TBMMN Y5 2015

TBMMN CHN ON & IU TR

(i tng: Y5 Thi gian: 02 tit)
BS. H Hu Tht BM. Thn kinh
Trng H Y Khoa Phm Ngc Thch

Mc tiu bi ging
1. Chn on phn bit c cc th bnh thng gp ca TBMMN
(nhi mu no, xut huyt no), v phn bit c TBMMN vi
cc bnh l khc (u no, p xe no).
2. Chn on c c ch bnh sinh ca nhi mu no v xut huyt
no.
3. Nm c mt s phng php x tr nhi mu no v xut huyt
no trong giai on cp.
T kho: nhi mu no (NMN), xut huyt no (XHN), nhi mu
no do thuyn tc t tim (cardioembolic stroke), nhi mu no do bnh l
x va M ln, nhi mu no do c ch mch mu nh (small-vessel
stroke).

I.

M U

Du rng cc phng php iu tr ban u i vi NMN cp

thng khng ph thuc vo c ch bnh sinh, vic xc nh nguyn
nhn ca NMN ng vai tr quan trng trong iu tr phng nga NMN
ti pht. Vic xc nh nguyn nhn c bit khu tr vo rung nh v x
va M cnh, v c nhiu chng c trong iu tr phng nga Q th
pht cho cc nhm nguyn nhn ny.
Khm lm sng thng gip thu hp c cc nguyn nhn c th
gy NMN. S dng cc phng php cn lm sng hp l thng gip
xc nh c nguyn nhn. Tuy vy, khong 30% cc trng hp NMN
vn khng xc nh c nguyn nhn mc d kho st y lm
sng v cn lm sng.
Phn nhm xut huyt ni s da vo v tr xut huyt v bnh l
mch mu gy xut huyt. Xut huyt ngoi mng cng v di mng
cng ch yu do nguyn nhn chn thng. Xut huyt khoang di nhn
c th do chn thng, hoc do v cc ti phnh ng mch trong s
(intracranial aneurysms). Bi ging ny cp xut huyt trong nhu m
no (intraparenchymal hemorrhage, m trong thc hnh lm sng thn
kinh hc thng dng ngn gn l xut huyt no).

II.

C CH BNH SINH
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TBMMN Y5 2015

1. NHI MU NO
Nhi mu no do thuyn tc t tim (cardioembolic stroke):
Huyt khi t tim chim khong 20% tt c cc trng hp NMN.
Q do bnh l t tim ch yu do huyt khi hnh thnh trong thnh ca
tm tht hoc tm nh, hoc cc van ca bung tim tri. Cc cc huyt
khi, sau , i vo tun hon h thng, v i vo tun hon no. Cc cc
huyt khi c th ly gii nhanh chng gy ra cc cn thiu mu no cc
b thong qua, hoc lm tc nghn M ko di gy ra NMN.
Cc nguyn nhn thng gp nht ca NMN do thuyn tc t tim
l rung nh khng do bnh van tim hu thp, nhi mu c tim, van tim c
hc, bnh van tim hu thp, v bnh c tim thiu mu cc b.
Nhi mu no do bnh l x va M ln (cn gi l NMN do c
ch mch mu ln):
Cc huyt khi c hnh thnh trn mng x va c th gy
thuyn tc cc M trong s gy ra NMN do thuyn tc t M n M
(artery-to-artery embolic stroke). Ngoi ra, M b x va cng c th b
tc nghn cp tnh ti ni c mng x va, gy ra NMN thuc vng nhu
m do M chi phi.
Khng ging vi cc M cp mu cho c tim, i vi NMN, c
ch thuyn tc t M n M thng gp hn so vi c ch tc nghn
cp tnh ti ni c mng x va (local thrombosis). M b x va c th
l cung M ch, M cnh chung, M cnh trong, M no gia, M t
sng, v M thn nn. Mng x va ti v tr chia i ca M cnh, l
nguyn nhn thng gp nht ca NMN do c ch mch mu ln.
Nhi mu no do c ch mch mu nh (small-vessel stroke):
Cng c khi c gi l NMN l khuyt, chim khong 20% tt c
cc trng hp NMN. Nhi mu no do c ch mch mu nh gy ra do
tc nghn cc M nh trong no, thng l cc nhnh xuyn (cc nhnh
u vn ca M no gia, cc nhnh xuyn ca M thn nn).
Biu hin lm sng thng gp l cc hi chng l khuyt: (1) Q
yu na ngi n thun (pure motor hemiparesis) do nhi mu vng
cnh tay sau bao trong, hoc phn nn cu no; (2) Q cm gic n
thun (pure sensory stroke) do nhi mu phn bng i th; (3) Q
yu na ngi tht iu (ataxic hemiparesis) do nhi mu phn bng
cu no hoc bao trong; v (4) Q ni v bn tay vng v (dysarthria
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TBMMN Y5 2015

and a clumsy hand) do nhi mu phn bng cu no hoc phn gi

ca bao trong.
Nhi mu no do cc nguyn nhn t gp:
Ngoi cc nguyn nhn thng gp nh trnh by, NMN cn c
th do cc nguyn nhn t gp hn nh: cc bnh l tng ng, cc bnh
vim M h thng, huyt khi xoang tnh mch no, hoc phnh bc tch
M
2. XUT HUYT NO
XHN chim khong 10-15% tt c cc trng hp Q, v kt hp
vi 50% tt c cc trng hp t vong do Q. T l XHN c bit cao
nhm BN chu v ngi da en. Tng huyt p, chn thng, v d
dng mch mu no (v d AVM: Arteriovenous malformation), bnh l
thoi ha dng bt, ri lon ng mu, xut huyt trong u l cc nguyn
nhn thng gp nht ca XHN.
XHN thng c chn on bng CT scan no. X tr Q trong
giai on cp, CT scan no thng c u tin ch nh hn MRI
thng quy v nhy cao v tnh ph bin ca CT scan. V tr xut
huyt gip khu tr chn on phn bit vo mt s nguyn nhn nht
nh.
XHN do tng huyt p thng do v cc nhnh ng mch xuyn,
nh, nm su trong no b. Cc v tr thng gp nht ca XHN do tng
huyt p l hch nn (c bit l nhn bo), i th, tiu no, v cu no.
Khi xut huyt nm ti cc v tr khc hoc BN khng km theo tng
huyt p, cn kho st cc nguyn nhn cn li.

III.

IU TR
1. NHI MU NO
Phng nga tin pht:

Phng nga Q tin pht bng cch iu chnh cc yu t nguy c

c th iu chnh c (tng huyt p, ri lon lipid mu, i tho ng,
ht thuc l, bo ph, v t vn ng th lc).
Aspirin: c bng chng cho thy aspirin lm gim s mi mc
cc s c tim mch (bao gm c Q) i vi nhm BN c nguy c cao.
Q do thuyn tc t tim: cng c ch nh iu tr phng nga Q
tin pht i vi cc BN c bnh l tim mch c th khi pht Q nh
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TBMMN Y5 2015

rung nh, nhi mu c tim cp vi huyt khi tht tri, van tim c hc.
Warfarin vi liu duy tr INR t 2-3 lm gim nguy c Q nhm
BN ny khong 50%-75%.
Hp M cnh khng triu chng: hp M cnh t 70%-99% cng
lm tng nguy c Q. Tc hon ton M cnh khng phi l yu t nguy
c, v tc hon ton M cnh m khng gy triu chng Q cho thy
c tun hon bng h y . Vic chn la phng php iu tr ni
khoa hay phu thut bc tch M cnh ty thuc vo mt s yu t nh
t l bin chng do phu thut
iu tr giai on cp:

iu tr ni khoa:

Huyt p: khng nn h huyt p qu nhanh, tr nhng bnh nhn

c ch nh iu tr tiu si huyt (thrombolytic) cn phi h huyt p tm
thu di 185 mmHg v huyt p tm trng di 110 mmHg.
Chng kt tp TC (antiplatelet): vi nhi mu no khng do thuyn
tc t tim, BN c ch nh iu tr vi aspirin/dipyridamole, aspirin, hoc
clopidogrel.
Khng ng: c ch nh hepain v khng ng ng ung i vi
NMN do c ch thuyn tc t tim. Du rng vic iu tr khng ng
trong giai on cp c th lm tng nguy c chuyn dng xut huyt
trong vng nhi mu, iu tr khng ng vn mang li li ch nhiu hn
tr khi vng nhi mu qu ln.
Statins (v d atorvastatin hoc rosuvastatin): cng c ch nh iu
tr nhi mu no trong giai on cp do c ch mch mu ln, thuyn tc
t tim, hoc c ch mch mu nh.

iu tr can thip:

Thuc tiu si huyt ng tnh mch (intravenous thrombolysis):

rTPA (recombinant tissue plasminogen activator) hoc alteplase
(Actylyse liu 0,9 mg/kg ti a 90 mg) trong vng 4,5 gi u sau Q
gip lm gim t l tn ph v t vong.
Thuc tiu si huyt ng ng mch (intraarterial thrombolysis):
c ch nh trong vng 9 gi sau Q gip ti thng mch mu tt hn
so vi tiu si huyt ng tnh mch, tuy vy hiu qu ci thin t l tn
ph v t vong vn ang c nghin cu.

TBMMN Y5 2015

Ly huyt khi bng dng c c hc (nh dng c MERCI hoc

SOLITAIRE) c th c li trong iu tr nhi mu no, c bit nhi mu
no do tc on gc M no gia. Tuy vy, cc phng php ny c
thc hin vi c mu nh, v cn c nghin cu thm.
iu tr giai on mn tnh:
iu tr NMN giai on mn tnh ch yu l phng nga Q th
pht trnh ti pht, v gip phc hi ti a cc triu chng biu
hin.
iu tr phng nga Q th pht: iu tr cng tng t vi phng
nga Q tin pht bao gm iu chnh cc yu t nguy c, cc thuc
chng kt tp tiu cu v statin, hoc cc thuc khng ng ng ung
i vi NMN do c ch thuyn tc t tim.
iu tr phc hi chc nng: hu ht cc triu chng thn kinh s
t hi phc trong vng 3 n 6 thng. Ngoi ra vt l tr liu, phc hi
chc nng, ngn ng tr liu s gip hi phc nhanh hn. Nn bt u tp
vt l tr liu sm.
2. XUT HUYT NO
Cn theo di st v bo v ng th v XHN thng gy ri lon
thc. Nn duy tr mc huyt p ban u ca BN cho n khi c kt qu
CT scan no. S gia tng th tch khi mu t thng kt hp vi mc
huyt p cao. Tuy vy, vn cha chc chn liu h huyt p c lm gim
s gia tng th tch khi mu t hay khng.
Mt s nghin cu gn y (v d nghin cu INTERACT:
Intensive Blood Pressure in Acute Cerebral Hemorrhage Trial) cho thy
h huyt p tch cc bng cc thuc h p ng tnh mch (duy tr
HATT di 140 mmHg trong 24 gi u sau XHN) gip lm gim s gia
tng th tch v ph no xung quanh khi mu t.
TI LIU THAM KHO

1. Aminoff MJ, Greenberg DA, Simon RP. Stroke. In: Aminoff MJ, Greenberg
DA, Simon RP. Clinical Neurology, eighth edition, McGraw-Hill, New York,
2012.
2. Harrisons principles of Internal Medicine, 18th edition, McGraw-Hill, New
York, 2012.
3. Tai bin mch mu no, bi ging Y3, BS. H Hu Tht, Trng HYK
Phm Ngc Thch, 2012.