健侧脑感觉运动区在局灶性脑梗死后偏瘫肢体运动功能康复中的作用

Effect of the sensorimotor area of contralateral brain in the rehabilitation of hemiplegic limb motor function after focal cerebral infarction

目的探讨局灶性脑梗死后健侧大脑半球感觉运动区在偏瘫上肢运动功能恢复中的作用和意义。方法前瞻性非随机对照研究。纳入扬州大学附属医院神经内科2015年6月—2017年12月经严格筛选的17例初次发病的纹状体内囊区脑梗死(SCI)伴单侧严重上肢瘫患者作为研究对象(观察组),同时选取15例健康者作为对照组。分别于发病后1周内(初期)、1个月及3个月时,在偏瘫侧被动手指屈伸(FE)任务下行血氧水平依赖功能磁共振成像(BOLD-fMRI),通过SPM8软件观察健侧大脑半球感觉运动(SMC)区激活情况,再根据健侧大脑半球SMC区激活强度及时程将观察组分成3个亚组。通过Xjview软件对观察组健侧SMC区激活进行观察并同对照组行动态比较,同时对亚组感兴趣区动态变化进行比较分析。采用简化Fugl-Meyer评分量表上肢部分(FM-UL),分别于发病1周内及发病1、3个月行功能磁共振成像(fMRI)扫描前,对观察组患者患侧上肢运动功能进行评定。结果(1)BOLD-fMRI显示:对照组受试者在一侧手指被动FE运动时,可见对侧大脑半球SMC、辅助运动区(SMA)、双侧下顶叶及同侧小脑激活。根据健侧大脑半球SMC区激活强度及时程将观察组分成3组:组1共6例患者,其发病初期健侧SMC区即存在明显激活,发病后1、3个月,随着患肢的康复,健侧SMC区激活逐渐减低,其成像模式逐渐趋于对照组;组2共5例,发病初期健侧SMC区无明显激活,发病后1、3个月时健侧SMC区激活逐渐增强;组3共6例患者,于发病初期、1个月及3个月时均未见健侧SMC区明显激活表现。发病1周内FM-UL评分3个亚组间比较差异无统计学意义(P>0.05);发病1个月时患者FM-UL评分3个亚组间,以及亚组间两两比较,差异均具有统计学意义(P值均<0.01);发病3个月时,观察组1与组2患者FM-UL评分比较差异无统计学意义(P>0.05),但均高于观察组3,差异均有统计学意义(P值均<0.01)。结论健侧大脑半球SMC区参与了皮层下脑梗死后的运动功能重组,其激活时程同患者偏瘫肢体运动功能恢复的速度相关。

Objective To explore the role and importance of the sensorimotor cortex(SMC)in the contralateral hemisphere in the motor function recovery of the upper limb after cerebral infarction by blood oxygenation level-dependent function magnetic resonance image(BOLD-fMRI)and passive motor rehabilitation technique.Methods A prospective,non-randomized controlled study was conducted.Strict clinical screening in the Department of Neurology of the Affiliated Hospital of Yangzhou University was performed from June 2015 to December 2017.Seventeen patients with primary onset of striatal intracapsular infarction with unilateral severe upper limb paralysis were selected as the research objects,and 15 healthy volunteers were selected as the control group.BOLD-fMRI was performed within 1 week,1 month,and 3 months after stroke onset.SMC activation in the healthy side was observed by SPM8 software.The observation group was divided into three subgroups according to the activation intensity and time course of the SMC in the contralateral hemisphere.The activation of the region of interest(ROI)in BOLD-fMRI was observed by xjview software and compared with the standard brain activation area dynamically,and dynamic changes in the ROI in the subgroups were compared and analyzed.The upper limb motor function of the affected side of the patients was assessed using the simplified Fugl-Meyer score scale for the upper limb(FM-UL).The upper limb motor function of the selected patients was evaluated before fMRI scanning and at 1 and 3 months after onset.Results The bold-fMRI results showed that the contralateral cerebral hemisphere SMC,supplementary motor area(SMA),bilateral inferior parietal lobes and ipsilateral cerebellum were activated when the subjects in the control group were subjected to unilateral finger passive FE movement.The experimental cases were divided into three groups according to the activation intensity and time course of the contralateral SMC.Group 1(n=6)had obvious activation in the contralateral SMC at the early onset stage,and some cases were even stronger than the affected side.The activation of the contralateral SMC decreased gradually and tended to be lower than that in the control group with the recovery of the affected limb.Group 2,had no substantial activation of the contralateral SMC at the early stage of stroke,and the activation of the contralateral SMC increased gradually after 1 and 3 months.The remaining six patients belong to the third group.No SMC activation on the contralateral side was found in the early stage,in January and March.There was no significant difference in FM-UL score among the 3 subgroups within 1 week of onset(P>0.05).At 1 month after onset,the FM-UL scores of patients were compared among the 3 subgroups and pairwise among subgroups,and the differences were statistically significant(all P values<0.01).At 3 months after onset,there was no significant difference in FM-UL scores between observation group 1 and 2(P>0.05),but they were all higher than observation group 3,with statistical significance(all P values<0.01).Conclusions SMC in the contralateral hemisphere is involved in motor function reorganization after subcortical cerebral infarction,and its activation time is related to the recovery speed of limb motor function.