Y HQC VlfeT NAM T H A N G 12 - S 6 1/2012 - So luttng bgch cau giam nhieu nhat d ngay
sot thu" 6, trong do bach cau da nhan trung tfnh giam tu* scfm, bach cau Iympho va mono tang tiTdng doi.
- S3 lu'dng tieu cau giam nhieu nhat 6 ngay thCfe.
2. Ve liSn quan giu'a d$c digm xuat huy€t voH giam sd lu'dng tiSu cau
- Vcfi 3 mu'c dp phan chia so luWng tieu cBu, 6 cac benh nhan d^u thay xuat h u y ^ du'di da la chu yeu, xuSt huyet niem mac dilrtig thu' 2, xuat huyet tieu hoa la thap nhSt.
- So Iu'dng tieu cau cang giam, d^c biet diidi 50 G/l thi ty le xuat huyet tieu hoa d i n g tSng len.
{Xin cam dn s i / tham gia nghien cu\j khoa hoc cila CN Nguyen Thj Thanh Binh, CN Nguyen Minh Hiiyen- bo mon MiSn djch- Sinh ly benh, Sinh vien D$ng Du'c Thinh, Vu Thi Hong Phudng sinh vien Y3 nSm 2010-2011).
T A I U E U T H A M K H A O :
1. B^nh hpc truyen nhigm (2001). Sot xu3t huyet va sot xuat huyet Dengue, NXB Y hpc. 122 -130.
^. Takol Chareonsirisuthigul et al (2007).
Dengue virus (DENV) antibody dependant enhancement infection upregulate the production of anti-inflammatory cytokine but suspresses anti- DENV free radical and pro-inflammatory cytokine production In THPl cells. Joumal of genaral urology. 365 - 375.
3. Thierry Tlievenot et al (2006). Complementary traitments of chronic viral hepatitis, Gastroenterologie ainiqueet Blologlme. 30(2): 197 - 214.
-.. To chu'c Y tS The gidi (2001). Tai li^u hu'dng dan ph6ng chSng sSt Dengue vci sot xuat huyS't Dengue, NXB Y hpc 2001,12 - 20.
5. Vi sinh v$t y hpc (2007). Virut Dengue, NXB Y hpc, 335 - 339.
6. va van Tru'dng, Phgm Quang Vinh vd 08(2008). Mpt so d|c diem te bao mau d benh nhSm sot xuft huyet Dengue gSp tal bi|nh vien Bach Mai.
NGHIEN Clill AP DUNG THANG DIEM NIHSS dBENH NHAN NHOI MAU NAO CA'P TAI KHOA CA'P CIJU
Mai Duy T o n * , Vu Viet H a * , Nguyen D^t Anti*
T 6 M TAT:
M^c tieu: Ap dung thang diem NIHSS d benh nhan nhoi mau nao cap tat Khoa Cap CCTU. Phu'dng phap: Nghien cull tien ciiu, mo ta d 90 benh nhan nhol mau nao cap tai Khoa Cap citu Benh vien Bach Mai. K€tqua: 80% benh nhanco diem NIHSS tr§n 5, thdi gian tu' khi l^di phat den khi nhap vien trong 9 gid chiem 72,2 %. Sy' khac biet ve the tfch thieu mau nao giud b^n c3u n i o tT^I v^ ban diu nio phii tren phim chup cpng hudng tif so nao tu'dng uVig vdi cac mii'c diem NIHSS <5, 5-15, 6-21 va > 21 khong co y nghTa thong ke (p > 0,05). Diem NIHSS trung binh va the tich thieu mau theo dpng mach chi phoi gom dpng mach nao budc, dpng mach n3o giu^, d$ng mach nao sau vk ddng mach than n i n Miac biet co y nghia thong ke (p < b,000i). Ket lu$n: Diem NIHSS tu'dng quan vdi dOng mach nao chl phoi nhulig khong tu'dng quan vdi bdn cSu nao bj ton thudng.
Cic tiy chinh: dot guy nao, ban r^u nao, NIHSS, biuhu^idiS
'Khoa cip cOv, B$nh vi$n Bach Mai Phan bi#n khoa hpc: GS.TS L§ Oire Hinh
RESEARCH ON THE APPLICATION OF NIHSS SCORE IN ACUTE ISCHEMIC STROKE PATIENTS IN EMERGENCY DEPARTMENT
ObjectivetAppIication of NIHSS score in acute ischemic stroke patients in Emergency Department.
Methods: a prospecbve, observative researdi on 90 patients with acute ischemic stroke in Emergency Department,Bach Mai Hospital. Results: 80% of patients have NIHSS score above 5, time from onset to admission within 9 hours is 72,2%. The difference of ischemic volumes on MRI conflated to NIHSS score below 5, 5-15,16-21, andabove 21 are not statistically significant (p>0,05). The average NIHSS sojre and ischemic volumes of cerebral arteries (induding anterior cerebral artery, middle cerebral artery, posterior cerebral artery and basilar artery) are significantly different (p<0,0001).Conclusions: NIHSS score has a relationship with occluded cerebral artery but not with lesions of cerebral hemisphere.
Y HpC VigT NAM THANG 12 • S 6 1/2012 Key words: stro/ce, hemisphere, NIHSS,
thiumbolysis I. DAT V i N DE:
Ttiang (Jlem dot quy nio cua Vl^n Y t€ qu5c gia Hoa Ky (NIHSS) dS du'ijc ip d^ing rOng rSI tt^n the gWI nhSm dinh gl4 ban dSu b?nh nhSn mSc tal bISn mach n5o dSc bl|t trSn nhffng b^nh nhan nhBI miu nao cSp khi c6 cic dSu hieu thlSu s(5t thin kinh xiy ra nhiTng chua c6 ton thu'dng tren phim chup cSt Idp vl tinh sp nao.Mpt s6 tic gii cho rSng gii trj cua thang dlSm NIHSS cdn gliip thay thuSc den luijng du^c nhinh dpng m?ch nao bl tSn thuBng v i mffc dp thieu miu cua nhu m6 nao nhim dffa ra chi dfnh v i chong chi djnh dung thuoc tl§u huyet khSI, l i mpt k9 thuit dieu tr! triet d l nhat cho nhffng b^nh nhin dot quy nao cip. Do-do, chung toi tlen hinh dS tal "Nghiin citu ip dyng thang diim NIHSS 6 b$nh nhin nhBI miu nSo cSp t^l Khoa CSp c t / t / ^ h i m muc tieu sau:
- Nhan xet mpt so die dilm lam sang cua benh nhan dot quy nao cap trong 24 gid dau.
- Tim hieu moi lien quan giffa diem NIHSS vdi bin cSu ton thffdng v i dpng mach chl phpi
II. O ^ tUQNG V& PHUONG PHAP NGHIEN CCU:
2.1.051 ti/dng nghlSn cihi
Benh nhan dffdc chan doin nhoi mau nao cap vio Khoa Cap dSu tCr thing 1 nim 2011 den thing 8 nim 2011 thoa man cic tieu chuan sau;
- Tiiu chuan chgn b$nh nhin Tai bien m?ch nao theo tieu chuan ciia To chffc Y te The gidi khdi phit trong 24 gid dffdc chup cpng hffdng tff sp nao vdi chan doin l i nhoi miu nao.
- Tliu chuin lo^l tritb^nh nhin Khong cd bSng chffng nhol miu nao tren phim chup CP"9 hffdng tff sp nao (CHT).
2.2. Phu'dng p h i p nghien cii'u
Thiet ki'nghlSn ciiu. Nghien cffu den cllti, md t i cSt ngang.
PhWdng phip: B$nh nhan vio vien nglii ngd mic tai bien mach nao trong vdng 24 gid dBu thep tieu chuSn nghien cffu. Cic b|nh nhan dSu dffdc khim lim sing toan dl$n, xff tri dc tinh tr^ng cip cu\i, v i danh gii thang diem NIHSS t?l thdi dilm ngay trffdc khi chup cong hffdng tff sp nap.
Cic blln s6 thu thip trong thang dilm NIHSS gom 15 muc: y thffc, djnh hudng, thg'c hl|n menh Ilnh, cim giic, thj trffdng, chffc ning vin d$ng mit, mit, tff chi, dliu phoi dpng tic, ngon ngff...
Dilm NIHSS se dffpc dinh gii hai lin dpc lip dp hai thay thuSc d i dffdc dip tap ve quy trinh dinh gii dilm NIHSS; sff chlnh l|ch dilm NIHSS khdng qui hai diem.
Ngay sau khi dinh gii dilm NIHSS v i tinh trang benh nhin pn djnh se chup c^ng hffdng tiT sp nao tren may 1.5 fesia ciia hang Siemens tai Khoa Chan doan hinh inh Benh vl|n Bach Mai.
Quy trinh chup cd dinh gii hinh inh nhu mo nao tren chuoi xung khuech t i n v i bin d5 ADC nhim xic djnh nhol miu nao giai doan sdm va d'nh toan t h i tich 6 thieu mau (cm'), chuoi xung T2W' nhim loai trff chay miu nhu mo nao va chuoi xung TOF nhim danh gii tinh trang tic mach nao [1]
Danh gia sff tudng quan giffa dilm NIHSS theo cic mijt dp [4] va the tich 6 nhoi miu nao tren phim chgp cpng hffdng tff sp nap.
Cac so lieu dffdc xff \y theo ehffdng trinh toin thong ke SPSS 16.0.
III. KET QuA NGHllN CCIU:
Qua nghien cutj 90 benh nhan mic nhoi miu nao cap tal Khoa Cap cffu B^nh vien Bach Mai, chung tdl thu duBc cic ket qui nhff sau:
l.Cic dSc diSm chung Bing 1: Cic die dilm chunq
Die dl^m b$nh nhin Tu6i (nim)
Gidl (nam/nfr)
Thdi gian tCr khdi phit din luc nhip vi$n
Trunq binh (qid) Du'di 3 qid 3 - 9 qid
Gii trirry l«(%) 62,8 ±12,89 48/42(1,14) 11,8 ±6,24 14(15,6%) 11 (12.2%) 94
Y HQC VIET NAM THANG 12 - SO 1/2012 {>|c diim b^nh nhin
Clem NIHSS
Trfen 9 qid Du'di 5 dilm 5-15 dilm 16 -21 dilm TrSn 21 diim
Gii trWTy l#(%) 65 (72,2%) 18(20,0%) 45 (50,0%) 11 (12,2%) 16 (17,8%) Nhin xit: Phan Idn binh nhin cd thdi gian tff khdi phit den liic vao vien l i tren 9 gId.Ty II benh nhan nam cao hdn nff.Mpt nffa so benh nhan cd dilm NIHSS 5-15
2.M6I liSn quan giu'a diem NIHSS, the tfch S nhol m i u va b i n cau ton thuang Trong so 90 benh nhin, cd 63 benh nhan cd tdn thffdng bin cau nao, dffpc danh gia moi lien quan giu^ diem NIHSS, t h i tich 6 nhoi miu v i ban cau ton thffdng.
Bing2.\Jien quan giiia diem NIHSS, the tich 6 nhoi miu vi bin ciu ton thtfpnq
Oiim NIHSS
Ban ciu nao t r i i (n = 35 binh nhin) S6 bfnh nhin ThUichlhiSr
miu
Bin ciu nio phii (n = 28 bdnh nhin) S6 b^nh nhin Thi tich thIiu
miu
104.6 ±46,19 >0,05
Ting >0.05
Nhin jrefcSff khic biet ve the tfch thieu mau nao tren phim chup cpng hffdng tff sp nap giiia nhdm cd ton thuyng bin rau nao trai va ban cau nao phii tffpng ffng vdi mffc diem NIHSS khong cd sff khic biet cd y nghla thong ke vdi (p > 0,05).
3.Moi li€n quan giu'a diem NIHSS, the tfch thieu m i u theo dpng mach ton thu'dng.
Bing 3: Lien quan qluci dilm NIHSS, the tich thieu miu theo donq mach ton thffonq DIVI nio tru'dc DM nao giu'a
(n = 48)
DM nao sau DM than nen
Bllm NIHSS 5,6 ± 2.83
Thi tfch 6 thilu miu 19,9 ±19,97
Nhin xef.'Dllm NIHSS trung binh va the h'ch thieu miu theo ddng mach chi phoi khac biet cd y nghTa thong ke (vdi p < 0,0001).
IV. BAN LUAN:
l.Cac dac diem chung
Tuoi trung binh cac benh nhan trong nghien diu l i 62,8 ± 12,89 va ty le benh nhin nam cao gip 1,14 lan so benh nhan nff. Kit qui nay tudng tff vdi kit qui nghien cffu cua Toyoda [3].
Thdi gian tff liic khdi phat den luc nhip vien chl) yeu tren 9 gid (72,2%), ty I? benh nhan den vien sdm trffdc 3 gid chi chiim 15,6%. Diy la thdi dilm rat quan trpng d l thay thuoc cd t h i tien hinh cic dieu tri can thiep tich cffc cho benh nhan, l i vile sff dung thuoc tieu huyet khoi Alteplase dffdng tTnh mach d nhdm benh nhan din trffdc 3 gid ma Ciddc chan doin thieu mau nao cap [1].
Liic benh nhan vao vien, chung tdi thay ty le benh nhan cd dilm NIHSS tff 5-21 chiim 62,2%.Nhffng benh nhin niy neu den vien trffdc 3 gid se li lua chpn tdt 6& dieu tri thuoc tiiu huyit khoi dffdng ffnh mach [3]. Dilm NIHSS dffdl 5 chlem 20%, khi dilm NIHSS dffdl 5 diem thffdng tffdng urig tren lim sang vdi benh nhin cd bieu hien trieu chiimg nhe, trai lai nhffng benh nhin cd dilm NIHSS trin 21 (chiem 17,8%) thffdng cd bilu hien lam sang mffc dp nang [5].
2.Lfen quan diem NIHSS, the tfch o nhBI m i u va b i n cau ton thu'dng.
Tuy nhien sff khic biet cua t h i tfch thllu mau tren phim chup CHT lai khong cd y nghTa thong ke. Nhff vay, tdn thffdng d hai ban cau nao tffdng tff nhau ve mat the tfch thieu mau tren 95
Y HQC VigT NAM THANQ 12 - S6 1/2012 CHT. Ket qui nay ctia chiing t6l tu'dng t\f vdl
Daniel W [4] vh CQng sy khi nght§n ciiu tren 290 b^nh nhan nh3l m^u nao vcio vl$n trong 24 gid dau v^ Unh todn t h i tfch thieu mdu trSn phim chgp c3t !dp vi tfnh tutii mdu thay the tfch thl^u mdu cua nh6m c6 ton thu'dng bdn c3u phdi tudng tu" nh6m c6 ton thu'dng bdn cBu nSo trdi.
Tuy nhlfin 6 miic diem NIHSS 15 - 20 thi tfch thieu mdu trung binh cua bdn dBu nao phdi Id 133 cm3 (81 - 209 cm3) 1^1 Idn gSp hai Hn thi tfch thl€u mdu 6 bdn cSu nSo trdi Id 102 cm3 (28 - 158 cm3) vdl mu'c y nghia thong kg p < 0,005.
Theo chijng tdl sd dt c6 si/ khde bl$t ve diem NIHSS d hai bdn diu dgi nao khi bj t6n thu'dng vi bdn cau nao b i i thuidng Id bdn clu du thi kiim sodt cdc chut ndng v€ ngon ngu' vd Idl ndi. Trong thang diem NIHSS cd cdc diem ddnh gid y thu'c bSng ldi ndi vd ngon ngu* nen khi bdn cau u'u thi bj tSn thudng thi cdc ctiOt ndng ndy bj dnh huidng nhieu hdn. Tuy nhien cdc myc ndy lal co so diem tu'dng dol nhd nen cd th^ khi chung toi chia cdc mu'c diem NIHSS nhu' tren lai khong lam bpc Id 51/ khde biet glQ^ nhdm ton thu'dng bdn c3u nao trdi va nhdm l^n thu'dng bdn cau nao phdi. Hdn nu^ cd the do trong nghien citu ciia chung ^1 so lutfng benh nhan trong m5l nhdm cdn nhd nen kit qua chu^ du de k§t luan sd khac biet.
S.Lien quan diem NIHSS vd ddng mach Uin thu'dng
Trong nghien cutJ ndy, chung toi nh$n thay cb sd khac biet ve diem NIHSS giCfe cdc nhdm cd ton thu'dng dong mach khac nhau (vdl p<
0,0001). 6 nhdm benh nhan ton thu'dng dong mach nao trudc vd dpng mach nao sau thu'dng diem NIHSS chi d mii'c nhd hdn 10 nhuTig thay bleu hien ciia benh nhan thu'dng thieu sdt cdc vdn dong chi gay dl chihig ndng ne. Do dd, mot so tai lieu hien nay da ban luan khi benh nhan cd diem NIHSS thap nhu'ng cd bieu hien thieu sdt ve mdt van ddng ndng ne va cd nguy cd tan phg cao van nen duttc chi djnh tieu sdi huyet bSng rtPA.
Ngu'dc lal, doi vc^ nhdm bfnh nhan ton thut^ng ddng mach nao gfu^ va ddng m^ch than nen bieu hien lam sang ciia b^nh nhan rat nang ne vdl diem NIHSS trung binh rat cao, cd nhOUg
b?nh nhan hdn mi sau ngay tir dau. Thi tfch thieu mdu tren CHT d hai nhdm ndy cung rat Idn n§n nguy cd chdy mdu trong 6 nhdl mdu thu'dng cao. DISu ndy phii hpp vdl cdc khuyen cdo hi?n nay khi bfnh nhan cd bdng chiing ton thu'dng d$ng m?ch nio glij^ ho$c dpng mach song-nen kdm theo bl^u hifn Idm sdng n^ng ne se khdng cd chi djnh diing thudc tieu stfi huyet do nguy cti chdy mdu cao hdn ldi fch cd the mang 1^1 cho bfnh nhdn [3]. Tgi Khoa Cdp ciiU diiing toi thu'dng khdng chi d[nh tieu sdi huyet ddi vdi cdc b|nh nhdn cd diem NIHSS tren 24 vd/ h o ^ o6 ton thu'dng tdc dpng m^ch nao glu^ vdi toi thu'dng thieu mdu trdn 1/3 bdn cau,
V. KCT LUJ|iN:
Qua nghien ctitj 90 bfnh nhan dpt quy nao ciip vao Khoa Cap ciili trong vdng 24 gid, chting tdl riit ra cdc ket luan sau; (1): Hau h ^ benh nhan dpt quy nao cSp cd diem NIHSS tren 5, (2) Khdng cd si/ khac bift ve diem NIHSS vdi bdn c^u t^n thu'dng, (3):Cd sd tu'dng quan gi(j^ d l ^ NIHSS vdi ddng mach nao bj ton thuUng.
TAI L I | U T H A M K H A O :
1. GoIdmldt4,CaplanLR(2011},Camnangxu'tritai bien m^ch mdu ndo, Nguyen Oat Anh vd cdng s;
bien djch, NXB Y hpc, tr.33-43.
2. Nguyin D^t Anh, NguySn U n Vl$t, NguySn Quoc Anh, Ph^m Quang Vinh (2011), Thang diem dpt quy da sii^ doi aia Vifn Suit khde quSc gia Hoa K^, Cdc thang diem thia ySu s* dgng trong thu'c hdnh Idm sdng, NXB Y hpc, tr.313-31S.
^ Toyoda K, Koga M, Naganuma H, Shiokawa Y, Nalcagavi/ara 3, Furui E, et al(2009), "Routine Use of Intravenous Ljow-Dose Recombinant Tissue Plasminogen Activator in Japanese Patients: General Outcomes and Prognostk: Factors From the SAMURAI Register*, Stroke, 40(11), pp.3591-5.
4. Daniel W, Broderick JP, et al (1999), "Does the Nabcmal Institutes of itealdi Sbolce Saie Favor Left Hemisphere Sbo/cesr,3ddk.e, 30, p.2355- 2359.
5. Nicholas A. B, Ilene S, Nora C and Louise D.
M (2010), 'ThnDmboly^s In Right versus Left Hemispheric SbTike", Journal of Sbo/ce and Cerebrovascular Diseases, 19 (4), pp.269-272.