摘要
脑卒中是中枢神经系统常见疾病之一，严重危害人类健康，死亡率、残疾率高。在存活患者中进行积极的康复治疗，可使90％重新步行和生活自理，30％恢复一些较轻的工作。而不进行康复治疗者，上述两方面恢复的百分率只有60％和5％。因此，为了提高患者生活质量及尽早重返社会，脑卒中的康复已日益受到重视。而探讨中枢神经系统损伤后功能恢复的机理得到广泛关注。
多年来的大量实验和临床研究使人们认识到，无论在非哺乳类动物还是在哺乳类动物中，成年动物的CNS在损伤后具有在结构上或功能上重新组织的能力或可塑性，使损伤后的恢复成为可能。脑可塑性是指脑有适应能力，即在结构和功能上有修改自身以适应改变了的现实的能力。CNS的可塑性表现在多个层次、多个环节，既有突触及神经元水平、通路水平，也有大脑皮质水平，这是由于进行任何一项活动均需要大量神经元的同步活化，许多神经通路及高位中枢的参与。如果进行某项活动的主要区域损伤或致病，则这一活动会转换到调节这些活动的其他神经元、神经通路和大脑支配区。这种改变一方面取决于人的神经系统的巨大潜能使之能够代偿和适应损伤造成的解剖功能上的缺损，另一方面则是与病人的后天环境下损伤前后的运动学习情况密切相关。如能及时进行康复训练，则可促进该活动转变到新的通路。
康复训练在损伤的早期、中期和后期都十分重要，它是通过与他人和环境相互作用，练习在接受刺激时及时和适当地作出反应，
第四军医大学硕土研究主学位论文
一
适应环境和重新学习生活、工作所需的技能的过程。除非病情极轻，
否则CNS的自发恢复总是有限的，要提高恢复的程度和使患者能够
适应环境和独立生活，就必须功能训练。但其机制尚不十分清楚。
本实验即是通过观察康复训练对脑梗死大鼠大脑皮质中NOS（一
氧化氮合酶）阳性神经元和n38（svnantoPhvsin；突触膜糖蛋白）
免疫阳性物质表达的影响，探讨康夏训练促进大脑功能恢复的机制，
为临床脑卒中康复提供理论基础。
NOS是NO（一氧化氮）合成的限速酶，是调节＼0的最重要环节。
＼0是一种生物信使分子，参与脑内多种生理或病理过程。在脑缺血
过程中卜0具有双重作用，既有神经毒性作用，又有神经保护作用。
P3S是位于突触小泡膜上的特异性糖蛋白，构成突触小泡特异性膜通
道；参与突触小泡膜与突触前膜的融合和神经递质释放。p38作为突
触终末特异性标记物，可间接反映突触的密度及分布，己广泛用于
神经系统的发育、疾病、损伤和再生等的研究。
本实验将60只大鼠随机分为正常组，梗死24h组，康复训练l。
2、3、4。组，制动1、2、3、4W组，每组6只。采用光化学法制作
脑梗死大鼠模型：叶绿素衍生物IV号（CPD。）为光敏剂，He十e激光
照射左侧前后肢皮质代表区20分钟。康复组大鼠每天进行水迷宫。
转棒、滚笼训练，制动组网状笼内固定。在脑梗死后不同时间灌注
切片，使用组织化学技术观察大脑皮质＼OS阳性神经元的表达，以
及通过免疫组织化学ABC法和图像分析方法观察P38免疫阳性物质
的表达，SPSS统计软件方差分析。
结果发现：门）正常大鼠双侧大脑皮质中即有NOS阳性神经元
表达。梗死24h梗死灶周围及对侧相应皮质中＼OS阳性神经元表达
明显增多（P＜0．05）。Iw时，NOS阳性神经元双侧表达减少，制动组
较康复训练组减少的更加明显（P＜0．01）。2。时，在梗死灶周围阳性
神经元数量两组相差仍显著（P＜0．05），对侧皮质己不明显（P＞0．05）。
－2－
第四军医大学硕士研究生学位论文
3、4W时两组在梗死灶周围和对侧皮质相差均不显著（p＞0．05）。
（2）正常大鼠双侧大脑皮质中即可见到 P3S免疫阳性产物点
状分布，梗死24h梗死灶周围及对侧相应皮质中免疫染色未见明显
变化（p＞0．05）。Iw时，康复训练组、制动组和正常鼠之间 p38染色
亦无明显差异（…0．05）。ZW时，康复组大鼠在梗死灶周围皮质及对
侧相应皮质中，邓8表达明显增加（小0．0U：制动组大鼠亦有明显
增高（P＜0．05）。但康复训练组与制动组相比，在梗死灶周围和对侧
皮质中均无明显差异（P＞0．05）。3＼4W时，两组大鼠P38表达较正
常鼠有显著升高（P＜0．of），而且康复训练组无论在梗死灶周围还是
对侧皮质，P38表达较制动组均有明显增加（P＜0．05）。
我们认为：＊
Stroke is found as one of common diseases in central nervous system, and seriously dangerous to the human health. It leads to high mortality and incidence of disability. Active rehabilitation could make 90 percent of survivors recover walking and self-care, and 30 percent reengage in trivial work. Without rehabilitation, those recoveries above are only limited 60% and 5% respectively. In order to improve quality of life and return to society earlier, rehabilitation is more and more important for the patients with stroke, and it is widely supported to explore the bases that CNS function could recover from injury.
From lots of experiments and clinical researches for many years, it has been recognized that mature CNS could acquire ability to reorganize the structure and function or has plasticity whatever among mammallian or nonmammallian species, which makes it possible to recover from damage. The plasticity is defined that brain has adaptation that is brain could alter its structure and function to adjust to changed conditions. The plasticity of CNS is performed to occur at multi-levels and stages such as synapses, neurons, pathway and cerebral cortex as well. This is because any activity needs synchronous activation of many neurons and participation of lots of pathway and cortex. If major area where a certain activity is conducted is injured or diseased, this activity will be transferred to other neurons, pathway and areas of cortex. The alteration is determined by CNS potency of recovery and adaptation from damage,
as well as by motor learning before and after injury. Prompt rehabilitation training could promote this alteration.
It is increasingly clear that rehabilitation training plays an important role in the brain functional reorganization. The training is a process to exercise to react to stimulation promptly and properly, adapt to environment and relearn technique in life and work through interaction with other people and surroundings. The spontaneous recovery of CNS is limited unless patients' status is not serious at all. It is necessary for patients to take rehabilitation training in order to improve the effectiveness of recovery, adapt to surroundings and take self-care. But the mechanisms are not entirely clear.
The present study is to investigate the effects of rehabilitation training on the expression of NOS-positive neurons and synaptophysin (p38) immunoreactivity in the cortex of cerebral infarcted rats, and to explore the mechanism of rehabilitation training promoting cerebral function recovery, to provide theoretic bases to clinical rehabilitation of stroke.
NOS (nitric oxide synthase) is the rate-limiting enzyme during NO (nitric oxide) synthesis and the most important step in modulation of nitric oxide. As a biologic messenger molecule, NO is involved in many normal biological processes and pathological states. In brain ischemia, NO is dual functional, not only in participating in neuronal excitotoxicity, but also in neuroprotection. P38 is a major glycoprotein of the synaptic vesicle membrane, and is capable of forming transmembrane channels. P38 could participate in vesicle-plasma membrane fusion and in releasing neurotransmitter. As an indicator of synapse, p38 measured by immunohistochemistry and subsequent image analysis has become an
- 6 -
? US
established indirectly way reflecting synaptic density and distribution, and is used in many researching fields of neural development, disease, injury and regeneration of neural system.
In the experiment 60 rats were divided into different groups randomly and 54 rats were made cerebral infarction models by photochemistry method: laser irradiation on the cortex areas of the left forelimb and hindlimb 10 minutes after the intravenous injection of photosensitive drug as chlorophyll derivative I\ . Rehabilitation group were given water maze, rotating bar and rolling cage exercises everyday, while immobilization group were fixed in cages. Histochemistry was used to detect the NOS-positive neurons express
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