Abstract: Objective To investigate the effect of repetitive transcranial magnetic stimulation (rTMS) applied to the thumb motor cortex representation area on hand function in patients with acute ischemic stroke. Methods A total of 78 patients in the acute phase of ischemic stroke admitted to our hospital between July 2023 and March 2024 were included as study subjects.These patients were divided into two groups based on different treatment methods:an experimental group (n=46) that received high-frequency repetitive transcranial magnetic stimulation (rTMS) treatment and a control group (n=32) that underwent sham rTMS treatment.Evaluations were conducted after 10 days of treatment.Clinical efficacy was compared between the two groups.Pre-treatment and post-treatment (10 days) data on neurologic deficit scores,active range of motion (AROM) of the wrist and hand joints,simplified Fugl-Meyer Assessment (FMA) for hand function,MBI and MEP were collected.Resting-state functional magnetic resonance imaging (fMRI) scans were acquired before and 10 days after treatment.Independent component analysis (ICA) and seed-based functional network analysis were used to extract resting-state motor networks and assess the functional connectivity within these networks.Changes in the motor function network and intranetwork node connectivity were compared between pre- and post-treatment conditions for both groups and between the two groups post-treatment. Results The total effective rate of experimental group was 89.13%,which was significantly higher than that of control group (68.75%) (P＜0.05).There were no significant differences between the two groups in terms of neurologic deficit scores,FMA scores,AROM parameters,and sEMG parameters before treatment (P＞0.05).After 10 days of treatment,the experimental group showed significantly greater improvements in neurologic deficit scores,FMA scores,AROM parameters,MBI and MEP compared to the control group (P＜0.05).Resting-state motor network analysis revealed that high-frequency rTMS treatment led to significantly enhanced functional connectivity in the affected side's precentral gyrus,postcentral gyrus,supplementary motor area (SMA),and contralateral postcentral gyrus in the experimental group (P＜0.05,corrected by Alphasim).In contrast,the control group demonstrated increased functional connectivity in the contralateral precentral gyrus,contralateral middle frontal gyrus,and bilateral SMA (P＜0.05,corrected by Alphasim).Compared to the control group,the experimental group exhibited more pronounced increases in functional connectivity in the bilateral precentral gyri,bilateral SMA,ipsilateral middle frontal gyrus,and contralateral postcentral gyrus.However,the impact of high-frequency rTMS on functional connectivity in the contralateral middle frontal gyrus was weaker (P＜0.05,corrected by Alphasim).Functional connectivity between various motor-related brain regions was significantly enhanced in the experimental group after rTMS treatment,particularly between the ipsilateral M1 and ipsilateral/contralateral SMA,the ipsilateral SMA and ipsilateral M1/PMA,the ipsilateral PMA and ipsilateral SMA/contralateral M1,the contralateral M1 and ipsilateral S/PMA,and the contralateral SMA and ipsilateral M1/PMA (P＜0.05).No such significant enhancements were observed in the control group (P＞0.05). Conclusion High-frequency rTMS can effectively improve hand function in patients with acute ischemic stroke,likely due to its ability to enhance the connectivity of the hand motor function network,promote recovery of the affected hemisphere's motor function network,and improve the coordination of functional connectivity between nodes in the affected and unaffected hemispheres.

Key words: Acute ischemic stroke, Repetitive transcranial magnetic stimulation, Hand function, Resting-state functional MRI, Functional network

摘要： 目的 探讨重复经颅磁刺激(rTMS)作用拇指大脑皮层运动代表区对急性缺血性脑卒中患者手部功能的影响。方法 收集2023年7月至2024年3月于我院收治的缺血性脑卒中急性期患者78例为研究对象,依据治疗方法不同分为试验组(46例,接受高频rTMS治疗)和对照组(32例,接受rTMS假性刺激治疗)。治疗10 d后,比较2组患者的临床疗效。收集2组患者治疗前、治疗10 d后的腕手关节主动活动度(AROM)、神经功能缺损程度评分、改良Barthel指数(MBI)量表、手背部肌肉运动诱发电位(MEP)振幅、简化Fugl-Meyer运动功能评分法(FMA)(手部分)。分别于治疗前、治疗10 d后获取fMRI图像。采用独立成分分析(ICA)及基于种子点的功能网络分析方法提取静息态下的运动功能网络。结果 试验组的总有效率分别为89.13%,明显高于对照组(68.75%)(P＜0.05)。治疗10 d后,与对照组比较,试验组的FMA评分、神经功能缺损评分、腕手部关节AROM各参数、MBI评分及MEP振幅的治疗前后差值均明显较高,差异有统计学意义(P＜0.05)。试验组rTMS治疗后,脑卒中患者的运动网络显示患侧中央后回、患侧中央前回、健侧中央后回及患侧辅助运动区(SMA)的功能连通性显著增强(P＜0.05,经Alphasim校正);对照组rTMS假性治疗后,运动网络显示健侧中央前回、健侧额中回及双侧SMA的功能连通性明显增强(P＜0.05,经Alphasim校正);与对照组比较,试验组在双侧SMA、患侧额中回、健侧中央后回及双侧中央前回的功能网络连接性增强更为显著。然而,试验组在健侧额中回运动网络功能连通性的影响较弱(P＜0.05,经Alphasim校正)。试验组rTMS治疗后,患侧M1与患侧SMA及健侧SMA、患侧SMA与患侧M1、患侧前辅助运动区(PMA)及健侧M1、患侧PMA与患侧SMA及健侧M1/SMA、健侧M1与患侧SMA/PMA、健侧SMA与患侧M1/PMA之间的功能连接性增强显著(P＜0.05)。对照组则未观察到上述功能连接性的显著增强(P＞0.05)。结论 高频rTMS可有效改善急性缺血性脑卒中患者的手部功能,可能机制包括增强患侧运动网络连通性、促进受损半球运动区恢复及优化双侧大脑间功能协调。

关键词: 急性缺血性脑卒中, 重复经颅磁刺激, 手部功能, 静息态功能磁共振, 功能网络