柯文哲林清淵臺灣大學：方信元FANG, Hsin-YuanHsin-YuanFANG2007-11-272018-07-062007-11-272018-07-062004http://ntur.lib.ntu.edu.tw//handle/246246/55568腦血管疾病佔台灣地區十大死因的第二位，根據衛生署的統計，民國九十一年台灣地區因腦血管疾病死亡的人數約12,000人。腦血管疾病是指由各種原因引起腦的動脈系統與靜脈系統發生病理性改變所造成的疾病，大體上分成兩大類：一是出血性，二是缺血性。在台灣地區出血性腦血管疾病所佔的比例大約是百分之二十至三十，遠高於西方國家的百分之十至十五。出血性腦血管疾病的死亡率也明顯較缺血性腦血管疾病為高，所以自發性腦內出血病患，早期預測其預後，可以預防病情惡化，改善病患臨床治療效果。 根據西方國家的文獻報告，預測自發性腦內出血病患預後的指標包括：腦內血塊的體積、昏迷指數分數、血塊周圍腦組織水腫程度、是否合併腦室出血、糖尿病、發作時的收縮壓、血糖濃度及體溫。我們首先收集109個台灣中部地區自發性腦內出血病患，分析顯示除了上述的臨床預後指標外，在台灣地區，凝血因子、血小板數目與白血球數目均呈現與自發性腦內出血病患的預後也有明顯相關。 基於上述臨床研究結果，我們假設自發性腦內出血病患發作時，依據腦內出血量的多寡、腦組織受傷的程度、血塊周圍腦組織水腫的程度、是否發生水腦，產生大腦局部及全身性免疫反應有所不同。本實驗主要假說為免疫反應的強弱與快慢，與自發性腦內出血病患的預後有相關。 本實驗收集自發性腦內出血病患，前四天的周邊血液與腦脊髓液之標本，並收集臨床相關資料包括年齡、血壓、體溫、昏迷指數分數、腦內出血分數(Intracerebral hemorrhage (ICH) score)、急性生理及慢性健康評估分數(Acute Physiology and Chronic Health Evaluation II (APACHE II) score)、血糖濃度等。利用反轉錄聚合酶連鎖反應(Reverse transcription-polymerase chain reaction (RT-PCR))與酵素免疫分析的方法(Enzyme-linked immunosorbent assay (ELISA))，測量其血液與腦脊髓液中細胞激素之濃度，測量之細胞激素包括熱休克蛋白70(Inducible heat shock proteins 70 (HSP70))，介白素-18(Interleukin-18 (IL-18))，腫瘤壞死因子(Tumor necrosis factor alpha (TNF-?)，介白素-11(Interleukin-11 (IL-11))。其中HSP70，IL-18與TNF-ㄛ隻韭薑瑑o免疫反應之促進發炎細胞激素（pro-inflammatory cytokines），IL-11則為抑制發炎之細胞激素(anti-inflammatory cytokines)，並探討這些細胞激素濃度與臨床預後指標之間的相關性。本實驗並取得彰化基督教醫院人體試驗委員會同意書。 實驗結果顯示，在自發性腦內出血的病患，收集其周邊血液的單核球，利用反轉錄聚合酶連鎖反應的方法定性的方法顯示HSP70，IL-18，TNF-ㄢㄖe現持續陽性反應。並進一步利用酵素免疫分析的方法定量血漿與腦脊髓液內細胞激素濃度，比較存活者與非存活者，發現在非存活者一組中，其血漿內第一天的HSP70，與TNF-ˋ@度有統計意義的顯著升高。比較第一天的血漿與腦脊髓液內細胞激素濃度發現，腦脊髓液內的TNF-˙PIL-11較血漿中的為高，IL-18則相反，血漿與腦脊髓液內HSP70的濃度相當。 綜合以上結果顯示，自發性腦內出血病患發作時，可先後產生大腦局部及全身性免疫反應，使血漿與腦脊髓液內的一些細胞激素濃度上升，這些細胞激素與病患的臨床預後因子呈現明顯相關，藉由早期偵測血漿中細胞激素之濃度變化，可以早期預知自發性腦內出血病患的預後。Background: The volume of intracerebral hemorrhage (ICH), Glasgow Coma Scale (GCS) score, peripheral relative edema around the hematoma, and hydrocephalus are all good early predictors of mortality in spontaneous ICH patients from Western Countries. However, the significance of hematological and biochemical parameters associated with spontaneous ICH has not been extensively studied. The first purpose of this study was to determine the prognostic factors of spontaneous ICH in Taiwanese patients. Inducible Heat shock proteins 70 (HSP70) is a stress protein whose expression is upregulated when cell or organism is placed under condition of stress and detected in the central nervous system. The tumor necrosis factor alpha (TNF-? and Interleukin-18 (IL-18) are multi-potential cytokines with early inflammatory properties and detected in the central nervous system and peripheral blood. Interleukin-11 (IL-11) is a multi-potential cytokine with anti-inflammatory and fibrogenic properties. It is detected in the central nervous system. The second purpose of this study was to determine plasma and cerebral spinal fluid (CSF) levels of HSP70, IL-18, TNF-? and IL-11 in patients with spontaneous ICH and to correlate these cytokines with related edema of brain, hydrocephalus, and severity of disease. Methods: We prospectively studied 109 consecutive patients with spontaneous ICH between September 2002 and June 2003 admitted to surgical intensive care units of Changhua Christian Medical Center in central Taiwan. Clinical and laboratory data were collected and analyzed. The plasma and CSF samples were collected on the first, second, third and fourth day after spontaneous ICH onset. Results: The mean age of our patients was 62.3±13.7 years. There were 63 men (58%) and 46 women (42%). The differences in GCS score and ICH score between the survival and non-survival groups were statistically different. Laboratory data was statistically different between the two groups for platelet count, prothrombin time (International Normal Ratio (INR)), and blood glucose levels using multivariate analysis. The m-RNA of HSP70, IL-18, and TNF-?continued expressed in peripheral mononuclear cells after spontaneous ICH onset. The levels of TNF-?in CSF were higher than in plasma. The levels of IL-18 in CSF were about one-fourth of that in plasma. The levels of IL-18 in plasma were significantly higher than in CSF, but did not associate with mortality. On the first day of spontaneous ICH, plasma levels of TNF-?and HSP70 were significantly higher than in the non-survival group. Plasma levels of IL-11 in the non-survival group were significantly higher than those in the survival group after the second day of ICH onset. In the hydrocephalus group, plasma levels of IL-11 were significantly higher than these of the non-hydrocephalus group on the fourth day. The volume of hematoma had a statistical correlation with plasma IL-11 on the third day. Conclusions: This is the first study providing information on predictors of spontaneous ICH mortality in Taiwanese patients. The prothrombin time and platelet count on the first day were good early predictors of mortality. This finding in Taiwanese patients is different from the picture in patients from Western Countries. TNF-? and HSP 70 were released to the peripheral blood from the damaged brain and highly associated with mortality in spontaneous ICH patients. We believed that TNF-? and HSP70 could be useful predictors of outcome in spontaneous ICH patients. IL-11 was highly associated with mortality of spontaneous ICH, and predicted the hydrocephalus occurring after ICH onset. We believed that IL-11 could be a useful clinical maker for spontaneous ICH patients.誌謝 1 目錄 2 一、中文摘要 4 二、緒論 6 台灣地區的腦血管疾病 自發性腦內出血的診斷及病因探討 急性腦內出血的臨床治療方法 預測自發性腦內出血病患的預後 台灣自發性腦內出血患者的預後情形 自發性腦內出血病患發作後，早期預測其預後之臨床重要性 自發性腦內出血病患引發之天然與後天免疫炎症反應 實驗假說 自發性腦內出血與促進炎症狀態細胞激素 自發性腦內出血與抑制炎症狀態細胞激素 研究的目的 三、研究方法與材料 10 研究一：台灣地區自發性腦內出血病患臨床分析 自發性腦內出血病患之族群分析 急診室自發性腦內出血病患之臨床與實驗室檢查評估 急診室自發性腦內出血病患者神經學評估 腦內出血分數(ICH分數)之定義 Relative edema分數之定義 腦部電腦斷層掃描之水腦判定標準 自發性腦內出血患者臨床預後的評估 研究二、三：自發性腦內出血與促進炎症狀及抑制炎症狀態之細胞激素分析 自發性腦內出血病患之族群分析 自發性腦內出血病患之血漿及腦脊髓液標本的收集 反轉錄聚合酶連鎖反應(RT-PCR) 酵素免疫分析法(ELISA)，測量血漿與腦脊髓液中細胞激素的濃度 統計分析方法 四、結果 13 第一部份：台灣中部地區自發性腦內出血病患臨床分析結果 第二部份：自發性腦內出血與促進炎症狀態細胞激素分析結果 第三部份：自發性腦內出血與抑制炎症狀態細胞激素分析結果 五、討論 17 第一部份：台灣中部地區自發性腦內出血病患臨床分析 第二部份：自發性腦內出血與促進炎症狀態細胞激素分析 第三部份：自發性腦內出血與抑制炎症狀態細胞激素分析 結論 六、展望 22 七、論文英文簡述 23 八、參考文獻 25 九、圖表 29 表一：ICH分數之定義與計算方式 表二：比較腦內出血病患之基本資料與神經狀態評估(第一部份) 表三：比較腦內出血病患之急診住院時生命狀態與實驗室檢驗值(第一部份) 表四：比較存活組與非存活組，腦部電腦斷層掃描的差異(第一部份) 表五：比較腦內出血病患，存活組與非存活組的差異(第二部份) 表六：比較腦內出血病患，存活組與非s活組的差異(第三部份) 圖一：腦部電腦斷層掃描來評估relative edema分數之定義 圖二：分析自發性腦內出血病患一年之存活情形 圖三：腦內出血病患依據Glasgow outcome scale分數之分析 圖四：促進炎症狀態細胞激素之反轉錄聚合酶連鎖反應 圖五：促進炎症狀態細胞激素，在存活組與非存活組之血漿內濃度差異 圖六：促進炎症狀態細胞激素在血漿內和腦脊髓液之濃度差異 圖七：促進炎症狀態細胞激素相關係數與回歸分析 圖八：抑制炎症狀態細胞激素IL-11，在存活組與非存活組之血漿內濃度差異 圖九：血漿和腦脊髓液中，IL-11之濃度差異 圖十：IL-11和relative edema分數之關係 圖十一：IL-11和與水腦之關係 圖十二：血塊的體積與血漿內IL-11濃度的相關與線性回歸 十、附錄 47 相關論文 人體試驗委員會同意書3631020 bytesapplication/pdfen-US腫瘤壞死因子細胞激素自發性腦內出血預後介白素-18介白素-11腦血管疾病熱休克蛋白70cytokinesinducible heat shock proteins 70tumor necrosis factor alphainterleukin-11cerebrovascular diseasespontaneous intracerebral hemorrhageinterleukin-18prognosisotherhttp://ntur.lib.ntu.edu.tw/bitstream/246246/55568/1/ntu-93-P91421002-1.pdf