急性脑缺血后再灌流损伤及脑梗塞治疗的新方向

急性脑缺血后再灌流损伤及脑梗塞治疗的新方向广东省佛山市第二人民医院（５２８０００）梁永耀随着对急性脑缺血／再灌流损伤的研究和自由基病理学方面的进展，使脑梗塞传统的病理生理及治疗方法受到挑战。不少学者通过多项研究证实了在脑急性缺血超过一定时间后恢复血液...     

脑缺血再灌注损伤的治疗研究

<正> 脑血管疾病因其发病率高、复发率高、死亡率高和致残率高而严重危害人类健康,其中缺血性脑病占有很大比例。恢复缺血组织的血液灌注是救治脑缺血的前提,于是溶栓法成为目前治疗急性缺血性脑血管疾病的主要方法。但治疗结果导致的再灌注损伤,即缺血组织恢复血流后反造成组织损伤进行性加重,又成为棘手的问题。目前国内外在这方面尚无治疗的特效药和(或)特效方法。本文就其发生机理,对近年来脑缺血再灌注损伤的防治措施作     

细胞因子与脑缺血再灌注损伤

<正>脑缺血再灌注时,缺血区有大量白细胞浸润。既往认为:缺血区白细胞的聚集浸润是继发于组织坏死的迟发的炎性反应,作用是清除梗死区坏死组织碎屑和参与疤痕形成;近年研究发现:白细胞不但在脑梗死的组织修复阶段起作用,而且脑缺血的早期即出现,在缺血再灌注损伤中发挥重要作用,使缺血向不可逆的梗死方向发展。白细胞到达缺血区是多步骤过程:附壁、与内皮细胞粘附、浸润到脑实质,每一步骤都受到细胞因子的调节。细胞因子是低分子量蛋白质,可由多种细胞产     

脑缺血再灌注损伤治疗的实验研究进展

在脑缺血再灌注损伤过程中,脑组织的缺血缺氧导致氧化应激反应,产生的氧自由基可通过某些途径如脂质过氧化、蛋白质变性造成细胞坏死;线粒体、内质网途径、死亡受体途径的激活及直接的DNA损伤等导致细胞凋亡;炎症瀑布级联反应以及细胞信号调节等途径造成细胞死亡。目前实验研究发现,通过抗氧化剂、细胞凋亡抑制剂、抗炎、干扰细胞信号调节的药物以及中医药针灸等,可以缓解脑缺血再灌注损伤。本文综述了脑缺血再灌注损伤相关的实验研究,为临床脑缺血患者的治疗提供实验依据。     

地塞米松、甘露醇对大鼠全脑缺血再灌注损伤的治疗作用

目的 :观察地塞米松、甘露醇对缺血再灌注损伤脑组织的作用。方法 :Wistar大鼠 4 2只 ,随机分为 6组 ,正常对照组 (n =5 ) ;假手术组 (n =6 ) ,仅电凝双侧椎动脉 ;缺血对照组 (n =7) ,电凝双侧椎动脉 ,夹闭双侧颈总动脉 10min后恢复脑血流灌注 ;地塞米松治疗组 (n =8) ,脑缺血复灌后腹腔注射地塞米松 10mg·kg-1,每日 2次 ;甘露醇治疗组 (n =8) ,脑缺血复灌后尾静脉注射 2 0 % (体积分数 )甘露醇 10ml·kg-1,每日 3次 ;地塞米松复合甘露醇治疗组 (n =8)脑缺血复灌后腹腔注射地塞米松 10mg·kg-1,每日 2次 ,同时给予 2 0 %甘露醇 10ml·kg-1,尾静脉注射 ,每日 3次。 6组均于 72h后断头取脑 ,于颞叶最宽处切取 3mm厚冠状面脑组织切片 ,行病理HE染色和TUNEL染色 ,计数海马区神经元密度和缺血细胞。其余脑组织行干—湿称重法测脑水含量。结果 :各药物处理组均能有效减轻脑水肿。与其他处理组比较 ,地塞米松处理组缺血性脑损伤表现最严重 ,而在地塞米松复合甘露醇处理组脑损伤表现最轻。结论 :地塞米松可加重脑缺血再灌注损伤 ,甘露醇具有确切的减轻再灌注脑损伤的作用 ,甘露醇复合地塞米松治疗效果最佳     

脑缺血再灌注损伤病理生理机制研究进展

随着对急性脑缺血再灌注和缺氧复氧损伤研究的进展，对脑梗塞的病理生理机制有了新的认识。大量研究已经证实了急性缺血后恢复血液灌流，会使病变加剧而发生再灌注损伤。目前从细胞内钙离子、ＮＭＤＡ受体、自由基、花生四烯酸代谢、缺血区酸碱平衡破坏、基因表达及蛋白质...     

脑缺血再灌注损伤机制与治疗现状

脑缺血再灌注损伤是一种复杂的病理生理过程,这个级联反应包括多种因素多种环节相互作用、共同参与。现就脑缺血再灌注损伤的机制和治疗做一综述。     

脑缺血-再灌注损伤机制及其药物治疗方法的研究进展

脑缺血-再灌注损伤(CIRI)是多种机制参与的复杂的病理生理过程,主要与自由基过度形成、兴奋性氨基酸毒性作用、细胞内钙超载、炎性反应和细胞凋亡多种机制有关,多种环节因素之间又互相作用,进一步促进CIRI后的神经功能破坏和脑梗死灶形成。本文作者从发病机制和药物治疗靶点两方面对最新研究进展予以综述。
［关键词］ ［中图分类号］     

Surgical treatment of brachiocephalic vessel involvement in Takayasu’s arteritis

Background Takayasu＇s arteritis （TA） is a chronic idiopathic inflammatory disease that affects large and medium size arteries. The brachiocephalic trunk is the most frequently involved site in TA, and multi-vessel lesions are common. Surgical treatment includes vessel reconstruction surgery and percutaneous transluminal angioplasty （PTA）. Herein, we report our preliminary experience with surgical treatment of cerebral ischemia caused by cervical arterial lesions due to TA.Methods From January 2000 to December 2007, 38 patients with cerebral ischemia caused by cervical arterial occlusive lesions due to TA were treated surgically. There were three males and 35 females, with an age range of 15-42 years （mean 26.5 years）. All patients had operative repairs undertaken. Twenty eight patients received bypass operation and 10 patients received percutaneous transluminal angioplasty. One case with coronary stenosis received coronary artery bypass simultaneously. Patients were followed up for 11 months to eight years.Results There were no peri-operative deaths in cerebrovascular reconstruction patients. Symptoms of cerebral ischemia were improved or cured in 25 of 38 patients. There was a low incidence of cerebral reperfusion syndrome. Two patients died at five and seven years after surgery due to heart failure. Another 8 patients （20%） required further surgery for stenosis （5 patients） or anastomotic aneurysms （3 patients）. Percutaneous transluminal angioplasty was performed successfully for treatment of aortic and renal lesions. Repeated angioplasty for revascularization was performed in six PTA cases with restenosis after 5-24 months.Conclusions When cerebral perfusion has potential to be affected by TA, a definitive corrective procedure is advised when the patient is relatively stable. Although the recurrence rate is very high, percutaneous transluminal angioplasty is the first choice procedure. Bypass operation is optimal for brachiocephalic-vessel involvement in TA. Cerebral reperfusion syndrome can be avoided by careful selection of the operation method and improved post-operative treatment.     

颈动脉大动脉炎64层螺旋CT影像表现

目的探讨64层螺旋CT诊断颈动脉大动脉炎的临床价值。方法分析并比较20例颈动脉大动脉炎患者(病例组)和10例无明显颈动脉血管病变和脑神经症状患者(对照组)的颈动脉CT血管成像(CTA)表现。结果颈动脉增强扫描结合三维重建方法可清晰显示大动脉炎患者颈动脉管腔的改变,表现为狭窄、闭塞、扩张及瘤样改变。病例组患者颈动脉的管壁厚度较对照组明显增厚[(0.36±0.13)cmvs.(0.03±0.02)cm,P<0.05],活动期组患者的颈动脉管壁厚度亦较非活动期患者明显增厚[(0.44±0.09)cmvs.(0.24±0.10)cm,P<0.05]。结论大动脉炎的重要CT征象是动脉壁增厚,CTA可同时显示管腔及管壁情况,颈动脉管壁厚度可能与疾病活动性相关。     

Management of cerebral ischemia due to Takayasu’s arteritis

Objective To explore the management of cerebral ischemia caused by Takayasu’s arteritis. Methods Ninety-three cases treated from June 1984 to September 1999 at the General Post &amp; Telecom Hospital, the Sir Run Run Shaw Hospital, the First Af filiated Hospital of Zhejiang University, the Second Medical College of Beijing University, Beijing An Zhen Hospital, and the Beijing Union Medical College Hosp ital, including 10 men and 83 women, were reviewed.Of the 93 cases, bypasses f rom the ascending aorta to the axillary or subclavian artery and from graft to t he carotid artery were performed in 47 cases.Subclavian to carotid bypass was performed in six cases.Percutaneous transluminal angioplasty (PTA) was used in five cases and stenting in one.Results Marked improvement was achieved in 30.3%, fair in 34.9%, improvement in 21.2 %, unchanged in 4.6%, and death in 9.0% before discharge; 30.6%, 38.8%, 16 .3%, 4.1%, and 2.0% respectively during a mean follow-up of 48 months, and r ecurrence requiring revision in 8.2%.Conclusion Patients with occlusive lesions of all four cervical arteries always have severe cerebral ischemia and their distal runoff is always unvisualised by angiography . However, we found by exploration that the internal carotid artery is patent in all but one patient. Therefore, an ascending aorta to carotid bypass is feasib le in most instances, and this can and should be done when the cerebral perfusio n is jeopardized at a time when the patient is in a stable or relatively stable condition. Unfortunately, the cerebral re-perfusion syndrome is still a serious and not completely solved problem.     

中国大动脉炎性肾动脉炎(TARA)诊治多学科专家共识

 大动脉炎（Takayasu's arteritis,TA）是中国、日本等东亚国家及地区青年女性好发的大血管炎症性疾病。TA累及肾动脉可引起大动脉炎性肾动脉炎（Takayasu's arteritis-induced renal arteritis,TARA）,导致大动脉炎性肾动脉狭窄（Takayasu's arteritis-induced renal artery stenosis,TARAS）,是青年人群发生恶性高血压、肾功能不全的首要原因。目前国内外均无TARA的临床诊治规范及指南,因此我们联合国内风湿免疫科、血管外科、心血管内科、泌尿系统内外科和放射诊断科等专家共同制定了中国大动脉炎性肾动脉炎诊治多学科专家共识,旨在规范疾病诊疗、促进多学科协作,为全科医师及不同学科医师提供临床实践指导。本共识的主要观点为：（1）TA是40岁以下高血压人群中的首要病因。（2）TARA高危人群为40岁以下高血压、腹部杂音、不明原因的肾萎缩患者。（3）TARA肾动脉中重度狭窄激活肾素-血管紧张素-醛固酮系统（renin-angiotensin-aldosterone system,RAAS）,继而导致恶性高血压、心脑血管疾病、缺血性肾病等严重并发症,是TA不良预后以及早期死亡原因之一。（4）影像学检查是诊断与评价TARA的主要手段,包括血管多普勒超声、磁共振血管造影（magnetic resonance angiography,MRA）、计算机断层血管造影（computed tomography angiography,CTA）等,数字减影血管造影（digital subtraction angiography,DSA）仍是诊断金标准。（5）对TARA应当全面评估疾病活动度、肾脏功能学以及其他重要靶器官,对临床病情严重性予以分层。（6）TARA治疗应以风湿免疫科为主导,对于中重度严重患者由多学科合作诊疗制定个体化治疗方案。（7）TARA内科治疗诱导病情缓解和维持持续缓解,主要以糖皮质激素与化学合成缓解病情抗风湿病药（conventional synthetic disease-modifying anti-rheumatic drugs,cDMARDs）、生物合成缓解病情抗风湿病药（biological disease-modifying anti-rheumatic drugs,bDMARDs）联合治疗。（8）TARA外科治疗强调术前抗炎治疗并获得病情充分缓解、术后继续序贯内科治疗与评估,外科手术可获得较好的长期生存。（9）TARA合并多处血管病变,高血压可按照"脑-心-肾"依次评估并制定降压目标和降压决策。（10）对于TARA患者的妊娠风险与时机,需要多学科团队（multidisciplinary team,MDT）全面评估病情活动度,充分权衡脏器功能水平。     

基于ECTA队列的大动脉炎患者心脏受累横断面调查

目的 总结华东地区大动脉炎(East China Takayasu's Arteritis,ECTA)队列大动脉炎(Takayasu's arteritis,TAK)患者的心脏受累特征.方法 纳入2009年1月至2019年12月复旦大学附属中山医院ECTA队列TAK患者,所有患者均符合1990年美国风湿病学会TAK分类...     

多发性大动脉炎颈动脉病变的超声诊断价值

目的 总结多发性大动脉炎颈动脉病变的超声表现特点,提高其诊断价值.方法 回顾性分析25例经临床诊断为多发性大动脉炎的颈动脉超声声像图表现.用彩色多普勒超声检查患者的颈总动脉、颈内动脉和颈外动脉,观察并测量颈动脉管腔内径、内膜-中膜(IMT)厚度、彩色多普勒血流显像(CDFI)和脉冲多普勒,分析颈动脉血流变化的频谱及彩色多普勒声像图指标;鉴别颈动脉狭窄与闭塞,估测狭窄程度以及评估颈动脉闭塞的范围;并与数字减影血管造影(DSA)检查结果进行比较.结果 25例患者中共有50条颈动脉受累,其中39条(78%)颈总动脉受累,4条(8%)颈外动脉受累,7条(14%)颈内动脉受累.在39条受累的颈总动脉中,37条表现为动脉壁IMT弥漫性增厚;2例局限性增厚.1例颈总动脉内膜剥脱伴夹层动脉瘤形成,IMT厚度1.8～5.7 mm,管腔都有不同程度的狭窄和闭塞.超声检查血管狭窄或闭塞的诊断符合率与DSA结果比较差异无统计学意义(χ2=0.4224,P>0.05).结论 应用彩色多普勒超声能显示颈动脉管壁的特征性变化,并可显示管腔内血流动力学异常,为临床提供重要的诊断信息.     

多发性大动脉炎颈动脉病变的超声诊断价值

目的总结多发性大动脉炎颈动脉病变的超声表现特点,提高其诊断价值。方法回顾性分析25例经临床诊断为多发性大动脉炎的颈动脉超声声像图表现。用彩色多普勒超声检查患者的颈总动脉、颈内动脉和颈外动脉,观察并测量颈动脉管腔内径、内膜—中膜（IMT）厚度、彩色多普勒血流显像（CDFI）和脉冲多普勒,分析颈动脉血流变化的频谱及彩色多普勒声像图指标;鉴别颈动脉狭窄与闭塞,估测狭窄程度以及评估颈动脉闭塞的范围;并与数字减影血管造影（DSA）检查结果进行比较。结果 25例患者中共有50条颈动脉受累,其中39条（78%）颈总动脉受累,4条（8%）颈外动脉受累,7条（14%）颈内动脉受累。在39条受累的颈总动脉中,37条表现为动脉壁IMT弥漫性增厚;2例局限性增厚。1例颈总动脉内膜剥脱伴夹层动脉瘤形成,IMT厚度1.8～5.7mm,管腔都有不同程度的狭窄和闭塞。超声检查血管狭窄或闭塞的诊断符合率与DSA结果比较差异无统计学意义（χ2=0.4224,P〉0.05）。结论应用彩色多普勒超声能显示颈动脉管壁的特征性变化,并可显示管腔内血流动力学异常,为临床提供重要的诊断信息。     

多发性大动脉炎57例临床分析

目的 分析多发性大动脉炎(TA)患者血管受累的特点,探讨该疾病累及血管全程者与仅累及血管起始端者临床表现的差异.方法 回顾性总结57例诊断明确并接受过全身CT血管成像(CTA)检查的TA患者的临床资料,按受累血管病变部位的不同,将其分为病变血管全程受累的患者组(以下简称全程组)和病变血管仅起始端受累的患者组(以下简称起始端组),比较两组间差异.结果 (1)TA患者男女比1∶10.4,临床分型以广泛型最为常见,最常累及颈总动脉及锁骨下动脉.(2)全程组与起始端组患者比例为1.28∶1;全程组从发病到确诊时间长于起始端组,临床分型中头臂动脉型少于起始端组(P＜0.05).(3)全程组患者以头痛等非特异症状起病较多;且病程中出现间歇运动障碍、体重下降和小便异常等症状的概率要高于起始端组(P＜0.05).(4)全程组中37.5%的患者C反应蛋白(CRP)升高,而起始端组高达64%(P＜0.05).结论 TA累及血管全程者并非少见,其起病更为隐匿、CRP阳性率低,应注意早期诊断.

Abstract：

Objective To analyze the characteristics of vascular involvement in Takayasu's arteritis (TA) patients and explore the differences between the involvements of whole range versus origin of vessels and those whose origin of vessecs were involved. Methods A total of 57 TA patients were divided into the origin and whole range groups according to their CTA (computed tomography angiography) examination reports. Then a retrospective analysis was performed on their clinical data. Results (1) TA had a female arteries were the most common sites of involvement. (2) The ratio of whole range and origin groups was group was 1.28∶1.The delay of whole range group from the onset to a correct diagnosis was longer than that of origin group (P ＜ 0. 05 ). The rate of aortic arch type in whole range group was less than that in origin group (P ＜0. 05 ). (3) More patients in whole range group had the initial symptom of headache than those in origin group, as well as the subsequent symptoms of claudication, weight loss and urination problems (P ＜0. 05 ).(4)37.5% of patients in whole range group and 64% in origin group had an elevated level of C-reactive protein (CRP) (P ＜ 0. 05 ). Conclusion Patients with whole range of arteries involved in TA are common. With atypical clinical manifestations and a low positive rate of CRP, a diagnostic delay is an important issue. Thus due attention should be paid to its clinical diagnosis and treatment.     

大动脉炎诊断及活动性评价中国专家调查

 目的 调查中国医师对大动脉炎(Takayasu′s arteritis, TA)临床诊断与活动性评价的现状。方法 全国19位风湿免疫专家、3位血管外科专家参与,通过问卷设计、网络打分,首次就目前TA临床诊断及活动性评估等问题进行回答,采用加权平均法计算相应问题的平均分。结果 中国专家目前主要采用1990年美国风湿病学会(American College of Rheumatology, ACR)分类标准进行TA临床诊断。其中,年龄、肢体跛行、黑矇等症状,无脉或脉搏减弱、血管杂音、双侧脉压差增大、高血压等体征,以及急性时相反应蛋白检测,有助于疾病诊断。此外,计算机断层血管造影(computed tomography angiography, CTA)、磁共振血管造影(magnetic resonance angiography, MRA)、血管彩色多普勒超声、正电子发射计算机断层显像(positron emission tomography, PET)等无创影像学检查均被认为具有重要的诊断价值。对于TA活动性评估,中国专家主要采用美国Kerr评分体系。急性时相反应蛋白以及各种无创影像学检查均具有重要的病情活动性评估价值。在影像选择方面,颈动脉受累者更推荐血管超声检查,对于肺动脉、胸/腹主动脉主干受累者则CTA略优于MRA。结论 急性时相反应蛋白以及无创影像学检查有助于中国医师对TA的临床诊断及活动性评价。     

缺血后适应对脑缺血再灌注损伤保护作用的研究进展

后适应是在缺血后再灌注早期机械地阻断血流从而减轻器官缺血/再灌注损伤的一种现象.本文对后适应对脑缺血再灌注损伤的保护作用及机制作一综述.