中枢神经系统损伤与保护方法的评估

・论　著・

中枢神经系统损伤与保护方法的评估

管玉龙,董培青,杨 ,万彩红,何美玲

(首都医科大学附属北京安贞医院体外循环科,北京100029)

摘要:目的　通过系列的动物实验及临床观察,探讨如何对心脏手术围术期中枢神经系统的损伤程度以及不同方法的脑保护效果进行合理的评估。方法　对体外循环(CP B)、停循环以及上腔静脉逆行灌注(RCP)期间的血液灌注进行观察,检测组织生化酶学和活体脑组织钙离子荧光强度,并进行组织病理及电镜检测。采用便携式眼底镜在临床手术患者进行前瞻性观察。结果　眼底血管造影、彩色多普勒超声波检查和同位素99m T c-ECD均证实:逆行灌注期间的大脑灌注与单纯停循环相比,RCP能够明显减轻停循环后一氧化氮(NO)的产生量以及钙超载的发生,维持组织较高的Na+ -K+ATP酶、超氧化物歧化酶、谷胱甘肽过氧化物酶活力,较少丙二醛产生,从而减轻停循环后神经细胞的缺血缺氧程度。便携式眼底镜在临床手术患者同样观察到逆灌期间的血液灌注。结论　激光共聚焦显微镜技术和核磁共振仪检测脑组织中钙超载以及NO产生量、多种酶学检测结合组织病理检查可作为动物实验中对神经细胞损伤程度评价的手段。同位素99m T c-ECD、眼底血管荧光造影、彩色多普勒超声波检查可以评定脑组织的灌注状况,是直观而敏感的观察脑灌注的方法。

关键词:脑保护;深低温停循环;逆行灌注;体外循环;缺血

中图分类号:R451,R654.1　文献标识码:A 文章编号:1672-1403(2003)02-0081-05

Assessm ent of C ereb ral I nju ry and E ffcct Different of P rotection

on B rain du ring C ardiopu lmonary B yp ass

(G UAN Y u-long,DONG Pei-qing,Y ANGJing,W AN Cai-hong,HE Mei-ling.

(Department of CP B Beijing A nzhen Ho spital,Beijing100029,China) Abstract:OB JE CTIVE　Investigate apt methods for assessment of cerebral in jury and effect of different protection on brain retro2 spectively.METH ODS　Animal m odels of dee p hypothermic circulatory arrest(DHCA)and retrograde cerebral perfusion(RCP) during DHCA were established,cerebral blood perfusion was observed by fundus flu orescein angiography(FFA),color D oppler s onography and is otope scanning.The concentration of Na+-K+ATPase,su peroxide dismutase(SOD),glutathione peroxidase

(G SH-PX),malondialdehyde(MDA)were measured.The level of nitric oxide(NO)was detected by nuclear magnetic res onace

(NMR)and calcium flu orescent intensity of vital brain slice by Laser C onfocal S canning Microscope(LCSM).S ome preliminary clinical observations were made with o phthalm oscope.RE SU LT S　FFA,color D oppler s onography and is otope scanning(99m T c-ECD)all dem onstrated that cerebral perfusion existed during RCP.C om pared with DHCA,RCP could attenuate cerebral in jury af2 ter DHCA through maintaining higher concentration of Na+-K+ATPase,SOD,G SH-PX and decreasin g production of MDA, NO and calcium overload.C ON C LU SI ON　In animal experiment cerebral in jury can be assessed by measurement of calcium flu o2 rescent intensity of vital brain slice,production of NO and s ome biochemical markers.FFA,color D o ppler s onography and is otope scanning are practicable for m onitoring cerebral perfusion in clinics.

K ey w ords:　cerebral protection;dee p hypothermic circulatory arrest;retrograde cerebral perfusion;cardiopulm onary bypass;is2 chemia

在过去的半个世纪,心脏外科技术取得了很大的进展,手术成功率得到了很大的提高。但是与心内直

收稿日期:2003202215;　修订日期:2003203225

基金项目:国家自然科学基金(39770733)

作者简介:管玉龙(1972),男,主治医师,博士研究生视手术相关的并发症以及由此导致的死亡率仍然较高1。有关心脏手术围术期的神经系统保护成为近几年研究的热点。特别是一些重症患者,如先天性复杂畸形、动脉瘤病变累及主动脉弓部等,这类手术难度大、操作复杂,而且在手术过程中一般需要暂时中断大