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中华脑科疾病与康复杂志(电子版)

中华脑科疾病与康复杂志(电子版) ›› 2024, Vol. 14 ›› Issue (04) : 193 -200. doi: 10.3877/cma.j.issn.2095-123X.2024.04.001

临床研究

急性缺血性脑卒中患者脑白质微结构改变对长期认知功能损伤的预测价值研究
吉莉1, 苏云楠1, 王斌2, 沈滔1, 刘团结1, 毛蕾1, 徐玉萍1, 张婷3, 王博1,†()   
  1. 1.201900 上海，复旦大学附属中山医院吴淞医院神经内科
    2.201900 上海，复旦大学附属中山医院吴淞医院放射科
    3.201900 上海，复旦大学附属中山医院吴淞医院康复医学科
  • 收稿日期:2023-11-21 出版日期:2024-08-15
  • 通信作者: 王博
  • 基金资助:
    上海市科学技术委员会基金（16411972900）上海市宝山区科学技术委员会医学卫生项目（21-E-43）

Prediction study of white matter microstructural changes on long-term cognitive impairment in patients with acute ischemic stroke

Li Ji1, Yunnan Su1, Bin Wang2, Tao Shen1, Tuanjie Liu1, Lei Mao1, Yuping Xu1, Ting Zhang3, Bo Wang1,†()   

  1. 1.Department of Neurology, Wusong Branch, Zhongshan Hospital Affiliated to Fudan University, Shanghai 201900, China
    2.Department of Radiology, Wusong Branch,Zhongshan Hospital Affiliated to Fudan University, Shanghai 201900, China
    3.Department of Rehabilitation Medicine, Wusong Branch,Zhongshan Hospital Affiliated to Fudan University, Shanghai 201900, China
  • Received:2023-11-21 Published:2024-08-15
  • Corresponding author: Bo Wang
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引用本文：

吉莉, 苏云楠, 王斌, 沈滔, 刘团结, 毛蕾, 徐玉萍, 张婷, 王博. 急性缺血性脑卒中患者脑白质微结构改变对长期认知功能损伤的预测价值研究[J]. 中华脑科疾病与康复杂志(电子版), 2024, 14(04): 193-200.

Li Ji, Yunnan Su, Bin Wang, Tao Shen, Tuanjie Liu, Lei Mao, Yuping Xu, Ting Zhang, Bo Wang. Prediction study of white matter microstructural changes on long-term cognitive impairment in patients with acute ischemic stroke[J]. Chinese Journal of Brain Diseases and Rehabilitation(Electronic Edition), 2024, 14(04): 193-200.

目的

利用弥散张量成像（DTI）和基于纤维束示踪的空间统计（TBSS）后处理方法，分析基线期认知功能受损的急性缺血性脑卒中（AIS）患者脑白质微结构完整性的演变，以及探索卒中后认知障碍（PSCI）早期预测的影像学标志物。

方法

选取自2021 年8 月至2023 年4 月于复旦大学附属中山医院吴淞医院神经内科住院或门诊随诊的55例AIS 后3 d内出现认知受损的患者进行前瞻性研究，在治疗前和治疗后6个月对所有患者进行DTI扫描和认知评估。根据6个月后患者是否发生认知障碍分为PSCI 组和卒中后非PSCI（N-PSCI）组。TBSS 横向分析2 组患者的各向异性（FA）、平均弥散率（MD）的差异，纵向分析组内治疗前和治疗后6个月的FA、MD值变化。

结果

55例患者中，4例患者失联，3例患者拒绝进一步参与，1例患者死亡，最终入选47例，其中PSCI组22例，N-PSCI 组25 例。治疗后6 个月，33 例患者认知功能改善，14 例患者认知功能保持不变。组间横向分析显示，治疗前，PSCI 组右侧上纵束（SLF）的FA 值较N-PSCI 组低，差异具有统计学意义（P＜0.05）。组内纵向分析显示，相较于治疗前，2 组患者治疗后6 个月时均有较多的脑白质（SLF、丘脑前辐射、皮质脊髓束等）完整性退化，差异具有统计学意义（P＜0.05）。

结论

基线期认知功能受损的AIS 患者，即使慢性期改善或恢复正常，仍存在脑白质微结构损伤，可能对长期认知产生负面影响。右侧SLF纤维束FA值的改变对PSCI发生具有一定的预测效果。

关键词: 急性缺血性脑卒中, 认知障碍, 弥散张量成像, 基于纤维束示踪的空间统计方法, 上纵束

Objective

To analyze the evolution of white matter microstructural integrity in acute ischemic stroke (AIS) patients with impaired cognitive functions using diffusion tensor imaging (DTI) and post-processing method based on tract based spatial statistics (TBSS), and to explore imaging biomarkers for early prediction of post-stroke cognitive impairment (PSCI).

Methods

A prospective study was conducted on 55 patients with cognitive impairment within 3 d after AIS who were hospitalized or followed up in the Neurology Department of Wusong Branch, Zhongshan Hospital Affiliated to Fudan University from August 2021 to April 2023.DTI scans and cognitive assessments were performed on all patients before and 6 months after treatment.According to the cognitive scores after 6 months, patients were divided into PSCI group and post-stroke non-cognitive impairment (N-PSCI)group.By TBSS,horizontally analyzed the differences in fractional anisotropy (FA) and mean diffusivity (MD) between two groups, and vertically analyzed the changes in FA and MD values before and 6 months after treatment within the group.

Results

Among the 55 patients, 4 patients lost contact, 3 patients refused further participation,and 1 patient died,47 patients were enrolled,including 22 in the PSCI group and 25 in the N-PSCI group.Compared with baseline, cognitive performance improved in 33 patients and remained unchanged in 14 patients after 6 months of treatment.Horizontal analysis between groups showed that the FA value of right superior longitudinal fasciculus (SLF) in the PSCI group was lower than that in the N-PSCI group before treatment, and the difference was statistically significant (P＜0.05).Longitudinal analysis showed that the dispersion of multiple white matter tracts (SLF, anterior thalamic radiation, corticospinal tract, etc.)recorded after 6 months of treatment worsened than those recorded before treatment in both groups with statistically significant (P＜0.05).

Conclusion

Patients with baseline impaired cognitive functions still have white matter microstructural damages at 6 months, even if their cognitive function has improved or returned to normal, which may have a negative impact on long-term cognition.The change of FA value of the right SLF fiber bundle has a certain predictive effect on the occurrence of PSCI.

Key words: Acute ischemic stroke, Cognitive impairment, Diffusion tensor imaging, Tract based spatial statistics, Superior longitudinal fasciculus
图1 认知功能受损的AIS患者治疗前和治疗后6个月的认知变化
Fig.1 Cognitive changes during 6 months in AIS patients with impaired cognitive function at baseline
表1 2组患者的临床资料分析
Tab.1 Clinical characteristics analysis of two groups
项目 PSCI组（n=22） N-PSCI组（n=25） t/χ2/U值 P值
年龄（岁，Mean±SD） 63.73±3.69 62.56±4.70 0.937 0.354
性别（男/女） 13/9 11/14 1.066 0.302
受教育年限（年，Mean±SD） 9.55±0.86 9.96±1.14 -1.396 0.169
高血压病[例（%）] 16（72.73） 15（60.00） 0.844 0.358
糖尿病[例（%）] 18（81.82） 15（60.00） 2.664 0.103
高脂血症[例（%）] 15（68.18） 13（52.00） 1.272 0.259
吸烟史[例（%）] 12（54.55） 8（32.00） 2.433 0.119
病灶侧（右/左） 17/5 13/12 3.237 0.072
NIHSS评分（分，Mean±SD） 2.23±1.23 2.44±1.26 -0.583 0.563
关键部位病灶[例（%）] 16（72.73） 6（24.00） 11.159 0.001
梗死病灶体积[mL，M（P25，P75）] 1.71（0.90，2.33） 1.28（0.90，1.45） -1.771 0.077
MoCA评分[分，M（P25，P75）]
治疗前 18（17，21） 20（19，23） -1.881 0.060
治疗后6个月 23（19，24） 28（27，29） -5.892 ＜0.001
MMSE评分[分，M（P25，P75）]
治疗前 23（19，24） 22（21，24） -1.434 0.152
治疗后6个月 23（20，25） 28（27，30） -4.907 ＜0.001
图2 PSCI组与N-PSCI组治疗前的FA数据全脑对比分析 A：MNI坐标为x=29；B：MNI坐标为y=-5；C：MNI坐标为z=18；红色代表PSCI组FA值显著低于N-PSCI组的部位；绿色为平均纤维骨架（均P＜0.05，FWE校正）；PSCI：卒中后认知障碍；N-PSCI：卒中后非认知障碍；MNI：蒙特利尔神经坐标；FA：各向异性分数
Fig.2 Comparative analysis of FA data between PSCI group and N-PSCI group before treatment
表2 TBSS横向+纵向分析差异具有统计学意义的白质纤维束
Tab.2 Transverse and longitudinal analysis by TBSS in white matter fiber bundles that showing statistically significant differences
白质纤维束 簇体积(mm3) 峰值体素MNI坐标 差异 P值
x y z
治疗前PSCI vs N-PSCI
FA
右SLF（外囊） 230 29 -5 18 N-PSCI＞PSCI 0.040
治疗后6个月PSCI vs N-PSCI
FA
右SLF 307 28 -5 27 N-PSCI＞PSCI 0.016
左ATR 410 -26 -6 26 N-PSCI＞PSCI 0.016
左IFOF 133 -25 32 -1 N-PSCI＞PSCI 0.016
左SLF 283 -36 -42 32 N-PSCI＞PSCI 0.017
左CST 82 -26 -23 14 N-PSCI＞PSCI 0.018
右CST 85 21 -31 49 N-PSCI＞PSCI 0.018
胼胝体 178 15 25 20 N-PSCI＞PSCI 0.020
MD
左SLF 278 -31 -20 36 PSCI＞N-PSCI 0.024
左CST 829 -26 -18 23 PSCI＞N-PSCI 0.026
PSCI组内的纵向差异
FA
左CST 305 -8 -20 -32 治疗前＞治疗后6个月 0.010
右SLF（外囊） 60 50 -2 17 治疗前＞治疗后6个月 0.010
右ATR 58 9 -46 -33 治疗前＞治疗后6个月 0.010
胼胝体 2010 8 15 20 治疗前＞治疗后6个月 0.034
MD
右SLF（外囊） 3008 34 -9 8 治疗后6个月＞治疗前 0.007
左ATR 354 -14 -51 -20 治疗后6个月＞治疗前 0.016
左CST 121 -18 -30 -36 治疗后6个月＞治疗前 0.016
N-PSCI组内的纵向差异
FA
左CST 475 -22 -40 -36 治疗前＞治疗后6个月 0.034
右CST 2840 20 -23 50 治疗前＞治疗后6个月 0.036
左SLF 605 -18 -20 45 治疗前＞治疗后6个月 0.038
右ATR 85 9 -38 -36 治疗前＞治疗后6个月 0.040
MD
左CST 73 -21 -58 -30 治疗后6个月＞治疗前 0.024
右CST 127 18 -58 -28 治疗后6个月＞治疗前 0.024
左SLF 1487 -33 -17 25 治疗后6个月＞治疗前 0.022
右IFOF（外囊） 890 30 10 8 治疗后6个月＞治疗前 0.022
图3 PSCI组与N-PSCI组治疗后6个月的DTI数据全脑对比分析 A～C：FA 值；A：MNI坐标为x=-28；B：MNI坐标为y=-7；C：MNI坐标为z=20；红色代表PSCI组FA 值显著低于N-PSCI组的部位；D～F：MD 值；D：MNI 坐标为x=-29；E：MNI 坐标为y=-18；F：MNI 坐标为z=24；蓝色代表PSCI 组MD 值显著高于N-PSCI 组的部位；PSCI：卒中后认知障碍；N-PSCI：卒中后非认知障碍；MNI：蒙特利尔神经坐标；FA：各向异性分数；MD：平均弥散率
Fig.3 Comparative analysis of DTI data between PSCI group and N-PSCI group at 6 months of treatment
图4 PSCI组治疗前和治疗后6个月的纵向DTI数据全脑对比分析 A～C：FA 值；A：MNI坐标为x=50；B：MNI坐标为y=-40；C：MNI坐标为z=10；红色代表PSCI组治疗后6个月FA 值显著低于治疗前的部位；D～F：MD 值；D：MNI 坐标为x=30；E：MNI 坐标为y=-15；F：MNI 坐标为z=8；蓝色代表PSCI 组治疗后6 个月MD 值显著高于治疗前的部位；PSCI：卒中后认知障碍；MNI：蒙特利尔神经坐标；FA：各向异性分数；MD：平均弥散率
Fig.4 Longitudinal analysis of DTI data in the PSCI group before treatment and after 6 month treatment
图5 N-PSCI组治疗前和治疗后6个月的纵向DTI数据全脑对比分析 A～C：FA值；A：MNI坐标为x=-16；B：MNI坐标为y=-30；C：MNI坐标为z=37；红色代表N-PSCI组治疗后6个月FA值显著低于治疗前的部位；D～F：MD值；D：MNI坐标为x=18；E：MNI坐标为y=-17；F：MNI坐标为z=8；蓝色代表N-PSCI组治疗后6个月MD值显著高于治疗前的部位；N-PSCI：卒中后非认知障碍；FA：各向异性分数；MD：平均弥散率
Fig.5 Longitudinal analysis of DTI data in the N-PSCI group before treatment and after 6 month treatment
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