Improving Clinical Outcomes Following Subarachnoid Hemmorhage Using CT Perfusion

描述（由申请方提供）：对脑血管痉挛的了解不充分，导致蛛网膜下腔出血（A-SAH）后诊断不确定和治疗延迟。由于永久性神经功能缺陷、中风和死亡，与血管痉挛相关的临床结局较差。在高达81%的A-SAH患者中检测到卒中，在美国每年影响21，000 - 33，000人。多达46%的人有长期的认知障碍，影响功能状态和生活质量。因此，这种疾病也与公共卫生保健费用和资源的巨大负担有关，主要与住院、长期护理和残疾的间接经济费用有关。我们的长期目标是通过实施CT灌注（CTP）改善A-SAH后患者的临床结局，以1）提供更早和更准确的血管痉挛诊断，2）指导有效的治疗策略。我们对这项研究建议的假设是，适当使用CTP将通过提供更早和更准确的血管痉挛诊断来改善A-SAH患者的临床结局。采用前瞻性队列研究设计，将根据A-SAH患者的症状、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。主要目的是确定CTP作为血管痉挛评价诊断工具的性能，具体目的如下：1）确定CTP的灵敏度、特异性、阳性和阴性预测值，2）比较CTP与症状、TCD、CTA和DSA的灵敏度和特异性，3）确定提供最早诊断的模式组合。次要目的是评价CTP对血管痉挛诊断的影响，具体目的如下：4）评估CTP对诊断确定性和管理决策的影响，5）确定CTP对临床结局的影响，以及6）进行成本效益分析。我所在机构的一个强有力的指导计划，以及哈佛公共卫生学院和康奈尔大学威尔医学研究生院的结构良好的教育课程，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.