缺血性卒中基礎與臨床研究進展

馬媛媛 楊國源

腦卒中系各種原因引起的腦血管病變致局灶性神經(jīng)功能缺損或中樞神經(jīng)系統(tǒng)損傷［1］。腦卒中是目前導致全球人類死亡的第2位疾病，是導致成人永久性病殘的首要病因［2?3］。美國每40秒即有1例罹患腦卒中［4］。2013年，全球有 103×106例發(fā)生腦卒中，65×106例死于腦卒中，達11.30×106/殘疾調(diào)整生命年（DALY）［5］。由于不發(fā)達國家腦卒中危險因素增加，其造成的經(jīng)濟負擔仍有增加趨勢。預計截至2030年，腦卒中病死例數(shù)將達120×106例，達0.20×109/殘疾調(diào)整生命年［6］。我國是腦卒中負擔最重的國家之一，過去30年間腦卒中負擔增加，特別是農(nóng)村地區(qū)［7?8］，2013 年我國腦卒中患病率、發(fā)病率和病死率分別為1114.80/10萬、246.80/10萬和114.80/10 萬［9］。

腦卒中包括缺血性卒中（約占87%［10］）和出血性卒中。既往數(shù)十年，腦卒中的臨床治療取得新的進展，特別是血管內(nèi)機械取栓的出現(xiàn)，開啟缺血性卒中治療的新篇章。對于梗死灶小且有良好側(cè)支循環(huán)的患者，血管內(nèi)機械取栓可以顯著改善臨床癥狀［11?12］。隨機對照臨床試驗顯示，缺血性卒中 8 小時內(nèi)予血管內(nèi)機械取栓治療可以有效改善臨床癥狀［13］。英國國家衛(wèi)生與臨床優(yōu)化研究所（NICE）制定指南，只要條件允許，靜脈溶栓和血管內(nèi)機械取栓是缺血性卒中治療的“金標準”［1］。目前，缺血性卒中的治療策略主要分為三步：建立卒中單元；對符合條件的患者進行靜脈溶栓；血管內(nèi)機械取栓重新開通堵塞的血管［14?18］。但是由于嚴格的治療時間窗（腦卒中后4.50小時內(nèi)）或存在嚴重的并發(fā)癥風險，僅不足5%的患者予以重組組織型纖溶酶原激活物（rt?PA）靜脈溶栓，部分行rt?PA 靜脈溶栓治療的患者可同時行血管內(nèi)機械取栓治療，大多數(shù)缺血性卒中患者僅行對癥支持治療［19］。有研究顯示，行rt?PA靜脈溶栓的患者中僅10%臨床預后較好，行血管內(nèi)機械取栓的患者中71%實現(xiàn)血管再通、僅50%實現(xiàn)缺血?再灌注［20?22］。因此，積極尋找改善缺血性卒中預后的方法即顯得尤為重要。盡管缺血性卒中病理生理學機制復雜，臨床治療進展緩慢，尚待大量動物實驗和臨床前試驗以加快臨床轉(zhuǎn)化進程，但是目前已有眾多臨床前或臨床治療策略顯示出較好的治療潛能。本文擬就我國國民經(jīng)濟和社會發(fā)展第十二個五年規(guī)劃（以下簡稱“十二五”）時期取得的缺血性卒中基礎與臨床研究進展進行概述。

一、組學技術進展

無論是靜脈溶栓，還是快速有效促進組織修復或減少損傷均需要有特定方向，多組學技術的出現(xiàn)為缺血性卒中提供新的特異性治療靶點。多組學技術包括基因組學、二代基因測序、轉(zhuǎn)錄組學、蛋白質(zhì)組學和代謝組學。通過上述組學技術，不僅可以發(fā)現(xiàn)腦卒中損傷或修復相關病理生理學機制，同時還可以為臨床藥物試驗提供快速評價藥物毒性和治療效果的分子學標志物。全基因組相關性研究（GWAS）業(yè)已發(fā)現(xiàn)眾多與腦卒中發(fā)生與發(fā)展相關的重要遺傳學標志物，如定位于12q24的ALDH2基因與所有類型缺血性卒中密切相關，而某些基因如HDAC9基因和定位于1p13.2的TSPAN2基因與大動脈粥樣硬化型（LAA型）密切相關，PITX2和ZFHX3基因與心源性栓塞型（CE型）密切相關［23］，某種單核苷酸多態(tài)性（SNP）與冠心病密切相關［24］。最近研究顯示，髓過氧化物酶（MPO）基因表達上調(diào)與腔隙性梗死密切相關，由于該基因不受環(huán)境因素的影響，提示MPO基因是腦血管病的致病基因［25］?；蚪M學的進展為早期采取有效措施干預腦卒中高危人群生活方式和針對性治療提供可能。

蛋白質(zhì)組學和代謝組學的快速發(fā)展有利于腦卒中的診斷、治療和預后評價。蛋白質(zhì)組學技術發(fā)現(xiàn)，rt?PA靜脈溶栓可以引起腦卒中患者血漿蛋白酶如基質(zhì)金屬蛋白酶（MMPs）表達變化，提示rt?PA可能通過改變相關蛋白質(zhì)表達水平或調(diào)節(jié)蛋白酶活性發(fā)揮治療作用或引起顱內(nèi)出血等并發(fā)癥［26］。蛋白質(zhì)組學技術有助于發(fā)現(xiàn)腦卒中后血?腦屏障（BBB）破壞相關關鍵靶分子，從而拓寬rt?PA靜脈溶栓的治療范圍。蛋白質(zhì)組學技術顯示，血清淀粉樣蛋白A（SAA）水平升高與腦卒中后感染密切相關，提示可以通過檢測血清淀粉樣蛋白A表達變化以預測并預防腦卒中后感染的發(fā)生［27］。臨床前實驗方面，通過蛋白質(zhì)組學技術發(fā)現(xiàn)，與缺血性卒中組和缺血預處理組小鼠相比，缺血性卒中耐受組小鼠腦組織轉(zhuǎn)錄抑制蛋白特別是多梳家族（PcG）水平升高，介導腦卒中后神經(jīng)保護的表觀遺傳學機制［28］。亦有研究顯示，缺血性卒中患者移植骨髓間充質(zhì)干細胞（BMSCs）后，一些蛋白質(zhì)如Abca1、Grb2、Ptgds等水平升高，提示其可能是骨髓間充質(zhì)干細胞發(fā)揮治療作用的關鍵［29］。因此，蛋白質(zhì)組學技術可以提供更多有價值的信息，有助于研究人員更好地探討缺血性卒中的病理生理學機制，為臨床治療缺血性卒中提供新的靶點。代謝組學通過檢測體液中小分子代謝物，一方面可以增加影像學檢查的敏感性，另一方面可以有助于預測短暫性腦缺血發(fā)作（TIA）患者發(fā)生腦卒中的可能［30?31］。有學者采集腦卒中患者體液包括血漿、尿液和糞便進行代謝組學分析，發(fā)現(xiàn)血漿和尿液同型半胱氨酸（Hcy）、葉酸、支鏈氨基酸和脂質(zhì)代謝物水平可以預測腦卒中復發(fā)風險［32］。此外，血漿支鏈氨基酸和脂質(zhì)代謝物水平降低與腦卒中后抑郁（PSD）和腦卒中后認知功能障礙（PSCI）相關［33］。根據(jù)腦卒中特殊病理生理學變化，聯(lián)合代謝組學技術可以將腦卒中分為不同亞組，以進行更加精準的治療［34］。更重要的是，代謝組學技術不僅可以彌補蛋白質(zhì)組學不能快速診斷的缺陷，而且可以將蛋白質(zhì)組學和基因組學信息相聯(lián)系。有學者采用代謝組學技術研究白藜蘆醇治療缺血性卒中的作用機制，發(fā)現(xiàn)神經(jīng)元沉默信息調(diào)節(jié)因子1（SIRT1）基因可以調(diào)節(jié)葡萄糖代謝和糖酵解過程，影響實驗動物對缺血性卒中的耐受程度，提示代謝組學可以作為研究缺血性卒中發(fā)病機制和藥物作用機制的新方法［35］。未來有望通過上述組學技術、多學科合作，更好地研究腦卒中發(fā)病機制和損傷機制［1］。

二、基因治療進展

腦卒中后數(shù)小時至數(shù)周，腦組織損傷仍在繼續(xù)，為基因治療提供可能。目前，基因治療的主要措施是通過外源性導入具有抗凋亡、增加細胞存活、靶向引導干細胞、促進血管再生和神經(jīng)再生等作用的基因，最大程度地促進組織恢復、減輕腦組織損傷［36］?？沟蛲龌蛑饕荁細胞淋巴瘤/白血病?2（Bcl?2）家族成員，包括 Bcl?2、Bcl?xL 和 Bcl?2l2或 Bcl?w，可以調(diào)節(jié)細胞凋亡、促進神經(jīng)再生［37］。基礎研究顯示，多種病毒載體，如單純皰疹病毒（HSV）［38］、腺病毒［39］、腺相關病毒（AAV）［40］和慢病毒［41］等均可介導缺血性卒中后 Bcl?2 過表達，且發(fā)揮良好治療作用。通過單純皰疹病毒載體在腦組織中過表達Bcl?2，可以減少梗死灶體積、減輕神經(jīng)膠質(zhì)細胞增生，可能是通過抑制骨形態(tài)發(fā)生蛋白4（BMP?4）表達上調(diào)以促進腦缺血后紋狀體區(qū)神經(jīng)再生［42］。過表達Bcl?2可以抑制腦卒中后腦組織凋亡誘導因子（AIF）的核轉(zhuǎn)位，增加神經(jīng)元存活［43］。亦有研究顯示，缺血性卒中患者腦組織過表達熱休克蛋白（HSP）家族成員HSP72和谷胱甘肽過氧化物酶（GSH?Px），通過上調(diào) Bcl?2表達以發(fā)揮減少腦缺血后神經(jīng)元損傷、促進長期功能恢復的作用［44?45］。

神經(jīng)營養(yǎng)因子具有調(diào)節(jié)神經(jīng)細胞生長、發(fā)育、增殖、分化，并在生理和病理環(huán)境下促進神經(jīng)細胞存活，維持神經(jīng)細胞穩(wěn)態(tài)的作用。目前，多項研究采用不同病毒載體在腦組織過表達神經(jīng)營養(yǎng)因子相關基因，如血管內(nèi)皮生長因子（VEGF）［46］、腦源性神經(jīng)營養(yǎng)因子（BDNF）［47］、膠質(zhì)細胞源性神經(jīng)營養(yǎng)因子（GDNF）［48?50］、睫狀神經(jīng)營養(yǎng)因子（CNTF）［48］、腦多巴胺源性神經(jīng)營養(yǎng)因子（CDNF）［51］和類肝素結(jié)合樣表皮生長因子（HB?EGF）［52］，可以不同程度減小梗死灶體積和抑制凋亡通路激活，從而減輕腦組織損傷。除直接過表達神經(jīng)營養(yǎng)因子相關基因以發(fā)揮神經(jīng)保護作用外，亦可以過表達增加內(nèi)源性干細胞活性的基因和促內(nèi)源性修復的基因，如趨化因子CXCL12，又稱基質(zhì)細胞衍生因子?1（SDF?1），于缺血性卒中后表達上調(diào)［53］。研究顯示，缺血性卒中前3天預過表達或腦卒中后1周過表達CXCL12，可以減輕腦萎縮，促進血管新生和神經(jīng)再生，促進少突前體細胞遷移、分化、髓鞘再生，從而加速腦組織修復［54?56］。另一種神經(jīng)生長因子——軸突導向因子?1（netrin?1）在生理狀態(tài)下可以促進神經(jīng)軸突生長、發(fā)育和成熟，發(fā)生缺血性卒中時表達上調(diào)。研究顯示，缺血性卒中小鼠腦組織過表達軸突導向因子?1，可以促進腦缺血后少突膠質(zhì)前體細胞增殖和成熟，減輕白質(zhì)損害，改善腦卒中后運動功能、肢體協(xié)調(diào)能力和探索能力［57?58］。在既往研究中，過表達基因的時間點從預處理至腦卒中后即刻、數(shù)小時、1周，治療時間窗廣泛，為不同類型腦卒中的治療提供理論基礎。

三、微小RNA治療進展

微小RNA（miRNA）是小序列非編碼RNA，轉(zhuǎn)錄后可以調(diào)節(jié)多種蛋白質(zhì)表達。1993年，Lee等［59］首先在秀麗線蟲體內(nèi)發(fā)現(xiàn)miRNA。迄今已在200余種物種中發(fā)現(xiàn) 30 × 103余種 miRNA［60］。過去 10 年間，關于miRNA結(jié)構(gòu)、功能、生物學特性和病理生理學作用機制的研究發(fā)展迅速［61］。在病理條件下，血漿和體液miRNA含量迅速變化，通過調(diào)節(jié)下游靶蛋白表達加速或延緩疾病進程［62］。多種miRNA均與缺血性卒中高危因素如高血壓、糖尿病和動脈粥樣硬化等相關（表1），研究顯示，與正常對照者相比，高血壓患者血清miRNA?7?5p 和 miRNA?26b?5p 水平升高［63］，推測miRNA可能與高血壓的發(fā)生與發(fā)展相關；過表達miRNA?21可以通過抑制Bcl?2表達而誘導胰腺β細胞凋亡［64］，提示miRNA?21高表達可能加速糖尿病的發(fā)生；人動脈粥樣硬化血管組織中，miRNA?206 水平降低［65］；體外實驗結(jié)果顯示，過表達miRNA?206可以抑制血管平滑肌增殖，誘導其凋亡［66］，提示 miRNA?206可能是動脈粥硬化的治療靶點。缺血性卒中急性期，miRNA表達變化與腦卒中病理生理學機制如興奮性毒性、炎癥反應、氧化應激、細胞凋亡、血?腦屏障破壞等相關（表1），例如，缺血性卒中急性期血漿miRNA?181c水平降低，與血小板計數(shù)呈正相關［67］；缺血性卒中模型小鼠急性期腦組織過表達miRNA?181c，可以增加神經(jīng)元和小膠質(zhì)細胞凋亡及梗死灶體積［67］；缺血性卒中恢復期，miRNA通過調(diào)節(jié)神經(jīng)再生和血管再生促進腦組織修復［61］（表 1）。鑒于 miRNA 在缺血性卒中病理生理學機制中的重要作用，多項研究采用miRNA治療缺血性卒中，側(cè)腦室過表達miRNA?148b可通過調(diào)節(jié) Wnt/β?連環(huán)蛋白（β?catenin）信號轉(zhuǎn)導通路，促進缺血性卒中后神經(jīng)干細胞（NSCs）分化為成熟神經(jīng)元和星形膠質(zhì)細胞，從而促進神經(jīng)功能恢復［68］；腦組織過表達miRNA?1906可通過下調(diào)Toll樣受體4（TLR?4）水平以發(fā)揮減小梗死灶體積、促進功能恢復的作用［69］；過表達 miRNA?29b 可減輕血?腦屏障破壞、減小梗死灶體積，可能與抑制水通道蛋白4（AQP4）表達有關［70］。由于miRNA在體液中穩(wěn)定存在且具有組織特異性，有多項研究檢測血漿miRNA表達變化，旨在探討可以有效預測缺血性卒中和評價預后的新型miRNA，以填補臨床尚無針對缺血性卒中血漿分子生物學標志物的空白。最新研究顯示，腦卒中后抑郁患者血漿miRNA?92a?3p水平升高，與抑郁程度和前腦白質(zhì)高信號相關［71］，提示miRNA?92a?3p可能介導腦卒中后抑郁。另一項研究對缺血性卒中患者和正常對照者進行miRNA組學分析，證實缺血性卒中后血漿miRNA?125a?5p、miRNA?125b?5p和 miRNA?143?3p水平升高，提示這3種miRNA有望成為缺血性卒中早期診斷的分子標志物。盡管關于miRNA作為缺血性卒中分子標志物的研究較多，但目前臨床進展仍較緩慢，主要是由于既往miRNA檢測存在異質(zhì)性，且后續(xù)驗證缺乏科學嚴謹?shù)膶嶒炘O計［72］，尚待更多研究加速miRNA作為缺血性卒中分子標志物的臨床轉(zhuǎn)化過程［73］。

表1 腦卒中相關miRNATable 1. miRNAs associated with ischemic stroke

四、干細胞治療進展

目前，除rt?PA靜脈溶栓和血管內(nèi)機械取栓外，干細胞治療是最有可能從根本上促進缺血性卒中治療進展的方法［14］。干細胞治療包括胚胎干細胞（ESCs）［74?75］、誘導型多能干細胞（iPSCs）［76］、神經(jīng)干細 胞［77?79］、骨 髓 間 充 質(zhì) 干 細 胞［80?83］、造 血 干 細 胞（HSCs）［84］、內(nèi)皮祖細胞（EPCs）［85?86］、脂肪間充質(zhì)干細胞（ADSCs）［87］，可以改善缺血性卒中預后（表2）。具體作用機制尚待進一步研究，但目前實驗研究結(jié)果顯示，干細胞通過抑制炎癥反應、調(diào)節(jié)免疫應答、分化為成熟神經(jīng)元或內(nèi)皮細胞、促進神經(jīng)突觸重塑、促進神經(jīng)再生和血管再生、分泌神經(jīng)營養(yǎng)因子等多種途徑發(fā)揮治療作用［88?91］。干細胞治療缺血性卒中的基礎研究成果顯著，過去15年間有多項干細胞治療缺血性卒中的早期臨床試驗，其中一項多中心隨機雙盲Ⅱ期臨床試驗顯示，缺血性卒中急性期（24～48小時）靜脈移植異體多能干細胞（MultiStem?，美國Athersys公司）安全，能夠改善腦卒中后1年的神經(jīng)功能［91］。干細胞治療的最常見不良反應是頭痛和發(fā)熱，但多呈自限性，主要與移植途徑有關，頭痛主要出現(xiàn)在接受立體定位注射移植的患者［82，92?93］。最新的研究采用新的移植方式——經(jīng)鼻內(nèi)途徑移植。研究顯示，經(jīng)鼻內(nèi)途徑移植骨髓間充質(zhì)干細胞治療缺血性卒中可以促進神經(jīng)血管再生，改善神經(jīng)功能［94?95］。與其他移植方式如動脈注射移植、靜脈注射移植和立體定位注射移植相比，經(jīng)鼻內(nèi)途徑移植的優(yōu)勢在于簡單、無創(chuàng)且移植細胞可以快速通過鼻黏膜進入腦實質(zhì)。因此，經(jīng)鼻內(nèi)途徑移植有可能成為臨床干細胞移植途徑的新選擇［91，96］。多項研究證實，干細胞治療缺血性卒中安全、有效，關于其最佳治療時間窗和最佳移植途徑的臨床試驗仍在進行中［91，97］。移植的干細胞主要是外源性神經(jīng)干細胞、自體骨髓來源的間充質(zhì)干細胞（MSCs）、單核細胞和CD34+干細胞；移植途徑包括靜脈注射移植、動脈注射移植、鞘內(nèi)注射移植和立體定位注射移植；治療效果評價的最短時間是移植后24小時（https://www.clinicaltrials.gov/ct2/results?cond=&term=NCT00859014&cntry1=&state1=&recrs=，試驗編號：NCT00859014）、最長時間是移植 后 5年（https://www.clinicaltrials.gov/ct2/results?cond=&term=NCT01151124&cntry1=&state1=&Search=Search，試驗編號：NCT01151124）。干細胞治療缺血性卒中業(yè)已展現(xiàn)出巨大潛能，未來需要解決的問題主要有：（1）移植干細胞的來源。（2）干細胞治療的最佳時間窗。（3）最大程度發(fā)揮和維持移植干細胞促組織修復的功能特性有待突破。（4）移植時導致肺栓塞或腦栓塞及移植后成瘤（胚胎干細胞或誘導型多能干細胞）［92，98］有待解決。因此，尚待更多試驗設計科學、合理的大規(guī)模隨機對照臨床試驗以驗證干細胞治療的安全性和有效性，以及實驗設計科學、合理的基礎研究，以闡明干細胞生物學特性、提高干細胞治療效果。

表2 干細胞治療缺血性卒中臨床試驗Table 2. Clinical trials of stem cell therapy for ischemic stroke

五、藥物治療進展

腦卒中是一種由包括環(huán)境因素和遺傳因素在內(nèi)的多因素共同導致的疾病，其病理生理學過程復雜，多種生物學分子、細胞和信號轉(zhuǎn)導通路激活，給臨床治療帶來巨大挑戰(zhàn)，也同時提供多個可干預的治療靶點。缺血性卒中治療的首要目標是恢復腦組織灌注且不加重腦組織損傷，同時對加重缺血?再灌注損傷的因素進行調(diào)節(jié)，促進腦組織修復［1］。過去20年間有450種藥物應用于缺血性卒中的治療研究。迄今僅40種藥物進入臨床試驗階段，19種藥物在不同國家批準上市。目前，處于缺血性卒中臨床試驗階段或已應用于臨床的藥物主要包括溶栓藥、抗血小板藥、神經(jīng)保護藥和促組織修復藥［99?100］（表3）。

1.溶栓藥 主要包括rt?PA、瑞替普酶和替奈普酶［101］。一項I期臨床試驗結(jié)果顯示，急性缺血性卒中3～6小時聯(lián)合應用瑞替普酶和阿昔單抗可以改善腦缺血癥狀［102］。另一項Ⅱ期臨床試驗比較瑞替普酶與替奈普酶的治療效果，結(jié)果顯示，急性缺血性卒中3～4小時，替奈普酶組患者腦組織再灌注和神經(jīng)功能均優(yōu)于瑞替普酶組，認為替奈普酶有望進入Ⅲ期臨床試驗階段［103］。最近一項臨床試驗比較瑞替普酶和替奈普酶（相同時間點和相同治療劑量）的治療效果，結(jié)果顯示，二者對挽救缺血腦組織并無明顯差異［104］，提示兩種藥物的治療效果尚待大規(guī)模隨機對照臨床試驗的驗證。

2.抗血小板藥 主要包括阿司匹林、氯吡格雷和西洛他唑。阿司匹林通過抑制環(huán)氧合酶、氯吡格雷通過抑制ADP和嘌呤受體抗血小板聚集。阿司匹林是目前最主要的缺血性卒中二級預防藥物，氯吡格雷可用于阿司匹林過敏的腦卒中患者二級預防。由于可以增加顱內(nèi)出血風險，不推薦長期聯(lián)合應用阿司匹林和氯吡格雷［105］。研究顯示，缺血性卒中初期，與單純應用阿司匹林相比，更換另一種抗血小板藥或聯(lián)合應用其他抗血小板藥，發(fā)生心血管并發(fā)癥和腦卒中復發(fā)風險降低［106］。因此，阿司匹林和氯吡格雷的最佳臨床治療策略尚待進一步基礎與臨床研究。西洛他唑是新一代抗血小板藥，通過抑制磷酸二酯酶3（PDE3）抗血小板聚集。動物實驗顯示，在全腦缺血模型小鼠中，西洛他唑通過抑制C?Jun氨基末端激酶3（JNK3）/Caspase?3信號轉(zhuǎn)導通路以發(fā)揮減少神經(jīng)元凋亡和預防腦卒中后認知功能障礙的作用［107］。此外，西洛他唑還可以通過抑制細胞間粘附分子?1（ICAM?1）表達和激活小膠質(zhì)細胞，改善長期預后［108］。目前，西洛他唑主要用于治療血栓閉塞性脈管炎，未推薦用于缺血性卒中的治療，尚待進一步在缺血性卒中動物模型中進行研究，以為西洛他唑治療缺血性卒中提供理論證據(jù)。

3.神經(jīng)保護藥 包括中成藥銀杏葉和芹菜提取物丁苯酞（NBP）、甲磺酸法舒地爾、胞二磷膽堿、尤瑞克林、洛伐他汀、多奈哌齊、依達拉奉［109］、格列本脲、重組人活化蛋白C、Caffeinol等。臨床藥物主要針對缺血性卒中后介導腦組織損傷的不同病理生理學應激過程發(fā)揮作用，包括擴血管和增加腦血流量（CBF）［110?113］、抗氧化應激［114］、抗細胞凋亡［115?117］、抑制興奮性毒性［118?119］和抑制炎癥反應［99?100，120?121］等，其中，丁苯酞已進入Ⅳ期臨床試驗［99］。盡管臨床藥物治療研究取得一定進展，但某些藥物的臨床效果仍缺乏足夠證據(jù)，尚待高質(zhì)量的大規(guī)模隨機對照臨床試驗進一步驗證［122?124］。

表3 缺血性卒中治療藥物分類及作用機制Table 3. Classification and therapeutic mechanism of drugs for clinical treatment of ischemic stroke

4.促組織修復藥 目前臨床應用相對較少，基礎和臨床研究較多的主要是粒細胞集落刺激因子（G?CSF），可以促進造血干細胞動員和分化［125?126］，廣泛應用于遺傳性或獲得性粒細胞減少癥以及促進移植干細胞增殖［127］。近年動物實驗顯示，除用于造血系統(tǒng)疾病的治療外，粒細胞集落刺激因子還可以通過抑制細胞凋亡和炎癥反應，促進血管新生和神經(jīng)再生，促進腦組織修復，改善缺血性卒中小鼠長期預后［128?131］。小規(guī)模臨床試驗顯示，缺血性卒中24～48小時內(nèi)應用粒細胞集落刺激因子是安全的，但并未起到改善神經(jīng)功能的效果［132?135］。因此，粒細胞集落刺激因子治療缺血性卒中的效果尚待進一步基礎研究和大規(guī)模隨機對照臨床試驗的驗證。

六、展望

腦卒中是全球性疾病，病理生理學機制復雜，多種基礎研究有效的治療方法在臨床實踐中效果欠佳，提示基礎研究策略與臨床實際應用仍然存在較大差距，需要科研工作者和廣大臨床醫(yī)師之間加強交流與合作。一方面，科研工作者在設計實驗時盡可能遵循腦卒中臨床發(fā)作規(guī)律，如選擇高齡、有多個基礎疾病的實驗動物，選擇患者易接受的治療方法如靜脈滴注或口服，不僅應重視急性期治療效果，而且應重視長期預后；另一方面，臨床醫(yī)師應對進入臨床試驗階段的藥物進行科學嚴謹?shù)拇笠?guī)模隨機對照臨床試驗，以明確藥物治療效果。國家“十二五”時期，我們課題組通過藥物治療、基因治療、miRNA治療、干細胞治療等方法對缺血性卒中治療效果及作用機制進行較為深入的研究，主要在調(diào)節(jié)缺血性卒中后血管功能、促進血管新生和神經(jīng)再生方面取得一些成果。未來在我國國民經(jīng)濟和社會發(fā)展第十三個五年規(guī)劃（簡稱“十三五”）時期，我們課題組將加強再生醫(yī)學的前沿研究，注重學科交叉與轉(zhuǎn)化，在基因治療、組織工程、干細胞技術、生物醫(yī)學材料等方面進行新理論指導下的技術提升。此外，將重點針對缺血性卒中病理生理學過程中涉及炎癥反應調(diào)控機制、神經(jīng)免疫調(diào)節(jié)機制及移植干細胞和其他神經(jīng)細胞的相互調(diào)節(jié)機制進行研究，以期為個體化精準治療提供新方法和新策略?？傊?，腦卒中基礎研究與臨床治療是一項艱巨且需長期堅持的任務，只有加強多方面人才、多學科交叉與合作，方能加快基礎研究向臨床轉(zhuǎn)化的進展。

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