【作者】 孟辉；

【导师】 冯华； 王宪荣；

【作者基本信息】 第三军医大学 ， 外科学， 2006， 博士

【摘要】 脑积水是脑出血后常见的并发症,发生率很高。国外统计高达50%的自发性脑出血合并有脑室出血,其中35%会发展成为出血后脑积水。研究表明脑积水形成后会导致脑实质的继发性损害,是病情加重、致死和预后不良的重要原因。迄今为止,脑出血后慢性脑积水的发生机制尚不完全清楚,推测可能是蛛网膜下腔纤维化导致脑脊液(cerebrospinal fluid,CSF)的循环吸收障碍所致,但缺乏直接的证据并存在较多争议。因此目前国内外对脑出血后慢性脑积水的治疗困难,实践表明传统的分流术因并发症较多而易致手术失败,其主要并发症为分流管堵塞及术后感染,国外统计堵管率大约40%,感染率约15%,部分患者因反复手术失败而成为难治性脑积水。近年来,采用经神经内镜+分流术治疗脑出血后慢性脑积水,虽然较传统分流术的效果稍好些,但对于部分病例的治疗仍非常困难,而成为临床亟待解决的一个难题。本研究在回顾性总结神经内镜手术治疗184例脑积水及症状性透明隔囊肿的基础上,根据内镜观察脑出血后慢性脑积水患者脑室内较多纤维蛋白沉积这一现象,推测这些纤维蛋白沉积物可能在脑出血后慢性脑积水的形成中具有重要意义,同时可能也是分流术后分流管堵塞的主要原因。并对脑出血后慢性脑积水的可能发生机制进行了初步实验研究。材料与方法:首先采用放射免疫分析法(RIA)检测了组织纤维化标志物PⅠCP、PⅢNP、HA、LN在人脑出血后慢性脑积水的CSF中的含量;然后分别建立了小型猪及大鼠实验性脑室出血后慢性脑积水动物模型,采用MRI动态观察猪脑室容积改变、SPECT观察猪蛛网膜下腔CSF循环的改变,及脑积水形成后猪脑的病理改变、超微结构改变;同时分别采用免疫组化、原位杂交方法观察了大鼠脑室出血后LN及LNR1、水通道蛋白(AQP1)及AQP1mRNA在大鼠脑内的表达及尿激酶腹腔注射的干预作用。结果:1.神经内镜手术治疗184例脑积水及透明隔囊肿,总治愈率79.35%、好转率14.67%、有效率94.02%。并发症为9.24%。脑出血、脑外伤后慢性脑积水患者脑室内较多胶冻样或絮状沉积物,病理检查为纤维蛋白成分。2.脑出血及脑外伤后慢性脑积水患者CSF中PⅠCP、PⅢNP、HA、LN的含量显著高于对照组(P＜0.01)。3.猪实验性脑室出血后30d 7只出现慢性脑积水,占63.64%(7/11),大鼠实验组30d出现慢性脑积水为80%(4/5),尿激酶治疗组30d出现慢性脑积水为60%(3/5)。4.猪脑室出血后各时相点蛛网膜下腔核素显影均局限在椎管穿刺点附近,显示CSF循环障碍。5.猪脑室出血后主要病理改变有蛛网膜下腔轻度增宽、脉络丛萎缩、室管膜萎缩,未发生脑积水动物病理改变较发生脑积水动物略轻。6.猪脑室出血后主要超微结构改变为蛛网膜细胞间隙纤维样结构增多,未发生脑积水动物改变较发生脑积水动物略轻。7.大鼠脑室出血后主要病理改变有脑室明显扩张,蛛网膜下腔增宽水肿、脉络丛萎缩、室管膜萎缩,未发生脑积水动物病理改变较发生脑积水动物略轻。8.实验组大鼠脑室出血后LN在脉络丛的疏松结缔组织膜、纵裂池、软脑膜、蛛网膜、硬膜、脑内毛细血管壁、蛛网膜下腔血管壁的表达在3d时增加,7d表达继续增加,14d表达最强较对照组、假手术组差异显著(P＜0.01),30d仍强烈表达;尿激酶治疗组较实验组无明显差异。9.实验组大鼠脑室出血后LNR1在脉络丛的立方上皮细胞胞浆及顶质膜、室管膜细胞、软脑膜细胞、蛛网膜细胞、硬膜、纵裂池、胶质细胞的表达增加。LNR1在蛛网膜下腔的表达变化与LN基本一致。10.对照组大鼠AQP1在脉络丛上皮细胞顶质膜强烈表达,室管膜、纵裂池、软脑膜、蛛网膜、硬脑膜也有较强烈表达;实验组脑室出血后3d表达减少,7d表达继续减少,14d表达最弱较对照组、假手术组差异显著(P＜0.01),30d表达仍较弱;尿激酶治疗组表达强度较实验组明显增强(P＜0.01)。11.大鼠AQP1mRNA在脑内的表达强度较AQP1弱,表达部位及变化与AQP1基本一致。结论:1.神经内镜手术可作为单纯的梗阻性脑积水及症状性透明隔囊肿的首选治疗方法;神经内镜脑室冲洗有可能减少脑出血后慢性脑积水分流术的堵管率。2.脑出血后慢性脑积水患者CSF中PⅠCP、PⅢNP、HA、LN的含量显著增高,提示人脑出血后蛛网膜下腔可能存在纤维化趋势。3.小型猪实验性脑室出血后蛛网膜下腔的CSF循环吸收障碍可能与电镜所发现的蛛网膜纤维化有关。4.大鼠实验性脑室出血后LN及LNR1的表达上调可能参与蛛网膜纤维化的形成。5.大鼠实验性脑室出血后AQP1表达下调导致CSF吸收减少可能也参与脑出血后慢性脑积水的形成。更多还原

【Abstract】 Background Hydrocephalus is a major complication of intracerebral haemorrhage. The incidence of intraventricular hemorrhage amalgamating intracerebral haemorrhage is greater than 50%,of which 35%will develop into progressive posthemorrhagic hydrocephalus（PPHH）.PPHH can induce secondary injury to brain,and is an important causation of mortality and morbidity in these intracerebral haemorrhages.Up to date,the definite pathogenesis of posthaemorrhagic chronic hydrocephalus is not clear.It is speculated that the obstruction of CSF absorption induced by subarachnoid space fibrosis after intraventricular hemorrhage might be the cause of posthaemorrhagic chronic hydrocephalus;however,there is no definite evidence to support it and many disputes still exist.So,it is very difficult to seek the proper treatment for posthaemorrhagic chronic hydrocephalus.The traditional ventriculoperitoneal shunt has not achieved satisfactory curative effects because of the complications such as blockages and infections.Lately, although posthaemorrhagic chronic hydrocephalus via neuroendoscopic approach is more effectual than the traditional shunt,in some cases such treatment still faces great challenges.We reviewed 184 cases patients with hydrocephalus or intracranial cyst underwent neuroendoscopic operation.Based on the clinical discovery of fibrous tissues deposit in ventricles of posthaemorrhagic chronic hydrocephalus,we think these fibrous tissues deposit of ventricles might be the aetiology of chronic hydrocephalus and the cause of shunt blockages,and the primary experimental study of the pathogenesis of posthaemorrhagic chronic hydrocephalus was made.Methods 184 cases patients with hydrocephalus or symptomatic septum pellucidum cysts underwent neuroendoscopic operation were reviewed.The levels of procollagen I C-propeptide（PⅠCP）,procollagenⅢN-propeptide（PⅢNP）、hyaluronic acid（HA） and laminin（LN） in patients with posthaemorrhagic chronic hydrocephalus were detected by radioimmunoassay.The experimental models of posthaemorrhagic chronic hydrocephalus in pigs and rats were founded.The changes of pigs’ ventricular dimension were observed with MRI and CSF circulation in subarachnoid space observed by SPECT.The changes of structures in pigs’ brains after intraventricular hemorrhage were investigated by light and electron microscopy,and the changes of structures in rats’ brains were investigated by light microscopy.The changes of LN,laminin receptor1（LNR1）,AQP1 and AQP1 mRNA expressions in rats brains after intraventricular hemorrhage were detected with the aid of immunohistochemical techniques and in situ hybridization,respectively,and the effect of urokinase was observed synchronously.The possible pathogenesis of posthaemorrhagic chronic hydrocephalus was discussed.Results 1.184 cases patients with hydrocephalus or symptomatic septum pellucidum cysts underwent neuroendoscopic surgery.The total rate of cure was 79.35%（146/184）, 14.67%（27/184） had catabatic symptom;total effectual rate was 94.02%（173/184）,and 9.24%（17/184） had complications.2.The levels of PICP、PⅢNP、HA and LN in patients with posthaemorrhagic chronic hydrocephalus group were significantly increased than those in the controlled group（P＜0.01）.3.In 30 days after intraventricular hemorrhage, chronic hydrocephaluses were found by MRI in 7 experimental pigs,63.64%（7/11）.In 30 days after intraventricular hemorrhage,4 rats（80%） and 3 rats（60%） chronic hydrocephalus were produced in the experimental group and the urokinase therapeutic group,respectively.4.The persistently obstruction of CSF circulation and absorption in pigs subarachnoid space after intraventricular hemorrhage was detected by SPECT.5.After hemorrhage,the major changes in pigs’ brains included enlargement of subarachnoid space, atrophy of choroids plexus and ependyma.Non- hydrocephalus pigs had less obvious changes than hydrocephalus pigs did.6.Augmented fibrous tissues in hydrocephalus pigs arachnoid space were found by electron microscopy,and these changes were less obvious in non- hydrocephalus pigs.7.The major changes in rats’ brains included ventricular dilatation,enlargement and edema of subarachnoid space,atrophy of choroids plexus and ependyma.The changes in non- hydrocephalus rats were less obvious than that in hydrocephalus animals.8.After intraventricular hemorrhage,the increases of LN expressions in experimental rats’ brains were found in loose connective tissue stroma of choroids plexus,pia mater,arachnoid,dura and vascular wall.On the 14^th day,the expressions of LN reached to the peak and had evident increase compared with the controlled group（P＜0.01）.The Urokinase therapeutic group had no difference with the experimental group.9.The increase of LNR1 expressions in the experimental rats’ brains were found in cuboidal epithelium of choroids plexus,epithelium of pia,arachnoid,dura and vascular endothelial cell.On the 14^th day,the expressions of LNR1 reached to the peak and had evident increase compared with the control group（P＜0.01）.The Urokinase therapeutic group had no difference with the experimental group.10.In the controlled group rats,the intense expressions of AQP1 were found in the apical of cuboidal epithelium of choroids plexus,ependyma,pia mater,arachnoid and dura.After intraventricular hemorrhage,the expressions of AQP1 gradually descended in experimental group rats and dropped to bottom on the 14^th day（P＜0.01）.The Urokinase therapeutic group had evident increase compared with the experimental group（P＜0.01）.11.The expressions of AQP1 mRNA accorded with those of AQP1 basically.Conclusions 1.Neuroendoscopic operation could be an effective,safe,convenient and preferred therapeutic method for simplex obstructive hydrocephalus and symptomatic septum pellucidum cysts.The irrigation of ventricles via neuroendoscopic approach might reduce the blockages of shunt in posthaemorrhagic chronic hydrocephalus.2.The increases of PⅠCP、PⅢNP、HA and LN of cerebrospinal fluid in patients with posthaemorrhagic hydrocephalus imply that there is a tendency of arachnoidal fibrosis after intracerebral haemorrhage.3.The obstruction of CSF circulation and absorption after pigs’ intraventricular hemorrhage might be derived from arachnoid fibrosis detected by electron microscopy.4.The increase of LN and LNR1 expressions after rats’ intraventricular hemorrhage might involve the development of arachnoidal fibrosis.5.The decrease of CSF absorption induced by the decline of AQP1 expressions after rats’ intraventricular hemorrhage might also relate to the development of posthaemorrhagic chronic hydrocephalus.更多还原