Summary
ANGIOARCHITECTURAL FEATURES ASSOCIATED WITH COMPLETE OBLITERATION OF BRAIN ARTERIOVENOUS MALFORMATIONS BY HISTOACRYL EMBOLIZATION
Objective: The suecessfull rate of endovascular treatment df brain arteridvendus malformations (AVMs) with N - butyl cyanoaerylate (Histoacryl) according to the reporters were very differents. This study aims to correlate the angioarchitecture of AVMs with their complete obliteration of such treatment in a Viet nam population. Methods: A total of 161 patients with 162 AVMs were studied between May 2000 and May 2009. The angiographic features of each brain A V M have analysed on angiography associated with CT or/
and MRI, include: location of AMVs (cortical, deep feeders and both of them); maximum size of nidus ( <
3cm, 3 - 6em and > =6cm); location and number ( 1 ; 2; and > 2) of feeders; and location and numbers ( 1 ; 2; and > 2) of draining veins; classification according to Spetzler - Martin from I to V grade. Univariate and multivariate analyses were conducted in order to test the associations between morphological features and complete obliteration of AVMs. Results: Complete embolization was achieved in 46 eases (28.4%).
Embnlizatidn resulted in mdrtalily rate of 4.35% and a morbidity rate of 1.24%. AVMs had total emboliza- tion with with single feeder in 92.86% (OR, 43.66; 9 5 % Cl, 8.64 to 220.70) and with AVMs < 3em in 4 7 . 3 1 % (OR, 17.20; 9 5 % Cl, 5.50 to 84.46). Complete embolization was negatively associated with AVMs location, site of feeders, site and number of venous drainage. Conclusion: This study suggest that the overall cure rate of AVMs with histoacryl embolization was 28.4%. AVMs w i t h single feeder and small nidus < 3cm were significant asoeiated features for complete embolization.
Keywords: brain arteriovenous malformations, angioarchitectural features, cyanoaerylate glue embolization
NGHIEN CL/U MOT SO YEU TO NGUY CO LIEN QUAN BENH TIM MACH CUA H O I C H L / N G SA SUT TRI TUE TREN
BENH NHAN ALZHEIMER
Pham Thang', Tran Viet Li/c^
• ' 'Benh Vien Lao Khoa Trung dang;'Tnfdng Dai hoc Y Ha Noi Muc tieu: nghien cdu vd phdn lich mot sd yeu td nguy ca mach mau cua hdi chdng sa sut tn tue (SSTT) tren benh nhan mdc benh Alzheimer tai Benh vien Lao khoa Trung ddng. Dd'i tugng vd phuang phap nghien cdu: nghien cdu theo phddng phap benh - chdng. Nhdm benh: 81 benh nhan ddde chan doan xac dinh mdc benh Alzheimer theo tieu chuan DSM- IV- TR, nhdm chdng: 87 benh nhan khdng bi sa sut tri tue, cung ludi, cung gidi, cung tnnh do hoc van, khdng bi cdc benh cap tinh lam rd'i loan y thdc nhd tai bien mach mdu nao giai doan cap cdu, viem ndo, dp xe nao, viem mang nao cap, rdi loan chuyen hda cap va khdng bi cac tat giac quan. Tat ca cac benh nhan ddac khdm lam sang, lam cdc trdc nghiem than kinh tam ly vd xet nghiem can thiet. Ke't qua: sd khac biet gida hai nhdm ve mot sd ye'u td thudc mach mdu vdn ddcic coi Id yeu td nguy cd cua sa sut tri tue cd y nghia thdng ke. Ndi bat nhat la cac yeu td nhd tang huyet dp, suy tim, beo phi, tang cholesterol, tang dddng mdu vd yeu td viem. Ke't luan: nghien cdu da khang dinh ddac vai trd cua mot sd yeu id nguy ca lien quan den tim mach nhd: beo phi, tang cholesterol, suy tim trong hoi chdng sa sut tri tue tren benh nhan mdc benh Alzheimer
I. DAT VAN DE
Ngdy nay, tud'i thp eiia con ngu'di dang tang len nhanh chdng. So' ngddi gid (tir 65 tud'i trd len) tren the gidi se tang td 420 trieu nam 2000 len k h o i n g 1 ty ngddi vac nam 2030. Sa sui tri tue"
(SS FF) la locii benh ly thUdng gdp d ngddi gid, do n h i l u nguyc'Mi nhan khac nhau. Day la nguyen nhan chinh gay nen tan phe, phai nhdp vien vd lam giam sut tud'i thp cua ngUdi gia. ITong cac nguyen nhan gdy sa sdt t i i tue, benh Alzheimer Id nguyen nhan hay gap nha't, tiep den la sa sdt tri tue do nicich mdu vd mdt so nguyen nhdn khde.
Mac clu da cd nhicni lif-'n bd trong vic^c chan doan sdm nhdng vd'n d l d i l u tr| benh cdn nhieu hcin d i e . Tdc dphg va k i l m soat cdc yen td nguy cd la mdt hddng t d t r i l n vong nhdm gdp phdn lam chcim tdc dp tie'n trien cua benh. CTiinh vi Vciy, tren the gidi, rcit nhic^u cdng trinh nghien cdu Cjliy md ldn da ddoc tien hanh c\a tim ra cdc yc'ti to' nguy ed gdy b(}nh Alzheimer. I rong so cdc ycnl to' nguy cd cd the cai bie'n ddde, yen to nguy ca v l mach mdu ddde nghien edu nhieu nhci't tren thc"^' gidi. CJ Vict Nam, van de SSFT ngdy cdng clddc chu y n h i l u hon. Tuy vdy, so Iddng edng Irihh nghien cdu ve cae ye'u to nguy ed cua SSTT ndi chung vd trong benh Alzheimer ndi rieng, vdn ehda t d nhieu. Xuci't phdt tCr ly do neu tren, vdi hy vong cung cap cho thdy thuci'c ldm sang mcit so' Ihdng tin hCru ich trong kiem sodt benh Alzheimet, chdng tdi tien hdnh de (ai: "Nghien cdu mot sd yeu td nguy ca ve mach mau ciia hcji chdng sd sut tri tuif Iren benh nhan Alzheimer tai Benh vicn Lao Khoa Trung dang" ^cu muc tieu:
Phan tich va danh gia vai trd cua mgt sd ye'u td nguy ca mach mau cua SSTT tren benh nhin mac benh Alzheimer tai Benh vicn Lao khoa Trung uang.
II. DOI TUONG vA PHL/ONG
P H A PNGHIEN CL/U
1 . Doi tddng nghien cdu
- Nhdm benh: 81 benh nhdn ddde t h a n dodn xdc dinh hi benh Al/heimc^r theo tic'ii chuan cua DSM-IV-TR.
- Nhdm chdng: 87 ngddi khdng bj sa sut trf tue, t i i n g ludi, t u n g gidi, t d n g trinh dp hpc: vdn, bi mdt so' benh nhd: thodt v| dia clem tot sdng t h i t ldng, migraine, hcii t h d n g l\vn dinh, thodt vj dia clem cc)t song tei' boat bj t h e n ep luy to . Nhdng benh nhdn bj t d t benh t a p tinh lam rdi locin y t h d t nhd tai bie'n m.ith mdu nao giai dcwn tci'p t d u , viem nao, dp xe nao, viem mang ndo t a p , rdi loclli t h u y i n hda, t h a n thddng sp nao giai doan Ccip edu se khdng ddcic (\da vdo nghic'^i cdu.
Cdc benh nhan tham gia nghien cdu kHdhg bj cdc tcit gide quan vd khdng mu thCr.
- Fcit t a cdc btuih nhan hode ngddl ckai dien trdng nghien edu d i u Id ngUyc'n ky giay ddng y tham gia nghien cdu. C^iiy Irinh nghien cdu cua de lai da ddde Hdi ddng Y ddc eua bc'^ih vien thdng qua.
2. Phu'dng phap nghien cu'u
Phddng phdp nghien t d u Benh Clidng:
- Tcit ca t d t dd'i tddng nghien t d u ddde khdm ldm sdng tl ml, ldm cdt trdc i i g h i | m than kinh tdm ly edn thiet de chan dodn.
- Td't e l IxMih nhan ddde lam cdc xel nghiem Ccin ldm sang cdn thiet.
- Xd ly so lieu b i n g chdong trinh Epi. Info 6.0 vd SPSS phien b i n 15.0.
III. KET QuA
1. Dae diem ehung ciia nhom nghien cufu
60 n SO-
SO
0
31
50
1 ,
43
1
n Alzheimer D Chirng
D < 65 tuoi D >= 65 tu6l Nam NO' Bieu dd 1. Ty le nam vd nd gida hai nhdm nghien cdu
35 30 25 20 15 10 5 0
alzheimer chu-ng Bieu dd 2. Cdc nhdm tudi trong qudn the nghien cdu
2. M()t so yeu to nguy co mach mau t lia sa sut tri tue
2.1. Md'i lien quan gida benh beo phi, rd'i loan lipid mau vdi sa sut tri tue
Bdng 1. Mdi tuang quan gida chi sd BMI vd lipid mdu gida hai nhdm nghien cdu
BMI
17 9 31
1
30.4
1
RICH lipid 1
C'holeslerol 1 riglycerid
IIDF-C FDF-C
Alzheimer (X ± SD) 21,87 ± 2,75
6,28 ± 1,11 4,25 ± 2 , 5 7 1,40 + 0,66 2,94 ± 0,83
81
Chiirng (X ± SD) p 20,64 ± 2,74 0,004
5,10 ± 1,04 0,045 2,58 ± 1 , 6 0 0,049 1,26 ± 0 , 5 1 0,15 2,92 ± 0,73 0,08
87
Nhan xet: nhdm Ijenb nhan bi benh Alzheimer cd cbl sd BMI cao ban so vdi nhdm chdng. Ket qua nay tddng ttf ket qua ciia cde tac gid D.S.Knopman; A.S. Buchman, j.A. Liichsinger. Trong nhdm benh, iwng dci cholesterol va triglyceride cao ban nhdm chdng. Sd khac biet cd y nghia thdng ke. I lai thanh phan cdn lai cua lipid mdu (H3t-C; EIDL-C) khdng khde /j/et gida hai nhdm bc'nh va chdng. Ket cjiia trong nghien cdu nay phu help vdi nghien cdu cua tdc gia A.Solomon.
2.2. Moi lien quan gida benh dai thao dudng va sa sut tri tue
Bang 2. Md'i lien quan gida henh tJTD vd sa sut tri tue
Glucose HbAlC Mieroalbumin nieu
Alzheimer (X ± SD) 7,49 ± 2,55 5,98 ± 1,35 26,85 ± 6,58
Chdng (X ± SD) 5,95 ± 3,05 5,97 ± 1,30 24,75 ± 13,36
P 0,032
0,99 0,36 Nhan xet: ndng do dddng gida hai nhdm benh vd chdng khdng cd y ngbla thdng ke
2.3. Md'i lien quan gida benh ly tim mach, huye't ap va sa sut tri tue
Bang 3. Md'i lien quan gida huyet ap, benh tim mach vd sa sut tri tue
Benh van tim Suy tim Rung nhi
Alzheimer (n = 81) 12
39 5
ehufng (n = 87) p 1 0,041 9 0,03 2 0,15 Cde benh tim khde
Tang FIA
FIA tam thu HA tdm trUdng
145,93 ± 18,49 (X ± SD) 77,47 ± 1 1 , 1 3
124,08 ± 15,13 (X ± S D ) 75,52 ± 9 , 4 9
0,048 0,22
Cd tang HA 60/81(74,1%) 41/87(47%) 0,049
Nhan xet: cac benh nhan bl benh Alzheimer cd ty le mac benh tim mach cao han. Ddc biet nhom benh van tim vd suy tiin d nhdm bi sa sut tri tue cao ban ban so vdi nhdm chdng. Sd khac biet co y nghia thdng ke. Ket qua nay cua chung tdi tdang td vdi tdc gia C.Quiu. Nhdm benh cd ty le bi tang huyet dp cao han nhdm chdng. Trong dd, chii yeu eac benh nhan bi tang huyet dp tam thu. Ket qua nay phu he/p vdi nghien cdu ciia tdc gia L.B.hloffmann.
2.4. Md'i lien quan gida xa vda mach, nong do CRP va sa sut tri tue
Bang 4. Moi lien quan gida benh tinh trang DM canh, ndng do CRP va sa sut tri tue
Hc?p t i e ddng mach d n h
Nong dp CRP
Cd Khdng Trung binh So tang CRP
Alzheimer
52 6 4 , 2 % 29 35,8%
1,68 ± 0 , 5 7 30/81 (37%)
ehu'ng
35 4 0 , 2 % 52 59,8%
0,46 ± 0,93 4/87 (9,2%)
P, OR
0,075, OR:2,66 0,043 OR: 3,78
0,032 Nhan xet: sd khac fa/er gida hai nhdm ben/i va chdng ve hnh trang ddng mach canh khdng cd y ngbla thdng ke nhdng ndng do CRP lai khac biet nhieu gida hai nhdm.
IV. BAN LUAN
Nghien cdu ndy ddoc thdc hien nham tim hieu cdc yen tei' m<ich mdu cd lien quan den sa sdt tri tue . Ndi v l md'i lien quan gida sa sut tri lue vd tinh trcing beo phi, k h i n g djnh thdng qua cbl sd BMI va vdng bung cdn cd n h i l u y kie'n khde nhau. Mdt so tdc gia nhd A.S. Buchman, j.A.
Luehsinger khang djnh beo phi cd lien quan mcit thiol vdi sa sdt trf tue. Ngddc" \a\, theo M.T.
Sturnman, BMI cao khdng cd gid trj tien Iddng sa sut tri tue d ngddi eao tud'i | 8 l . Fhcim chi, theo nghic^n edu c\\a D.S.Knopman, d phu nd bj sa sut tri tue, t h i sd' BMI thddng thd'p trong vdng 10 ndm trddt khi benh bieu hien tren ldm sang |3|. Fdt gia J.A.Luthsinger t h o r i n g , b i n than ngildi gia thddng t d t h i so BMI thd'p, kem theo cac rd'i locin frong giai do<in tien ldm sang cua sa sut tri tue da the giciii mdi lien c|iian giCra bc^o phi vd sd rd'i loan tua hoat ddng nhcin thdc d ngddi cao tud'i |5]. Rdi loan lipid mail eung ddde cdi la mdt yeu to nguy cd eiia sa sut tri tue, nha't la nong dp cholesterol toan p h i n . Theo nghien edu cua A.Soldinon.'nong dci cholesterol todn p h i n eao d tud'i trung nien Id nguy cd eao cua sa sdt tri tue [ 1 | . i i i y nhien, theo nghien cdu c:ua M.M.MieIke, nong dp cholesterol thddng tha'p d benh nhan sa sut tri tue giai dejin mupn. Tham ehi, nong dp cholesterol toan p h i n va FDF- C cao thudng di kem vdi k h i nang hoat dpng tri tue lot hon d nhdng ngddi tud'i rat eao (tren 90 tud'i), khdng bj sa sdt tri tue va khdng mang allele AP0E4 | 9 l . Dai thao dddng type II ddde khang dinh Id mdt yen to' nguy cd cua sa sut tri tue dc benh Alzheimer va hdn hdp, nha't la khi xua't hien tren ngddi mang allele AP0E4 [4].
Frong nghien cdu cua ehung tdi, cd sd lien quan khd rd net gida nong dp dddng trong mdu va sa sut tri tue. i u y nhien, bie'n chdng tren than eua benh tieu dddng (the hien qua nong dp mieroalbumin nieu) ehda thdy khde biet gida hai
dUdc de cap nhieu trong cdc yen to nguy ed sa sdt tri tue trong benh Alzheimer. Nhdng bc'nh nhdn tang huye't dp ddde dieu trj thudt ha dp deu dan se it t d nguy t d bj bc'iih Alzheimer hdn do mdt dp t d t ton thddng benh ly nhd ddm rdi t d t h a n kinh hoat m i n g lao hda it hdn, nhat la d khu \idc hdi hdi ma (khu \idc hay bj td'n thddng nhcit trong benh Alzheimer) [6|. Benh ly tim m<itli, nhd't la suy tim, cdng lam tang t'/ le mdi m i c cua benh Alzheimer. Mdi liem quan gida benh tim vd sa sdt tri tue cd the ddde giai thich qua mdt sd cd che.
Thd nhdt, suy tim ldm g i i m cung lildng tim va cd the se dan tdi giam Idu lirpng mdu nao trong thdi gian ddi. Thd hai, suy tim vd ede benh tiin la ye'u tc nguy cd cua nhdi mdu nao, benh ndo chat t r i n g , t i e maeh ndo... cdc benh ly nay cd lien quan den sa sdt tri tue va phan nao lien c|iian ddn benh Alzheimer. I h d ba, cac phan dng cua he mcTch ndo do suy tim keo ddi se lain nang them tinh trang g i i m tddi mdu vd cde ten thddng thddi hda [2]. Trong nghic^n edu eua ehung tdi, nhdm benh nhdn sa sdt tri tue ed ty le suy tim cao hon h i n so vdi nhdm chdng. Sd khde biet ed y nghia thdng ke. Cae yeu to' eua qua trinh viem nhd eac interlcukinc, TNF, C- reactive protein ddde coi la cde marker ve nguy ed bj benh Alzheimer trdng tddng lai [10|. D i l u ndy edng ddde k h i n g djnh trong eae nghien cdu ve mdi lien quan gida yeu Id' eua qud trinh viem va benh Alzheimer. Do vdy, n h i l u nghien edu can thiep doi vdi sa sut trf tue da sd dung cdc thud'e khang viem de phdng ngda va lam cham tie'n t r i l n eua benh. Tuy vdy, ede nghien edu sd dung thud'e khdng viem khdng steroid de ban ehe tdc dp tien trien cua benh Alzheimer da p h l i ddng lai do cac tdc dung phu eua thudc.
V . K E T L U A N
Nghien cdu da k h i n g djnh ddde vai trd eua
cholesterol mdu, suy tim va ye'u to eua phan dng viem (CRP). Can md rdng nghien edu de xae dinh vai trd ciia cdc ye'u to' nguy cd khac nham tac dieu kien cho cdc nghien edu can thiep sau nay.
T A I L I E U T H A M
KHAO
, 1 . A. Solomon et al (2007), Serum cholesterol changes after midlife and late-life cognition. Neurology, 68: 751 - 756.
2. C. Quiu et al (2006), Heart-failure and risk of dementia and Alzheimer disease. Arch Intern Med, 166: 1003 - 1008.
3. D.S. Knopman et al (2007), Incident Dementia in women is preceded by weight less by at least a decade. Neurology, 69: 739 - 746.
4. F. Irie et al (2008), Enhanced risk for Alzheimer disease persons with type 2 diabetes and APOE 64, Arch Neurol, 65(1): 89 - 93.
5. I.A.Luchsinger et al (2006), Measures df adiposity and dementia risk in the Elderly, Alzheimer Dis Assoc Disord, Volume 20,
Supplement 2: si 04.
6. L.B.Hoffmann et al (2009), Less A l z h e i m e r neuropathology in m e d i c a t e d hypertensive than nonhypertensive persons.
Neurology, 72: 1720 - 1726.
7. M.C. Irizarry et al (2005), Association of homocysteine with plasma amyloid d protein in aging and neurodegenerative disease. Neurology, 6 5 : 1 4 0 2 - 1408.
8. M.T.Sturnman et al (2008), Body mass indexand cognitive decline in a biraeial community population. Neurology, 70: 360 - 367.
9. R.West et al (2008), Better memory functioning associated with higher total and Low-density Lipoprotein cholesterol levels in very elderly subjects without the Apolipoprdtein e4 allele. Am j Geriatr Psychiatry 2008, 16:
781 - 785.
10. Tan.Z.S et al (2007), Inflammatory markers and the risk of Alzheimer disease.
Neurology, 69: 1902 - 1908.
Summary
STUDY ON VASCULAR RISK-FACTORS OF DEMENTIA IN PATIENTS SUFFERING FROM ALZHEIMER DISEASE
Objective: To study and analyze the relation of vascular risk factors with dementia syndrome. Method:
The study was conducted by ease-control study method. Patient group: 8 1 , diagnosed as Alzheimer disease based on the criteria of DSM IV TR, control group: 87. All the subjects in the study were examined thoroughly and carefully. Necessary neuropsychological tests as well as paraelinicai exams have been done. Result: There is statistical differences in terms of vascular risk factors between two groups, especially such factors as: hypertension, heart failure, hypercholesterol, hyperglycemia. Conclusion: This study has confirmed the role of some vascular risk factors of dementia syndrome such as: obesity, hypercholesterolemia, heart failure, increased CRP. Further studies need to be conducted to facilitate the future interventional studies for dementia .
Keywords: dementia, Alzheimer, risk factor
