尼莫地平对动脉瘤性蛛网膜下腔出血脑血管痉挛的临床疗效研究

目的:观察尼莫地平对动脉瘤性蛛网膜下腔出血脑血管痉挛的临床疗效及安全性,为临床治疗提供依据。方法:对我院2010年2月~2013年2月期间收治的92例动脉瘤性蛛网膜下腔出血患者进行随机分为观察组和对照组,每组46例。两组患者入院后均进行常规治疗,绝对卧床休息、镇静、给予氨甲环酸止血、脱水降颅压、防治感染及对症治疗。观察组在上述治疗基础上给予尼莫地平(德国拜尔公司)持续微泵静脉注射20 mg·d-1,连用14 d,后改为口服尼莫地平片40 mg,qid,至第21天,根据监测血压调整剂量。观察两组患者1个月内脑血管发病情况、CT评价情况,并进行对比分析。结果:两组患者治疗后,观察组有效率91.3%;对照组有效率73.91%。两组比较差异明显,观察组疗效明显优于对照组,具有统计学意义(P0.05)。两组患者在治疗期间,观察组发生脑血管痉挛4例,占8.7%;对照组发生脑血管痉挛26例,占56.52%,两组比较差异明显,具有统计学意义(P0.05)。结论:尼莫地平能够显著降低动脉瘤性蛛网膜下腔出血脑血管痉挛的发生率,对脑血管再出血具有积极防治作用,建议推广应用。     

前列地尔联合尼莫地平对动脉瘤性蛛网膜下腔出血后脑血管痉挛患者血管内皮功能及炎症因子水平的影响

目的:探讨前列地尔联合尼莫地平对动脉瘤性蛛网膜下腔出血(aSAH)后脑血管痉挛(CVS)患者血管内皮功能及炎症因子水平的影响。方法:选取76例于2015年3月～2017年8月间在中南大学湘雅医院住院治疗的aSAH后CVS患者为研究对象,按随机数字表法将患者分为对照组(n=38)及观察组(n=38)。对照组在常规治疗基础上采用尼莫地平治疗,观察组在对照组基础上加用前列地尔治疗。比较治疗前后两组患者的大脑前、后、中动脉平均血流速度,观察并比较两组患者血浆降钙素基因相关肽(CGRP)、内皮素-1(ET-1)水平以及血清血管内皮生长因子(VEGF)、白细胞介素-8(IL-8)、超敏C反应蛋白(hs-CRP)、肿瘤坏死因子-α(TNF-α)水平的变化情况,评价两组疗效并观察治疗过程中的不良反应发生情况。结果:与对照组比较,治疗后观察组大脑前、后、中动脉血流速度均明显降低(P0.05)。与治疗前比较,治疗后两组患者CGRP水平明显升高,与对照组比较,治疗后观察组CGRP水平明显升高(P0.05),而治疗后两组患者ET-1、VEGF水平明显下降,且观察组低于对照组(P0.05)。与治疗前比较,治疗后两组患者IL-8、hs-CRP、TNF-α水平均明显下降,且与对照组比较,观察组IL-8、hs-CRP、TNF-α水平均降低(P0.05)。观察组患者治疗的总有效率为92.11%,明显高于对照组的73.68%(P0.05)。观察组总不良反应发生率与对照组比较差异无统计学意义(P0.05)。结论:前列地尔与尼莫地平联合使用治疗aSAH后CVS能明显改善患者的血管内皮功能,降低炎症因子水平,且未增加用药的不良反应,治疗效果较好。     

内皮舒张因子与氧自由基在脑血管痉挛发病中的作用

实验性兔蛛网膜下腔出血后,基底动脉壁丙二醛（ＭＤＡ）含量及超氧化物峻化酶（ＳＯＤ）、过氧化氢酶（ＣＡＴ）活性发生改变,基底动脉出现痉挛,应用ＳＯＤ后上述变化减轻。离体采用生物检定法发现,基底动脉受自由基损伤后,去甲肾上腺素（ＮＥ）诱导的血管收缩效应增强,而ＡＣｈ诱导的血管舒张效应减弱。用ＳＯＤ防止了ＡＣｈ诱导的血管舒张效应的减弱。结果表明,氧自由基参与了脑血管痉挛的发生,而脑血管受自由基损伤后,其内皮舒张因子释放减少是脑血管痉挛发病的重要因素。     

尼莫地平联合丁基苯酞对外伤性蛛网膜下腔出血患者脑微循环的影响

目的:探究尼莫地平联合丁基苯酞对外伤性蛛网膜下腔出血患者脑微循环的影响。方法:选取我院外伤性蛛网膜下腔出血患者36例,随机分为实验组和对照组,每组18例。对照组给予尼莫地平治疗,实验组给予尼莫地平联合丁基苯酞治疗。观察并比较两组患者治疗前后脑微循环的变化情况。结果:实验组总有效率(88.9%)高于对照组(61.1%),差异有统计学意义(P0.05);与治疗前相比,两组脑血容量(CBV)、脑血流量(CBF)水平均增高,平均通过时间(MTT)水平降低(P0.05);与对照组相比,实验组CBV和CBF水平较高,MTT较低(P0.05);与对照组相比,实验组格拉斯哥昏迷评分(GOS)评分较高、临床并发症发生率较低、6个月病死率较低,差异有统计学意义(P0.05)。结论:尼莫地平联合丁基苯酞可有效改善外伤性蛛网膜下腔出血患者的脑微循环,提高患者的生存率。     

辛伐他汀对大鼠蛛网膜下腔出血后脑血管痉挛的治疗效果研究

目的:观察辛伐他汀对大鼠蛛网膜下腔出血后脑血管痉挛的治疗效果并探讨其可能机制。方法:将48只健康Wistar大鼠随机分为正常对照组、模型组、辛伐他汀组,每组各16只。模型组以及辛伐他汀组给予枕大池注入自体动脉血法以建立大鼠蛛网膜下腔出血后脑血管痉挛的动物模型,辛伐他汀组于第1次注血后开始给予辛伐他汀皮下注射,其余两组给予等体积生理盐水皮下注射。比较各组大鼠情况、组织学检查结果、蛛网膜下腔出血量评分、神经功能缺损评分、血管内径、血管舒张度、血管痉挛程度、eNOS以及TNF-α蛋白表达水平。结果:实验过程中,正常对照组无大鼠死亡,模型组大鼠死亡率为33.33%,辛伐他汀死亡率为6.67%,较模型组显著降低(P0.05)。治疗后,与正常对照组相比,模型组及辛伐他汀组大鼠蛛网膜下腔出血量评分及TNF-α阳性表达率较高(P0.05),神经功能缺损评分、血管内径、D/T及eNOS阳性表达率较低(P0.05);与模型组相比,辛伐他汀组蛛网膜下腔出血量评分及TNF-α阳性表达率较低(P0.05),神经功能缺损评分、血管内径、D/T及eNOS阳性表达率较高(P0.05)。结论:辛伐他汀可有效改善蛛网膜下腔出血后脑血管痉挛,这可能与其上调eNOS蛋白表达并下调TNF-α蛋白表达有关。     

蛛网膜下腔出血对大鼠脑血流量和体感诱发电位的影响

目的：探讨蛛网膜下腔出血（ＳＡＨ）后脑血流量、体感诱发电位（ＳＥＰ）潜伏期的改变及其与一氧化氮（ＮＯ）的关系。方法：对假手术对照组和ＳＡＨ模型组大鼠检测２４ｈ局部脑血流量（ｒＣＢＦ）、ＳＥＰ潜伏期和血清及脑组织ＮＯ含量动态变化。结果：非开颅刺破Ｗｉｌｌｉｓ环的方法可成功地诱发ＳＡＨ。ＳＡＨ后ｒＣＢＦ立即降低,在２４ｈ内无恢复趋势。ＳＥＰ潜伏期于ＳＡＨ后１ｈ开始至２４ｈ明显延长。血清和脑组织ＮＯ含量     

内皮素对失血性休克鼠脑微循环的影响及尼莫地平、川芎嗪的治疗作用

利用大鼠颅骨开窗观察软脑膜微循环的方法研究了内皮素（ＥＴ－１）１０－１０－１０－７ｍｏｌ／Ｌ对软脑膜微循环的影响以及失血性休克时软脑膜对ＥＴ－１的反应性。并用１０－７ｍｏｌ／Ｌ造成失血性休克后脑血管痉挛的模型,观察尼莫地平、川芎嗪、６５４－２对内皮素引起血管痉挛的治疗作用。１０－９、１０－８和１０－７ｍｏｌ／Ｌ３种浓度ＥＴ－１可使软脑膜小动脉、细动脉强烈收缩,收缩率分别为２７．７％、４６．８％、７８．５％,其收缩强度与ＥＴ－１的浓度有关。对静脉的作用不明显。１０－１０ｍｏｌ／ＬＥＴ－１可使细动脉轻度扩张。出血性休克时,软脑膜血流明显减慢,小动脉、细动脉管径对ＥＴ－１的收缩作用更敏感,脑组织血流明显减少。尼莫地平具有较好的拮抗ＥＴ－１引起软脑膜动脉的收缩和改善局部微循环的作用。川芎嗪也能拮抗ＥＴ－１引起软脑膜动脉的收缩,但作用较尼莫地平弱。６５４－２不能缓解ＥＴ－１对软脑膜动脉的收缩作用。     

利多卡因联合尼莫地平预防颅内动脉瘤术后脑血管痉挛的临床疗效观察

目的:比较利多卡因加尼莫地平联合治疗与尼莫地平单药治疗在预防颅内动脉瘤术后脑血管痉挛(CVS)的临床疗效与患者预后评估。方法:选择2012年1月-2015年6月在我院就诊的颅内动脉瘤患者65例,通过显微外科开颅动脉瘤夹闭术后,分成对照组与治疗组。对照组接受常规尼莫地平治疗,治疗组在尼莫地平治疗基础上联合利多卡因治疗,观察比较两组患者在14天内的大脑中动脉血流速度变化,并分析两组患者发生CVS、脑梗死、临床死亡情况及患者预后差异。结果:治疗组的大脑中动脉血流速度在治疗前,治疗后第7天,治疗后第14天分别为133.81±12.35m/s、78.88±5.05m/s、77.28±4.78m/s明显低于对照组的136.02±11.67m/s、96.74±4.25m/s、85.96±7.87m/s,差异有统计学意义(P=0.000)。治疗组患者最终发生CVS3例,对照组9例,差异有统计学差异(P=0.026)。但在脑梗死例数、死亡例数及最终预后上,未发现明显差异。结论:尼莫地平联合利多卡因治疗预防颅内动脉瘤夹闭术后CVS的临床效果显著优于尼莫地平单药组,可以作为术后预防有效的治疗联合方案。     

有氧运动对高蛋氨酸饮食大鼠血浆NO、ET和NO/ET系统的影响

目的：探讨有氧运动对高蛋氨酸饮食大鼠血浆总一氧化氮合成酶（T-NOS）、一氧化氮（NO）、内皮素（ET）和NO/ET系统的影响。方法：雄性Wistar大鼠随机分为正常饮食对照组（对照组）、高蛋氨酸饲料组（高蛋氨酸组）和有氧运动＋高蛋氨酸饮食组（运动干预组）。对照组喂饲普通饲料,高蛋氨酸组和运动干预组喂饲含3%蛋氨酸的高蛋氨酸饲料,运动干预组同时每日同时进行90 min无负重游泳运动,实验共8周。分别测定血浆同型半胱氨酸（Hcy）、ET、NO和T-NOS含量。结果：高蛋氨酸组血浆Hcy含量显著高于对照组达2倍以上（P〈0.01）,T-NOS和NO含量显著降低,ET含量显著升高（P〈0.01）,且NO/ET比值均显著降低（P〈0.05）;与高蛋氨酸组相比,运动干预组血浆Hcy含量显著下降（P〈0.05）,T-NOS,NO含量和NO/ET比值显著升高（P〈0.05）,且与对照组相比上述各项指标无显著差异。结论：高蛋氨酸饮食可诱发大鼠高同型半胱氨酸血症,血浆NO/ET失衡;有氧运动可降低高蛋氨酸饮食大鼠血浆Hcy水平,改善NO/ET失衡,预防高同型半胱氨酸血症。     

大鼠局灶性脑缺血后一氧化氮合酶基因表达的变化

目的:观察大鼠局灶性脑缺血后3种类型一氧化氮合酶(NOS)mRNA表达的变化.方法:大鼠随机分为正常对照组、缺血后2、6、12、24 h组,以逆转录-聚合酶链反应(RT-PCR)法分别检测缺血脑组织NOS基因表达的变化.结果:脑缺血后eNOS、nNOSmRNA表达增强,分别于2、6 h达高峰;iNOS mRNA表达亦增高,但在缺血后12 h达高峰.结论:大鼠脑缺血早期eNOS和nNOS占主要地位,缺血后期iNOS占主要地位.     

Phosphoramidon prevents cerebral vasospasm following subarachnoid hemorrhage in dogs: the relationship to endothelin-1 levels in the cerebrospinal fluid

There is increasing evidence that the conversion of big endothelin-1 (big ET-1) to endothelin-1 (ET-1) is specifically inhibited by the metalloproteinase inhibitor phosphoramidon. We investigated the effect of phosphoramidon on delayed cerebral vasospasm from subarachnoid hemorrhage (SAH) using a two-hemorrhage canine model. The magnitude of the vasospasm and the drug effect were determined angiographically. On SAH Day 7, diameter of the basilar artery decreased to about 55% of the control value obtained before SAH (on Day 0). Immunoreactive ET (IR-ET) in the cerebrospinal fluid (CSF) significantly increased after SAH (on Day 7). The intracisternal pretreatment of phosphoramidon potently suppressed the decrease in diameter of the basilar artery after SAH, i.e., observed decrease was only about 20%, compared with the value before SAH. In the phosphoramidon group, IR-ET in CSF markedly increased (on SAH Day 2), but the increased levels of IR-ET significantly declined on SAH Day 7. These results clearly indicate that phosphoramidon effectively prevents delayed cerebral vasospasm. Whether the prevention is due to the inhibition of conversion of big ET-1 to ET-1 is now under study.     

An in vitro model of aneurysmal subarachnoid hemorrhage: oxidation of unconjugated bilirubin by cytochrome oxidase

Aneurysmal subarachnoid hemorrhage is a stroke subtype with high rates of mortality and morbidity. Cerebral vasospasm can lead to ischemic injury or death and is a common complication of aneurysmal subarachnoid hemorrhage, usually occurring 3-9 days afterwards. The cause of vasospasm is not known. Recently, there has been strong evidence that vasoactive oxidation products of bilirubin may be involved. Currently, the factors that lead to bilirubin oxidation are poorly characterized. In this study, we have designed an in vitro model of hemorrhagic stroke in order to investigate conditions that promote the oxidation of bilirubin to form vasoactive compounds. Using our model, we created a basic hematoma system of blood, CSF, and hemeoxygenase-1. We manipulated this system in various ways, incubated it and determined the concentration of vasoactive bilirubin oxidation products that resulted. Conditions where cytochrome oxidase was stimulated caused an increase bilirubin oxidation products (292.6 +/- 39.9 micromol/L respectively, vs. 79.3 +/- 1.3 micromol/L for the basic reaction, p < 0.05), which was attenuated by cyanide. Our data suggest that bilirubin oxidation products may be produced by oxidation(s) requiring an oxygen-utilizing enzyme like cytochrome oxidase.     

Cortical spreading depression aggravates early brain injury in a mouse model of subarachnoid hemorrhage

Cortical spreading depression (CSD) has been observed during the early phase of subarachnoid hemorrhage (SAH). However, the effect of CSD on the cerebral blood flow (CBF) and cerebral oxyhemoglobin (CHbO) during the early phase of SAH has not yet been assessed directly. We, therefore, used laser speckle imaging and optical intrinsic sinal imaging to record CBF and CHbO during CSD and cerebral cortex perfusion (CCP) at 24 hours after CSD in a mouse model of SAH. SAH was induced by blood injection into the prechiasmatic cistern. When CSD occurred, the change trend of CBF and CHbO in Sham group and SAH group was the same, but ischemia and hypoxia in SAH group was more significant. At 24 hours after SAH, the CCP of CSD group was lower than that of no CSD group, and the neurological function score of CSD group was lower. We conclude that induction of CSD further aggravates cerebral ischemia and worsens neurological dysfunction in the early stage of experimental SAH. Our study underscores the consequence of CSD in the development of early brain injury after SAH.     

Exogenous nitric oxide negatively regulates c-Jun N-terminal kinase activation via inhibiting endogenous NO-induced S-nitrosylation during cerebral ischemia and reperfusion in rat hippocampus

Nitric oxide (NO), synthesized from l -arginine by NO synthases, is a small endogenous free radical with multiple functions. The c-Jun N-terminal kinase (JNK) signaling pathway plays a critical role in mediating apoptosis in cerebral ischemia and reperfusion. In this study, we found that the NO donor sodium nitroprusside (SNP) can decrease the damage of hippocampal neurons induced by cerebral ischemia and reperfusion. Our current study demonstrates that SNP can suppress the phosphorylation of JNK3 by suppressing the increased S-nitrosylation of JNK3 induced by cerebral ischemia and reperfusion. In contrast, dithiothreitol reversed the effect of SNP on S-nitrosylation of JNK3. Furthermore, the inhibitor of nNOS (7-NI) and the inhibitor of iNOS (AMT) can decrease JNK3 phosphorylation through decreasing S-nitrosylation of JNK3. Our data suggest that endogenous NO synthesized by NO synthases can increase JNK3 phosphorylation by means of S-nitrosylation during global ischemia/reperfusion in rat hippocampus. However, the exogenous NO (SNP) can reverse the effect of endogenous NO by inhibiting S-nitrosylation of JNK3. Together, these results suggest that the exogenous NO may provide a new clue for stroke therapy.     

尼莫地平对急性脑缺血大鼠一氧化氮和自由基的影响

本文在大鼠双侧颈总动脉闭塞的不完全性脑缺血模型上,观察了尼莫地平在脑缺血中对一氧化氮（ Ｎ Ｏ） 和自由基的影响。发现尼莫地平显著降低脑缺血大鼠血清中乳酸脱氢酶（ Ｌ Ｄ Ｈ） 活性,丙二醛（ Ｍ Ｄ Ａ）含量,增加 Ｎ Ｏ 含量。结果提示：尼莫地平对脑缺血大鼠的保护作用可能与其抗脂质过氧化及增加 Ｎ Ｏ 有关。     

大鼠脑线粒体NOS及L—Arg转运的生化特性

测定分离纯化的大鼠脑线粒体(mitochondria,Mt)L-精氨酸(L-arginine,L-Arg)/一氧化氮合酶(nitricoxidesynthase,NOS)/NO系统,L-Arg转运和NOS的活性。结果显示正常大鼠脑Mt膜上存在高亲和、低转运、可饱和的L-Arg转运体。最大转运速率Vmax为5.87±0.46nmol/mgpro·min     

Nitric oxide down-regulates caveolin-1 expression in rat brains during focal cerebral ischemia and reperfusion injury

As a signalling molecule of the integral membrane protein family, caveolin participates in cellular signal transduction via interaction with other signalling molecules. The nature of interaction between nitric oxide (NO) and caveolin in the brain, however, remains largely unknown. In this study we investigated the role(s) of NO in regulating caveolin-1 expression in rat ischemic brains with middle cerebral artery occlusion (MCAO). Exposure to 1 h ischemia induced the increases in neuronal nitric oxide synthase (nNOS) and NO concentration with concurrent down-regulation of caveolin-1 expression in the ischemic core of rat brains. Subsequent 24 h or more reperfusion time led to an increase in inducible NOS (iNOS) expression and NO production, as well as a decline of caveolin-1 protein at the core and penumbra of the ischemic brain. Afterwards, NOS inhibitors and an NO donor were utilized to clarify the link between NO production and caveolin-1 expression in the rats with 1 h ischemia plus 24 h reperfusion. N(G)-nitro-l-arginine methyl ester (L-NAME, a non-selective NOS inhibitor), N(6)-(1-iminoethyl)-lysine (NIL, an iNOS inhibitor), and 7-nitroindazole (7-NI, a nNOS inhibitor) prevented the loss of caveolin-1 in the core and penumbra of the ischemic brain, whereas l-N(5)-(1-iminoethyl)-ornithine (L-NIO, an endothelial NOS inhibitor) showed less effect than the other NOS inhibitors. S-Nitroso-N-acetylpenicillamine (SNAP, a NO donor) down-regulated the expression of caveolin-1 protein in normal and ischemic brains. These results, when taken together, suggest that NO modulates the expression of caveolin-1 in the brain and that the loss of caveolin-1 is associated with NO production in the ischemic brain.     

Inducible nitric oxide synthase expression in the ischemic core and penumbra after transient focal cerebral ischemia in mice

The present observations examined the hypothesis that the iNOS expression in the ischemic penumbra after a transient focal ischemic insult is involved in the recruitment of penumbra into infarction. The middle cerebral artery in mice was occluded for 2 h by an intraluminal filament and then recirculated. The measurement of iNOS activity, iNOS protein formation and NO concentration in the ischemic core and penumbra, and the determination of infarct volume were performed at 6, 12, 24 and 48 h after reperfusion. iNOS protein and iNOS enzymatic activity appeared at 6 h, peaked at 24 h, and declined at 48 h in the penumbra after reperfusion. iNOS protein was not detectable in contralateral area and in sham-operated brains. The time course of iNOS protein, enzymatic activity and NO concentration in the penumbra but not in the core matched the process of infarct maturation. Treatment with iNOS inhibitor aminoguanidine (100 mg.kg(-1), i.p.) at 6 and 12 h after reperfusion inhibited iNOS activity by 88.0 +/- 10.4% and reduced NO concentration by 48.5 +/- 8.3% in the penumbra, and lessened infarct size by 48.8 +/- 7.2%. The iNOS activity and NO level in the core were not affected by the administration of aminoguanidine. These results suggest that iNOS expression in the ischemic penumbra is involved in the recruitment of penumbra into infarction and thereby contributing to the enlargement of infarct.     

不同亚型一氧化氮合酶在脑缺血/再灌注早期的表达变化

目的:观察脑缺血/再灌注(CI/R)早期缺血区脑组织的内皮型一氧化氮合酶(eNOS)与神经型一氧化氮合酶(nNOS)表达的变化。方法:健康wistar大鼠60只,体重200～280g,由中国医科大学动物中心提供,雌雄各半。随机分为6组(n=10):假手术组、缺血1h组、缺血2h组、再灌注0.5h组、再灌注1h组、再灌注2h组。采用线栓法制作大鼠CI/R模型,免疫组化方法检测缺血区脑组织的eNOS与nNOS蛋白表达情况。结果:与假手术组比较,CI/R模型大鼠脑组织血管内皮细胞内eNOS表达在缺血1h内升高,之后到再灌注2h内持续降低。而nNOS的表达在缺血到再灌注2h内持续上升。结论:CI/R模型中缺血区脑组织的eNOS与nNOS的变化趋势不同,表明一氧化氮在缺血性脑损伤病理过程的作用与一氧化氮合酶亚型的变化有关。