胡国娣　　胡希文　　向梅　　王林利

[关键词] 卒中后抑郁症;认知功能障碍;重复经颅磁刺激;强化认知锻炼;下丘脑-垂体-肾上腺素轴

[中图分类号] R743          [文献标识码] B          [文章编号] 1673-9701（2021）14-0099-04

Impacts of repetitive transcranial magnetic stimulation combined with intensive cognitive exercise on HPA axis in patients with post-stroke depression and cognitive dysfunction

HU Guodi   HU Xiwen   XIANG Mei   WANG Linli

Department of Geriatrics， Hangzhou Seventh People′s Hospital， Hangzhou   310013， China

[Abstract] Objective To investigate the impacts of repetitive transcranial magnetic stimulation（rTMS） combined with intensive cognitive exercise on hypothalamic-pituitary-adrenaline（HPA） axis in patients with post-stroke depression （PSD） and cognitive dysfunction. Methods A total of 84 PSD patients with cognitive dysfunction from January 2017 to September 2019 were selected and randomly divided into the combined groupand the control group， with 42 cases in each group. Both groups were given basic treatments such as controlling blood lipid， blood glucose and blood pressure，nourishing cerebral cells and improving cerebral microcirculation. On this basis，the control group was given intensive cognitive exercise，and the combined group was given rTMS treatment on the basis of the control group. Both groups were treated for 8 weeks. The changes of HPA axis function before and after treatment were observed， and the neurological， depressive symptoms and cognitive function were evaluated. Results After 8 weeks of treatment， serum CRH， ACTH and Co were significantly decreased in both groups （P<0.05 or P<0.01）， and the change was more obvious in the combined group（P<0.05）. At the same time， CSS scores and HAMD scores were significantly decreased， while MoCA score was significantly increased （P<0.05 or P<0.01）， and the change value of the combined group was more obvious （P<0.05）. Conclusion RTMS combined with intensive cognitive exercise can accelerate the recovery of neural function， relieve depression symptoms and improve cognitive function in PSD patients with cognitive dysfunction， and its mechanism is closely related to inhibiting CRH， ACTH and Cor secretion and correcting disordered HPA axis function.

[Key words] Poststroke depression; Cognitive dysfunction; Repetitive transcranial magnetic stimulation; Intensive cognitive exercise; Hypothalamic-pituitary-adrenaline axis

卒中后抑郁癥（Post-stroke depression，PSD）是卒中后常见的多发的精神合并症，约占卒中患者1/3，大部分患者伴随着认知及记忆能力下降[1]。有研究证实，PSD伴认知功能障碍的发病机制与下丘脑-垂体-肾上腺素（HPA）轴功能失调存在一定的关系[2]。强化认知锻炼是一种对获得性脑损伤引起认知障碍而采取的干预措施，近年来用于PSD伴认知功能障碍具有一定的效果[3-4]。重复经颅磁刺激（Repetitive transcranial magnetic stimulation，rTMS）是一种非侵袭性的颅脑刺激技术，已有研究证实对因脑损伤而致认知功能障碍有很好的效果，但其联合强化认知锻炼对HPA轴功能及认知功能的影响国内报道较少[5-6]。本研究观察rTMS联合强化认知锻炼对PSD伴认知功能障碍患者HPA轴的影响，现报道如下。

1 资料与方法

1.1 一般资料

选取2017年1月至2019年9月我院老年科就诊治疗的PSD伴认知功能障碍患者84例。纳入标准[7]：①符合《全国第四届脑血管疾病学术会议》制定的脑卒中相关诊断标准[8]者;②符合《中国精神障碍分类与诊断标准》中抑郁症标准[9]，且汉密尔顿抑郁量表评分≥18分者;③蒙特利尔认知评估量表（MOCA）<22分者。排除标准[10]：①以往有神经、精神及代谢性疾病史者;②其他原因引起认知功能下降者。采用随机数字表法分为联合组和对照组，每组各42例。两组性别、年龄、病程及MOCA评分基线资料比较，差异无统计学意义（P>0.05），具有可比性。

1.2方法

两组均予控制血脂、血糖和血压、营养脑细胞及改善脑部微循环等基础治疗。对照组在此基础上予强化认知锻炼，具体方法如下：①注意力训练：采用猜测游戏、从电话本中找出号码等方法进行注意……