重复经颅磁刺激对难治性耳鸣患者的临床疗效及其脑功能网络调控效果

Effects of repetitive transcranial magnetic stimulation on refractory tinnitus and regulation of brain function network

目的观察重复经颅磁刺激(repetitive transcranial magnetic stimulation,rTMS)对难治性耳鸣疗效、安全性及治疗前后静息态功能磁共振(rs-fMRI)成像差异,探讨rTMS调控耳鸣可能的中枢机制。方法选择2022年9月至2023年2月在川北医学院附属医院就诊的难治性耳鸣患者37例,分为试验组(n=20)与对照组(n=17)。试验组予rTMS治疗,对照组予以相同参数的假刺激。治疗前后行耳鸣残疾量表(tinnitus handicap inventory,THI)、耳鸣响度视觉模拟评分(loudness visual analogue scale,VAS)及rs-fMRI扫描。扫描后行局部一致性(regional homogeneity,ReHo)计算,并选取差异脑区为感兴趣区(ROI),行全脑功能连接(functional connectivity,FC)分析。结果试验组与对照组年龄、性别、教育水平、耳鸣患侧、病程、听力水平、抑郁自评量表评分、焦虑自评量表评分差异均无统计学意义。治疗前两组患者THI、VAS评分差异无统计学意义;干预2周后,试验组THI、VAS评分降低(P<0.001),对照组无明显改变。在治疗过程中,试验组有3例患者出现左侧面部肌肉颤动或短暂轻微的头皮疼痛,无其他明显不良反应。试验组rTMS后左侧小脑9区ReHo增加(P<0.005);对照组干预后右侧颞下回、左侧中央后回、左侧中央前回的ReHo增加(P<0.005)。试验组rTMS后右侧颞下回与左侧眶部额下回、左侧前扣带回FC增强(P<0.005),与左侧缘上回FC减弱(P<0.005);试验组rTMS后右侧楔叶与左侧梭状回、右侧枕上回FC减弱(P<0.005)。对照组干预后右侧楔叶与左侧梭状回FC增强(P<0.005),其他FC无明显改变。结论rTMS对难治性耳鸣有一定治疗作用,安全性较高;调控听觉脑网络及相关非听觉脑网络可能是rTMS治疗难治性耳鸣的中枢机制之一。

Objective To observe the efficacy and safety of repetitive transcranial magnetic stimulation(rTMS) on refractory tinnitus and the differences of resting-state functional magnetic resonance imaging(rs-fMRI) imaging between before and after treatment, and to explore the possible central mechanism of rTMS regulation of tinnitus. Methods Thirty-seven patients with refractory tinnitus admitted in Affiliated Hospital of North Sichuan Medical College from September 2022 to February 2023 were selected and were divided into experimental group(n=20) and control group(n=17). The experimental group was given true rTMS treatment, and the control group was given sham stimulation with the same parameters. Tinnitus handicap inventory(THI) score,tinnitus loudness visual analogue scale(VAS) score and rs-fMRI scan were performed before and after treatment. Regional homogeneity(ReHo) was calculated after scanning, and the different brain regions were selected as the area of interest(ROI) and the whole brain functional connection(FC) was performed. Results There were no significant differences in age, gender, education level, tinnitus side, course of disease, hearing level, self-rating depression scale, self-rating anxiety scale the experimental group and control group. There were no significant differences in THI and VAS scores between the two groups before treatment;the THI and VAS scores in the experimental group decreased after 2 weeks of rTMS treatment(P<0.001), while there was no significant difference in the two scores in the control group before and after treatment. Only 3 patients in the experimental group experienced left facial muscle tremor or transient mild scalp pain during treatment, without other serious side effects. The ReHo of the left cerebellar area 9 increased in the experimental group after rTMS(P<0.005);the ReHo values in the right inferior temporal gyrus,left posterior central gyrus and left anterior central gyrus increased in the control group after intervention(P<0.005). The FCs between the right inferior temporal gyrus and the left orbital inferior frontal gyrus, the left anterior cingulate gyrus increased in the experimental group(P<0.005), and FC between the right inferior temporal gyrus and the left superior marginal gyrus decreased(P<0.005). The FCs between the right cuneus and the left fusiform gyrus, right superior occipital gyrus decreased in the experimental group after rTMS(P<0.005). The FC between the right cuneus and the left fusiform gyrus increased in the control group after intervention(P<0.005),while other FCs remained unchanged. Conclusions rTMS has a certain therapeutic effect on refractory tinnitus with higher safety;regulation of auditory brain network and related non-auditory brain network may be one of the central mechanisms of rTMS treating refractory tinnitus.