YHOC VIET NAM THANG 7 - SO 2/2012
NGHIEN ClAJ MOI LIEN QUAN Gli^A DIEM NIHSS ven HINH ANH GONG HlrifNG TUTKHUECH TAN SO NAO or BENH NHAN NHQI MAU NAO CAP DO TAG DONG MACH NAO GlOA
T O M TAT
Muc tieu: Tim hieu moi lien quan giffa diem dot quy nao cua Vien sire khoe quoc gia Hoa ky-NIHSS va hinh anh ton thu'dng tren cong hUdng t y khuech tan so nao 6 benh nhan nhoi mau nao cap do tac dong mach nao giO'a trong 24 gid dau. Phu'dng phap:
Nghien cyu tien ciTu, mo ta cat ngang thiTc hien d 48 benh nhan nhoi mau nao cap do tac dong mach nao giiJa tai Khoa Cap cyu Benh vien Bach mai tir thang 1 den thang 8 nam 2011. Ket qua: Vdi nhom ton thUOng do tac doan Ml ciia dong mach nao giUa diem NIHSS trung binh la 23,2± 7,29 va the tfch thieu mau nao tren hinh anh cong hu'dng tir khuech tan trung binh la 105,48± 37,217 c m l Nhom benh nhan ton thUdng tac doan M2 cua dong mach nao giO'a co diem NIHSS trung binh 11,4±3,69 va the tich thieu mau nao tren hinh anh cong hu'dng t y khuech tan la 48,76±30,730 cm^ He so tUdng quan giiJa diem NIHSS va the tich 6 thieu mau tren hinh anh cong hudng tiT khuech tan la 0,831 (p < 0,05). Ket luan:
Diem NIHSS co mdi lien quan tuyen tinh chat che vdi the tfch 6 thieu mau nao tren chyp cong hUdng t y khuech tan so nao vdi he so tu'dng quan r = 0,831,
ABSTRACT
Research on the relationship between NIHSS score and ischemic lesions on MRI in acute Ischemic stroke due to middle cerebral artery
occlusion
Objective: To find the relationship between NIHSS score and ischemic lesions on magnetic resonance Imaging in acute ischemic stroke due to middle cerebral artery occlusion within 24 hours of symptom onset. Methods: a prospective, observabve research on 48 pabents with MCA occlusion in Emergency Department, Bach Mai Hospital from January to August, 2011. Results: Patients with Ml and M2 occlusions had NIHSS score average of 23,2±
7,29 and 11,4±3,69, respectively, ischemic lesions on MRI were 105,48± 37,217 cm^and 48,76±30,730 cm^
respectively. Conclusions: NIHSS score has a closely linear relationship with ischemic lesions on MRI.
I.
OAT V A N OETac dpng mach nao giu'a la the lam sang ed tien lydng nang, ty le tiT vong cao va de lai nhieu
* Khoa cap cifu - BV Bach Mai Phan bien khoa hoc: GS.TS. Le Du'c Hinh
Mai Duy T o n * , Vu V i e t H a * , Nguyen Oat Anh*
di chyng nhat trong so cae benh nhan nhoi mau nao. Oieu tri nhoi mau nao do tae dpng mach nao giffa bang thuoe tieu sdi huyet rt-PA la mot trong nhyng bien phap dieu tr; cd ban va thu dypc nhieu ket qua tot neu benh nhan nhap vien trong vdng 3 gid dau. Tuy nhien, ty le benh nhan dupe sir dyng thuoe tieu sdi huyet rt-PA khong nhieu do benh nhan thydng den vien muon sau 3 gid, Vi vay viee tien lypng dUdc nhCTng benh nhan nhoi mau nao do tac dpng maeh nao giiJa trong vdng 24 gid dau rat quan trong, giiip eho viee theo ddi benh nhan tot hdn. Mot trong nhii'ng bien phap tien lypng la dya vao danh gia the tieh 6 nhoi mau tren phim chyp eong hydng tir so nao, nhyng khong phai tat ea cae cP sd deu ed the thye hien dypc [ 2 ] . Theo hydng dan dieu trj ciia Hiep hgi Opt quy nao Hoa ky [4] co the sir dung thang diem NIHSS [1] de danh gia mire dp nang ciia benh nhan nhoi mau nao cap.
Vi the ehung tdi thye hien de tai nay nham myc tieu; Tim hieu moi lien quan giiJa diem NIHSS va hinh anh ton thydng tren eong hydng tiT khuech tan sp nao 6 benh nhan nhdl mau nao do tac dpng maeh nao giUa trong 24 gid dau.
II. OOI TUONG VA PHUONG PHAP NGHIEN CCfU l.l.Do'i tu'dng nghien cu'u
Tat ea benh nhan 6it6c chan doan nhoi mau nao cap do tac dpng maeh nao giO'a vao Khoa Cap eiTu tir thang 1 nam 2011 den het thang 8 nam 2011 thda man eae tieu chuan sau:
- Tieu chuan chpn benh nhan Nghi ngd tai bien mach mau nao theo tieu ehuan cua To chu'e Y te the gidi khdi phat trong 24 gid dyde ehup edng hydng tir ehan doan la nhoi mau nao cap do tac dpng maeh nao giu'a.
- Tieu chuan ioai trd benh nhan Khong ed bang chiTng nhdi mau nao do tae dong maeh nao gitTa tren phim chup cong hydng tir sp nao.
2.2. Phu'dng phap nghien cu'u Thiet ke nghien cdu. Nghien ciTu tien ciru, mo ta cat ngang.
Y HOC VIET NAM THANG 7 - SO 2/2012 Phdang phap. Benh nhan vao vien nghi
ngd ed^tai bien mach nao trong vong 24 gid dau theo tieu chuan nghien ciru. Cac benh nhan deu dyde kham lam sang toan dien, xii tri cac tinh tr?ng cap ciTu va danh gia diem NIHSS tai thdi diem ngay tryde khi chyp cong hydng tir so nao.
Cac bien eo thu thap du'pc trong thang diem NIHSS bao gom 15 myc: Danh gia y thu'e, thye hien menh lenh, cam giac, kha nang nhin, ehye nang van dpng mat, mat, tir ehi, dieu phdi, ...
Diem NIHSS se dype danh gia hai lan doe lap do hai nghien cu'u vien da 6\j:(ic dao tao ve quy trinh danh gia diem NIHSS. Khi sy chenh lech diem NIHSS qua 2 diem ,benh nhan se dypc thay thuoe ehuyen khoa than kinh danh gia lai.
Ngay sau khi danh gia diem NIHSS va on djnh tinh trang benh nhan se ehup cong hydng tir sp nao.
Benh nhan dype ehup eong hydng tir tren III. KET Q u A NGHIEN CCrU
Bang 1. Dae diem ehung ( n = 48 benh nhan)
may ciia hang Siemens 1,5 Tesla tai Khoa Chan doan hinh anh Benh vien Baeh Mai. Quy trinh chyp cd danh gia hinh anh nhu md nao tren chuoi xung khuech tan va ban do ADC nham xac dmh nhoi mau nao giai doan sdm va tinh toan the tich 0 thieu mau (cm^), chuoi xung T2W*
nham loai t r y ehay nao va chuoi xung TOF nham danh gia tinh trang tac mach [ 5 ] .
Chan doan xae dinh nhoi mau nao do tae dpng mach nao giffa khi ed hinh anh tang tin hieu tren hinh anh cong hydng tir khuech tan thuoe vung cap mau ciia ddng maeh nao giu^ va vi tn tac maeh thuoc M l hay M2 dya vao vj tri dpng mach bi gian doan fren chuoi xung TOF [2].
Danh gia sy typng quan giya diem NIHSS va the tieh o thieu mau nao tren phim ehup cong hudng tiT so nao.
Cac so lieu 6\i6c xxi ly theo chypng trinh toan thong ke SPSS 16.0.
Dac diem Tuoi (nSm)
Thcli gian niiap vien
Gidi Oiem NIHSS
Trung binh (gicT) Du'di 3 qid
3- 9 qid Tren 9 qid Nam/ nii' 5-15 16-25
>25
Gia tri 60,9 ± 11,6
8,8 ± 6,4 9 (18,8%) 24 (50,0%) 15 (31,3%) 24/24 27 (56,1%) 12 (25,0%) 9 (18,9%)
Nhan xet - Hau het benh nhan den vien trong vdng 3 - 9 gid ke tir khi xuat hien trieu chiTng dot quy nao dau tien.
- Ty le nam/ nu' tydng dydng nhau.
- Phan Idn benh nhan eo diem NIHSS < 16 diem.
Bang 2. Diem NHI55 vdi hinh anh cong hydng tir khuech tan so nao
Oiem NIHSS trung binh The tich 6 thieu mau nao tren phim
cong hudnq tiT
Doan M l ( n = 18 benh nhan)
23,2± 7.29 105,48± 37,217
Doan M2 (n= 30 benh nhan)
11,4±3,69 48,76±30,730
p- value
< 0,05
< 0,05 Nhan xet: - Oiem NIHSS trung binh khae biet ed y nghTa thong ke giti'a tae dpng mach nao giUa doan M l va doan M2 ( p < 0,05).
- The tieh thieu mau nao tren hinh anh ehup edng hydng tir cung khac nhau giiJa tae doan M l va doan M2 (p < 0,05).
Bang 3: Moi lien quan giu'a diem NIHSS va the ti'eh thieu mau nao tren hinh anh ehup eong hydng tir khuech tan
Y HOC VIET NAM THANG 7 - SO 2/2012
He so typng quan giu'a diem NIHSS va the tich thieu mau tren phim cong hydng tiT khuech tan so nao vdi r = 0,831 (p < 0,05)
Nhan xet: Co mdi lien quan chat che giffa diem NIHSS vdi the tich thieu mau nao tren phim cong hydng tir khueeh tan.
IV. BAN LUAN
Nghien eiTu nay gom 48 benh nhan dyde ehan doan xae dinh la nhoi mau nao cap do tae dpng maeh nao giO'a vao vien trong khoang thdi gian 8,84 gid sau khi xuat hien trieu ehu'ng khdi phat dau tien; trong sd nay 9 benh nhan ed the dyde ap dyng cae bien phap tai tydi mau sdm.
Tuy nhien ehi 6 benh nhan khi vao vien sdm co diem NIHSS dydi 24 mdi dyde dieu tri rt-PA dydng tinh mach chiem ty le 12,5 % . Ty le nay cung phi] hdp nhy trong nghien eiTu eiia Mai Duy Ton va edng sy da edng bo [3]. Theo ly thuyet, eac iTng vien ly tydng de dieu tri tieu sdi huyet CO diem NIHSS tiT 4 den 24 (khiem khuyet than kinh mire dp tir nhe den trung binh). Cdn nhiJng benh nhan ed diem NIHSS tren 24 (khiem khuyet than kinh nang) ed nguy ed ehay mau trong so can dype can nhac eu the doi vdi tirng trydng hdp.
Diem NIHSS trong nghien eiTu nay rat eao, trung binh la 23,2± 7,29 vdi ton thydng tae nhanh doan M l ciia dpng maeh nao giUa va tydng irng co the tieh 6 thieu mau nao tren hinh anh chyp eong hydng tCr khuech tan trung binh la 105,48± 37,217 e m l Nhy vay hau het eac benh nhan nhoi mau nao do tae doan M l eiia dpng maeh nao giu'a it cd kha nang dyde ean thiep tai tydi mau vi ed dien tich 6 nhoi mau Idn nam trong chong chi dinh eiia dieu tri thuoe tieu sdi huyet dydng tinh maeh. Ngype lai, nhom benh nhan ton thydng tac doan M2 eiia dpng mach nao giu'a eo diem NIHSS trung binh 11,4±3,69 va the tich thieu mau nao tren ehup eong hydng tir khuech tan tydng iTng la 48,76±30,730 cm^; nhy vay neu nhom nay nhap vien sdm cd the xem xet sir dung dieu trj thuoe tieu sdi huyet dydng tinh maeh.
GiUa the tieh o nhoi mau nao tren hinh anh chyp eong hydng tir vdi diem NIHSS khi danh gia tren lam sang, ehung tdi nhan thay ed mdi tydng quan tuyen tinh ehat ehe vdi he sd tydng quan r=0,831 (p < 0,05). Nhy vay, ed the sir dung diem NIHSS de tien lypng miTc dp nang ciia benh nhan nhoi mau nao do tae dpng mach nao gitTa trong nhffng trydng hdp benh nhan khdng CO dieu kien chyp cong hydng tiT sp nao.
V. KET LUAN
Oiem NIHSS ed mdi lien quan chat ehe vdi the tieh 6 thieu mau tren ehup eong hydng tiT khuech tan so nao vdi he so tydng quan r = 0,831 va ed the diing de tien lydng miTc dp nang va theo doi dien bien lam sang ddi vdi nhdm benh nhan nhoi mau nao do tae dpng mach nao giiJ^.
TAI UEU T H A M KHAO
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^. Goldmidt AJ, Caplan LR(2011), Cam nang xu" tri tai bien mach mau nao, Nguyen Dat Anh va cong sir bien idich, NXB Y hoc, tr 33- 43.
J. Mai Duy Ton, Nguyen Oat Anh, Le Van Thinh (2011), "Oanh gia hieu qua dieu tri ciia thuoc Alteplase lieu 0,6 mg/kg d benh nhan nhoi mau nao cap do tac dpng mach nao giu'a tai Khoa Cap ciiU Benh vien Bach mai", Y hpc Viet Nam, 12, tr 69-72.
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