發(fā)布時間：2018-04-19 17:03

  本文選題：經(jīng)顱多普勒 + 頸動脈內(nèi)膜剝脫術(shù)��； 參考：《蘇州大學(xué)》2014年碩士論文

【摘要】：本課題包括兩個部分：（1）研究頸動脈內(nèi)膜剝脫術(shù)（carotid endarterectomy, CEA）中腦血流動力學(xué)變化；（2）研究CD40及基質(zhì)金屬蛋白酶（matrix metalloproteinases,MMPs）在CEA斑塊中的表達(dá)及對斑塊穩(wěn)定性的影響。 第一部分研究頸動脈內(nèi)膜剝脫術(shù)中腦血流動力學(xué)變化 目的運(yùn)用經(jīng)顱多普勒超聲（transcranial doppler, TCD）在CEA術(shù)中實(shí)時監(jiān)測腦血流動力學(xué)變化，對如何防止腦缺血及過度灌注進(jìn)行前瞻性研究。 方法29例（35例次）接受CEA治療的頸動脈狹窄患者，分為雙側(cè)狹窄組（雙側(cè)頸動脈中-重度狹窄或一側(cè)閉塞）及單側(cè)狹窄組。設(shè)定TCD監(jiān)測指標(biāo)調(diào)控血壓：臨時阻斷頸動脈后（臨阻后），手術(shù)側(cè)大腦中動脈（middle cerebral artery, MCA）平均血流速度（mean blood flow velocity, Vm）低于臨阻前的70%，則提升血壓；解除臨阻后，手術(shù)側(cè)MCAVm超過臨阻前的100%，則降低血壓。手術(shù)前、后頭頸部血管均行TCD、彩色多普勒血流顯像（color doplor flow image, CDFI）、磁共振血管成像（magneticresonance angiography, MRA）和/或CT血管造影（computed tomography angiography,CTA）和/或數(shù)字減影血管造影（digital subtraction angiography, DSA）檢查，判斷血管的狹窄程度及再通狀況；行CT灌注成像（computed tomography perfusion, CTP）評判腦灌注狀況；行計算機(jī)體層攝影（computerized tomography, CT）及磁共振成像（magnetic resonance imaging, MRI）評判腦實(shí)質(zhì)有無出血或缺血改變；術(shù)前行TCD檢查以判斷側(cè)枝循環(huán)。 結(jié)果（1）兩組患者：臨阻前，手術(shù)側(cè)MCAVm較麻醉前減低（P=0.000）；臨阻后，MCAVm略低于臨阻前（P0.05），血壓提升（23.76±9.15）%（P=0.000）；解除臨 阻后，MCAVm較臨阻前增高（P=0.000），血壓降低（6.70±6.89）%（P=0.000）。 （2）兩組間比較：臨阻后，雙側(cè)狹窄組手術(shù)側(cè)MCAVm較單側(cè)狹窄組減低（P0.05），血壓提升幅度較單側(cè)狹窄組大（P0.01）；解除臨阻后，雙側(cè)狹窄組血壓降低幅度較單側(cè)狹窄組�。≒0.05），兩組間MCAVm差異無統(tǒng)計學(xué)意義（P0.05）。（3）預(yù)后：患者腦灌注均改善，神經(jīng)功能得到不同程度的改善。結(jié)論TCD在CEA術(shù)中實(shí)時監(jiān)測腦血流動力學(xué)變化，評估腦灌注，指導(dǎo)麻醉調(diào)控血壓，能顯著提高手術(shù)成功率。 第二部分研究CD40及MMPs在CEA斑塊中的表達(dá)及對斑塊穩(wěn)定性的影響 目的研究CD40及MMPs在頸動脈易損斑塊及穩(wěn)定斑塊中的表達(dá)，探討CD40與MMPs表達(dá)的相關(guān)性及影響斑塊穩(wěn)定性的可能機(jī)制。 方法收集CEA術(shù)后的粥樣硬化斑塊標(biāo)本35例次，根據(jù)術(shù)前CDFI檢查判斷斑塊性質(zhì)、TCD檢查是否監(jiān)測到微栓子信號（microembolic signals, MES）及是否發(fā)生急性缺血性卒中事件，將患者分為易損斑塊組及穩(wěn)定斑塊組。采用實(shí)時熒光定量聚合酶鏈反應(yīng)（realtime fluorescent quantitative PCR, Realtime PCR）和免疫印跡法（Westernblotting）檢測兩組標(biāo)本中CD40及MMPs（MMP-1、MMP-2、MMP-9、MMP-14）的mRNA和蛋白表達(dá)水平。 結(jié)果（1）Realtime PCR檢測結(jié)果：易損斑塊組CD40和MMP-9mRNA表達(dá)水平較穩(wěn)定斑塊組顯著增高（P0.01），兩組間MMP-1、MMP-2、MMP-14mRNA表達(dá)水平的差異無統(tǒng)計學(xué)意義（P0.05）；通過相關(guān)性分析，CD40mRNA與MMP-9mRNA之間呈顯著正相關(guān)（r=0.9006，P0.0001），CD40mRNA與MMP-2mRNA之間呈正相關(guān)（r=0.4322，，P=0.0135），但CD40mRNA與MMP-1mRNA（r=0.0282）、CD40mRNA與MMP-14mRNA（r=0.0876）之間無明顯相關(guān)性（P0.05）；（2）Western blotting檢測結(jié)果：鑒于易損斑塊組CD40mRNA與MMP-9mRNA的表達(dá)顯著高于穩(wěn)定斑塊組，且CD40mRNA與MMP-2mRNA、CD40mRNA與MMP-9mRNA之間呈正相關(guān)，因此，選取CD40、MMP-2及MMP-9進(jìn)一步進(jìn)行蛋白水平分析，結(jié)果提示：易損斑塊組CD40、MMP-2及MMP-9的蛋白表達(dá)量均較穩(wěn)定斑塊組明顯增高。結(jié)論CD40不僅參與動脈粥樣硬化斑塊的形成，而且可能通過調(diào)控MMP-2、MMP-9的表達(dá)影響動脈粥樣硬化斑塊的穩(wěn)定性，促進(jìn)斑塊破裂，造成缺血性卒中的發(fā)生。
[Abstract]:This topic includes two parts: (1) the study of cerebral hemodynamic changes in carotid endarterectomy (CEA); (2) the study of the expression of CD40 and matrix metalloproteinase (matrix metalloproteinases, MMPs) in CEA plaque and the effect on the stability of plaque.
The first part is to study the changes of cerebral hemodynamics during carotid endarterectomy.
Objective using transcranial Doppler (TCD) to monitor the changes of cerebral hemodynamics in real time in CEA, and to investigate how to prevent cerebral ischemia and overperfusion.
Methods 29 cases (35 cases) of carotid stenosis treated with CEA were divided into bilateral stenosis group (bilateral carotid - severe stenosis or unilateral occlusion) and unilateral stenosis group. The TCD monitoring index was set to regulate blood pressure: temporary occlusion of the carotid artery (post obstruction), and the mean blood flow velocity of the middle cerebral artery (MCA) on the operative side (mean B). Lood flow velocity, Vm) was lower than 70% before obstruction, and the blood pressure was raised. After the removal of impaction, the operating side was 100% before the obstruction, and the blood pressure was reduced. Before the operation, the blood vessels of the head and neck were all TCD, color Doppler flow imaging (color Doplor flow image, CDFI), magnetic resonance angiography (magneticresonance), and / or blood. Computed tomography angiography (CTA) and / or digital subtraction angiography (digital subtraction angiography, DSA) were used to determine the degree of stenosis and repassage of blood vessels. The perfusion of CT perfusion imaging (computed tomography perfusion) was used to evaluate the cerebral perfusion status. Magnetic resonance imaging (MRI) was used to assess whether there was hemorrhage or ischemia in the parenchyma of the brain. Preoperative TCD examination was performed to identify collateral circulation.
Results (1) two groups of patients: MCAVm before anesthesia was lower than before anesthesia (P=0.000); after obstruction, MCAVm was slightly lower than before obstruction (P0.05), blood pressure was raised (23.76 + 9.15)% (P=0.000);
After blocking, MCAVm increased (P=0.000) and blood pressure decreased (6.70 + 6.89)% (P=0.000).
(2) comparison between the two groups: after the obstruction, the operative side of the bilateral stenosis group was lower than that of the unilateral stenosis group (P0.05), and the blood pressure elevation was larger than that of the unilateral stenosis group (P0.01). After the termination of the impending obstruction, the decrease of blood pressure in the bilateral stenosis group was smaller than that of the unilateral stenosis group (P0.05), and the difference between the two groups was not statistically significant (P0.05). (3) the prognosis of the patients in the two groups was (P0.01). Good, neural function is improved in different degrees. Conclusion TCD can monitor cerebral hemodynamic changes in real time in CEA, evaluate cerebral perfusion and guide the control of blood pressure by anesthesia, and can significantly improve the success rate of operation.
The second part is to study the expression of CD40 and MMPs in CEA plaques and its effect on plaque stability.
Objective to investigate the expression of CD40 and MMPs in vulnerable plaques and stable plaques of carotid artery, and to explore the correlation between CD40 and MMPs expression and the possible mechanism of plaque stability.
Methods 35 cases of atherosclerotic plaque after CEA were collected. The properties of plaque were determined by CDFI examination before operation. TCD detected the micro embolus signal (microembolic signals, MES) and the occurrence of acute ischemic stroke. The patients were divided into vulnerable plaque group and stable plaque group. Real time fluorescence quantitative polymerase chain reaction (RT) was used. Realtime fluorescent quantitative PCR, Realtime PCR) and immunoblotting (Westernblotting) were used to detect the levels of CD40 and MMPs (MMP-1, MMP-2, MMP-9, and proteins) in two groups of specimens.
Results (1) Realtime PCR detection results: the expression level of CD40 and MMP-9mRNA in vulnerable plaque group was significantly higher than that in the stable plaque group (P0.01). There was no significant difference in the expression level of MMP-1, MMP-2, MMP-14mRNA between the two groups (P0.05). The correlation analysis showed that the CD40mRNA and MMP-9mRNA were positively correlated (r=0.9006,) There is a positive correlation between RNA (r=0.4322, P=0.0135), but there is no significant correlation between CD40mRNA and MMP-1mRNA (r=0.0282), CD40mRNA and MMP-14mRNA (r=0.0876). (2) Western blotting detection results: the expression of vulnerable plaque group and the expression of the plaque is higher than that of the stable plaque group. There is a positive correlation between CD40, MMP-2 and MMP-9. The results suggest that the protein expression of CD40, MMP-2 and MMP-9 in vulnerable plaque group is higher than that of the stable plaque group. Conclusion CD40 not only participates in the formation of atherosclerotic plaque, but also may affect the atherosclerotic atherosclerotic atherosclerosis by regulating the expression of MMP-2. The stability of atherosclerotic plaque promotes plaque rupture and causes ischemic stroke.

【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R743.3

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