基于任务态fMRI的rTMS促进脑卒中伴运动功能障碍患者运动功能恢复及其机制的研究

rTMS based on fMRI in task state promotes the recovery of motor function in stroke patients with dyskinesia and its mechanism

目的探讨基于任务态功能性磁共振成像(fMRI)的重复经颅磁刺激(rTMS)促进脑卒中伴运动功能障碍患者运动功能恢复的机制。方法选取2017年1月—2019年1月南通大学附属南通第三医院收治的脑卒中伴运动功能障碍患者120例,按照完全随机化设计将所有患者分为高频组、低频组和假刺激组,每组40例。高频组患者使用高频rTMS(10 Hz)治疗,低频组患者使用低频rTMS(1 Hz)治疗,假刺激组患者行rTMS假刺激治疗。比较3组患者治疗前后的上肢功能、运动功能、平衡功能、大脑皮层兴奋性及任务态fMRI影像变化。结果3组患者的性别、平均年龄、病灶部位比较,差异无统计学意义(P>0.05)。3组治疗前、治疗后5 d、治疗后3个月上肢Fugl-Meyer评定量表(运动功能)(FMA)评分、Wolf运动功能测试量表(WMFT)评分、运动功能评估量表(MAS)评分、Berg平衡量表(BBS)评分、患侧半球运动诱发电位(MEP)潜伏期及MEP最大振幅比较,差异有统计学意义(P<0.05)。与治疗前比较,治疗后假刺激组患者患侧运动区激活无明显改善,低频组患者患侧运动区激活增加,健侧运动区激活降低,高频组患者患侧运动区激活明显增加。治疗后高频组与假刺激组比较,高频组患者患侧M1、SMA明显正激活;低频组与假刺激组比较,低频组患者患侧M1明显负激活;高频组与低频组比较,两组患者双侧M1、辅助运动区(SMA)均明显正激活。结论基于任务态fMRI的rTMS促进脑卒中伴运动功能障碍患者运动功能恢复的机制可能与改善患者大脑皮层兴奋性、局部神经活动有关。

Objective To study the mechanism of repetitive transcranial magnetic stimulation(rTMS)based on task state functional magnetic resonance imaging(fMRI)to promote the recovery of motor function in stroke patients with dyskinesia.Methods A total of 120 stroke patients with motor impairment admitted to our hospital from January 2017 to January 2019 were randomly divided into high-frequency group,low-frequency group,and pseudo-stimulation group,with 40 cases in each group.The high frequency group was treated with high frequency rTMS(10 Hz),the low frequency group was treated with low frequency rTMS(1 Hz),and the false stimulus group was treated with rTMS.The changes of upper limb function,motor function,balance function,cortical excitability,and task-state fMRI images before and after treatment were analyzed.Results There was no significant difference between the three groups in gender,average age,focus location,and other general data(P>0.05).The changes of FMA,wmft,MAS,BBS,MEP latencies,and maximum amplitude of MEP in upper limb of high frequency group,low frequency group,and false stimulation group before treatment,5 days after treatment,and 3 months after treatment were compared by ANOVA of repeated measurement data(P<0.05).The changes of FMA and wmft in upper limb of high frequency group,low frequency group,and false stimulation group were different.The scores of MAS and BBS in high frequency group,low frequency group,and false stimulation group were different(P<0.025).The changes of MEP latency and MEP maximum amplitude in the affected hemisphere of high frequency group,low frequency group and false stimulation group were different(P<0.05).Compared with the pre-treatment,there was no improvement in the activation of the patient's side motor area in the false stimulation group after treatment,the activation of the patient's side motor area in the low frequency group increased,the activation of the healthy side motor area decreased,and the activation of the patient's side motor area in the high frequency group increased significantly.After treatment,M1 and SMA in the affected side of the patients in the high frequency group were significantly positively activated compared with the false stimulation group;M1 in the affected side of the patients in the low frequency group was significantly negatively activated compared with the false stimulation group;M1 and SMA in both sides of the patients in the high frequency group were significantly positively activated compared with the low frequency group.Conclusion Based on fMRI,it was found that the mechanism of rTMS promoting motor function recovery in stroke patients with motor dysfunction may be related to the improvement of cortical excitability and local nerve activity.