TAP CHi Y HOC VigT NAM TAP 459 • THANG 10 • SO 1 - 2017 nong dp C3, C4 va lam giam mdt so Ig MD. MP
xung lam giam nong dp TFNA, iL6, ILIO so vdi tru'dc dieu trj, tuy nhien ehi ed TNFA giam cd y nghTa thong ke.
TAI UEU T H A M KHAO
1. Ph^m Huy Thong, Phan Quang Doan (2012),
"Nghien cOli hieu qua dieu tri lupus ban do he thong cd deft cap ton thu'dng than bang methylprednisolon du'dng tTnh mach lieu cao". y Hgc Thue Hanh, 3 (813), pp. 83-85.
£. Pham Hu]^ Thong (2011), "Burdc dau nghien eiru sir thay doi mot sd yeu to mien dich dich the d b^nh nhan lupus ban do he tiiong cd ton thu'dng than trudc va sau dieu tri Methyl-prednisolone lieu cao truyen tinh mach". Y Hoc ThUc Hanh, 10 (788), pp. 80-82.
3. Alba P, Bento L, Cuadrado MJ, Karim Y, Tungekar MF, et al. (2003), "Anti-dsDNA, anti- Sm antibodies, and the lupus anticoagulant:
significant-factors associated with lupus nephritis".
Annals of the rheumatic diseases, 62 (6), pp.
556-560.
4. Bai LQ, Chen XM, Mao 3 (1994), "Effects of methylprednisolone pulse therapy on TNF alpha levels in chronic nephritis". Zhonghua nelke za zhi, 33 (12), pp. 827-829.
5. Barile-Fabris L, Ariza-Andraca R, Olguin- Ortega L, Jara U , Fraga-Mouret A, et al.
(2005), "Controlled dinical tnal of IV cyclophosphamide versus IV methylprednisolone in severe neurological manifestations in systemic lupus erythematosus". Annals of the Rheumatic Diseases, 64 (4), pp. 620-625.
6. Criteria American College of Rheumatology Ad Hoc Committee on Systemic Lupus Etythematosus Response (2004), 'The American College of Rheumatology response criteria for systemic lupus erythematosus clinical trials: measures of overall disease activity".
Arthritis and rheumatism, 50 (11), pp. 3418.
7. Grondal G, Gunnarsson I , Ronnelid J, Rogberg S, Klareskog L, et al. (2000), "Cytokine production, semm levels and disease activity in systemic lupus erythematosus". Qinical and experimental rheumatology, 18 (5), pp. 565-570.
KET QUA BAN DAU DIEU TRI KHOI DI DANG DONG TINH MACH NAO V&
BANG P H A U THUAT PHdl HgP VO^I NUT MACH TAI BENH VIEN BACH MAI
Nguyen H&u An*, Tran Anh Tuan*, Phaim Minh Thdng*
TOIVI TAT
Myc tieu: Nghien CLTU ve dac diem hinh anh va ket qua bUdc dau dieu tn di dang dpng tlnh mach nao vd (DDDTMN) bang phaii tliua't phoi hpp nut niach tai B&nh vien Bach Mai. Phu'dng phap: Nghien cifu tien cu^j theo doi doe theo thdi gian^khdng doi chdng 20 benh nhan DDDTMN v3 dUde phau thuat phdi hdp vdi niit mach tai benh vten Bach Mai td 8.2014 den 2.2017. Ket qua': Co 20 benh nhan co^DDDTMN v3 duWc dieu tri bang nut mach sau dd phau,thuat. Cac dac diem pho bien d cac d\ dang nay la 6 di dang d sau, tinh mach dan lulj sau va phinh dgng mach trong 6 di dang. Bien chu'ng chay mau sau niit mach gap d 2 b|nh nhan (10%). Ton thu'dng khuyet nhu,mo nao sau md phan Idn la nhd hdn kich thifdc ciia 6 dj dancj (85%). Ka qua tot vdi 100% cac di dang nho (Spetzler-Mart:in I H I I ) het di dang va co lam sang tot sau dieu trj, 80% cac d| dang Idn (Spetzler-Martin IV- V) het dl dang sau mo vdi 60% benh nhan cd ket qua l§m sang tot. C6 01 benh nhan td vong sau dieu tri.
Ket luSn: Phdi hdp phau thuat va niit mach la chi dinh phu hdp cho cac khdi DDDTMN vd Idn hoac co
*'Benh vien Bach Mai
ChjU trach nhiem chinh: Nguyen Wdu An Email: [email protected] Ngay nhan bai: 18.7.2017 Ngay phan bien khoa hpc: 5.9.2017 Ngay duyet bai: 14.9.2017
ddng mach nudi sau. Di dang d sau, tlnh mach dan luii sau, phinh dgng mach trong 6 dj dang la nhuYig yeu to nguy cd gay chay mau can dUdc can nhic de dieu tri vdi cac DDDTMN chUa v3.
SUMMARY
COMBINED ENDOVASCULAR EMBOLIZATION AND SURGERY I N TTIE MANAGEMENT OF RUPTURED CEREBRAL ARTERIOVENOUS MAlK)RMATION ATTHE BACH MAI HOSPITAL
Objective: To study the radiology features of ruptured cerebral artenovenous malformation and the results of combined endovascular and surgical management of ruptured cerebral AVM. Methods:
Uncontrolled follow-up study of 20 ruptured cerebral AVM underwent surgery combining with prior embolization in Bach Mai Hospital from 8.2014 to 2.2017. Results: Twenty patients were treated by combined endovascular and surgical management, These common imaging features were deep brain location, deep venous drainage and arterial aneurysms located in the AVI^ nidus. Complication of embolization includes bleeding in 10%. Postoperative parenchymal lesions were much smaller than the size of AVM in 85% cases. Radical resection was achieved in 80%
with good overall result 100% in small AVM and 60%
in large AVM. There was one patient died after treatment. Conclusions: The combination of endovascular embolization and surgery was an ideal indication for large AVM and deep feeder artenes.
VIETNAM MEDICAL JOURNAL N°1 - OCTOBER - 2017 Deep brain location, deep venous drainage and arterial
aneurysms located in the AVM nidus were the high-nsk factors of hemorrhage and should be considered while making thadedsion for treatment unmptured AVM.
Key words: ruptured cerebral arteriovenous malformation, surgery, endovascular embolization.
I. BAT VAN DE
Dj dang dgng - tTnh mach nao (DDDTMN) la di dang mach bam sinh nguy hiem nhat. Day la benli ly hiem gap nhu'ng thu'dng bieu hien bang cac trieu chdng than kinh keo dai va cd nguy cd vd eao gay chay mau nao cd the dan tdi td vong.
De quyet dinh dieu tri DDDTMN can can nhae gi&a nguy ed dien tien tiT nhien va nguy cd cua dieu tri. Vao cuoi nam 2014 nghien cu'u ARUBA [1] (la nghien cu'u thLir nghiem lam sang ngau nhien cd doi chu'ng duy nhat so sanh dieu trj ndi khoa va can thiep ndi chung tren eae DDDTMN chuia v3) d u ^ ra khuyen cao thi nguy cd dieu trj nhin chung cao hdn phan Idn nguy cd td nhien cua cac DDDTMN chu'a v3. Nguy ed chay mau theo nam ddi vdi DDDTMN chu'a v3 khoang 2%- 4%, khi DDDTMN da vd thi nguy cd vd lai d nam dau tang len 6%- 8% [2] bdi vay dieu trj d u l diem du'dc ung hd sau khi tinh trang xuat huyet noi so da on dmh. Dieu trj cd the gom nut mach, phau thuat, xa phau hoac phoi hdp cua 3 phu'dng phap di/a tren tdng ton thu'dng (kich thu'de, vj tri d vung chu'c nang, va cac dac diem nguy ed eao anh hu'dng tdi nguy ed vd). Vdi nut mach ddn thuan thu'dng khdng nut du'dc hoan toan khoi di dang edn dieu tri phlu thuat ddn thuan vdi khdl DDDTMN Idn cd nguy cd mat mau cao trong md. Bdi vay viec phdi hdp nut mach sau do phau thuat lay bd dj dang dang du'dc nhieu trung tam tren the gidl ItTa chon. Hu'dng dieu trj phoi hdp nay bat dau dddc thdc hien tai Benh vien Bach Mai tu" thang 8.2014 tuy nhien van chda cd mot nghien cu'u nao danh gia ve hieu qua cua viec phoi hdp dieu trj. Chinh vi vay, chung tdi tien hanh nghien cu'u: "Kit qua ban dau dieu tn khdi di dang dgng tinh mach nao vd bang phau thuat phdi hdp vdi nut mach tai benh vien Bach Pfai" vdi hai myc tieu: 1. Phan tfch cac dac diem hinh anh cua DDBTf^N vd tu" do giup tien lu'dng yeu td nguy cd cho cac dj dang chda vd. 2. Ket qua ban dau dieu tri DDDTMN v8 bang phdi hdp phau thuat va nut mach.
W. £)dl TU'QNG VA PHU'CFNG PHAP NGHIEN CUOJ 1 . Ooi tu'dng nghien cii'u: benh nhan cd DDDTMN vS, du'dc dieu trj nut mach sau do mo lay di dang td thang 8.2014 den thang 2.2017 tai khoa CDMA va khoa PTTK
2. Phu'dng phap nghien cu'u: Tien eiru theo ddi dpc theo thdi gian khdng doi chu'ng
3. Tieu chuan lUa chpn: DDDTMN da vg du'dc chan doan tren COHA. Dieu tri phdi hdp hai phu'dng phap: nut mach va phau thuat. Du ho sd benh an, phim anh.
4. Tieu chuan^loai tru': Benh nhan chi du'dc dieu tri bang p h l u thuat hoac nut mach ddn thuan. khdng du ho sd benh an, phim anh.
III. KET QUA NGHIEN CCru
TCr thang 8.2014 den thang 2.2017, tai benh vien Bach Mai, cd 20 benh nhan du'dc chan doan chay mau trong nao do vd khoi DDDTMN, du'dc dieu tri phau thuat sau khi nut mach.
1. Dac diem tuoi -gidi:
- 16 nam: 4 nti'
- Tudi trung binh 36,1 (tir 16 den 67).
Phan bo theo tuoi j
DoCuoi
Bieu do 1. Phan bo theo tudi Nhan xet: So benh nhan tre tudi cd dj dang vd chiem da so (tudi trung binh 36 ±15.5)
2. Dac diem chup mach
2 . 1 . Cac yeu t d nguy cd chay mau cao Bang 1. Cac dac diem nguy ed cao chay mau ddi dang
Dac diem dj dang Cd 1 trong eac yeu
to nquy cd Khdng ed yeu td
nquy cd
So bgnh nhin
17 3
Tyle 85 15 {Ghi chu: cac yeu to nguy ed eao chay mau gom dj dang d sau, tTnh mach dan lull sau, phinh hinh qua dau ddng mach cap mau)
Nhan xet: nhdm dj dang cd eac yeu td nguy ed cao chay mau chlem da sd (85%)
2.2. Phan do Spetzler-Martin
I - A- . _ ,. . _ ^ I PlinndoSpetzler-Miirtin i
Dpi DpII e^lll D^tV DpV SpeUler-Martiii
Bieu do 2. Phan dp Spetzler-Martin
TAP CHl Y HOC VlgT NAM TAP 459 - T H A M G 10 - SO 1 - 2017
Nhan xet: nhdm di dang dd IV chiem da sd (60%).
3. Cac dac diem ciia qua trinh nut mach 3 . 1 . Phan tram khoi AVM du'dc nut va so Ian niit
I 5 -
Ket quo nut tik - - - -5 4-
;= 20%30%40%SO%60%7(l%a(i%90% " Ket Wa nut tac ' >o Phantranididaiigniittac
M • •
Bieu dd 3. Ket qua niit tac Nhan xet: nhdm dj dang niit tac >50%
chiem da sd (chiem 65%).
3.2. So lan niit mach Bang 2. Sd lan nut mach So lan nOt mach
1 2
So benh nhan 17
3
°/o 85 15
Vat lieu nut mach Onyx Onyx va Hystoacryl
Squid Tong so
So benh nhan 14 3 3 20
»/o 70 15 15 100 Nhan xet: vat lieu nut mach chinh du'dc sCr dung la Onyx (cliiem 70%). TTie tich vat lieu nut mach trung binh: 2.31 ± 1.34ml ^ddi vdi eae benh nhan du'dc niit mach 2 lan thi the tfch vat lieu nut mach duUc tinh chung). Benh nhan dung nhieu nhat: 4.5ml. Benh nhan dung it nhat: 0.7mi
3.4. Cac bien chii'ng sau nut: Bien chu'ng gap phai d 2 benh nhan va deu la chay mau trong di dang sau nut. Khdng cd bien chiTng yeu, liet hay tiT vong sau niit mach.
4. Cac dac diem ciia qua trinh phlu tiiuat 4 . 1 . Phu'dng phap phau thuat: Phu'dng phap phau thuat du'dc tdm tat trong bang 4;
Bang 4. Phu'dng phap phau thuat Phu'dng phap PT So BN Ty \% % Lay toan bd dj dang
Lay mot phan dj dang va kep cac ddng mach nudi Kep ddng mach nudi ddn thuan, khdng lay dj dang
18 90
Nhan xet: cd 01 benh nhan mo lay mdt phan dj dang va kep dpng mach nudi do khdi dl dang
d sau khong lay du'dc het. 01 benh nhan md kep ddng mach nudi ddn thuan do benh nhan ed tinh trang suy than nang khdng ed kha nang chju ddng cuoc mo keo dai.
4.2. Bien chii'ng sau mo: Cd 3/20 benh nhan (15%) xuat hien bien chu'ng yeu/liet i / 2 ngu'di sau md, Cd 1/20 benh nhan (5%) t d v o n g sau mo.
5. Cac ket qua dieu tri 5 . 1 . Ve di dang mach Bang 5. I<et qua ve hinh anh
PSA hoac MSCT Het toan bd d\ dang
So BH Ty le %
Cdn mdt phan di dang
17 85
10
Nhan xet: phan Idn benh nhan du'dc nut mach 01 lan, cae benh nhan du'dc nut 02 lan do the tich nut du'dc d lan t h d nhat it.
3.3. Vat lieu nut mach va th€ b'ch da dung Bang 3. Vat lieu ntit mach da dung
Nhan xet: 19/20 benh nhan du'dc chup kiem tra sau mo (MSCT hoac DSA) phan idn het hoan toan di dang (85%). Cd 01 benh nhan tinh trang nang len sau mo chi du'dc chup CTseanner khdng tiem, sau dd benh nhan td vong.
5.2. Ve ton thu'dng nhu mo sau mo Bang 6. Bang so sanh ton thu'dng nhu md nao vdi the tich di dang
Ton thu'dng nhu mo so v6i di dang Nho hdn hoac bang
Ldn hdn
S o B N 14
2 T y l e
87,5
%
12,5 Nhan xet: cd 16 benh nhan du'dc chup CLVT sau md thi phan idn benh nhan cd vung ton thu'dng nhu md nao sau phau thuat nhd hdn the tich eua dj dang (chiem 87,5%)". Cd 02 benh nhan vung ton thu'dng rong hdn so vdi the tich dj dang thi 01 benh nhan t d j / o n g va 01 benh nhan ed bien chii'ng liet sau phau thuat.
5.3. Ket qua ve lam sang: Du'dc danh gia theo dp Rankin cai tien ngay sau mo va tai thdi diem theo doi sau 03 thang. Dp 0-2 du'dc phan loai la tot, 3-4 la trung binh, 5-6 la xau. ket qua lam sang du'dc tdm tat trong bang 7 va 8.
Bang 7. Ket qua lam sang sau mo
D d l l (N=2) D d l l l (N=4) DdIV (N=12) OdV (N=2)
Sau mo Sau 3 thang Sau 3 thang Sau mo
Sau 3 thang Sau 3 thang
100 Trung
binh
50 Xau
Nhan xet: ddi vdi cac di dang nhd (dp I I - I I I ) ket qua lam sang sau dieu trj tot (100% cd mRS
<2). Trong nhdm dj dang do IV cd 1/12 benh nhan cd hoi phuc iam sang trong thdi gian theo
VIETNAM MEDICAL JOURNAL N°1 - OCTOBER - 2017
doi va lap phuc hoi chii'c nang (diem mRS giam td 3 diem xuong 2 diem).
Bang 8. Ket qua lam sang doi vdi nhdm dj dang dp IV theo % nut mach
Ket qua Tot Trung binh
Xau
Tie <50%
33%
56%
1 1 %
1 Tac >50 % 67%
33%
1 0 Nhan xet. ket qua sau mo tot hdn d nhdm benh nhan niit mach du'dc >50%, day cung etiinh la ly do chiing tdi khuyen nghj niit tac them cho vdi cac di dang ma niit mach du'dc
<50% d lan 1.
IV. BAN L U A N
1 . Dac diem tuoi, gidi cua benh nhan:
Tudi benh nhan tu" 16-67^ trung binh 36 ±15.5 tu'dng tu" dp tuoi du'dc chan doan DDDTI^l vS ndi Chung. Ty le 4 nam/1 nu' khong tu'dng dong vdi ty le chung tnang y van |;3]. Nguyen nhan la do
^so lu'dng benh nhan trong mau chu'a dii Idn va sd li/a chpn khdng ngau nhien trong nghien ciili ciia chiing tdi.
2. Ve dac di€m cua DDDTM va ket qua dieu tri: Cac dac diem pho bien cua cac 6 dj dang^frong nhdm nghien ciili cua chung tdi lei cac 6 di dang d sau, dj dang cd tTnh mach dan lull sau va dj d?ng cd eac phinh tTnh mach dan lutj. Cac dac diem nay phu hdp vdi cac bao cao ve cac dj dang dpng tTnh mach nao v8.
Chiing tdi khong chi dinh phau thuat phoi hdp vdi nut mach diTa vao mot dac diem ddn thuan nao ciia khoi di dang ma du'a vao phan tich tdng hdp cac yeu t d : phan loai dj dang, kich thu'de va phan do khdl dj dang.
Trong nhdm benh nhan eua chiing toi thi dd IV chlem da so (60%). Vdi cac DDDTM nhd thi
VI DU MINH HOA:
ket qua ban dau cho thay hieu qua dieu tri tSt vdi 100% benh nhan h i t 6 di dang va lam sang tot. Vdi cae dj dang Idn thi ket qua ^ t chi dat 50%. Trong sd nhdm dj dang dp IV la nhom chlem da sd trong nghien edu thi ket qua sau dieu tri d nhdm niit mach du'dc >50% di dang ia tot hdn khi so sanh vdi nhdm niit mach du'dc
<50% dj dang. Td quan sat trdc quan nay chiiiig tdi khuyen nghj nen niit tac Idn hdn 50% cac o dj dang khi dieu kien cho phep.
3. K§t qua dieu trj: Ket qua tot trong nghien edu cua chiing tdi chiem t^ le (60%) thap hdn so vdi bao cao ciia VInuela (1991) vdi ty le ket qua tot (89%) [4] nguyen nhan do nhoni benh nhan cua chiing tdi ed ty ie eac di dang I6n hdn (60% benh nhan cua chiing tdi cd Spetzler- Martin dp IV so vdi nhdm cua Vinuela ehi cd 42%) va hdn niJa chi cx5 mdt ni^a trong so benh nhgn trong nghien ciili ciia VInuela la cd xuat huyet nil sp. Trong nghien ciiXi ciia chiing toi ed 1 b§nh nhan tu' vong. Benh nhan nay sau mo xuat hien sSt eao, sau dd hdn me va sau dd tu" vong.
Khi so sanh vdi ket qua eiia phau thuat ddn thuan trong nghien cu'u eua Ren, Quingqulng va cs [5] thi vdi nhdm dj dang nhd (dp II-III) ket qua ban dau 100% benh nhan ed ket qua ^ t (so vdi 86% so vdi bao cao cua Ren). Doi vdi cac dl dang Idn dp IV thi ket qua tot thu du'dc t i ^ nghien CLTU ban dau la'50% (tu'dng t i / v d i b a o - S cua Ren la 52.5%) do van de phau thuat vdi die q dang Idn van that sd la nhiJVig thach'thiTc 95%
benh nhan kham lai du'dc chup kiem tra sau m ^ 17/20 benh nhan (85%) het hoan toan khdl di dang. 2 benh nhan khdng lay du'dc khS di dang du'dc theo doi va chup phim kiem tra dinh ky.
TAP CHi Y HOC VtgT HAM TAP 459 - THANG 10 • SO 1 - 2017
Ca 1: BN nam, 25 tuoi, dau dau dot ngpt, hon me. A, B, C. O d\ dang tran-dinh trong ben phai Spetzler-Martin dp 3 vd, cap mau tCr nhanh sau dpng mach quanh trai ben phai. D, E, F. Sau mo lay mau tu cap cii'u BN du'dc nut mach tien phlu 80% di dang va cuong DM quanh trai. G, H, I. Chup CLVTva mach s^',. mo layhoan toan di dang.
Ca 2: BN nam 26 tuoi di dang AVM ldn tran ngoai trai Spetzler-Martin 4 diem, da niit mach 01 lan nam 2015. A, B,C. V3 di dang tren CLVT. D, E, F. Nut thi 2 tac 90% dj dang. G, H, I . Chup MSCT sau md, het hoao toan o di dang.
V. KET LUiOLN
Chi djnh phoi hdp phau thuat vdi niit mach rat phij hdp vdi nhij'ng khoi dj dang vifa (Spetzler-Martin 2-3). Vdi eac dj dang idn (Spetzler-Martin 4-5) ket qua dieu tri ban dau chu^a eao.
TAi UEU T H A M KHAO
1. Mohr, J., et al.. Medical management with or without interventional therapy for unruptured btain artenovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial The Lancet, 2014. 383(9917): p. 614-621.
J., da Costa, L., et al.. The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke, 2009. 40(1):
p. 100-105.
3. Lawton, M.T., Seven AVMs: Tenets and Technigues for Resection. 2014: Thieme.
4. Vinuela, F., et ai.. Combined endovascular embolization and surgery In the management of cerebral arteriovenous malformations: expen'ence with 101 cases. Journal of neurosurgery, 1991.
75(6): p. 856-864.
5. Ren, Q., et al.. Microsurgery for intracranial arteriovenous malformation: Long-term outcomes in 445 patients. PloS one, 2017. 12(3): p.
e0174325:
