Theta脉冲刺激联合认知训练对卒中后认知障碍的疗效观察

The Effect of Theta Burst Stimulation Combined with Cognitive Training on Patients with Post-Stroke Cognitive Impairment

摘要: 目的：观察theta脉冲刺激(theta burst stimulation, TBS)联合认知训练对卒中后认知障碍(post-stroke cognitive impairment, PSCI)患者的认知以及日常生活活动能力的疗效。方法：38例PSCI患者按照随机数字表法分为3组，最终36例病人完成本研究，其中双侧刺激组12例，单侧刺激组12例，假刺激组12例。3组患者均进行常规康复训练(包括认知训练)和常规药物治疗(包括改善认知药物)。在进行上述治疗的基础上，双侧刺激组给予左前额叶背外侧间歇性TBS和右前额叶背外侧持续性TBS，单侧刺激组给予左前额叶背外侧间歇性TBS和右前额叶背外侧的假刺激，假刺激组给予双侧的假刺激，5次/周，共治疗3周。治疗前后采用简易智力状态检查(Mini-mental State Examination, MMSE)、蒙特利尔认知评估(Montreal Cognitive Assessment, MoCA)评价认知功能，采用磁共振波谱分析(magnetic resonance spectroscopy, MRS)评估脑组织代谢及影像学变化，采用改良Barthel指数(Modified Barthel Index, MBI)评估患者日常生活活动能力。结果：双侧及单侧刺激组患者治疗后的MMSE、MoCA、MBI评分较治疗前显著改善(P < 0.05)，假刺激组MBI评分较治疗前显著改善(P < 0.05)。与治疗后假刺激组比较，双侧刺激组的MoCA评分、MMSE中语言能力(命名、复述、阅读、三步指令、书写、结构能力总分)评分显著改善(P < 0.05)。双侧及单侧刺激组治疗后双侧海马区MRS代谢值NAA/Cr显著升高(P < 0.05)。与治疗后假刺激组比较，双侧刺激组NAA/Cr升高更为明显(P < 0.05)。3组患者治疗前后双侧海马区MRS代谢值NAA/Cr差值与MoCA评分差值呈中度正相关(r = 0.663~0.710, P < 0.05)。结论：TBS联合认知训练可改善PSCI患者的认知功能，双侧前额叶背外侧刺激可能疗效更佳。

Abstract: Objective: To observe the effect of theta burst stimulation (TBS) combined with cognitive function training on cognitive and daily living ability in patients with post-stroke cognitive impairment (PSCI). Methods: According to the random number table, 38 patients with PSCI were divided into 3 groups. Finally, 36 patients completed this study, including 12 patients in the bilateral stimulation group, 12 patients in the unilateral stimulation group, and 12 patients in the sham stimulation group. 3 groups of patients were given routine rehabilitation training (including cognitive function training) and conventional drug treatment (including improving cognitive drugs). On the basis of the above treatment, the bilateral stimulation group was given intermittent TBS in the left dorsolateral prefrontal cortex (DLPFC) and continuous TBS in the right DLPFC. The unilateral stimulation group was given intermittent TBS in the left DLPFC and sham stimulation in the right DLPFC. The sham stimulation group was given bilateral sham stimulation in the bilateral DLPFC. All 3 groups were treated 5 times per week for 3 weeks. Before and after the treatment, Mini-mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were used to evaluate cognitive function, magnetic resonance spectroscopy (MRS) was used to evaluate brain tissue metabolism and imaging changes, and the Modified Barthel Index (MBI) was used to evaluate the patients’ daily living ability. Results: After treatment, MMSE, MoCA and MBI score of patients in the bilateral and unilateral stimulation group were significantly improved compared with those before treatment (P < 0.05). MoCA score and LANGUAGE (naming, repetition, comprehension, reading, writing, copying total score) of MMSE score were significantly improved in the bilateral stimulation group (P < 0.05). After bilateral and unilateral stimulation, the NAA/Cr of MRS metabolism in bilateral hippocampus was significantly increased (P < 0.05). Compared with the sham stimulation group, NAA/Cr increase was more significant in the bilateral stimulation group (P < 0.05). The difference value of NAA/Cr in MRS metabolism of bilateral hippocampus and MoCA score of 3 groups of patients before and after treatment was moderately correlated (r = 0.663~0.710, P < 0.05). Conclusions: Theta burst stimulation combined with cognitive function training can significantly improve the cognitive function of patients with PSCI. And bilateral DLPFC stimulation may be more effective.