【作者】 梁华庚；

【导师】 肖传国；

【作者基本信息】 华中科技大学 ， 泌尿外科学， 2009， 博士

【摘要】 第一部分人类排尿中枢和抑制排尿中枢中不同神经通路的fMRI研究目标：首次研究正常人脑管理排尿和抑制排尿的不同神经通路。方法：通过fMRI比较正常人排尿行为和抑制排尿行为的大脑激活区差异，研究高位中枢中管理排尿和抑制排尿的不同神经通路。结果：排尿和抑制排尿过程都发现共同的前额叶皮质区激活，激活强度和激活范围基本一致；中央后回、扣带回、岛盖、补充皮质运动区在排尿和抑制排尿过程也发现都有激活，但是激活强度和激活范围并不相同；下丘脑只在排尿时激活，桥脑L区只在抑制排尿时激活。排尿过程和抑制排尿过程的小脑激活完全不同。结论：前额叶是排尿和抑制排尿的共同管理中心，也可能是不同膀胱行为的意识决策和信息处理的最高中枢。扣带回、岛盖、补充皮质运动区参与排尿行为的决策，但是不同排尿行为的决策可能需要这些皮质的不同部位参与。小脑的不同部位参与不同的排尿决策执行，下丘脑等参与排尿决策执行，桥脑L区参与抑制排尿决策执行，即排尿和抑制排尿的大脑管理结构中存在不同的神经通路。第二部分人类自然排尿过程的fMRI研究目的：我们首次研究人类自然排尿过程的高位控尿中枢功能图谱。目前人类的高位控尿中枢功能图谱主要是通过研究模拟膀胱活动得到。自然排尿过程是一种生理过程，研究这种过程的大脑管理结构可以提供最准确，最真实的高位控尿中枢功能图谱。方法：通过fMRI研究正常人自然排尿过程。结果：排尿前期的激活区包括前额叶、岛盖、皮质补充运动区和小脑；排尿期激活区包括前额叶、岛盖、中央后回、扣带回、皮质补充运动区、下丘脑、中脑导水管周围灰质、桥脑和小脑。皮质补充运动区在排尿前期的激活远远强烈于排尿期，小脑在排尿前期和排尿期的激活部位不相同。结论：生理排尿过程的前额叶、岛盖、皮质补充运动区的激活贯穿着整个排尿过程，因此这些结构可能与排尿活动的不同决策的最初级意识反应有关。扣带回、海马和眶回等皮质结构只在排尿期激活，这些皮质结构可能只参与排尿环境的监控和膀胱行为的维持。下丘脑、中脑导水管周围灰质和桥脑等结构只在排尿活动中激活，表明排尿决策的执行，需要不同亚皮质结构的参与。第三部分脊柱裂并先天性尿失禁患者的控尿体系的fMRI研究目的：首次研究先天性尿失禁患者的高位控尿体系，了解靶器官先天性无法有效支配后，高位中枢功能发育情况。方法：以脊柱裂并发先天性尿失禁患者为研究对象，通过fMRI研究其模拟排尿过程的大脑管理结构。结果：患者排尿期的大脑激活区显著减少，只有前额叶皮质、中央后回、海马和小脑激活，小脑的激活部位不同于正常人。结论：脊柱裂并发先天性尿失禁患者由于长期失去对靶器官的有效支配，大部分排尿中枢功能失活。但是前额叶、海马、中央后回和小脑仍可有激活，提示着患者尽管无法有效控制膀胱，但是在部分膀胱感觉的支配下，在患者的成熟的认知体系中，仍可发展为不成熟的尿意反应体系。第四部分人工反射弧修复脊柱裂并先天性尿失禁患者膀胱功能后的高位控尿中枢功能重组的fMRI研究目标：研究人工反射弧修复脊柱裂并发先天性尿失禁患者膀胱功能后高位控尿中枢功能重组的机制。方法：通过fMRI研究脊柱裂并发先天性尿失禁患者在人工反射弧修复膀胱功能前后高位控尿中枢功能图谱，并与正常人的结果比较。结果：脊柱裂并发先天性尿失禁患者在膀胱功能修复后，自然排尿过程的大脑激活可分为桥脑和桥脑上结构，桥脑的激活强烈，位置不同于正常人；桥脑上结构的激活区包括前额叶、中央后回、扣带回、海马、岛盖、皮质补充运动区、中央前回、丘脑和楔叶。其中前额叶、中央后回、扣带回、海马、岛盖、皮质补充运动区在正常组也有激活。与正常组相比，术后组未见眶回和下丘脑激活，但是可见丘脑、中央前回和楔叶激活。小脑的激活区和正常人以及术前组都不同。结论：人工反射弧修复脊柱裂并发先天性尿失禁患者膀胱功能后，患者发生脑功能重组，可出现新的桥脑控尿中枢。而桥脑上结构作为尿意决策体系也可获得随意决策功能。更多还原

【Abstract】 Part oneTwo different pathway of brain control of void and void suppressionin human: an fMRI studyObjective: To observe two different pathways in brain structures control of void andvoid suppression in human.Methods: The different pathway was elucidated through comparing brain activation invoid and void suppression with fMRI.Results: The frontal cortex was activated in void and void suppression with similarintensity and coordinate. While the cingulate、insular、supplement motion cortex and postalcentral gyms were activated in void and void suppression with distinct intensity andcoordinate. The cerebellum had different part activated in void and void suppression. Thehypothalamus and L-region of pontine were only activated in void and the putamen wasonly activated in void suppression. The M region of pontine and PAG were not activatedperhaps because the intubation interrupted the synergetic contraction of bladder.Conclusions: The frontal cortex was the conjunct center of decision void or voidsuppression, and might be the most highest level center to deal with all kinds of bladderactions. The cingulate、insular、supplement motion cortex and postal central gyrus assistedin void decisions making, but different decisions making may required different parts of these cortexes. Different sub-cortex structures participated in either void or voidsuppression. The study suggested that there were tow different pathways in the braincontrol of void and void suppression. Part twoAn fMRI study of natural void procedure in humanObjective: We observed brain activation in natural void procedure fristly, whichoffered more precise and real functional brain mapping of void regulation than that insimulative bladder action. The result would benefit the understanding of urinaryincontinence result from brain diseaseMethods: The brain activation in natural void procedure was studed with fMRI.Results: The frontal cortex、postal central gyrus、supplemental motion area andcerebellum were activated in pre-void period. And cingulate、insular、supplemental motioncortex、postal central gyrus、hypothalamus、PAG、pontine and cerebellum were activatedin void period. The coordinates of active frontal cortex were similar in pre-void and voidperiod, and the coordinates of active cerebellum are different in pre-void and void period.Conclusions: The frontal cortex、postal central gyrus、supplemental motion areaallowed void and maintained void. The hypothalamus、supplement motion area、PAG、pontine and some parts of cerebellum only took part in void regulation. Some parts ofcerebellum only took responsibility for allow void in pre-void period. Part threeThe void center in spinal bifida patient with congenitalurinal incontinence: an fMRI studyObjective: To observe the function of micturition center in spina bifida patient withcongenital urinary incontinence.Methods: The fMRI was applied in this study to compare the brain activation innatural void in the normals with that in simulative natural void in the patients.Results: The frontal cortex、postal central gyrus、hippocamp and cerebllum wereactivated in simulative natural void procedure in the patient group, and besides the similaractive region of the cortexes found in patients, the active supplemental motion area、opercula and some sub-cortex structures were founded in natural void in the contrast group.Conclusions: In the spina bifida patients with congenital urinary incontinence, most of themicturition center were not activated in simulative natural void. The only active cortex offorntal cortex, postal central gyrus、hippocamp and cerebellum suggested that the voiddecisison making is unmatured. Part fourBrain functional reorganization after restoring the bladder in thespina bifida patient with artificial nerve arcObjective: To elucidate the brain functional reorganization after restoring bladderfunction with artificial nerve arc in the spina bifida patient with congential urinaryincontinence.Methods: The brain functional reorganization mechanism was elucidate wthcomparing the brain activation in void procedure pre- and post-operatively with fMRIResults: No active pontine was found in pre-operative group, strongly active pontinewas found post-operation group with coordinate different from that in the normals. Theactive suprapontine structures in pre-operative group only contained frontal cortex。postalcentral gyrus、hippocamp and cerebellum. The major active suprapontine structures inpost-operative group were similar as that in the normals.Conclusions: An new brain stem viod center formed in the post-operational patient,and Suprapontine strctures developed mature functional to serve as voluntary void control.No active sub-cortex except cerebellum were found in pre-operative group patient and littleactive cortexes were found, which meant a founctionally unmatured void decision makingsystem in the pre-operative group.更多还原