Contralesional repetitive transcranial magnetic stimulation for chronic hemiparesis in subcortical paediatric stroke: a randomised trial
Contralesional repetitive transcranial magnetic stimulation for chronic hemiparesis in subcortical paediatric stroke: a randomised trial
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DOI：
10.1016/s1474-4422(08)70096-6
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发表时间：
2008-06-01
期刊：
影响因子：
48
通讯作者：
deVeber, Gabrielle
中科院分区：
文献类型：
--
作者：
Kirton, Adam;Chen, Robert;deVeber, Gabrielle
背景：动脉缺血性卒中（AIS）可导致儿童致残性偏瘫。我们的目的是测试对照性、抑制性重复经颅磁刺激（rTMS）是否可以影响半球间抑制，以改善慢性皮质下儿童AIS患者的手功能。方法：参加SickKids儿童卒中项目、患有皮层下AIS超过2年、经胼胝体保留、年龄超过7岁、手部运动障碍、无癫痫发作或运动障碍、未服用改变皮层兴奋性药物的患者符合这项平行随机试验的条件。患者根据年龄和虚弱程度进行配对，并在每对患者中随机分配到假治疗或抑制性低频rTMS（20分钟，1200次刺激），每天一次，持续8天。一名职业治疗师在第1天（基线）、第5天、第10天和第17天（治疗后1周）对手功能进行了标准化测试，主要结果是握力和上肢功能墨尔本评估（MAUEF）在基线和第10天之间的变化。患者、家长和职业治疗师对治疗分配不知情。分析是按协议进行的。10例小儿卒中患者（中位年龄13-25岁[IQR 10.08-16.78]岁，卒中后平均时间6.33 [SD 3.56]年）：轻度虚弱4例，中度虚弱2例，重度虚弱4例。重复测量方差分析显示，时间和治疗对握力的影响之间存在显著的相互作用（p=0.03）。第10天，rTMS组握力比基线增加2.28 (SD 1.01) kg，假药组握力比基线减少2.92 (1.20)kg （p=0.009）。平均握力在第17天持续获益（rTMS组比基线增加2.63 [0.56]kg，假治疗组比基线减少1.00 [0.70]kg, p=0.01）。第10天，rTMS组的MAUEF评分比假手术组改善更多（比基线高7.25[3.8]比0.79[1.3]分；p=0.002），但这种益处并没有持续到第17天。未受影响的手的功能保持稳定。rTMS耐受性良好，无严重不良事件。对侧抑制性rTMS对儿童皮质下AIS患者是安全可行的，并且似乎可以改善偏瘫患者的手功能。需要进一步的研究来证实rTMS在小儿神经康复中的潜在作用。
Background Arterial ischaemic stroke (AIS) can cause disabling hemiparesis in children. We aimed to test whether contralesional, inhibitory repetitive transcranial magnetic stimulation (rTMS) could affect interhemispheric inhibition to improve hand function in chronic subcortical paediatric AIS.Methods Patients were eligible for this parallel, randomised trial if they were in the SickKids Children's Stroke Program and had subcortical AIS more than 2 years previously, had transcallosal sparing, were more than 7 years of age, had hand motor impairment, had no seizures or dyskinesia, and were taking no drugs that alter cortical excitability. Patients were paired for age and weakness and were randomised within each pair to sham treatment or inhibitory, low-frequency rTMS over contralesional motor cortex (20 min, 1200 stimuli) once per day for 8 days. An occupational therapist did standardised tests of hand function at days 1 (baseline), 5, 10, and 17 (1 week post-treatment), and the primary outcomes were changes in grip strength and the Melbourne assessment of upper extremity function (MAUEF) between baseline and day 10. Patients, parents, and occupational therapists were blinded to treatment allocation. Analysis was per protocol.Findings Ten patients with paediatric stroke were enrolled (median age 13-25 [IQR 10.08-16.78] years, mean time post-stroke 6.33 [SD 3.56] years): four with mild weakness, two with moderate weakness, and four with severe weakness. A repeated-measures ANOVA showed a significant interaction between time and the effect of treatment on grip strength (p=0.03). At day 10, grip strength was 2.28 (SD 1.01) kg greater than baseline in the rTMS group and 2.92 (1.20) kg less than baseline in the sham group (p=0.009). Benefits in mean grip strength persisted at day 17 (2.63 [0.56] kg greater than baseline with rTMS and 1.00 [0.70] kg less than baseline with sham treatment; p=0.01). Day 10 MAUEF score improved by more in the rTMS group than in the sham group (7.25 [3.8] vs 0.79 [1.3] points greater than baseline; p=0.002), but this benefit did not persist to day 17. Function of the unaffected hand remained stable. rTMS was well tolerated with no serious adverse events.Interpretation Contralesional inhibitory rTMS was safe and feasible for patients with paediatric subcortical AIS, and seemed to improve hand function in patients with hemiparesis. Further studies are required to confirm the potential role of rTMS in paediatric neurorehabilitation.