CN103990184A - 用于治疗中枢神经系统病理的装置和方法 - Google Patents

用于治疗中枢神经系统病理的装置和方法 Download PDF

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CN103990184A
CN103990184A CN201410085313.1A CN201410085313A CN103990184A CN 103990184 A CN103990184 A CN 103990184A CN 201410085313 A CN201410085313 A CN 201410085313A CN 103990184 A CN103990184 A CN 103990184A
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bioabsorbable material
nervous system
central nervous
tissue
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L.C.阿尔真塔
D.L.凯罗尔
N.H.利瓦伊
J.刘
M.J.莫里克瓦斯
S.塔特
W.D.沃纳
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Wake Forest University Health Sciences
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Abstract

本发明一般地涉及治疗中枢神经系统组织的装置和方法，更具体但不排他地，涉及治疗脑组织的装置和方法。

Description

用于治疗中枢神经系统病理的装置和方法
本申请是2009年1月9日提交的题为“用于治疗中枢神经系统病理的装置和方法”的国家申请号为200980108899.6(PCT／US2009／030581)的发明专利申请的分案申请。
相关申请
本专利申请主张2008年1月9日提交的美国临时专利申请61／019968和2008年7月18日提交的美国临时专利申请No.61／081997的优先权，其全部内容作为参考并入本文。
技术领域
本发明一般地涉及使用亚大气压(sub-atmospheric pressure)治疗中枢神经系统组织的装置和方法，更具体但不排它地，涉及使用亚大气压治疗脑组织的装置和方法。
背景技术
与中枢神经系统(CNS)有关的解剖学、生理学和病理学过程使CNS组织具有独特性。对三维结构解剖学和神经元显微解剖学关系(神经元功能特异地依赖于和其它神经元以及其它支持细胞之间的空间关系)的保存以及对适当含氧的血流以及其中存活了神经元的均匀基质的保持对中枢神经系统组织的存活和功能是至关重要的。此外，中枢神经系统细胞的不能再生性强调了最大程度使每个可能神经元存活的需要。出于这些原因，对中枢神经系统中开放和封闭空间病理的治疗是独特的。
在威胁CNS组织存活的临床问题中，对中枢神经系统水肿、感染和血液供给的控制是中心内容。通过收集大量间质性水肿，脑对外伤和创伤产生响应。由于脑封闭在封闭空间中(硬膜和颅骨)，因此水肿导致CNS的血流和营养表现受到压缩和损害，从而极大地损害了中枢神经系统的生理恢复并且其自身通常导致CNS主质损害和死亡的发展。用于减少水肿的当前可用治疗方法包括降低血管通透性的试剂(糖皮质激素：地塞米松、泼尼松、甲基脱氢皮质甾醇)、利尿药、机械性心室引流术、脑主质切除术和广泛颅骨切除术。然而，这些治疗方法的缺点包括不良结果、由药物引起的并发症和不一致的结果。
由于CNS中感染和水肿快速发展的严重后果以及高可能性，因此对快速和有效治疗的需求仍是至关重要的。目前，很少有成功的方法可用于治疗影响颅内和椎管内腔、CNS主质和周围结构的病理。在其它处组织可以通过改变敷料进行治疗的情况下，CNS由于其难以接近、结构不确定、易感染和创伤发展等原因而不适合采用这类治疗。有证据说明对中枢神经系统外伤和其它病理的炎症和免疫反应的长期后果与初发外伤或损伤的相当或更大。CNS对继发于水肿的血流降低的反应导致了缺氧和局部缺血／再灌注介导的创伤。这些创伤导致产生神经病理学后遗症，其极大地促进了颅脑损伤不良结果的产生。
此外，脑需要连续提供含氧血液以发挥功能和存活。在将流向脑的血流完全中断的三分钟内会造成不可逆的脑损伤，尽管脑仍然可以保持存活并且经过更长的时间可以从减少的血流中恢复。有证据说明脑的病灶区域可以在几天内保持局部缺血和相对无功能并且仍能够恢复。这一发现导致产生了称为半影区或晕区的缺血区概念，该区域围绕着不可逆创伤区。第二种现象是由受创伤的神经元所局部释放的兴奋毒素的释放、病灶血流中的变化和水肿。
脑血管疾病可以由以下情况造成：由于灌注压低、血管破裂导致的局部脑区域直接创伤和相邻组织的挤压所造成的流向脑细胞的血液不足。如动脉粥样硬化、动脉瘤、炎症等的脑血管固有疾病或从如心脏的其它处进入并固定在脑血管中的远血栓可以产生脑血管疾病。中风是定义由于所述一些病理过程而发生的神经学创伤的术语。65岁以上的人群中有5％的人患有脑血管疾病，该疾病是发达国家中第三主要的死亡原因。此外，经常会造成终生衰弱、无法在社会和家庭中工作并发挥作用以及频繁需要护理院治疗。患有中风的人通常在他们剩余的生命中经受严重的伤害。
发展中的中风或进行性中风是指初始事件后发展或变化的神经缺陷。据认为这是由于以下原因所引起的：相关动脉的进行性痉挛或狭窄、初发创伤周围脑水肿的发展、由于血流减少或受创伤脑细胞所释放的局部细胞因子所引起的血栓蔓延。幸运地是，脑中血管之间存在称作侧支循环的一些连通。从这些侧副管供给血液可以防止缺血区中脑细胞的死亡。
在颅内出血的情况下，出血通常是从小块开始并通过压力剥离使体积增加，并导致相邻脑组织的移位和挤压。出血周围相邻挤压组织中的水肿可能导致质块效应，并通过损伤更大面积脑组织使临床状况恶化。相邻脑中的水肿可能造成进行性恶化，这通常在12至72小时内可以观察到。脑内出血后一周内发生的水肿通常使预后恶化，特别是在中老年人中。血肿周围的组织被移位和挤压，但并不一定会受到致命的损害。由于血肿的再吸收和相关组织重新恢复功能从而可以得到改善。
这些病况的治疗一直令人失望。在一些情况下，对出血的手术减压可以有助于防止不可逆挤压。如甘露醇和一些其它渗透剂的试剂可以降低由水肿所引起的颅内压。在这些情况下，类固醇的价值还不确定，并且最近已提议使用高压氧。
因此，尽管对受伤皮肤和皮下组织应用负压(或亚大气压)疗法表明与传统方法相比治愈率得到提高(如美国专利No.5645081和5636643，7198046和7216651以及美国公开的专利申请No.2003／0225347、2004／0039391和2004／0122434中所述，它们的内容作为参考并入本文)，但是仍需要专门适合中枢神经系统独特组织使用的装置和方法。
发明简述
本发明一般地涉及使用亚大气压治疗中枢神经系统组织的装置和方法，更具体但不排它地，涉及使用亚大气压治疗脑组织的装置和方法。根据本发明的一个示例性程序，提供了使用亚大气压治疗损伤的中枢神经系统组织的方法，其包括将多孔材料邻近(proximate)所述损伤的中枢神经系统组织定位以提供所述多孔材料的一个或多个孔与所述损伤的中枢神经系统组织之间的气体连通。在一些情况下，可以将所述多孔材料直接置于所述损伤的中枢神经系统组织上方。可以将所述多孔材料邻近所述损伤的中枢神经系统组织原位密封以提供在所述损伤的中枢神经系统组织周围(about)的区域，用于在所述损伤的中枢神经系统组织处维持亚大气压。然后，可以将真空系统可操作地与所述多孔材料连接并激活所述真空系统，从而在所述损伤的中枢神经系统组织处提供亚大气压。可以在所述损伤组织处维持足够时间的亚大气压以减少所述中枢神经系统处的水肿。
在本发明的另一方面，提供了治疗损伤的中枢神经系统组织的设备。该设备可以包括如开孔胶原的多孔生物可吸收材料，其具有配置以允许所述多孔材料的一个或多个孔与要治疗的所述中枢神经系统组织之间气体连通的孔结构。所述多孔材料的生物可吸收本质可以避免对除去所述多孔材料的二次程序的需要。该设备还包括用于产生亚大气压的真空源；可以放置所述真空源使其与所述多孔材料气体连通从而将亚大气压分配至所述中枢神经系统组织。所述多孔材料至少在所述多孔材料的所选表面上可以具有足够小的孔以防止组织在其中生长。此外，所述多孔材料至少在所述多孔材料的所选表面上可以具有比成纤维细胞和中枢神经系统细胞尺寸小的孔径，并且可以在除所述所选表面以外的位置具有比成纤维细胞和中枢神经系统细胞大的孔径。所述多孔材料的孔径可以足够大以允许白蛋白尺寸大小的蛋白通过其运动。另外，所述多孔生物可吸收材料可以包含至少一个密封的表面以防止亚大气压通过其传输。该设备还可以包括盖，其配置以覆盖所述损伤的中枢神经系统组织从而在所述损伤的中枢神经系统组织处在所述盖的下方维持亚大气压。
在使用中，本发明可以提供压力梯度从而将水肿从中枢神经系统中除去，因此，在更接近生理保存的状态保留了神经功能并提高了恢复和存活的可能性。反过来，中枢神经系统浮肿的减小可以导致颅内压降低，从而使中枢神经系统损害和疝出的风险最小化。除消除水肿之外，本发明可以除去增强中枢神经系统中组织对于创伤的炎性和神经病理学反应的介体、降解产物和毒素。
本发明可以保护中枢神经系统免受外源性感染和污染，并且在组织受到中枢神经系统脓肿、脑膜炎、脑室炎和脑组织感染的污染时有利于并最大可能地使颅内和邻近结构治愈。也可以通过增加血流和直接减少细菌负荷来保护中枢神经系统组织免受邻近感染，如以亚临床状态存在于窦(sinuses)、口腔中的感染以及在正常人体状况中存在的其它潜在感染的腔室(space)。此外，本发明所述的装置和方法可以使(prepare)中枢神经系统组织达到治愈和减少细菌数的阶段从而可以成功地接受二次处理(例如，垫片、骨移植物)。
本发明还可以有利于使中枢神经系统和硬膜外隙之间连通(communicating)的病理开放的闭合，例如，在硬膜外隙和硬膜下／硬膜上和／或蛛网膜下腔之间。同样地，可以最大程度地降低病理过程的发展、减少生理学中枢神经系统完整性的破坏以及对中枢神经系统血流和营养的干涉。
本发明所述的设备和方法可以用于治疗下列病况：由于外伤、手术、感染或任何其它病理过程造成的中枢神经系统暴露；对中枢神经系统周围任何腔室和组织的治疗，其包括：硬膜下／硬膜上和脑室内腔；对继发于任何原因的中枢神经系统主质水肿的治疗，所述原因包括：出血、外伤、肿瘤、感染或任何其它病理状态；对由于任何上述原因造成的颅内压和椎管内压升高的治疗；和对脑脊液病理的治疗，其中脊髓液与任何非解剖学和非生理腔室病理学连通。另外，本发明可以用于在发生了中枢神经系统破裂的区域中促进肉芽组织的形成，并且可以用于控制脑脊液的泄露。另外，经过修饰的本发明的材料可以用于控制或闭合存在于中枢神经系统、皮肤间隙、鼻内腔和窦内腔之间的缺陷。
附图说明
当结合所附附图阅读时，将可以最好地理解本发明优选实施方式的上述简述以及随后的详细说明。
图1以分截面示意性地示出了本发明示例性设备的透视图，该装置原位显示了对脑损伤的治疗；
图2和3示出了未用亚大气压治疗的脑创伤对照动物的核磁共振成像(MRI)扫描；
图4示出了用亚大气压治疗8小时的脑损伤动物的核磁共振成像扫描；
图5示出了未用亚大气压治疗的脑创伤对照动物的核磁共振成像扫描；
图6和7示出了用亚大气压治疗24小时的脑创伤动物的核磁共振成像扫描；
图8示出了未用亚大气压治疗的脑创伤对照动物的核磁共振成像扫描；
图9以分截面示意性地示出了大鼠颅骨的正常解剖图，其包括脑和周围肌肉、骨及其它组织；
图10以分截面示意性地示出了图2动物的图片12／26，其显示了血液或流体挤压和累积的区域；
图11以分截面示意性地示出了图4动物的图片12／24，其显示了用多孔材料挤压和覆盖就位(drape in place)的区域；
图12以分截面示意性地示出了图5动物的图片12／24，其显示了用多孔材料挤压就位的区域；
图13以分截面示意性地示出了图6动物的图片12／24，其显示了用多孔材料挤压和覆盖就位的区域；
图14示意性地示出了本发明的多层多孔材料；
图15A和15B分别示出了图5和6的核磁共振成像扫描的右下部分，其放大以显示非治疗动物受冲击脑中相对更多的流体含量；
图16示出了轴面的T2-加权核磁共振图，其显示了从大鼠脑的活体内获得的核磁共振光谱体素(voxels)的位置；
图17示出了从假手术脑、创伤脑、以及创伤并治疗的脑中获得的单体素核磁共振光谱。将代谢产物标记为Ins(肌醇)、Tau(牛磺酸)、Cho(含有胆碱的化合物)、Cr+PCr(肌酸和肌酸磷(phosphorus creatine))、Glu+Gln(谷氨酸和谷氨酰胺)、NAA(N-乙酰天冬氨酸)、GABA(γ-氨基丁酸)和Lac(乳酸(lactate))；和
图18A和18B示出了通过对脑样品进行硝基酪氨酸染色而进行的神经元退化和死亡的免疫组织化学分析，其中所述脑样品在冲击后72小时收获，其中治疗组暴露于亚大气压整72小时；深褐色点是死亡和正在死亡的细胞。
发明详述
现在参考附图，其中同样的元件在全文中用相同的数字标号，本发明涉及使用亚大气压(或负压)治疗损伤的中枢神经系统组织的装置和方法。如本文所使用的，将“损伤(的)”组织定义为包括受到创伤、损害或以任何其它方式受到伤害的组织，例如，如由于外伤、疾病、感染、手术并发症或其它病理过程所造成的损伤。具体参见图1，示出了本发明的亚大气压中枢神经系统治疗装置100的示例性构造。亚大气压中枢神经系统治疗装置100可以包括邻近所述损伤的中枢神经系统组织(例如，如脑组织9)放置的多孔材料10，其用于将亚大气压输送和分配到损伤脑组织9。亚大气压中枢神经系统治疗设备100还可以包括真空源30，其通过管20与多孔材料10气体连通从而向损伤的脑组织9提供亚大气压。
现在更详细地说明图1，以分截面在具有周围组织的动物中原位示出了本发明的亚大气压中枢神经系统治疗装置100的示例性构造。所示组织包括皮肤2、肌肉组织4、颅骨5和损伤脑组织9，在损伤脑组织9上缺失了一部分颅骨5以提供通向损伤的脑组织9的治疗(provide treatment access to thedamaged brain tissue9)。可以将多孔材料10置于邻近脑组织9的空间(space)从而向所述损伤脑组织9提供亚大气压治疗。所述治疗可以包括，例如，降低颅内压、减少水肿、除去有害流体或不需要的化合物等。
多孔材料10可以具有足够大的孔以使得能够将不需要的化合物从脑组织9和周围的一个或多个空间／组织中除去并且可以具有足够小的孔以阻止或防止脑组织向内生长到多孔材料10中。就此而言，所述孔径可以足够大以允许将如细胞因子、毒性物质或其它介体(mediators)的材料转运出脑组织9从而将该类材料减少至临床期望的水平。例如，所述孔径可以足够大以允许白蛋白通过多孔材料10。此外，所述孔可以足够小(至少在多孔材料10与脑组织9接触的地方)以阻止或防止组织生长到多孔材料10中从而使得多孔材料10不粘附到脑组织9并且在去除时不会对脑组织9造成损伤。例如，为了最大程度减少向内生长并且避免可能干扰脑生理功能的肉芽组织的过度产生，所述孔径可以小于成纤维细胞和脑细胞的尺寸。
所述多孔材料10可以在组成上和／或形态上是均匀的，或在多孔材料10内部或在多孔材料10不接触脑组织9的任意位置处可以具有相对较大的孔径。例如，多孔材料110可以包含非向内生长层112，其具有足够小的孔径从而在与脑接触放置时防止组织在其中生长，并且可以具有附加层114，附加层114为具有相对较大孔径(例如，比成纤维细胞和脑细胞大)的不同材料，其与非向内生长层112接触但不和脑接触，如图14。例如，多孔材料10可以具有足够大的孔径以促进损伤脑组织9周围空间内其它组织处的肉芽组织的形成。另外，多孔材料10可以包括多孔材料10的一个或多个侧或面，将所述侧或面密封以防止亚大气压通过其传输，并且同时具有至少一个面，通过该面可以传输亚大气压。多孔材料10的这种构造可以在多孔材料10的一侧提供对组织的优先治疗而在所述密封侧不治疗组织。例如，当置于脑主质上脑主质与脑室腔的界面时，可以使用这种多孔材料10。可以通过多孔材料10一侧上的面治疗所述主质；同时多孔材料10的一个或多个密封面不会使脑室腔排液从而不会除去所述脑室腔中的流体。类似地，渗透性沿其长度而不同的多孔材料10将使得亚大气压能够应用到脑主质而不促进如沟、室和蛛网膜下腔的脑脊液(CSF)腔中的亚大气压，因此，并不优先地从那些腔体中除去脑脊液。
多孔材料10可以包括生物可吸收的或随时间无害降解的材料，如胶原，或在提供亚大气压疗法后需要除去的材料。多孔材料10可以是不需过多的包装即可容易地符合脑或腔壁表面的材料，并且可以不需要过多的修整和成型即可达到这样的要求。例如，可以以带或链的形式提供多孔材料10，它们可以置于脑／颅上或内。所述的带或链可以具有足够的强度从而在其从头中拉出时不会断裂或留下残余物。例如，当其中置有多孔材料10的腔填充(fill in)时，可以逐渐和逐步除去多孔材料10的带或链。因此，多孔材料10可以是带或条或链的形式(例如，5×5×200毫米)，具有足够的弹性从而使其在治疗后可以从颅骨5的小孔中拉出而不需要二次手术。多孔材料10可以是柔性片，其可以折叠和改变以安装到中枢神经系统的特定区域中，如直接安装在外伤后的脑主质或脑室系统中。
另外，多孔材料10可以是足够顺应(compliant)的从而它对损伤的脑的挤压不会达到干扰脑功能的程度。然而，多孔材料10可以是足够坚硬的从而其不会倒塌以至于拉动脑或使脑变形至可能干扰脑功能的程度。可以在多孔材料10中使用的示例性材料可以包括开孔胶原材料、聚乙醇酸和／或聚乳酸材料、合成聚合物、柔性片状网、开孔聚合物泡沫、泡沫部分、多孔片、聚乙烯醇泡沫、聚乙烯和／或聚酯材料、弹性蛋白、透明质酸、海藻酸盐、聚二醇柠檬酸酯(polydiolcitrates)、聚羟基丁酸酯、聚羟基富马酸酯、聚碳酸三亚甲基酯(polytrimethylenecarbonate)、聚癸二酸甘油酯(polyglycerolsebecate)、脂肪族／芳香族聚酐或其它适合的材料和以上材料的组合，上述材料中的任一种可以通过，例如，电纺丝(electrospinning)、铸塑或印刷制造。该类材料包括壳聚糖溶液(1.33％质量／体积的2％乙酸溶液，总体积为20mL)，可以将所述壳聚糖溶液注入到适当尺寸的模具。然后将所述溶液在-70℃冷冻2小时，然后转移到冻干机中并施加真空24小时。可以通过2.5％-5％的戊二醛蒸气使所述材料交联12-24小时(或通过紫外辐射交联8小时)以提供铸塑的多孔材料10。
另外，可以通过铸塑聚己内酯(PCL)制备多孔材料10。聚己内酯可以与氯化钠(1份己内酯比10份氯化钠)混合并置于足够量的氯仿中以溶解所述组分。例如，可以将8mL溶液倾入到适当尺寸和形状的容器(contained)中并使其干燥12小时。然后，可以使氯化钠在水中析出24小时。
还可能使用电纺丝材料制备多孔材料10。制备电纺丝(electrospun)多孔材料10的一个示例性制剂和方法是使用以质量计76％：4％：20％的I型胶原：6-硫酸软骨素(CS)：聚1，8-辛二醇柠檬酸酯(POC)的组合制备。对于胶原／CS／POC使用了两种溶剂。将CS溶于水并将胶原和POC溶于2，2，2-三氟乙醇(TFE)。然后使用20％水／80％TFE溶液(体积／体积)的溶液。对于电纺丝，将含有胶原：CS：POC混合物的溶液置于安装了18Ga针头的3mL注射器中。使用注射泵(New Era Pump Systems，Wantaugh，NY)将溶液以2.0毫升／小时的速率送料到针尖。通过高压电源(HV Power Supply，Gamma High Voltage Research，Ormond Beach.FL)提供10-20千伏的电压并将电压施加到相距15-25厘米的针头(阳极)和接地的接收器(阴极)之间。然后将该材料与戊二醛交联(等级II，25％的溶液)并加热聚合(80℃)48小时。还可能用初始浓度80毫克／毫升的胶原在1，1，1，3，3，3-六氟-2-丙醇(HFP)中的溶液开始电纺丝I型胶原多孔材料，然后使用与胶原：CS：POC组合相同的电纺丝条件进行。
用于产生多孔材料10的其它方法是使用热喷墨印刷技术。可以印刷生物可吸收材料，如胶原、弹性蛋白、透明质酸、海藻酸盐和聚乳酸／聚乙醇酸共聚物。例如，将I型胶原(Elastin Products Co.，Owensville，MO)溶于0.05％的乙酸，然后用水稀释至1毫克／毫升，从而可以印刷该溶液，采用同样的方法也可以印刷1毫克／毫升的海藻酸钠(Dharma Trading Co.，SanRaphael，CA)水溶液。还可以印刷I型胶原(2.86毫克／毫升在0.05％的乙酸中的溶液)和聚乳酸／聚乙醇酸(PURAC America，Blair，NE)(14.29毫克／毫升在四甘醇(Sigma Aldrich，St.Louis MO)中的溶液)的混合物。可以将来自Hewlett Packard660c打印机的硬件安装到平台上，所述打印机包括步进电动机和墨粉鼓托架。然后，可以调节硬件在平台以上的高度用于成层印刷。多孔材料10可以包括MRI相容材料从而可以当多孔材料10就位时进行核磁共振成像。
接着说明将亚大气压递送到多孔材料10并分配到损伤脑组织9，可以直接或间接地连接管20从而与多孔材料10在管20的远端22气体连通。例如，可以将管20的远端22包埋在多孔材料10中或者可以将其置于多孔材料10上方。管20的远端22还可以包括一个或多个穿孔以辅助将亚大气压递送到多孔材料10和损伤脑组织9。管20可以延伸穿过皮肤和皮下组织2中的开孔，可以将所述皮肤和组织用缝合线固定到管20周围以辅助提供管20周围的密封。可以将管20的近端24可操作地连接到如真空泵的真空源30以提供亚大气压，所述亚大气压通过管20传输到多孔材料10和损伤脑组织9。
真空源30可以包括控制器32以调节亚大气压的产生。例如，可以配置真空源30以连续或间歇产生亚大气压；例如，可以循环开关真空源30以提供产生和不产生亚大气压的交替周期。产生和不产生之间的工作循环可以在1比10(开／关)和10比1(开／关)之间。此外，可以通过周期或循环波形(如正弦波)施加间歇亚大气压。可以在初步治疗后循环真空源30(如每分钟若干次)以模拟更接近生理的状况。根据需要，可以根据对损伤脑组织9中压力监测所确定的情况间歇循环亚大气压。一般说来，可以配置真空源30从而输送在大气压和低于大气压75毫米汞柱(Hg)(例如，如约20毫米汞柱)之间的亚大气压以最大程度降低亚大气压对脑主质造成损害的可能性。(过低的负压可能导致血液流入主质)。该亚大气压的应用可以促使从损伤脑组织9中消除水肿，从而因此保持了神经学功能以提高在更接近生理的保存状况下恢复和存活的可能性。此外，亚大气压的应用可以使颅内压正常化至临床期望的水平，可以使组织体积和密度正常化至临床期望的水平和／或可以使血压和心率中至少一项正常化至临床期望的水平。例如，亚大气压的应用可以使颅内压正常化至基本正常的损伤前的生理状态，可以使组织体积和密度正常化至基本正常的损伤前的生理状态和／或可以使血压和心率中至少一项正常化至基本正常的损伤前的生理状态。
为了辅助维持损伤脑组织9处的亚大气压，可以邻近损伤脑组织9设置柔性盖／片50或刚性(或半刚性)盖以在损伤脑组织9周围提供区域，在该区域可以维持亚大气压。具体地，参考图1、11、13，可以通过将盖50粘附到邻近损伤脑组织9的组织(如皮肤2、202、502)以将盖50设置到损伤脑组织9和多孔材料10上方从而限定了损伤脑组织9和多孔材料10周围的包围(enclosed)区域。例如，可以使用如纤维蛋白胶的粘合剂将盖50粘在皮肤2、202、502和／或其它适当组织上。所述粘合剂可以包括自动聚合胶和／或可以期望包括填充剂从而为所述粘合剂提供足够大的体积以允许所述粘合剂符合所述粘合剂所接触的可能不规则表面的形状。所述粘合剂可以作为单独组件提供或作为盖50的一部分提供从而提供自粘盖50。例如，盖50可以包括柔性自粘片，所述自粘片在其一个或多个表面上包含适合的粘合剂。
可以通过盖50和管20之间的配合在盖50下方传输亚大气压。具体地，盖50可以包括连接管20的远端22的真空口以提供管20与损伤脑组织9上方的盖40下方的空间之间的气体连通。作为另外一种选择，盖50可以包含贯通器(pass through)52，通过该贯通器使管20通过从而将管20的远端22置于损伤脑组织9上方的盖50下方的空间内并与该空间气体连通，如图1所示。此外，盖50还可以保护损伤脑组织9免受超出多孔材料10和缝合皮肤2已提供的保护范围之外的外源性感染和污染。同样地，盖50还可以保护周围组织免受损伤脑组织9的感染传播，如脑脓肿、脑膜炎和脊椎组织感染。作为另外一种选择，不需要使用盖50并且可以缝合、订合或夹合闭合皮肤2和／或硬膜以在损伤脑组织9周围提供区域，在该区域可以提供亚大气压。
在本发明的另一方面，本发明还提供了使用亚大气压治疗损伤脑组织的方法。具体地，该方法可以包括将多孔材料10邻近损伤脑组织9定位以提供多孔材料10的一个或多个孔与损伤脑组织9之间的气体连通。可以邻近损伤脑组织9原位密封多孔材料10从而提供损伤脑组织9周围的区域用于在损伤脑组织9处维持亚大气压。可以将管20在管20的远端22处连接到多孔材料10，并且可以用缝合线7在皮肤2和皮下组织原位密封多孔材料10以提供损伤脑组织9周围的区域用于维持亚大气压。可以任选地将其它气密覆盖物或盖50置于缝合位点上方以促进气密密封。该方法还可以包括将盖50粘附性地密封和粘合到损伤脑组织9周围的组织(例如，皮肤2)的步骤。可以采用自粘片50的形式提供盖50，所述自粘片可以定位到损伤脑组织9的上方。在这种情况下，密封盖50的步骤可以包括将自粘片50粘附性地密封并粘合到损伤脑组织9周围的组织从而在片50和损伤脑组织9周围的组织之间形成密封。另外，可操作地连接与多孔材料10气体连通的真空系统30的步骤可以包括将真空系统30与盖40的真空口连接。
可以将管20的近端24连接到真空源30从而一旦启动真空系统30则能够将亚大气压提供给损伤脑组织9。例如，可以将亚大气压维持在比大气压低约20至75毫米汞柱。可以在损伤脑组织9处维持足够时间的亚大气压从而：1)使颅内压正常化至基本正常的损伤前的生理状态；2)使组织体积和密度正常化至基本正常的损伤前的生理状态；3)使血压和心率中至少一项正常化至基本正常的损伤前的生理状态；4)使细胞因子、毒性物质或其它介体减少至临床期望的水平；和／或5)改善患者的认知、意识、运动或感觉功能，其可以通过格拉斯哥分数(Glasgow score)指示。此外，可以在损伤脑组织9处维持足够时间的亚大气压从而准备脑组织9以达到治愈和细菌数减少的阶段从而可以成功地接受二次治疗(例如，垫板)。
该方法可以使用至少三小时，或可以使用多天。在真空治疗结束时，可以除去缝合线7并使皮肤2再开放。接着，可以除去多孔材料10并再次缝合使皮肤2闭合。
实施例
大鼠脑创伤和亚大气压暴露
实验1
进行实验以发展脑挫伤模型和挫伤脑的真空治疗。获得十二只(12)300克的斯普拉-道来(氏)大鼠(Sprague Dawley rat)并使它们适应居住环境。对于其中两只动物，在执行任何其它程序前获得脑核磁共振成像扫描(Bruker Biospin Horizontal Bore7Tesla小动物扫描器，Ettlingen，Germany)。用异氟烷(2％吸入)使这些动物镇静并获得脑扫描。使这些动物从麻醉中恢复并回到笼中。为了产生创伤，在手术当天用异氟烷使动物镇静(2-2.5％吸入)。刮剃头顶部并用脱毛剂除去毛发。如图1，向下进行中线切开1至骨5。除去右侧颅骨，从而暴露出右半部脑；硬膜保持完整。将动物置于冲击器设备上的立体定位支架(气动(皮层)冲击设备；AmScien instruments，Richmond VA)。然后冲击每只动物的右前脑。对于第一只动物，用直径3毫米的棒冲击至2.0毫米深。(表1，1号大鼠)。认为该创伤不够明显。尝试对动物2提高创伤的严重性。用直径6毫米的棒冲击到第二只动物的脑中至2.5毫米深。(表1，2号大鼠)。认为该创伤过于严重。对于其余的动物，用直径6毫米的棒冲击到右前脑中至2.0毫米深。(表1，3-12号大鼠)。对于手术前已进行核磁共振成像扫描的两只动物，这两只动物在冲击后5分钟内死亡。(表1，3号和8号大鼠)。
成功冲击了两只非治疗的对照动物并使它们在加热的笼中从麻醉中恢复。(表1，4号和5号大鼠)。8小时后，再次麻醉这些动物并获得了核磁共振成像扫描以显现肿胀程度和水的存在(T2加权核磁共振成像图像)。然后成功冲击了两只真空处理动物，并将尺寸等于所述除去的骨的一小片聚乙烯醇真空覆盖物(VersaFoam，Kinetic Concepts，Inc.，San Antonio，TX)置于脑上方。(表1，6号和7号大鼠)。将小孔抽气管置于所述覆盖物上方和所述皮肤下方。将所述管的端部切成角度并放置该管从而使得管端部的开口紧靠覆盖物。在所述抽气管侧面切出侧口并放置该管从而使得所述的口与泡沫覆盖物接触。该管伸出切口位点并缝合该切口使其闭合。将一片薄膜覆盖物(Ioban，3M，St Paul，MN)置于所述切口的上方以确保气密密封。使这些动物从麻醉中恢复并置于加热的笼中。将小孔抽气管与真空源连接。将25毫米汞柱的低水平空真(即比大气压低25毫米汞柱)在这两只动物的创伤区域应用8小时。接着，用异氟烷(2％吸入)使动物再次麻醉并进行核磁共振成像扫描。对于其中一只动物，当将该动物置于核磁共振成像扫描仪中时挤压了创伤位点，从而对脑造成了其它但未定量的创伤。(表1，6号大鼠)。对该动物的扫描显示脑组织从所述真空覆盖物的一边挤出。
成功冲击了其它两只对照动物并将一块聚乙烯醇真空覆盖物置于所述除去的骨的上方。(表1，9号和12号大鼠)。所述真空覆盖物的面积比所述除去的骨的面积大，并且稍微延伸到产生以暴露脑的孔的外周之外(1-2毫米)。然后缝合皮肤使其闭合并允许动物在加热的笼中从麻醉中恢复。接着，在24小时后再次麻醉这些动物并获得了核磁共振成像扫描。成功冲击了其它两只真空处理动物，放置较大的真空覆盖物，其稍微延伸到产生以暴露脑的孔的外周之外(1-2毫米)。小孔抽气管伸出切口位点并缝合该切口使其闭合。抽气管平行于未创伤皮肤朝尾部方向伸出切口位点。将缝合线7置于颈部皮肤2并用该缝合线7将抽气管20固定到皮肤2上以防止抽气管20在动物移动时移位。(表1，10号和11号大鼠)。再次放置一小块薄膜覆盖物50以确保气密密封。将25毫米汞柱的低水平真空应用24小时。接着，再次麻醉这些动物并获得核磁共振成像扫描。此时，据发现血块阻塞了这些动物其中一只的抽气管，并且不能辨别是否确实将真空施加到创伤区域。(表1，11号大鼠)。图2-8示出了如表1第5列中所指明的大鼠的核磁共振成像图像，而图10-13以MRI图像所选图片的分截面示意性地加以说明，其中以“2”结尾的参考编号(即，102、202、302、502)表示皮肤，以“3，，结尾的编号(例如，203)表示气袋，以“4”结尾的编号表示肌肉，以“5，，结尾的编号表示颅骨，以“6”结尾的编号表示脑，以“8”结尾的编号表示血液或其它液体，而以“9”结尾的编号表示脑冲击区域。图9以分截面示意性地示出了使用相同编号规定的与图10-13相同的视图(即，皮肤402、肌肉404、颅骨405、脑406)，但是它示出了在进行这些试验中所使用的任何程序前的动物中的视图。
动物研究结果显示对照动物在冲击后8小时和24小时在创伤组织109、309处表现出具有多余水的明显肿胀。(表1，4、5、9和12号大鼠，图2、10、3、5、12、8)。在冲击后8和24小时(真空治疗8小时和24小时)，真空治疗的动物在创伤区域209、509处表现出更小的肿胀和更少的多余水。(表1，7和10号大鼠，图4、11、6、13。以及9号大鼠，图15A，相对于10号大鼠，图15B)。根据这些结果，得到结论为用6毫米直径的棒冲击大鼠脑至2.0毫米深在冲击后产生了显著的肿胀程度，所述肿胀程度在24小时比在8小时显著。对所述脑应用25毫米汞柱的真空显著地降低了脑肿胀，在冲击后24小时应用了24小时真空的效果尤其显著。
*核磁共振成像扫描为T2加权图像，其中水用白色表示。
表1
注释：
大鼠1-发展模型的动物，使用小直径的棒(3毫米)冲击-未包括在结果内。
大鼠2-发展模型的动物，6毫米直径的柱塞以2.5毫米深度产生大创伤，对于其余的动物，将深度降低至2毫米-未包括在结果内。
大鼠3-冲击前进行核磁共振成像扫描，用于与冲击后的扫描进行比较，但是动物在冲击后几分钟内死亡。
大鼠4-对照动物，冲击后8小时进行核磁共振成像扫描，显示冲击区域处的脑肿胀和突出。
大鼠5-对照动物，冲击后8小时进行核磁共振成像扫描，显示冲击区域处的脑肿胀和突出。
大鼠6-真空治疗的动物，在应用真空前连续出血。将小块聚乙烯醇覆盖物置于颅骨洞中。在冲击／治疗8小时后进行核磁共振成像扫描。将动物置于核磁共振成像扫描仪中时，核磁共振成像技术人员按压／挤压脑对脑造成了其它外伤-由于人为误差而未包括在结果内。
大鼠7-真空治疗的动物，用小块聚乙烯醇覆盖物置于颅骨洞中。在冲击／治疗8小时后进行核磁共振成像扫描。
大鼠8-冲击前进行核磁共振成像扫描，用于与冲击后的扫描进行比较，但是动物在冲击后几分钟内死亡。
大鼠9-对照动物，将直径较大的海绵置于颅骨中的缺陷上方，延伸到缺陷边缘之外。将皮肤在海绵上方缝合。放置海绵以确定位于缝合皮肤下的海绵是否将会成为肿胀的机械障碍。冲击后24小时进行核磁共振成像扫描。
大鼠10-真空治疗的动物，将直径较大的海绵置于颅骨中的缺陷上方，并延伸到缺陷边缘之外。将皮肤在海绵上方缝合。冲击后立即应用真空24小时，然后进行核磁共振成像扫描。
大鼠11-真空治疗的动物，将直径较大的海绵置于颅骨中的缺陷上方，并延伸到缺陷边缘之外。将皮肤在海绵上方缝合。冲击后立即应用真空24小时，然后进行核磁共振成像扫描。血块阻塞了管并且无法确定管阻塞的时间以及是否确实将真空应用到脑。未包括在结果内。
大鼠12-对照动物，将直径较大的海绵置于颅骨中的缺陷上方，并延伸到缺陷边缘之外。将皮肤在海绵上方缝合。放置海绵以确定位于缝合皮肤下的海绵是否将会成为肿胀的机械障碍。冲击后24小时进行核磁共振成像扫描。
实验2
外伤性脑创伤后的细胞死亡是两阶段的，初始死亡是由于外伤本身造成的，然后进行性死亡是兴奋性氨基酸的释放、乳酸积累等的后果。兴奋性氨基酸(谷氨酸、天冬氨酸)的释放造成通过激动剂开放通道的离子体内平衡紊乱，因此增加了能量需要并提高了乳酸的产生。已表明谷氨酸水平的升高与乳酸水平的升高具有相关性。乳酸的这种增加反映了损伤供给期间(局部缺血)能量需要的增加，并与患者结局逆相关。乳酸的产生导致细胞凋亡性神经元细胞死亡。
在这一初步研究中，对麻醉的大鼠沿中线旁1毫米在前卤和人字缝尖之间进行了直径8毫米的颅骨切除术。使用实施例1中所述的设备产生了硬膜完整的受控皮层冲击创伤。冲击器尖的直径为6毫米而冲击深度为2毫米。假手术组仅进行颅骨切除术；对非治疗对照进行冲击；以及冲击了治疗组，并将25毫米汞柱的亚大气压对其应用48或72小时。
脑损伤后24小时，用异氟烷麻醉大鼠并将其置于绞合线笼(Litz-cage)容积线圈内部(内径38毫米)。使用水平7T磁铁(实施例1中的Bruker Biospin装置)进行所有MRI和MRS实验。使用RARE因子为8的快速采集弛豫增强(RARE)脉冲序列获得T2-加权图像。重复时间(TR)为1500毫秒，回声时间(TE)为41毫秒，激励次数(NEX)为1，视场(FOV)为4，而矩阵大小为128×128。
以重复时间(TR)为2500毫秒，回声时间(TE)为20毫秒，激励次数(NEX)为256和边长为4毫米的立方体素的条件使用了点分辨波谱序列(PRESS)。在采集代谢产物光谱时，使用具有最佳弛豫延迟(VAPOR)的可变功率射频水抑制。
以背部第三胸室作为测量参比，根据冲击后24小时进行的核磁共振成像扫描计算了创伤(受冲击)区域的组织体积和整体密度。结果如表2所示，显示了T2加权核磁共振成像中创伤区域的组织体积和整体密度。脑部非治疗冲击区域的组织体积和密度显著大于假手术组和治疗组的区域(p<0.01)。假手术组和治疗组区域的组织体积和整体密度不具有显著差异。对水肿的其它测量为水含量。表3显示了手术／冲击后进行／未进行48小时治疗组脑组织的水含量(湿重-干重／湿重％)。治疗组区域的水含量显著低于未治疗动物区域的水含量，p<0.05。
组织体积和整体密度
表2
水含量％(括号中为动物编号#)
假手术组 创伤-未治疗组 创伤-治疗组
78.90(51右侧) 83.36(9) 80.07(10)
79.79(51左侧) 83.97(14) 80.02(52)
78.91(53右侧) 83.72(55) 80.20(54)
79.06(53左侧)
平均值±标准偏差 79.17±0.42 83.68±0.31 80.10±0.09
表3
图16从轴面示出了T2-加权MR图像，该图像示出了MR光谱体素的定位，其中用白箱标出光谱体素。图17显示了从假手术组动物(左侧)、未治疗组的动物(中间)或治疗组动物(右侧)获得的单体素MR光谱的实例。光谱显示假手术组动物中乳酸水平低(箭头)，未治疗组动物的水平高，而治疗组动物的水平较低。表4示出了所有测量的代谢产物。假手术组区域中乳酸的水平显著低于未治疗组动物。假手术组动物和治疗组动物之间的乳酸水平无显著差异。治疗组动物中乳酸水平表现出比未治疗组动物低的趋势。表5中标出了具有显著差异的剩余代谢产物(和p值)，其中治疗组动物未表现出与假手术组动物的显著差异。
表4
表5
硝基酪氨酸是细胞退化和死亡的标志物。通过对手术／冲击后72小时收获的脑样品中硝基酪氨酸的免疫组织化学染色完成了神经元退化和死亡分析。将治疗组动物暴露于亚大气压整72小时。图18A显示了未治疗脑部分的组织切片，而图18B显示了治疗脑部分。黑点代表正在退化和死亡的细胞。所述未治疗部分中正在退化和死亡的细胞比所述治疗部分中的要多的多，从而显示出治疗的益处。
根据以上说明，本发明的这些以及其它优势对本领域技术人员将是显而易见的。因此，本领域技术人员将认识到在不背离本发明广泛的发明构思的情况下，可以对上述实施方式做出变化和改变。因此，应理解本发明不局限于本文所述的具体实施方式，而是旨在包括如权利要求中所述的本发明范围和精神内的所有变化和改变。

Claims (10)

1.一种制备多孔印刷的生物可吸收材料的方法，所述多孔印刷的生物可吸收材料用于放置邻近损伤的中枢神经系统组织，所述多孔印刷的生物可吸收材料具有配置以允许亚大气压连通通过其传输至损伤的中枢神经系统组织的孔结构，所述方法包括如下步骤：
a) 制备包含生物可吸收材料的混合物；和
b) 打印所述混合物以提供多孔印刷的生物可吸收材料，其中所述打印步骤包括向多孔印刷的生物可吸收材料提供一表面，用于放置邻近损伤的中枢神经系统组织，以防止中枢神经系统组织在所述多孔印刷的生物可吸收材料中生长。
2.一种制备多孔电纺丝的生物可吸收材料的方法，所述多孔电纺丝的生物可吸收材料用于放置邻近损伤的中枢神经系统组织，所述多孔电纺丝的生物可吸收材料具有配置以允许亚大气压连通通过其传输至损伤的中枢神经系统组织的孔结构，所述方法包括如下步骤：
a) 制备包含生物可吸收材料的溶液；和
b) 将所述溶液进行电纺丝以提供多孔电纺丝的生物可吸收材料，其中所述电纺丝步骤包括向多孔电纺丝的生物可吸收材料提供一表面，用于放置邻近损伤的中枢神经系统组织，以防止中枢神经系统组织在所述多孔电纺丝的生物可吸收材料中生长。
3.一种制备多孔铸塑的生物可吸收材料的方法，所述多孔铸塑的生物可吸收材料用于放置邻近损伤的中枢神经系统组织，所述多孔铸塑的生物可吸收材料具有配置以允许亚大气压连通通过其传输至损伤的中枢神经系统组织的孔结构，所述方法包括如下步骤：
a) 制备包含生物可吸收材料和形成孔的前体的溶液；
b) 将所述溶液沉积到模子中；和
c) 从模制溶液中去除所述形成孔的前体，以提供多孔铸塑的生物可吸收材料，其中所述去除形成孔的前体的步骤包括向多孔铸塑的生物可吸收材料提供一表面，用于放置邻近损伤的中枢神经系统组织，以防止中枢神经系统组织在所述多孔铸塑的生物可吸收材料中生长。
4.根据权利要求1-3中任一项所述的方法，其中所述生物可吸收材料包括胶原。
5.根据权利要求1-3中任一项所述的方法，其中所述生物可吸收材料包括聚二醇柠檬酸酯。
6.根据权利要求5所述的方法，其中所述聚二醇柠檬酸酯包括聚1,8-辛二醇柠檬酸酯（POC）。
7.根据权利要求1-3中任一项所述的方法，其中所述生物可吸收材料包括聚乙醇酸、聚乳酸、聚己内酯、聚酯、聚癸二酸甘油酯、聚酐、聚羟基丁酸酯、聚羟基富马酸酯、聚碳酸三亚甲基酯或其组合。
8.根据权利要求1-3中任一项所述的方法，其中所述生物可吸收材料包括聚二醇柠檬酸酯和胶原。
9.根据权利要求1-3中任一项所述的方法，其中所述生物可吸收材料包括弹性蛋白、壳聚糖、硫酸软骨素、透明质酸、海藻酸盐，或它们的组合。
10.根据权利要求3所述的方法，其中所述形成孔的前体包括氯化钠。
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IL249528A0 (en) 2017-02-28
KR101597699B1 (ko) 2016-02-29
ZA201004517B (en) 2011-04-28
CA2710880A1 (en) 2009-07-16
AU2009204094A1 (en) 2009-07-16
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IL206899A0 (en) 2010-12-30
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US20090254120A1 (en) 2009-10-08
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CN102014980B (zh) 2014-04-09
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