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双向障碍患者前额叶皮层与边缘 神经系统病变的神经影像学诊断

Neuroimaging Diagnosis of Prefrontal Cortex and Peripheral Nervous System Lesions in Patients With Bipolar Disorder

临床医学前沿 / 2021,3(4)：100-119 / 2021-10-22 636 1371

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• 作者： 蔡政忠¹      严诗晨²      陈宇欣¹      林琪祯¹      苏翎清³      陈玲滢⁴     
• 单位：

  1．莆田学院医疗健康产业管理系，莆田；
  2．新奥尔良大学，美国路易斯安那州；
  3．黄冈师范学院，黄冈；
  4．福州超德中学，福州

• 关键词： 双向障碍；前额叶皮层；边缘神经系统；结构影像学；功能影像学
• Bipolar Disorder; Prefrontal Cortex; Peripheral Nervous System; Structural Imaging; Functional Imaging
• 摘要： 双向障碍（Bipolar Disorder，BD）又称为双极性疾患，是很常见的精神疾病，全球患病率达到3%，是世界排名第六大致残性的疾病，双向障碍不只分为轻 躁狂双向障碍Ⅱ型，又有躁狂双向障碍Ⅰ型的分别，临床表现有认知、情感、运动的症状，实际上还有情绪不稳定、自主神经功能异常、认知损害、精神病性症状与特别容易冲动等。本文在早期神经外科手术惯用治疗狂躁症、过动症与具有暴力倾向的反社会型人格疾患的“眶额叶切断术”（Transorbital Lobotomies）基础上，对比近代神经影像学的研究发现，双向障碍患者的表现与眶额叶切断术的患者在很大程度上有雷同之处，均出现个性迥异、记忆力恶化、智力低下、情绪失控与人格缺陷等问题。功能磁共振成像（fMRI）正在成为一种流行的非侵入性工具，用于对健康和疾病中的功能活跃的大脑区域进行成像，功能磁共振成像技术是探究脑功能的重要手段，基于血氧水平依赖（Blood Oxygenation Level Depended ，BOLD）的脑皮层功能成像和基于扩散张量成像（Diffusion Tensor Imaging ，DTI）的脑白质功能成像是目前应用最为广泛的功能磁共振成像技术。几种神经病理学的研究模式来概念化心境障碍中，情感改变潜在神经生物学机制，目前全球专家聚焦以下几个研究方向：第一，大脑奖赏环路遭破坏导致双向障碍患者明显动机受损；第二，处在应激环境下，HPA 轴与大脑心境反应的关系；第三，躁狂和抑郁本是互相调节平衡的状态，神经生物学认为一旦神经组织出现破坏才是导致双向障碍的主因。Philips 团队在2003 年发现，调控人类情感的神经系统主要集中在前额叶腹侧皮层（VPFC）、眶额叶皮层（OFC）、岛叶、前扣带回腹侧皮层、腹侧纹状体、杏仁核、小脑蚓部、脑干核团（中缝核、躯体运动核、特殊内脏运动核、网状结构网状核、蓝斑核）。腹侧系统主要负责感知情绪刺激、形成情感状态、产生自主反应。与此相反的是， 背侧系统包含前额叶背外侧皮层（DL-PFC）、前额叶内侧皮层（VM-PFC）、前扣带回背侧皮层（DL-ACC）、海马等负责调控情感状态、情绪抑制、工作 记忆与专注力。近年来磁共振成像和波谱技术的发展已经改变了双向障碍的神经生理学研究，结构影像学还能识别大脑感兴趣区（ROIs）引导后来者的研究 力度。
• As a commonly seen mental illness with a global prevalence rate of 3%, bipolar disorder(BD), also known as a bipolar affective disorder, ranks top 6 among global disabling diseases. Besides the categories of hypomanic BD type Ⅱ and I, BD also shows the clinical symptoms in cognition, affection and movement, such as out-of-control emotions, abnormal autonomic nerve function, impaired cognition, psychotic symptoms and impulsive disposition. In this paper, based on the transorbital lobotomies of inchoate neurosurgery for mania, attention deficit hyperactivity disorder (ADHD) and antisocial personality disorders with violent tendencies, and the comparison between the studies of modern neuroimaging, it was found that there are great similarities between the symptoms of patients with BD and those with transorbital lobotomies, such as personality difference, memory loss, hypophrenia, mood disorders and personality defects. Functional magnetic resonance imaging (fMRI) is becoming a popular non-invasive tool for brain region imaging with active functions. As an important means to explore brain functions based on blood oxygenation level depended (BOLD) functional imaging of the cerebral cortex and diffusion tensor imaging (DTI) based functional imaging of the white matter, fMRI has become the most widely used technique. Several neuropathology research models are used to conceptualize the underlying neurobiology mechanism of mood disorders. Nowadays, the attention of global experts is mainly paid to the directions as follows. First, the destruction of brain reward circuits leads to obvious motivational impairment in patients with BD; Second, in a stressful environment, the relationship between the HPA axis and the brain’s mood response; Last but not least, mania and depression are a state of mutual adjustment and balance. In neurobiology, it is believed that the damage of the nerve tissues is the major cause of BD. According to Philip’s findings, the nervous system of regulating human emotions is mainly concentrated in the ventral lateral prefrontal cortex (VPFC), orbitofrontal cortex (OFC), insular cortex, ventral anterior cingulate cortex, nucleus accumbens, amygdala, cerebellar vermis, and brainstem nucleus (raphe nuclei, somatic motor nucleus, special visceral motor nucleus, Reticular formation, reticular nucleuslocus coeruleus) in 2003. The ventral system is mainly responsible for sensing emotional stimuli, forming emotional states, and generating autonomous responses. In contrast, the dorsal system involves the dorsal lateral prefrontal cortex (DLPFC), dorsal medial prefrontal cortex, dorsal anterior cingulate cortex and hippocampus, which are responsible for regulating emotional states, emotional inhibition, working memory, and concentration. Over these years, the development of magnetic resonance imaging and spectroscopy technology has changed the neurophysiological research of bipolar disorder. Structural imaging can also identify regions of interest (ROIs) in the brain to guide the research efforts of latecomers.
• DOI： https://doi.org/10.35534/fcm.0304012
• 引用： 蔡政忠，严诗晨，陈宇欣，等．双向障碍患者前额叶皮层与边缘神经系统病变的神经影像学诊断［J］．临床医学前沿，2021，3（4）：100-119．