X)URNAL OF 108 - CLINICAL MEDICINE A N D PHARMACY
Nghien cuu dac diim lam sang va hinh anh chup cat lop vi tinh so nao cac benh nhan co that mach man nao sau chay man duoi nhen
study the Clinical Features and The images of Cranial Computerized Tomography in Patients with Cerebral Vasospasm after Subarachnoid Hemorrhage
Nguyen Hoang Ngpc, Nguyin Van Tuy§n Benh vien Trung vong Qudn doi 108
Co th^t mach mau nao la nguyen nhan chinh gay hau qua lam sang nang ne eho cac benh nhan sau chay mau dUdi nhen, Nhdi mau nao sau co that maeh mau gap t d 20 - 40% cac benh nhan co that mach mau nao chung sau chay mau dUdi nhen. Can fim hieu cac yeu t d nguy co nhdi mau nao do co that mach mau nao de dieu tri dU phdng cd hieu qua. Muc tieu nghien cdu: Nghien eUu dae diem lam sang, cac yeu t o nguy co cCia nhdi mau nao sau chciy mau dUdi nhen. Phuang phdp: Nghien eUu, hoi cdu ket hpp tien cUu, eat ngang m d t a 122 benh nhan chciy mau dUdi nhen nam dieu trj npi tru tai trung tam dot quy nao Benh vien Trung uong Quan dpi t d thang 1 nam 2009 den thang 5 nam 2014. Ket qud: Nghien eUu tren 122 benh nhan chay mau dudi nhen, ty le bien chdng co that maeh mau nao gay nhdi mau nao tren lam sang va chup cat Idp vi tfnh sp nao la 32,8%. Thdi gian xay ra co that mach mau nao trong tuan dau sau chay mau dUdi nhen cao nhat (chiem 70%)-. Cac trieu chdng lam sang chu yeu la eac trieu chdng tuang Ung cua cac mach hep d o co that, thudng cac trieu chdng cua ban eau dai nao gay cae trieu ehUng thieu hut van dpng nUa ngUdi 65%, rol loan ngdn ngU 35% va t o n thUOng day III, day VII trung uong 40%. Cae vi tri tdn thuong co that mach gay nhdi mau nao t h u d n g cung ben ban cau nao cd vj t r i phdng dpng mach nao chiem 75%. MUc d p tdn thuong la nhoi mau dien rdng chiem 60%; ngoai ra ton thuang nhd rcii rac vung chat trang va vd nao eua ban cau dai nao chiem 25%. Moi lien quan cua mpt so yeu t d den tinh trang co that mach mau nao sau chay mau dUdi nhen trong nghien eUu cua chung tdi dd la khdi phat cd ddng kinh, mUc dp chay mau nang vdi Fisher dp 111, IV; lam sang nang hdn me Glasgow dudi 9 diem la nhUng yeu yeu t d lam tang nguy co co that maeh mau nao vdi OR 3,1; 3,8 va 2,6. Sot eao va ha natri mau la nhUng yeu t d li§n quan gap ty le eao han d nhdm benh nhan C nhdi mau nao d o so that mach mau nao.
TUkhda: Chay mau dUdi nhen, eo that mach mau nao, nhdi mau nao
Summary:
Background and purpose: Cerebral vasospasm is a major cause serious clinical consequences for patients after subarachnoid hemorrhage (SAH). Cerebral infaraion after vascular spasm oceure from 20-40% of patients with cerebral vasospasm following SAH. Need to find out the risk factors for cerebral infarction due to cerebral vasospasm for prophylaxis is effeaive.Od/'ecf/ves,- Study the clinical characteristics, risk faaors of cerebral infarction after subarachnoid hemorrhage. Methods: Cross sectional prospective study on 122 patients who suffered from (SAH) addmited to stroke center, 108 hospital from January, 2009 t o may 2014.
Phan bien khoa hpc: TS. LE VAN T R U O N G 154
TAP CHl Y DUpc LAM SANG 108 Tap 9-So 2/2014
Results and conclusions: The study on 122 patients with SAH, the rates of cerebral vasospasm causing cerebral infarction was 32.8%. Time happens cerebral vasospasm in the first week after SAH (70%). The main clinical symptoms correspond with the narrow vessels spasm. Hemiplegia occures 65% of patient, speech disorders is 35%. The location of cerebral infarction is ipsilateral hemisphere of the aneurysms, accounted for 75%. The large infarction accounted for 60%; and the small lesions in white matter and cortex of the cerebral hemispheres account for 25%. The relationship of some factors to the condition cerebral vasospasm after SAH is that the onset of epilepsy, severe bleeding level with Fisher grade III, IV;
Glasgow score is less than 9, they are major factors that increase the risk of cerebrovascular spasm with OR of 3.1, 3.8 and 2.6. High fever and hyponatremia are higher proportion in the patients with cerebral vasospasm.
/Ceywords; subarachnoid hemorrhages, cerebral vasospasm, cerebral infarction
I . D a t v a n d e
Co t h ^ t maeh mau nao la nguyen nhan chinh gay hau q u ^ lam sang nSng ne cho cac benh nhan sau ehSy mau dUdi nhen. Tmh trang hep dUdng kinh cac mach mau nao d doan gan va xa tren chup mach mau nao chiem t y le kha cao tU 70% den 95% va thudng x^y ra vao ngay t h U 7 - ngay thU 14 sau dot quy chSy mau dudi nhen [11]. Nhoi mau nao sau co tUk mach mau nao gay cac thieu hut than kinh rd tr§n ISm sang va chup eat ldp vi t i n h sp nao (eo that maeh mau nao eo trieu ehUng) gap t d 20-40% cae benh nhan co t h ^ t mach mau nao chung sau chay n i a u d u d i n h e n [ 5 , 7, 8,9].
De tim hieu them dac diem lam sang eo that mach mau nao va vj tri t d n thUPng nhdi mau nao do eo that mach mau nao sau chay mau dudi nhen ehung tdi tien hanh nghien cdu nay nham mue dich
Tim hieu lam sang, cac yeu t d nguy ea gay nhdi mau nao do eo t h i t maeh mau d benh nhan chay mau dudi nhen
Kh^o sat vj tri tdn thuang tren hinh anh chup eat Idpvi tinh sp nao cae benh nhan nhdi mau nao do eo thSt mach mau nao sau chay mau dudi nhen.
2.Doi tugng va phucrng phap nghien ciiru Gom 122 benh nhan dieu tri ndi tru tai Trung tam dot quy nao Benh vien Trung UPng Quan dpi 108 t d thang 1/2009 den thang 5/2014 6dgc chan do^n xae dinh chay mau dUdi nhen khdng do chan thuong sp nao.
TSt c3 e^e benh nhan dupe theo ddi dieu tri theo
"i6t phac do thong nhat theo hudng dan dieu tri eua
hdi dot quy My bao gdm chdng phu nao bang . mannitol; Dung thudc chdng co thSt mach mau nao (Nimotop: tmyen tinh mach trong 3-5 ngay dau tU khi tiep nhan benh nhan, sau do duy tri dang vien udng den ngay 21 sau dot quy). Bao dam truyen du nude va dien giai theo xet nghiem va ap lue tinh maeh trung uong. Dieu chinh huyetap duy tri huyetap trung binh 1 0 0 - I I O m m H g .
Theo ddi lam sang eac benh nhan chay mau dudi nhen hang ngay, khi phat hien cac trieu chdng than kinh khu tru mdi hoac y thdc xau hon, ehung tdi tien hanh chup lai CT sp nao ngay de danh gia t o n t h u a n g xac dinh tinh trang co that maeh mau nao gay thieu mau. Mpt so benh nhan duoc lam sieu am xuyen so va chup DSA xae ehan mdc do co that mach mau nao.
Trong 122 benh nhan chay mau dUdi nhen ehung tdi ed 40 benh nhan ed nhdi mau nao do eo that mach mau nao tren lam sang, sieu am xuyen so va chup eat ldp vi tinh so nao,
Xd t r i sd lieu theo thuat toan thdng ke y hpc.
3. Ket qua nghien cdu
3.1. Ty le co that mach mau nao trong chay mau dudi nhen khdng do chan thuang: Tren 122 benh nhan chay mau dUdi nhen trong nhdm nghien cdu nay cd 40 benh nhan cd trieu chdng nhdi mau nao do co that mach mau nao tren lam sang, bieu hien xuat hien cac tneu chdng than kmh khu tru t u a n g Ung vdi hinh anh tdn thuong tren chup cSt ldp vi tinh so nao (ton thuong nhoi mau mdi so vdi phim chup lan dau cua ehay mau dudi nhen), chiem ty le 32,8%
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol9-N°2/2014
3.2. Ddc diem chung nhdm nghien cdu
Bang 3.1. €>ac diem lam sang chung
Trieu chij'ng lam sang Tuoi trung binh
Khdi phat dot ngot cap tinh Thdi gian vao vien trung binh (gicJ) Dau dau dCrdoi dot ngot Buon non va non vot Co giat dgng l<inh khi I<h6i phat Hoi churng mang nao (cLfng gay; Kernig) Huyetap tam thu trung binh luc vao vien Huyet ap tam truang trung binh lucvao vien Mach trung binh khi vao vien Roi loan y thtrc khi vao vien Glasgow < 9 diem Roi loan y thiJc khi vao vien Glasgow tir 9 diem den 15
Phan theo dp Hunt - Hess luc vao vien:
B o l - I I B 6 I I I - I V - V
Nguyen nhan do v6 phong dgng mach nao Mure do mau chay tren chup CT so Fisher do III-IV
Nhom CO that mach mau nao gay nhdi mau nao
n = 4 0 50,3 ± 1 7 , 2 37 (92,5%) 27,5 ± 6,4 38 (95%) 26 (65%) 14(35%) 38 (95%) 123,7 ± 2 4 , 9 m m H g
78 ± 14,2mmHg 1 0 2 , 9 ± 1 2 , 8
16(40%) 24 (60%)
18(45%) 22 (55%) 30 (75%) 32 (80%)
Nhom khong co t h i t mach mau nao
n = 82 48,6 ± 1 8 , 4 75 (91,4%)
28,2 ± 5,9 76 (92,6%) 52 (63,4 %) 12(14,6%) 69(84,1%) 145,3 ± 2 1 , 5 m m H g
8 3 ± 1 2 , 3 m m H g 89 ± 1 4 , 5 17(20,7%) 65 (79,2%)
60 (73%) 22 (27%) 42 (58%) 42 (51,2%)
P
>0,05
>0,05
>o;o5
>0,05
>0,05
<0.05
>0,05
<0,05
>0,05
<0,05
<0,01
<0,01
<0,05
<0,05
Cac tneu chdng lam sang chay mau dudi nhen trong nhdm nghien cUu nay thudng gap nhat la khdi phat cap tinh vdi trieu ehUng dau dau dot ngpt, ndn, edng gay. Dd la tam chdng noi bat eua hpi chUng mang nao, gap ty le eao d ca hai nhdm cd co that mach nao va khdng eo that maeh nao. Khdng co sU khac biet gida hai nhdm ve cae trieu chUng nay. Thdi gian vao vien dUOc cap cdu dieu trj ea hai nhdm nhu nhau vao gid thd 27- 29 sau ddt quy
Co giat dpng kinh khi khdi phat, huyet ap tam thu trung binh thap, maeh luc vao vien nhanh >100 Ian/phut d nhdm co that mach mau nao eao han nhdm khdng eo thit maeh mau nao cd y nghTa thdng kevdi p< 0,05.
Rdi loan y thUc vdi diem Glasgow dUdl 9 diem va mde dp nang eua chay mau dudi nhen (theo phan dp Hunt - Hess III - IV - V va mde dp mau chay theo Fisher dp III, IV) va nguyen nhan do vd phdng
ddng mach nao d nhdm co that maeh mau nao eao hon han so vdi nhdm khong co that mach mau nao.
Su khae biet ed y nghTa thdng ke vdi p < 0,05.
3.3. Dac diem lam sang nhom nhoi mau nao do CO that mach mau nao
Khi cae benh nhan duac theo ddi chat ehe theo gid, neu phat hien eac trieu chdng than kinh khu tru mdi so vdi thdi diem khi vao vien hoac dien bien y thUc xau hon gida hai lan kham lien tiep trong ngay, cac benh nhan nay dupe chup lai CT sp nao, mpt so it chup mach mau nao loai trU ehay mau tai phat va phat hien eac ton thuang nhoi mau mdi chdng minh hau qua eua ton thUOng co that maeh mau nao. Trong 122 benh nhan ehay mau dudi nhen cd 40 benh nhan cd nhoi mau nao do co that mach mau nao tren lam sang rd va hinh 5nh chup cat Idp vi tinh.
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TAP CHl Y DLfOC L A M S A N G 108
Tap 9 - S o 2 / 2 0 1 4
Bang 3.3. Trieu chijfng Iam sang nhom co that mach mau nao Trieu chijfng lam sang
Xay ra co that mach nao trong 3 ngay dau X3y ra co that mach nao tir ngay 4 - 7 X l y ra co that mach nao tir ngay 8 - 1 4 X l y ra CO that mach nao tCr ngay 14 - 21 Llet nCra ngudi
Llet mot tay hoac mgt chan don thuan Llet hai chan
Roi loan ngon n g i j k e m theo Liet cac day than kinh sg nao (day III, VII)
Solugng n = 4 0
10 18 8 4 26 12 2 14 16
T y l e % 25%
45%
20%
10%
65%
30%
5%
35%
40%
Co that maeh mau nao xay ra t r o n g tuan dau sau ehay mau d u d i nhen eao nhat (ehiem 70%). Cae trieu chdng lam sang chu yeu eua eo that mach mau nao sau chay mau d u d i nhen la eac trieu chUng
t u o n g Ung cua eac mach hep do co t h i t , t h u d n g cac trieu chUng eua ban eau dai nao gay cac trieu ehUng thieu h u t van d d n g , n g d n ngU va day VII T r u n g u o n g .
Being 3.4. Dac diem tdn thUPng tren chup cat ldp vj tinh so nao
V i t r i t o n t h i / o n g
6 nhoi mau khu vuc lien quan gan tcfi mach nao ton thuong (co phinh mach)
Nhoi mau dien rong ban cau Nhoi mau vung phan thuy
Nhoi mau nho rai rac vung chat trang va vo nao
Soluong n = 40
30 24 6 10
Ty le % 75%
60%
15%
25%
Cac vi tri t o n t h u o n g eo that mach gay nhdi mau nao t h u d n g cung ben ban eau nao cd vj tri phong ddng mach nao chiem 75%. MUe dp t d n
t h u o n g la nhdi mau dien rpng chiem 60%; ngoai ra ton t h u a n g nhd rai rac vung chat t r l n g va vd nao cua ban cau dai nao chiem 25%
Bang 3.5. Lien quan mot so yeu t o v d i tinh trang co that mach mau nao
Cac yeu to lien quan Co giat dong kmh khi khcJi phat
Huyet ap tam thu trung binh thap dudi lOOmmHg
Mach nhanh >100 I/phut khi vao vien R6i loan y thifc khi vao vien Glasgow < 9 diem Mile do chiiy mau tren CT so nao Fisherdolll-IV
Sfit cao
Ml loan dan truyen QT keo dai
Nhdm cothSt mach mau nao
n = 4 0 14(35%) 15(37,5%) 21 (52,5%) 16(40%) 32 (80%) 30(75%) 19(47,5%) 15(37,5%) 18 (45%)
Nhdm khdng CO th^t mach mau nao
n = 82 12(14,6%) 22 (26,8%) 40 (48,8%) 17(20,7%) 42(51,2%) 42(51,2%) 29(35,3%) 23 (28%) 22 (26,8%)
OR 3,14 1,64 1,1 2,6 3,8 2,85 1,65 1,54 2,2
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vo!9-N<^2/2014
Nhdn xet: Khao sat m d t sd yeu t o lien quan chung t o i thay khdi phat cd d p n g kinh, mdc d p ehay mau nang vdi Fisher dp III, IV; lam sang nang h o n m e Glasgow dUdi 9 diem la nhu'ng yeu yeu t d lam t a n g nguy c o c o that maeh mau nao vdi OR 3,1;3,8va 2,6.
M d t so yeu t d khae nhU ha natri m a u , huyet ap t r u n g b i n h t h a p , sot cao eung anh hUdng d e n benh nhan chay m a u d d d i n h e n c d t h e lam t a n g nguy eo bien c h d n g eo t h a t maeh m a u nao vdi OR 1,6.
Hinh dnh chdy mdu dddi nhen do vd phong dgng mach ndo gida ben trdi ngdy thd nhdt tren chup cat ldp vi tfnh sg ndo vd chup mgch md hda xoa nen
Hinh dnh nhoi mdu ndo dien rong bdn cau trdi gdy phu ndo dc tinh do eo that mgch mdu ndo sau chdy mdu dddi nhen ngdy thd 12
4. Ban luan
4.1. Co that mach mau nao la mdt trong nhUng bien chdng hay gap nhat va quan t r p n g nhat eua chay mau dUdi nhen, chiem khoang 70%, t u y nhien chi ed khoang 30% gay nhdi mau nao d o hau qua eua t i n h trang co t h a t nay. Bien ehUng nay I n h
h d d n g nhieu d e n t y le t d v o n g va di c h d n g nang cua chay mau d u d i n h e n [4, 6, 9]. Ty le bien chdng co t h a t mach mau nao gay nhoi m a u nao t r o n g nhdm nghien eUu ciJa ehung t d i la 32,8%. Trong nghien eUu cda tac g i l Vu Q u y n h H u o n g la 31,3%, [1 ] tac giS Vd Hdng Khdi la 37,5% [2]. M p t n g h i e n edu cda tae gia Stefan Weidauer va cpng s u t r e n 364 benh nhan
TAP CHfVDUpCLAM SANG 108 Tap 9-So 2/2014
diSymau d u d i nhen cd 117 benh nhan (32,1%) [10]
CO giam t u d i mau nao d o eo that maeh gay nhdi maunao. N h u v a y k^t qua eua chung t d i eung t u o n g tii nhu cae tae g i ^ t r o n g va ngoai nude.
4.2. Lam sang tinh trang nhoi mau nao do co that mach mau nao sau ehay mau dUdi nhen la khdng dae hieu. T h u d n g bien chdng co that mach mau nao xuat hien sdm tu" ngay t h U ba sau chay mau dudi nhen va d i n h eao la ngay t h d bay, giam dan t d ngay t h d 14 cho den ngay thU 21 cua benh - thd beiy [3, 4, 9]. Bieu hien lam sang la t i n h trang ngUdi benh da on d i n h hoac t h u y e n giam lai t r d nen nang hon vdi trang thai y thdc lu lan, thieu sdt than kinh khu tru n h u Met nda ngudi, liet cae day than kinh so, rdi loan ngdn ngU. Ket qua eua chung tdi co thit mach m a u nao xay ra t r o n g tuan dau sau chay mau dudi nhen cao nhat (chiem 70%). Cac trieu chdng lam sang ehCi yeu la eac trieu chdng t u o n g Lfng cOa cae maeh hep do co that, t h u d n g cac trieu chdng cda ban cau dai nao gay cac trieu ehUng thieu hut van dpng nda ngUdi 65%, rdi loan ngdn ngd 35%
va ton thuong day III, day VII trung uong 40%. Cae nghien cUu thay r i n g eo that maeh thudng xay ra d dpng maeh dupc bao quanh bdi khdi lUpng mau ehay nhieu trong khoang dudi nhen va ddng mach cd tui phinh bi vd [4, 6, 7, 8]. Co che co t h i t maeh nao t h d phat sau ehay mau dudi nhen do eac san pham thoai bien cua hdng eau trong djch nao tuy, t d Oxyhemoglobin thanh Deoxyhemoglobin rdi Methemoglobin cudi cung thanh Bilirubin, hydroperoxyde va tham nhiem cua bach cau cae chat nay kich thich thanh mach gay co maeh [4,6,9].
Theo cae tae gia su phan huy cua hdng cau d khoang dudi nhen tao ra cac san pham n h u Serotonin, Prostaglandin, Thromboxan A2, Angiotensin, eathecolamin, Histamin..., cac chat thoai hda tU tieu cau va cac chat de gay viem khac, cae chat nay gay phan Ung viem dan den co t h i t mach. Ket qua ehung tdi 75% 6 nhdi mau nao d khu VUe b i n eau nao eung ben vdi vj tri tui phong bj v d v l mdc do t o n t h u o n g gay nhdi m l u nao dien rdng la 60% (do elc tui p h o n g d da g i l e Willis) ( b i n g 3.4).
C6 25% benh nhan ed 6 nhdi mau nao khu vUc chat trlng v l vung v d , d day ed the lien quan den g i l m
luu lupng m l u n i o chung eua cae benh nhan c h l y mau dudi nhen do t i n h trang phu nao h o l e huyet ap t r u n g binh thap dan den thieu mau v u n g giao thdy g i l p ranh gida eac vdng noi trong sp [3,6, 7,9].
Trong m p t nghien eUu eua tac g i l Stefan V/eidauer, MD; Heinrieh L, nam 2007, k h i o sat chup cat Idp vi tinh tudi mau nao ddi chieu vdi xac djnh mUe dp hep mach m l u do co that, ket qua cho thay eac t o n t h u a n g gay nhdi mau nao sau ehay m l u dudi nhen I I hau qua eua eo t h i t maeh mau nao khi mde dp eo mach gay hep tren 50% dudng kinh Idng mach. 87,5% eac benh n h i n x l y ra co t h i t mach vao ngay t h d 7-14, trong so dd cd 52,5% la co that mach cd trieu chUng vdi bleu hien 6 nhdi mau nao tUong Ung vung phan phdi eua mach m l u bi eo that tren ehup e l t Idp vi t i n h so nao. Vj tri 6 nhdi m l u Idn x l y ra ngay canh vung ton thUpng mach chiem 47%;
nhdi m l u 6 khuyet 20%, nhdi m l u dang p h i n thuy (watershed infarcts) 26%, nhdi m l u vung vd ndng chiem 7% [9].
Nhu vay ket q u i cua ehung tuy khdng dUpc chup maeh mau nao tat ca cac benh n h i n nhdi mau nao do eo t h i t , nhung hinh I n h tren chup e l t Idp vi tinh sp nao cung tUong Ung vdi nhUng mach m l u bj ton t h u a n g nhU cd tui phdng, hoac x l y ra d elc mach Idn nen so n h u dpng mach nao gida, ddng mach nao trUdc (nhdng vung cd nhieu mau trong khoang dUdl nhen nhU be quanh cau}, g l y nhdi m l u nao 6 Idn hoac dien rpng b i n e l u ciJng ben mach bj t d n t h u a n g .
MUe dp nang v l dien ton thuong cua nhdi mau nao sau co that mach m l u nao nay r i t phu thudc v I o tinh trang tuan hoan bang he cua tdng benh nhan va tinh trang eo t h i t doan gan hay xa cua mach mau nao. Tac g i l Stefan Weidauer trong nghien cdu cua minh eung nhan thay nhoi mau nao 8 1 % elc benh n h i n nhdi m l u nao cd eo t h i t mach m l u mdc do nang, 16% eo t h i t raUc dd vda va 3%
eo t h i t mUe d d nhe tren chup DSA mach nao. Cac nhdi mau 6 Idn dien rdng do eo t h i t doan gan cua maeh m l u bao gom ddng mach c i n h doan trong so C l , ddng maeh nao gida M l , ddng mach nao trudc A l . d d n g maeh nao sau P I , ddng mach than nen v^
doan ddng mach dot sdng trong so V4 chiem
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol9-N°2/2014
68/134 benh n h i n (50,7%) [9]. Ket qua cua chung t d i nhoi m a u nao dien rdng I I 60%, cao hpn tae gia t r e n . 4.3. Moi lien quan cua mpt so yeu to den tinh trang nhoi mau nao do co that mach mau nao sau chay mau d u d i nhen t r o n g n g h i e n edu eua c h u n g t d i d d la khdi p h i t ed d p n g kinh, mdc d p chay mau nang vdi Fisher d p III, IV; lam sang nang hdn m e Glasgow dUdi 9 diem la n h d n g yeu yeu t d lam t a n g nguy co co that maeh mau nao vdi OR 3,1;3,8 va 2,6.
M d t sd yeu t o khac n h u ha natri m a u , huyet ap t r u n g binh thap, sdt eao eung anh h u d n g den benh nhan chay m l u d u d i nhen cd t h e l i m t a n g n g u y eo bien ehUng eo that maeh mau nao vdi OR 1,6.
Theo e l c tae gia tren t h e gidi cd sU lien quan gida t i n h trang co that mach mau nao vdi so lUpng mau c h l y t r o n g khoang dUdi nhen tren p h i m chup cat Idp vi t i n h sp nao t r o n g v o n g 4 ngay ke t d khi v d mach gay chay m l u d u d i nhen. Theo cac tac g i l nay thi be day cua mau t r o n g khoang dudi nhen d cac be day tren 3 m m , hoac be day cua m l u t r o n g e l c ranh cudn nao tren 1 m m thi da so g l y co that maeh.
Cae benh n h i n c h l y mau d u d i nhen nguyen nhan do v d p h o n g d d n g mach nao eung bi co that mach mau nao nhieu hon n h d m ehay mau dudi nhen d a n t h u a n do chan t h u o n g [6, 9]. G i l l thich dieu n l y e l c nghien cdu eho rang khi v d p h o n g d p n g mach nao, Idp ndi mac tang sinh, day len, hoai t d spi ea va x o hda Idp l o gida, tang sinh eo t r o n , lang d p n g collagen, tang ket d i n h tieu cau d i n den day thanh d d n g mach g l y hep Idng mach, roi loan cae yeu t d v i n maeh, mat kha n i n g t u dieu hda dan den eo t h i t maeh nao va g l y nhdi m l u nao [3,6, 8,9].
Tmh trang co giat d d n g kinh khi khdi phat t h u d n g do v d nhdng p h d n g d d n g mach Idn gay nen, lupng m l u chay ra khoang dUdi nhen nhieu va d o t ngot dd cung chinh la yeu t d lam t a n g co t h i t maeh m l u nao, t h e m vao d d t i n h trang thieu d xy nao t r o n g can eo giat eung l i m t a n g n g u y eg nhdi m l u nao. Sdt keo d i i , ha natri mau la nhdng yeu t d lam tang phu nao va t d n t h u o n g te b i o nao, do vay lam tang t h e m mdc dp thieu mau hau qua l l nhoi mau nao.
Trong nghien cUu eua ehung tdi eung nhan thay elc benh nhan ehay mau dudi nhen cd bieu hien sdt eao keo dai eung n h u rdi loan ha natri m l u hau q u i
hpi c h d n g SIADH va CSW hoac d o d u n g lpi tieu, c h o n g p h u nao m a n n i t o l , lam t a n g n g u y eP co t h i t mach m a u nao v d i OR la 1,5 va 1,65. Viec dieu tri ha sot eung n h u b u d i e n giai d u eho b e n h nhan c h l y m a u d u d i n h e n hy v p n g se g i a m dupe n g u y co co t h a t mach mau nao.
5. Ket luan
Nghien cdu tren 122 b e n h nhan ehay mau dudi nhen, t y le bien chUng co t h i t mach m a u nao g l y n h d i mau nao tren l i m sang va ehup eat Idp vi tinh sp nao la 32,8%. Thdi gian xay ra co t h a t maeh m l u nao t r o n g t u a n dau sau ehay m l u dUdi nhen eao nhat (ehiem 70%). Cac trieu c h d n g lam sang ehu yeu la eac trieu chUng t u a n g Ung eua e l c maeh hep do CO that, t h u d n g cac trieu c h d n g cua b i n cau dai nao gay cae trieu chUng thieu h u t van d d n g nda ngudi 65%, roi loan n g d n n g d 35% va t d n t h u a n g day 111, day VII t r u n g u a n g 40%.
Cac vi t r i t o n t h u a n g co t h i t mach g l y nhoi m l u nao t h u d n g c u n g ben b i n cau nao cd vj tri phong d d n g maeh nao chiem 75%. MUc dp t o n t h u a n g la nhoi m l u dien rpng c h i e m 60%; ngoai ra t o n thuong nhd rai r i c v u n g chat t r a n g va v d nao cua ban cau dai nao chiem 25%.
M o i lien quan cua m p t sd yeu t d den t i n h trang eo t h a t mach m l u nao sau c h l y mau dUdi nhen t r o n g nghien edu cua chung t o i d d la khdi p h I t ed d d n g kinh, mde dp chay mau nang vdi Fisher dp III, IV; lam sang nang h d n m e Glasgow dUdi 9 diem la n h d n g yeu yeu t d l i m t a n g n g u y eo co that mach m l u n I o vdi OR 3,1; 3,8 v l 2,6. Sdt cao va ha natri m a u la n h d n g yeu t d lien q u a n gap t y le cao hpn d n h d m b e n h nhan cd co t h a t maeh m a u nao.
T a i l i e u t h a m khao
1. Vu Quynh Huong (2009), Nghien cUu lam sang, c^n l i m s i n g t i n h trang co t h i t maeh mau nao bang sieu am Doppler xuyen sp mau d benh nhan c h l y m l u dudi nhen, Luan an tien si.
^. Vd Hong Khdi (2011), Nghien eUu dac diem lam sang, hinh anh Doppler xuyen so v l c i t Idp vi tinh 64 day d benh nhan co t h i t mach mau nao sau chay m l u dudi nhen, Luan an tien sT y khoa.
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TAP CHl Y DUOC LAM SANG 108 Tap9-S62/2014
Nguyen Van Thdng (2013), "Chay mau dudi nhen do phinh mach" B^nh hpc than kinh (Giao trinh sau dai hpc), NXB Y hpc, tr 119 -127 American heart Association (2012), Guidelines for the management of Aneurysmal Subarachnoid Hemorrhage, Stroke, 43; 1711 -1737
Caplan L.R (2009), "Subarachnoid Hemorrhage, Aneurysms, and Vascular Malformations" in Stroke: A Clinical Approach, Fourth Edition by Saunders, an i m p r i n t of Elsevier Inc, Trang 446 - 486
Forsting M, Wanke I, Dorfler A (2008), Intracranial Vascular Malformation and Aneurysm (from Diagnostic Work - Up to Endovaseular Therapy), Springer, pp 1 - 270
Henneriei MG, BogousslavskyJ, Sacco RL (2005),
"Subarachnoid Hemorrhages", Stroke in clinical practices Series, Churchill livingstone A division of Harcourt and company, pp 83 -125.
James D. Geyer, Camilo R. Gomez (2009), Stroke A Practical Approach by Lippincott Williams and Wilkins, Kluwer business, pp 226 - 237 Mayer SA, Bernardini GL, Solomon RA (2010)
"Subarchnoid hemorrhage" in :Rowland LP, Merrit's Neurology, 12'^ Edition, Lippincott William and Wilkins; pp 308-317
Stefan Weidauer, MD; Heinrieh lanfermann, MD..
(2007), Impairment of cerebral perfusion and infarct patterns attributable to vasospasm after aneurismal subarchnoid hemorrhage. Stroke; 38:
1831 -1836.
