【作者】 李扬；

【导师】 熊利泽；

【作者基本信息】 第四军医大学 ， 麻醉学， 2004， 硕士

【摘要】 脑缺血性疾病常可导致不同程度的神经功能障碍，严重影响患者生活质量，甚至危及生命，给患者及其家庭带来了痛苦，增加了社会负担。近年来，随着对脑缺血性损伤病理生理机制的深入研究，发现了许多新的脑保护措施及药物，然而在实际的临床治疗中并未取得良好的疗效。参附注射液作为一种中药复方制剂，在脑缺血性损伤中的保护作用已被动物实验证实，但对其脑保护作用机制及临床治疗效果报道较少。本文旨在以局灶性脑缺血模型及颅脑手术病人为研究对象，探讨参附注射液脑保护作用及其部分机制。 实验一：目的 研究参附注射液对大鼠短暂性局灶性脑缺血再灌注损伤HSP70和HSP90表达的影响。方法 30只雄性SD大鼠，随机分为三组（每组n=10）：假手术组（Sham组）；单纯缺血再灌注组（MCAO组）；保护组（SF组），分别在缺血前30min经腹腔注射生理盐水或参附注射液10ml·kg^-1。采用颈内动脉尼龙线线栓法致右侧大脑中动脉栓塞（120min）模型，观察再灌注后24h时脑组织HSP70和HSP90的表达及病理学改变。结果 再灌注24h后SF组组织病理学损害轻于MCAO组。免疫组化结果显示假手术组HSP70及HSP90均未见表达；MCAO组可见到较多的HSP70第四军医夕气学硕士学位论文免疫阳性细胞（0 .73士0.68），与假手术组有明显差别（P<0.05）;sF组HsP70免疫阳性细胞（2 .02士0.86）分布较McAO组广泛，数量明显增多，胞浆及胞核都可见HSP7O的表达，与MCAO组有明显差别（p<0.05），而SF组HSpgo（0.13士0.15）的表达与MCAO组（0 .14士0.12）比较无明显变化（P>0.05）。结论参附注射液可增加脑缺血再灌注损伤后HSP7O的表达，但对HSPgO的表达无明显影响。 实验二:目的观察参附注射液对颅脑手术病人血清SOD活性和MDA含量的影响。方法40例ASAI一H级幕上肿瘤行择期开颅手术的病人，随机分为两组:I组（n二20），生理盐水对照组;11组（n=20）SF组。11组于切开硬脑膜后，用0.9%生理盐水将50ml参附注射液稀释至200ml，输注时间为20min;I组于同一时间点输入0.9%生理盐水200ml作为对照。分别于输注前（BI）、输注后即刻（Al）及输注后60min（AI60）三个时间点，采集颈内静脉球部血样，检测血清中超氧化物歧化酶（S OD）和丙二醛（MDA）的活性和含量，并记录对应时间点的心率（HR）、平均动脉压（MAP）。结果对照组（I组）MDA含量于输注后60min（AI60）明显升高，与输注前（BI）比较有显著性差异（P<0.05），与输注后即刻（Al）比较则无明显变化（P>.05），输注前（BI）及输注后即刻（Al）的MDA含量无明显变化（p>0.05）;sF组（11组）MDA含量在输注前（BI）、输注后即刻（Al）及输注后60min（AI60）三个时间点无明显变化（P>0.05）。对照组（I组）S oD活性在输注前（Bl）、输注后即刻（Al）及输注后6omin（Ax6o）三个时间点均无明显变化护>0.05);sF组（11组）soD活性于输注后6Omin（AI60）明显升高，与输注前（BI）比较有显著性差异（P<0.仍），与输注后即刻(AD比较则无明显变化（P>.05），输注前(BD及输注后即刻（Al）的s0D活性无明显差异（P>0.05）。组间比较:输注后6Omin时的MDA含量对照组明显高于SF组（P<0.05），sOD活性SF组明显高于对照组（P<0.05）。结论在颅第四军医大学不页士学位论文脑手术围术期应用SF可提高脑内SOD活性，降低MDA含量，具有清除氧自由基、抗氧化损伤的作用。 实验三:目的观察参附注射液对颅脑手术病人康复效果的影响。方法200例ASAI一H级颅内肿瘤行择期开颅手术的病人，随机分为两组:I组（n二100），生理盐水对照组;11组（n二100），SF组。麻醉稳定后，11组即用0.9%生理盐水将50ml参附注射液稀释至200ml，输注时间为20min;I组于同一时间点输入0.9%生理盐水200ml作为对照。分别记录术毕清醒时间、拔管时间、住神经外科监护室（NICU）天数、住院天数，并采用Karnofsky评分量表分别在术前及出院时对病人的生存质量作出评估。结果两组病人的苏醒时间、拔管时间及住NICU天数无明显差别（P>0 .05），而SF组的住院天数（25士7.65）较对照组（27士7.37）减少（P<0.05），两组病人出院时的评分均较术前明显降低（P<0.05），但两组间无明显差异（P>.05）。结论在颅脑手术围术期给予参附注射液能够缩短平均住院日，但对出院时病人的生存质量无明显改盖 实验四:目的观察参附注射液对颅脑手术病人脑氧供需平衡的影响。方法30例ASAI一H级幕上肿瘤行择期开颅手术的病人，随机分为两组;I组（n=15），生理盐水对照组;H组（n=15），SF组。术中切开硬脑膜后，11组即用0.9%生理盐水将50ml参附注射液稀释至200ml于20min内静脉输入;I组在同一时间给予0.9%生理盐水200ml。分别于输注前（BI）、输注完即刻（AI）及输注后30min（AI30）三个时间点，同步采集颈静脉球和足背动脉血行血气分析，并计算动脉、颈静脉球血氧含量（CaOZ、CjvOZ）、动-颈内静脉血氧含量差（Ca一vOZ）及脑氧摄取率（C ERoZ）;结果输注sF前后两组间HR和MAP无明显变化（p>0.05）;SjvOZ，PjvOZ，caoZ，ca-jvo:及cERo:等指标在SF输注前、后均无明显变化，两组间亦无显著性差异（P>0.05）。结论在神经外科手术围术期第四军医大学不页d匕学t立论文给予参附注射液对脑的氧供需平更多还原

【Abstract】 Background Ischemic cerebrovascular disease often leads to neurologic deficits which seriously influence the quality of life and even threaten the survival of patients. Recently, a number of measures and drugs have been proved to protect neurons from ischemia-reperfusion damage. However, there is no effective therapeutic drug in clinic practice. Shenfu injection, a traditional Chinese medicine, was proved to have protective effects on cerebral ischemia-reperfusion injury in rats. But its mechanism and therapeutic efficacy in clinical patients are still unclear. The present study was designed to disclose the mechanism of neuroprotection induced by Shenfu injection and evaluate the therapeutic efficacy in clinical patients.Experiment 1. Objective: To investigate the effects of Shenfu injection (SF) on the expression of HSP70 and HSP90 after cerebral ischemia-reperfusion in rats. Methods: Thirty male Sprague-Dawley (SD) rats weighing 280~320g were randomized into three groups (n=10 in each group): sham-operated group; MCAO group and SF group . The rats in SF group received intraperitoneal injection of SF 10ml kg-1 at 30 min before 120min MCAO. Thepathological outcome and the expression of HSP70 and HSP90 were evaluated at 24h post reperfusion. Results: The pathological outcome of SF group was better than that of MCAO group. The expression of HSP70, HSP90 was negative in sham-operated group. The expression of HSP70 in SF group was significantly stronger than that of MCAO group at 24h after reperfusion, but the expression of HSP90 in SF group presented no difference to that in MCAO group. Conclusion: Transient focal cerebral ischemia induced the expression of HSP70. Administration of SF before cerebral ischemia could increase the expression of HSP70, but HSP90 protein levels remained constant.Experiment 2. Objective: To investigate the effect of Shenfu injection (SF) on the superoxide dismutase activities (SOD) and malondialdehyde (MDA) levels in patient undergoing craniotomy. Methods: Fourty ASA grade I -II patients undergoing elective craniotomy for supratentorial cerebral tumor removal were included in a randomized study consisting of 2 groups: Patients in group II (SF group, n=20) received SF 50ml diluted with 0.9% NaCl 150ml within 20 minutes after opening the dura. Blood samples were taken from internal jugular venous bulb for measuring SOD activities and MDA levels before infusion (BI), after infusion (AI) and 60 min after infusion (AI60), respectively, and Heart rate (HR), Mean arterial pressure (MAP) were recorded. While patients in group I (control, n=20) received 0.9% NaCl 200 ml at the same time. Results: Compared with BI, MDA levels were significant increased at AI60 (P<0.05), but no significant difference was found between BI and AI in group I (P>0.05). In group II , there was no significant difference in MDA levels among BI, AI and AI60 (P>0.05).Compared with BI, SOD activities significantly increased at AI60 (P<0.05), but no significant difference was found between BI and AI in group II(P>0.05). No significant difference was found among BI, AI, and AI60 in group I (P>0.05). Sixty minutes after infusion, MDA levels in group II were significantly lower (P<0.05), and SOD activities in group II were significantly higher (P<0.05) than that in group I , respectively. Conclusion: Infusion of SF attenuates the formation of free radicals in patients undergoing craniotomy .Experiment 3. Objective: To investigate the effect of Shenfu injection (SF) on the recovery in patient undergoing craniotomy. Methods: Two hundred ASA grade I - II patients undergoing elective craniotomy for cerebral tumor removal were included in a randomized study consisting of 2 groups: Patients in group II (SF group, n=100) received SF 50ml diluted with 0.9% NaCl 150ml within 20 minutes after anesthesia .While group I as control group (control, n=100) received 0.9% NaCl 200 ml at the same time. Awakening time from anesthesia (Awak), time of extubation (Extu), length of stay in neurosurgical intensive care unit (NICU), le更多还原