本文選題：遠(yuǎn)程缺血預(yù)處理 + 腦保護　； 參考：《第四軍醫(yī)大學(xué)》2012年碩士論文

【摘要】：腦卒中(stroke)是一種突然起病的腦血液循環(huán)障礙性疾病。隨著外科技術(shù)的推廣應(yīng)用，重要臟器的手術(shù)越來越多，圍手術(shù)期腦卒中的發(fā)生率也隨之增加，腦的缺血再灌注損傷是其最主要原因，雖然臨床上目前使用很多措施但效果不理想。尤其是心臟手術(shù)后腦損傷發(fā)生率較高，表現(xiàn)為一系列的腦功能紊亂，如中風(fēng)、腦病及認(rèn)知功能下降等。其中中風(fēng)的發(fā)生率為1%～3%，而認(rèn)知功能障礙的發(fā)生率在術(shù)后1月可高達(dá)30%～65%，在術(shù)后5月仍有20%～40%。體外循環(huán)狀態(tài)下腦的栓塞和血流灌注不足所致的腦缺血／再灌注損傷被認(rèn)為是術(shù)后腦損傷的主要原因。 近年研究發(fā)現(xiàn)肢體遠(yuǎn)程缺血預(yù)處理對腦和脊髓具有保護作用，可以明顯減輕缺血再灌注導(dǎo)致的神經(jīng)組織損傷。由于遠(yuǎn)程缺血預(yù)處理是一種簡單、安全的預(yù)處理方式，與經(jīng)典缺血預(yù)處理相比，更能方便安全地應(yīng)用于臨床患者。研究發(fā)現(xiàn)，生物體內(nèi)普遍存在高度保守的Notch信號通路，Notch信號在神經(jīng)系統(tǒng)中與神經(jīng)元分化、成熟、再生、功能形成、以及神經(jīng)系統(tǒng)疾病存在著密切的關(guān)系。那么，Notch信號通路是否參與了遠(yuǎn)程缺血預(yù)處理誘導(dǎo)神經(jīng)保護過程？神經(jīng)組織細(xì)胞在缺血遠(yuǎn)程缺血預(yù)處理過程中具有何種反應(yīng)？這些都是有待闡明的相關(guān)機制問題。本研究對于以上問題進(jìn)行了實驗研究，提供了遠(yuǎn)程缺血預(yù)處理誘導(dǎo)腦保護機制的Notch、S-100B、NSE初步證據(jù)。 實驗一遠(yuǎn)程缺血預(yù)處理誘導(dǎo)腦保護與Notch分子表達(dá)變化的實驗研究 目的探討Notch信號在遠(yuǎn)程缺血預(yù)處理誘導(dǎo)腦保護效應(yīng)的可能參與作用。 方法采用大腦中動脈阻閉（MCAO）法制備大鼠局灶性腦缺血模型，將36只雄性SD大鼠隨機分為假手術(shù)組(Sham)、MCAO組和肢體遠(yuǎn)程缺血預(yù)處理（RIPC）組+MCAO組（n=10），分別觀察各組大鼠腦梗死灶的大小和神經(jīng)功能學(xué)評分，并用免疫組織化學(xué)染色以及Western blot、Real-Time PCR檢測再灌注2h、24h、72h大鼠腦組織紋狀體區(qū)Notch信號通路中NICD（Notch intracellular domain）及靶基因HES-1表達(dá)的變化。結(jié)果1.RIPC組腦梗死容積小于MCAO組，具有統(tǒng)計學(xué)差異（P＜0.05）。2.其神經(jīng)功能學(xué)評分也明顯優(yōu)于MCAO組（P＜0.05）。3.免疫熒光：RIPC組2h、24hNICD表達(dá)明顯少于MCAO組。4.Western blot：RIPC組NICD表達(dá)量在再灌注2h、24h降低，MCAO組NICD表達(dá)量在再灌注2h、24h強于同時間點RIPC組（P＜0.05），但兩組均高于假手術(shù)組（P＜0.05）。5.Real-Time PCR：受體Notch-1mRNA表達(dá)在MCAO組再灌注2h、24h增高，RIPC組Notch-1表達(dá)量在再灌注2h、24h低于同時間點MCAO組（P＜0.05），，靶基因HES-1mRNA表達(dá)MCAO組在再灌注2h、24h逐步增高，RIPC組表達(dá)量在再灌注2h、24h低于同時間點MCAO組（P＜0.05）。但再灌注72h兩組表達(dá)量無統(tǒng)計學(xué)差異。結(jié)論肢體遠(yuǎn)程缺血預(yù)處理對腦的缺血再灌注損傷具有保護作用，肢體遠(yuǎn)程預(yù)處理可以使Notch信號通路相關(guān)分子Notch-1、NICD、HES-1表達(dá)發(fā)生變化，肢體遠(yuǎn)程預(yù)處理誘導(dǎo)腦缺血耐受的機制可能與Notch信號表達(dá)下降有關(guān)。 實驗二遠(yuǎn)程缺血預(yù)處理對心臟圍手術(shù)期腦缺血再灌注損傷保護作用研究 目的觀察遠(yuǎn)程缺血預(yù)處理對心臟手術(shù)體外循環(huán)（CPB）所致腦缺血再灌注損傷的保護作用及其檢測評價。方法80例擇期行心臟瓣膜置換術(shù)患者在麻醉誘導(dǎo)前隨機分成兩組：肢體遠(yuǎn)程缺血預(yù)處理組和對照組，每組各40例。肢體遠(yuǎn)程缺血預(yù)處理使用充氣式止血帶對右上肢實施3次5分鐘缺血、5分鐘再灌注，充氣壓力為200mmHg。檢測麻醉誘導(dǎo)前、CPB前、術(shù)畢及開放后6、24、48、72h血清S-100B和神經(jīng)元特異性烯醇化酶（NSE）濃度。術(shù)前及術(shù)后1W、3M、6M進(jìn)行認(rèn)知功能評估。結(jié)果遠(yuǎn)程缺血預(yù)處理組開放后6、24、48、72h血清S-100B和開放后24、48、72h的NSE釋放明顯減少（P＜0.05）。盡管兩組患者認(rèn)知功能評估雖不統(tǒng)計學(xué)差異，但遠(yuǎn)程預(yù)處理組評分優(yōu)于對照組。結(jié)論肢體遠(yuǎn)程缺血預(yù)處理減輕心臟圍手術(shù)期患者神經(jīng)組織細(xì)胞損傷引起的血清S-100B和NSE釋放，提示其對缺血再灌注患者的腦組織可能具有一定的保護作用。
[Abstract]:Cerebral apoplexy (stroke) is a sudden onset of cerebral blood circulation disorder. With the popularization and application of surgical techniques, the operation of important organs is more and more, the incidence of cerebral apoplexy in the perioperative period is increasing, and cerebral ischemia reperfusion injury is the most important reason. Although many measures are used at present, the effect is not satisfactory. The incidence of brain injury after cardiac surgery is high, showing a series of cerebral dysfunction, such as stroke, encephalopathy and cognitive decline, among which the incidence of stroke is 1% to 3%, and the incidence of cognitive dysfunction can reach 30% ~ 65% in January after operation, and there is still 20% ~ 40%. of cerebral embolism and blood flow irrigation in May after operation. Cerebral ischemia / reperfusion injury caused by insufficient injection is considered to be the main cause of postoperative brain injury.
In recent years, remote ischemic preconditioning has been found to have protective effects on the brain and spinal cord, which can obviously reduce the nerve tissue damage caused by ischemia-reperfusion. Because remote ischemic preconditioning is a simple and safe preconditioning method, it is more convenient and safe to apply to clinical patients compared with classical ischemic preconditioning. There are highly conserved Notch signaling pathways in the body. Notch signals are differentiated from neurons in the nervous system, maturation, regeneration, function formation, and nervous system diseases. Is the Notch signaling pathway involved in the long distance ischemic preconditioning induced neuroprotection process? Neural tissue cells are short of ischemia. What is the reaction in the process of blood preconditioning? These are relevant mechanisms to be elucidated. This study has conducted experimental studies on the above problems and provided preliminary evidence of Notch, S-100B, and NSE for the mechanism of brain protection induced by remote ischemic preconditioning.
Experimental study on the changes of Notch expression induced by remote ischemic preconditioning
Objective to investigate the possible role of Notch signaling in remote ischemic preconditioning induced brain protection.
Methods the rat model of focal cerebral ischemia was prepared by middle cerebral artery occlusion (MCAO) method. 36 male SD rats were randomly divided into sham operation group (Sham), group MCAO and +MCAO group (n=10) of limb remote ischemic preconditioning (RIPC) group. The size of cerebral infarction and the score of neurologic function were observed in each group, and immunohistochemical staining was used. Western blot and Real-Time PCR were used to detect the changes of NICD (Notch intracellular domain) and the expression of target genes in the Notch signaling pathway in the striatum of the brain tissue of the rats with 2H, 24h and 72h. Results the volume of cerebral infarction was less than that of the group. Immunofluorescence: the expression of 2h, 24hNICD in group RIPC was significantly less than that in group.4.Western blot:RIPC of group MCAO, NICD expression was reduced to 2h, 24h decreased, NICD expression of MCAO group was in reperfusion 2h, but the two groups were higher than those in the sham group (0.05). 24h increased, the expression of Notch-1 in group RIPC was 2h, 24h was lower than that in group MCAO (P < 0.05) at the same time point (P < 0.05). The expression of target gene HES-1mRNA in MCAO group was gradually increased in 2H and 24h, and the expression of RIPC group was lower than that in the same time. There was no statistical difference between the two groups. It has protective effect on cerebral ischemia reperfusion injury. Remote preconditioning can change the expression of Notch-1, NICD, and HES-1 in Notch signaling pathway. The mechanism of remote preconditioning induced cerebral ischemia tolerance may be related to the decrease of Notch signal expression.
Experiment two the protective effect of remote ischemic preconditioning on cerebral ischemia-reperfusion injury during perioperative period
Objective To observe the protective effect of remote ischemic preconditioning on cerebral ischemia reperfusion injury induced by cardiac surgery extracorporeal circulation (CPB). Methods 80 patients undergoing elective cardiac valve replacement were randomly divided into two groups before induction of anesthesia: limb remote ischemic preconditioning group and treatment group, 40 cases in each group. The inflatable tourniquet was used for 3 times 5 minutes of ischemia, 5 minutes of reperfusion, and inflatable pressure of 200mmHg. before anesthesia induction, before CPB, 6,24,48,72h serum S-100B and neuron specific enolase (NSE) concentration. Preoperative and postoperative 1W, 3M, 6M were evaluated for cognitive function. Results remote ischemic preconditioning group was open. The release of 6,24,48,72h serum S-100B and the release of NSE after open 24,48,72h decreased significantly (P < 0.05). Although the cognitive function assessment of the two groups was not statistically different, the distance preconditioning group was superior to the control group. Conclusion limb remote ischemic preconditioning alleviated the serum S-100B and NS caused by the injury of nerve tissue cells in the perioperative patients. The release of E suggests that it may have some protective effects on cerebral tissue in patients with ischemia-reperfusion.

【學(xué)位授予單位】：第四軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R363

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