王大明，李捷，王金辉，罗芳富，赵瀛，王凌燕，李永祥，张明贵，宋杰.小脑中脚扩散张量成像参数预测大脑中动脉梗死患者步行能力恢复的临床价值[J].中华物理医学与康复杂志,2017,39(1):11-16
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| 小脑中脚扩散张量成像参数预测大脑中动脉梗死患者步行能力恢复的临床价值 |
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| DOI： |
| 中文关键词: 脑梗死 扩散张量成像 预后 小脑中脚 步行 |
| 英文关键词: Ischemic stroke Diffusion tensor imaging Middle cerebellar peduncles Motor recovery Fractional anisotropy |
| 基金项目:浙江省金华市科技局社会发展重点项目(2013-3-015) |
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| 中文摘要: |
| 目的探讨扩散张量成像（DTI）检查脑梗死恢复期患者小脑中脚的扩散参数在起病3个月内及1年左右的动态改变，分析其与脑卒中后远期步行能力的可能关系。 方法选取有偏瘫体征的首次发病的亚急性期大脑中动脉供血区梗死病例10例，分别于发病后3个月内（首次）及发病1年左右（第2次），基于兴趣区方法在大脑脚锥体束解剖学区域和小脑中脚桥小脑束解剖学区域测定左右两侧的部分各向异性（FA）值，作为影像学参数；采用国立卫生研究所卒中量表（NIHSS）对入选患者的神经功能缺损情况进行评估，包括上下肢运动评定部分，并作为偏瘫分级（PG）的依据，即上肢和下肢运动评分之和，均于DTI检测时同步评定，并于最后1次随访的同时，分别采用Brunel平衡量表（BBA）、改良的Rankin量表（mRS）和功能独立性评定量表（FIM）评定患者的平衡功能、功能预后和生活自理能力。 结果①发病3个月内，首次扫描的大脑脚病灶受累侧的FA值（0.396±0.102）和发病后1年时的FA值（0.447±0.067）较未受累侧的FA值［（0.540±0.109）和（0.535±0.081）］明显降低（P<0.01）；而首次扫描的小脑中脚受累侧的FA值（0.599±0.116）和发病后1年时的FA值（0.539±0.102）较未受累侧FA值［（0.489±0.047）、（0.483±0.070）］明显升高（P<0.05）；②首次大脑脚的rFA值与同时间点上下肢运动各自PG分值及运动结局总PG分值均呈明显相关（P<0.05），亦与发病1年随访时NIHSS、上肢运动PG分值、运动总PG分值以及与mRS和FIM评分呈显著相关（P<0.05）；③首次小脑中脚的rFA值与同时间点的上肢运动PG分值及运动总PG分值呈明显相关（P<0.05），亦与发病1年随访时的NIHSS、上肢运动PG分值、运动总PG分值、mRS和FIM评分呈显著相关（P<0.05），而与发病1年随访时下肢运动PG分值的关联性虽较大脑脚rFA值相关性更大，但差异无统计学意义（r=-0.605,P=0.064），与平衡能力的相关性也较大脑脚rFA值相关性更大，但差异亦无统计学意义（r=0.592,P=0.071）；④长期运动的总结局与年龄、运动功能缺损程度、病灶大小、首次大脑脚rFA值及小脑中脚rFA值五个参数变量均无显著相关性(P>0.05)，但病灶大小和小脑中脚rFA值两个参数均与下肢运动结局显著相关（P<0.05），而年龄、病灶大小、大脑脚rFA值及小脑中脚rFA值四个变量与上肢运动结局呈显著相关（P<0.05）；⑤首次小脑中脚rFA值对应的受试者操作特性曲线（ROC）下面积比值为（0.81±0.15），大于同时间点大脑脚rFA值的ROC下面积比值（0.76±0.19），预测下肢运动预后的小脑中脚rFA最佳界值点为0.83（敏感度71%，特异度100%），大脑脚rFA值的最佳界值点为0.77（敏感度57%，特异度100%）。 结论亚急性期大脑中动脉梗死患者小脑中脚的DTI参数（两侧对比的FA值）在预测步行能力方面较大脑脚DTI参数的预测能力更大。 |
| 英文摘要: |
| Objective To quantify and predict long-term motor outcomes after ischemic stroke using diffusion tensor imaging (DTI). MethodsTen patients with middle cerebral artery infarction were prospectively studied using DTI within 3 months and 1 year after the onset. A region-of-interest-based analysis was performed for the fractional anisotropy (FA) of the pyramidal tract in the cerebral peduncles (CP) and the pontocerebellar tract in the middle cerebellar peduncles (MCP). Neurological function was evaluated using the National Institutes of Health′s stroke scale (NIHSS) and the degree of paresis was assessed at the same time using paresis grading (PG). During the last follow-up, the functional outcome, ability in the activities of daily living and balance function were evaluated using the modified Rankin scale (mRS), functional independence measures (FIMs) and the Brunel balance assessment (BBA) respectively. Results The average fractional anisotropy on the affected side of the CP was significantly lower than that of healthy persons at both 3 months and 1 year after onset. The FA of the MCP was significantly higher than on the healthy side. The ratio of the FA on the affected side to that on the unaffected side (rFA) in both the CP and MCP was significantly correlated with the paresis grading within 3 months, and significantly correlated to the NIHSS score, the upper extremity′s PG, total PG, mRS score and FIM score at the end of the follow-up. At the end of follow-up, the rFA of the MCP correlated in a better tendency with the lower limb PGs and balance ability than that of the MCP, although the differences were not significant. Long-term motion function was not significantly correlated with a patient′s age, motion dysfunction, size of focus, or the rFA of the CP and MCP. However, lower limb function was significantly correlated with the size of the focus and the rFA of the MCP, while upper limb mobility was significantly correlated with age, the size of the focus and the rFA of both the CP and the MCP. The area under the receiver operating characteristic (ROC) curve for the rFA in the MCP was greater than the area for the rFA in the CP. The cutoff point for the rFA in the MCP for a good lower extremity motor outcome was determined to be 0.826 (sensitivity of 71%, specificity of 100%). For the CP the cutoff was 0.77 (sensitivity of 57%, specificity of 100%). ConclusionsDTI can predict the lower extremity motor outcomes and prognosis after stroke. |
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