脑干卒中后吞咽障碍患者改良导管球囊扩张治疗中枢调控机制的fMRI研究

Balloon dilatation therapy for treating dysphagia after brainstem stroke： A fMRI study

目的探讨改良球囊扩张治疗脑干卒中后上食管括约肌功能障碍患者的中枢神经调控机制。方法选取上食管括约肌开放不全或完全不开放的脑干卒中后吞咽障碍20例，按随机数字表法分为常规治疗组和球囊扩张组，每组10例；另选取健康受试者10例设为正常组。治疗前、后，采用功能性磁共振成像检查观察3组受试者吞咽唾液时吞咽相关皮质兴奋性的变化（正常组于2组患者治疗后进行检查），并比较3组受试者治疗前、后皮质和皮质下激活情况。结果正常组受试者双侧大脑皮质及皮质下激活广泛，脑干卒中后吞咽障碍患者脑区激活明显减少。治疗后，球囊扩张组中有7例患者恢复完全经口进食，常规治疗组仅3例恢复经口进食，且球囊扩张组患者激活脑区较组内治疗前明显增多，包括前扣带回、岛叶、辅助运动区、额叶、楔前叶等，但激活体素较低（P〈0．01）；常规治疗组患者后脑区仅左侧楔前叶较组内治疗前激活增多，且激活体素仅为22（P〈0．01）。结论改良球囊扩张术可激活感觉运动皮质及皮质下吞咽相关的功能区，并通过离皮质通路来改善吞咽功能。

Objective To explore the effects of modified balloon dilatation therapy for treating upper esoph- ageal sphincter dysfunction after a brainstem stroke. Methods Ten healthy adult volunteers and 20 dysphagic pa- tients with upper esophageal sphincter dysfunction after a brainstem stroke were recruited. The 20 patients were divid- ed into a balloon dilatation therapy group of ten who were treated with catheter balloon dilatation therapy, and a con- trol group of ten who received conventional therapy. All were given block-designed task fMRI scans guided by a matched visual presentation system before and after the treatment. Results Widespread activation was observed in both hemispheres, including the bilateral cerebral cortex, the brainstem and the cerebellum, but the activated areas were significantly smaller in the stroke patients before treatment. After the treatment, seven patients in the balloon dilatation group were totally orally fed, while only three patients in the control group recovered totally oral intake. Af- ter dilatation, significantly more regions were activated, including the anterior cingulate, insula, supplementary motor area, preeuneus and the frontal lobe. They were activated with relatively low voxels in the treatment group, while in the control group significant activation was observed only in the precuneus after treatment. Conclusion Modified balloon dilatation therapy can increase activation of the cortex and subcortical structures related to swallowing, promo- ting better swallowing function.