The Effect On Cerebral Functional Areas By True Needling At Waiguan (TE5) In Ischemic Stroke Patients:an FMRI Study

ObjectiveIn this study, we observed the active/negative encephalic region activation specialty effects of needling Waiguan (TE5) in ischemic stroke patients by functional brain imaging techniques. And observed the fMRI cerebral function imaging comparison of Waiguan (TE5) sham needling, non-acupoint needling and Waiguan (TE5) needling on normal people, analysis the relative specificity of Waiguan (TE5) acupuncture on ischemic stroke patients from different angles, to provide a preliminary basis for the elaborate mechanism of acupuncture treatment for stroke.Methods1. DesignA block design; Neuroimaging study.2. Time and settingThe experiment was performed at the MRI Center, Nanfang Hospital, China, from October2008to August2010.3. Ethics CommitteeThe study program was approved by the Ethics Committee of the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine [(2008)024], and registered in Chinese clinical trials online(http://www.chictr.org), registration ID:ChiCTR-NRC-00000255.4. Volunteers24cases of ischemic stroke patients are from the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, and divided into TE5group and non-acupoint group (n=12) randomly by random number table.6healthy volunteers are from the Southern Medical University. Each volunteer signed an informed consent before the test.5. Ischemic stroke diagnostic criteriaThe Traditional Chinese Medicine (TCM) diagnosis standards in line with apoplexy standard of stroke diagnosis and therapeutic evaluation diagnosis, which published in the journal of Beijing University of Traditional Chinese Medicine by State Administration of Traditional Chinese Medicine encephalopathy acute Collaborative Group,1996"(Gen2). Western diagnostic criteria in line with the article diagnostic criteria of various types of brain disease diagnostic points in ischemic stroke from the Neuroscience Society and the Neurosurgery society in the Fourth National Cerebrovascular Disease Conference,1995.6. Inclusion criteria①Ischemic stroke inclusion criteria:a. Patients were coincident the diagnostic criteria above and suffered with left basal ganglion ischemia proved, which manifested as the typical hemiplagia of right side (Upper limbs and/or lower extremity muscle strength stroke clinical neurological function deficit scores Scale score≥4points) and sensory disturbance; b. Patients passed the acute state and were under the stable pathogenic condition; c. Patients ate and slept almost regularly, did not over smoke and over drink tea or coffee, and were not over weighted (18.5≤BMI≤23.9); d. Patients just received the basic treatment and the therapy had not been changed during the last month before the experiment; e. The ages of the patients were40-65years old; f. Patients were right handedness.②Healthy volunteers inclusion criteria:a. Aged between21-28years old, male or female college students; b. volunteers ate and slept almost regularly, did not over smoke and over drink tea or coffee, and were not over weighted (18.5≤BMI≤23.9); c. volunteers haven’t received acupuncture treatment within a month; d. No metal in the body (such as cardiac stents); e. Volunteers were right handedness; f. No history of mental illness such as claustrophobia; g. No acupuncture contraindications such as hemophilia.7. Exterior criteria①Ischemic stroke exerior criteria:a. Patient whose disease history was more than1year; b. Patient who received acupuncture treatment4weeks before the experiment; c. Patient combined serious diseases, such as serious dysfunction of heart, liver and kidney, serious infection, malignant hypertension and malignant tumor, etc; d. Patients suffered from serious aphasia, unconsciousness and mental disorders (including Fear of confined spaces), which affected the cooperation during the experiment; e. Pregnant or lactation woman; f. Patient with some metal being set in his/her body, such as cardiac supporter, cardiac pacemaker and metal pontic; g. Patient suffered from thrombocytopenia or hemophilia, which belong to the counterindication of acupuncture;②Healthy volunteers exterior criteria:a. Volunteers who can not cooperate with the experimental (who refused to sign an informed consent or unreasonably withheld the study, etc.); b. At physiological period (female).8. Study Procedures①Subjects (ischemic stroke patients or healthy subjects) were conventional closed vision and auditory till the end of the fMRI detects(Earplugs from Aearo Company, USA, batch R5A018; goggles from Hanjiang Jiang Xinhua Tourist Products Factory, Yangzhou, China, batch XHYZ-001).②Ischemic stroke patients received the TE5and non-acupuncture stimulation randomly, healthy volunteers only to accept TE5acupuncture stimulation, the same subjects received sham acupuncture and real acupuncture in succession. TE5locates on the forearm,2cun (cun, a special length unit in acupuncture. The distance between the transverse crease of the elbow and that of the wrist is12cun.) above the transverse crease of the dorsum of wrist, between the radius and ulna. Location of the sham acupoint:Level with TE5, on the midpoint of the lines in forearm where Sanjiao Meridian of hand-Shaoyang and Small intestine meridian of hand-Taiyang travel.③fMRI scanning was performed with a3.0T whole-body MRI scanner (GE, Bethesda, MD, USA) and a standard head coil. The subjects used earplugs (Aearo Co., Hartford, CT, USA) and were blindfolded (Xinhua Tourism Co., Hangzhou, China). Each subject rested on the bed for5-10minutes before the scan.3D anatomy images were collected with a T1-weighted3D gradient echo-pulse fast spin sequence prior to acupuncture, with axial view T1fluid-attenuated-inversion-recovery scan (repetition time,2300ms; echo time,21ms; time of inversion,920ms; slice thickness,6.0mm; gap1.0mm for20layers for a total of2minutes45seconds; field of view,24cm×18cm; matrix,320×256; number of excitations=2; field of view echo train length,9; and band width,50).④Acupuncture was performed by one physician, who had engaged in clinical acupuncture for more than three years. The tubes were purchased from Dongbang AcuPrime Co.(Exeter, England) and the0.3cm×40cm silver needles from Zhongyan Taihe Co.(Beijing, China). Volunteers received sham acupuncture stimulation on right TE5/non-point6minutes and30seconds, at the same time scanned sham acupuncture stimulation stage blood oxygen level dependent (BOLD) functional magnetic resonance6minutes and30seconds. Sham needling:the location of TE5, the sterilization, the needling instruments were the same as above. The stimulation was designed with the block procedure of the alternative of gently touching the skin with the tip of the needle lmm above the tube for30seconds or non-touching the skin with lifting the needle for each30seconds, and the stimulation was lasted to360seconds totally, too. Detection parameters:The GR (gradient the recalled)/EPI (Echo-Planar imaging)/90, TR3000ms/20ms/FE Flip angle90, FOV24cm x24cm, thickness6mm/interval1.0mm, matrix96×96/NEX=1, PhasePer location:130,2600/6min30s.⑤And3D scanning after6minutes2seconds. Detection parameters:Ax (axial) of3D T1FSPGR (fast spoiled gradient echo)/20T1450, TR7.6ms/TE 3.3ms, FOV24cm x18cm, Flip angle20Bandwidth25, matrix256×256/NEX=1, thick1.2mm/-0.6mmov, a total of248layers,6min2s.⑥Continue true acupuncture (needles instrument the same as④) to stimulate the right TE5on the same group of patients6minutes and30seconds, the true acupuncture stimulation stage BOLD functional MRI scans of6minutes and30seconds. True needling:sterilized the local skin routinely and inserted the needle with tube insertion method (the tubes were from DONGBANG AcuPrime Co., England and the silver needles of0.3×40cm were from Zhongyan Taihe Co., China). The physician sticked the auxiliary part of the tube on the local skin, put the needle into the matching tube over the acupoint and tapped the end of the needle to make the tip of the needle inserted, removed away the tube and punctured the needle to the depth of15±2mm, and twirled the handle of the needle to get the needling sensation. Then the physician manually stimulated the needle with an even reinforcing and reducing manipulation by twirling the needling with±180°nd60times/min. The stimulation was designed with the block procedure of the alternative of twirling or non-twirling for each30seconds, and the stimulation was lasted to360seconds totally. Detection parameters the same with④.9. Study Procedures①The fMRI data were processed with the software SPM2(http://www.fil.ion.ac.uk) MATLAB6.5(The MathWorks, Inc., USA) platform for processing to obtain statistical parameters Figure. a. Pre-Processing:Slight movements of the head were corrected; The images were normalized to the standard brain template of the Montreal Neurological Institute space; and then smoothed spatially to reduce errors produced during imaging construction and eliminate tiny differences in brain structures among subjects; b. First analysis:The smoothed data were analyzed with a generalized linear model voxel by voxel. The value of each voxel was calculated by two-sample t-tests, and statistical parametric mapping was based on the t values (P<0.001, uncorrected, K>30). Significant changes in different brain regions during stimulation and control conditions were identified and superimposed on the standard brain image mode of each subject’s anatomic images; c. Secondary Analysis:the activated/deactivated con file of the model of stroke patients and normal controls was further analyzed using a two-independent sample t-test. The remaining procedures were the same as those reported in.②Determine the brain area location and anatomical position:Central coordinates from statistical parameters determined using SPM software package were reproduced and input in Talairach Client (download from http://www.talairach.org/client.html) to obtain the anatomical location and the BA range of the functional areas of the brain, which were corrected by a physician of the neurological medicine department according to anatomic knowledge and clinical experience.Results1. SubjectsThe subjects include details of24cases of patients with ischemic stroke, scanning of2patients of TE5group and1case of non-acupoint group was broke off for strenuous movements, and the data was removed. There were9male patients and1female in TE5group; aged47-65years old, with an average of56.10±5.53years; course of disease from1month to12months, an average of5.30±3.71months; CSS score15-27points, an average of18.20±4.02points;9patients had a history of hypertension, a history of diabetes in the two cases. Patients with non-acupoint group including9male and2female; ages48-65years old, with an average of59.27±6.13years; course of disease from1month to12months, an average of4.09±3.83months; CSS score11-15points, with an average of16.91±5.24;9patients with a history of hypertension,2patients had a history of diabetes. General information of the remaining volunteers in the two groups have no significant difference between comparable.6cases included healthy volunteers completed the trial, no data removed.3males and3females; ages21-27years old, an average of23.33±2.61years old.2. The fMRI brain function imaging comparative study results of true acupuncture and sham acupuncture ischemic stroke patients on TE5.The true needling of TE5activated the areas of BA7,10,17,18,19,21, 23,39,40, while BA3,4,5,6,10,21were deactivated. The activated areas in the right cerebral regions are more than those in the left. The number of the deactivated areas is the same in the both sides.No activated area was elicited in the sham needling of TE5. BA7of both cerebral regions were deactivated.Compared with the activated area by true needling, sham needling significantly activated BA2,3,4and6. True needling significantly deactivated BA3,4, and6with a comparison of the areas deactivated by sham needling.3. The fMRI brain function imaging comparative study results of TE5acupuncture and non-acupoint acupuncture on ischemic stroke patients.Acupuncture the right non-acupoints active/deactivation of brain regions of ischemic stroke patients:the right side of the brain the B A7appear activated point, the left brain BA10appear deactivation point.Sham acupuncture the right non-acupoints activation/deactivated brain regions in patients with ischemic stroke:no activation point and deactivation point appear.Difference of acupuncture the right TE5and non-acupoint activation/deactivation brain regions in patients with ischemic stroke:compared with that of acupuncture non-acupoints, acupuncture the TE5can only activate relatively weakened right side brain regions BA5.4. Differences in fMRI brain function imaging between acupuncture at TE5on stroke patients and healthy controls.Acupuncture the right TE5active/deactivation brain regions of healthy controls:The left side of the brain BA6,8,13,18,19,20,21,22,37,40,42,44,47, below the lenticular nucleus, putamen, cerebellum tonsil rear, lower part of the claustrum and infratemporalback, and the right side of the brain BA613,19,20,21,22,27,37,38,40,42,45pituitary second half of lobular cerebellar vermis vertical rear hypothalamus, below the lenticular nucleus,putamen, the bottom of the temporal lobe, hippocampal gyrus, occipital lobe and inferior temporal gyrus appear activation point. The left brain BA1,3,4,6,18,31,40, and the right side of the brain the BA1,5,10,11appear deactivation point.Differences in activated brain areas between stroke patients and healthy controls after acupuncture at TE5:Compared with healthy controls, patients with relatively enhanced activate brain regions in the right side of the left and right brain after acupuncture, the left is more concentrated in BA5,6,7,18,19,24,32, as well as the hypothalamus the bottom; more concentrated distribution in BA4,6,7,18,19and32. Activated relatively weakened areas of the brain are mainly distributed in the left, more concentrated in BA13, the lower part of the insular lobe, the back of tonsil of cerebellum, below the thalamus, corpus albicans, hypothalamus below the anterior lobe of the ventral posterior lateral nucleus and the peak anterior lobe; mainly focused on regions BA13of right brain.Differences in deactivated brain areas between stroke patients and healthy controls after acupuncture at TE5:Compared with healthy controls, the relative enhancement of patient deactivation brain regions are distributed in the left and right brain after acupuncture, the left is more concentrated in BA6,11,20,22,37,47, and front lingula of cerebellum, the back of the cerebellar tonsils and the peak anterior lobe of cerebellum; right side is more concentrated in BA8,37,45,47, as well as the peak anterior lobe of cerebellum, the front of the cerebellum nodules, below the lenticular nucleus leaves, outside of the globus pallidus, the bottom of the temporal lobe and hippocampal gyrus. Deactivate brain regions relative weakening of the left brain area BA7.ConclusionBy comparing This study preliminary indicated there are some differences among the acupuncture TE5and sham acupuncture, acupuncture TE5and non-acupoints, acupuncture TE5between normal subjects and patients with ischemic stroke; At the same time, the study shows that acupuncture TE5specificity directional activation/deactivations, it may be one of the mechanisms of TE5treatment of ischemic stroke movement disorders, sensory impairments, visual impairments and the aphasia, also preliminary corroborated central regulation of acupuncture TE5is to implement network-based regulation.