusion therapy. In this study, we tested the hypothesis that a small acute perfusion lesion predicts good clinical outcome regardless of thrombolysis administration.
  
  
  METHODS
  We used a prospectively collected cohort of acute ischemic stroke patients being assessed for treatment with IV-alteplase, who had CTP before a treatment decision. Volumetric CTP was retrospectively analyded to identify patients with a small perfusion lesion (<15ml in volume). The primary analysis was excellent 3-month outcome in patients with a small perfusion lesion who were treated with alteplase compared to those who were not treated.
  
  
  RESULTS
  Of 1526 patients, 366 had a perfusion lesion <15ml and were clinically eligible for alteplase (212 being treated and 154 not treated). Median acute National Institutes of Health Stroke Scale score was 8 in each group. Of the 366 patients with a small perfusion lesion, 227 (62%) were modified Rankin Scale (mRS) 0 to 1 at day 90. Alteplase-treated patients were less likely to achieve 90-day mRS 0 to 1 (57%) than untreated patients (69%; relative risk [RR] = 0.83; 95% confidence interval [CI], 0.71-0.97; p = 0.022) and did not have different rates of mRS 0 to 2 (72% treated patients vs 77% untreated; RR, 0.93; 95% CI, 0.82-1.95; p = 0.23).
  
  
  CONCLUSIONS
  This large observational cohort suggests that a portion of ischemic stroke patients clinically eligible for alteplase therapy with a small perfusion lesion have a good natural history and may not benefit from treatment. Ann Neurol 2016;80:286-293.
authors.affiliation: Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: Bivard
authors.affiliation: Department of Neurology, the Second Affiliated Hospital of Zhejiang University, Hangzhou, China.
authors.forename: Min
authors.initials: M
authors.lastname: Lou
authors.affiliation: Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Levi
authors.affiliation: Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
authors.forename: Venkatesh
authors.identifier: http://orcid.org/0000-0001-6651-2189
authors.initials: V
authors.lastname: Krishnamurthy
authors.affiliation: Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Xin
authors.initials: X
authors.lastname: Cheng
authors.affiliation: Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
authors.forename: Richard I
authors.initials: RI
authors.lastname: Aviv
authors.affiliation: Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
authors.forename: Patrick
authors.initials: P
authors.lastname: McElduff
authors.affiliation: Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
authors.forename: Longting
authors.initials: L
authors.lastname: Lin
authors.affiliation: Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia.
authors.forename: Tim
authors.initials: T
authors.lastname: Kleinig
authors.affiliation: Department of Neurology, Gosford Hospital, Gosford, Australia.
authors.forename: Billy
authors.initials: B
authors.lastname: O'Brien
authors.affiliation: Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Butcher
authors.affiliation: Department of Neurology, Baotou Central Hospital, Baotou, China.
authors.forename: Zhang
authors.initials: Z
authors.lastname: Jingfen
authors.affiliation: Department of Neurology, The Queen Elizabeth Hospital, Adelaide, Australia.
authors.forename: Jim
authors.initials: J
authors.lastname: Jannes
authors.affiliation: Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Qiang
authors.initials: Q
authors.lastname: Dong
authors.affiliation: Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Parsons
mesh_terms: D000368:Aged; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D008297:Male; D020521:Stroke / Q000000981:diagnostic imaging* / Q000188:drug therapy*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator