丘脑底核脑深部电刺激对帕金森病认知功能的影响

Effects of subthalamic nucleus deep brain stimulation on cognitive function in patients with Parkinson＇s disease

目的 随访经丘脑底核脑深部电刺激（DBS）临床治疗的帕金森病患者,观察丘脑底核DBS术对其认知功能的影响.方法 应用统一帕金森病评定量表第二、三部分（UPDRSⅡ,Ⅲ）,改良Hoehn-Yahr （H-Y）分级,系列神经心理学量表简易智能量表（MMSE）、韦氏记忆量表（WMS）、Nissen软件（SRTT）、残图命名、词语流畅性（VF）和画钟测验等方法,分别于丘脑底核DBS术前1周及术后12个月对20例帕金森病患者的临床特征和认知功能进行评估.以20名与之匹配的健康人作为健康对照.结果 帕金森病患者DBS术后无论“开期”还是“关期”日常生活能力（UPDRSⅡ）、运动功能（UPDRSⅢ）、病情（H-Y分级）较术前均有显著的改善（P＜0.01）.术前帕金森病患者记忆商为88.10±16.70,明显低于对照组（100.90±6.45;t=-3.187,P＜0.01）.帕金森病患者DBS手术前后的记忆商及各项分测验比较差异均无统计学意义.SRTT测试获得的平均反应时（Tavg）对照组、术前帕金森病组及术后帕金森病组分别为（1.09±0.32）、（1.58 ±0.83）、（1.62±0.83）s,术前帕金森病组较对照组延长（t =2.432,P＜0.05）;对3个组组内各小节间比较发现,帕金森病患者手术前后各节Tavg差异均无统计学意义;对错误率比较,对照组、术前帕金森病组及术后帕金森病组的总错误率分别为4.84％±4.27％、9.76％±1.52％和13.41％±1.11％.MMSE和残图命名测验结果显示,对照组、术前帕金森病组和术后帕金森病组3组间差异均无统计学意义;对于VF测验结果,对照组和术前帕金森病组比较差异有统计学意义（Z=-2.927,P＜0.01）,术后VF较术前下降差异有统计学意义（Z=-2.469,P=0.014）;对于画钟测验结果,对照组和术前帕金森病组比较差异有统计学意义（Z=-2.762,P＜0.01）,术后较术前有所提升（Z=-2.165,P=0.03）.结论 丘脑底核DBS术在一定程度上可以引起帕金森病患者认知功能的改变：VF下降,视空间功能和注意力改善,可能内隐记忆和执行功能下降等.

Objeetive To follow up the patients with Parkinson＇s disease （PD） who underwent subthalamic nucleus （STN） deep brain stimulation （DBS） therapy,and to compare the changes of cognitive function before and after this functional surgery.Methods The authors set up a series of clinical tests including unified Parkinson＇s disease rating scale （UPDRS） Ⅱ ＆ Ⅲ,Hoehn ＆ Yahr stage （H-Y stage）,mini mental state examination （MMSE）,Wechsler memory scale （WMS）,serial reaction time task （SRTT）,degraded picture naming （DPN）,verbal fluency （VF）,clock drawing test （CDT） to measure the performance of both clinical characteristics and cognitions 1 week before and 12 months after STN-DBS operation in 20 PD patients,matched with 20 healthy adults who just assessed by the neuropsychological tests.Results Activity of daily life （UPDRS Ⅱ）,motor manifestations （UPDRS Ⅲ） and disease condition （H-Y stage） were all significantly improved whether they were ＂on period＂ or ＂off period＂ （P 〈 0.01）.In the test of WMS,the memory quotient （MQ） scores of PD patients （88.10 ± 16.70） were significantly lower （t =-3.187,P 〈0.01） than the control group （100.90 ± 6.45）.By SRTT test,the mean average response time （Tavg） of the control group,pre-operation and post-operation groups was （1.09 ± 0.32） s,（1.58 ± 0.83） s and （1.62 ± 0.83） s,respectively.As to the comparison of the blocks,no changes were found within each group of PD （pro-F =0.329,P =0.964 ; post-F =0.377,P =0.945）,by contrast,it had been proved to be statistically significant in the control group （F =2.316,P 〈0.05）.The mean error rates of the control group,pre-operation and post-operation groups were 4.84% ± 4.27%,9.76% ± 1.52% and 13.41% ± 1.11% respectively,and the control group was not different from pre-operation group （t =1.388,P =0.173） while significantly different compared with post-operation group （t =3.225,P 〈0.01）.As for MMSE and DPN results,no significant benefits were obtained in the control,pre-operation and post-operation groups.In regard to VF,there was a statistically significant difference between control group and pre-operation group （Z =-2.927,P 〈 0.01）,and it was significantly worse after surgery （Z =-2.469,P =0.014）.As for CDT,significant benefits were obtained in both preoperation （Z =-2.762,P 〈 0.01） and post-operation groups （Z =-2.165,P =0.03） compared with control group.Conelusions To some extent,STN-DBS can affect the cognition of PD patients,such as lowing VF,improving visual-spatial function and attention,a decreasing trend of implicit memory and executive function.Explicit memory is partly dissociated with implicit memory.