脑血管搭桥术后脑梗死严重运动功能障碍患者运动通路重塑机制的研究

Bypass surgery is a promising treatment methodfor hemodynamic cerebral ischemia. The clinical research found that bypasssurgery can promote the functional recovery in patients with partial cerebralinfarction associated with severe dyskinesia, however, whether the surgicalreperfusion can promote nerve remodeling is still lack of theoreticalexplanations. Previous study found that patients whose motor function area residue or replacement, the postoperative functional area become larger, its signal enhanced and the anisotropy between each part increased. So, we consider that bypass surgery ,for patients who suffer stoke and have severe motor dysfunction ,can promote not only the motor function areas reorganization, migration, and alternative but also the corticospinal tract reconstruction or recanalization .In order to verify this idea, we will make a randomized controlled trials, based on fMRI, DTI, muscle strength,level of NGF in plasma and CSF to assessment the state of motor pathways. This is a Forward-looking experiment. In this experiment we analysis the size,distribution of fMRI motion activated area before and after bypass surgery , as well as the FA and MD values,number of fibers in DTI .These are the radiographic parameters of the motor pathways. We will also dynamiclly test the level of NGF in plasma and GSF , compare wether their function improved significantly or not between the surgical group and control group.

对血流动力学性脑缺血患者，脑血管搭桥手术是很有前景的治疗手段。临床发现搭桥术可促进部分脑梗死伴严重运动障碍的患者功能恢复，但手术后再灌注是否能促进神经重塑尚缺乏理论阐述。前期研究发现，运动功能区残留或替代的患者，术后功能区信号增强，面积增大，部分各向异性增大。据此我们考虑：在脑梗死严重运动功能障碍患者中，搭桥术能促进运动通路发生运动功能区重组、迁移和替代，皮质脊髓束重建或再通。为了验证此想法，我们将设立随机对照实验，结合fMRI、DTI、肌力评估运动通路的状态，动态监测血浆及脑脊液NGF水平，进行前瞻性研究。分析搭桥术前后fMRI运动激活区大小、分布、DTI的FA、MD值、纤维数量等运动通路功能影像学指标及血浆、脑脊液NGF水平的动态变化，比较手术组与对照组的差异以及功能改善显著组与不显著组的差异。总结搭桥术对动功能区重组、迁移和替代，皮质脊髓束重建或再通等运动通路恢复的机制。

对血流动力学性脑缺血患者，脑血管搭桥手术是很有前景的治疗手段。临床发现搭桥术可促进部分脑梗死伴严重运动障碍的患者功能恢复，但手术后再灌注是否能促进神经重塑尚缺乏理论阐述，同时此类患者运动通路神经重塑的机制尚不明确。本研究通过前瞻性队列研究，运用功能影像对搭桥手术促进神经重塑的机制进行研究。研究证实运动功能区残留或替代的患者，术后功能区明显信号增强，面积增大，神经纤维部分各向异性增大，搭桥可促进部分脑梗死伴严重运动障碍的患者功能恢复，同时，研究发现搭桥术后运动功能障碍的恢复机制可能为搭桥术后功能区血运的改善，导致部分缺血未坏死的功能皮质得以恢复，神经纤维得以恢复，同时血运的改善增强了手术侧功能网络之间的有效连接，因此运动功能改善，而不同脑区的功能代偿或神经飘逸并未参与功能的恢复。另外，该研究证实SUMO-2/3蛋白对脑梗死患者的脑保护作用；搭桥手术供血血管外膜的剥离有助于增加搭桥的血供；伴有多支血管病变的患者容易于搭桥术后出现远隔部位的脑梗死。因此，该研究阐述了搭桥术促进部分脑梗死伴严重运动障碍的患者功能恢复的机制，同时对手术的操作等临床问题进行细化，为临床治疗提供理论依据。