不同治疗时程的重复经颅磁刺激对脑卒中患者上肢运动功能及脑功能连接的影响

关键词：重复经颅刺激  缺血性脑卒中  上肢运动功能  前运动皮质区  功能连接

Keywords:repetitive transcranial magnetic stimulation  ischemic stroke  upper limb motor function  premotor cortex  functional connectivity

摘要：

      摘要 目的：以非受累侧前运动皮质区（premotor cortex， PMC）为刺激靶点，比较不同治疗时程的重复经颅磁刺激（repeated transcranial magnetic stimulation， rTMS）对脑卒中患者上肢运动功能及脑功能连接的影响。 方法：将60例缺血性脑卒中后上肢运动功能障碍患者随机分到6周rTMS组、4周rTMS组和2周rTMS组以及对照组，每组15例。在治疗前后采用上肢Brunnstrom分期、Fugl-Meyer运动功能评分上肢部分（Fugl-Meyer assessment of upper extremity， FMA-UE）和Wolf运动功能评分（Wolf motor function test， WMFT）进行行为学评定，另外以非受累侧PMC为种子点采用静息态功能磁共振成像（resting state functional magnetic resonance imaging， rs-fMRI）进行功能连接分析。 结果：治疗后，2周rTMS组的FMA-UE和WMFT的评分与4周及6周rTMS组间有显著性差异（P<0.05），但4周rTMS组的FMA-UE和WMFT的评分与6周rTMS组间无显著性差异（P＞0.05）。非受累侧PMC区为种子点的功能连接分析显示，rTMS治疗后非受累侧PMC与同侧中央前回、对侧颞中回和楔前叶功能连接增强（P<0.05）。 结论：研究结果表明，以非受累侧半球PMC为靶点的低频rTMS治疗可有效促进偏瘫上肢运动功能的恢复，其中与2周rTMS干预和6周rTMS干预相比，4周rTMS干预具有最佳的时间-效益比，这可能与其增强双侧半球间、非受累半球内皮质-皮质间的功能连接有关。

Abstract:

      Abstract Objective： To explore the effects of repeated transcranial magnetic stimulation （rTMS） at different stimulating sessions on upper limb motor function and brain functional connectivity in stroke patients， targeting on stimulate the contralateral premotor cortex （PMC）. Method： Sixty patients with upper limb motor dysfunction after ischemic stroke were randomly assigned to 6-week rTMS group， 4-week rTMS group， 2-week rTMS group or control group, each with 15 participants. Upper limb Brunnstrom stage， Fugl-Meyer assessment for upper extremity （FMA-UE） and Wolf motor function test （WMFT） were assessed before and after treatment to evaluate behavioral outcomes. The functional connectivity was analyzed by resting state functional magnetic resonance imaging （rs-fMRI） with the contralateral PMC as the seed point. Result： After treatment， the FMA-UE and WMFT scores of the 2-week rTMS group were significantly different from those of the 4-week and 6-week rTMS groups （P<0.05）， but there was no significant difference between the 4-week rTMS group and the 6-week rTMS group （P>0.05）. Functional connectivity analysis using contralateral PMC as a seed point showed that functional connections were enhanced between contralateral PMC and ipsilateral anterior central gyrus， as well as the contralateral middle temporal gyrus and precuneus after rTMS treatment （P<0.05）. Conclusion： The 4-week rTMS group has the best duration-benefit compared with the 2-week rTMS group and the 6-week rTMS group. The probable mechanism was related to that rTMS treatment could reduce the effect of interhemispheric inhibition on motor cortex， and then enhance the cortico-cortical functional connectivity in the contralateral hemisphere effectively， resulting in the recovery of upper limb motor function.