本文關(guān)鍵詞： 腦性癱瘓 早產(chǎn)兒 足月兒 危險(xiǎn)因素 彌散張量成像 FA值 粗大運(yùn)動(dòng)功能　出處：《安徽醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的分析腦性癱瘓的危險(xiǎn)因素,比較危險(xiǎn)因素在早產(chǎn)兒腦癱和足月兒腦癱中分布的差異,為腦癱的早期預(yù)防和診斷提供一定的依據(jù)。同時(shí)運(yùn)用磁共振彌散張量成像技術(shù)中的白質(zhì)纖維束的各向異性FA值和粗大運(yùn)動(dòng)功能評(píng)估量表中粗大運(yùn)動(dòng)功能分值,分別分析早產(chǎn)兒和足月兒腦癱組兩項(xiàng)指標(biāo)之間的相關(guān)性,進(jìn)而分析彌散張量成像在兩組中應(yīng)用價(jià)值。材料和方法選取2013年9月至2016年12月安徽省兒童醫(yī)院康復(fù)科就診的確診為腦性癱瘓的兒童120例(早產(chǎn)48例、足月72例;男性88例、女性32例),進(jìn)行腦癱的危險(xiǎn)因素分析;選擇臨床資料完整的病例入早產(chǎn)兒腦癱組(32例:男性25例;女性7例)和足月兒腦癱組(32例:男性25例;女性7例),進(jìn)行磁共振彌撒張量成像應(yīng)用價(jià)值的比較。危險(xiǎn)因素的調(diào)查采用回顧性分析的方法,按照事先設(shè)計(jì)好的表格,依據(jù)危險(xiǎn)因素的定義,查閱我院已歸檔的電子病歷收集資料,部分信息不完整的病歷電話詢問(wèn)家長(zhǎng)完善資料。使用英國(guó)Rusell等人編制修訂的GMFM-88項(xiàng)量表評(píng)估患兒的粗大運(yùn)動(dòng)功能(gross motor function measure,GMFM),量表共分為躺和翻身,坐位,爬與跪,站立位和行走、跑、跳5個(gè)功能區(qū),評(píng)估由康復(fù)科高年資醫(yī)師及治療師操作、本人參與完成,最后通過(guò)GMFM的統(tǒng)計(jì)軟件GMAE自動(dòng)分析處理分別得出5個(gè)功能區(qū)得分比值和總分比值。磁共振檢查采用安徽省兒童醫(yī)院磁共振室的飛利浦Achieva 1.5T磁共振掃描儀完成頭顱磁共振成像,磁共振平掃和彌散張量成像(diffusion tensor imaging,DTI),測(cè)量白質(zhì)不同部位的部分各向異性(fractionalanisotropy,FA)值,感興趣區(qū)(regions of interest,ROI)的選擇依據(jù)是在解剖清晰明確的纖維束經(jīng)過(guò)的區(qū)域,分別是內(nèi)囊前肢(ICAL)、內(nèi)囊膝部(ICG)、內(nèi)囊后肢(ICPL)、胼胝體體部(BCC)、胼胝體膝部(GCC)、胼胝體壓部(SCC)及皮質(zhì)脊髓束(CST)。最后運(yùn)用工作站自帶的Service Pack 9軟件處理獲得數(shù)值,并在DTI圖像上獲得錐體束三維彩色示蹤圖。所有數(shù)據(jù)采用EXCEL2007和SPSS19.0軟件進(jìn)行統(tǒng)計(jì)和分析,定量數(shù)據(jù)的結(jié)果以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,用獨(dú)立樣本均數(shù)的t檢驗(yàn)進(jìn)行分析,定性資料運(yùn)用檢驗(yàn),對(duì)不同部位FA值與GMFM值進(jìn)行pearson相關(guān)分析,相關(guān)系數(shù)用r表示,所有統(tǒng)計(jì)以α=0.05為檢驗(yàn)水準(zhǔn)。結(jié)果(1)腦性癱瘓的危險(xiǎn)因素出現(xiàn)的比率依次為:新生兒窒息、異常妊娠、早產(chǎn)、低出生體重、黃疸、缺氧缺血性腦病、新生兒感染、顱內(nèi)出血、低血糖。早產(chǎn)兒組危險(xiǎn)因素較高的依次為:低出生體重、新生兒窒息、異常妊娠、黃疸;足月兒組較高的為:新生兒窒息、異常妊娠。(2)兩組比較,低出生體重、新生兒窒息、黃疸在兩組中出現(xiàn)的比率的差異有統(tǒng)計(jì)學(xué)意義(P0.05),且均是早產(chǎn)兒組足月兒組;兩種及兩種以上危險(xiǎn)因素在兩組中出現(xiàn)的比率的差異也有統(tǒng)計(jì)意義(P0.001),早產(chǎn)兒組(97.9%)足月兒組(40.3%)。(3)120例患兒MRI平掃報(bào)告8例未見明顯異常(8/120,6.67%),63例側(cè)腦室旁白質(zhì)軟化(PVL)(63/120,52.5%),早產(chǎn)組39例,足月組24例,PVL在兩組中出現(xiàn)的比率的差異有統(tǒng)計(jì)意義(P0.001),早產(chǎn)兒組(81.3%)足月組(33.3%)。(4)64例腦癱患兒測(cè)定的FA值結(jié)果在空間不同部位上,胼胝體皮質(zhì)脊髓束內(nèi)囊后肢內(nèi)囊膝部?jī)?nèi)囊前肢,在胼胝體部位的各向異性FA值壓部體部膝部。早產(chǎn)兒腦癱組和足月兒腦癱組組內(nèi)比較也符合此規(guī)律。(5)同一部位的FA值足月兒腦癱高于早產(chǎn)兒腦癱,在右側(cè)內(nèi)囊后肢、胼胝體壓部和左、右側(cè)皮質(zhì)脊髓束部位足月兒和早產(chǎn)兒間存在統(tǒng)計(jì)學(xué)差異(P0.05)。早產(chǎn)兒和足月兒組內(nèi)左右對(duì)稱部位的FA值差異均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)(6)早產(chǎn)兒腦癱組的FA值與GMFM-88分值在雙側(cè)內(nèi)囊前肢、雙側(cè)內(nèi)囊膝部、雙側(cè)內(nèi)囊后肢和胼胝體膝部的相關(guān)性具有統(tǒng)計(jì)意義(P0.05),其中在左側(cè)內(nèi)囊后肢的相關(guān)的密切程度最高(r=0.616 P0.001),共有七個(gè)部位的相關(guān)性有統(tǒng)計(jì)意義;足月兒腦癱組的FA值與GMFM-88分值僅在右側(cè)內(nèi)囊膝部的相關(guān)性有統(tǒng)計(jì)意義(P0.05),在右側(cè)內(nèi)囊膝部的相關(guān)系數(shù)r=0.411,小于早產(chǎn)兒腦癱組在此部位的相關(guān)系數(shù)(r=0.474)。(7)綜合評(píng)價(jià)內(nèi)囊前肢、膝部、后肢、胼胝體和皮質(zhì)脊髓束的FA值與GMFM-88分值的相關(guān)性,早產(chǎn)兒組內(nèi)囊前肢、膝部和后肢與GMFM-88的相關(guān)有統(tǒng)計(jì)意義(P0.05),其中內(nèi)囊后肢的相關(guān)密切程度最高(r=0.572 P=0.001),足月兒組五個(gè)部位的相關(guān)性均無(wú)統(tǒng)計(jì)意義(p≥0.05)。結(jié)論(1)腦性癱瘓較多見的危險(xiǎn)因素有新生兒窒息、異常妊娠、早產(chǎn)、低出生體重、黃疸。(2)早產(chǎn)兒比足月兒更易發(fā)生PVL。(3)早產(chǎn)兒腦癱比足月兒腦癱更易出現(xiàn)兩種及兩種以上的本研究所設(shè)定的危險(xiǎn)因素。(4)早產(chǎn)兒腦癱比足月兒腦癱更易合并低出生體重、新生兒窒息和黃疸等危險(xiǎn)因素。(5)早產(chǎn)兒腦癱的整體白質(zhì)發(fā)育較足月兒腦癱明顯延遲。(6)早產(chǎn)兒腦癱的FA值比足月兒腦癱的FA值更能代表和反應(yīng)患兒的運(yùn)動(dòng)功能,DTI在早產(chǎn)兒腦癱中的應(yīng)用價(jià)值比足月兒腦癱高。(7)DTI檢查中內(nèi)囊后肢的FA值可作為早產(chǎn)兒腦損傷的評(píng)價(jià)及動(dòng)態(tài)監(jiān)測(cè)白質(zhì)發(fā)育的一項(xiàng)指標(biāo)。(8)DTI有著較廣闊的應(yīng)用空間,應(yīng)用價(jià)值待挖掘和探索。
[Abstract]:Objective to analyze the risk factors of cerebral palsy, the difference in the distribution of risk factors of cerebral palsy of premature infants and full-term infants with cerebral palsy, provide a basis for prevention and early diagnosis of cerebral palsy. At the same time using the assessment of magnetic resonance diffusion tensor imaging of white matter fiber anisotropy FA values and gross motor function scale gross motor functional scores were analyzed in term and preterm infants with cerebral palsy group correlation between the two indexes, and then analyzes the application value of diffusion tensor imaging in two groups. Materials and methods from September 2013 to December 2016 in Anhui province children's hospital were diagnosed with cerebral palsy children in 120 cases (48 cases of premature delivery, 72 cases of full-term male; in 88 cases, female 32 cases), analysis of risk factors of cerebral palsy; clinical data of cases of cerebral palsy of premature infants (32 cases in group: 25 cases; 7 cases of male and female) and full-term infants brain Paralysis group (32 cases, 25 cases; 7 cases of male and female), compare the application value of diffusion tensor imaging. The risk factors were investigated by retrospective analysis method, according to the designed forms, according to the definition of risk factors, access to electronic medical records in our hospital have been archived data collection part information complete medical call ask parents perfectinformation. GMFM-88 scale assessment of children with gross motor function using British Rusell et al. Preparation of revised (gross motor function measure, GMFM), the scale is divided into lying and sitting, kneeling and turning, climbing, standing and walking, running, jumping 5 functional areas, evaluation operated by the Department of rehabilitation doctors and therapists high years, I had done, and finally through the GMFM statistical software GMAE automatic analysis were obtained in 5 functional areas and the ratio of total score. The ratio of magnetic resonance examination by the children's Hospital of Anhui province Co The vibration chamber of the PHILPS Achieva 1.5T MRI scanner to complete cranial magnetic resonance imaging, MRI and diffusion tensor imaging (diffusion tensor, imaging, DTI), fractional anisotropy measurements of white matter in different parts (fractionalanisotropy, FA), a region of interest (regions of, interest, ROI) on the selection is in clear anatomy the fibers pass through the region, which is the anterior limb of internal capsule (ICAL), genu and posterior limb of the internal capsule (ICG) (ICPL), corpus callosum (BCC), corpus callosum (GCC), splenium of corpus callosum (SCC) and corticospinal tract (CST). The last 9 software obtained by the workstation with Service Pack, and cone beam 3D color tractography on DTI images. All the data were collected and analyzed by EXCEL2007 and SPSS19.0 software, the results of quantitative data to mean + standard deviation (x + s) said, t test the number of independent samples Analysis of qualitative data using the test, the different parts of the FA value and GMFM value of Pearson correlation analysis, correlation coefficient r, all statistics to test the level of a =0.05. Results (1) the ratio of risk factors in children with cerebral palsy were: neonatal asphyxia, abnormal pregnancy, premature birth, low birth weight, jaundice, hypoxic ischemic encephalopathy, neonatal infection, intracranial hemorrhage, hypoglycemia in premature infants. High risk factors were as follows: low birth weight, neonatal asphyxia, abnormal pregnancy, jaundice of full-term infants; high: abnormal pregnancy and neonatal asphyxia,. (2) the two groups, low birth weight, neonatal asphyxia, was statistically significant the difference in the ratio of jaundice occurring in the two groups (P0.05), and are also the full-term infants in premature group; there was statistical difference ratio of two and more than two kinds of risk factors in the two group (P0.001), in the premature infant group (97.9% ) of full-term infants (40.3%). (3) in 120 cases with MRI scan 8 cases had no obvious abnormalities (8/120,6.67%), 63 cases of periventricular leukomalacia (PVL) (63/120,52.5%), preterm labor group 39 cases, 24 cases of full-term group, there were significant differences between the ratio of PVL in the two groups (the P0.001), preterm infants (81.3%) term group (33.3%). (4) of 64 cases of children with cerebral palsy FA measured results in different parts of the space, corpus callosum, corticospinal tract in the posterior limb of the internal capsule genu anterior limb of the internal capsule, pressing part body knee anisotropic FA values in the corpus callosum. Premature infants with cerebral palsy group and foot the cerebral palsy group compared with the law. (5) the same parts of the FA value is higher than that of full-term infants with cerebral palsy cerebral palsy of premature infants, in the right posterior limb of the internal capsule, corpus callosum and left, there was a statistically significant difference between the right parts of the corticospinal tract in term and preterm infants (P0.05). Between preterm and full-term children in symmetrical part The FA value had no significant difference (P0.05) (6) the value of FA in cerebral palsy of premature infants with GMFM-88 scores in the bilateral anterior limb of internal capsule, bilateral genu, with statistical significance of the correlation between the bilateral posterior and genu of the corpus callosum (P0.05), which in the left posterior limb of the internal capsule related closely to the highest degree (r=0.616 P0.001) a total of seven parts, the correlation has statistical significance; the value of FA in cerebral palsy infants with GMFM-88 scores only in the correlation of right internal capsule knee has statistical significance (P0.05), the correlation coefficient of r=0.411 right genu, the correlation coefficient is less than the group on the site of cerebral palsy of premature infants (r=0.474). (7) the comprehensive evaluation of internal capsule the forelimbs, hind legs, knees, correlation between GMFM-88 score and corpus callosum and corticospinal tract FA, premature group and hind knee anterior limb of the internal capsule, and GMFM-88 related statistical significance (P0.05), which is closely related to the posterior limb of the internal capsule The highest level (r=0.572 P=0.001), the correlation of full-term infants in five positions were no statistical significance (P = 0.05). Conclusion (1) cerebral palsy risk factors were more common in neonatal asphyxia, abnormal pregnancy, premature birth, low birth weight, premature infant jaundice. (2) more easily than full-term infants (3 PVL.) cerebral palsy of premature infants than in full-term infants with cerebral palsy is more prone to risk factors of two and more than two set by this research. (4) cerebral palsy of premature infants with low birth weight are more likely than full-term infants with cerebral palsy, asphyxia neonatorum and jaundice risk factors. (5) the overall development of the white matter of cerebral palsy of premature infants in full-term infants with cerebral palsy significantly delay. (6) the FA value of cerebral palsy of premature infants than in full-term infants with cerebral palsy FA better motor function in children with representative and reaction, the application value of DTI in cerebral palsy of premature infants than in full-term infants with cerebral palsy. (7) DTI in the posterior limb of the internal capsule FA value can be used as a brain injury in preterm infants And dynamic monitoring of the development of white matter. (8) DTI has a wider application space, and the application value should be excavated and explored.

【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R742.3

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本文編號(hào)：1539570