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据最新流行病学调查报告，我国每年新发脑卒中病人约200万人，其中急性脑梗死是最常见类型，约占全部脑卒中的69.6%~70.8%[1]。急性脑梗死病人年致死/致残率高达33.4%~33.8%[2]，给社会、家庭及个人带来沉重的负担。因此探讨急性脑梗死的病理生理学机制及其预防、治疗具有重要意义。急性脑梗死后脑组织损伤除与血管闭塞导致脑细胞缺血坏死有关外，还与脑梗死继发的脑内炎性反应关系密切，抑制炎性反应能够减轻脑组织损伤，减小脑梗死体积，促进神经功能恢复[3]。但脑梗死后炎性反应发生、发展的具体机制尚不十分明确。S100钙结合蛋白A12(S100 calcium binding protein A12，S100A12)属于钙结合蛋白家族，与晚期糖基化终末产物受体(receptor for advanced glycation end products，RAGE)结合后促进多种炎性及免疫反应[4]。RAGE可通过激活其下游信号分子核因子-κB(nuclear factor-κB, NF-κB)促进炎性因子表达和炎性级联反应发生[5]。本研究观测急性脑梗死后血清S100A12、RAGE以及NF-κB水平的动态变化，探讨S100A12/RAGE/NF-κB信号通路与脑梗死严重程度的相关性，从而为干预脑梗死后炎性反应通路相关靶点、改善脑梗死预后提供理论依据。
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纳入我院神经内科2019年1-12月收住的急性脑梗死病人(发病24 h内)82例为观察组，其中男59例，女23例，年龄(63.45 ±9.70)岁。诊断均符合《中国急性期缺血性脑卒中诊治指南2018》标准[6]，临床资料完整，并经头颅MRI证实为急性脑梗死。另纳入85例因非脑血管病住院病人为对照组，其中男54例，女31例，年龄(63.48 ±10.75)岁。排除标准：(1)6个月内患有急性脑血管意外；(2)合并其他颅内病变(脑出血、梗死后出血转化、癫痫、颅内感染、肿瘤、血管畸形、静脉窦血栓形成、动脉夹层等)；(3)患有严重肝、肾、心脏疾病以及血液系统疾病、肿瘤、感染、自身免疫病等。2组病人之间年龄、性别、合并脑梗死危险因素[高血压、糖尿病、高脂血症、高同型半胱氨酸(HCY)、心房颤动、吸烟等]比较差异均无统计学意义(见表 1)。
分组 n 男 女 年龄/岁 高血压 糖尿病 高脂血症 高HCY 心房颤动 吸烟 观察组 82 59 23 63.44 ± 9.77 73(89.02) 30(36.59) 30(36.59) 21(25.61) 8(9.80) 23(28.05) 对照组 85 54 31 63.48 ± 10.75 60(70.59) 21(24.71) 25(29.41) 14(16.47) 5(5.9) 20(23.53) χ2 — 1.35 0.93* 0.99 1.48 0.49 1.38 0.75 0.26 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示t值 表 1 2组一般资料比较[n; 百分率(%)]
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观察组于入院后1、3、7 d抽取晨间空腹血，以ELISA试剂盒检测血清S100A12、RAGE、NF-κB水平(按说明书步骤操作)，并记录1、3、7 d NIHSS评分。对照组于入院后1 d抽取晨间空腹血，以ELISA试剂盒检测血清S100A12、RAGE、NF-κB水平。
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采用t检验、χ2检验、方差分析和二元定距相关分析法。
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观察组各时间点S100A12、RAGE、NF-κB水平与对照组比较差异均有统计学意义(P < 0.05~P < 0.01)。脑梗死后S100A12、RAGE、NF-κB水平1 d时均最高(P < 0.05)，3 d和7 d水平差异均无统计学意义(P>0.05)(见表 2)。
分组 时间 S100A12/ (μg/mL) RAGE/ (μg/mL) NF-κB/ (pg/mL) 对照组 21.29±2.79 482.08±107.25 15 60.91±267.42 观察组 1 d 26.05±3.74** 541.27±93.94** 1 779.34±347.88** 3 d 25.66±3.65*△ 526.12±90.36*△ 1 710.76±323.28*△ 7 d 24.97±3.20*△ 518.60±83.91*△ 1 676.80±306.71*△ F 35.42 5.95 7.15 P < 0.01 < 0.01 < 0.01 MS组内 11.301 8 907.300 97 537.768 与对照组比较*P < 0.05，**P < 0.01；与1 d比较△P < 0.05 表 2 2组血清S100A12、RAGE、NF-κB水平比较(x±s)
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脑梗死后1、3、7 d的NIHSS评分分别为(4.00±3.11)、(3.74±3.05)、(3.52±3.06)分。三个时间点S100A12、RAGE、NF-κB水平与相应NIHSS评分均呈正相关关系(P < 0.05~P < 0.01)(见表 3)。
指标 1 d 3 d 7 d S100A12 0.26* 0.25* 0.26* RAGE 0.23* 0.23* 0.24* NF-κB 0.39** 0.28* 0.27* *P < 0.05，**P < 0.01 表 3 不同时间的S100A12、RAGE、NF-κB水平与NIHSS评分相关性(r)
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脑梗死后S100A12表达增加，被认为是脑梗死后的标志性蛋白[7]。S100A12具有调节炎性细胞因子及趋化作用，促进白细胞在血管内皮黏附浸润，损伤细胞外基质，破坏血脑屏障完整性，进而导致脑水肿、出血转化和细胞死亡[8]。WAKISAKA等[9]发现急性脑梗死病人血清S100A12表达上调，且与脑梗死严重程度呈正相关关系，并能影响急性脑梗死病人预后。LI等[10]研究证实对大脑中动脉栓塞(Middle cerebral artery occlusion，MCAO)大鼠模型腹腔注射神经生长因子后，与对照组相比，MCAO大鼠血清S100A12水平明显下降，脑梗死体积缩小，神经功能缺损评分(Longa法)降低。以上研究结果表明S100A12在脑梗死后表达升高并参与脑组织损伤。本研究中，观察组病人血清S100A12在急性脑梗死后1 d即明显升高，发病后3、7 d虽有下降趋势，但仍处于较高水平，从而有利于炎性反应的维持。从相关性分析结果可以看出，S100A12水平与脑梗死严重程度呈正相关，进一步证实S100A12持续高表达加重脑组织损伤。
RAGE在炎性反应中处于中心地位，其与S100A12结合后激活下游NF-κB，NF-κB进入细胞核后促进炎性细胞因子(白细胞介素-1、肿瘤坏死因子α等)等目的基因及RAGE自身的表达[11]，从而促进炎性级联反应发生。HU等[12]发现MCAO大鼠模型体内RAGE明显升高，体内注射骨髓间充质干细胞后RAGE水平下降，且可减轻血脑屏障渗漏，促进大鼠神经功能恢复。SHI等[13]应用SMTP-44D降低MCAO缺血再灌注大鼠RAGE表达水平，明显减小脑梗死体积，改善大鼠神经功能评分。本研究中，观察组血清RAGE明显升高且可持续高表达至脑梗死后7 d，其变化趋势与S100A12相同，推测急性脑梗死后S100A12高表达能够促进RAGE表达和活化。张婧等[14]在大鼠脑缺血预处理研究中发现，脑梗死区皮质RAGE mRNA在脑梗死后1 d表达最高，随后逐渐下降，但到7 d时仍高于对照组[14]，该变化趋势与脑梗死后神经功能缺损一致，进一步证实RAGE相关信号通路在缺血性脑损伤中的作用，但该研究未进行各时间点之间RAGE水平的比较。WANG等[15]研究结果表明RAGE、NF-κB在脑梗死后1 d表达最高，48 h、72 h、7 d、14 d表达逐渐降低，与1 d时比较均有明显差异。本实验中RAGE及NF-κB水平变化趋势与既往研究相似，进一步比较各时间点RAGE及NF-κB水平后发现，脑梗死后1 d RAGE及NF-κB水平与3、7 d比较有明显差异，而3、7 d之间RAGE及NF-κB水平比较变化不明显。表明脑梗死后RAGE及NF-κB水平下降趋势逐渐放缓。
RAGE/ NF-κB信号通路是调控炎性反应的关键环节[16]。急性脑梗死后NF-κB表达增加，抑制NF-κB表达有利于减轻炎性反应，促进神经功能恢复[17]。XU等[18]发现使用铁线莲苷抑制MCAO大鼠脑内NF-κB表达后，炎性反应减轻，神经细胞存活率增加，运动和记忆功能明显改善。XIANG等[19]在MCAO小鼠体内利用慢病毒过表达泛素特异性蛋白酶18(USP18)，能显著减小脑梗死体积，促进神经再生，其机制可能与USP18抑制小胶质细胞活性，减少NF-κB表达有关。SIMMONS等[20]证实神经调节蛋白-1对MCAO缺血再灌注大鼠具有神经保护作用，其机制可能与神经调节蛋白-1抑制NF-κB诱导的肿瘤坏死因子α和白介素-6的释放增加，减轻炎性反应有关。本研究中，急性脑梗死后血清NF-κB水平明显增加且持续至脑梗死后7 d，其变化趋势与S100A12和RAGE相同，推测脑梗死后S100A12促进RAGE/NF-κB炎性信号通路的表达及活化。相关性分析结果显示NF-κB水平与NIHSS评分呈正相关关系，表明NF-κB异常表达促进神经损伤。
S100A12/RAGE/NF-κB炎性信号通路与急性脑梗死严重程度的相关性
Correlation between S100A12/RAGE/NF-kB inflammatory signal pathway and severity of acute cerebral infarction
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摘要:
目的观察急性脑梗死病人血清中S100钙结合蛋白A12（S100A12）、晚期糖基化终产物受体（RAGE）及核转录因子-κB（NF-κB）的动态变化，并分析其与脑梗死严重程度的相关性。 方法纳入82例急性脑梗死病人为观察组，于入院后1、3、7 d进行美国国立卫生研究院卒中量表（NIHSS）评分，ELISA检测相应时间点血清S100 A12、RAGE及NF-κB水平变化，并与NIHSS评分进行相关性分析；另纳入85例因非脑血管病住院病人为对照组，于入院后1 d检测S100 A12、RAGE及NF-κB水平。 结果观察组1、3、7 d血清S100 A12、RAGE及NF-κB水平均明显高于对照组（P < 0.01）；1 d血清S100 A12、RAGE以及NF-κB水平均最高（P < 0.05~P < 0.01）；3 d与7 d水平差异均无统计学意义（P>0.05）。相关性分析显示，各时间点血清S100 A12、RAGE及NF-κB水平与相应NIHSS评分均呈正相关关系（P < 0.05~P < 0.01）。 结论脑梗死急性期S100 A12、RAGE及NF-κB水平升高，且与急性脑梗死后神经功能缺损严重程度相关。 -
关键词:
- 脑梗死 /
- S100钙结合蛋白A12 /
- 晚期糖基化终产物受体 /
- 核转录因子-κB
Abstract:ObjectiveTo observe the dynamic changes of S100 calcium binding protein A12(S100A12), receptor for advanced glycation end products(RAGE) and nuclear factor κB(NF-κB) in patients with acute cerebral infarction, and analyze the correlation between them and severity of cerebral infarction. MethodsEighty-two patients with acute cerebral infarction were set as the observation group.On the 1 d, 3 d and 7 d after admission, the NIHSS scores in the observation group were evaluated, the serum levels of S100A12, RAGE and NF-κB were detected using ELISA, and the correlation between the above indexes and NIHSS score was analyzed.Eighty-five patients without cerebrovascular disease were set as the control group, and the serum levels of S100A12, RAGE, NF-κB were detected on the first day after admission. ResultsThe serum levels of S100A12, RAGE and NF-κB in observation group on the 1 d, 3 d and 7 d were significantly higher than those in control group(P < 0.01).The levels of S100A12, RAGE and NF-κB was highest on the 1 d(P < 0.05 to P < 0.01), and tbe differences of which between 3 d and 7 d were not statistically significant(P>0.05).The results of correlation analysis indicated that the serum levels of S100A12, RAGE and NF-κB were positively correlated with NIHSS score at each time point(P < 0.05 to P < 0.01). ConclusionsThe levels of S100A12, RAGE and NF-κB increase, which are related to the severity degree of neurological deficit in patients with acute cerebral infarction. -
表 1 2组一般资料比较[n; 百分率(%)]
分组 n 男 女 年龄/岁 高血压 糖尿病 高脂血症 高HCY 心房颤动 吸烟 观察组 82 59 23 63.44 ± 9.77 73(89.02) 30(36.59) 30(36.59) 21(25.61) 8(9.80) 23(28.05) 对照组 85 54 31 63.48 ± 10.75 60(70.59) 21(24.71) 25(29.41) 14(16.47) 5(5.9) 20(23.53) χ2 — 1.35 0.93* 0.99 1.48 0.49 1.38 0.75 0.26 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示t值 
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表 2 2组血清S100A12、RAGE、NF-κB水平比较(x±s)
分组 时间 S100A12/ (μg/mL) RAGE/ (μg/mL) NF-κB/ (pg/mL) 对照组 21.29±2.79 482.08±107.25 15 60.91±267.42 观察组 1 d 26.05±3.74** 541.27±93.94** 1 779.34±347.88** 3 d 25.66±3.65*△ 526.12±90.36*△ 1 710.76±323.28*△ 7 d 24.97±3.20*△ 518.60±83.91*△ 1 676.80±306.71*△ F 35.42 5.95 7.15 P < 0.01 < 0.01 < 0.01 MS组内 11.301 8 907.300 97 537.768 与对照组比较*P < 0.05，**P < 0.01；与1 d比较△P < 0.05
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表 3 不同时间的S100A12、RAGE、NF-κB水平与NIHSS评分相关性(r)
指标 1 d 3 d 7 d S100A12 0.26* 0.25* 0.26* RAGE 0.23* 0.23* 0.24* NF-κB 0.39** 0.28* 0.27* *P < 0.05，**P < 0.01
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