原发性高血压与延髓腹外侧血管压迫的相关性研究进展

回顾分析近些年来国内外有关原发性高血压病的发病机制、临床研究、影像学、以及治疗等研究进展。探讨原发性高血压的神经生理调节及延髓腹外侧（VLM）显微血管减压术（MVD）对高血压的治疗效果,延髓腹外侧微血管减压手术对原发性高血压的降压作用,并对MVD治疗原发性高血压的适应证、有效性和安全性进行更深入的探索。     

MRTA对原发性高血压"颅内血管压迫"病因诊断的探讨

目的探讨磁共振影像学原发性高血压“颅内血管压迫”病因诊断的可能性和特征。方法采用稳定快速进动程序(FFE序列)磁共振断层成像血管显像术(MRTA)。分别对10例原发性高血压患者和10例正常人进行检查。结果受检者MRTA影像均显现延髓及双侧Ⅸ、Ⅹ颅神经人脑干段和椎动脉,10例原发性高血压患者组中发现9例左侧延髓腹外侧及Ⅸ、Ⅹ颅神经人脑干段有血管压迫,而10例正常组中只发现1例有颅内血管压迫。结论认为MRTA可作为原发性高血压“颅内血管压迫”病因诊断的一种检查方法。     

SHR大鼠延髓腹外侧头端区血管紧张素Ⅱ的作用研究

探讨ＳＨＲ及ＷＫＹ大鼠延髓腹外侧头端区（ｒｏｓｔｒａｌｖｅｎｔｒｏｌａｔｅｒａｌｍ ｅｄｕｌｌａ, ＲＶＬＭ）内微量注射血管紧张素Ⅱ（Ａｎｇ Ⅱ）和血管紧张素Ⅱ受体阻滞剂［Ｓａｒ１,Ｔｈｒ８］Ａｎｇ Ⅱ对心血管活动的影响。在ＳＨＲ及ＷＫＹ 大鼠,ＲＶＬＭ 微量注射人工脑脊液,不引起明显的心血管效应。ＲＶＬＭ 内微量注射递增剂量的Ａｎｇ Ⅱ（ｐｍ ｏｌ：０１,１０,１０,１００）,引起血压升高,心率增加。两组实验动物血压、心率的变化无统计学差别。Ａｎｇ Ⅱ的效应可被预先注射［Ｓａｒ１,Ｔｈｒ８］Ａｎｇ Ⅱ所阻断。相反,ＲＶＬＭ 微量注射剂量递增的［Ｓａｒ１,Ｔｈｒ８］Ａｎｇ Ⅱ（ｐｍ ｏｌ：０１,１０,１０,１００）,引起血压下降,心率减慢。在ＳＨＲ大鼠,血压下降的幅度明显大于ＷＫＹ大鼠,而心率的变化在两组动物中无显著差别。实验结果提示大鼠ＲＶＬＭ 内Ａｎｇ Ⅱ具有升高血压和增加心率的作用。Ａｎｇ Ⅱ的作用与Ａｎｇ Ⅱ受体介导有关。ＳＨＲ大鼠ＲＶＬＭ 内神经元对内源性Ａｎｇ Ⅱ的敏感性增高。ＳＨＲ大鼠高血压的形成与ＲＶＬＭ 内Ａｎｇ Ⅱ的升压作用增强有关。     

血管紧张素Ⅱ1型（AT1）受体在Wistar和自发性高血压大鼠延髓头端腹外侧区的表达特点

免疫荧光双标记结合共聚焦显微镜观察到 :Wistar和自发性高血压大鼠 (SHR)的延髓头端腹外侧区(RVLM )大多数谷氨酸能神经元 (分别为 62 %～ 91%和 73 %～ 92 % )、GABA能神经元 (分别为 5 6%～ 78%和 5 3 %～ 84 % )以及酪氨酸羟化酶免疫阳性 (TH IR)神经元 (分别为 74 %～ 93 %和 67%～ 91% )均与AT1受体共存。结果说明 ,两种动物RVLM区有AT1受体表达的神经元大致相似 ;且血管紧张素Ⅱ (angiotensinⅡ ,ANGⅡ )不仅可激活兴奋性神经元 ,还可激活抑制性神经元。为了了解AT1受体在两种动物上分布差异 ,我们用免疫组化结合图像分析的方法观察到 :SHR的RVLM区细胞表面AT1受体的平均光密度 (MOD ,0 .35 1± 0 .0 30 )显著大于 (P <0 .0 5 ,n =5 )Wistar的MOD(0 .2 0 6± 0 .0 31)。免疫电镜结果证实 ,两种动物RVLM区AT1受体分布于内质网 (RER)、细胞膜及神经突起。我们推测 ,SHR对ANGⅡ急性刺激敏感性的提高可能与其细胞膜上AT1受体的高表达有关     

Hypertension and neurovascular compression of the left lateral medulla oblongata in ischemic stroke

Hypertension is a major risk factor for stroke. Neurovascular compression (NC) of the left ventrolateral medulla oblongata may cause arterial hypertension. We evaluated the relationship between the two ischemic stroke patients. We classified 69 patients under 50 years old (49 men and 20 women, aged 43.6 +/- 7.3 years) based on magnetic resonance imaging findings as follows: NC patients (n = 38; 10 with NC on the right side, 18 with NC on the left side, and 10 with NC on both sides) and non-NC patients (n = 31). We compared the following clinical characteristics between the two groups: (1) risk factors for stroke, including hypertension, diabetes mellitus, hypercholesterolemia, and smoking and (2) stroke subtype. Hypertension was more frequent in the NC group than in the non-NC group (58 vs. 19%, p = 0.001). Hypertension was more frequent in patients with left-side NC than in those with right-side NC (78 vs. 20%, p = 0.005). No other differences were observed between the two groups. Twelve patients presented with atherothrombotic stroke, 16 with cardioembolic stroke, 24 with lacunar stroke and 17 with stroke of miscellaneous etiology. NC was significantly more common in patients with lacunar stroke as compared with those affected by other stroke subtypes (p = 0.015). We found a significant relationship between hypertension and NC of the ventrolateral medulla oblongata on the left side in ischemic stroke patients younger than 50 years of age. Some patients with lacunar stroke may have hyptertension related to NC.     

Arterial hypertension in patients with left primary hemifacial spasm is associated with neurovascular compression of the left rostral ventrolateral medulla

The aim of the study was to clarify the relationship between neurovascular compression of the rostral ventrolateral medulla and arterial hypertension in patients with primary hemifacial spasm. We enrolled 82 patients with primary hemifacial spasm and 82 age- and sex-matched magnetic resonance imaging (MRI) controls of the posterior cranial fossa. Neurovascular compression of the rostral ventrolateral medulla was assessed by MRI, and its association with arterial hypertension was investigated. No significant differences were found in prevalence of arterial hypertension between patients with primary hemifacial spasm and control subjects (39.0 vs. 29.3%, p=0.19). Thirty-two percent of the patients with left primary hemifacial spasm (n=44) and 47% of the patients with right primary hemifacial spasm (n=38) were hypertensive. Neurovascular compression of the left rostral ventrolateral medulla was observed in 86% of those with left (ipsilateral) primary hemifacial spasm with arterial hypertension (n=14) and 33% of those with left (ipsilateral) primary hemifacial spasm without (n=30). The association between neurovascular compression of the left rostral ventrolateral medulla and arterial hypertension was significant in patients with left (ipsilateral) primary hemifacial spasm (p=0.0012), but not in patients with right (contralateral) primary hemifacial spasm (p=0.18). Neurovascular compression of the left rostral ventrolateral medulla was more frequently observed in hypertensive patients with left primary hemifacial spasm, and neurovascular compression of the left rostral ventrolateral medulla correlated with arterial hypertension in these patients. These results are of potential clinical importance for the treatment of primary hemifacial spasm with arterial hypertension.     

Essential hypertension as a result of neurochemical changes at the rostral ventrolateral medulla

Acute ischemia of the brainstem has been known to produce hypertension. After an initial review of central nervous system mechanisms contributing to systemic hypertension and the impact of the rostral ventrolateral medulla (RVLM) on arterial pressure, the authors propose that essential hypertension involves neurochemical changes at the level of the RVLM which are triggered by cerebral ischemia. Experimental and clinical data are presented to show that there is a link between ischemia of the brainstem and chronic hypertension. Atherosclerosis of the cerebral circulation leads to ischemia of the RVLM and other regions with autonomic function. This ischemic process results in increased availability of angiotensin II in the RVLM, which maintains the chronic hypertensive state via either direct stimulation of the RVLM or exacerbation of brainstem ischemia due to increased vasoconstriction.     

神经原性高血压的病因及外科治疗实验研究

将２４只狗随机分为四组，左侧实验组、左侧减压组、右侧实验组、正常对照组，每组６只。分别在手术显微镜下游离出狗的耳后动静脉肌膜瓣，使其动脉形成襻状，植入到延髓外侧，造成延髓受压，而正常对照组的动脉瓣植于小脑表面。结果动物模型（左侧实验组和左侧减压组）均形成高血压，当左侧减压组解除血管压迫后血压降至正常；对照组（右侧实验组和正常对照组）无血压变化。实验结果提示原发性高血压可能与延髓左侧受血管压迫有关。解除血管压迫可使高血压缓解。     

A case report of quadriparesis due to compression of the medulla oblongata by the elongated left vertebral artery

A patient, 30-year-old man, was admitted to Shinshu University Hospital with gait disturbance and numbness of both arms and legs in June 1985. General physical findings were normal except for facial asymmetry, i.e. mild right facial hemiatrophy. Blood pressure was normal and there were no signs of arteriosclerosis. Neurological examination revealed marked bilateral pyramidal tract signs, muscular weakness of all extremities predominant of the right side, spastic gait and sensory disturbance with impairment of pin prick and light touch sensation in the second and third trigeminal nerve regions and extremities of the left side, and mild loss of vibratory sense and numbness in all extremities. X-ray examination of the cervical spine and the myelogram of the spinal canal were normal. CT scan of the brain performed 3 hours after the myelography showed that the left vertebral artery extended from the left side of the medulla oblongata to the midline and distorted it by compression. MRI confirmed the findings of the CT scan. Vertebral angiography disclosed that the elongated left vertebral artery crossed the ventral aspect of the medulla oblongata. Compression of the medulla oblongata by the vertebral artery was diagnosed and neurovascular decompression was performed. About one month after the operation his spastic gait and muscular weakness were slightly improved, but these symptoms progressed thereafter. One year after operation his spastic gait was more marked than preoperatively. In many cases with dolichoectatic intracranial arteries, hypertension and arteriosclerosis have been reported to be usually associated with this condition. In other opinions dolichoectasia has been suggested to be a congenital disease, because such vessels are occasionally present in children.(ABSTRACT TRUNCATED AT 250 WORDS)     

A study of the perineurium in peripheral nerve pathology

Summary The response of the perineurium to the following experimental systems was investigated by light and electron microscopy: nerve crush, cold lesion and microinjection of (a) histamine liberator, (b) potassium cyanide, (c) lysophosphatidyl choline (LPC). Where myelin breakdown occurred, lipid globules were seen within Schwann cells, macrophages and also perineurial cells. Where increased vascular permeability occurred, proteinaceous material leaked from endoneurial vessels into the endoneurial space and later appeared between perineurial laminae. It is suggested that the normal homeostatic function of the perineurium is extended in pathology to the removal of protein and lipid debris. In this way the perineurium contributes to the restoration of the normal microenvironment of peripheral nerve fibres.A synopsis of this paper was presented at the VIIth International Congress of Neuropathology, Budapest.     

One year efficacy and tolerability of clonidine administered by the transdermal route in patients with mild to moderate essential hypertension — a multicentre open label study

The clonidine patch offers for the first time the unique possibility of a once-a-week transdermal therapy of hypertension due to direct absorption of clonidine through the skin. The present study investigates the efficacy and safety of the transdermal administration on a sample of the Italian population. 101 patients entered the study, 51 male, 50 female (mean age: 53 years, SD ± 10; range: 30–71 years), they were given clonidine by a therapeutical transdermal system as starting dosage. If blood pressure was not adequately controlled (DBP < 90 or 10 mmHg decreased from baseline value) the dosage was increased on a 2 week basis assessment. The patients were then followed for 12 months after the start of treatment. The decrease in both systolic and diastolic blood pressure continued up to one month after start of treatment and remained constant for at least 9 months. A total of 70% of the patients were controlled by the antihypertensive treatment as monotherapy, while in 6% additional combination with a diuretic lead to blood pressure control. 5% of the patients showed no reduction in blood pressure at the end of the titration phase. 24 (23%) patients complained of skin reaction; 21 patients of these (ten male, eleven female) were withdrawn from the trial due to predefined skin reaction criteria. No serious side effects have been observed during the run of the study. No rebound phenomena occurred in the week after treatment discontinuation. It is concluded that the transdermal treatment of hypertcnsion with a clonidine containing transdermal system is therapeutically effective and probably associated with a high acceptability and increased compliance.The investigators and institutions participating in the APIS (Antihypertensive Patch Italian Study) are listed in the appendix.     

原发性高血压患者左室舒张功能与血清瘦素浓度的关系

目的 探讨原发性高血压(EH)患者左室舒张功能与血清瘦素(Leptin)浓度关系的临床研究。方法 采用放免法测定30例正常人和54例EH患者的血清瘦素浓度。用多普勒组织成像(DTI)技术检测正常人及EH患者二尖瓣环舒张早期运动速度(Ea)、舒张晚期运动速度(Aa)及Ea/Aa,比较其测定值与血清瘦素浓度的相关性。结果 患者组二尖瓣环DTI参数明显低于正常对照组(P<0.01);患者组血清瘦素浓度与Ea、Ea/Aa呈负相关(r=-0.41 P<0.01,r=-0.43 P<0.01)。结论 检测血清瘦素浓度有利于EH患者左室舒张功能受损程度的判断。     

Effects of angiotensin blockade in the rostral ventrolateral medulla on maintenance of hypertension induced by chronic L-NAME treatment

The major aim of the present study was to evaluate the role of the angiotensin II receptors located within the rostral ventrolateral medulla (RVLM) in the maintenance of high blood pressure following chronic nitric oxide inhibition. Rats were treated orally with L-NAME (70 mg/kg/day) for 1 week. We inhibited the RVLM neurons using drugs such as Sarthran, Losartan and glycine in urethane-anesthetized rats (1.2 to 1.4 g/kg, i.v.). (1) Bilateral microinjection of Sarthran into the RVLM decreased BP in the hypertensive and normotensive groups, but the depressor effect of the drug was lower in hypertensive than in normotensive rats. (2) The decrease in BP in response to Sarthran in the RVLM compared with glycine was significantly smaller in the hypertensive group, but not in the normotensive group. (3) No change in MAP was observed in response to bilateral microinjection of the Ang AT(1) receptor antagonist Losartan into the RVLM in either group. These results suggest that (1) the endogenous angiotensin receptors of the RVLM are involved in the maintenance of high BP in L-NAME-treated animals and (2) the tonic action of Ang II is not dependent on AT(1) receptors within the RVLM. The possibility of an action via other Ang II receptors remains to be investigated.     

不同责任血管所致面肌痉挛与原发性高血压的相关性分析

目的 分析不同责任血管所致面肌痉挛（HFS）与原发性高血压（HTN）的相关性.方法 回顾性纳入武警后勤学院附属医院脑科中心2014年11月至2016年4月采用显微血管减压术（MVD）治疗的267例HFS患者,其中88例合并HTN（合并HTN组）,179例不合并HTN（不合并HTN组）.按照责任血管类型将HFS患者分4组,分别为小脑前下动脉（AICA）组（114例）、小脑后下动脉（PICA）组（85例）、椎-基底动脉（VA）组（49例）和复合动脉（MA）组（19例）.其中88例合并HTN的HFS患者按照责任血管类型也分4组,分别为HTN-AICA组（32例）、HTN-PICA组（24例）、HTN-VA组（22例）和HTN-MA组（10例）.比较合并HTN和不合并HTN组间的临床资料,分析HFS患者发生HTN的影响因素及不同责任血管类型的HFS患者与HTN发生的相关性.结果 合并HTN组和不合并HTN组患者的性别、HFS的侧别、病程、MVD有效率和复发率的差异均无统计学意义（均P〉0.05）,合并HTN组的年龄和发病年龄均大于不合并HTN组（均P〈0.001）.多因素分析显示,HFS的发病年龄是HTN发生的影响因素（P〈0.001）,且HFS发病年龄每增加1年,HTN的发病风险增加1.098倍.MA、VA组HFS患者HTN的发生率高于AICA、PICA组（分别为52.6％、44.9％、28.1％和28.2％,P=0.035）,VA组患者左侧的HTN发生率高于右侧（分别为54.3％、21.4％,P=0.033）.合并HTN的4组患者,年龄、性别、HFS发病年龄和病程、HTN的发病年龄和病程之间的差异均无统计学意义（均P〉0.05）.结论 HFS的发病年龄是HTN发生的影响因素,责任血管为VA和MA的HFS患者合并HTN的比例更高,且责任血管为左侧VA的患者更易并发HTN.