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摘要：
目的 探讨不同时相远隔缺血预处理（remote ischemic preconditioning, RIPC）对颈动脉内膜剥脱术（carotid endarterectomy, CEA）患者术后认知功能的影响。 方法 选择择期CEA手术患者60例，按照随机数字表法分为3组（每组20例）：对照组（C组）、术前60 min施行RIPC组（RIPCⅠ组）、术前24 h施行RIPC组（RIPCⅡ组）。于患者右下肢大腿中下1/3交界处放置止血带，加压到200 mmHg（1 mmHg=0.133 kPa），予以3个周期5 min缺血/5 min再灌注处理；C组仅相同位置放置止血带，不加压。检测术前1 d（T0，RIPC实施前）、术后6 h（T1）、术后24 h（T2）3组患者血清中人S100β蛋白、神经元特异性烯醇化酶（neuron specific enolase, NSE）、脑源性营养因子（brain‑derived nutritional factors, BDNF）的水平，评估T0、T2、术后48 h（T3）、术后72 h（T4）、术后7 d（T5）、术后1个月（T6）的简易精神状况检查（Mini‑Mental State Examination, MMSE）评分。 结果 与T0时比较，3组患者血清中S100β蛋白、NSE水平在T1和T2时均明显升高（P<0.05）；RIPCⅠ组、RIPCⅡ组在T1和T2时血清S100β蛋白、NSE水平较C组有不同程度降低（P<0.05），且RIPCⅡ组在T1和T2时均低于RIPCⅠ组（P<0.05）。C组患者在T1时血清BDNF水平明显高于T0，RIPCⅠ组、RIPCⅡ组在T1、T2时仍明显高于T0（P<0.05）；RIPCⅠ组于T2时血清BDNF水平高于C组（P<0.05）；RIPCⅡ组在T2时血清BDNF水平明显高于C组及RIPCⅠ组（P<0.05）。3组患者MMSE评分在T2时均明显低于T0时（P<0.05）；C组持续降低至T4时（P<0.05）；RIPCⅠ组持续低至T3时（P<0.05）并于T3时高于C组（P<0.05）；RIPCⅡ组MMSE评分于T3、T4时明显高于C组及RIPCⅠ组（P<0.05）。 结论 RIPC技术可在一定程度上减轻CEA患者术后脑损伤，促进术后早期认知功能的恢复，且延迟时相（RIPCⅡ组）的作用更为明显，可能与其持续增强机体内源性BDNF的生成有关。
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Abstract: Objective To investigate the effect of different phase windows of remote ischemic preconditioning (RIPC) on the cognitive function of patients with carotid endarterectomy (CEA). Methods Sixty patients with selective CEA surgery were divided by random digital tables into three groups (n=20 each): a control group (group C), a RIPCⅠgroup (RIPC was performed 60 min before operation), and a RIPC Ⅱ group (RIPC was performed 24 h before operation). In the RIPC I and RIPCⅡgroup, the tourniquet was placed at the junction of the middle and lower 1/3 of the right lower thigh, and the tourniquet was pressurized to 200 mmHg (1 mmHg= 0.133 kPa). Three cycles of 5 min ischemia/5 min reperfusion were performed. The tourniquet was placed at the same position in the control group without pressure. The levels of serum S100β protein, neuron specific enolase (NSE) and brain‑derived nutritional factors (BDNF) were measured on the first day before operation (T0, before RIPC), 6 h after operation (T1) and 24 h after operation (T2). The Mini‑Mental State Examination (MMSE) scores on the T0, T2, 48 h after operation (T3), 72 h after operation (T4), 7 d after operation (T5) and 1 month after operation (T6) were evaluated. Results Compared with T0, the serum levels of S100β protein and NSE were significantly increased in the three groups at T1 and T2 (P<0.05), the serum S100β protein and NSE levels of the RIPCⅠgroup and RIPCⅡgroup were lower than those of the group C (P<0.05), and the serum S100β concentration level of the RIPCⅡgroup was lower than that of the RIPCⅠgroup at T1 and T2 (P<0.05). The serum BDNF level of patients in group C at T1 was significantly higher than that at T0 (P<0.05), the serum BDNF level of patients in RIPCⅠ group and RIPCⅡ group at T1 and T2 was still significantly higher than that at T0 (P<0.05), the serum BDNF level of patients in RIPCⅠ group at T2 was significantly higher than that in group C (P<0.05), the level of serum BDNF in the RIPCⅡ group was significantly higher than that in the group C and RIPCⅠgroup at T2(P<0.05). The MMSE scores of the three groups were significantly reduced at T2 than T0(P<0.05), the MMSE scores of group C continued to decrease to T4 (P<0.05), the MMSE scores of RIPCⅠ group continued to decrease to T3 and was higher than group C at T3 (P<0.05), the MMSE scores of RIPCⅡgroup had significantly higher at T3, T4 than the group C and RIPCⅠgroup (P<0.05). Conclusions Remote ischemic pretreatment can reduce the brain injury and promote the recovery of early cognitive function in patients with CEA to a certain extent, and the effect of delayed phase (RIPCⅡ group) is more obvious, which may be related to the continuous enhancement of endogenous BDNF production.
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