Y HOC VIET NAM THANG 5 - SO 2/2015
DAC DIEM HINH ANH vA KET QUA DIEU TRI THONG DONG TINH MACH M A N G CITNG XOANG HANG QUA DU'O'NG TINH MACH
T O M TAT
Muc dich: Mo ta dac diem hinh anh va danh gia hieu qua dieu tn benh ly thong dong tTnh mach mang cirng xoang hang bang can thiep "niit qua dirdng tmh mach.
Doi tu'dng va Phu'dng phap: Trong thdi gian tiT thang 01/2012 den thang 03/2015 cd 33 benh nhan dUdc chan doan thdng dpng tJnh mach mang cirng viing xoang hang dUdc chi djnh dieu trj can thiep qua dudng tinh mach (TM).
Ket qua; Cd 6 nam/27 niJ, tudi trung binh 55,2±11,9. Phan Idn cac benh nhan cd cudng nudi phii'e tap, type D theo Barrow, chiem 93,9% vdi bieu hi^n lam sang chii yeu la do va Idi mat. Can thiep dieu trj chii yeu qua du'dng tinh mach da dudi (60,6%) vdi vSt lieu diSu tri chinh la vong xoSn kim loai (VXKL) ket hdp Onyx (45,4%). Sau can thiep, ti le tac hoan toan luong thdng chiem 87,9%, trong do 22 benh nhan khdng cdn tneu chirng benh tren theo doi lam sang.
Ket lu$n: Dieu tn tiep can va can thiep qua dudng tInh mach ddi vdi cac tru'dng hdp thong dpng tinh mach mang cirng viing xoang hang la phu'dng phap cd ty le tac va hieu qua dieu tn cao, ty le tai thdng thap.
TW khoa: Thdng dpng tinh mach mang cirng, xoang hang, dj dang macli
SUMIVIARY
EVALUATING I M A G I N G CHARACTERISTIC AND THE RESULT OF TREATMENT I N PATIENTS W I T H DURAL ARTERIOVENOUS
FISTULA OF CAVERNOUS S I N U S BY VENOUS APPROACH Objective: Evaluating the results of treatment in patients having dural arteriovenous fistula of cavernous sinus by venous approach.
Material and methods: From Jan 2012 to March 2015, 33 patients suffered from arteriovenous dural fistula of cavernous sinus undenwent the embolization treatment using venous approach.
Result: There are 6 males and 27 females with mean age 55.2±11.9. Most pabents (93.9%) have
* Bd mdn Chan doan hinh anh, TrWdng Dai hgc Y Ha Noi Chju trach nhiem chfnh: Vu Dang LUu
Email: [email protected] Dt; 0944716768 Ngay nhan bai: 6/2/2015
Ngay phan bien khoa hoc; 30/3/2015 Ngay duyet bai: 13/4/2015
Vu Dang L y u * complicated fistulas (classified as type D according to Barrow classification) with clinical symptoms are orbital proptosis and chemosis. We approach cavernous sinus mostly by the inferior petrous sinus (60.6%), and embolized by Coils combine with Onyx (45.4%). After intervention, there are 29 patients (87,9%) demonstrating totally oculled fistula in image, and 22 of them have good clinical outcome (not any symptom) when follow up.
Conclusion: Treatment of dural atenovenous fistula of the cavernous sinus accessed by venous way has the good outcome with less recurrence.
Keywords: Dural fistula, cavernous sinus, vascular malformation
I.
DAT VAN OEThdng ddng mach (DM) mang ciTng xoang hang la mdt benh ly it gap, ehiem khoang 10- 15% cae benh ly di dang mach mau ndi so [1].
Thdng DM mang eu'ng xoang hang ehii yeu gap d niJ nhieu hdn nam, trong dd chu yeu la phu nd tudi man kinh nhu'ng ddi khi cung gap d nhu'ng phu nu" tre cd tien sir ve sinh san. Can thiep niit mach la phu'dng phap du'dc li/a chpn u'u tien de dieu t n loai di dang nay. LiTa chpn du'dng tiep can qua tinh mach, ddng maeh hay phdi hdp ca hai phu thudc hinh thai, kieu tinh mach dan lu'u.
Tru'dc day can thiep niit mach sir dung hat PVA qua du'dng ddng mach giiip giam trieu chiTng tam thdi, kha nang tac thap va dan tdi tai phat cao 60-70% [2].
Nhd SLT tien bd vu'dt bac ciia cae cdng cu can thiep mach trong thdi gian gan day nhu' vat lieu nilt vinh vien vdng xoan kim loai, keo Onyx hay squide, dieu t n ean thiep ndi mach da dem lai ket qua vdi ti le tac hoan toan rat cao va tai phat rat thap. Chfnh vi vay chiing tdi thu'c hien de tai nay nham danh gia ket qua dieu trj thdng ddng tmh mach mang ciTng xoang hang bang can thiep npi maeh qua du'dng tinh maeh.
II. OOI TU'ONG VA PHU'aNG PHAP NGHIEN COU 2 . 1 . Odi tu'dng
Tat ea eae benh nhan du'dc chan doan thdng dpng tinh mach mang ciTng xoang hang va ean thiep qua du'dng tinh mach thiTc hien tai Khoa
Y HOC VIET NAM THANG 5 - SO 2/2015 chan doan hinh anh Benh vien Bach Mai tiT 2012
den thang 3/2015.
2.2. Phu'dng phap nghien cu'u Md ta cat ngang ghi nhan cac dac die'm lam sang hinh anh lien quan den cau true 6 dj dang, phan loai, chien Iu'dc sir dung vat lieu can thiep va ket qua danh gia tac hoan toan hay khdng hoan toan luong thdng
2.2.1. Phin loai luong thong dgng TM ming cWng vung xoang hang theo Barrow:
- Kieu B: Luong thdng gian tiep vao xoang hang nguon nudi chi tir DM eanh trong.
- Kieu C: Luong thdng gian tiep vao xoang hang nguon nudi chi tir DM canh ngoai.
- Kieu D: Luong thdng gian tiep vao xoang hang nguon nudi bao gom ca DM canh trong va DM canh ngoai ( B + C )
2.2.2. Qui trinh thWchien - Ky thuat niit luon thdng dpng TM mang cirng bang VXKL: thii thuat du'dc tien hanh bdi hai bac sy dien quang can thiep, BN du'dc gay te tai cho hoac gay me toan than, dat dung cu md mach mau (sheath) 6F vao TM diii va DM dui.-Thudc chdng ddng; Heparin du'dc tiem tire thi 2500 ddn vi khi dat xong dung cu md maeh mau va duy tri 10-20 ddn vj/kg/gid.
- Chup dpng mach danh gia luong thdng va dan lu\j tmh mach: lu'a chpn du'dng vao tTnh mach theo tinh mach dan \du gian: xoang da du'di, tinh mach mat, tinh mach thai du'dng ndng.
Tien hanh dat ong thdng dan du'dng kep 6F Chaperon vao TM canh trong hoac canh ngoai, cd gang day long 5F len cao nhat cd the. Luon vi dng thdng qua du'dng tTnh mach tiep can xoang
hang tdi vj tri luong thdng ed the ciing ben ho^c tiT ben ddi dien, sau dd nut bang VXKL de tac hoan toan hoac de giam lu'u lu'dng rdi phdi hdp nilt tac bang keo Onyx hoac squide. Tru'dng hdp cdn mdt sd nhanh nhd khdng the lap tac thi se dUdc nut bd xung bang hat PVA tiT DM canh ngoai chpn loc DM ham trong
- Ngay sau qua trinh can thiep, BN se AdOc bat dpng ehi du'di ben da dUdc chpn lam can thiep, theo ddi sat tinh trang toan than, mach nhiet dp huyet ap trong vdng 24 gid.
- Benh nhan du'dc diing thuoc chdng ddng tnang lu'dng phan tir thap (Fraxiparin hoac Lovenox) du'di da 40mg x 1 dng/ngay trong 5 ngay va Solumedrol 40mg x 1 dng/ngay x 5 ngay.
- Theo ddi danh gia sau dieu t n
+ MiTc dp tac ngay sau dieu trj tren anh chup DSA: Tae hoan toan neu khdng cdn hien hinii tTnh maeh dan lu'u. Tae ban phan neu cdn thay hien hinh tTnh mach dan luXi,
+ Oanh gia thay ddi trieu chirng lam sang trong 1 tuan dau: do mat, loi mat, liet cac cd van nhan
+ Theo ddi kiem tra lam sang sau tdi thieu 3 thang
III. KET QUA OIEU TR!
Tdng sd cd 33 benh nhan du'dc chan doan thdng dpng tinh mach mang ciTng viing xoang hang tiT nam 2012 den thang 3/2015 va dUdc dieu trj can thiep niit mach qua du'dng tinh mach tai khoa CDHA benh vien Bach Mai. Tudi trung binh 55,2 ± 11,9. Ti le nu'/nam la 4 . 5 / 1 .
Bingl:Tr\eu chirng lam sang Trieu chu'ng Iam sang
Loi mat 1 ben Loi mat 2 ben Do mat 1 ben Do mat 2 ben
Utai Liet cd van niian
Giam ttil lu'c Tien sir ciian tiiLTdng/ viem
N 22 1 21 1 18 8 10 3
66,7 %
3 63,6
3 54,5 24,2 30,3 9,1
Nhin xit: trieu ciTng ioi, do mat va u tai iiay gap ntiat. Trieu ctiiTng giam tinj Ida va iiet van niian ctiiem 30,3% va 24,2%.
Phan ioai theo Barrow: Cd 31 binh nhan chiim 93,9% cd luong thdng thudc type D theo Barrow va cd 2 benh nhin chiem 6,1% cd Iudng thdng thuoc type C.
Y HOC VIET NAM THANG 5 - 3 0 2/2015
Bang2:T\nh trang tinh mach din lu'u Tinh trang tTnh mach
Tr»l da du'di TI^ mat-TM mat TM mat- TM da du'di TM mat- TI^ tiiai du'dng nong
Xoanq iianq doi dien Tac TM da dudi
Tac Ti^ mat Bat ttiu'dng goc do ve Tl^ mat
Tong
N 7 12 13 4 6 11 1 2 3 3 e dan lu'u qua tTnh macii da dudi ciiiem 60,6%, qua
Ti ie % 21,2 36,4 39,4 12,1 24,2 33,3 3 6,1 1 0 0 tTnii macii mat 8
hien hinh tTnh mach mat 36,4% va tTnh mach thai du'dng ndng 12,1%.
g3: Lu^ clion du'dnq tTnii macii tiep can Du'dng tiep can Xoanq da dudi
T M m a t TM thai du'dng nonq Phau thuat boc 16 f l ^ mat TI^ tLT ben doi dien qua xoang iianq Phoi hdp du'dng donq mach nut hat hay i<eo
tong
N 20 10 3 0 6 8 3 3
Ti le %
60,6 30,3 9,1 0 18,2 24,2 1 0 0
Nh^n xit: Du'dng tiep can qua xoang da
du'di hay du'dc ap dung chiem 60,6%, qua tinh mach mat chiem 30,3%, qua xoang hang doi dien chiem 18,2%, qua tinh mach thai du'dng ndng 9,1% va phoi hdp du'dng tinh mach va dpng mach chiem 24,2%.
- Ti le sii' dung vat lieu: Diing VXKL ket hdp Onyx cd 15 benh'nhan'(45,5%), diing VXKL ddn thuan 9 benh nhan (27,3%), VXKL ket hdp PVA cd 7 benh nhan (21,2%), dung Onyx ddn thuan cd 1 benh nhan (3%), cd 1 benh nhan diing VXKL ket hdp Onyx va PVA (3%).
-ket qua:
+ Tac hoan toan 29 (87,9%), tac ban phan 4 (12,1%)
+ Thay ddi trieu chutig lam sang: tat ca cac benh nhan du'dc dieu trj sau theo doi deu cd cai thien trieu chijng lam sang ro ret. Cd 22 benh nhan khdi hoan toan; 7 benh nhan giam nhe thj ILTC; 3 benh nhan lac nhe hoac nhin ddi, khdng cd benh nhan nao sup mi; i benh nhan cdn ii tai.
+ Khdng cd tru'dng lidp tiT vong va chay mau sau can thiep
IV. BAN LUAN
Thdng dpng tinh maeh mang cirng viing xoang hang hay gap nhat ehiem 20-40% trong cac dj dang thdng ddng tinh mach mang cirng.
Nguyen nhan hien nay chu^ rd, tuy nhien ti le
gap nhieu nu" gidi tuoi trung nien, sau man kinh va du'dc xem lien quan hdc mdn Estrogen. Yeu td khac gdp phan hinh thanh thdng ddng tTnh mach mang ciTng khi cd tinh trang hep tac cac tTnh mach hay xoang tTnh mach dan lu'u do hau qua viem, chan thu'dng hay sau phau thuat.
Trong sd 33 benh nhan 6ddc chan doan thdng
dpng tinh mach mang ciTng, ti le nu'/nam la
4.5/1 va tudi trung binh 52T, cd 9,1% ed tien siT
ehan thu'dng va viem viing xoang hang, cd
33,3% cd bieu hien tac xoang tTnh mach da dudi
tren anh chup mach. Theo tac gia Yoshida et al
2009 qua nghien cdu 44 benh nhan thdng dpng
tinh mach mang cirng xoang hang, ti le nu'/nam
2.3/1, tudi trung binh 66T, tat ca benh nhan deu
cd dd mat, Idi mat gap 14%, dd mat hai ben gap
9%, liet van nhan gap 36%, giam thj liTc gap
11%, ^pe B chiem 11%, type C chiem 9%, type
D chiem 80%. Theo nghien ciTu Kim va cs 2006,
dieu trj 56 benh nhan thdng dpng tinh mach
mang ciTng xoang hang, tudi trung binh 57,
nCr/nam 4/1, tneu chirng dd mat 32%, loi mat
21%, dau mat 34%, giam thi ILTC 34%. Trieu
ehirng lam sang tiiy thupe tinh mach dan !u\j vdi
bieu hien hay gap la dd mat, ii tai neu dan lu'u ra
tru'dc hoac ra sau. Trieu chiTng liet van nhan, loi
mat do chen ep vimg xoang hang. Mot sd trieu
chirng hiem gap lien quan chay mau nao, nhoi
mau nao tinh mach. Giai doan dau chan doan
Y HOC VIET NAM THANG 5 - SO 2/2015 thudng khd tren lam sang, de nham vdi benh ly
viem gay dd mat. Tham kham hinh anh tren sieu am Doppler thay gian tinh mach mat tren va dao chieu ddng chay. Tren CLVT hoac CHT thay mat loi, gian rdng xoang hang, gian tinh mach mat tren gdi y chan doan.
Muc dich dieu tri la dat dieu trj trieu chu'ng Uu tien, cd nghia la phai tac luong thdng va tTnh maeh dan lu'u ra gay trieu chirng dac biet tinh mach mat lien quan loi va dd mat. Juy nhien het siTc can trpng vdi cac tinh maeh dan lu'u cdn lai bj trao ngu'dc khi da tac tinh mach dan lull cinfnh, nhat la tinh maeh vd nao viing^thai du'dng va tTnh mach quanh eudng dai nao-tieu nao. Yeu cau bat bupc la phai kiem soat tac goc cac tinh mach vd nao nay de tranh bien chirng chay mau hay nhoi mau tinh mach[2,5].
Du'dng tiep can: Tiep can theo du'dng tTnh mach va bdm vat lieu dang djch Idng keo Onyx hay squide du'dc xem la kha an toan, giam bien chu'ng tac cac vi ddng mach nhanh ndi vdi cac vimg chirc nSng nhu' dm mat, dm nudi cac
Hinh 1: TM dan lUu va hu'dng tiep can qua du'dng tTnh mach:
SOV - tinh mat mat tren. STV - TTnh mach thai dWdng nong.
IPS - xoang da d&dl. SMV - tfnh mach nao glu^. BPS- xoang da tren[2]
+ Qua du'dng TM xoang da du'di: Khi xoang da du'di hien hinh thi day ia du'dng tiep can Uu tjen do gan xoang hang va thanh cdng cao. Vi dng thdng du'dc luon tdi xoang hang, tdi goc tTnh mach mat tren. Vj trf tha VXKL vao gdc tTnh maeh mat gay tac tinh maeh mat tren tru'dc va tiep tue mpt phan vao xoang. Sau do tiep tuc niit tae hoan toan bang VXKL hoac keo Onyx hoac Squide.
+ Qua du'dng tiep can phia tru'dc (qua TM mat va TM thai du'dng ndng)
Du'dng tiep can phd blen thir hai la qua TM mat va TM thai du'dng ndng hoae ngu'di ta cd the rach thang qua TM tren d mat de tao du'dng vao va sau dd vi dng thdng du'dc luon vao dat d phfa
nhanh than kinh. Du'dng tiep can gan xoang hang qua xoang da du'di du'dc uli tien neu khdng cd tac xoang nay. Cac du'dng tiep can khac qua tTnh mach mat bang each ludn ong thdng din du'dng qua tTnh mach canh trong, ddi khi qua tTnh maeh canh ngoai neu cd bien the giai phau[5,6]. Tiep can qua tTnh maeh thai du'dng nong thi dng thdng dan du'dng di theo tTnh mach canh ngoai. LUa chpn dng thdng kep vdi long trong 5F mem giiip luon xa vao tTnh mach mat hay tinh maeh thai du'dng ndng, tiT dd d l dang day vi dng thdng tien xa vao xoang hang. Trong nghien eiTu ciia chimg tdi, t i le can thiep qua du'dng xoang da du'di chiem da sd 50,6%, qua du'dng tinh mach mat chiem 30,3%, qua tinii mach thai du'dng ndng 9 , 1 % , va t i le tiep can qua xoang hang ben doi dien chiem 18,2%, Theo nghien ciru Kim va cs 2006, tiep can qua xoang da du'di 6 4 % , xoang hang doi dien 7 \ tmh mach mat 13%, choc tru'c tiep tTnti mach m a t 5 % . [ 4 ]
/
V
Uncal V
\6 5
^ v -
\ 2'" i\
Fadal V j . . ^ *ts^' Plerygoid plexus j j y H
& Basilar plexus * iit3 thanh sau cua xoang hang tai goc do ve xoang da dudi. VXKL du'dc tha bat dau nut tir pliia thanh sau xoang, tinh mach mat tren dUdc niit tac cuoi ciing. C i n \du y iihi tiep can qua du'dng nay la vi ong thong qua doan tinh mach rat dai va ngoan ngoeo can sir ho t r d ong thong d§n du'dng tot de co lire day i(a idem soat dau vl ong thong d vj t r i mong^muon, dong thdi tranh ton thu'dng tTnh mach mat.
H- Cac du'dng tiep can khac; Ngoai ra co the tiep can Tl^ dudi vo, Tl^ tren xu'dng da, TM dam roi nen. Tuy vay cac du'dng tiep can nay la it gSp hdn va chi diing khi hai du'dng tiep can trin khong diing du'dc.
Y HOC VIET NAM THANG 5 - S O 2^2015
Hinh 2: BN nam 61 tudi, benh dien bien 1 thang. Khdi dau dau mat trai, dd mat trai va giam thj
ILTC mat trai. BN dUdc chup chup DSA: Hinh anh luong thdng dpng^tTnh mach mang eu'ng xoang hang, cd nhanh cap mau tiT DM canh trong va DM eanh ngoai, dan lu'u ve TM mat- tTnh maeh thai dUdng ndng - TM eanh ngoai - xoang da du'di hep tae (A). TM thai dudng ndng gian rat to(B). Can thiep qua tinh maeh thai du'dng ndng, vao tTnh mach mat tren rdi vao xoang hang, tha lan lu'dt 6 Coils Niit tac hoan toan Iudng thdng dpng TM mang ciTng (C).
Sir dung ket hdp VXKL va bdm keo dang djch Idng (Onyx ho3c Squide) mang lai mot sd uU diem nhu': VXKL giup giam bdt lulj lu'dng va tranh trao ngu'dc qua nhieu tTnh mach khdng mong mudn, keo dang djch Idng khi bdm se ian
sau vao cac khe luong thdng nhd va trao ngu'dc ve mao ddng mach giiip dieu trj triet de hdn.
Tuy nhien can luli y do kha nang trao ngu'dc qua ddng mach nen can kiem soat lan xa vao dpng mach Idn ndi no.
B
Hinh 3: Thdng dpng tTnh mach mang eu'ng
xoang hang hai ben (A-B-C). Dan lulJ tTnh mach mat- tm mat, tac xoang da du'di trai (D).
Luon qua tinh mach mat trai vao xoang hang tha coil (E-F), bdm Onyx trao sang ben doi dien (G-H). Tac hoan toan luong thdng (K-L).
Trong so 33 benh nhan du'dc dieu trj, ti le diing phdi hdp VXI<L va keo Onyx hoac Squide chiem 45,5%, trong khi diing VXKL ddn thuan 27,3%. Khdng cd tru'dng hdp nao tir vong hay bien chimg do tac xoang. Ti le dat tac hoan toan tdi 87,9%, chi cd 12,1% tac ban phan. Ti le khdi
hoan toan khdng cdn trieu chu'ng chiem 22/33
(66,67%), ti le cdn di chirng liet van nhan 3/33
(9,09%) giam nhieu so vdi 24,2% tru'dc can
thiep, ti le cdn giam nhe thi ILTC chlem 7/33
(21,21%) so vdi 30,3% tru'dc khi can thiep.
Y H O C VIET NAM THANG 5 - SO 2/2015 Theo nghien ciru Kim va es 2006, ket qua tac
hoan toan 52%, gan hoan toan 2 3 % va ban phan la 25%. Trieu chu'ng lam sang cai thien 9 1 % , khdng eai thien 4 % va tai phat 4 % . Bien ehirng liet day than kinh sp 1 0 , 7 1 % , rach tinh mach 5,35%, phii than nao 3,57%. Dieu t n phdi hdp dudng ddng mach va tinh mach 11 ca chiem 19,6% trong dd sir dung hat PVA va keo NBCA[4]. Theo nghien ciTu Bink va cs 2010, dieu trj 16 benh nhan thdng dpng tTnh mach mang cirng xoang hang niit bang VXKL, qua theo ddi trung binh 4,4 nam thay t i le cdn dl chiTng trieu chirng liet van nhan va giam thj ILTC chiem 44%[7]. Tac gia Yoshida dieu tri 44 benh nhan thdng ddng tinh mach mang cirhg xoang hang bang VXKL, ti le nut qua xoang da dUdi 90%, ti le tac hoan toan 81,6%, tac gan hoan toan cdn luong thdng nhd 13,6% va cdn thdng Idn chiem 4,5%, tl le tai phat qua theo ddi 9 , 1 % , cac bien chung gap 2 1 % gom Het van nhan 14%, nhoi mau than nao 7%, chay mau 5%.[3]
Ket qua cho thay can thiep qua du'dng tTnh mach va siT dung phoi hdp hai vat lieu VXKL va keo dem lai t i le thanh cdng rat cao, va cac trieu chiTng lam sang nhu" liet van nhan du'dc hoi phuc sau dieu trj, trong khi trieu chirng giam thj li/c hdi phuc kem hdn.
V. K I T LUAN
Oieu trj thdng dpng tTnh mach mang cirng vung xoang hang qua du'dng tfnh mach diing vat
lieu colls hoac ket hdp bdm keo onyx hoac squide cd ket qua tac eao, an toan va tranh tai phat.
TAI LIEU T H A M KHAO
1. Fox. A. D. 1992. "Dural Arteriovenous Fistula."
Annual meeting of the American Society of neuroradiology, St Louts.
2. Kiyosue H, M. Y. H, Mika Okahara, Shuichi, M. Y et a l 2004. 'Treatment of Intracranial Dural Arteriovenous Fistulas:Current Strategies Based on Location and Hemodynamics, and Alternative Techniques of Transcatheter Embolization." RadioGraphics 24:1637-1653.
3. Yoshida.K et al. 2009. 'Transvenous Embolization of Dural Carotid Cavernous Fistulas:
A Senes of 44 Consecubve Patients." A3NR Am J Neuroradiol 31: 651-655.
4. Kim DJ., Kim D.I., Suh 5.H. et aL 2006. Results of Transvenous Embolization of Cavemous Dural Arteriovenous Fistula: A Single-Center Experience with Emphasis on Complications and Management AINR A m : Neuroradiol 27:2078 - 82.
5. Biondi A, Milea D, Cognard C et al. 2003, Cavernous Sinus Dural Fistulae Treated by Transvenous Approach through the Facial Vein:
Report of Seven Cases and Review of the LiteratureAJNRAm J Neuroradiol. 24:1240-1246.
6. Quin''ones. D, D. G., Gobin.P.Y, et aL 1997.
"Embolizabon of Dural Cavernous Fistulas via Superior Ophthalmic Vein Approach." A3NR Am J Neuroradiol 8:921-928.
7. Bink A., Goller K., Liichtenberg M. et al.
2010. Long-Term Outcome after Coil Embolization of Cavernous Sinus Arteriovenous Fistulas A3NR Am J Neuroradiol. 31: 1216-1221.
HIEU QUA GIAI P H A P TRUYEN THONG GlAO DUG SITC K H 6 E CHO NGir D A N D A N H B A T HAI S A N XA B a H U Y E N V A N D O N ( Q U A N G NINH)
TOM TAT
* Hoc vien Quan Y
*' Tn/dng Cao dang Yte Quang Ninh Chju trach nhiem chinh: Hoang Hai Email: [email protected] Dt: C Ngay nhan bai; 20/2/2015 Ngay phan bien khoa hoc: 30/3/2015 Ngay duyet bai: 1/4/2015
Dao Xuan Vinh*, Hoang Hai*, Tang Xuan Chau**, Nguyen Hong Hanh**
Nghien ciilJ can thiep cdng ddng tdi 100 ngUdSn danh belt hai san xa bd ciia nghiep doan nghe ca Cai Rdng, huyen Van Don, tinh Quang Ninh. Sau ktii truyen thdng giao due sire khde, tap huan nang cao kien thirc, thai dp, thuc hanh ve phdng, xd ly benh tai nan thUdng tfch thu'dng gap ciia ngu dan trong khi danh bat hai san xa bd tren bien thay hieu qua ttiay ddi thai do, kien thirc va thyc hanh diing cua ngU dan tSng len rat ro rang (SLT khac biet deu cd y nghia thdng ke) nhU: giam ty le ngu dan t y xd ly benh, tai