皮层小梗死导致手指功能障碍的预探索研究

doi:10.3969/j.issn.1673-5765.2018.10.006

摘要/Abstract

摘要：

目的以皮层小梗死引起单纯手指无力的临床表现较为少见，本文旨在探讨其发病机制、临床及影像学特点。

方法连续入选2009年7月-2016年12月来郑州人民医院就诊的以手指功能障碍为临床表现的皮层小梗死患者，临床上记录患侧手部肌力、手部感觉异常情况及手指无力的详细查体（屈、伸、内收和外展，依据0～5级肌力记录法），并记录患者可能的发病机制或病因，依据主要功能障碍手指为小指或拇指分为主要尺侧手指功能障碍组和主要桡侧手指功能障碍组。影像学上应用弥散加权成像进行病灶定位，并测量大脑镰至病变中心及大脑最外侧缘的距离（其比率定义为B/A）。

结果共入组符合标准的皮层小梗死患者13例，根据临床及影像学分析表明，主要累及尺侧手指 6例，主要累及桡侧手指7例。主要累及尺侧手指功能组B/A=0.50±0.07，主要累及桡侧手指功能组 B/A=0.71±0.06，两组比较差异有统计学意义（t =-5.67，P＜0.05）。主要累及尺侧手指功能组5例发病机制为大动脉狭窄／栓子清除障碍，1例为不明原因栓塞；主要累及桡侧手指功能组4例发病机制主要为动脉-动脉栓塞，2例为心源性栓塞，1例为烟雾病。

结论尺侧手指代表区靠近皮层内侧，梗死部位位于大血管分水岭区，发病机制可能与低灌注有关。桡侧手指代表区靠近皮层外侧，梗死部位位于大脑皮层，发病机制可能与栓塞事件有关。

文章导读： 大脑皮层小梗死引起单纯手指无力相对少见，容易漏诊或误诊，本文提高了对其的认识。

关键词: 皮层小梗死; 手指功能障碍; 发病机制

Abstract:

Objective Simple fingers weakness caused by small cortical infarction is rarely found in clinical practice. This study aimed to investigate the pathogenesis mechanism, clinical presentation and imaging features of such cases.

Methods Outpatients with the main manifestation of fingers dysfunction caused by small cortical infarcts from Zhengzhou People’s Hospital from July 2009 to December 2016 were included in this study. The analyzed clinical data included sensory and moter functions in fingers, muscle strength of fingers (bending, stretching, adduction and outreach), and the possible pathogenesis mechanism or etiology in medical records. According to the predominant impaired fingers, the patients were divided into ulnar-lateral group and radial-lateral group. The locations of cerebral infarction were identified by diffusion weighted imaging. Based on the imaging, the distance from cerebral falx to lesion core (B) and distance from cerebral falx to the lateral margin of brain (A) were measured and the ration of B/A were calculated.

Results A total of 13 cases with small cortex infarction were included, with 6 ones in ulnar-lateral group and 7 ones in radial-lateral group. B/A in ulnar-lateral group was (0.50±0.07), while B/A in radial-lateral group was (0.71±0.06), and the difference between the two groups had statistical significance (t =-5.67, P <0.05). The possible pathogenesis mechanism or etiology in ulnar-lateral group were as follows: large artery stenosis/impaired clearance of emboli in 5 cases and unexplained embolism in 1 case; and that in radial-lateral group were the following: artery-to-artery embolism in 4 cases, cardiogenic embolism in 2 cases, and Moyamoya disease in 1 case.

Conclusions The simple impaired finger function is associated with small cortical infarction. The ulnar-lateral finger impairment is associated with medial cortex infarction, which may be associated with hypoperfusion. The radial-lateral finger impairment is associated with lateral cortex infarction, which may be associated with embolism.

Key words: Small cortical infarction; Finger dysfunction; Pathogenesis

付胜奇, 张杰文, 杨冬冬, 石宝洋, 李浩然, 张洪涛, 张淑玲. 皮层小梗死导致手指功能障碍的预探索研究[J]. 中国卒中杂志, 2018, 13(10): 1029-1034.

FU Sheng-Qi, ZHANG Jie-Wen, YANG Dong-Dong, SHI Bao-Yang, LI Hao-Ran, ZHANG Hong-Tao, ZHANG Shu-Ling. Observational Study on Fingers Dysfunction due to Small Cortical Infarction[J]. Chinese Journal of Stroke, 2018, 13(10): 1029-1034.

参考文献

[1] SCHIEBER M H，SANTELLO M. Hand function：

peripheral and central constraints on performance[J].

J Appl Physiol，2004，96（6）：2293-2300.

[2] LEE P H，HAN S W，HEO J H. Isolated weakness of

the fingers in cortical infarction[J]. Neurology，1998，

50（3）：823-824.

[3] PHAN T G，EVANS B A，HUSTON J. Pseudoulnar

palsy from a small infarct of the precentral knob[J].

Neurology，2000，54（11）：2185.

[4] LANG C E，BLAND M D，BAILEY R R，et al.

Assessment of upper extremity impairment，function，

and activity following stroke：foundations for

相关的症状及体征。一些中央前、后回病变的

患者（例6、例11）也可出现感觉症状，也可能是

由于感觉功能区并非仅限于中央后回[8]。并且

感觉症状及体征与运动障碍的程度相一致，呈

现出阶梯样改变。研究表明，可能是因为患者

的运动功能区与感觉功能区关系密切[3]。

总之，皮层小梗死导致的一侧手指功能障

碍临床较为罕见，尺侧手指皮层病变部位更靠

近运动皮层手功能区内侧，而桡侧手指皮层病

变部位更靠近运动皮层手功能区外侧，部分研

究表明皮层手指功能分布区存在重叠性及变

异性。本研究结果显示主要尺侧手指受损的患

者发病机制多与大动脉严重狭窄或闭塞导致低

灌注／栓子清除障碍密切相关，而主要桡侧手

指功能受损的发病机制多与栓塞事件相关。但

本研究为单中心的回顾性研究，且样本量有限，

对于不同表现形式的急性孤立性手麻痹相关发

病机制的研究仍需多中心、大样本量、随机、双

盲的前瞻性研究，并进行长期随访、系统评估

进一步证实。

clinical decision making[J]. J Hand Ther，2013，26

（2）：104-115.

[5] CHEN P L，HSU H Y，WANG P Y. Isolated hand

weakness in cortical infarctions[J]. J Formos Med

Assoc，2006，105（10）：861-865.

[6] QU W，GARDINER M. Isolated unilateral hand

weakness due to cortical cerebral ischemia[J]. PM R，

2017，9（4）：419-421.

[7] UEMATSU S，LESSER R，FISHER R S，et al.

Motor and sensory cortex in humans：topography

studied with chronic subdural stimulation[J].

Neurosurgery，1992，31（1）：59-72.

[8] NII Y，UEMATSU S，LESSER R P，et al. Does the

central sulcus divide motor and sensory functions?

Cortical mapping of human hand areas as revealed

by electrical stimulation through subdural grid

electrodes[J]. Neurology，1996，46（2）：360-367.

[9] TAKAHASHI N，KAWAMURA M，ARAKI

S. Isolated hand palsy due to cortical infarction：

localization of the motor hand area[J]. Neurology，

2002，58（9）：1412-1414.

[10] FOERSTER O. The motor cortex in man in the light

of hughlings Jackson's doctrines[J]. Brain，1936，59

（2）：135-159.

[11] ALSTADHAUG K B，SJULSTAD A. Isolated hand

paresis：a case series[J]. Cerebrovasc Dis Extra，

2013，3（1）：65-73.

[12] KIM J S. Predominant involvement of a particular

group of fingers due to small，cortical infarction[J].

Neurology，2001，56（12）：1677-1682.

[13] TIMSIT S，LOGAK M，MANAÏ R，et al. Evolving

isolated hand palsy：a parietal lobe syndrome

associated with carotid artery disease[J]. Brain，1997，

120（Pt 12）：2251-2257.

[14] MELO T P，BOGOUSSLAVSKY J，VAN MELLE G，

et al. Pure motor stroke：a reappraisal[J]. Neurology，

1992，42（4）：789-795.

[15] IQBAL J，BRUNO A，BERGER M. Stroke causing

pure brachial monoparesis[J]. J Stroke Cerebrovasc

Dis，1995，5（2）：88-90.

[16] UGUR H C，KAHILOGULLARI G，

COSCARELLA E，et al. Arterial vascularization of

primary motor cortex（precentral gyrus）[J]. Surg

Neurol，2005，64（Suppl 2）：S48-S52.