B GIO DC O TO B QUC PHềNG VIN NGHIấN CU KHOA HC Y DC LM SNG 108 CHUYấN IU TR CHY MU NO THT Thuc ti: NGHIấN CU MT S YU T TIấN LNG CA BNH NHN CHY MU I TH Cể MU VO NO THT GIAI ON CP TNH DO TNG HUYT P Nghiờn cu sinh: inh Th Hi H H NI 2016 B GIO DC O TO B QUC PHềNG VIN NGHIấN CU KHOA HC Y DC LM SNG 108 CHUYấN IU TR CHY MU NO THT Thuc ti: NGHIấN CU MT S YU T TIấN LNG CA BNH NHN CHY MU I TH Cể MU VO NO THT GIAI ON CP TNH DO TNG HUYT P Nghiờn cu sinh: inh Th Hi H Giỏo viờn hng dn: GS.TS Nguyn Vn Thụng H NI 2016 MC LC H NI 2016 .1 B GIO DC O TO B QUC PHềNG .2 H NI 2016 MC LC TI LIU THAM KHO 16 DANH MC HèNH .17 t qu nóo c coi l mt bnh lý cú th phũng nga v iu tr c Trong vũng hai mi nm qua, nhng tin b v khoa khc ó thay i quan im cho t qu nóo l hu qu ca tui tỏc v khụng th phũng nga dn n kt cc l t vong hoc tn tt Cỏc bng chng gn õy cho thy hiu qu ca cỏc chin lc iu tr d phũng tiờn phỏt v th phỏt, nhn bit cỏc bnh nhõn cú nguy c cao v can thip cú hiu qu triu chng t qu nóo xut hin Nhng hiu bit v iu tr t qu nóo c nõng cao, kốm theo ú vai trũ ca phc hi chc nng gim di chng tn tt cho bnh nhõn cng ngy cng c ci thin .1 t qu chy mỏu nóo mc dự chim t l ớt hn so vi t qu nhi mỏu nóo, song bnh cnh lõm sng rm r hn, e da cỏc chc nng sng sau khi phỏt, t l t vong v tn ph cao hn Chy mỏu nóo tht l mt bin chng ca chy mỏu s (ICH) v cú ý ngha tiờn lng xu vi t l t vong lờn ti 50-80% Chớnh vỡ vy vic iu tr sm, tớch cc, ỳng phỏc , c bit vai trũ ca iu tr tớch cc t u l rt quan trng Do tớnh cht phc v nguy him ca bnh, vic nghiờn cu cỏc bin phỏp iu tr nhm gim ch t l t vong v tn ph cn phi tip tc c hon thin .1 ú chớnh l lý chỳng tụi vit chuyờn III: iu tr chy mỏu nóo - nóo tht .1 I I CNG 1.1 nh ngha .2 1.2 V trớ chy mỏu nóo, mỏu vo nóo tht 1.3 Lõm sng chy mỏu nóo nóo tht II C CH TN THNG TRONG T QU CHY MU NO NO THT 2.1 Gión nóo tht 2.2 S lan rng mỏu t 2.3 Phự nóo 2.4 Thiu mỏu nóo 2.5 Cỏc hot cht sinh hc gõy viờm 10 III IU TR CHY MU NO NO THT .10 + iu tr ton din tỡnh trng thn kinh v cỏc chc nng sng (huyt ỏp, mch, oxy, nhit ) trờn c s theo dừi thng xuyờn .11 + D phũng v iu tr cỏc bin chng 11 + Dn lu nóo tht ngoi, v dn lu nóo tht ngoi cú kt hp tiờu huyt nóo tht 11 + iu tr c hiu tỏc ng vo cỏc yu t bnh sinh ca t qu 11 + Phc hi chc nng sm, tỏi hũa nhp bnh nhõn vi cng ng 11 + D phũng th phỏt sm, ngn chn t l chy mỏu tỏi phỏt 11 3.1 iu tr ton din, gi cõn bng cỏc chc nng sinh lý .11 3.1.1 m bo hụ hp 11 - Hỳt m dói, khai thụng ng th 11 - t bnh nhõn t th u cao 300, thng trc, th oxy n lớt/phỳt, m bo bóo hũa oxy mỏu trờn 95%, trỡ cung cp oxy cho t chc l rt quan trng giỳp gim tn thng thờm t bo nóo 11 - Nu cú ri lon nut hoc ri lon ý thc cn t sonde d dy trỏnh tro ngc dch d dy gõy viờm phi hớt 11 - Nu cú biu hin suy hụ hp cn t ni khớ qun v tựy thuc vo mc suy hụ hp s th mỏy h tr, xột nghim khớ mỏu ng mch iu chnh ch th 11 3.1.2 m bo huyt ỏp, tun hon .11 Tng huyt ỏp thng gp giai on cp ca chy mỏu nóo nóo tht, thm nhng bnh nhõn khụng cú tin s tng huyt ỏp Trong hu ht cỏc trng hp tng huyt ỏp phn ng kộo di vũng n 10 ngy v huyt ỏp thng tng ti a 24 gi u iu tr h huyt ỏp sau chy mỏu nóo v lõu di lm gim t l t vong v tn ph Tuy nhiờn sau chy mỏu nóo thỡ thi im h huyt ỏp v h huyt ỏp mc bao nhiờu cũn cha thng nht v cũn nhiu tranh lun Tng huyt ỏp sau chy mỏu nóo cú th lm tng nguy c lan rng mỏu t, phự nóo v nhng bin chng ton thõn khỏc Mt khỏc, h huyt ỏp cú th gõy thiu mỏu nóo lm tn thng th phỏt sau chy mỏu nóo - nóo tht, c bit vựng na ti na sỏng iu tr huyt ỏp chy mỏu nóo nóo tht l mt phc cn phi cõn nhc gia li ớch v nguy c .12 Nghiờn cu quan sỏt vi s h tr ca hỡnh nh thn kinh tiờn tin cho thy khụng cú vựng thiu mỏu cc b na ti ỏng k CMN Vin gim t trng xung quanh mỏu t c chng minh l huyt tng thoỏt Mt th nghim lõm sng ngu nhiờn s dng CT ti mỏu CMN nguyờn phỏt va v nh cho thy khụng cú gim ỏng k lu lng mỏu nóo khu vc xung quanh mỏu t liờn quan n vic h HA tớch cc sm vi gi u CMN vi mc tiờu HA tõm thu 180 mmHg hoc huyt ỏp trung bỡnh > 130 mmHg v cú bng chng hoc nghi ng tng ỏp lc ni s thỡ xem xột theo dừi ỏp lc ni s v iu tr gim huyt ỏp bng thuc truyn tnh mch ngt quóng hoc liờn tc vi mc tiờu gi ỏp lc ti mỏu nóo khong 61 80 mmHg .13 + Huyt ỏp tõm thu > 180 mmHg hoc huyt ỏp trung bỡnh > 130 mmHg v khụng cú bng chng hoc khụng nghi ng tng ỏp lc ni s thỡ xem xột iu tr gim nh huyt ỏp (mc tiờu huyt ỏp trung bỡnh 110 mmHg hoc huyt ỏp tõm thu 160 mmHg) bng thuc truyn tnh mch ngt quóng hoc liờn tc, thm khỏm li bnh nhõn mi 15 phỳt 14 - Cỏc thuc h huyt ỏp c hi tim mch v t qu Hoa K khuyn cỏo l nhng thuc tỏc dng ngn, ng tnh mch, tờn thuc v liu dựng nh sau: 14 + Thuc chn beta (vớ d labetalol) v thuc c ch men chuyn i angiotensin (ACEIs) (vớ d enalapril) 14 + Trng hp cn h nhanh chúng huyt ỏp dựng thuc: nh nicardipin v hydralazine (trỏnh dựng nitroprusside vỡ cú th lm tng ỏp lc ni s) 14 Trong nghiờn cu ATACH, nicardipin tnh mch c bt u vũng gi sau phỏt t qu v tip tc 24 gi ti 14 S dng thuc cú th iu chnh c liu nh nicardipin v labetalol: 14 Nicardipin mg/gi v iu chnh n liu 15 mg/gi nu cn 14 Labetalol 10-20 mg tiờm liu np tnh mch, nhc li nu cn cho n liu 60 mg 14 Nu huyt ỏp tt cn xem xột v iu chnh cỏc nguyờn nhõn dn ti huyt ỏp thp (do dựng thuc h huyt ỏp quỏ mc, mt nc in gii, suy tht trỏi, nhi mỏu c tim, ri lon nhp) Cn iu tr nguyờn nhõn, cú th s dng cỏc thuc mch nõng huyt ỏp nu cn thit 14 3.1.3 Duy trỡ mc Glucose mỏu 14 ng huyt cao lỳc nhp vin tng nguy c t vong v d hu xu bnh nhõn cú v khụng cú ỏi thỏo ng 14 Gim Glucose mỏu dn n tn thng mụ nóo vỡ th nu cú cn phi c iu chnh Ngc li, nhiu nghiờn cu cng ó ch nhng bnh nhõn cú mc Glucose mỏu cao nhp vin cú hu qu chc nng nng n hn Khi Glucose mỏu cao dn n tng lactic v pyruvic vựng na ti na sỏng (kt qu ca chuyn hoỏ ym khớ lng oxy mỏu khụng ) dn n tng toan hoỏ mụ v c cho t bo thn kinh Vỡ vy cỏc tỏc gi khuyờn nờn gi Glucose mỏu mc n mmol/lớt Kim soỏt ti u tỡnh trng tng ng huyt c khuyn cỏo (Class I, mc bng chng C), theo dừi ng huyt thng xuyờn trỏnh h ng huyt cng nh tng ng huyt 14 3.1.4 Duy trỡ cõn bng nc, in gii 15 - Cn ỏnh giỏ lng nc vo (dch truyn, thuc), thc n bm qua sonde d dy, lng nc thi (nc tiu, m hụi, phõn, mt nc th mỏy, st cao ), theo dừi ỏp lc tnh mch trung tõm, m bo cõn bng nc vo 15 - Cn theo dừi in gii hng ngy cỏc trng hp chy mỏu nóo ln cú ri lon ý thc, ri lon in gii bự kp thi, hn ch tn thng ri lon in gii gõy nờn 15 3.2 D phũng v iu tr cỏc bin chng ton thõn, bin chng thn kinh 15 3.2.1 iu tr tng ỏp lc s nóo 15 Phự nóo l nguyờn nhõn chớnh gõy tng ỏp lc s nóo, hu qu gim ti mỏu nóo Mc tiờu ti u ca iu tr l cựng lỳc khụi phc v trỡ mt ỏp lc ti mỏu nóo ti u (trờn 70mmHg), trỡ ỏp lc ni s di 20mmHg iu tr phự nóo l tng hp nhiu bin phỏp khỏc nhau, bao gm cỏc bin phỏp iu tr c hiu v khụng c hiu Cỏc bin phỏp chớnh iu tr phự nóo, tng ỏp lc s nh sau: 15 a, H thõn nhit ch ng 15 c bỏo cỏo ln u v h thõn nhit ch ng iu tr chn thng s nóo vo nhng nm 1950, phng phỏp ny hin cũn nhiu tranh lun v vai trũ iu tr tng ỏp lc ni s Hin ti h thõn nhit khụng c khuyn cỏo ỏp dng iu tr tng ỏp lc ni s cỏc tỡnh lõm sng [22] H thõn nhit lm gim chuyn hoỏ nóo v gim lu lng mỏu nóo v gim ỏp lc ni s Cỏc nghiờn cu ban u v h thõn nhit b hn ch bin chng ton thõn ca phng phỏp ny bao gm ri lon nhp tim v ri lon ụng mỏu Tuy nhiờn, cỏc nghiờn cu sau ny cho thy h thõn nhit ch ng cú th lm gim ỏp lc ni s v ci thin tiờn lng ca bnh nhõn H thõn nhit cú v nh cú tỏc dng h ỏp lc ni s sau cỏc bin phỏp khỏc tht bi [23] H thõn nhit ch ng cú th t c thụng qua phng phỏp lm h thõn nhit ton thõn bao gm bm nc lnh vo d dy, chn lnh, mc ớch lm thõn nhit trung tõm gim xung 32 n 34 C Phng phỏp tt nht (vớ d ton thõn hay ti ch), ớch h nhit ti u v thi gian h thõn nhit bao lõu cũn cha c rừ rng 15 Cỏc nghiờn cu thc nghim ó chng minh tỏc dng bo v nóo ca bin phỏp h thõn nhit va phi (32 n 340C) H thõn nhit c tin hnh trc hoc sau giai on phự nóo ó t cú hiu qu tt c cỏc nghiờn cu thc nghim lm gim s lan rng ca cỏc tn thng thiu mỏu nóo hoc lm ci thin v mt chc nng thn kinh Mt nghiờn cu khỏc trờn thc nghim li núi n tỏc dng nguy him ca h thõn nhit va phi (320C) i vi cỏc t bo thn kinh m: H thõn nhit c ch enzym bm mng t bo Na+/K+-ATP ase, hot húa cỏc antiport Na+/H+ iu ú dn n tớch t Na+ t bo v phự cỏc t bo thn kinh m T l st bnh nhõn chy mỏu nóo l khỏ cao, c bit l bnh nhõn chy mỏu nóo tht Mt nghiờn cu ó c cụng b cú 19% bnh nhõn chy mỏu nóo st nhp vin v cú ti 91% st 72 gi u [22] nhng bnh nhõn sng sút sau 72 gi u tiờn sau nhp vin, thi gian b st cú liờn quan n d hu v dng nh l mt yu t tiờn lng c lp Giỏ tr ca liu phỏp h thõn nhit cũn phi tip tc c khng nh, nhng li ớch ca iu tr tng thõn nhit (iu tr st) cỏc bnh nhõn cú tn thng thn kinh bng cỏc bin phỏp vt lý phi hp vi s dng paracetamol ó c khng nh v tr thnh bt buc (Class IIb, bng chng C) St lm d hu xu hn cỏc mụ hỡnh th nghim tn thng nóo 16 b, T th u ca bnh nhõn .17 C s gii thớch cho gúc nõng ca u l gim ỏp lc xoang dc gia dn n gii thoỏt mỏu tnh mch nóo vo cỏc xoang mch nóo v t ú vo h tun hon chung Gim th tớch tnh mch nóo s lm gim phự n nóo Trong a s cỏc trng hp nm u cao cú tỏc dng gim ALNS T th ti u l u bnh nhõn c nõng cao 300, iu ny cú th lm gim ALNS trung bỡnh 7mmHg (cú th ti 10mmHg) m khụng lm thay i lu lng ti mỏu nóo [2] 17 Cn lu ý l t th u cao cú th lm gim ỏp lc ti mỏu nóo, nhiờn, m bo hiu qu ca t th u cao, hu ht cỏc chuyờn gia u khuyn cỏo l u cao chng no m ỏp lc ti mỏu nóo cũn nm gii hn phự hp [27],[28] 17 c, Cỏc thuc gõy ng 17 Barbiturates (Thiopental) 17 Ch nh dựng Barbiturate lm gim ALNS bng cỏch gim chuyn húa nóo, gim s dng oxy, gim lu lng mỏu nóo v gim th tớch mỏu nóo Nhng tỏc dng quan trng nht ca Barbituric l phõn phi li mỏu t khu vc nóo lnh v khu vc nóo tn thng (Hiu ng th tớch o ngc hiu ng Robin Good), gim tit dch nóo ty, cú tỏc dng n nh mng t bo, tỏc dng by cỏc gc t v lm gim Peroxy húa Lipid [2] 17 T lõu ngi ta ó chng minh c Barbituric cú tỏc dng kim soỏt ALNS Mc dự cú tỏc dng cú li trờn ALNS nhng vic s dng Barbituric cho cỏc bnh nhõn phự nóo cũn tip tc tho lun vỡ cha cú nghiờn cu lõm sng no chng minh c mt cỏch rừ rng s ci thin ca nú i vi tiờn lng ca cỏc bnh nhõn phự nóo Barbituric lm gim ALNS nhng s mt i nhanh chúng nu nh tt huyt ỏp ng mch xy m khụng c khc phc Barbituric gõy tt huyt ỏp l va gõy gión mch h thng va cú tỏc dng c ch c tim, vỡ vy cn khụi phc lng tun hon trc dựng Barbituric 17 Thụng thng, ngi ta dựng Barbituric vi liu ban u mg/kg tiờm tnh mch vũng n 10 phỳt, tip theo truyn tnh mch vi liu 6mg/kg/gi Cn gim liu thuc c th bt u bóo hũa Barbituric trỏnh nguy c quỏ liu v try tim mch Liu phỏp dựng thuc ng khụng nờn kộo di quỏ n ngy vỡ thuc cũn hiu lc nhiu ngy sau ngng thuc 18 Propofol .18 Propofol l thuc tỏc dng ngn cú th lm gim ỏp lc s nóo nhng li gõy gión mch h thng nờn dựng chỳ ý phũng tt huyt ỏp 18 d, iu chnh huyt ỏp ng mch 18 Huyt ỏp ng mch (HAM) gi vai trũ quan trng trỡ lu lng ti mỏu nóo Huyt ỏp khụng n nh cú nguy c lm nng thờm tỡnh trng phự nóo .18 Tng HAM nhm mc ớch n nh ỏp lc ti mỏu nóo v lu lng mỏu nóo c coi nh mt mc ớch iu tr chin lc Sau ó bự lng tun hon, cú th dựng cỏc thuc nõng huyt ỏp n nh HAM Cú th dựng Noradrenalin liu khụng vt quỏ 0,01 àg/kg/phỳt hoc kt hp vi Dopamine lm gim cỏc tỏc dng ph ca thuc co mch Noradrenalin Dopamine liu àg/kg/phỳt cũn giỳp d phũng tn thng thn nh tỏc dng gión mch thn 18 e, S dng dch truyn .19 Hng ro mỏu nóo l mt cu trỳc c bit khụng thm vi cỏc protein cng nh cỏc ion v ớt thm vi nc Vỡ vy cn cú mt s chờnh lch ln v ỏp lc thm thu lm chuyn nc t phớa ny sang phớa bờn ca hng ro mỏu nóo Vỡ kh nng to ỏp lc thm thu ca cỏc protein mỏu l thp (1mOsm/kg) so vi kh nng to ỏp lc thm thu ca cỏc cht in gii dung dch (285mOsm/kg) Bỡnh thng chuyn nc tuõn theo s chờnh lch ỏp lc thm thu cỏc ion (Na+, K+, Ca++) v cỏc cht cú hot tớnh thm thu gõy nờn (ure, manitol, glucoza) C ch ny l rt mnh vỡ s chờnh lch ỏp lc thm thu 1mOsm tng ng vi s chờnh lch ỏp lc thy tnh l 19 mmHg Khi hng ro mỏu nóo b tn thng thỡ s chuyn nc cũn tuõn theo chờnh lch v ỏp lc thy tnh Vỡ vy vic la chn dch truyn phi l cỏc dch tinh th cú kh nng to ALTT cao nh huyt mn 0,9% (ỏp lc thm thu l 304mOsm/kg), HTM u trng (Lu ý Ringer lactate l mt dch nhc trng cú ALTT 255mOsm/kg) 19 Trong iu tr phự nóo cn tuyt i trỏnh ỏp lc thm thu huyt tng thp hn 285mOsm/kg Gim ỏp lc thm thu mỏu cú th dựng cỏc dung dch nhc trng (dch glucoza hoc Ringeer lactate) Nhng cng cn trỏnh cung cp quỏ nhiu dch tinh th, nú cú th lm nng thờm phự nóo lm gim ỏp lc keo ca huyt tng Cụng thc tớnh ỏp lc thm thu mỏu: 19 ALTT mỏu = ( Na ( mmol/l ) x ) + Glucose (mmol/l ) + ure ( mmol/l ) .19 (bỡnh thng 290 n 310 mosmol/kg) .19 Liu phỏp thm thu 19 + Mannitol 19 Mannitol cú tỏc dng: Chng phự nóo, ci thin tớnh lu huyt v nõng huyt ỏp Trong vũng phỳt sau truyn Mannitol, ỏp lc thm thu (ALTT) ca huyt tng tng, Gradient thm thu ny s kộo nc t khong k ca bt k c quan no vo khu vc lũng mch, lm gim lng nc t ngoi t bo, iu ny cng kộo theo vic gim nht ca mỏu (gim Hematocrite) Mỏu s d dng lu thụng h thng mch nóo, thỳc y s trao i oxy vi t bo nóo Mannitol thng c s dng vi liu 0,25 n 0,5g/kg truyn tnh mch cỏch n gi Cn lu ý nhng vựng nóo cú tn thng hng ro mỏu nóo nng, vic dựng Mannitol liu cao v kộo di s cú nguy c tớch t thuc khoang ngoi lũng mch dn n phự nóo xut hin nng hn (tỏc dng phn hi) Mannitol cũn cú tỏc dng li tiu thm thu, trng hp cú kt hp vi Lasix thng gõy nguy c mt nc in gii, vỡ vy dựng nú cn chỳ ý b sung lng mỏu lu hnh Kh nng bt li ca Mannitol trờn ng thn c tớch ly dn dn, nu iu tr bự dch khụng y cú th dn n tn thng ng thn v c bit cỏc trng hp cú iu tr phi hp vi mt s thuc nõng huyt ỏp, khỏng sinh dũng Aminoglucoside cú th dn ti hu qu suy thn trỏnh tn thng thn thỡ ỏp lc thm thu ca huyt nờn c trỡ phm vi 310-320mOsmol 19 + Huyt mn u trng 20 Tỏc dng ca HTM u trng lờn ỏp lc ni s l rt rừ, nhiu tỏc gi ó s dng HTM u trng cỏc trng hp tng ỏp lc ni s tr lỡ vi cỏc bin phỏp iu tr thụng thng (manitol, tng thụng khớ, barbituric) Chỳ ý, mi trng hp, ỏp lc thm thu huyt tng khụng c vt quỏ 320mOsm/kg vỡ cú th gõy tn thng thn kinh tng thm thu 20 f, M hp s gim ỏp (gii chốn ộp) 20 Phu thut ny khụng thuc nhúm phu thut ly b cỏc choỏn ch ni s nh mỏu t, u, ỏp xe Hin cũn tranh lun ỏnh giỏ hiu qu ca phu thut m s gii phúng chốn ộp vi vai trũ l mt bin phỏp iu tr chng phự nóo Phu thut ny ly b mt mnh xng rng v kốm theo vic m rng mng cng Cú th m rng hp s v mng cng mt bờn hoc hai bờn thụng thng l vựng trỏn thỏi dng nh Mc ớch l tng kớch c vũm s, cung cp khong trng cho vic m rng cỏc mụ nóo b phự v gim thoỏt v ni s ca nóo Phu thut ny thng c s dng nh mt n lc cui cựng kim soỏt tng ALNS mi bin phỏp iu tr bo tn chng tng ỏp lc ni s tht bi 20 g, Tng thụng khớ va phi 21 Tng thụng khớ l hỡnh thc iu tr hiu qu tng ALNS Ngi ta thy lu lng mỏu nóo gim 40% vũng 30 phỳt sau gim paCO2 15 n 20mmHg [16] Tng thụng khớ lm gim 32 rt-PA c dựng ch sau loi b v iu tr ht cỏc ngun gc gõy chy mỏu thờm vo nóo tht nh tỳi phỡnh b v hoc ri lon ng mỏu Cỏc bnh nhõn m s nóo vũng 48 gi cng b loi tr - Cỏch dựng Alteplase (rt-PA) Lng rt-PA c quyt nh theo d oỏn lng mỏu nóo tht Liu thng dựng l 3-5mg rt-PA (nng 4mg/ml); liu cao (8mg) c dựng bnh nhõn hụn mờ vi chy mỏu lan rng c nóo tht Trong trng hp cú th, nờn rỳt bt trc mt lng dch nóo ty bng vi th tớch thuc a vo Nờn bm vo 1-1,5ml nc mui sinh lý sau tiờm thuc Sau ú, kp ng dn lu nóo tht li hn gi v theo dừi sỏt ỏp lc ni s Nu ỏp lc ni s tng hn 25mmHg hn phỳt, m kp ng dn lu ly bt 1-2ml dch nóo ty Nu ỏp lc ni s khụng i, tip tc th thut Sau gi u, ng dn lu s c kp v m mi gi mt ln vũng 12 gi - iu tr lp li Quyt nh iu tr lp li sau nhn c kt qu theo dừi trờn phim CT Scan s nóo hoc MRI nóo iu tr lp li sau 12-24 gi Theo khuyn cỏo ca AHA/ASA nm 2015, iu tr tiờu huyt nóo tht bnh nhõn chy mỏu nóo tht l hiu qu v an ton, bin chng thp (Class IIb, bng chng B) 3.4.3 Ni soi hỳt cc mỏu t nóo tht v phu thut m thụng nóo tht Theo nghiờn cu gn õy ca Hailey (2012), so sỏnh 48 bnh nhõn chy mỏu nóo tht th phỏt sau chy mỏu nóo v iu tr bng ni soi hỳt cc mỏu t nóo tht cho thy 17% cn t dn lu nóo tht vnh vin so vi 50% nhúm iu tr bng dn lu nóo tht n thun (n=48 ) Kt qu tớnh theo im Rankin ci biờn l tng t Phng phỏp iu tr ni soi hỳt 33 cc mỏu t nóo tht ó c AHA/ASA khuyn cỏo hng dn iu tr chy mỏu nóo tht nm 2015 class IIb, mc bng chng B 3.4.4 Cỏc bin phỏp ó cụng b khỏc d phũng v iu tr gión nóo tht bnh cnh ny ang c nghiờn cu: - S dng phng phỏp tip cn ni mch thn kinh (neuroendovascular approach) ly b mỏu nóo tht dng nh y hn mt s ớt cỏc nghiờn cu ca bnh - M thụng nóo tht III qua ni soi (endoscopic third ventriculostomy) cng c s dng mt s cỏc trng hp ó c cụng b iu tr gión nóo tht cp liờn quan ti chy mỏu nóo tht Hỡnh M thụng nóo tht III qua ni soi 34 3.5 iu tr chy mỏu nóo bng phng phỏp phu thut 3.5.1 Phu thut m hp s ly b mỏu t Mt th nghim quc t v phu thut BN chy mỏu nóo (STICH: International Surgical Trial in Intracerebral Heamorrhage), tin hnh ngu nhiờn trờn 1033 BN chy mỏu nóo, c phu thut 96 gi u ỏnh giỏ t l t vong, thang im Glasgow Outcome, Rankin ci biờn sau thỏng Kt qu khụng thy li ớch ca iu tr phu thut so vi nhúm iu tr ni khoa (kt qu tt 26% so 24%, P= 0,41) Cng nghiờn cu ny, mt nhúm bnh nhõn cú im Glasgow 9-12, cú mỏu t nụng cỏch v nóo 1cm, cú kt qu tt hn mc dự kt qu khụng cú ý ngha thng kờ, ny cn nhng nghiờn cu sõu hn na khng nh Theo hng dn ca AHA/ASA 2015 khuyn cỏo: i vi hu ht cỏc bnh nhõn chy mỏu nóo trờn lu, li ớch ca phu thut cha c thnh lp (Class IIb, bng chng A) nhng cú th cú li nhng bnh nhõn cú lõm sng xu i (Class IIb, bng chng A) Trong mt th nghim lõm sng khỏc, nhng bnh nhõn chy mỏu tiu nóo cú ng kớnh > cm, hoc cú chốn ộp thõn nóo, hoc cú gión nóo tht iu tr phu thut cú kt qu tt hn iu tr ni khoa n thun [21] Theo hng dn ca AHA/ASA 2015 khuyn cỏo bnh nhõn chy mỏu tiu nóo lõm sng ang xu i hoc chốn ộp thõn nóo v / hoc gión nóo tht nờn phu thut cng sm cng tt (Class I, bng chng B) Khụng khuyn cỏo u tiờn iu tr dn lu nóo tht hn phu thut (Class III, bng chng C) 3.5.2 Phu thut xõm nhp ti thiu a, Ni soi hỳt mỏu t Mt th nghim ngu nhiờn tin hnh trờn 100 BN tui 30 n 80, chy mỏu nóo, iu tr 48 gi, th tớch ti thiu 10ml cỏc bnh nhõn c tin hnh ni soi , bm v hỳt mỏu t bng cỏch truyn dch nóo ty nhõn 35 to vi ỏp lc 10 n 15 mmHg, hỳt ngt quóng ly mỏu t (dch nóo ty ln mỏu) Nhúm khỏc c iu tr ni khoa n thun Kt qu, t l t vong nhúm c phu thut 42% so vi nhúm iu tr ni khoa tớch cc 70 % (P=0,01) Trong s BN cú th tớch mỏu t trờn 50ml t l sng sút c ci thin nhng khụng ci thin v mt chc nng Nhng li ớch ca ni soi hỳt mỏu t c khng nh rừ rng hn nhúm BN chy mỏu nóo thựy v cú tui di 60 [27] b, Liu phỏp tiờu huyt v hỳt mỏu t Mt th nghim ngu nhiờn a trung tõm tin hnh trờn 72 BN, im Glasgow 5, th tớch mỏu t >10ml, iu tr 72 gi u Truyn Urokinase 5000UI mi gi 48 gi qua l khoan s Kt qu, th tớch mỏu t nhúm can thip gim 40%, nhúm iu tr bo tn gim 18%, chy mỏu tỏi phỏt nhúm can thip 35% v nhúm bo tn 17% T l t vong gim 40% nhng khụng cú s khỏc bit v mc hi phc chc nng gia hai nhúm [12], chớnh vỡ vy m Urokinase khụng c ỏp dng liu phỏp tiờu huyt v hỳt mỏu t ti Hoa K Ngy rt-PA ang c nghiờn cu thay th cho Urokinase liu phỏp tiờu huyt v hỳt mỏu t, cỏc nghiờn cu ang c tin hnh [17] 3.6 Chm súc, nuụi dng, phc hi chc nng 3.6.1.Chm súc ti bnh vin v cỏc n v t qu nóo giai on cp bnh nhõn cn c chm súc ti cỏc c s y t chuyờn sõu nh n v hay Trung tõm t qu nóo Cỏc nghiờn cu thng kờ cho thy vic c chm súc cỏc n v, Trung tõm t qu ó lm gim t l t vong v tn ph mi nhúm bnh nhõn khụng ph thuc vo tui, gii tớnh hay mc bnh [9] 3.6.2 Nuụi dng Vi bnh nhõn cú ri lon ý thc hoc nh hng n kh nng nut cn nuụi dng qua ng sonde d dy bng cỏc cht dinh dng lng giỳp 36 tng cng chuyn húa c th v trỏnh cỏc bin chng ri lon nut gõy nờn bnh nhõn chy mỏu nóo ln lng calo cn cung cp bao gm nng lng tiờu phớ c bn + 20% bự nng lng tiờu hao nh tng thõn nhit, nhp tim nhanh, tng tit m hụi, tng huyt ỏp Bờn cnh ú cng trỏnh khụng nờn nuụi dng quỏ nhiu dn n tng CO2 mỏu [8] 3.6.3 Phc hi chc nng sm Tp phc hi chc nng sm khụng ch giỳp tng kh nng hi phc ca bnh nhõn m cũn giỳp gim cỏc bin chng nm lõu nh bi nhim, huyt tnh mch, teo c, loột t ố Tuy nhiờn, trỏnh nhng bin chng cú th xy ng sm nh l chy mỏu tỏi phỏt, thoỏt v nóo, tt huyt ỏp t th, trc cho ch nh cn ỏnh giỏ c ton trng bnh nhõn: v trớ, mc chy mỏu nóo, cỏc ri lon chc nng, kim soỏt tinh trng tim mch, st, ng mỏuv cú ch nh phự hp nh th ng hay ch ng 3.7 Cỏc thuc bo v t bo thn kinh + Tỏc ng nhm c ch lờn kờnh Canxi (Nimodipin) + Cỏc yu t tng dinh dng thn kinh (Cerebrolysin) + Tỏc ng lờn tun hon ca mụ b thiu mỏu (Ginkgobiloba; Bufflomedil; stugeron, duxil ) + Tỏc dng lờn cht trung gian tng hp chuyn hoỏ acetylcholin v photpholipit (Citicolin) + Tỏc dng tng hp lờn cỏc chc nng ca nron thn kinh (Gliatilin) Cỏc thuc bo v thn kinh tng i an ton iu tr nhng hiu qu cha c khng nh cỏc th nghim lõm sng nờn ch c xem nh mt bin phỏp iu tr b tr 37 3.8 D phũng th phỏt sm ngn chn t l chy mỏu tỏi phỏt T l chy mỏu tỏi phỏt c xỏc nh 2,1 n 3,7% mt nm [13] Yu t nguy c cao nht c khng nh l chy mỏu nóo thựy tiờn phỏt iu ny cú th liờn quan ti bnh mch mỏu thoỏi húa dng tinh bt Chy mỏu tỏi phỏt tng huyt ỏp cng hay xy nhng bnh nhõn ó chy mỏu vựng nhõn xỏm, i th v thõn nóo Ngoi cũn cỏc yu t nguy c khỏc nh tui cao, dựng thuc chng ụng, thuc chng kt tiu cu, x gan, cỏc bnh ri lon ụng mỏu Trong ú tng huyt ỏp l yu t nguy c quan trng nht cú th thay i c Sau giai on cp huyt ỏp phi c iu tr v theo dừi thng xuyờn, trỡ mc huyt ỏp di 140/90 mmHg (di 130/80 mmHg i vi ngi ỏi thỏo ng, suy thn) Ngoi cn phi khuyn cỏo bnh nhõn b thuc v khụng ung nhiu ru, bia, cht kớch thớch Cú ch n ung sinh hot iu , th dc thng xuyờn iu tr tt cỏc bnh khỏc kốm theo nh ỏi thỏo ng, suy thn, x gan IV TIấN LNG T l t vong bnh vin ca chy mỏu nóo nóo tht c cụng b thay i t 20% n 50% Tui cao, cú bnh ri lon ụng mỏu, im hụn mờ Glasgow di 8, gión nóo tht ti thi im phỏt cng liờn quan ti t l t vong cao hn Trong nhiu nghiờn cu ó cho thy rng mc chy mỏu nóo tht (im Graeb cao) tng quan vi tiờn lng, thỡ mt s nghiờn cu khỏc thỡ khụng cho thy nh vy Cỏc kt qu ca mt nghiờn cu ó cho rng th tớch mỏu nóo tht III l yu t d bỏo mnh m v c lp cho kt cc kộm, th tớch mỏu nóo tht bờn, nóo tht IV hoc ton b h thng nóo tht li khụng tng quan mt cỏch cú ý ngha vi tiờn lng Cỏc tỏc gi ó cho rng mỏu nóo tht III cú th nh hng ti cu trỳc lin k quan trng nóo gia TI LIU THAM KHO Adams Robert E, Diringer Michael 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