偏瘫肢体运动与针刺阳陵泉穴的fMRI和DTI成像在脑功能重塑中的研究

【作者】 崔方圆；

【导师】 邹忆怀；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2009， 博士

【摘要】 中风病是中老年人的常见病、多发病,具有高发病率、死亡率和致残率的特点。偏瘫是中风病主要症状之一,偏瘫造成患者生活不能自理,给社会和家庭带来巨大负担。脑的可塑性是运动等各种脑功能恢复的重要机制,是目前中风病临床治疗和基础研究的热点。中医药治疗中风具有悠久的历史和良好的疗效,其中针灸治疗是中风偏瘫康复的重要治疗方法,但针灸对脑功能重塑的影响尚待研究。功能影像学技术的飞速发展为研究中风后脑的损伤恢复和针刺的疗效机制提供了契机,为较全面、直观、无创的观察生理、病理状态下的脑功能变化,以及针刺对脑运动功能重塑的作用位点和作用途径研究提供有力的技术支持。本研究以健康人和中风偏瘫病人为对照,在不同机体状态下进行上肢运动和针刺阳陵泉穴的脑功能影像研究,并进行激活区、纤维、病灶的三维重构和对比分析研究。1.偏瘫患者针刺阳陵泉及左上肢运动的脑功能成像研究目的:探讨偏瘫肢体运动与脑功能激活的关系,以及针刺阳陵泉穴对中风后大脑运动功能区可能存在的影响。方法:根据诊断和纳入标准,纳入5例受试病例,进行神经功能评价。在核磁试验中采集患者结构像、左上肢运动和针刺左侧阳陵泉的Block模式脑功能成像。使用BrainVoyager软件和SPM5软件等对fMRI数据进行后处理。结果:(1)左上肢运动在两侧小脑、基底节核团、大脑初级感觉运动皮层和次级运动皮层有明显激活,右侧皮层运动区激活较左侧明显。(2)针刺左侧阳陵泉在脑干中脑、左侧大脑皮层的运动前区和次级运动区有明显激活。(3)运动和针刺两种刺激方式的脑功能成像比较未见明显重合激活区域。结论:(1)针刺阳陵泉穴可能调节中枢的张力反馈通路,影响中枢运动协调整合功能,以此改善痉挛状态和运动功能。(2)偏瘫上肢运动的脑激活区域可能与脑损伤后功能代偿有关,说明脑功能重塑是偏瘫肢体运动功能恢复的重要机制。2.健康人针刺阳陵泉穴及左上肢运动的脑功能成像及两组对比研究目的:探讨正常肢体运动的神经传导通路和针刺的脑效应;分析在生理病理不同状态下运动和针刺脑激活结果的差异和意义。方法:根据纳入标准纳入8例健康受试者,分别进行结构像、左上肢主动运动和针刺左侧阳陵泉穴的Block模式脑功能成像,数据处理方法与偏瘫病例组相同。结果:(1)正常组运动激活区主要在左侧小脑、右侧大脑初级感觉运动皮层和部分次级运动区。(2)针刺阳陵泉穴激活区主要在左侧小脑、两侧中央后回和顶下小叶。(3)两组运动任务在初级感觉运动皮层有共同激活簇,针刺在左顶下小叶有共同激活簇。两组间对比存在激活脑区的差异。结论:(1)正常人肢体运动的脑激活区与一侧肢体受对侧大脑和同侧小脑支配神经解剖定位相符。(2)正常人针刺阳陵泉可对运动调节中枢产生反应。(3)偏瘫肢体活动与健康人相比可能受到更广泛的中枢调节控制;生理和病理不同状态下针刺阳陵泉穴在大脑功能激活效应不同,从而对机体产生不同的反馈调节作用。3.fMRI与DTI联合应用对脑运动功能损伤和恢复机制及预后分析目的:分析运动功能障碍与纤维束受损的关系;探讨偏瘫肢体的运动通路的损伤和恢复机制,对运动功能恢复进行预后分析。方法:根据试验一和试验二的纳入标准纳入7例受试者,进行DTI成像扫描,使用BrainVoyager软件和SPSS13.0统计软件包进行图像和数据分析,进行fMRI、DTI以及病灶的三维重建与图像融合。结果:(1)病例组的健侧大脑内囊后肢的FA值与正常人差异不明显;正常组右侧FA值明显优于病例组。偏瘫患者病损脑区与健侧脑区相比FA值显著降低。(2)fMRI、DTI以及病灶的三维重建与图像融合结果请参见正文图示。结论:DTI技术可以清晰显示皮质脊髓束等神经纤维受压、中断和破坏的情况,病损具体部位、大小与临床症状和神经功能的恢复程度和恢复机制密切相关,可以用以了解患者的病损信息、指导康复治疗、推测预后等。更多还原

【Abstract】 Apoplexy is the common and frequently occuring disease with high disease incidence, mortality and mutilation rate.Hemiparalysis,one of the present symptoms of apoplexy,makes the patients no self-care,which brings great burden to family and society.Brain plasticity is the important mechanism for cerebral functional recovery,and it is the hot spot of clinical and basic research on apoplexy.Chinese Medicine treatments on apoplexy has a long history with favorable curative effect,among them,acupuncture and moxibustion therapy is the important way for hemiparalysis rehabilitation,while the influence of acupuncture and moxibustion on cerebral function remodeling.Quick development of functional imageology brings the moment of researching on impairment recovery of epencephalic after stroke and the therapy mechanisms of acupuncture and moxibustion.What’s more,it provides potent technique support on cerebral function change under normal and pathologic state and the function point and pathway of brain function remolding full-scale,direct view and without injury.This research compares normal persons and apoplexy hemiparalysis,undergoes cerebral function imageology research on different organism state while doing upper extremity exercise and acupuncture Yanglingquan(GB34).At the same time,the reasearch carries out three-dimensional reconstruction and contrast analysis of transactivation area,fiber and disease focus.1.Cerebral function imaging on hemiplegic patient taking Yanglingquan(GB34) acupuncture and left upper extremity exercise.Objective:Acquiring cerebral transactivation area results of left upper extremity exercise and GB34 acupuncture under pathological state,discussing the relation between hemiparalysis limbs movement and cerebral function activation,also the influence of cerebrum motor function area while acupuncturing GB34.Methods:Assessing 5 patients’ nerve function collecting patient structure image and Block model cerebral function imaging with fMRI.Results:Left upper extremity exercise obviously activates bilateral cerebellum,basal ganglia kernel,cerebrum primary sensorimotor cortex(SM1)and posterior parietal cotex(PPC),right parietal cotex is more active than left;acupuncturing GB34 obviously activates mesencephali of brain stem,left premotor cortex(PMC) and PPC.Conclusion:acupuncturing GB34 can regulate tension feedback path of central nervous system (CNS) and affect CNS’s motor coordination integration which ameliorate spasticity and motor function;cerebral activation areas of upper extremity exercise are concerned with compensation of CNS,which declares that cerebral function remolding is one of the important mechanism of limbs motor function recovery.2.Cerebral function imaging of acupuncturing GB34 and left upper extremity exercise and their comparative study in normal personsObjective:Acquiring two kinds of normal cerebral activation by cerebral function imaging of acupuncturing GB34 and left upper extremity exercise in normal persons,discussing the neural conduction path of extremity exercise and cerebral effect of acupuncture.Analyzing the difference and significance of motor and acupuncture cerebral activation in normal and physiological states.Methods:Collecting 8 patients’ structure image,left extremity motor and Block model of acupuncturing left GB34 cerebral function imaging with fMRI.The data processing is the same with hemiplegia group.Results:motor activation areas in normal group locate at left cerebellum,right cerebral SM1 and part PPC;acupuncturing GB34 activation areas locate at left cerebellum,bilateral posterior central gyrus and inferior parietal lobule;two groups have the same activation cluster at SM1; there is significant difference between two groups’s activation areas.Conclusion:The motor activation areas of normal person match the neural dissection localization of one side limb receiving opposite cerebrum and homonymy cerebellum control; acupuncturing GB34 in normal person responses the centers of motor accommodation.;there is probably more central regulaton mechanism in hemiparalysis extremity than normal one;the different activation effects of acupuncturing GB34 in normal and pathological state generate different feedback regulation action.3.Uniting fMRI and DTI(Diffusion Tensor Imaging) to analyze the mechanism and prognosis of cerebral motor function injury and rehabilitationObjective:Analyzing the relation between motor dysfunction and fiber bundle injury; investigating the injury and rehabilitation mechanism of hemiparalysis extremity’s motor path.Methods:According to the inclusion criteria of test 1 and 2,DTI scaning 7 patients,image and data analysis by BrainVoyager and SPSS13.0;processing fMRI,DTI and focus of disease three-dimensional reconstruction and image fusion.Results:There is no obvious difference m FA values of uninjured internal capsule of cerebrum between case group and normal group;the normal group FA values is obviously better than case group;the FA values in hemiparalysis patient’s impairment encephalic region is much lower than the uninjured side;please refer to the text for the results of fMRI,DTI and focus of disease three-dimensional reconstruction and image fusion.Conclusion:DTI technique can clearly display the compression,breaks and destruction of condition of corticospinal tracts;there is close relationship between locations and sizes of specific impairment and rehabilitation level and mechanism of nerve function.更多还原