Improving Clinical Outcomes Following Subarachnoid Hemmorhage Using CT Perfusion

描述（由申请人提供）：脑血管痉挛尚不清楚，导致动脉瘤性蛛网膜下腔出血（A-SAH）后诊断不明确和治疗延误。由于永久性神经功能缺损、中风和死亡导致的血管痉挛的临床预后较差。中风在高达81%的A-SAH患者中被发现，在美国每年影响21,000-33,000人。多达46%的人有长期认知障碍，影响功能状态和生活质量。因此，这种疾病还与公共卫生保健费用和资源的沉重负担有关，主要与住院、长期护理和残疾的间接经济成本有关。我们的长期目标是通过实施CT灌注（CTP）作为一种手段来改善a - sah患者的临床结果，1)提供更早、更准确的血管痉挛诊断，2)指导有效的治疗策略。我们本研究的假设是，适当使用CTP可以通过更早、更准确地诊断血管痉挛来改善A-SAH患者的临床结果。采用前瞻性队列研究设计，a - sah患者将根据其症状、经颅多普勒超声（TCD）、CT血管造影（CTA）、CTP和数字减影血管造影（DSA）检查进行监测。主要目的是通过以下具体目的确定CTP作为评估血管痉挛的诊断工具的性能：1)确定CTP的敏感性、特异性、阳性和阴性预测值；2)比较CTP与症状、TCD、CTA和DSA的敏感性和特异性；3)确定提供最早诊断的模式组合。次要目的是评估CTP对血管痉挛诊断的影响，具体目的有：4)评估CTP对诊断确定性和管理决策的影响，5)确定CTP对临床结果的影响，6)进行成本-效果分析。在哈佛大学公共卫生学院和康奈尔大学威尔医学研究生院有一个强大的指导计划，以及结构良好的教育课程，这将极大地提高我的临床研究技能，并在我之前的研究经验的基础上发展成为该领域的独立临床研究者。

DESCRIPTION (provided by applicant): Cerebral vasospasm is not well understood leading to indeterminate diagnosis and delayed treatment following aneurysmal subarachnoid hemorrhage (A-SAH). There is poor clinical outcome associated with vasospasm due to permanent neurologic deficit, stroke and death. Stroke has been detected in up to 81% of A-SAH patients, affecting 21,000-33,000 persons each year in the United States. As many as 46% have long-term cognitive impairment, affecting functional status and quality of life. Thereby, this disorder is also associated with a substantial burden on public health care costs and resources, mostly related to hospitalization, long-term care and indirect economic costs of disability. Our long-term goal is to improve clinical outcomes of patients following A-SAH by implementing CT perfusion (CTP) as a means to 1) provide earlier and more accurate diagnosis of vasospasm, and 2) guide effective treatment strategies. Our hypothesis for this research proposal is that appropriate use of CTP will improve the clinical outcomes of A-SAH patients by providing earlier and more accurate diagnosis of vasospasm. Using a prospective cohort study design, A-SAH patients will be monitored according to their symptoms, transcranial Doppler ultrasound (TCD), CT angiography (CTA), CTP and digital subtraction angiograpghy (DSA) exams. The primary objective is to determine the performance of CTP as a diagnostic tool in the evaluation of vasospasm, by these specific aims: 1) To determine the sensitivity, specificity, positive and negative predictive values of CTP, 2) to compare sensitivity and specificity of CTP with symptoms, TCD, CTA and DSA, and 3) to identify the combination of modalities that provides the earliest diagnosis. The secondary objective is to evaluate the impact of CTP for diagnosis of vasospasm, with these specific aims: 4) To assess the effect of CTP on diagnostic certainty and management decision making, 5) to determine the effect of CTP on clinical outcomes, and 6) to perform cost-effectiveness analysis. A strong mentoring program at my institution with a well-structure educational curriculum at the Harvard School of Public Health and Weill Graduate School of Medical Sciences of Cornell University will greatly enhance my clinical research skills and build on my prior research experience to develop into an independent clinical investigator in this field.