1、神经保护剂及脑卒中的治疗策略,内容,神经保护治疗的概念神经保护剂的现状从失败到成功自由基清除剂神经保护剂的分层用药神经保护剂的联合用药,急性缺血性卒中,References: 1. Lipton P. Ischemic cell death in brain neurons. Physiological Reviews. Oct 1999; vol. 79; 1431-1568. 2. Lo EH, Dalkara T, Moskowitz MA. Mechanisms, challenges and opportunities in stroke. Nat Rev Neurosci. 200
2、3;4(5):399-415.,正常组织,半暗带组织,坏死组织,脑血流,正常脑血流的40%,正常脑血流的150%,缺血核心和半暗带,缺血性卒中的病理生理,血栓形成或栓塞,脑血流量,ATP,Nai+ Cai2+ Cli- Ke+,Ca2+i,激活脂酶、 蛋白酶、核酸内切酶,细胞损伤,细胞毒性水肿,谷氨酸,脂肪酸,脂质过氧化,生物化学级链反应,氧和能量底物减少,膜去极化,钙超载,谷氨酸释放钙离子内流,NMDA/AMPA 受体,References: 1. Dirnagl U, Iadecola C, Moskowitz MA. Pathobiology of ischaemic stroke: a
3、n integrated view. Trends Neurosci. 1999;22(9):391-7. 2. Lee JM, Grabb MC, Zipfel GJ, Choi DW. Brain tissue responses to ischemia. J Clin Invest. 2000;106(6):723-31.,神经保护可以改善临床预后,急性缺血性卒中,神经细胞死亡,再灌注级链反应,缺血级链反应,一氧化氮,自由基增加,自由基增加,其中一个途径使减少自由基损害1,2,References: 1. Bright, R, Mochly-Rosen D. The role of pr
4、otein kinase C in cerebral ischemic and reperfusion injury. Stroke. 2005;36(12):2781-90. 2. Lipton P. Ischemic cell death in brain neurons. Physiol Rev. 1999;79(4):1431-568.,去极化,NMDA/AMPA 受体活化,谷氨酸释放,钙离子增加,神经保护和神经恢复,神经保护剂的作用,Reference: 1. Fisher M. The ischemic penumbra: identification, evolution and
5、 treatment concepts. Cerebrovasc Dis. 2004;17(suppl 1):1-6.,内容,神经保护治疗的概念神经保护剂的现状从失败到成功自由基清除剂神经保护剂的分层用药神经保护剂的联合用药,神经保护应用的范围,神经外科心脏外科Beating heart心脏骤停颈动脉治疗创伤卒中（缺血性和出血性）,潜在治疗,缩短缺血时间减少细胞内钙离子浓度减少细胞内钠离子浓度阻断谷氨酸作用Block effects of glutamate抑制自由基Trap free radicals抑制PARP活性阻断caspase活性阻断白细胞黏附改变细胞膜流动性降低组织温度,神经保护剂
6、:夭折的婴儿,动物实验有效临床试验无效,卒中神经保护治疗是否是基础科学工作者编织的梦？Is Neuroprotective Stroke Therapy Just a Fanasy Invented by Basic Scientists?,缺血神经保护剂：路在何方？,New Pharmacological agentsCocktail approach,Consummating the Marriage Between the Laboratry and Bedside,Grotta JC. University of Texas-Huston Medical School,Ubiquiti
7、n-Proteasome Complex,Ubiquitin-Proteasome Complex,Ubiquitin-Proteasome Complex,Hu et al, J. Neurosci, 2000, 20(9):3191,Following 15 min global cerebral ischemia, protein aggregates are ubiquitin labeled,CA1,DG,血管保护治疗,Synthesis and Screening10,000Pre-clinical development appraisal6,000Phase I50Sub-ac
8、ute toxicity 20Phase IIA (PoC) 15Chronic toxicity 10Clinical Phase II 5Carcinogenicity 3PLA1Market1Post Market?Probability of Success = 1 in 10,000,COST PER COMPOUND $US1 BN,New discovery compounds,内容,神经保护治疗的概念神经保护剂的现状从失败到成功自由基清除剂神经保护剂的分层用药神经保护剂的联合用药,神经保护剂的误区(Pitfalls),临床前研究的时窗极短，而临床研究的时窗较长临床前治疗靶区是半
9、暗带，而临床试验则不是临床前治疗偏向对灰质的保护，而临床不针对特定的临床定位尚不清楚确切疗程临床前研究疗效判定主要依据梗死面积，而临床主要依据行为学临床前主要依据早期预后，而临床是远期评价卒中模型为同质性,而人类卒中为异质性预后测量方法比实际疗效更重要用小规模试验回答大规模试验要回答的问题,内容,神经保护治疗的概念神经保护剂的现状从失败到成功自由基清除剂神经保护剂的分层用药神经保护剂的联合用药,Oxygen Metabolism,Mitochondria e - transport,H2O2,H2O,O2,O2.-,SER,P-450,PHSAAPGsLTs,H2O,O2,O2.-,Perox
10、isomeOxidases,O2,Membrane,MPx,NOS,NO.,H2O2,O2.-,NO.,HOCl-,PS,O2,1O2,hn,缺血半暗带超氧化物(自由基)增加(n=18),600,500,400,300,200,100,0,100,200分钟,缺血1小时后再灌注脑中动脉缺血对照,超氧化物化学发光计数,PetersO.etal.,1996,钙超载导致自由基产生,促氧化酶1: 一氧化氮合成酶 环氧化酶, 腺嘌呤脱氢酶，腺嘌呤氧化酶，NADPH氧化酶 髓过氧化酶和单氨氧化酶,References: 1. Chan PH. Reactive oxygen radicals in sig
11、naling and damage in the ischemic brain. J Cereb Blood Flow Metab. 2001;21(1):2-14. 2. Schild L, Reiser G. Oxidative stress is involved in the permeabilization of the inner membrane of brain mitochondria exposed to hypoxia/reoxygenation and low micromolar Ca2+. FEBS J. 2005;272(14):3593-601.,自由基可以损害
12、细胞和DNA,MMP活化,细胞处理过程失调,内皮细胞,DNA氧化损伤,自由基,线粒体破坏,细胞膜破坏,References: 1. Lipton P. Ischemic cell death in brain neurons. Physiological Reviews. Oct 1999; vol. 79; 1431-1568. 2. Dirnagl U, Iadecola C, Moskowitz MA. Pathobiology of ischaemic stroke: an integrated view. Trends Neurosci. 1999;22(9):391-7.,自由基损
13、伤线粒体,References: 1. Dirnagl U, Iadecola C, Moskowitz MA. Pathobiology of ischaemic stroke: an integrated view. Trends Neurosci. 1999;22(9):391-7. 2. Sasaki C, Kitagawa H, Zhang WR, Warita H, Sakai K, Abe K. Temporal profile of cytochrome c and caspase-3 immunoreactivities and TUNEL staining after pe
14、rmanent middle cerebral artery occlusion in rats. Neurol Res. 2000;22(2):223-8.,缺血/再灌注使自由基产生增加,神经细胞,胶质细胞,内皮细胞,Stroke. 2004;35:1449-1453,SAINT I outcomes,1.20 (1.01-1.42),mRS,Subgroup interactions with primary endpoint not significant,Treatment-timep=0.92Treatment-agep=0.62Treatment-severityp=0.72Tre
15、atment-alteplasep=0.93Treatment-diabetesp=0.98Treatment-glucosep=0.27etc,Safety: ICH after thrombolysis,Asympt ICHSympt ICH,20.9%,P0.005,SAINT-I结论,The administration of NXY-059 within six hours after the onset of acute ischemic stroke significantly improved the primary outcome (reduced disability at
16、 90 days), but it did not significantly improve other outcome measures, including neurologic functioning as measured by the NIHSS score. Additional research is needed to confirm whether NXY-059 is beneficial in ischemic stroke.,Treatment Interactions with Important Covariates,Primary Outcome at 90 D
17、ays According tothe Score on the Modified Rankin Scale,SAINT-II,NXY-059 is ineffective for the treatment of acute ischemic stroke within 6 hours after the onset of symptoms.,国内II期临床结果,入组病例229例，实际完成病例213例ESS评分：神经功能缺损评分、有效率在第7天、14天、21天均有显著性差异，且随着时间延长差异逐步明显；ADL评分：日常生活活动量表评分、有效率在第7天、14天、21天、90天均有显著性差异，且
18、随着时间延长差异逐步明显,*复旦大学附属华山医院,第二军医大学长征医院,浙江大学医学院第二附属医院,江苏省人民医院南京医科大学附属脑科医院，依达拉奉治疗急性脑梗塞_随机、双盲、叠加、对照、多中心临床试验,日本III期临床,CerebrovascularDiseases2003;15(3):222-9Effectofanovelfreeradicalscavenger,edaravone(MCI-186),onacutebraininfarction.Randomized,placebo-controlled,double-blindstudyatmulticenters.,三期临床有效!,Ed
19、aravone Acute Infarction Study Group, Cerebrovascular Diseases 2003;15(3):222-9,神经保护治疗的概念神经保护剂的现状从失败到成功自由基清除剂神经保护剂的分层用药神经保护剂的联合用药,Kidwell CS et al, Ann Neurol 52:698-703, 2002,Reperfusion injury ?,再灌注增加自由基的产生,MMP 活化,再灌注,DNA氧化损伤,自由基,炎性细胞活化,细胞因子(TNF, IL-1),References: 1. Schild L, Reiser G. Oxidative
20、stress is involved in the permeabilization of the inner membrane of brain mitochondria exposed to hypoxia/reoxygenation and low micromolar Ca2+. FEBS J. 2005;272(14):3593-601. 2. Dirnagl U, Iadecola C, Moskowitz MA. Pathobiology of ischaemic stroke: an integrated view. Trends Neurosci. 1999;22(9):39
21、1-7. 3. Lo EH, Dalkara T, Moskowitz MA. Mechanisms, challenges and opportunities in stroke. Nat Rev Neurosci. 2003;4(5):399-415.,血管再通时间与出血转化,Stroke 2001;32:1079-1084,血管灌注后的高灌注综合征,内容,神经保护治疗的概念神经保护剂的现状从失败到成功自由基清除剂神经保护剂的分层用药神经保护剂的联合用药,Interaction within ischemic pathophysiology of the currently most pr
22、omising candidates for a multimodal neuroprotective approach,从神经保护到脑保护,神经保护,血管保护,胶质保护,脑保护,Vessel occlusion,ISCHAEMIA,Endogenousthrombolysis,Free radicals,GluNMDA,Voltagegated,Ca entry,Apoptosis,CELLDEATH,InflammatoryresponseNo Reflow,The Ischaemic Cascade,Combination Therapy: Nicotinamide plus Melatonin2 hrs Transient MCAo Spraque-Dawley Rats,VehicleNicotinamideMelatoninCombination,Gupta S, Kaul C, Sharma S. Neurol Res, 26: 103-7, 2004,* P .05,Y Yan, Q Li, A Shuaib Neuropharmacol 39:881-888, 2000,Rat embolic model: Urokinase plus Topiramate,谢谢,
