健侧半球间歇θ脉冲刺激和低频重复经颅磁刺激治疗卒中后视空间忽略的效果比较

Efficacy comparison of contralesional intermittentθburst stimulation and low-frequency repetitive transcranial magnetic stimulation on visual spatial neglect after stroke

目的对比间歇θ脉冲刺激(iTBS)刺激健侧半球前额叶背外侧(DLPFC)与1 Hz重复经颅磁刺激(rTMS)刺激健侧半球顶后皮质(PPC)治疗卒中后视空间忽略的疗效。方法前瞻性连续纳入2019年4月至2021年3月入诊首都医科大学宣武医院康复医学科的33例卒中后视空间忽略患者,采用随机信封法将所有患者随机分为3组[iTBS组11例,rTMS组11例,假刺激组11例(1例因胆囊炎转往外科治疗,无法继续参与本研究)]。3组患者均接受常规肢体康复训练(包括手法治疗、物理因子治疗和传统康复治疗)及每日1次30 min的视觉扫描训练,在此基础上,iTBS组给予左侧大脑半球DLPFC区iTBS刺激,rTMS组给予左侧半球PPC区1 Hz的rTMS刺激,假刺激组线圈置于左侧小脑半球,每日2次,每周5 d,共治疗2周。分别于治疗前后对3组进行线段二等分、线段划消、星型划消量表测试及日常生活活动能力(ADL)评分量表评估并进行组内治疗前后及组间的比较。结果(1)3组患者的年龄、性别、病程、病灶体积的差异均无统计学意义(均P>0.05)。(2)治疗后iTBS组和rTMS组线段二等分、线段划消、星型划消量表测试结果均较治疗前明显降低[iTBS组:分别为(11.1±10.8)%、(10±7)%、(18±8)%比(28.9±15.5)%、(32±14)%、(42±15)%;rTMS组:分别为(19.3±14.4)%、(19±12)%、(29±13)%比(35.9±25.1)%、(30±13)%、(47±19)%;均P<0.05]。线段二等分、线段划消、星型划消量表测试结果治疗前后差值假刺激组、iTBS组与rTMS组3组间差异均有统计学意义[线段二等分分别为(3.6±2.4)%、(17.8±7.7)%、(16.0±12.4)%;线段划消分别(5±5)%、(22±9)%、(11±6)%;星型划消量表评分分别为(3±5)%、(24±12)%、(19±13)%;F值分别为8.270、15.929、10.891,均P<0.01]。iTBS组治疗后线段二等分、线段划消、星型划消量表测试结果较治疗前的改善明显优于假刺激组,rTMS组治疗后线段二等分、星型划消量表测试结果改善明显优于假刺激组,iTBS组治疗后线段划消测试结果改善明显优于rTMS组,差异均有统计学意义(均P<0.05)。(3)与治疗前比较,治疗后假刺激组、iTBS组、rTMS组ADL评分均明显提高[分别为(58±9)分比(54±9)分、(77±19)分比(61±17)分、(65±12)分比(58±13)分],差异均有统计学意义(均P<0.01)。假刺激组、iTBS组、rTMS组治疗前后ADL评分差值分别为(-4±4)、(-16±7)、(-6±3)分,3组间差异有统计学意义(F=14.251,P<0.01);iTBS组治疗前后ADL评分差值绝对值明显高于假刺激组和rTMS组,差异均有统计学意义(均P<0.05)。结论健侧半球iTBS和1 Hz的rTMS对卒中亚急性期至慢性期视空间忽略患者的恢复有益,其中iTBS治疗效果可能优于rTMS。

Objective To compare the therapeutic effect of intermittentθburst stimulation(iTBS)over the contralesional dorsal lateral prefrontal cortex(DLPFC)with 1 Hz low-frequency repetitive transcranial magnetic stimulation(rTMS)over the posterior parietal cortex(PPC)in patients with visual spatial neglect(VSN)after stroke.Methods A total of 32 VSN patients after stroke admitted at the Department of Rehabilitation Medicine of Xuanwu Hospital,Capital Medical University were prospectively recruited for the present study between April 2019 and March 2021.The patients were subdivided for iTBS(n=11),rTMS(n=11)and sham stimulation(n=11)by random envelope(one case with acute cholecystitis was tread by surgery and could not continue to participate in this study).All patients underwent routine daily training(including manual therapy,physical therapy and traditional rehabilitation treatment)and visual scanning training for 30 minutes a day.Patients in the iTBS group received iTBS over the left DLPFC,while those in the rTMS group received 1Hz rTMS over the left PPC and sham TMS over the left cerebellum.All patients received treatments twice a day,5 days per week for 2 weeks.Behavioral tests were assessed pre-and post-treatment using line bisection test,line cancellation test,star cancellation test and activity of daily living score(ADL).Then comparison before and after treatment and among groups were done,respectively.Results(1)There are no significant differences in age,gender,time since stroke onset and lesion volume between the three groups(all P>0.05).(2)After treatment,the iTBS group and rTMS group showed significantly greater improvement in line bisection test,line cancellation test and star cancellation test(iTBS group:[11.1±10.8]%,[10±7]%,[18±8]%vs.[28.9±15.5]%,[32±14]%,[42±15]%;rTMS group:[19.3±14.4]%,[19±12]%,[29±13]%vs.[35.9±25.1]%,[30±13]%,[47±19]%;all P<0.05).Significant difference of behavioral tests before and after treatment among the iTBS group,rTMS group and sham group were found(the line bisection test scores:[3.6±2.4]%,[17.8±7.7]%,[16.0±12.4]%;the line cancellation test scores:[5±5]%,[22±9]%,[11±6]%;the star cancellation test scores:[3±5]%,[24±12]%,[19±13]%;F values were 8.270,15.929 and 10.891,all P<0.01).The iTBS group showed significantly greater improvement than the sham group in line bisection test,line cancellation test and star cancellation test,while the 1 Hz rTMS group showed significantly greater improvement than the sham group in line bisection test and star cancellation test.In addition,the iTBS group showed significantly better in line cancellation test than those in rTMS group(all P<0.05).(3)Compared with the ADL scores before treatment,the ADL scores in the sham group,iTBS group and rTMS group was respectively increased after treatment([58±9]vs.[54±9],[77±19]vs.[61±17],[65±12]vs.[58±13];all P<0.01).The difference of ADL scores before and after treatment in sham stimulation group,iTBS group and rTMS group were(-4±4),(-16±7)and(-6±3),respectively.The difference among the three groups was statistically significant(F=14.251,P<0.01);the difference of absolute value of ADL scores before and after treatment in iTBS group was significantly higher than that in sham group and rTMS group(all P<0.05).Conclusions These results indicate that contralesional iTBS over the DLPFC and 1 Hz low-frequency rTMS over the PPC are effective in the treatment of visuospatial neglect in patients with subacute-chronic stroke.Treatment with contralesional iTBS over the DLPFC may be better.