【作者】 郭建文；

【导师】 陈绍宏；

【作者基本信息】 成都中医药大学 ， 中医内科学， 2004， 博士

【摘要】 [背景] 急性脑出血(AICH)是严重威胁人类生命的疾病之一。中国是世界上AICH的高发国家。相对缺血性脑血管病的研究，AICH的研究非常不足。目前没有关于AICH时间窗的系统临床研究，动物实验也仅处于探索阶段。 [目的] 研究急性脑出血(AICH)可能存在的治疗时间窗及中药复方中风醒脑口服液(ZFXN)的干预作用。 [方法] (1)系统总结导师陈绍宏教授“中风核心病机论”。 (2)临床研究 ①按照接受治疗时间分层，回顾性分析1988-2003年两个设计良好的随机对照(RCT)临床试验资料； ②分为0-6h,6-24h，24-48h，48-72h四个时间段，分别统计4个时间段ZFXN组和对照组的基线资料； ③疗效评价终点选用治疗后30，60，90天的病死率、NIHSS、残疾程度(GOS)和生活质量(BI)，并进行多因素回归分析，找出影响AICH预后的因素。 ④统计使用ZFXN30天后对凝血功能(PT，APTT)的影响；分析ZFXN对发病6h之内AICH再出血的影响。 (3)实验研究： ①采用脑脊液药理学和原代神经细胞培养的方法，用Beagle犬的含ZFXN脑脊液(CSF)体外培养SD大鼠大脑皮层的神经细胞； ②用凝血酶合并缺血缺氧损伤(TIH)神经细胞，建立AICH的体外细胞模型； ③用MTT法筛选最佳含药CSF的剂量用于实验；成都中医药大学博士学位论文 ④在TIH损伤后6，12，24，72h，用M竹法检测神经细胞线粒体活力， 用双波长荧光法，使用Fula-2/AM检测神经细胞内游离钙，用流式细胞 仪(FCM)检测神经细胞凋亡等。【结果】 (1)“中风核心病机论”基于把“中风”作为一个疾病整体认识，提出元气为本，痰、癖为中间病理产物，火、风为最终发病因素，制定复元醒脑、逐痪化痰、泄热熄风的治疗原则。 (2)临床研究: ①全部样本共367例，ZFXN187例，对照组181例。 ②基线资料中，除48一72h收缩压、舒张压和平均动脉压ZFXN组比对照 组升高外(P<0.05)，其余均有可比性(P>0.05) ③在O一72h的时间窗内，ZFXN可以降低AICH患者3Od、60d的病死率， 改善90d的生活质量。在48一72h的时间窗内，ZFXN可以降低AICH 患者60d病死率，改善90d生活质量。 ④无证据表明ZFXN可以增加发病6h内的AICH再出血发生率。 ⑤治疗方法和基线NlHSS(P< 0.05)是影响AICH患者90天生活质量(BI) 的因素。接受治疗的时间对治疗的结果无显著性影响(P>0.05)。(3)实验研究 ①凝血酶合并缺血缺氧损伤的体外培养神经细胞模型(TIH)是研究急性 脑出血较好的细胞模型。它更加符合ICH后对神经细胞损伤的病理生理机制。 ②zFXN的Beagle犬含药脑脊液对神经细胞有保护作用，其最佳剂量为小 剂量组的20%脑脊液。 ③ZFXN干预ICH的时间窗有:增加细胞活力在6h内效果最好，O一72之 内都有作用;减少LDH漏出方面，48一72h的效果最好，0一72h都有作用。在 抑制细胞内钙超载方面，0一6h作用最明显0一48h内均有作用。在抑制细胞凋 亡方面，O一24h是最佳干预时机，O一72h内仍有意义。The Thesis ofthe Doctoral Degree，Chengdu Unive伟ity ofT口心itional Chinese Medieine【结论】 (1)“中风核心病机论”反映了中风病的本质。 (2)在设计AICH临床方案时，72h是可以接受的时间窗。 (3) ZFXN可以早期(0一6h)使用，没有证据表明ZFXN增加再出血的发生率。ZFXN在AICH发生后干预的时机越早越好，72h是可能的干预时间窗。 (4) ZFXN可以在48一72h的时间窗内，可以降低赶CH患者60d病死率，改善90d生活质量。 (5)在川CH发生时，不要过于积极的处理高血压和治疗颅内高压，除非有强适应征。 (6) ZFXN是一个神经细胞保护剂，可以增加细胞线粒体活力、减轻神经细胞内钙超载、抑制神经细胞凋亡. (7)应进行设计良好的RcT进行赶CH的研究，探讨其确切治疗时间窗，减少病死率和致残率，提高生活质量.更多还原

【Abstract】 BACKGROUNDAcute intracerebral hemorrhage (AICH) is one of life-threaten diseases. The AICH morbidity rate is very high in China. The studies are very limited all over the world. There is not systematic 5 clinical study in AICH therapeutic time window and the animal experiment only lies the beginning stage. OBJECTIVETo study the possible therapeutic time window (TTW) of AICH, and the intervention of Zhongfengxingnao oral liquid (ZFXN) to AICH TTW. 10 METHODS(1) Systematically summarizing "Stroke Core Pathogenesis Theory " of Professor Chen Shaohong.(2) Clinical Study:(1)Retrospectively analyze the two AICH randomized clinical trail from1988-2003, sub-groups differentiating according the time from onset to the first treatment. (2)We15 divided into 0-6h, 6-24h, 24-48h, 48-72h, the baseline date include sex, age, blood pressure, medical history scale, concomitant disease scale, Glasgow Coma Scale (GCS), National Institute of Health Stroke Scale (NIHSS). (3)The endpoints include mortality rate, NIHSS, Glasgow Outcome Scale (GOS), Barthal Index (BI), and Multiple Regression Analysis on Effect factors of 90d BI Improvement. (4)Analyze the hematoma enlargement after ZFXN treatment. (3) Neuron20 Culture Study:(1)We adopt cerebrospinal fluid (CSF) pharmacology and primary neuron culture experimental methods, culturing the cerebral cortex neuron of SD rats by Beagle dog CSF containing the ZFXN in vitro, (2)making AICH cell model in vitro by thrombin and ischemic & hypoxia combinational injure to neuron (TIH model), (3)screening the optimal dose of herbal CSF via MTT assay method.(4)6,12,24,48, 72 hrs after TIH injured, MTT assay to analyze the25 mitchondria metabolism, Fura-2/AM loaded cells of TIH injured neuron by double wavelength fluorescence to detect the cytosolic free Ca2+ ([ Ca2+]i), propidium iodide (PI) dying the model neuron by flow cytometry to analyze the apoptosis of the neuron after AICH. RESULTS:(1) "Stroke Core Pathogenesis Theory " is based on as whole disease, including deficient30 Original Qi as root, Phlegm and Blood Stasis as indirect pathological product caused by deficient original Qi, Wind and Fire are the final pathogenic factors, So recovering the Original Qi and restoring consciousness, removing the Blood Stasis and resolving Phlegm, dispelling Fire and subduing Wind are the treatment rules. (2)Clinical study 漏Total patient sample is 367, including 187 ZFXN and 181 control, (2)in the baseline data have not significant difference between ZFXN35 and control group except systolic blood pressure (SBP), diastolic blood pressure (DBP) and meanarterial pressure (MAP) of 48-72H. (3) In the time window from 0 to 72hrs, ZFXN was able to decrease the mortality rate of 30 and 60d, improve the BI of 90d. In the time window from 48 to 72hrs, ZFXN was able to decrease the mortality rate of 60d, improve the BI of 90d. (4)ZFXN was able to decrease the prothrombin time (PT), no evidence showed that ZFXN was able to increase 5 the hematoma enlargement. (5) The treatment selection and baseline NIHSS are the effect factors of 90d BI (P<0.05) . The therapeutic time window from 0 to 72hrs have not significant effect on the 90BI (PX).05). (3) Neuron Culturing Study庐 TIH cell model fits in the pathophysiological changes after AICH, which is a optimal cell model to study AICH in vitro, (2)herbal CSF containing ZFXN can protect neuron, the optimal dose is 20% CSF in low dosage group. (3)10 From 0 to 72hrs after AICH, the mitchondria metabolism capability, lactate dedydrogenase (LDH) revealing, neuron apoptosis have changes curve, [ Ca2+]/ overload happened from 0 to 48hrs after AICH. (4)The ICH intervention time window of ZFXN including, the optimal effect to enhance the mitchondria metabolism capability lies in 0-6 hrs, and have effect from 0-72hrs. the optimal effect of decreasing the LDH revealing is from 48 to 72 hrs, and have effect from 0 to 72hrs. the15 optimal inhibiting the[ Ca2+]i overload is 0 to 24hrs, and a更多还原