Release time ：2023-04-11
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Speaker - Dr. Wu
Yi Wu
Professor, PhD Supervisor
Director of Rehabilitation Medicine Department, Huashan Hospital Affiliated to Fudan University; Dean, Department of Rehabilitation Medicine, Shanghai Medical College, Fudan University.
Hello everyone, I am Yi Wu from the Department of Rehabilitation Medicine, Huashan Hospital Affiliated to Fudan University. It is a great honor to have the opportunity to share some clinical knowledge and my experience in stroke rehabilitation treatment on the "Brain Hacker" live broadcast platform today.
The title of my lecture today is: Precise positioning and neuromodulation therapy for stroke patients. I will use several common symptoms of brain injury as a starting point, combined with relevant clinical cases, to briefly describe some more effective treatment options.
As we all know, when our brain is damaged, it may cause a variety of brain function abnormalities, such as: movement disorder-hemiplegia, disturbance of consciousness, speech disorder-aphasia, cognitive impairment, abnormal muscle tone-increase, swallowing disorder, sensory disturbances, balance and gait disturbances, and more.
Structure determines function. When the structure of the brain is damaged, it may affect the whole body, and the whole body will have obvious signs of symptoms.
The core of rehabilitation medicine is actually the recovery of patients’ dysfunction. The rehabilitation department of Huashan Hospital uses “precise positioning” to find the root cause of the patient’s disease, make a “precise diagnosis”, and then truly achieve “precise rehabilitation”.
German neuroscientist Brodmann divided the brain into 52 regions according to different functions, which is the famous Brodmann map.
In order to facilitate understanding and memory, according to the Brodmann map, I drew a simple anatomical diagram of the cerebral cortex functional areas. The cerebral cortex is mainly composed of the frontal lobe, temporal lobe, occipital lobe and parietal lobe, with different structures and very different functions.
For example, if we use the central sulcus as the dividing line, in front of the central sulcus are brain areas 4, 6, and 8 of the frontal lobe, which are mainly involved in human motor functions; while functional areas 1, 2, 3, 5, and 7 are related to sensation; functional areas 9, 10, and 11 are related to cognition; functional areas 17, 18, and 19 are involved in visual function; areas 44 and 45 (Broca area), 42 and 22 (Wernicke area) are related to language; area 39 is Reading language center; area 8 is the math center.
Therefore, if you want to understand the brain in depth, you must memorize the structural and functional characteristics of different regions of the brain.
Next, I will discuss with you in five parts, how to achieve precise positioning and precise neural regulation.
The first part introduces the neural regulation parts. To do neuromodulation, we first need to find a neuromodulatory target.
The most common site of neuromodulation is the thalamus, the largest part of the diencephalon. The thalamus is generally located on both sides of the third ventricle, about four centimeters long, and is an oval mass of gray matter that contains abundant nuclei and nerve conduction pathways.
The thalamus is the receiving station and relay station under the sensory conduction cortex. When our thalamus is damaged, it will cause sensory disturbance or pain in the patient.
Because the impulse needs to pass through the thalamus to reach the cerebral cortex to produce consciousness, the thalamus is also called the "consciousness gate", so the impairment of consciousness is also inseparable from the damage of the thalamus.
Whether it is pain or disturbance of consciousness, precise positioning and precise regulation of the thalamus are required to promote the improvement of the patient's sensory disturbance and the recovery of the awakening center.
The thalamus is a deep nucleus that requires attention to depth when stimulating. Even though some existing methods may not be able to fully stimulate the thalamus, we can achieve good therapeutic effects with strong stimulation or repeated stimulation.
We give two examples of stimulating the thalamus through neuromodulation technology to improve the patient's condition.
Case 1:
Patient: female, 47 years old. She went to see a doctor because of "left hemiplegia with left limb pain for more than 1 year after cerebral hemorrhage". The CT scan showed that the patient had hemorrhage in the right thalamus, which caused hemiplegia and pain in the left limb, and affected sleep. The effect of drug treatment was not obvious.
We first performed a physical examination on the patient, and the results showed that the patient's muscle tone was good, reaching grade IV-V, and his consciousness was normal. Combined with the CT image and the patient's clinical symptoms, it was confirmed that the patient had cerebral hemorrhage. Due to poor efficacy of drug therapy, we opted for transcranial magnetic therapy. The effect of transcranial magnetic therapy is definite, the pain of the patient is alleviated, and the limbs recover well.
Case 2:
Let's take another example. Patient: male, 70-80 years old. The right thalamic infarction caused the patient to experience disturbance of consciousness. Two months later, he came to our Department of Rehabilitation Medicine for treatment.
At the beginning of the disease, the patient suddenly lost consciousness, blurred vision, ptosis of the right eye, unsteady walking, and gradually lost consciousness and coma.
The patient had a history of hypertension for 20 years, and took Norvasc to lower blood pressure on weekdays, and his blood pressure was poorly controlled. And the patient has a history of diabetes for nearly 20 years, accompanied by myasthenia gravis.
When admitted to the hospital for physical examination and specialist examination, the patient was in a weak state of consciousness, poor in spirit, with a fast heart rate, showing signs of cardiac insufficiency. Bilateral pupils are equal in size and circle, diameter 3mm, sensitive to light reflection, low muscle tone in limbs, hypotendon reflex, rough muscle strength of both upper limbs is grade 3, both lower limbs are grade 2, pathological reflex (-), and the rest of the physical examination can not cooperate.
CT and MRI images showed that the patient had multiple ischemic infarctions in the thalamus, bilateral frontoparietal lobes, side ventricles, basal ganglia region, and left frontal cortex demyelinating lesions were likely to occur, bilateral thalamic microbleeds, and bilateral thoracic cavities effusion.
The clinical diagnosis was tip of basilar syndrome (TOBS). Location: bilateral thalamus, right frontal lobe, brainstem (midbrain); Qualitative: ischemic stroke; functional diagnosis: disturbance of consciousness, swallowing disorder, speech disorder; accompanied by abdominal infection, bloodstream infection, hypertension disease, type 2 diabetes.
In addition to conventional treatment (rehabilitation training, standing bed, acupuncture treatment, etc.), patients are treated with transcranial magnetic therapy. Treatment site: left frontal cortex; treatment time: once a day, 20 minutes each time; treatment frequency: treatment five days a week, continuous treatment for 4 weeks.
One month later, the patient's consciousness gradually recovered, his eye function improved, he could open his eyes independently, and he could get out of bed slowly to do some rehabilitation training. The patient's recovery effect was particularly good.
TOBS was proposed by Calpan in 1980. It is a clinical syndrome of ischemic stroke caused by blood circulation disorder in five vessels centered on the top of the basilar artery caused by various reasons. Five arteries were involved: left and right posterior cerebral arteries, left and right superior cerebellar arteries, and basilar arteries. TOBS often causes multiple cerebral infarctions in the midbrain, thalamus, hypothalamus, upper pons, cerebellum, occipital lobe, and temporal lobe, and the posterior circulation disorder is obvious.
The clinical manifestations of TOBS mainly include: disturbance of consciousness, eyeball and eyelid abnormalities and other symptoms.
Disturbance of consciousness - due to bilateral thalamus damage in TOBS patients, it is often accompanied by disturbance of consciousness.
Eyeball and eyelid abnormalities: Eye movement disturbance, nystagmus and pupil abnormalities are the most prominent clinical features in TOBS patients. The main sign of eye movement disorder is bilateral oculomotor nerve palsy, and it can also be manifested as oculomotor nerve incomplete paralysis. Abnormal eyelid movement is also a common sign and may manifest as unilateral or bilateral ptosis.
Other symptoms: TOBS patients may also be accompanied by visual disturbances, visual hallucinations, and memory impairment.
The above examples left me with the impression that for patients with disorders of consciousness, we must first accurately find the target, which is an important prerequisite for precise treatment, and it can also greatly benefit the treatment effect.
So from the above two examples, we can see that for some rehabilitation patients, we need to provide personalized treatment to meet the individualized, intelligent and precise treatment as much as possible.
With the rapid development of science and technology, we cannot always stick to the rules and only use the scale to evaluate the disease. Some advanced imaging technology, electrophysiological technology, TMS technology, etc., can help us locate neuromodulation targets more quickly and accurately. Only by achieving "precise positioning" can we achieve "precise diagnosis" and finally achieve the goal of "precise rehabilitation."
Next, I will take our brain function detection and treatment platform in the Department of Rehabilitation Medicine as an example to briefly introduce the overall solution for neuromodulation treatment after brain injury.
Note: The above content is part of the text without changing the original meaning from the speakers. To watch the full live video (in Chinese), please go to Live Broadcast Entrance.
