本文選題：術(shù)后認(rèn)知功能障礙 + 核磁共振　； 參考：《第四軍醫(yī)大學(xué)》2014年碩士論文

【摘要】：背景： 社會(huì)在不斷的進(jìn)步，國(guó)人的壽命隨著社會(huì)的發(fā)展以及生活水平的提高也在逐漸延長(zhǎng)。國(guó)際通常的看法是，當(dāng)60歲以上的老年人口占全國(guó)總?cè)丝诘谋壤^10%，就可以定義為該國(guó)家處于老齡化社會(huì)。而2013年老年人口超過了2億人，老齡化水平從2011年第六次全國(guó)人口普查結(jié)果的13.26%增長(zhǎng)到了14.8%。以往的研究結(jié)果證實(shí)，冠心病的發(fā)病率與年齡相關(guān)，隨著年齡的增長(zhǎng)而增高。目前，治療冠心病有效的最終手段是行冠脈搭橋術(shù)。 術(shù)后認(rèn)知功能障礙（postoperative cognitive dysfunction, POCD）是冠脈搭橋術(shù)相對(duì)嚴(yán)重的術(shù)后并發(fā)癥之一，指患者在行麻醉手術(shù)后數(shù)天內(nèi)發(fā)生的記憶力障礙、抽象思維及方向辨別能力的下降，同時(shí)出現(xiàn)社會(huì)技能的減退。由于以往研究群體和方法不同，心臟術(shù)后POCD的發(fā)病率差異較大，有的研究結(jié)果顯示發(fā)病率甚至超過60%。POCD可導(dǎo)致患者康復(fù)延遲、醫(yī)療成本的增加，并且嚴(yán)重影響患者術(shù)后的生活質(zhì)量，給家庭和社會(huì)帶來碩大的負(fù)擔(dān)。其發(fā)病機(jī)制尚未研究透徹，但目前研究表明，高齡是導(dǎo)致POCD的主要危險(xiǎn)因素之一。POCD患者發(fā)生阿爾茨海默�。ˋlzheimer’sdisease，AD）的幾率遠(yuǎn)遠(yuǎn)高于正常人。隨著社會(huì)步入老齡化，醫(yī)療和社會(huì)問題也迎來了巨大的挑戰(zhàn)。目前還沒有找到行之有效的治療方法，所以怎樣預(yù)防POCD的發(fā)生并且找到其預(yù)警指標(biāo)則成為了至關(guān)重要的問題。 以往在輕度認(rèn)知功能障礙(mild cognitive impairment, MCI)和AD的研究中，核磁共振成像（magnetic resonance imaging, MRI）技術(shù)已經(jīng)非常成熟應(yīng)用在對(duì)其檢查和診斷當(dāng)中。有研究證明，海馬體積與AD有相關(guān)性。以往的研究已證實(shí)，手術(shù)后炎癥因子處于高表達(dá)狀態(tài)，與認(rèn)知功能的下降有關(guān)系。為此，設(shè)計(jì)了以下實(shí)驗(yàn)。 目的： 1.本研究應(yīng)用核磁共振技術(shù)檢查患者海馬體積，探討心臟手術(shù)患者海馬體積與術(shù)后認(rèn)知功能障礙的相關(guān)性 2.探討冠狀動(dòng)脈搭橋術(shù)后患者外周血炎癥和腦損傷因子與認(rèn)知功能障礙的關(guān)系 方法： 本研究納入58名擇期行冠狀動(dòng)脈搭橋術(shù)的患者以及51名健康中老年人作為研究對(duì)象。本研究使用神經(jīng)心理學(xué)量表評(píng)估所有受試者的認(rèn)知狀態(tài)。分別在術(shù)前對(duì)患者進(jìn)行神經(jīng)心理學(xué)量表評(píng)估和MRI掃描，術(shù)后第7d再次對(duì)患者進(jìn)行神經(jīng)心理學(xué)量表評(píng)估。健康組受試者也在與患者相同間隔時(shí)間進(jìn)行神經(jīng)心理學(xué)量表評(píng)估。使用國(guó)際術(shù)后認(rèn)知功能障礙研究協(xié)作組(international study of postoperative cognitivedysfunction, ISPOCD)推薦的“Z計(jì)分法”統(tǒng)計(jì)量表結(jié)果。使用德國(guó)Siemens公司3.0T磁共振對(duì)所有患者海馬體進(jìn)行檢查，通過計(jì)算機(jī)得出患者海馬體積。所有患者通過神經(jīng)心理學(xué)評(píng)分結(jié)果分為POCD組和非POCD組，然后與兩組患者之間的海馬體積進(jìn)行相關(guān)性分析。 健康受試者只采集一次靜脈血4ml�；颊卟杉�5次靜脈血，每次4ml。時(shí)間點(diǎn)為術(shù)前、手術(shù)后2h及術(shù)后1d、3d、7d。將采集好的靜脈血放入帶有促凝因子以及分離膠的試管中，然后在4℃冰箱里靜置30min后離心，取上層血清，保存在-80℃冰箱中，最后分別批量使用酶聯(lián)免疫吸附劑測(cè)定（enzyme linked immunosorbent assay，ELISA）方法檢測(cè)炎癥相關(guān)指標(biāo)IL-6和腦損傷指標(biāo)NSE及S100β的表達(dá)水平。 結(jié)果： 所有患者以及健康受試者完成了神經(jīng)心理學(xué)評(píng)估，所有患者完成了術(shù)前核磁共振的檢查。結(jié)果顯示，患者與健康的一般資料無統(tǒng)計(jì)學(xué)差異。根據(jù)神經(jīng)心理量表測(cè)試結(jié)果，對(duì)照組有4名健康中老年人的結(jié)果滿足診斷POCD標(biāo)準(zhǔn)，故本研究所采用的量表的假陽性率為7.8%。根據(jù)量表“Z值”結(jié)果劃分，患者當(dāng)中有32例發(fā)生POCD，老年患者行冠狀動(dòng)脈搭橋術(shù)后發(fā)生POCD率為55.2%。核磁共振檢查結(jié)果顯示：發(fā)生POCD患者的海馬體積（5.64±0.26）cm3明顯小于未發(fā)生POCD患者（5.81±0.35）cm3(P0.05），海馬體積與神經(jīng)心理學(xué)評(píng)分Z值呈負(fù)相關(guān)性。 擬行冠脈搭橋術(shù)的患者IL-6的基礎(chǔ)值明顯高于健康受試者。其中大于60歲的老年人，外周血中IL-6、NSE和S100β的基礎(chǔ)值明顯高于年輕人。大于60歲發(fā)生POCD的老年患者外周血中的IL-6基礎(chǔ)表達(dá)水平顯著高于其他人�；颊咄庵苎猩飳W(xué)標(biāo)記物的結(jié)果發(fā)現(xiàn)，經(jīng)過麻醉手術(shù)后可以引起IL-6、NSE和S100β表達(dá)水平不同程度的升高，隨時(shí)間的推移各自表達(dá)量逐漸下降。在術(shù)后2h時(shí)，POCD組表達(dá)量明顯高于非POCD組。NSE的表達(dá)量在術(shù)后1天時(shí)，POCD組和非POCD組間具有統(tǒng)計(jì)學(xué)差異。兩組間S100β表達(dá)量無統(tǒng)計(jì)學(xué)差異。 結(jié)論： 冠脈搭橋術(shù)患者發(fā)生POCD的概率較高，并且通過術(shù)前進(jìn)行核磁共振檢查，發(fā)現(xiàn)POCD患者的海馬體積較小。經(jīng)過統(tǒng)計(jì)分析，，得出海馬體積與POCD呈負(fù)相關(guān)，表明海馬體積可作為POCD發(fā)生的危險(xiǎn)因素，可為POCD早期預(yù)防的客觀影像學(xué)依據(jù)。 患者受到麻醉手術(shù)的刺激后，外周血中的炎癥因子和腦損傷因子的表達(dá)量都會(huì)增加，隨著時(shí)間的推移，這些生物學(xué)指標(biāo)又恢復(fù)到與術(shù)前相近的水平。老年人外周血中的這些因子表達(dá)水平較年輕人高。尤其是大于60歲老年人外周血中IL-6的基礎(chǔ)值若大于104.651pg/ml時(shí)，容易發(fā)生POCD。 小結(jié) 本實(shí)驗(yàn)研究對(duì)象為行冠狀動(dòng)脈搭橋術(shù)患者以及健康的中老年人。首先對(duì)兩組人群進(jìn)行神經(jīng)心理測(cè)驗(yàn)評(píng)估，以及術(shù)前對(duì)患者海馬體積的檢查，結(jié)果發(fā)現(xiàn)POCD組患者海馬體積比非POCD組小。隨后檢查這兩組人群外周血中IL-6、NSE和S100β含量。結(jié)果發(fā)現(xiàn)，當(dāng)受到麻醉手術(shù)刺激后，IL-6、NSE和S100β表達(dá)水平大幅度增加，POCD組和非POCD組之間，IL-6和NSE的表達(dá)量有統(tǒng)計(jì)學(xué)差異，但只有術(shù)前的IL-6表達(dá)量可以作為預(yù)測(cè)發(fā)生POCD的生化指標(biāo)。
[Abstract]:Background:
With the continuous progress of society, the life span of the people is gradually extending with the development of society and the improvement of the living standard. The international common view is that when the elderly population over 60 years of age accounts for more than 10% of the total population of the country, it can be defined as the country in an aging society. In 2013, the elderly population is over 200 million, aging water. According to the results of the sixth national census in 2011, the results of the sixth national population census were increased to the results of previous studies. The incidence of coronary heart disease was associated with age and increased with age. At present, the effective way to treat coronary heart disease is to bypass coronary artery bypass surgery.
Postoperative cognitive dysfunction (postoperative cognitive dysfunction, POCD) is one of the relatively serious postoperative complications of coronary artery bypass surgery. It refers to the memory impairment, the decrease of abstract thinking and direction discrimination within a few days after anesthesia, and the loss of social skills. In the same way, the incidence of POCD after heart surgery is very different. Some research results show that the incidence of the disease is even more than 60%.POCD can lead to the delay of rehabilitation, the increase of medical cost, and seriously affect the quality of life of the patients after the operation, and bring great burden to the family and society. One of the major risk factors for POCD,.POCD patients (Alzheimer 'sdisease, AD) is far higher than normal people. With the aging of the society, medical and social problems are also facing great challenges. No effective treatment has been found yet, so how to prevent the occurrence of POCD and find it is found Its early warning indicators have become a crucial issue.
In the previous studies of mild cognitive impairment (MCI) and AD, nuclear magnetic resonance imaging (magnetic resonance imaging, MRI) technology has been widely used in its examination and diagnosis. Studies have shown that the hippocampal volume is associated with AD. Previous studies have confirmed that the postoperative inflammatory factors are in a high table. Reaching the state is related to the decline of cognitive function. For this purpose, the following experiments were designed.
Objective:
1. in this study, we examined the hippocampal volume of patients with magnetic resonance imaging (MRI), and explored the correlation between hippocampal volume and postoperative cognitive dysfunction in patients undergoing cardiac surgery.
2. to explore the relationship between peripheral blood inflammatory and brain damage factors and cognitive dysfunction after coronary artery bypass grafting.
Method錛

本文編號(hào)：1901648