Gio trinh Than kinh hoe DOT QUY Nguyén Ba Thing Muc tiéu hoc tap 1. MO t& hé théng cung c4p mau cho no. 2. Trinh bay danh gia chung vé trudng hop éét quy. 3. M6 ta dac diém lm sang va can lam sang cia thigu mau nao cp, xuat huyét trong so va xuat huyét du6i nhén. 4, Trinh bay diéu tri dét quy. Ni dung - Béng mach ndo va cde véng bang hé - Bét quy: dinh nghia, dich té hoc, Iam sang - Cac khdo st cn lm sang trong dét quy - BOt quy thiéu mau (no) cuc b6 - Xudt huyét trong nao - Xuat huyét khoang dui nhén - Chan doan d6t quy - Didu tri dét quy BONG MACH NAO VA CAC VONG BANG HE BM abo truse. OM no gia (nhénn duet) PM thang sau ‘2M nko pide (han) Hinh 11.1: Mach mau nao va da giée Willis: 109Bai 11: Bt quy, Tu6i mau nao Vong dng mach day nfo la noi xuat phat ra cde déng mach cdp mau cho no, bao gdm ca viing trung fam (Sau) va ngoai vi (néng). ‘one ou mr a aku ‘sana p61 en ‘ou NAG WA ‘ou NAO ata eet ‘ou THAI DUONG Du nao ota em a= ‘sav Hq ‘4 on A Ntohove cone tmalaveng om TuAioyoNG *VONG THINH GIAC Ruse Hinh 11.2: Mat ngoai bin céu dai ndo voi cde nhénh cia déng mach néio giiea 5 ‘VUNG VAN BONG CUA CHAN, BAN CHAN ‘VUNG VAN BONG PHY, VA BANG QUANG VUNG CAM GiAc CUA CHAN NHANH DINH-CHAM V6 NAO THI GAC > (Vung van doc theo nash ranh eva) eM NAO SAU ‘®M THAI DUONG SAU 9M THAI DUONG TRUGC Hinh 11.3: Mat trong ban cau voi cdc nhénh ctia déng mach néio truéc va ding mach ndo sau 110Gio trinh Than kinh hoc Cac d6ng mach xuyén su: sinh ra tir vong dng mach day nio va tir géc cita ba cp dong mach nao, thuémg ob huéng xuyén tr day ndo di thing dig lén trén, di vio ede ca tric sau cla no. Cac déng mach nay tuéi mau cho ddi thj va ving dudi déi, nhan dau va nhan duéi, bao trong va ca cho dim réi ming mach. ~~ me Cac déng mach ngoai vi hay cdc nhanh néng Dong mach néo trade: xuat phat tir chd phan chia cia dong mach cinh trong, néi voi dong mach nio true déi bén bing dng mach thong tre, to ra mot sy thong not phia triée va thong lién cdnh. Tir dung gitta, dong mach nao truse di ra true va lén trén trong il Cée nhanh cia déng mach nao trude tuéi méu cho mit trong y trdn va 3/4 truée cia mat trong (thiy tran va thiry inh) va bé trén cia mt Idi ban cdu nao. Déng mach néo gitea: gin nhu tiép tyc huéng di cia dong mach canh trong doan tan, di hung ra ngoai vao khe bén cia nao (Khe sylvius) va t6a ra nhigu nhénh 48 tudi man mat ‘godi ban cau, tir bo truée (thud thiy trin) va bs duéi (thiy thai duomg) bén cdu nao. Déng mach ndo sau: xudt phat tir chd chia 6i cha d$ng mach nén, néi véi dong mach thng sau tao ra sy thong néi canh - séng nén. Tir vi tri d6, déng mach nao sau di quanh ‘rung no va tu6i mau cho m§t duéi va trong cua thiy thai duong va thiy chim. Ca ba d6ng mach néi trén c6 két néi voi nhau phong phii trén mat v6 nao (biing cdc nhanh tn) tgo thinh mét mang lui bang hé mang nudi. DOT QUY: DINH NGHIA, DICH TE HOC, LAM SANG Dinh nghia ra v6i cde ian oasis, v6i cin ig mach mau xay ra ty phat (loai tris nguyén nhin chén thuong s9 no). Xu huéng hign nay théng nat ding thuat ng “dot quy” (stroke) thay cho cae thuat ngér ct nh “Dot c6ng kich no” (brain attack), “Tai bién mach mau nfo” (Cerebrovascular accident). Dich t8 hoc Ot quy 1 nguyén nhén tir vong dimg hang thtt ba sau ung thu va bénh tim mach & hau hét cic nude. Riéng tai Vigt Nam, théng ké ciia BO Y té nim 2008, 2010 cho thay d9t quy 1 pguyén nha tt vong hing thir nhét. Dét quy edn duge ghi nhin 1a nguyén nhn gay tin phé hang dau 6 ngudi Gn» N6 cing la bénh phé bién, voi mdi nim Khoang 750.000 trong hop dt quy méi 6 Hoa Ky, va 200.000 6 Vigt Nam. Lam sang Phan logi Trong thu hinh lam sing, 49 111Bai 11: Bot quy Cerebral infarction). - Thiéu mau nao cuc bé (Dot quy thiéu mau - Ischemic stroke; Nhdi mau nao — e - Xuét huyét trong so (Intracranial hemorrhage), gm hai loai: © Xudt huyét trong nao (Intracerebral hemorrhage - ICH) Xudt huyét khoang dudi nhén (Subarachnoid hemorrhage - SAH) Dac diém lam sang Do dc tinh cha dot quy 1A dot ng6t. xuét hién cdc khiém khuyét than kinh, 06 thé nang ngay tir du hod tién trién nhanh, moi né Ie edn phai duge thyc hign do thé chiin dodn chinh xde va quyét dinh xirly kip thai, bao gém cap ciru va chim s6c diéu tri giai dogn cp, nhiim gitip bénh nhan héi phuc t6t nhat, hgn ché tir vong va nhimg bién chime khée do 46t quy. Chan don d6t quy cp dya m6t phin rit lon vao lam sing, Mét bénh cénh lam sang dot quy 6 dic diém: RHGHPRAL AGERE, thong duoc hiéu khi bénh nhan dang trong tinh trang strc khoé binh thuong, dot ngOt chuyén sang trang théi bénh ly ma biéu hign chinh 1a xuat hign cdc trigu chimg, cue bé hay khiém khuvét vi chite ning than kinh. 6% thiéu hut than kinh t6i da (ligt, hon mé, r6i logn van ngén, r6i logn cam Khi mot ving no bj tn thong, ngay lap tte ede Khiém Khuyét than kinh cing xudt hign; day c6 thé 18 mite 49 ning tdi da ma tinh trang xuat huyét hoge thiéu méu nao 6 thé gay ra, dat dune ngay tir dau, hodc lic dau nhe sau dé tién trién_nhanh chéng dén ‘Néu cdc khiém khuyét thin kinh nay hdi phyc nhanh chéng dén khdi hodn toan trong vong 24 gid thi duge goi la Se ET hay on thodng thu mis ndo (CTTMN). Mic di dinh nghia CTTMN nay ciia Té chire Y té Thé gidi van t6n tai t6i nay, nhiéu higp hoi va téc gid da dé xudt dinh nghia méi, trong 46 thay ddi méc thoi ae hoi phuc tir trong ving 24 gid xudng chiléenl “trong Vong 60 phit”)ding, a7 thém Cin phan bigt CTTMN voi cOmingét}'con dng kink ValMigtaine. Con ngit chi xay ra it gify, khong c6 khiém khuyét thin kinh khu tri. Nguge lai con déng kinh cuc b6 hay Migraine 06 thé 06 khiém khuyét than kinh khu tri nhung hodc vit hur trong déng kinh, hoc kéo dai hon trong migraine nhung lai khi mat y thie, ee Bénh ste va nhéng triéu ching chinh Bénh str : Ot quy cb mot bénh sit khé dc biét, ngudi ta ghi nhin khodng 80% trudmg hop 06 thé chin doan duge dét quy chi dya trén cdc théng tin bénh sit. Mét bénh sir chi tiét 14 phn quan trong nhat trong danh gid bénh nhén d6t quy, trong d6 théng tin quan trong nhat 1 bénh canh dot ngdt_xuat hign cde cée khiém khuyét thin kinh khu tra lién quan dén mot ving no bj ton thuong. 112Gido trinh Than kinh hoc ne ee aca oh.de} MOt so diém cdin lu ¥ Khai théc ky trong bénh sir d6t quy: Zook ef bénh nh§n thay 1 t8, yéu ligt tay hodic chan, réi loan ngén ngt. ~ Kigu khdi phét (46t ng6t hay it dt ng6t hon) va nhtmg su kign o6 thé ‘hfe xuat hign hodc tién trién (ging sttc, tut huyét dp, ting huyét dp,...), da ~ Hoan cénh phat bénh (dang ngi, dagpaee stte,...) diém bién va thdi gian khoi (Phiteiacdctrigiichime. Gd Av ~ Sw xuat hién céc trigu chimg ary ages kinh lic khéi phat, toan phat, cdc , quan trong nhat 1a cdc trigu thay d6i vé tinh trang ¥ thi a ~ Xudt hign céc trigu chimg @aif@atiinen6 gia - Tién trinh tién tri gian cla cae trigu chtmg than kinh sau giai doan khéi phat, dic bigt xudt hign cdc trigu chimg mdi. Bénh nbn d6t quy o6 thé khong nhé 13 hoc khéng m6 ti duoc céc biéu hign lam sing mot cach chi tit va thirty, do 46 cin thu thip bé sung ca dit ligu lam sing tir cdc thanh vien trong gia dinh va nhimg nguoi chimg kién hic bénh khéi phat. Céc trigu ching lém sang thuéng gap Dau déu: Trong dot quy dau ddu néu 06 thudmg@9ERg6E, nhung mite 46 dau tiy thudc thé lam sing. ‘Trong xuét huyét kioaiigi@irSilhény dal da ra didi, @QEIngot, bénh han mo ta “nher bia bo vao dau” hoic cim giéc dau nhu muén né tung. Bau dau thutng kém i va dau mang nfo. Tuy nhién khoang 20-30% truéng hop dau dau khéng dién hinh, mét s6 it khong dau. Trong xuat huyét nfo, khdi phat dau diu cing dot ngot nhung mite d9 thutng khéng qué nang né, hiém gip déu mang nao tri truémg hop xuat huyét ndo tran nfo that va khoang du6i nhgn. Thudmg dau diu kh6ng néi bét bing cde trigu chimg khiém khuyét than kinh tién trién va bién d6i ¥ thite. Cée bénh nhan nhdi méu no 46i khi o6 dau dau. (20%) véi mite 46 nhe va thoding qua, biéu hign chinh van 1a khiém khuyét than kinh, Chéng mat (vertigo): 1d biéu hign cia tin thuong tid Chéng mat trong d6t quy thutmg gap la chéng mat nguyén nhan i do tén thuong " Trong béi cénh dot quy, hau nhu chéng 10 gid cling két hyp véi cdc trigu chtmg khéc cia chite nang than nio hoi tiéu nao nhuf rung git nhiin cdu (nystagmus), ligt van nhan, (mat diéu hoa van ding). 9 Réi loan thi gid: trong bénh mach méu nao r6i loan thi giéc thudng gap 1 mat thi gidc, khiém khuyét thi truong va nhip doi, Mat thi lc m6t hay hai bén: xay ra trong bénh mach mau nfo 1a do thiéu mau vong mac, do 113Bai 11: D¢t quy Mi thodng qua do thiéu mau vong mac duge goi 1a “HHUIFUBAR” thudng do tic dongiigeh) , Him r6i loan hu lung méu dén mit, hoc do lép mach d6ng mach yong mac do cuc méu e6 nguén géc tir dogn gin ciia dng mach cinh, hoc cing c6 thé lip mach tirtim. Khiém kiuyét thi cing diebi dang ih: xy ra do thn nine: xay ra khi tin as cia cde thin thuong gap trong d6t quy,thén nao (twain hoan sau). Réi loan ngén ngie Mat ngén ngit van dng xuat hign khi tin thuong ving Broca (phd r6i logn nay, ngudi bénh mat kha nding néi thanh Idi, nhug cn ban v thong hiéu 1di néi, Cling cn phan bigt v6i n6i Kho (Rata) Ia r6i loan céc oo Iuoi va du hong, 6 day ngudi bénh cé thé van van dong co ludi va méi, nhung mat kha nang van dong cc cor phy trich d6ng tic Idi ndi. Mat ngén ngit cdm gidc (mat ng6n ngtt Wernicke) do tén thuong ving Wernicke, & phan Neudi bénh mit kha nang thong hiéu Idi néi, ngudi bénh ts nén khdng hiéu tiéng me dé, giéng nhu dang nghe mt ngoai ngir chu timg biét. Ngudi bénh thudng néi nhiéu, théo Idi, véi noi dung khéng phi hop, khéng 15 nghia, khong lién quan,,.. goi l mat ng6n ngit Luu loét. Céc réi loan cam giéc Khi dot quy xay ra & cdc ving cé hé théng cim gidc, bénh nhén sé xudt hign bat thudng cam gidc, trigu chimg thudng gap 1A té bi, mat cam gidc. Cac cdu tric lién quan hé théng cm giéc than thé gm v6 ndo cam gide va duong cim,gidedudi vo, 40% thi, thin néo. Mat cim gidc hoac réi loan cam gidc trong d6t quy thudn; theo véi ligt nira ngudi. Nhu bén can ign twang mci eco 6 thé yéu_nhe nia ngudi cing bén véi réi loan cam gic, do ton oe anh huéng -ngay canh di thi. vind : Wb ae a ey Yéu va liét nua nguoi ByydhKBm Hf ony. TEsolunt La dau higu thuémg gip trong 46t quy, xy ra Ne SS, Sin ntns ig eH duong van ong chi: dng (hé thap). Dac diém yeu liét va cde dau higu kém theo s@ gitip dinh khu vj tr tn thuong: Jiét mira ngudi khong déng déu gitta mat, tay va chan thuong thdy trong tén trong khi tn thuong bao trong thi ligt nira dong déu; ligt nira nguoi kem tén thron= fan kinh so bén kia (hdi chimg bat chéo) chi diém tén thuo: ethan nd) , 06 thé gp trong cdc hoi chimg Weber (trung nao), Millard-Gubler (cdu nfo)... Réi loan J thite va hén mé: su thre tinh Auge dy ti boi su kich hoat ia én ign tue cia he lui Ién v6 nao hai ban cau, 14 cdu tric Ludi trai tir clu ndo cao lén t6i di thy - ha d0i. ROi loan y ae va hon Me xAy ra khi tn thuong hoge roi logn chite nang eta hé Idi nay hoge ciia v6 nfo hai ban cau. Cobbaldangieha ae hon mé thudng gap trong d6t quy: Wo WN is \ v0 na Baur Gu 114Giéo trinh Than kinh hoe cla hé théng Iuéi kich hoat huéng Jén 4 thin nao: nhéi mau t\lén & cau nao cao, trang nao, déi thj hai bén, hodc tén thuong tiéu at luo than ni - Tén thuong mét bén ban cdu dai no: gay hén mé khi tin thuong Ion dign tién t6i thoat vi nao (tut ni) chén ép xuéng thin no, hoe chén ép sang bin cau d6i bén, trong d9t quy ig Bap tong nhoi mau nao dign rong hodc xuat huvét nao Ién. = Réiloan chite nang vo A t epi (Néu khong phai bénh cénh d6t quy, hon mé trong tinh hudng nay wong do réi loan chuyén héa, thiéu mau thiéu oxy todn b6, viém mang CAC KHAO SAT CAN LAM SANG TRONG BOT QUY Céc khdo sit hinh anh hoc va cde xét nghiém Khéc trong 46t quy cho phép Khiing dinh chan oan, dinh khu giai phdu ving xay ra tén thuong va huéng dén xdc dinh co ché bénh sinh cing nguyén nhén cia n6. Cac khao sit hinh anh hoc c6 vai tro rét quan trong trong dot quy, dac biét sw phat trién cdc ky thuat hién dai gitip ting cudng kha ning chin dodn, chon Joc bénh nhan dé cp ciru, diéu tri, tién lugng va dy phng tai phat. Can danh gid muc tiéu, Igi it, nguy co dé cé6 thé ra quyét dinh chon Iya khao sét pha hgp nhat véi béi canh lam sang ciia ting ngudi bénh. Chup cat lop vi tinh (CT Scan - Computerised Tomography Scan): day la ky thuat chyp c&t lop ding tia X, xit ly biing vi tinh cho ra hinh anh céc l6p cit ciia nao va so. CT Sean 6 kha nang phat hign SOmpRUAEhGyet trong’So (xudt huyét nio va xudt huyét duéi nhén) vA thay duoc t6n thuong nhdi méu néo di hinh thinh (giai doan mudp), nhung KbiGng)thiy duge cic ) Trong béi cénh cp ciru 6t quy thieu mau cuc b6 trong nhig gid dau, rat nhiéu trong hop CT Scan nao khéng thay duge tén thuong. Tuy nhién CT Scan van 1a khdo sét duge Iya chon diu tién trong nhiing gid dau tién cita d6t quy vi ludn sin 6, chup nhanh eu cau tién quyét 1a on 1a yéu cai i quyét dinh diéu tri tai thong cap ctu. Ngoai ra méy CT Scanner con cho phép thye hién chup CT mach méu (CT Angiography) va chyp CT tuéi mau (CT Perfusion), la cc khao sét ning cao rit hitu ich trong d6t quy. Céng huéng ti (MRI - Magnetic Resonance Imaging): nhin chung MRI cho hinh anh chi tiét hon CT va cung cp nhiéu théng tin vé cfc dc tinh mé hoc tén thyong, do dé né chung MRI wu viét hon CT Scan trong 46t quy. MRI 06 mt s6-loi diém sau: (1) 06 th Khao sat nhiéu mat phiing (trén, dig doc, ngang, nghiéng); (2) nhay cim véi céc mé, nhat Ja mé tn throng (nhfn dign chinh xdc he som, nhQi m4u than nao, phan biét d6 tu6i tOn thong nhoi mau, nhan dién ca nhimg xuat huyét of, nat Ti vi xuat huyét); (3) phat hign tic mach lin ma khong cdi tiém thudc (ky thuat TOFSD), 2) LASER SED vs biét d6t quy véi cdc nguyén nhéin 'y. Tuy nhién, do mite dé sn c6 khong bang va thoi gian chyp Ong huong tir dai hon CT, dong thoi cb mét s6 chéng chi dinh (di vat kim loai, miéy tao nhip,...), nén trong cp ctru dét quy, MRI thug chi ding tro: Oigid hGH phét hoe chin do ong Chae chin. Ky thuat MRI tudi 115Bai 11: Dot quy ‘8a mot Iua chon t6t bén canh CT Scan tub mau 6 muén (5 ) dé ti Oi giai doan cp ciru, MRI thug duc Iya chon hon so vai CT Sean d vi mic d9 tin thyong, cing nhur hé trg dinh hung tim nguyén nhan, MRT meh imu {GSST(MIRA) li ky thudt hinh anh khdng xdm lin gidp dénh gid tot he thong mach méu huéng nao, rat cén thiét trong 46t quy, gitip xc dinh tinh trang tic, hep dng mach, cing nnhur phat hign céc bat thuimg déng tinh mach Kha. Chup mach mau ky thuat s6 x6a nén (DSA - Digital Substraction Angiography): Chup mach mau v6i thude cn quang la phuong phép dang tin dy nha trong viée khio sit ton b9 hé théng mach mu no thuge ca twin hoan trudc va sau. DSA 1a ky thudt chup mach méu cao cap nhét hién nay, duige xem 1a tiéu chun vang trong khao sét mach méu, dc bigt 8 DSA ba chiéu. Tuy nhién, day la ky thugt xm Tan nén Suing mong khong dling trong 46t quy 4p véi mye dich chin don don thuan, DSA thuimg duge sir dung khi can dénh gié quyét dinh can thigp, kém theo ké hoach can thiép Ikhi ding chi dinh. Thong thuing in duge chi dinh trong cic tring hop nghi ngty bat thutng hé thong mach dang d6ng tinh mach, 7 déng tinh mach, phinh mach, hep dng mach cha 76 mite dé trén CTA hoe MRA, va dic bigt trong dt quy cap o6 tie mach cin cru, Siéu 4m Doppler ving 6 va Doppler xuyén so: Siéu am khao sat mach mau 14 mot ‘gy thudt khong xm ln, rétién va e6 thé thy hign lap Iai nhieu lan, Thém vao 46 Doppler gitip danh gié duge vin téc ding chay, tinh trang huyét déng nén rat o6 ich trong dainh gid dt quy. Tuy nhién, day 1a ant ky tht py tae ng i, trong 46 Doppler xuyén so cin phu thude vao cia s6 siéu am cia bénh niin, do 46 né durge coi la mét ky thuat khio sit b6 sung, thung khéng dugc ding trong béi cénh cép céru tai théng d6t quy. Ung dung hign tai cia ie ARLES 1 dnb gid tinh trang xoqvtayhigpyiticteialdéngimach -cdnh va dng mach dét sing ngoai so, anh gié duge tinh trang thanh mach, d6 day I6p ndi- trung mae, sy hign dign va tinh chat ming xo vita, céc tn thuong thinh mach Khe nhu béc fogn sin co-sgi, déng thoi dinh gid mite 46 hep dong mach, tinh trang dong chiy trong long mach. Doppler xuyén so chi c6 kha ning danh gid duge tinh trang ding chiy & cée mach mau Ién trong so, khéng nh gid durge tinh trang thinh mach, do 46 duge img dung dé danh gid tinh trang tigchep cdc dng mach Iém trong so, chiéu ding chay, tinh trang bang hé, tinh trang co mach trong xuat huyét du6i nhén, ngodi ra 06 thé dh gid dur tit gin mach va phat hign cdc tin higu vi kip mach, Truée day, Doppler xuyén so o6 thé diing dé hé tro thude tiéu soi huyét dé ting cuong lam tan cdc cuc mau tie cde dng mach Ién (chit yéu 18 dong mach nif git), tuy nhién hign kh6ng edn duge sit dung do higu qui vugt tri cia can thigp lay huyét kh§i eo hoc trong téc dng mach lén. Khao sat tim: ghi dign tim va siéu 4m tim: khio sit tim sé dugc thyc hién 6 tét ca bénh nn 46t quy. Ghi ign tim cho tat ed eée bénh nin, theo dOi ghi holter dign tim dé phat hién cdc r6i loan nhip man tinh hode timg dot, dac bi , 38 iéu Am Doppler tim c6 thé phat hign nhimg bénh tim 6 nguy eo lp mach nio li nguyén nhan gay d6t quy. Trong mét sé trudng hop, ngoai siéu 4m tim qua thinh ngye, 6 thé chi dinh siéu 4m tim qua thye quan dé khdo sat ky tinh trang nhi tri, tiéu ni, vach lién ni, va cung dng mach chi 116Gido trinh Than kinh hoe Cac khdo sat khac: bao gim cic khio sit sinh héa, huyét hoc thug quy, va mot sé khio sit chon loc trong mét sé tinh huéng, nh dign no trong trong hop nghi ngé déng kinh, dich do tity khi cn phan biét nhiém tring thin kinh, hod xuét huyét duéi nhén voi hinh anh CT am tinh, PET, SPECT khi cin dénh gid chuyén héa, tui mau nfo, céc khio sit tinh trang ing dng, cdc khdo sit bénh ly viém mach, tyr mign, di truyén khi ob nghi nga... DOT QUY THIEU MAU (NAO) CUC BO Gt quy thiéu mau (cye bO) xay ra Khi mot_ mach méu bj the do nguyén nhan tai chd (thrombosis) hoc do lap mach (embolism), dan t6i thiéu mai nudi va hoai fir o ving nao do dong mach 46 chju trach nhiém tuéi méu, Co ché bénh sinh thiéu mau cuc b6 Tén thuong thiéu méu cue b6 phu thude vao vi tri dng mach te, mite d6 twin hoan bang hg, va phan nao do kha ning dy tre tuéi méu no cing nhu ste chiu dymg eta m6 nao. Mach mdu nao eé kha ning ty diéu hda, gitt cho Iu Iugng méu ndo khéng thay di di huyét ap ting hay giim, voi diéu kign huyét 4p trung binh con trong khoang tir 70 mmHg dén 150mmHg. Huyét ép trung binh la dp le day mau trén nao, duoc tinh theo céng thire: HATB = 1/3 HA tam thu + 2/3 HA tam trong Sy digu hoa lu Iuong mau nio duge thyc hign thong qua oo ché Bayliss; khi tim bop manh diy mau 1én nfo nhiéu thi céc mach méu nhé nao co lai han ché tuéi mau, Khi 4p lye mau méu lén nio it hon thi mach méu no gin ra dé chira méu nhiéu hon va nhur vay Iuu long méu nfo lun hing dinh & ine 100 ES ITGD Ci hi huyét 4p trung binh 6 ngoai khong giéi han nay, luu Ing mu néo méi thay déi tuyén tinh theo thay doi huyét 4p: huyét 4p trung binh dudi 70mmlHg trong tinh trang s6c, gay thiéu tudi méu no vinng xa, ving ranh gi Khi cao hon 150mmHg, ¢6 thé gay pha vo hang rio miu ndo, gay bénh nao ting huyét 4p. ‘Tic mach do lép mach tir tim thug xay ra 6 ede dng mach én ode céc nhinh lin, trong khi lp mach tir déng mach thu’ng lim tc céc nhdnh dng mach nhé hon, do cue mau tir tim c6 kich thuée Ién hon cue mau tir mang xo’ vita cdc dng mach. Lap mach tir tim cing thuong gay nhdi mau nang hon do mach mau tic trude dé 06 thé dang hoan toan binh thuong nén khong kip phat sinh thém tuin hoan bang hé. Neuoc lai, tic mach do huyét khdi trén nén xo vita déng mach 6 tinh trang hep mach ting dan do xo vita nén thudng cé phat sinh tun hoan bang hé sin, han ché bét mite d6 tén throng thiéu mau. Khi mot dong mach nao bi the nghén, tusi mau nao bj gidm hoge mat di, ving nio do dong 46 cap mau sé ving trung tam v6i lu Iugme méu thép duéi 7100 dong sing té ae ums, am ving xung quanh o6 Iau Iugng ind t (Sing; trong 46 céc 8 bao nao chwa chét, van duy tri hoa , hign mat chite ning trén lam sing (cé trigu chimg). ‘Ving tranh toi hoat dong dién, bi tranh sing chinh fa ving muc tiéu cia diéu tr efp et d6t quy: néu duye ti thong dia méu én nudi kip thdi, hoc dudi tic dung cia mot loai thude ndo dé gitip cho té bao ho hap 7Bai 11: Dot quy duge, cdc té bao nao ving nay sé héi phyc. Ty mite 49 tuéi mau trong ving tranh, t6i tranh sing ma thdi gian séng sot trude khi hoai tir 06 thé tir ‘AENEAN i j trj dot quy phai tién hanh cing s6m cing tét. Thdi gian citu viing nay goi la cita s6 digu tj. Trigu ching lam sang theo vj tri déng mach Nhéi mau khu vue thu6c déng mach canh trong (tuan hoan truée) Nhéi mau d6ng mach nao git#a tin thuong gap trong 80% cdc trutmg hop nhéi mau cia ban cau nio. Tén throng nhanh néi tic cudi doan M1, dau doan M2 hodc mot trong cée nhanh dong mach tuéi mau cl ligt nita ng thuong héi trin Iéu), ri loan cdm gide nia HBtoi Adi ben (do tén thuong thity dinh), wu thé 6 cdm gid tinh vi (tu thé, vj tri, nhan thie a6 vat), ban manh ho&c g6¢ manh déng danh (do tin thuong phan tia thj di gan vo nao thai dong) va ete chire ning cao cap: - Néu ton thong ban cdu wu thé 06 thé €6 r6i loan ngén ngit kiéu Broca (mat van ng6n, ngén ngtt don gidn hoc rdi rac), r6i loan ngén ngit kiéu Wernicke (mat thong su, khong lap lai, néi thao 16%), (mat Xde dinh phai - tréis thtre ngén tay; mat kha nang viét va Lim tod). t6n thuong ban céu khong wu thé c6 thé c6 mat nhan thite co thé nia bén, mat nh§n biét khéng gian nira bén, Tat mia ben cnguer bénh phi Than thite nia ngudi, Hinh 11.4: Nhéi méu ving déng mach ndo gitta bén phai Tén thieong ving sdu (cdc nhénh xuyén): nhimg nhénh xuyén cia déng mach. di 5 ~ fe a iz a trong gay oeGio trinh Than kinh hoe Tén thong déng mach néo gitta toan bé: thuong th 6 nhoi mau dién rong va lam sang bao gid cing nang: ligt nira ngudi ira thuong ban cdu uu thé), bémmanhd6ngdanb, quay dau, quay mit ve bén ton thuong, mat nhdn thite nira ngudi, réi loan y thite, hén mé. - Nhéi méu déng mach néo trude: ligt mot chan hoc tén thuong lan rng gay ligt nita ngudi, chaningng/hon|tayy giam truong lye co, xuat hién phan xa cam nim, hoi chimg thy tran (phan xa cdm ndm mot bén hay hai bén), thio xu huémg dinh hinh, r6i loan hanh vi. Déi khi c6 mét bénh canh bat dng hay cdn goi la chimg TAAigthinkbAEtone ). - Nhéi méu dng mach mang mach truéc: tin thuong dy ligt nira ngudi todn b6 va dong déu, mat cam gide cdc logi nira ngudi, ban manh dng danb, khOng’ed roi loan ngOn ngit. Nhéi mau d6ng mach dét séng - than nén (tudn hoan sau) Déng mach dét sing tudi mau cho, Ong mach than nén tuéi mau cho hanh , ca (dOng mach tiéu ndo true duéi AICA tu6i cho thay nhung nit tiéu no, dng mach tiéu ndo trén SCA tudi cho mit trén tiéu nao). Bgng mach nao sau 06 céc nhénh xuyén tuéi mau ving trung nfo va dai thi, cdc nhénh tn tuéi cho mat trong thiy cham, bd truéc thé chai, mat trong thiy thai duong. - Nhdi mau d6ng mach nao sau © Bén manh ding danh. © Mat kha ning doc khi nhdi mau nfo ban cau wu thé. * Tam thin Id 1&n, quén (hoi chimg Korsakoff). (khong nhgn duge mat ngudi) khi nhdi méu no hai bén: ma vo no (cin phan xa Anh sng). © C6 thé mat cdm gidc nira ngudi d6i bén do tin thuong Gi thi, 06 thé c6 héi chimg Déjerine - Ri - Nhoi mau d6ng mac =) Néu nhdi mau 16n bénh nha Thang 1A lige tirchiyhhonme sau vartie ong! Trong truong hop ton thuong m6t phan thi cé cdc trigu ching sau: hoi chimg thap hai bén, (ligt ter chi, 1iGt VI, ligt day VII hai bén; chijeonlagngitae nhim|én). Néu nhdi mau cde nhanh nudi Cho thin no xudt phat tir dng mach thin nén: - Cudng néo: hoi chimg Weber hay hi chimg Claude (liét day so III bén tin thong, hi chimg tiéu nao d6i bén); - Céu ndo: hii chimg Millard - Gubler; hoi chimg Foville (ligt day so VI, ligt nhin ngang vé bén ton thuong, ligt nia ngudi déi bén); 119Bal 11: Det quy ~ Nhéi mau déng mach at séng: nhbi mau ving bén, sau bén hnh nfo do tén throng nhénh cia d@ng mgeh téwin saurdutis(PICA) thude dng mach d6t sng; Khoi du 6t ng6t, voi chong mit, r6i loan thang bing; c6 thé dau dau phia sau, non, Ae ete) sbillognnuét, khém 6 hoi chiimg Wallenberg v6i dae diém: Bén tén thong: Mat cam giéc dau nhiét nira mat (vain con cim gide si day V), hoi ching (co 16 hei), tn throng day so IX, X (liét nira man hau, hau va day thanh 4m), hdi chimg tiéu no, hdi chimg tién dinh. Déi bén tn thong: Mat cam giée dau nhiét nira than tir cb dn chan, tao nén hoi chimg cam gidc giao bén. Tién lugng thug tét, 06 thé dé lai di chimg 14 hOi chimg Claude-Bernard-Homer, r6i loan cam gid. - Nhéi mau tiéu ndo Bénh canh dot ngOt voi chong mat, nén, hi chimg tigu no, nystagmus. Tén thuong két hop voi nhdi mau no than no sé ¢6 céc hi chtmg than nfo kém theo. Dac diém nhoi mau tiéu nfo thu’mg 1 chén ép eéng nao giy ting ap lye nd: SWichip} c6 thé gay bién chimg , 1a mét cp ctu ngoai khoa cdn dain fer feat oterine Chali Spe aoc i Nguyén nhan nhéi mau nao Bénh mach mau lon Xo vita dng mach (atherosclerosis) c6 thé gay d6t quy, thiéu mau no qua co” ché huyét dong hgc hod tlic mach do huyét khéi. Mang xo vita lam hep dan dudémg kinh dng mach va tham chi bj bit tic, qua trinh nay tién trién chm khoang Co ché huyét dong 1a tinh trang giém luu long sau ché hep, nhdt 14 khi c6 kem theo tinh trang tut huyét 4p, gay tén thuong cfc vi vang ranh gidi. Tic mach cs ‘khéi 1a co ché kc ma hién nay da s6 cdc nha nghién ciru cho ring né cd thé chiém(4a’S6 Yong trudng hop thiéu méu ndo cp. Trén mang xo vita dng mach c6 kha ning xudt hig cdc tén thuong dudi dang loét hod hoai tir, din dén két tap tiéu cau, thu hit cae thinh phin méu, din t6i hinh thanh eye mau déng. MOt minh ela cue méu dong nay (node hiém khi 1a manh cia mang xo vita) 06 thé vo ra, troi doc theo dong mau, gay bit tie mét dng mach nh6 hon 6 xa, goi la lip mach “‘ira@ng mach t6i'dgng mach”. Khi mang xo giy hep nang va cuc huyét hi du Ién lam thc dng mach, gay ra nhdi méu do co ché tic mach tai chd, Vi tri thiéu méu nao cp do tic nghén mach mau 16n thong la dong Gaal du dong mach ndo gita, doan dau d6ng mach cbt séng thannén, hiém gap hon Ong mach nfo trudc (trong so, vong Willis va dgng nach nén [a thurmg bi nhat). 120Gio trinh Than kinh hoc Lép mach néo tir tim Bang 11.1: Cac yéu t6 nguy co gay ldp mach ndo Nhém nguy co lap mach cao: Nhém nguy co'lap mach viea: ~ Van tim nhin tao. ~ Sa van hai ld. ~ Hep van hai lé va rung nbi. ~ Voi héa ving van hai lé. ~ Rung nk, ~ Hep hai Ié khong rung nb. ~ Huyét khdi trong nhi tréi hoc tigu nh, --Vigm: ngi tam mac huyét khéi kh6ng nhiém tring. ~ H6i ching suy nit xoang. ~ Phinh mach vach lién ni. ~ Nhdi méu co tim <4 tuin. = Con bau duc ~ Huyét khdi that trdi. = Cudng nhi. + Bénh co tim dan né. ~ Rung nhi don dc. ~ V6 déng that trai. ~ Dang xody nhi trai, ~ Unbiy nbi trdi. + Suy tim tr huyét, ~ Viém n9i tam mae nhiém tring, — ~ Giim dng that trai, = Nhdi méu co tim > 4 tua. —.—qoiinei MOt so bénh tim c6 thé tao huyét khdi trong buéng tim, manh huyét khdi cé thé tréi theo dong méu lam tic dng mach nao gay d6t quy. Béng mach bj the thuimg la cde déng mach lon nhu dong mach cénliitFOfg) 1 Bila, cdc nhénh 1én va céc nhénh v6 nao, ty kich thuéc cuc mau gay lap mach. Lap mach tir tim cé thé cing Itc lam tic cdc nhénh Ong mach thudc nhiéu géc dng mach khéc nhau, nhu cée nhénh cia d$ng mach cinh hai bén, cic nhanh thudc hé canh va nhénh thudc hé dét séng thin nén,... Nhdi mau no do Tip mach ti tim 1a dang nhdi mau E Cé nhiéu bénh tim 6 kha nang tao cue méu déng gay lap mach ndi chung va lap mach no néi riéng. Mét sO bénh ly thuge nhém nguy co lip mach cao hode trung binh, mét s6 bénh khéc thude nhém nguy co thap hodc chua r6 (Bang 11.1). Trong céc nhém bénh tim gay lép mach, ftangHht 1d bénb Iy quan trong nhit, chid cdc trutmg hop, déng thoi ciing 1a tinh trang 6 nhiéu bing chimg nhat cho vige diéu tri dur phong bing thuéc khang dng. ue trén théng ké hoc ¢6 nm nguyén nha thong thuéng timgay rangi i: Bénh mach vanh Q.~ Bénh tim cao huyét 4p - Bénh co tim - Bah thap tim (rheumatic heart disease) G- Van tim nhan tao Bénh mach mau nhd ‘Ton thuong thudng nim trong s4u ving gian nao hach nén, di thi ia ‘ing gian no hach nén, 46i thi, cau nfo, 14 nhimg ving {uéi méu cia cée dng mach¢xuyéiHinh anh tn thuong do bénh mach mau nhé trén CT 1a nhiing ving ng kinh 121Bai 11: Bot quy kinh Ién nit), Do céc nhénh dng mach xuyén nay nay e6 bang hé ETE pin Haass d gay tén thuong nhéi mau, Céc bénh ly gay t6n thong mach mu nho gom: - Tang huyét 4p, hhuyét ap tam thu>160mmH, | huyét ap tam trong > 9SmmHg lam ting tin sudt nbdi mau nho. Hign tuong nay e5 thé do anh huémg gin tiép cha tinh trang ting huyét 4p téc dng lén tim va nao, dong thoi né lam cho tinh trang xo vita mach nang lén, kha nang hinh thanh huyét khdi ting lén. Bén canh ting huyét ap cn 1am tén thuong mach dudi dang hoai ttr fibrin, thoai ha mé hialin, vi phinh mach. Se oo - Trong nhimg bénh nhin déijtho duémgies;kéthgp taing|huyétiép nhdi méu GM cong ht taveng vip. Nhbi mault6knuyét la dang lim sing thudng gp (10-15%), do eéc nhénh dong. mach tn, xuyén trong sdu bj tc nghén hofc gidm liu lugng méu nudi do ling dong fibrin thanh mach, thodi hoa mé hyalin xo" vita mach hoe huyét Khoi i (Gi nhoi mau khu vue mach méu cung cdip, Lim sing cia nhdi méu 16 dot quy van dong dom thud nia ngudi kem that diéu ja sit tri Bénh huyét hoc Nhiing bat thug thanh phan té bao mau va protein huyét tong 06 thé din dén tinh trang. tng dong hoe giém dong déu lam thay déi 49 nhot cia mau va két tap tiéu cau. Nhig r6i Joan té bio mau va protein thuéng gip trong céc bénh: - Tang hing cau nguyén phat hay thir phat (polycythemia) - Bénh ting tiéu cdu (thrombocythemia) ~ Ban xuét huyét gidm tiéu cdu kém huyét khdi (thrombotic thrombocytopenic purpura) Bénh té bao liém (sickle-cell disease) Réi loan protein huyét (dysproteinemia); macroglobulin mau, cryoglobuline mau, dautiy H6i chimg khdng thé khéng phospholipid: khéng déng lupus, khang thé khang cardiolipin, hoi chimg Sneddon lién quan én thiéu hyt protein C - Bénh bach cdu (leukemia) - Dong méu ndi mach lan toa Huyét khéi finh mach nao eh pea nh6m nguyén nhén gay ra nhdi mau do huyét . Lam sang thutmg 06 ag ng ho&e MRI(nén chon) thudng i g duge phan loai dua theo %o via dong re von, Lap mach tir tim, Tae déng mach Ric va Khéng xac dinh nguyén if Oe 11.2).Gio wrinh Than kinh hoe Bang 11.2: Phan logi nguyén nhiin nhéi mau ndo theo TOAST Xoviradgng Thuyén Tic dng —Nguyén echo mach Ién tictirtim mgch hd nhan khéc Lam sing ~ RL chite nang vé nfo hoc tiéu nao. + re . Te ~ Hi chimg 15 khuyét. 4 = + +- Hinh anh hoe - Nhdi mu nfo vé no, tiéu nfo, than nao, + e 3 if du6i vo > 1,5cm. - Nhdi méu nfo duéi v6, thn ndo < 1,5cm. - = 4 + Céin lim sang Khe - Hep dng mach canh trong dogn ngoai so + - : ~ Ngudn thuyén tic tir tim 2 + “ . - Bat thudng khéc zi _ 3 + XUAT HUYET TRONG NAO ut huyét trong no, xy ra khi méu thoat khdi thanh mach vio nu. . Danh tir xudt huyét nio va mau ty (hematoma) vé mit gif phiu bénh Khong Khée nhau. Céc nha ngosi khoa thurng ding tir mau ty hon khi xem xét diéu tr] phdu thuét. Nguyén nhan Xuét huyét nao do tang huyét 4p: ting huyét 4p 14 nguyén nhén hang @awcia xudt huyét nao, Co ché xuat huyét nao do ting huyét 4p hién nay duge rit ra tir cdc nghién ctru cia Fishers va cng sir vio nhimg nim cia thip ky 1960, 1970. Ting huyét 4p téc dng dén céc dong 6 ca cho tn Cc ton thuong dong mach xuyén do ting yalinosis, va cudi cing hinh thanh Hinh 11.5: Chay mau ving doi thi va mau lan vao ndo that trén bénh nhan cao huyét dp 123Bai 11: DOtquy Xuét huyét nao ving sau 6 bénh nhén 6 ting huyét 4p chua dij dé khing dinh ting huyé 4p 14 nguyén nhfn. Can dénh gid céc tin thuong mach mau nhé khic lién quan ting huyét ap: (leukoaraiosis — bénh chat tring dudi vé do mach méu nhd), nhoi mau i iéu kh6ng hién dién cdc tén thuong nay, xem xét ca thém nguyén nhin khéc, dc biét la ving sau, Xudt huyét néo do bénh mach méu nao dang bét (CAA - Cerebral Amyloid’ Angiopathy): day cing 14 nguyén nhén phé bién cia xudt huyét nao, ‘Xuét huyét nao lién quan bénh mach méu dang bot 1A do vo cde d6ng mach bj tii amyloid, do ling dong protein amyloid 6 lop trung va ngoat mac cia cfc dong mach nao ch thude & . Vj fe fon thuong thuong naim 6 rath gidi Bilka chat xdmiva gay ra xudithhuyét nao thay. ‘Tiéu chun Boston duoc sir dung nhim phan logi xudt huyét nao la hung én (possible) hose gin chic (probable) do bénh mach mau nio dang bét et Mét yéu t6 quan trong nat trong tiéu chun nay 1a kiéu xuét huyét trén hinh anh hoc} xuat huyét nao thiy, vé nao, ranh gi6i vO - dudi v6 1a goi ¥ bénh mach mau dang bat. Mét huyét nhur vay 1a tie é hung dén CAA, hai hodc nhiéu 6 1a tiéu chudn cho chan don an chic CAA. Xudtlhuyét ANTi€u chudin Boston tuy c6 d9 dic Higa cancun 9 nhay va gid tr tién dodn am thap, do dé can duge sir dung linh déng trén lm sang, déng thoi cn phéi hgp véi cdc khao sat khadc tim nguyén nhan, C4c nguyén nhan khac - V@dj dang mach mau no: dj dang dong tinh mach (AVM) ni, 1 déng tinh mach, u mach hang. - Nhdi mau nfo chuyén dang xudt huyét: nhdi mau dign rng, nhdi mau nao do lip mach tir tim. ~ Hoi chimg co mach nfo 06 hi phe. - Bénh Moyamoya. Nhéi mau no xuat huyét do huyét khéi finh mach ndi so. Réi loan déng mau va ding thudc khéng déng. - Unio xuat huyét. Viém mach. Chan thuong dau: c6 thé gy tu méu ngoai mang cimg, dap néo va xuét huyét trong nhu mé nao. Trigu chieng lm sang theo vj tri xudt huyét Xuét huyét bao trong - nhan du: la thé thiedng gap ahd trong xudt huyét néo, c6 dic diém: Nguisi l6n > 50 tudi, ting huyét dp, khi dau d6t ng6t va thug liét nira hodn t w. ‘Truong hyp xuat huyét Ién thug gay hén mé nhanh, quay dau, quay mat ve bén ton thuong (1 ). 124Giéo trinh Than kinh hoe Xuat huyét di thj: thuing ligt nia ngudi 46i bén tén thuong, mét cm gide nita ngudi 46i_bén tn thuong (06 thé chi od" mst hoke mat em gide sau, dau). Truong hop xukt huyét nhigueo thé gay mat 4 hén mé sau. Mét sé bat thuéng khdc 06 thé xuat hign hu hi chimg CDE (@éng tir co nhé kém hep khe mi va giim tit md Oi nita mt), 06 thé c6 miia gidt, miia von 6 ngon chi. Xudt huyét nao thy: trigu chimg ahiteWapla trigu chimg thudng gap; 6 xudt huyét 6 ving hi lu dinh-théi duong-chim: thug tan, hiém khuyét van dong va cdm gide; bén manh dng danh; thét ngOn kiéu Wemicke (bén cau uu thé); mat nhén thire nia nguéi. © xuat huyét ving trin: ligt mhe nia nguisi va cae trigu chimg tam than, dng kin, phan xq cm nimi((@raspiig). O xudt huyét viing chim: bén manh déng danb, mat nan thite thi gide. Xuat huyét cau nao: Truong hop xudt huyét nhigu gay tn thuong toan b6 cdu nao: khoi dau d6t ng6t biing hon mé, liét tir chi, co ding tirh: tién trién tir vong. Thé khu tri géy h6i chimg/MillardGuble? voi lid eanphiatiog< Doi Khi c6 hoi chimg Foville véi ligt nira ngudi dbi bén tn wong, ligt van nhan ngang vé phia tin thong, quay mat, quay dau vé bén déi dién tin thuong (tite la nhin vé bén ligt cia ngudi bénh), Xudt huyét trung néo: hoi chimg Weber:_ligt diy II cing bén tn thuong; ligt nia ngubi di bén tn thuong, Hi chimg Parinaud: mét chite ning nhin lén; mat chire ning hoi ty niin cau; ngi nhiéu. Néu chay mau cudng tiéu ndo trén bénh nhan o6 trigu chimg tiéu nao kém theo. Xudt huyét tiéu nao: Loai xuat huyét nay hiém gp nhung néu phat bign sém va diu tr) bing phiu thuat sé han ché tir vong. © xuat huyét & 16 06 thé lam tut hanh nhan tiéu niio vaio 16 chin ee dot ng6t nhung lic dau khong hon mé hose C . C6 cdc dau higu lam sng ciia hdi i chimg tiéu nfo; céc dat higu cia thin no (liét day i Vihojc day VID); ligt nhe nia ngudi, Babinski (+) bén liét. Mét bénh cénh Jam sang ting ap? cae ee XUAT HUYET KHOANG DU‘! NHEN (XHDN) Xuat huyét trong so chiém khong 15% cdc trutng hgp dot quy, trong 46 10% xudt huyét ‘rong nhu mo (xuait huyét nfo) va 5% XHDN. XHDN dupe chia thinh cde nhém: do v6 tii phinh dng mach vi Khong do v6 ti phinh dna mach. mine ae see Ate yaa a sat iso © 4 9 du Wn O8tquy — Sbxtt ca auper 125Bai 11: Bot quy I Hinh 11.6: Hinh anh xudt huyét vao khoang diet nhén va ndo that Phan d6 xudt huyét doi nhén XHDN lA mét bién oi mach mau xay ra dt ngot. Viée djéu tri phd hop ty, thude vao mito i ning cia XHDN aa yan nn fot tS nhiig yéu td tién lugng quan trong hign nay. Thang diém GCS (Glasgow Coma Scale) Mac di thang GCS Khéng duoc ding 48 danh gid mire 49 cia XHDN, nhung né 1a mot thang thuong diing 48 danh gié mite 46 thik Thang diém GCS dénh gid ba yéu td: mit (B), ldi ndi (V) va van dong (M). Diém GCS cing cao thi két qua sau phi thudt cAng tot. Thang diém Hunt and Hess Bing 11.3: Thang aiém Hunt and Hess phan dg-XHDN DO ‘Trang thai thin kin Khéng trigu chimg hoge dau dau nhe va cimg gay nhe Dau dau nhiéu, cimg gay, 06 thé ligt day so Ngo ga hoi It lin nhe, c6 dau yéu ligt nhe Lo mo, liét nita ngudi.r6 (vita dén nang) Hon mé, ti wnRone Diém sé tiiglénmotmiedo néu bénh nhan co thém bénh ly hé thong nghiém trong (ting huyét dp, dai thao dudng, xo vita dong mach nng, bénh phOi man tinh) hoge 6 bién chimg, ‘én hinh anh mach mau nao, 126Glo trinh Thin kinh hoc Thang diém ph4n d6 XHDN cua WFNS (Lién doan Phau thuat Than kinh Thé gidi) Bang 11.4: Thang diém WFNS phan dé XHDN Mite d6 GCS Ligt van dng 1 15 Khong 2 13-14 Khong 3 aD co 4 7-12 C6 hoe Khong 5 3-6 C6 ho&c khong Dac diém lam sang V6 mach mau lam chay mau vao khoang duéi nhén chira dich nfo tiy giv it ddi va ting dp lye ngi so. - Dau diu 6i “chia timg gap trong déi bao gid”. Doi khi c6 thé dau dt > C6 thé kim Jo mo, budn di, 61. ~ CRETE, nto thing xiy Kha sa mae vi git (0th gan chuydn 30-50% bénh nhan o6 thé oé dau dau kiéu XHDN nhiéu con trude khi c6 con dit d6i 6-20 ngay (daiuldai eae — déu higu canh bdo dang ri mau). Cée dau higu than kinh khu tribiém gap, néu c6 sé goi y vj tri tii phinh vor yéu hai chan va tiéu khé (tii phinh dng mach thong trudc), ligt III (tai phinh déng mach théng sau), yéu nira ngudi (tii phinh dng mach nfo gitta trong khe Syivius),... - Métsé XHDN nang, c6 thé 06 xudt huyét duéi dich kich ch kich vong mac (thay trén soi day mit) (H6i chimg Tensor: tién lugng ming). Chan doan xuat huyét dui nhén am sing: dau dau nhw sét dénh, ri loan thitc tinh (tir nhe dén ning), budn 6i va 6i, dau kich thich mang nfo, xudt huyét dich kinh véng mac. ~ én lam sang chin don xéc dinh: CT!Seannao khong Gin qulafig, choc dé dich nfo tiy (néu cn), MRI nao (néu edn). © CT Scan nfo khéng can quang: 92%. fring bop XHDN of CT (+) vi hah anh Phan bé mau trén CT Scan ggi y nhi pts ingens anne, ngoai trir ving ng mach nfo truée, thong true mé nio. 6 nhay phat hién XHDN cia CT Scan cao nhdt cong 2G Bea (gin 100%), sau d6,gidm dan, BO nhay thép hon khi XHDN luong it. 127Bai 14: Dot quy Dich nao tay mau Wanigicon gap trong ting protein/dich nao tiy, tang bilirubin/dich nao tuy, cham mach gay chay méu nhiéu cia nhitn; trudc 15%) trong chan doan XHDN. Co ché: té bao méu bj chuyén héa sang oxyhemoglobipe > methemoglobine > bilirubine. Bilirubin trong dich nao tay hign dién(Salill2 gi6} dat dinh diém 48 aid va 06 thé kéo dai dén 4 tuan. © MRI nfo: xung Proton density va Flair o6 thé thdy hinh anh XHDN giai doan cp; xung Flair va T2 cé thé thay XHDN giai doan ban cdp (sau chay méu_> 4 ngay). Xéc dinh nguyén nhan M@t khi chin dodn XHDN 4a xéc dinh, cin phai tién hinh khao sét mach méu nao dé tim nguyén nhin, ¢6 thé ding ‘CT mach méu (CTA) hofc MRI mach mau, nhumg chyp mach nao can quang ky thudt sO x6a AéflDSAMAa khao sat 06 gid tH cao tr] cao nhat trong chan dodn tai phinh dng mach. Néu mach nfio 4} khong thdy trong Lin dau, xem xét lam lai saumaelangay. Khoing (@ 22% XHDN khong o6 tii phinh dng mach, Truimg hop hd ning phét hign tii phinh thép vi phimeninjgaye? DSA hay CT/MRI angiography CTA vi MRA 1a hai ky thuft chup khéng xém pham. Ky thugt CTA ngiy cing phat trién, 6 thé tai phinki3=5mm, 49 chinh xdc ngay cang ti DSA. CTA dé thy hién hon va 06 phan chinh xéc hon MRA, nhat Ja trong giai 4 Sars Te DSA Ia tiéu chudn vang trong chan dodn tai phinh d6n; 1, cho thiy hinh anh mach mau 6 nhiéu huémg, trink chong hinh mach méu, nhét la voi DSA ba chiéu. Tuy nhién, day 1a ky thuat xm Kin, di ti 1é tir vong cia bénh nhiin XHDN khi dang chyp DSA rit thép. ‘Thong thong chyp DSA sé di kém can tip logi bo ti phinh tron mot lin néu 06 thé duge, mot s6 trubng hgp dc tinh tii phinh Khong cho phép can thigp, hodic cn thém mot s6 dénh sid thém trade Khi can thigp thi s& dimg Iai 6 chup chin dodn, sau 46 sé lam Lin hai dé can thigp hodc chuyén sang phau thuat. Dé c6 thé chi dng lén ké hogch trude khi chup DSA (xn Tn, cid lupe Hi tung nt a hp CTA neay lic ehup CT ni xe inh xt usd ial Néu CTA inh, cdc ie Pl ic chup DSA kém can thiép noi mach chung mt thi, hoc chuyén sang phd thuét, 128Gio trinh Than kinh hoc XHDN do vé tai phinh déng mach Hinh 11.7: Hinh anh tii phinh ding mach néo truéc trén DSA La nguyén nhan thuong gap nhat cla XHDN. Phin Ién xay ra 6 40-60 tudi. M6t sé trong hop cé thé tré hon va gid hon.Bai 11: Bot quy, Hinh 11.9: Hinh anh tii phinh d6ng mach théng true trén CTA Yéu t6 nguy co” Tang huyét dp: 1a yéu t6 nguy co chinh cia XHDN. Hit thudc 1d: hut thuéc 14 lam ting nguy co XHDN gi 5 lan so véi nhém khong hist thude 1 Nguy co gidm nhanh kh ngumg hit thude, g rugu: udng rugu mite 46 trung binh dén ning lam tng nguy eo XHDN Yéu t6 di truyén: nguy co XHDN ting teén nhém bénh nhin than da nang, chimg ting aldosterol dap ting corticosterosis (glucocorticoid-remediable aldosteronisin) vit hoi chimg Ehier Danlos. ‘Ngudi cé tién cain gia dinh XHDN nguy co ting gap 4 lan. Céic thudc uréng giao cam: thanh phan phenylpropanolamine trong int 86 thudc cam 06 thé lam tang nguy co XHDN cia phy ntt. Thiéu estrogen: ty ie nit bi XHDN trdi hon nam (54-61%). Nir sau man kinh bi nhiéu hon: tnréc man kinh. Diéu trj estrogen thay thé sau man kinh lam giém nguy co XHDN. Bién chieng xuat huyét duoi nhén do vé tui phinh TY Ie tir vong cia XHDN do v6 tii phinh rit cao, trung vin(Si29) Cée bién ching gép phan tir vong cia XHDN do v6 ti phinh bao gom: Cac yéu t8 thuc tai phinh lén, - Chay méu tré Iai: phan lon trong 3 ngay dau, cao nhat trot nguy co chay mau tré lai bao gom{diém Hunt ‘and Hess huyét ép nhdp vign cao, c6 nhiéu Tot dau 130Gio trinh Than kin hoe ~ Co theit déng mach: o6 thé xay ra tir ngay thir 3, thudng gap nhét é ngay thir 7 hode 8. Du higu ghi nhan 1a xudt hign déwithanikinhidihilvi. Mire €} nang tay thude vao mie d§ co thit va mach méu anh huéng. Phat hign bing aeshensawins khi 06 biGu ign lam sang) hoa thay d méu nao khéng cén ximg). - Nh6i mau ndo: 06 thé gip nhbi mau vé nao don thuan hode nhdi méu nhigu 6, do bién chimg co mach hodc huyét khéi sau phdu thuat tii phinh dng mach. Nao ting thiy: hay xay ra 6 xudt huyét nao that, tii phinh tuin hoan sau va ngudi lén tudi. S22 eae Ting dp luc néi so. Co gidit: co gidt lic khdi bénh la yéu t6 nguy co cao cia co git sau nay va 1a yéu t5 tién Iuong kém. Cn chi y céc sang throng khu tri di kém 6 ngudi XHDN c6 co giat ‘ahi nhdi méu néo, tu mau dudi mang cimg. Ha natri mau: a bién ching thudng gap cia XHDN, cé thé lién quan voi tnlthuene, OR ng ch hop. Bat thaeing tim mach: thay 6i trén ECG nh StitecOT to eT SENT, ‘muEHIGAISOAEU? 20% c6 thiéu méu du6i ndi mac (thay 4éi trén men tim va ECG). Tang troponin cp sau XHDN di kém véi ting nguy eo cia bién chimg tim phdi va mach méu ndo nhur giém chite nang that tréi, phd phi, nhdi méu no do co mach. Tién lwong Bén canh céc nguyén nhin bang dp lye ngi si XHDN giy tir vong 10% truée nhap vign. Chi 1/3 06 két qua tét sau diéu tri. Tién lugng ign quan cée yéu t6: - Mite 49 hén mé va khiém khuyét than kinh lic nhfip vign = Tuéi (cang lén tudi cang xdu) - Luong mu trén CT Scan no dau tién - Ngoai ra dung huyét ting cao cing lién quan v6i két oye xdu thi 5 ih nhdi méu nfo, nao ing phan I6n bénh nhan tir vong giai doan cp do Xuat huyét du6i nhén khéng do vé tii phinh déng mach Khoding 15-20% truomg hop XHDN khéng sang thuong mach mau trén Khao sat bén hé mach nao. Nguyén nhan va co ché van chua difoc r6 ring. Nguyén nhan ~ XHDN quank trung néio khéng e6 tii phinh dong mach: vo dong mach xuyén do ting huyét dp, vo tinh mach, béc téch dng mach than nén, ~ Titi phinh mit: dén 24% truimg hop XHDN cé két qua mach nao 48 4m tinh trong lin 131Bai 11: Botquy chyp dau tién, nguyén nhin c6 thé do tai phinh 48 vo bi tao tap int kd tong ng ih Do 46, can chy INT viing true ma két qua lin du 4m tinh, Di dang ré déng-tinh mach trong néo va trong tity séng: xuat huyét trong nhu mé va tran vao khoang dudi nhén. Béc tich dong mach trong so. = Clic nguyén nhén khéc: huyét khéi tinh mich no, bénh héng cdu hinh liém, r6i loan dng méu hog ding thude khéng déng, xuat huyét trong tuyén yén, XHDN do chin thuong, nguési nghién cocain, tii phinh cia dng mach tly sing, bénh Moyamoya. Chan don = Buéc 1: Chin doa ob XHDN (lim sing dt ngot dau dau dit doi, du ming nfo, ting 4p luc ndi so; CT Scan thay xudt huyét khoang duéi nhén, néu khéng 16 s€ choc dd dich nao tay, m6t s6 trudng hop ae Buée 2: Khao sit mach méu: cé thé Ip lai ¢én(@AAnéW KHONG thay tHilphinh. Nén cliyp CTA iig lie ngay kilCD/Sean sc dinh xuat huyét dudi nhén; trong trong hop kh6ng thay tii phinh hoc khéng thay hét dic diém tii phinh sé étip!DSA'Sau 46. Trudng hop DSAVani tinh C6/the lap lai Sauld6 4214 iigay. = Bude 3: MRU€6 thé phi hign tdi phinh mo hogc huyét kh6i trong than mach eta céc trong hop béc tach dng mach. Cé tae gia dé nghj cdc trrong hop XHDN khéng thay tai phinh dng mach can duge chyp MRI nio va tiy séng c6 Gadolinium. ii, do co mach, hokc do Bién ching C6 thé gap cdc bién chimg nhu trong XHDN do v6 tai phinh, nhung ty 1¢ thép. CHAN DOAN BOT QUY ‘Trude mot bénh canh 46t quy, tién hinh thir ty theo cdc buée: ~ Xtc dinh day la dt quy? Bénh xay ra d6t ng6t (gidy-phuit-gid) v6i cdc khiém khuyét thin kinh khu tro? - Day 1d xuit huyét nfo hay thiéu méu nfo? Goi ¥ lm sing trong bang 11.5. Xéc dinh chin don bit bude phai (CT Scan ho§c MRI nao). = Néu li xudt huyét no, thi xudt huyét 6 dau va do nguyén nhan nao? (Xem phin Xudt huyét néio). algae GON aT = Néu la nhdi mau nfo thi 6 dng mach nao va co ché bén dudi la gi? (Xem phiin Thiéu méu cuc b6). Lae, Ree Chin dodn dot quy di tién va phin 16n 1a dia vao Laga sing: khéi ‘bénlilGOEnBOt voi cdc 1a hai yéu t6 then vaste anh dot ngét can duge xde ir ngudi bénh, ngudi nha, hoje ngudsi chimg kién, tot nh 1a c6 mét béi cdnh duge mé ta 0 ring thé hién mét diém moc chuyén 46i gitta trang thai 132Gio trinh Than kinh hoc binh thuong trude dé sang trang thai cé trigu chimg, vi dy flang dn roi dila, khong dura tay én duge nita. Khiém khuyét than kinh cing khu tra va cing khach quan cang t6t. Yéu liét chi mt bén, ligt mat (méo migng), r6i loan 161 n6i (ndi 46, ndi khong 16 khdng hiéu 10i,...), nhin d6i (ligt van nhan), ban manh déng danh, that diéw__[la nhimg khiém Khuyét khu tra va khéch quan, 6 gid tri chin dodn cao. Céc than phién(@au dau, chéng mit, choang ving, mé mit chung chung, té ran, mét, lir dir,..) khong khu tri 1 va khé xde dinh ban chat, la céc biéu hién it c6 gid tri khing dinh dét quy. Bang 11.5: Phan bit nhoi méu ndo va xudt huyét nao trén lim sing Dic tinh ‘Xuat huyét nao Nhoi mau nao Khoi phat Dot ng6t, sau doemngithEM Dor ngot, nhanh = +++ (rit nhanh) - + (lp mach) - Hiém é - Hiém Triéu chimg khoi dau - Dau dau - Thudng gip - Cé thé gap do tim - Non di DP - Thuing gap - Hiém gap ~ Giim y thi - 50% : - 15-30% Khi bénh canh lém sing d§t ngOt voi khiém Khuyét than kinh khu tra 16 thi chdn doan kha chic chiin, chi cn chan dodn phan biét véi céc trang théi gidng dét quy, bao g6 kinh véi ligt sau con, Migraine ligt nita ngudi, chin thyong so nao vi m6t sO it truéng hop can duge chon lic nay, trong béi canh cap citu, | thay nhimg tn thuong ahdi mau rong sém 6 Trong truéng khoi phat khong d6t ng6t 13, hodc bigucsién tnd khong 16, ae don dot quy lim sing chi 6 mite ghi ned) bigt. Hai trudng hyp nay nhat thiét phai chi dinh ch chan doan phan biét. DIEU TR] DOT QUY D6t quy 14 bénh de doa sé déin dén tinh trang tir vong hoe mot sy tin phé tram trong ca vé tinh than ln thé chat cita ngudi bénh. Cac thinh qua khoa hoc vugt bac trong va ky qua 43 mang lai cho ngudi bénh 46t quy co hdi vang dé hdi phyc ngoan mu, trénh tir vong va tin phé, Cac phuong phap ep eitu va digu tj d6t quy da duge ching minh va mang lai higu qua thye té cho ngudi bénh d6t quy bao gém: chim séc diéu tr) trong don vi dét quy, ding thuéc tiéu soi huyét duémg tinh mach va can thiép ly huyét khoi co hoc cho ngudi bénh d6t quy thiéu mau niio cap. iém khuyét than kinh khu i nhiéu chn doan phan xéc dinh chin dodn va 133Bai 11: Dot quy. DIEU TRI DOT QUY THIEU MAU CYC BO Diéu trj tai th6ng giai doan téi cép M6 niio thiéu méu cyc b6 theo thi gian s€ chuyén tir dang thiéu mau c6 hdi phe (ving tranh t6i tranh sang) sang hoai tir (16i nhéi mau). Didu tr) higu qua nhdt trong giai doan nay phat t6i ti théng cing léu, m6 nao hoai tir (nhéi mau) cing nhiéu. Do 46 can thiét phai chgn Iya ding bénh nhin ding thii phai dam bao thoi gian tdi théng cng sém cng tot. Diu trj tdi théng cdn duge thye hign tai bénh vign c6 don vi d6t quy, 06 461 ngii nhan vién y t6 da duge hudn luyén chuyén sau vé d6t quy va c6 quy trinh phdi hop day dit va r6 rang. - Chan doan d6t quy: bénh canh lam sang d6t ng6t xay ra khiém khuyét than kinh Khu tra. X.éc djnh la thoi gian Khoi phét d6t quy; néu khong r6 thoi diém Khoi phat (vi dy khoi phat lic thire day), can xée dinh thai diém cudi cing ma bénh nhin duge thay cdn binh thug va thi diém phat hign trigu chimg. Danh gid bing khém lim sang, dinh Iuong héa bing thang diém dot quy NIH National Institute of Health Stroke Scale). - Lép tire ch mach mau nfo) (néu bénh nhin én trong 6 tir khi khdi phat) dé logijtinxudtlhuyétva lotthay khong. - Quyét dinh diéu trj tiéu soi huyét dung tinh mach bing thudc alteplase (1a rtPA - recombinant Tissue-type Plasminogen Activator) di véi bénh nhan dén trong cita s6. 4,5 gid va khong cé-chéng chi dinh. Quyét dinh can thigp ni mach ly huyét khdi bling dung cu co hoc (mechanical thrombectomy) ¢6i voi bénh nhan dén irong cita sé 6 gid va cé tic dong machi (d@ng mach canh trong, déng mach nao gitta doan M1.,...). Quyét dinh duge thy hién ngay sau khi chyp CT, CTA, bat ké bénh nhfin c6 duge i sqi huyét hay khéng va khéng ché doi hoan tat hay dinh gid hiéu qua ciia thudc tiéw soi huyét. ‘Thuéc tiéu sgi huyét tinh mach alteplase: ~ Liu chudn 0omghkg cfin’ihing, liéu t6ida 90mg} ding 10% bolus tinh mach, 90% én lai truyén trong 60 phit. Liéu thap 0,6mg/kg (15% bolus tinh mach, 85% cn lat truyén tinh mach trong 60 phi) o6 higu qua khong bing nung it xuat huyét hon lida chuan, thudng duge chi dinh khi ngudi bénh cé nhiéu nguy co xudt huyét. Gip ting co héi hi phuc vé binh thudmg hoac gin binh thudng (diém mRS tir 0-1) & thdi diém 90 ngay tir 26 lén 39% néu thuc hién trong vong 3 gid tir khi khéi phat 468 quy (nghién ciu NINDS), va vin c6 higu qua khi thyc hign trong vong 4,5 gid! (nghién itu ECASS 3). 134Giéo trinh Than kinh hoe ~ Dieu tj iG SoH UEE EA Whe Hid Clng Som Ging Wr, kétcuc lién quan true tip én thoi gian tir khi khoi phat trigu chimg dén khi bit ddu diéu tri tigu soi huyét. Nguy co khi diéu trj rtPA 1a xudt huyét, tuy nhién, nguy co xudt huyét nao trong cira s6 diéu trj la rat thép, uéc lung Number needed to Harm (NN) la 126. - Chong@chidinhitPAlbao gdm: (1) Tién cin chin thuong dau nang hoge dét quy trong vong 3 thang; (2) trigu chimg ggi ¥ xudt huyét duéi nhén; (3) tha thuat choc dong mach 6 ving khong chén ép; (4) xuat huyét nao truée 46; (5) Khoi u trong so ho8e di dang dong tinh mach; (6) phd thugt so nao hogc edt séng gin day; (7) dang xudt huyét ndi hoa cé nguy co xudt huyét trén xét nghiém (tiéu cdu <100000, ding heparin v6i aPTT ting, INR>1.7, dang sir dung thudc khang déng tre ché thrombin hay te ché yéu t6 Xa); (8) Duong huyét < SOmg/dl; (9) nhdi mau nao lén da 13 tren CT Scan; (10) huyét 4p tam thu trén 185mmHg hodc huyét 4p tam truong trén 110mmHg (Néu gidm duge huyét ap duéi 185/110mmHg trong cita s6 cho phép thi van c6 thé diéu tr rtPA). Cac chéng chi dinh tuong 44i bao gdm dt quy nhe, con dong kinh lic kh6i phét dot quy, thai ky, phdu thuat Ion trong 14 ngay truée dé, xuait huyét tiéu hoa hoc xudt huyét dudmg tiét nigu trong 21 ngay truée dé va nhdi mau co tim trong 3 thing, (Can thiép n6i mach ldy huyét khdi bing dung cu eo hoc (mechanical thrombectomy): ~ Higu qua cia can thigp n6i mach léy huyét khéi bing dung cu da duge chimg minh qua m6t loat nghién cir cng b6 nam 2014 - 2015, nhu nghién cia MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, REVASCAT. Ciéc thir nghiém 46i chimg, ngdu nhién nay da xdc dinh hiéu qua cia phuong phap diéu trj lay huyét khdi bing dung cy co hoc, gitp ting ty 1¢ hoi phuc khong 1é thude vé mat chite ning 6 thoi diém 90 ngay cho ede trudng hop dt quy do tic céc dong mach Ién, so v6i dieu tr tiéu sgi huyét don thudn. ~ Chi dinh: d6t quy thiéu mau cyc b6 do te mach mau én ), ding A thyc hign trong ving 6 gid tir Khi Khoi phat trigu chimg dot quy. San thigp lay huyét khéi trong cira sé merngng (6224 B89 - Due ding cho cdc bénh nhan d9t quy khi thire da én saudn sau 6 gids cho dén 24 gids sau khoi phat. rs ~ C6 tie d6ng mach lon & vj tri can thigp duge. ~ C6 bing chtmg cho thay con ving tranh 161 tranh sing (ving thiéu mau e6 hdi phyc) J6n, trong khi 10i nhdi mau (ving hoai tir, khéng hdi phyc va 1a nguén géc gay bién chimg) khong Ién. Kich thude ving tranh tdi tranh sing va ving di nhdi mau phi duge dinh gia bing mot trong hai céch: (1) So sénh 49 ning lm sing (dai dign cho toan b> ving thiéu mau cuc b6) véi loi nhdi méu trén hinh anh MRI khuéch tan (DWI) hoke CT tui mau (goi 1a bat tuong hop lam sing - hinh anh), hoc (2) So sinh bat tuong hop gitta toan bé ving thiéu mau cuc b6 (bao gém ving tranh téi tranh sing va 16i nhdi méu) trén MRI tudi mau hoe CT tuéi méu véi ving 16i nhdi méu trén MRI khuéch tan hoc CT tuéi mau. 135Bai 11: Bot quy Chim séc diéu tri giai dogn cdp: bgnh nhan dpt quy da nhp vign ‘TAt cd cdc bénh nhan dot quy can duge diéu tri trong don vi d9t quy. Didu trj trong don vj d6t quy 4% duge chimg minh gidp cai thign két cuc nhiy phye hoi chite ning s6m va phing ngira cc bién chimg ndi khoa, giip giam tin phé, giam bién chimg, gidm thoi gian nim vign, gidm tir vong, ting kha ning tro vé cudc song d6c lap. Cham séc bénh nhan d6t quy sau diéu trj tai théng Bénh nhan éidu tri tiéu soi huyét durvmg tinh mach cn duge theo déi sit dé phong dién tién va bién chimg, Céc bién chimg cé thé gip gdm: phii Quinck va phan vé, xudt huyét ni so va xudt huyét noi khdc, Do 46, can luu ¥ va theo doi nhu sau: = Khéng cho an, khong dat sonde (trir khi bit budc), khong ding thudc chéng tiéu cau, Khdng dong trong ving 24 gid. ~ Phat hién ngay tinh trang nhc @at Buda én, nén'6i, huyét dp ting cao, rOi loamy thie, khiém khuyét thn kinh nang them. = Gir huyét ép180/0SmmHg, ting Nicardipine tinh mach néu cin. nine tinh mach n€ Bang 11.6: Theo dai sinh hiéu, 9 thike va khiém khuyét than kinh ‘Thoi gian Sinh hiéu, ¥ thire Dau thin kinh Gig dau (60 phut truyén rtPA): moi 15 phut Mi 15 phit Méi 15 phit Git thir 2 MGi 15 phit MBi 30 phi 6 gid ké (gid thir ba dén hét gid thir 8): méi 30 MOi 30 phut Moi gid. phat Tir gids thir 9 dén hét 24 gid: méi gid M6i gi M6i 2 gia fe ee Cham séc tich cyre déi voi nguréi bénh d6t quy cp Theo déi tim va sinh higu: bénh nhén dot quy méi can duge theo doi monitor dign tim va cdc théng s6 khéc 48-72 gid, it nhat 24 gid. Dot quy cb thé gay ra bién adi tryc ti tim va chite nang co tim ma khéng lién quan dén thiéu mau co tim. xay ra tir 25-40% bénh nhén d6t quy cép, khir cyc bat thuémg xay ra 20% bénh nhan mau no cp va 60% bénh nhan xuat huyét trong so. Monitor cling gitip phat hign rung nhi, ac biét 1a rung nhi con, huéng dén xéc dinh cin nguyén lap mach tir tim gay dt quy. Céic thong sé hé hap, tin s6 tim, huyét dp, SpO> ciing rat can thiét trong giai doan cp, nham hd trg kiém sodt huyét dp t6t, phat hién céc bién chimg ho hap vi Ce ap Iyc n6i so) 4é xit tri kip thoi. Cham séc duréng thé: Dim bao duéng thé thong suét la wu tién hing dau trong chim s6c bénh nhan suy gidm ¥ thre hoc bat ky bénh nhan nao 06 cic biéu hién vé van dé ho hap nhu: thé néng, thé ngit quing, thé ging site, Cac nguyén nin ciia sur can tro dudng thd 1A do thay déi cdu tric m6 mém trong hau, chat nén va chat tiét hau hong. Git sach dung the, hut dam khi cén thiét, dat tu the bénh nhan pha hop (vi dy nim nghiéng, dau cao 136Gio trinh Than kinh hoe 30 46) gitp a8 phong tic nghén duimg thé, khong nhiing han ché viém phéi hit-xep phdi, ma c6n gop phan chéng ting 4p lye ngi so (i COp va cdn tréy mu théng tinh mach sé lim ting dp Ire ndi so). Tho oxy hé try (2-5 livphiit béi éng sonde mai), duge chi dinh khi ap suét phan oxy méu dong mach (PaO) dudi 60mmHg, 46 bio hda oxy (SpO,) < 95%. PaCO> nén durge duy tri 6 mite binh thudng, trong trubng hop cdn thiét, c6 thé ting thong Khi chi dong 48 dura PaCO; xuéng 25-30mmHg. Dat ng ngi khi quin va ho hp hé tre duge thye hign khi 6 bit thuing hé hap, hode khi can ting théng Ki chi dng, thyc hign 6 nhimg bénh nhan nhéi mau ning, xuat huyét nang, bénh nhan ¢6 bién chimg ting 4p Iue ni so dang diéu tri o6 hoc khong két hop vei phi ni. Dé phéng hit scic va viém phdi hit: o6 dén Khoang 50% cdc bénh nhan d6t quy 6 van dé va uot, do 46 tat cd ce bénh nhin 46¢ quy eép cfn dugc Tam test sing loc nubt trude khi quyét dinh cho &n, uéng, ké cd udng thude. Néu jung bat thudng, bénh nhan can duoc chuyén vién am ngi tr ligu dah gid test nudt day du, ddng thoi thc hién nudi Sn qua sonde va/hogc nuéi &n tinh mach. Kiém soét huyét 4p: ‘Tang huyét dp c6 thé 1a bénh nén nhung dong thai cing la hau qua cia 46 quy (tang huyét ap phan img), cing nhu do dau, day bang quang. Huyét 4p ting phan (mg la dp img sinh ly cho hign tugng thiéu mau no cue b6 vivhode do ting dp Iye ‘Gi So, dp img huyét ap nay sé gidm trong vong 24-48 git sau dt quy, khi tin thong nao 4a 6n dinh va kh6ng cdn ting ap lye néi so. (do lam gidm Iuu Iugng tuan ho’n bang hé, gidm kha nang dap img dié mau ciia nhimg mach mau suy yéu). Vi vay, khong nén ha huyét ap noi chung cho eée bn nhin d6t quy, ma chi xem xét ha 4p Khi c6 chi dinh. Trong giai doan cp, néu c6 chi dinh ha ap, thudc duge chi dinh s€ la céc thude duomg tinh mach (abetalol, nicardipin,...), khong diing thudc dung uéng va dic biét 1A thudc ngim dusi lu6i vi khong kiém sodt duge huyét ap muc tiéu, Céc bign phdp diéu trj hé tre gidip én dinh huyét ap: - Diéu tr) lo king, dau, nén va buén non. - Diéu tr) ting ap luc ndi so. - Han ché cde phan tmg kich thich qué mite dan dén tang huyét dp. Chi dinh va céch diéu tr tinh trang tng huyét 4p (lum y, dot quy xudt huyét nao 6 chi dinh khéc) ~ Chi dinh ha huyét dp trong giai dogn cép trong cdc tru’mg hop: * Bénh nhin duge diéu tri tiéu soi huyét duémg tinh mach: truée diéu tri tigu soi huyét, can ha huyét ap xuéng <185/110mmHg; trong 24 gid sau khi diéu tr] tigu soi huyét, cn ha xuéng <180/10SmmHg. * Bénh nhan ting huyét 4p cé tén thuong eo quan dich nhu. suy tim sung huyét mat bu, nhoi mau co tim cdp, phinh déng mach chi béc tach, bénh nao do ting huyét 137Bai 11: Bot quy. 4p. Mire huyét dp chi dinh tay timg loai tén thuong co quan dich, thong thutng nén ha 15% mite huyét dp hién tai trong nhing gid dau ¢ Néukhéng thugc hai trudng hop trén, chi dinh thuéc ha 4p chi duge thy hién khi huyét dp 2 220/120mmHg - C&ch sir dung thuéc ha huyét ap (khi © chi dinh): a. Khong ding nifedipine ngém duéi Iwoi, Noi chung khéng nén ding thud ngim va thudc uéng trong giai doan cp vi khéng kiém soat duge huyét 4p myc tiéu. b. Muc tiéu ha 4p: duéi méc khuyén cdo, hoac ha 15% mite huyét ap hién tai trong 12 gid dau. c. Thudc ding: nicardipine truyén tinh mach; Iva chon khéc 14 labetalol tiém tinh mach nhung hign hiém cé tai Viét Nam; mét thudc ha dp tinh mach khéc ding trong trudng hop khéng dap img hai thudc trén 14 sodium nitroprusside cing kh6ng sin cé tai Viet Nam. Ha huyét 4p: 1a tinh trang hiém khi gap trén bénh nhan d6t quy, néu xay ra thudng 14 do gidm thé tich tun hoan. Xir tri dau tién khi bénh nhan bj ha huyét ap 14 dénh gid nguyén nhan gay gidm thé tich tuan hoan va bi dich néu can. Chi trong mét s6 trudng hp dic biét méi cdn ding t6i thude van mach. Tang than nhiét, néi chung hiém gap ting nhiét d9 trong ngiy dau thiéu mau nao cdp, trir mot s6 trudng hop xuét huyét trong so, nhat 1a xuat huyét than nfo. Nhing ngay sau 46, tang than nhiét thutmg Ja do nhiém tring. Tang thin nhiét lam tang chuyén héa 6 nao va lam tign lugng bénh xéu di. Xir tri dau tién 1a phai ha s6t bing thude va céc bign phip vat ly, ké tiép 1A xir ly nguyén nhan, ding khdng sinh néu c6 nhiém tring. Kiém soat dong huyét, ting duimg huyét lim cho két cue xu hon lién quan dén chuyén héa trong tinh trang glucose lam tn thong nao cang tram trong hon, ngay ca 6 cic bénh nbn khéng dai th4o duéng, Do 6, trit truéng hgp ha duéng huyét, cdn lai trong dot quy néi chung khOng truyén dung dich 06 duémg va dung dich nhuoe trumg. Khi ¢6 ting dutng huyét (ca bénh nhin cé tién sir dai théo duéng va khéng c6) can diéu chinh mite dutng huyét nhu trong cdc khuyén cdo diéu chinh dudng huyét trong cdc bénh nang hoi site, mirc duémg huyét khuyén cio khéi diu diéu chinh bing insulin 14/3 780mg/aL (1OmmoV/L), sau 46 duy tri trong giéi han ea EO) Nuéi duréng va cham séc: Céc bénh nhin suy gidm ¥ thite di hoi phai chit dc bigt vin 48 dinh dudng, chire nang ru6t, bing quang, chim séc da, ring miéng. - O cée bénh nhan hén mé hod cé van dé vé nudt, nudi duémg ban dau bing dich truyén tinh mach, nudi duong bing éng sonde da day duge xem xét khi tinh trang than kinh cia bénh nhin én dinh. Dam bao dinh cing SOT, thém vitamine, c6 thé bing dich nudi dutmg bom thu’mg xuyén theo ty Ié 75- 100ml/gid (1-15 calo/ml) hoc thtie &n try tiép. Dich an thay thé khoding 2 Iitngty v6i nude tiéu tir 500-1000mI/ngay. 138Giéo trinh Than kinh hoe Lam mém phan va dé phong chuéng rudt do téo bén hay giam nhu d6ng rugt; docusate 100mg uéng ngay hai Kin hoac cdc thude khdc nhu thuée nhuan trudng (Forlax). - © bénh nhin hén mé, ban diu dat sonde tiéu 4-6 gid/lin v6i muc dich han ché stress bang quang do nusc tiéu ir nhiéu hodc tiéu ty dng sé gay nhiém tring da. Sau 48-72 gid bénh nhfn vin mat y thite, mét sonde Foley o6 thé duc dat dé theo d0i nude tiéu nhung phuong phap nay c6 nguy co dn dén nhiém khudn va nhigm tring tiéu. - Cée bénh nhan hén mé sé duge tré minh trén giudng ci mot n€miikhi) ve ép than kinh, Duy tri cin bing made va dién gid trinh kigt nude (Anh hudng a6 quénh eta méu) hoe ngin ngira thira nuéc (bgnh nhin suy tim), Kiém sodt cén bing dién giai, xét nghiém nOng 49 tham théu cla mau va nude tiéu, néu c6 r6i loan cén diéu tri ngay. Diéu trj cdc bién ching vé than kinh Diéu trj phit nao va ting ap Iurc n6i so Tit vong trong tudn dau tién sau d6t quy phin Ién la do philiidG Walang SPIGENOTS, gay ra tut ket nao trén 1éu hoc chén & iéu nd 5 }-Céc r6i loan thin kinh do phi néo thuimg vio ngiy thir2 hoe ngay thir 3, nung cfing cé thé sém hon do nhdi mau ign réng hoac nhéi mau xuét huyét. Hinh anh CT so nfo 1a can thiét cho chan doan nay dé phan biét cdc bénh khéc. Didu tri ting n6i kho: Gincmtiee) - Nang cao dau giuéng. - Kich thich t6i thiéu. ~ Truyén dich: ding nuéc ty do t6i thiéu (Khong ding glucose 5%), han ché nude trong ngay dau khoang 1000ml/m? dién tich bé mat co’ thé/ ngay, - Ting théng khi dé dat t6i PCO» 25-35mmHg ngay lp tite/24 gids. ~ Truyén tinh mach nhanh Manitol 20%, 0,25-0,5e/kg edn ning ligu khdi diu va nhiéc lai sau 4-6 gid/lin. Khong qué 2p/kg/24 gid. Phau thuat mé so gidi ép: ~ Labign phép higu qua nhit trong diéu trj ting ap luc ndi so do nhdi mau nao dién rong. - Gitp ctu séng bénh nhén, phan nao nhung ni chung nguéi bénh sé & trong tinh trang ~ Chi inh Ki 06 hoi miu din rg (ahd min no de tinh dong mach nlo gia), tit nhat trong vong 24 dén 48 gid dau, Kiém soét co giat: co giat 14 biéu hign hiém nhung c6 thé gap trong d6t quy, phan Ién xay ra trong 24 gi dau cita dot quy, khong 90% truémg hop cé thé diéu tri voi mot loai thude: carbamazepin, phenyltoin, valproate, midazolam, diazepam. Cac thudc nay cd thé 139Bai 11: St quy iéu tri ca cho co gidt va trang thai dong kinh. Khong cé chi dinh thuéc chéng d9ng kinh phdng ngita khi bénh nhin chura c6 con déng kinh nao. Phéng ngtra cdc bién chieng ban cép Huyét khéi tinh mach sau va nhdi mau phéi: Thuyén tic phdi c6 thé 1a nguyén nhan giy tir vong (10%) nhanh chéng 6 bénh nhin d6t quy. Céc nghién ciru 6 Vigt Nam, cing nhu 6 chau A, cho th4y nguy co huyét khéi tinh mach su & ngudi bénh d6t quy efing cao tuong ty nhu cdc nghién citu trén ngudi Au MJ, gp 6 khoang 30% cdc bénh nhén dét quy. Do dé, can danh gid nguy co huyét kh6i tinh mach sau cho tat cd bénh nhan dt quy (thang va tién hinh cdc bién phap dur phong d6i véi cc bénh nhan nguy co cao. vige tng cuémg van dng, dich chuyén sém cho ngudi bénh dé gidm nguy co huyét khéi tinh mach sau va thuyén tic phdi, cdc bénh nhn nguy co cao sé duge Iya chon sir dung atid ép hoi ingit/quaing hoc tién heparin trong Iuong phan tir thap). V6 tinh mach duge chimg mi higu qua phong ngtra huyét khoi tinh mach sdu va thuyén tie phéi Ngan ngwa nhiém tring hé hap: Viém phéi lA mot trong nguyén nhn dc lap gay tir vong sau 49t quy. Nein ngita bing ech lam sach dung ho hp, van dong sém, ngdi da nhiéu lan trén giuéng, dan lun tu thé, ngin ngira trio ngugc, vb nguc. Néu cé sét sau dot quy cin tim ngay nguyén nhin viém phdi va cho khang sinh sém. Ngan ngiva nhiém tring tét nigu: Dé gim nguy co nhiém tring tiét nigu cin cung cp dii nude, Ioi tiéu, acid hoa nude tiéu va dat sOndeliéaingit quaiig)Ding khing sinh 6m khi c6 nhiém tring phéng ngira nhiém tring huyét. Loét myc: Loét myc trong bat dong trén givong ting dang ké ty 1¢ tir vong, tan phé. cuyén va dimgengm'thay @6ilpilye|e6 thé ngin ngiva hién tuong loét mye. Loét da day: Trén mot sb bénh nhan c6 thé c6 tinh trang viém loét da day (c6 thé xuat huyét tiéu hoa), 06 ding thud tre ché Hy hole tte ché bom proton e6 téc dung phong ngira. ‘Tranh aspirin véi ngudi 6 tién sir loét tiéu héa. Phuc héi chic nang va phéng ngwva tai phat Phye hdi chire ning clin duge dénh gié va thy hign ngay tir ngiy du tién cha 2 Phu hoi chire ning cho dt quy bao gim vatlyetrigligu (PT - Te heey) ae ligu (ST ~ Speech therapy) va alla Ocupational therapy). Cae chuyén vvién phyec hoi chire nding can dénh gid, lén ké hogch va thye hign can thiép trj ligu ngay tir ngiy dau tién va kéo dai xuyéh suét qua trinh diéu tr) trong bénh vign va sau khi ra vign. Didu trj dur phong tai phat bao gdm: = Tam soat cdc yéu t6 nguy co va truy tim nguyén nhan. - Diéu chinh cdc yéu t6 nguy co © Didu tr ting huyét 4p, dai thao dudng néu c6. 140Gido trinh Than kinh hoc Ché 46 n theo bénh IY, néi chung la in gidm min, gidm mo béo, ting cudmg rau xanh, ché 9 an giém cin di vi ngudi qué trong, gidm dung bot doi voi ngudi dai théo dudng. Tang cudng van d6ng, tap thé dyc. Diéu chinh céc r6i loan lipid mau. ¢ Tam soét ngung thé khi ngu va diéu tr} néu 06. Cai thuéc 14, giém rugu bia, chuyén bién php ngita thai véi phu nif tudi sinh dé néu cé lién quan. - Diéu trj phong ngita theo nguyén nhan ‘© Dénh gid nguyén nhan theo phan loai TOAST. * Voi dt quy do lp mach tir tim, dac biét la rung nhi: ding khang dong uéng, 6 thé Iya chon thudc khang vitamin K (warfarin, coumadin) voi INR mye tigu tir 2- SB (46i véi van tim nhan tao myc tiéu la 2,5- 3,5) hoe cae thudc khéng déng trac tiép (NOACs, gém dabigatran, rivaroxaban) d6i véi rung nhi khéng do bénh van tim (hep van hai 14 hau thép hoc van tim nhén tao). © V6i d6t quy khéng do tim (xo vita dng mach én, bénh dng mach nhé): ding thudc chéng tiéu eau va statin. Thuéc chéng tigu cau: cé thé Iya chon “Aspirinl(@impingay), aspirin_két hap véi dipyridamol phéng thich chém (200mg 2 Kin/ngay), hay clopidogrel (75 mg/ngay) déu 06 higu qua. Cilostazol (100mg 2 lin/ngay) o6 higu qua tuong ty aspirin trong phong ngira dét quy 6 bénh nhén chau A véi nguy co xuat huyét it hon. Thudc chéng tiéu cu kép: két oeseerrmrmemee! chi duge ae eo voi Be aay, “hg (NIHSS < 5 diém) ho: ang (khuyén céo dya theo nghién ctu CHANCE va POINT). M6t chi dinh khac ig cho dt quy thiéu méu cuc b6 do hep nang dong mach noi so ( 70% dug kinh), khéi dau trong vong 1 thang sau khdi phat va kéo dai khéng qué 3 thang (khuyén céo dya chit yéu theo nghién cu SAMPRIS).--— Statin: ding statin higu lye manhi(atorvastatin;-fosuvastatin), KhOng hodn ton phu thugc. vao mirc LDL cholesterol mau. > LDL cholesterol m Can thigp hoc phdu thuat d6i v6i hep déng mach canh trong ngoai so c6 trigu chimg: chi dinh véi hep tir 70% dén 99% dng mach canh trong ngoai so bén cé trigu chimg (c6 thé xem xét v6i hep tir 50-69%), thyc hién t6t nhat trong ving 14 ngay ké tir khi khdi phat, o6 thé Iya chon gitta phdu thuat bée ni mac dgng mach canh (CEA — Carotid Endarterectomy) hoc can thigp nong stent (CAS ~ Carotid Angioplasty and Stenting), uu tién CEA hon, dc biét la é ngudi > 70 tudi. Day la cdc khuyén céo rit ra dy theo két qua cia cde nghién ecru ECST, NASCET va CREST. Khéng 6 chi dinh can thigp nong - stent thuéng quy cho cdc bénh nhan hep déng mach ndi s9 (tir nghién cia SAMPRIS) 14]Bai 14: Botquy Diéu tri con thiéu mau nao thoang qua (TIA) Nén cho nhp vign nhiing bénh nhéin bi con TIA trong voni it cao. Mét thang diém phé bién dé danh gid nguy co tai phat con TIA la thang/ABCD22diém duge cho trong méi tiéu chufin sau'[tudi 260 (1 diém); huyét ép 2=140/90mmlHg (1 diém); trigu chimg lam sing yéu ligt khu fT diém), néi kho khong kém yéu ligt (1 di gian cia con TIA 260 phit (2 diém), 10-59 phiit (1 diém); dai thdo dutmg (1 did hi dinh gié thang ABCD2y24/lamguéng/edin nhpvign, Cing cin phai nhép vign 6 Se bénh nhan TIA véi s6 con ngay cang ting, cé hep déng mach canh, cé nguén thuyén tic tir tim hay tinh trang ting d6ng 4a biét trudc 46. Nhfp vign gitip hé tro can thigp sém khi tai phat ciing nhu tién hanh ngay viéc dic hong ngira thir phat cho bénh nhan. Muc dich diéu tri ni khoa 1a ngin ngira con TIA t4i phat cing nhu tién trién t6i nhdi mau nao that sy. Didu tri tt cdc yéu t6 nguy co: dai thao dudng, thudc tre ché men chuyén hay ite ché thy thé angiotensi 6 low-density lipoprotein (LDL-C). N: 6c ld i ngay ngudn thuyén tic tir tim néu 06. Khuyén céo gidm Tuy nguyén nhan s€ c6 chi dinh thude chéng huyét phi hop (Khang déng cho ngi 4p mach tir tim, Khdng tiéu cdu don hotic kép cho cic nguyén nhan khong do lap mach tir tim), statin, phau thuat hodc can thigp hep dng manh cénh nhu da dé cp o phan tren. DIEU TR] XUAT HUYET NAO Bénh nhfin nén duge nhap don vi chim séc tich cye dt quy ho’ie khoa hi sire (ICU) a8 cham séc va diéu tr} phi hop. Biéu chinh huyét dp: - Huyét ap ting cao lam gia ting nj méu tiép dién hod tai chdy méu, anh hudng déa Ket cuc. Nghién ciru INTERACT 2 cho thay ha huyét ap Tich cue xuéng mite khoang (40mmHgilam iim sL1¢ xuit huyét Jin thém nhumg khéng cdi thién 16 két cuc, trong khi nghién ciru ATTACH 2 cho thay ha huyét ap manh hon xuéng duéi 140mmHg (120-130mmHg) gay ra két cyc xdu hon. ~ Khuyén edo hign til néndithuyét 4p néu h huyét dp tam thultir 220mm ielen) 46i véi mite huyét 4p duéi 220mmHg, 06 thé ha xudng dén (40mmHg Van an toan (thong thug nén gitt huyét ap 6 mite hon 140mmHg dén 180mmHg) - Néucé chi dinh diéu chinh huyét 4p trong giai cdp, thudc duge khuyén cao 1a thudc ha ap dun; Biéu chinh céc r6i loan déng mau néu 06: - Truyén tiéu cau néu cé gidm tiéu cau. - Diéu chinh cdc réi loan déng méu bing huyét tuong tuoi dong lanh, phitc hop prothrombin, vitamin K (46i voi bénh nhan ding thude Khéng vitamin K) va cée thudc d6i khang phi hop (protamin cho bénh nhan ding heparin, idarucizumab cho bénh nhin ding dabigatran). 142Gio trinh Than kinh hoc - Can theo d6i ting pilvendijsoivardibute c6 thé dat du dd do dp lye ndi so trong nhu mé, trong néo that, diéu chinh ting 4p lye noi so bing cdc tac nhén thdm thdu (manitol, mudi wu trong) va bing diéu chinh thé tich dich nao tay (dan liu). Véi cée bénh nhan xuat huyét nao thét va no tng thity cdp, can dan Iu nao that. Phiu thuét gidi dp, ldy méu tu d6i v6i xudt huyét ban cau dai pio duge xem xét & cdc bénh nhan tré, 66 khOt mau ty nim ndng 6 chat kich thuée dit 1én va dang dién tién x4u higu tmg chon ch6 va thodt vi no. teu undo, cin xem xét phi th it gid ap Jay minty, dong thoi din luu no that, vi nguy co dign tién xdu va tir vong rat cao do chén ép than nao va cdng nao, trong khi diéu tri phdu thuat cé thé gitip hdi phyc hoan toan ede KLiém khuyét than kinh, Céc diéu tri ndi khoa tong tyr nhur chim s6c tich cue giai dogn cp cia d6t quy thiéu mau cuc bd. DIEU TR| XUAT HUYET DUO! NHEN DO VO’ TUI PHINH BONG MACH ‘Tat ca céc bénh nhan cn phai nhap vién diéu tri trong don vj héi site tich cyre hoge don Vi dt quy. Voi cde bénh nhin cén tinh téo, cin nir_nghi.tuyét d6i tai giuémg, tanh ging strc hay cing thing, diéu trj trigu chimg nhur day dau vile ting, cho thuéelehon@ ién ha huyét 4p tam thiflvél40mmilg cho dén khi digu tr] nguyén nhan cia xuat huyét duéi nhgn (tii phinh mach). Nhin chung, céc bénh nhan cdn duge nim vién it nhat 14 ngay dé theo doi, phong ngira va diéu tr] bién chimg co mach. Biéu tri chung XHDN Dieu tri chung giai doan cdp bao gdm: - Nghi ngoi tai guong. - Bi dich dam bao thé tich tuan hoan va CVP. Phong ngira huyét khéi tinh mach 6 bénh nhn béo phi (v6 chuyén biét). - Ding thuéc mém phan chéng téo bon. Chéng co mach bing nhém tte ché canxi. iém sodt huyét dp tim thu #1S0mmPtg (wu tiehitelehé BE@RIRLABASIGNIV), Cac nhém nitroprusside hoc nitroglycerin IV can han ché +i c6 tinh chat gin mach lim tang lugng mau lén no o6 thé gay ting Ap lye ndi so. Giém dau dau, Ching co giat (néu xy ra). M6t s6 chuyén gia phu thuat than kinh 06 xu hudng phong ngita co gidt dé gidm nguy co ti chiy méu, nhung diéu nay chua 6 dit bing chimg nghién citu, thm chi o6 thé anh huéng lén chute nang va nhén thitc ciia bénh nhan XHDN khi duge ding phéng ngtra co git (bing phenytoin). Ngimg cdc thude khang déng va chéng két tp tiéu clu. Xem xét diing lai khi da can thigp digu trj tai phinh. 143Bal 11: Dotquy hom ite ché calcium: Duge ding dé lam gidm h4u qua co thit mach sau XHDN. Chi dinh trong XHDN don thuin (khong c6 xuat huyét nhu m6 no). Pidu tri tot nhat la bat dau sém trong vong 4 ngay dau cia bénh. sdipine 60mg udng mbi 4 gid qua miéng hoe sonde da diy. Mot s6 trudng hop 06 thé ding dudng truyen tinh mach. Chit ¥ digu chinh céc r6i loan sinh ly chuyén héa thug gap: - Hanatri mau - Thiéu oxy mau - Toan chuyén héa - Tang dudng huyét ‘Tim mach khéng 6n dinh, huyét dp giao dong Diéu tri tai phinh ‘Mue dich diéu tr 1a phong ngira xudt huyét nhiéu hon cing nhur xudt huyét tai phat. Nguy co xuat buyet dui nhén tai phat do vo tai phinh lon nhat trong vai ngay dau sau Jan xuat huyét dau tién, khoang 20% bénh nhan sé xuat huyét tai phat trong vong 2 tuan va 40% trong ving 6 thang. V6 tai phinh tai phat gay tir vong 70% trudng hop. Bién phap hiu higu hat dé ngan vo tui phinh tai phat 1s neti < hai bign phap: pl h. ‘Ty 1é vo ti phinh trong khi can thiép (phiu thuat va n6i mach) khod a tir vong rit cao 6 nhém nay. Phdu thuGt kep cé titi phinh: khi cé tai phinh nhé va vi tri tiép cn duge dé kep. Hinh 11.11: Tii phinh dink dng mach than nén (hinh trai); Tii phi da bj kep 6 c6 (hinh phaii) 144Giéo trinh Than kinh hoc Can thiép n6i mach dat coil bit tii phinh: khi cd tai phinh to (khong kep duge va di rong dé tha coil) va vi tri ma thi thuat kep khdng voi t6i duge. Hinh 11.12: Titi phinh déng mach nao sau bén phai truce va sau khi can thigp tha coil Thdi diém can thigp didu trj tui phinh Mong muén diéu tr tét nhat 1a chéng tai vo.tii phinh, lr. Hai vige nay chi dat duoc khi da lam tic tii phinh d6ng mach. Do 46, can thigp sém 1a diéu ai cing mong muén, nhung diéu nay tly thude vao tinh trang bénh nhén (danh gid phan d6/Hunt and Hess). Hién nay: ~ BO 1dén II: can thigp sém trong ving 24 gifs, sau 46 bit dich chéng co mach ~ BQ IV: viin xem xét can thigp sm néu o6 thé can thigp n6i mach, song song véi hdi site ndi khoa. Trong truémg hop ti phinh khong thé can thigp n6i mach, thutmg phai tri olin phdu thugt cho dén khi tinh trang ndi khoa cho phép. ~ D6 V: tién Iugng xéu di can thigp s6m, nén diéu tri n6i khod va xem xét lai khi én dink hon, Dieu tri din liu nao thét: nao ing thiy ning. Cé thé gitip cai thign tién lugng cho céc bénh nhin & Biéu tri bién ching Xudt huyét duéi nhén do vor tii phinh c6 nhimg bién chimg rat nang n&, vi vay vige theo di sit sao trong don vj sin séc tich eye ICU la can thiét. Bién ching co mach Ligtinital ngUiliodc céc khié Kehuyét thn Kine €6 thé xay ra sau 2. 14 ngiy do oo thi dng mach nao, ‘Nguyén nhén co mach hién chua 16, c6 thé 6 nhiéu yéu én nhdi mau nao hay nhéi méu nao lon siy rating dp Ive ndi so cang nhieu hon, a bign phap khong x4m lin c6 thé sin mach, nhumg 1S chan doan xae dinh. Cac nghién cir gilip gidm bién chimg co mach, vii liéu 145Bai 11: Bot quy himg See EID mau bj co that eiing hitu ich. Nao ung thiy: Nao ting thay cdp, bién chimg xay ra do réi loan hp thu dich nao thy a mau xuat hign trong khoang duéi nhén. Can nghi ngo bin chimg nay khi tinh trang can chyp ngay@T/Seanis9indo dé chin dodn. Nao ting thiy cap gay ra ting ap luc ndi so ning né can dat shunt dan lm dich nao tay tam thei. Ha natri mau: Ha natri méu trong XHDN do ting tiét ADH khdng thich hgp. Bign phap ngi khoa thurong ding trong trumg hop nay la han ché nude, Gigi nay Khong phi hop trong digu tri XHDN. Do 46, can xem xét bi dich NaCl ding truéng két hgp voi wa trzong (néu can), Co giat: Cac thudc thuing a ding 1a phenytoin, carbamazepine, phenobarbital. Chu y tim cdc nguyén nhan hé th y co gidt (vi du: ha natri mau) Két cuc lau dai Khiém Khuyét thin kinh: Bia ting ty 1é suy gidm tri nhé, gidm khi sc va suy giam nhan thiic, sa sit tri tug. Chimg mat khira gid@\(anosmtia)jed thé xay ra bénh nhan phiiu thuat kep tdi phinh va 06 xuat huuyét vao nao that. Chay mau tai phat trén bénh nhén di duge can thigp: ty 16 rét thdp, thdy 6 bénh nhfn duge dic coil. Khuyén khich tim soat mach mau no 6 con cdi ngudi XHDN do vo tai phinh d6ng mach. DIEU TRI HUYET KHOI TINH MACH NOI SO Trigu chimg cia hujgUKROT RHR ROTS ebm dau daaleon/ dong kinh SUSU HORE TOAM di 89 Va cic khiém Khiuyétithain Kinki Khu tra. C6 thé xudt hign trong bénh cinh nhiém tring n6i-sa-hay cée ving lén en, tinh trang ting dong, trong thai ky, cde yéu t6 di truyén,... Chan dodn xéc dinh dya va ERRORS hale GI-OTYClitinhmach trong nhimg trong hop khong thé chup MRI. iu ty trigu chimg bao gbm thudc chéng dng kinh néu bénh nhan 6 con dng kinh, gam dau,... Digu tri dic higu biing thud khang déng chich heparin trong Iuong phan tir thép (Cow MoléGiilat Weight Hleparini=LMWH) theo sau la thudc khéng vitamin K gidp giém duge ty 1é ti vong ciing nhu tan phé. Thoi gian ding khéng déng thay doi ty nguyén nhan eta huyét kh6i, coe hop ting déng tir phat (nin nhiém tring, wong thube ngtra thai,...) ding, trong trudng hop ting dong tién phat thi ding kéo dai hon. ln § % , dy khéng phai la chéng chi dinh cia thuée khéng dng, Trong nhimg truing hop digu tr Khang dng heparin khéng higu qua, cfc ky thuat diéu tri ni mach nhw tiéu soi huyét va ly huyét khdi bing dung cu cfing cé ich Igi. Tuy nhién, van dang duge khéo sat trong cdc nghién ciru d6i chimg ngdu nhién. 146Gido trinh Than kinh hoe TAI LIEU THAM KHAO te Powers WJ, Rabinstein AA, Ackerson T, et al, on behalf of the American Heart Association ‘Stroke Council (2019), Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 50:e+++-er++, DOI: 10.1161/STR.000000000000021 1. Hemphill JC I, Greenberg SM, Anderson CS, et al on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, and Council on Clinical Cardiology (2015). Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. 46:000-000. DOI: 10.1161/STR.0000000000000069. Park J, (2017). Acute Ischemic Stroke Medical, Endovascular, and Surgical Techniques, Springer Science+Business Media Singapore. Derk Krieger, Wemer Hacke (2000). Stroke, third edition. Batjer H. Hunt (1997). Cerebrovascular disease, first edition. Lippincott-Raven. Robert J. Gewirtz and Gary K. Steinberg (1997). Management of cerebral edema. ICP in stroke, Academic Press, Stanley N. Cohen (2000). Management of ischemic stroke. McGraw-Hill. Nguy€n Van Dang (1997). Tai bién mach méu néo. NXB Y hoc. Phan Chic Lam, Nguyén Van Théng (2000). D6t guy ndo. NXB Thanh nién. ‘Vii Anh Nbj (2001). Tai bién mach mau nao. Than kinh hoc lm sing & diéu tri. NXB Mui CA Mau, tr.44-150, . Tamura A, Yasui N, Suzuki A, et al (1996). Glasgow Coma Scale in the prediction of outcome after early aneurysm surgery. Neurosurgery. 1996 Jul, 3 9(1):19-24, discussion 24-5. . Kassell NF, Tomer JC, Haley EC, et al (1990). The International Cooperative Study on the ‘Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg. 1990 Jul, 73(1):18-36, . Feigin VL, Rinkel GJ, Lawes CM, et al (2005). Risk factors for subarachnoid hemorrhage: an updated systematic review of epidemiological studies. Stroke. 2005 Dee, 36(12):2773-80. } Okamoto K, Horisawa R, Kawamura T, Asai A, et al (2003). Family history and risk of subarachnoid hemorrhage: a case-control study in Nagoya, Japan. Stroke. 2003 Feb, 34(2):422-6. . Van der Bilt IA, Hasan D, Vandertop WP, et al (2009). Impact of cardiac complications on outcome after aneurysmal subarachnoid hemorrhage: a meta-analysis. Neurology. 2009 Feb 17, 72(7):635-42. = Ropper AH, Samuel MA (2009). Cerebrovascular disease. In: Ropper AH, Samuel MA, Principle of Neurology, 9ed, 746-846. . Michael J. Aminoff, Vanja C. Douglas (2017). Nervous system disorders. In: Maxine A. Papadakis, Stephen J. McPhee. CURRENT Medical Diagnosis and Treatment 2017, Lange, Me Graw Hill Education, pp.991-1002. 147Bai 11: DOtquy, CAU HOI LUQNG GIA 1. M6 ta co sé giai ph&u sinh ly trong cp mau cho no? Dac diém lam sang cita d6t quy thiéu mau nao cp? ‘Dac diém lam sang cia xudt huyét no? Dac diém lam sang cita xudt huyét duéi nhén? Phan tich y nghia céc khao sat cfn lam sang trong dt quy. Cée bude xir 1y d6t quy néi chung va riéng timg thé lm sang (con thoding thiéu méu nao, thiéu mau nao cuc bé cp, xudt huyét ndo va xudt huyét duéi nhén)? aur en 148