本文選題：皮層下中風(fēng)　切入點(diǎn)：運(yùn)動(dòng)通路　出處：《天津醫(yī)科大學(xué)》2017年博士論文　論文類型：學(xué)位論文

【摘要】：研究背景及目的:中風(fēng)是世界范圍內(nèi)僅次于冠心病的第二位致死原因。中風(fēng)后,梗死灶的位置往往差異很大,這種病灶位置的差異被認(rèn)為與患者的功能預(yù)后相關(guān)�；坠�(jié)區(qū)中風(fēng)與腦橋中風(fēng)雖然都可能損傷皮層下運(yùn)動(dòng)通路,但二者累及的鄰近的腦內(nèi)結(jié)構(gòu)不同。大量研究證實(shí),中風(fēng)慢性期繼發(fā)性腦結(jié)構(gòu)損傷與可塑性是并存的。本研究的目的是通過(guò)比較慢性期基底節(jié)區(qū)中風(fēng)、腦橋中風(fēng)及正常被試?yán)^發(fā)性腦結(jié)構(gòu)損傷及可塑性,得到不同部位皮層下運(yùn)動(dòng)通路中風(fēng)隱匿性腦損害模式與神經(jīng)康復(fù)機(jī)制的差異。研究?jī)?nèi)容及方法:在這個(gè)前瞻性的研究中,MRI數(shù)據(jù)的采集來(lái)源于國(guó)內(nèi)三家三級(jí)甲等醫(yī)院的四臺(tái)磁共振掃描儀。所有被試在實(shí)驗(yàn)前都獲知情同意,自愿參加實(shí)驗(yàn),并經(jīng)天津醫(yī)科大學(xué)總醫(yī)院倫理委員會(huì)批準(zhǔn)�；趪�(yán)格的入組標(biāo)準(zhǔn)及排除標(biāo)準(zhǔn),115名基底節(jié)區(qū)中風(fēng)(capsular stroke,CS)患者、47名腦橋中風(fēng)(pontine stroke,PS)患者及116名正常被試(normal control,NC)進(jìn)入最終的統(tǒng)計(jì)學(xué)分析。評(píng)估被試的神經(jīng)功能并測(cè)量中風(fēng)患者的梗死灶體積。所有被試的MRI數(shù)據(jù)經(jīng)預(yù)處理后進(jìn)行統(tǒng)計(jì)學(xué)分析。根據(jù)梗死灶的位置,將所有中風(fēng)患者分為左側(cè)病灶組和右側(cè)病灶組,分別進(jìn)行基于體素的形態(tài)學(xué)分析(voxel-based morphometry,VBM),比較組間灰質(zhì)體積(gray matter volume,GMV)的差異。并進(jìn)一步將上述VBM分析的結(jié)果中GMV有顯著差異的團(tuán)塊定義為感興趣區(qū)(regions of interest,ROI),提取每個(gè)ROI的GMV值并定量地進(jìn)行組間比較,進(jìn)行基于體素的事后分析(ROI分析)。本文的三部分內(nèi)容分別進(jìn)行如下研究:1、應(yīng)用獨(dú)立樣本T檢驗(yàn),比較CS與NC之間GMV的差異。2、應(yīng)用獨(dú)立樣本T檢驗(yàn),比較PS與NC之間GMV的差異。3、應(yīng)用單因素協(xié)方差分析,比較CS、PS與NC之間GMV的差異。最后應(yīng)用基于表面的形態(tài)學(xué)分析方法Freesurfer比較GMV的組間差異,對(duì)VBM分析的結(jié)果進(jìn)行驗(yàn)證。在Freesurfer分析中GMV有顯著組間差異且團(tuán)塊位置與前述VBM分析結(jié)果一致的團(tuán)塊定義為ROI,進(jìn)行基于表面的事后分析,定量評(píng)價(jià)每個(gè)ROI的GMV、皮層厚度(cortical thickness,CT)及皮層表面積(surface area,SA)的組間差異。結(jié)果:1、左側(cè)及右側(cè)病灶組CS患者病灶同側(cè)感覺(jué)運(yùn)動(dòng)皮層(sensorimotor cortex,SMC)GMV均減低;右側(cè)CS患者雙側(cè)小腦的GMV顯著減低,而病灶對(duì)側(cè)額中回及雙側(cè)輔助運(yùn)動(dòng)區(qū)(supplementary motor area,SMA)的GMV增加。2、在左側(cè)及右側(cè)病灶組,PS患者均表現(xiàn)為雙側(cè)小腦的GMV顯著減低。左側(cè)病灶組中PS患者雙側(cè)SMA的GMV增加。右側(cè)病灶組中PS患者雙側(cè)前島葉皮層GMV顯著減低,但雙側(cè)旁中央小葉及病變同側(cè)額中回GMV增加。3、在左側(cè)和右側(cè)病灶組中,CS和PS患者都表現(xiàn)為病灶同側(cè)前島葉皮層GMV的減低及雙側(cè)SMA的GMV的增加。CS患者表現(xiàn)為病灶同側(cè)SMC的GMV減低,而PS患者表現(xiàn)為雙側(cè)小腦GMV的減低。此外,左側(cè)病灶組PS患者還表現(xiàn)為楔前葉GMV的增加,右側(cè)病灶組CS患者表現(xiàn)為病灶同側(cè)額中回GMV的增加。4、在Freesurfer分析的結(jié)果中,有3個(gè)GMV有顯著差異的團(tuán)塊與VBM分析結(jié)果的位置是一致的(包括左側(cè)病灶組中病灶同側(cè)SMC,右側(cè)病灶組中病灶同側(cè)SMC及病灶同側(cè)前島葉皮層)。其中,在左側(cè)病灶組病灶同側(cè)SMC,CS及PS患者的GMV及CT均顯著下降。在右側(cè)病灶組病灶同側(cè)SMC,CS患者的GMV、CT及SA都減低。在右側(cè)病灶組病灶同側(cè)前島葉皮層,CS患者的GMV,CT及SA均減低,且PS患者的GMV及SA減低。結(jié)論:1、基底節(jié)區(qū)中風(fēng)患者的繼發(fā)性損傷主要存在于感覺(jué)運(yùn)動(dòng)區(qū),而腦橋中風(fēng)患者主要表現(xiàn)為小腦的萎縮,提示這兩種不同部位皮層下中風(fēng)患者繼發(fā)性結(jié)構(gòu)損傷的解剖結(jié)構(gòu)是不同的。2、基底節(jié)區(qū)中風(fēng)與腦橋中風(fēng)患者輔助運(yùn)動(dòng)區(qū)的灰質(zhì)體積都增加,提示在這兩種不同部位皮層下中風(fēng)患者都可以將輔助運(yùn)動(dòng)區(qū)作為康復(fù)治療一個(gè)潛在的靶點(diǎn)。3、雖然都累及運(yùn)動(dòng)通路,基底節(jié)區(qū)與腦橋中風(fēng)患者都表現(xiàn)為認(rèn)知相關(guān)腦區(qū)的結(jié)構(gòu)損傷與重塑,可能為臨床評(píng)估和監(jiān)測(cè)中風(fēng)后的認(rèn)知功能提供一個(gè)新方法。4、基底節(jié)區(qū)中風(fēng)患者與腦橋中風(fēng)患者繼發(fā)性腦結(jié)構(gòu)損傷及可塑性的模式是存在差異的,這種差異可能為不同部位皮層下運(yùn)動(dòng)通路中風(fēng)患者更有針對(duì)性的個(gè)體化康復(fù)治療措施的制訂提供理論支持。
[Abstract]:Background and objective: stroke is the second leading cause of death worldwide after coronary heart disease. After a stroke, the infarct location often differ greatly, the difference of the location of the lesion was associated with prognosis. The function of patients with basal ganglia stroke and pons stroke may although subcortical motor pathway damage, but the two involved the adjacent brain structures are different. A number of studies have demonstrated that the chronic stage of apoplexy secondary brain injury and structural plasticity coexist. The purpose of this study is to compare the chronic stroke in basal ganglia, pons stroke and normal subjects in secondary brain damage and plasticity, differences in motor pathways of occult brain damage in stroke model and neural rehabilitation mechanism in different parts of the cortex. The research contents and methods: in this prospective study, MRI data collection from three domestic three hospitals in four A magnetic resonance scanner. All of the subjects in the experiment are given informed consent, participated in the experiment voluntarily, and approved by the ethics committee of General Hospital Affiliated to Tianjin Medical University. Inclusion criteria and exclusion criteria strictly based on the 115 basal ganglia stroke (capsular stroke, CS) patients, 47 cerebral stroke bridge (pontine stroke, PS) and patients 116 normal subjects (normal, control, NC) into the final statistical analysis. The evaluation subjects and measurement of nerve function in patients with stroke infarct volume. All of the subjects of the MRI data after pretreatment were analyzed. According to the location of the infarction foci, all stroke patients were divided into left and right lesion group focus groups were voxel based morphometry (voxel-based, morphometry, VBM) were compared between gray matter volume (gray matter volume, GMV). The differences and further the analysis results of VBM in GMV has a significant difference The same as the mass defined region of interest (regions of, interest, ROI, ROI) from each of the GMV value and the quantitative comparison between groups, after the voxel based analysis (ROI analysis). The three part of this paper are as follows: 1, independent samples T test was used to compare the difference between CS NC and GMV.2, independent samples T test was used to compare the difference between PS and NC GMV.3, CS analysis, comparison of covariance using the single factor, the difference between PS and NC GMV. Finally the application based on the difference in surface morphology analysis method of Freesurfer GMV group, to verify the results of VBM analysis. Freesurfer analysis in GMV analysis has significant difference between the groups and the mass position and results of VBM mass define a consistent ROI, after the analysis of the surface based on the quantitative evaluation of each ROI GMV, cortical thickness (cortical thickness, CT (surface) and cortical surface area Area, SA) the difference between the groups. Results: 1, left and right side group. Patients with CS lesion ipsilateral sensorimotor cortex (sensorimotor, cortex, SMC) GMV were decreased in CS patients; the right cerebellum GMV was significantly decreased, and the lesions in the back side and bilateral supplementary motor area (supplementary motor area, volume SMA GMV) increased.2 in the left and right lesion group, PS patients showed bilateral cerebellar lesions. GMV was significantly decreased in the group of PS patients with bilateral left SMA GMV. Right side in the group of PS patients with bilateral anterior insular cortex GMV was significantly decreased, but the bilateral paracentral lobule and ipsilateral frontal gyrus GMV.3, on the left and right lesion group, CS and PS patients showed reduction of ipsilateral and bilateral SMA lesions anterior insular cortex GMV GMV increased.CS patients showed ipsilateral SMC lesions reduced GMV and PS patients showed reduction of bilateral cerebral GMV. In addition, the left The lesion group of PS patients also showed increased leaf GMV CS patients with right precuneus, lesion group showed GMV ipsilateral to the lesion volume increased in.4, in the results of Freesurfer analysis, and mass VBM analysis results of 3 GMV had significant difference in position is consistent (including left infarction lesions SMC in the same side, right side group lesion ipsilateral SMC and ipsilateral anterior insular cortex lesions). Among them, in the left infarction lesion ipsilateral SMC, GMV and CT, CS and PS were significantly decreased. In the right side were the ipsilateral SMC, CS with GMV, CT and SA were decreased on the right side. The lesions were ipsilateral anterior insular cortex in patients with CS, GMV, CT and SA were reduced, and the GMV and SA of PS patients decreased. Conclusion: 1. The secondary injury of basal ganglia stroke mainly exists in the sensorimotor cortex, and pons stroke patients mainly manifested as cerebellar atrophy, suggesting that the two different parts of the skin The anatomical structure of injury in stroke patients secondary structure layer under different.2, the gray matter volume of basal ganglia stroke and the stroke patients in the supplementary motor area have increased, suggesting that in these two different parts of the subcortical stroke patients can be the supplementary motor area as the rehabilitation of a potential target of.3, although all involved the path of movement, basal ganglia and pons stroke patients showed the structure damage and remodeling of brain regions related to cognition, may provide a new method for.4 clinical assessment and monitoring of cognitive function after stroke, basal ganglia stroke patients with pontine stroke patients with secondary brain damage and plasticity model is different this difference may, for different parts of subcortical motor pathway in stroke patients and provide theoretical support for a more individualized rehabilitation measures of.

【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R445.2;R743.3

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