VIEM TUY CAP I D A I C lfO N G Ljch sur C) the ky thii XIX, hau het cac benh d song deu diidc goi la viem Morton Prince da viet Dercum’s Textbook of Nervous Disease nam 1895, de cap tdi viem chan thiidng, viem chen ep Cung vdi thdi gian, sii hieu biet ve cd che benh sinh cua benh than kinh da cd nhieu biidc tien bo, cac benh ly ve thudng ton cac nguyen nhan khac bi loai bo khdi bang phan loai va chi cdn lai thuat ngii viem Nhiing cho den sii lien quan giiia viem va nhiem khuan cdn chiia ro rang Mot vai virut cham khac thiidng cd the pha huy cac te bao than kinh nhiing khong xuat hien cac te bao viem Ngay thiic te thuat ngii benh (myelopathy) hay diidc dung hdn Thuat ngCr Tuy song la ndi cd the xay qua trinh viem, mot so" can nguyen tap trung pha huy cac neuron, so" khac tham gia qua trinh pha huy mang te" bao hoac chat trang va cd the gay hoai tii ca chat xam va chat trang Thuat ngut dUdc chap nhan hien tai cho tat ca cac benh ly la benh ly song (myelopathy) Ngoai cdn cd mot so" thuat ngii chuyen biet khac diidc sii dung de chi chi'nh xac hdn sii phan bo" cua qua trinh viem nhii sau: 103 Neu thiidng ton gidi han d chat xam la viem xam (poliomyelitis) - Thiidng (leucomyelitis) ton d chat tr&ng la viem trang Toan bo khu viic cat ngang cua deu bi thudng ton diidc goi la viem ngang (myelitis transversa) Neu thiidng ton d nhieu ndi va lan rong qua pham vi chieu dai la viem rai rac (diffuse hoac disseminated myelitis) - T huat ngii viem - m ang (meningomyelitis) la dung trUdng hdp co sii phoi hdp cua viem mang va song Co the phoi hdp viem song vdi viem day than kinh thi giac, goi la viem thi than kinh (neuromyelitis optica) - Cac dang benh ly viem cap cdn cd the phoi hdp mot so o viem dong thdi cd d song va d nao, goi la viem nao - cap tinh (encephalomyelitis acute) Cd the phoi hdp viem vdi viem re than kinh song goi la viem re song (myeloradiculiis) - Mot dang viem dac biet khac la viem leo (liet leo Landry) Khai niem ve the benh - Viem cap dUdc de cap cac trieu chiing benh xuat hien nhanh va dat giai doan toan phat vong vai Ban cap la benh tien trien khoang thdi gian tii den tuan - Viem man tinh vdi thdi gian hdn tuan ke tii khdi phat tdi phat trien day du benh canh lam sang 104 Nguyen nhan Viem cap bao gom nhiing thiidng ton cap ti'nh d song, co the la tien phat hoac thii phat, virut hoac vi khuan gay nen - Nhiem khuan: + Tien phat: virut dai, poliovirut, Arbo virut + Thii phat: virut bach hau, cum, sdi, vi khuan ly, phe cau, tu cau, lien cau, hoac cac benh nhiem trung phiic tap khac nhii triic khuan giang mai, thiidng han, ly va cac loai nhiem khuan huyet khac gay nen Nhilm doc: arsen, chi, thuy ngan va cac kim loai nang khac Dac diem thudng ton Hinh anh thiidng ton benh ly theo qua trinh tien trien cua benh gom giai doan: 5.1 Nhun Giai doan b it dau cua viem, bieu hien sung huyet phu ne tuy, gian mach, xuat huyet nho, nhiing te bao than kinh bi thiidng ton tan nhan, tao khong bao, vd te bao Cac sdi true bi huy myelin Ve mat dieu tri chi co the lam hoi phuc d giai doan nhun 5.2 Nhun trdng Cac te bao va to chiic than kinh bi hoai tii, te bao than kinh bi pha vd hang loat, sdi true bi pha huy 105 5.3 X o h o a To chtic than kinh bi hoai tti diidc thay bang to chtic xd, xen ke cac te bao than kinh dem Day la sii seo hoa d vi tri to chtic bi thiidng ton II VIEM TUY NGANG CAP Viem ngang cap (VTNC) la the lam sang thudng gap nhat cua viem cap Trong thiic te thiidng hay gap viem ngang d doan phinh that liing, doan ngiic, rat it gap d doan co Nguyen nhan chu yeu tien phat virut cung co the thii phat nhiing hiem (sau cum, sdi ) Lam sang 1.1 Hoi chitng nhiem khuan Benh thudng khdi phat cap tinh bang hoi chting nhiem khuan Sot cao d cac mtic khac (tuy nhien cung co triidng hdp sot khong ro) kem theo dau cac day than kinh d khu viic bi viem, dau lan khoanh doan da re than kinh cua cac khoanh chi phoi Sau mot vai ngav xuat hien trieu chting than kinh khu tru 1.2 Hoi chitng thitctng ton than kinh khu tru Tuy theo khu viic bi thiidng ton ma co nhting trieu chting tiidng ting, dau hieu lam sang phat trien dien hinh cua mot thiidng ton cat ngang song Roi loan van dong: kieu diidng dan truyen, liet phan cd the du'cli mtic thiidng ton, giai doan dau liet mem (dac diem quan trong), triidng liic cd phan chi liet giam, giai doan sau chuyen sang liet ciing 106 Roi loan ve phan xa: phan xa gan xUdng m at (tiidng iing phan chi liet), phan xa da bung mat Roi loan cam giac: mat cam giac kieu diidng dan truyen, mat toan bo cac loai cam giac diidi khoanh thiidng ton, tren vung thiidng ton mat cam giac la vung tang cam Roi loan cd vong: thiidng xuat hien sdm d da so’ benh nhan bieu hien la bf dai, dai kho, den liet nang chuyen sang dai dam Roi loan dinh dudng, thiic vat: benh nhan cd roi loan dinh diidng tram d khu vUc bi thiidng ton, bieu hien lam sang la loet diem ty sdm, loet rong, sau va rung long toe Tat ca cac trieu chiing tren chiing to tinh chat cua mot liet mem la hau qua cua mot giai doan soc nang ne Xet nghiem Dich nao tuy: nhieu triidng hdp khong thay doi dang ke, mot so" cd bieu hien tang albumin, bach ciu N, L Mau: cd the tang to"c mau lang, thay ddi cong thiic bach cau Cay khuan: cay DNT hoac cay mau ft phan lap diidc vi khuan Chan doan huyet dac hieu cung ft triidng hdp xac dinh diidc ro loai virut gay benh Chan doan 3.1 Chan doan xac djnh Chan doan viem ngang cap cd ban diia vao lam sang 107 Chan doan dinh khu can cti vao cac trieu chting than kinh (roi loan van dong, cam giac ) 3.2 Chan doan phan biet 3.2.1 Phan biet vdi roi loan tuan hoan tup: Co trUdng hdp viem cap khdi phat dot ngot bang liet hai chan, roi loan cam giac va roi loan cd vong kieu dot quy song, vi vay can chan doan phan biet vdi tac dong mach song Sif kien thifdng chi xay d khu vUc cua dong mach song trUdc Dong mach cung cap mau cho 2/3 trifdc cua tuy, tif nuoi dudng chi b in g mot so' nhanh mach mau rat han che Trong dong mach song sau difdc cung cap bdi so lifdng nhanh mach mau d nhieu mtic khac Hoi chting dong mach trUdc thifdng xay tac mot nhting mach nuoi Benh thifdng xay d ngifdi huyet ap cao, vtia xd dong mach, chan thifdng, chup dong m ach Benh canh lam sang dien hinh la khdi phat cap tfnh, bieu hien la: liet, m at phan xa, giai doan soc se het sau mot vai hoac tuan, tien trien liet m em vdi phan xa gan xUdng nhay va phan xa da gan chan dao ngifdc Them vao do, roi loan cam giac phan ly (mat cam giac dau, nhiet do, nhUng cdn cam giac sau va cam giac tif the vi cot sau dufdc nuoi dudng bdi dong mach song sau) 3.2 Phan biet vdi u Cd the viem gia u, trieu chting than kinh tien trien nang dan len, nhUng u tien trien cham hdn Dau la benh canh noi bat, d nhieu benh nhan benh khdi phat bat thifdng vdi cac trieu chting cua mot thifdng ton ngoai nhif dau re, dau khu tru d lifng, hoac dau lan toa d mot chi va vdi dac tfnh tang len ho hoac keo cang re 108 Roi loan van dong co the xay ra, liet ciing sdm, loet muon va nhe hdn Co tac lUu thong DNT, xet nghiem DNT co phan ly albumin - te bao, chup can quang thay vi tri bi chen ep 3.3.3 Giang m tuy' song: ThUdng ton: chu yeu gay thudng ton cot sau song, (hay gap la thifdng ton bo Goll va cac re sau vung that lifng- cung Trieu chiing lam sang: roi loan cam giac chu quan va khach quan; dau la trieu chiing dien hinh cua benh, tfnh chat cua dau rat dac biet: benh nhan dau d mot vung nhu kim nhon cham chfch, dau nhif dien giat hoac set danh, cdn dau xuat hien tii nhien hay kich thich Roi loan cam giac khach quan chu yeu hai chi dudi, mat cam giac sau Benh nhan di bang mat, do khong co anh sang benh nhan khong the di lai difdc G iam trUdng liic cd va m at phan xa gan xUdng (do thudng ton re sau cua cung phan xa khoanh tuy) Roi loan than kinh thiic vat Thay doi dich nao tuy: te bao tang, protein tang, chu yeu la globulin 3.2.4 X o nao - tup rai rac: Thuoc benh thoai hoa myelin, thudng ton bieu hien rai rac d nao, song, d tieu nao, day than kinh thi giac Benh tien trien tiing ddt mot va rat hiem gap d Viet Nam L am sang: bang lam sang rat da dang, thudng phoi hdp m ay hoi chiing nhU: hoi chiing thap, hoi chiing tieu nao, roi loan cam giac, roi loan mat va tien dinh 109 Dac biet can phan biet la cac triidng hdp thiidng ton benh ly khu tru d song Benh thiidng xuat hien d tuoi va trung nien, dien bien co tfnh chat tuan tien Co the ca qua trinh benh chi co trieu chiing liet hai chi dudi 3.2.5 N goai cdn phan biet vdi: Chan thiidng song - Cac benh ly cua cot song gay chen ep Dieu trj Dung khang sinh Dung corticoid - Vitamin nhom B - Thuoc kich thich tang ciidng dan truyen than kinh nhii Nivalin Nuoi diidng: chu y tang phan dam Chong loet: dem lot diem ty, trd minh - gid mot lan, lau sach da Chong nhiem trung dudng tiet nieu: khong dat sonde neu benh nhan dai dam, neu benh nhan bi dai thi cho dat sonde -3 rut ra, cho benh nhan tap di tieu tien, dan ltfu niidc tieu kin, vo trung Neu da nhiem khuan bang quang phai riia bang Rivanol l% o hoac dung dich thuoc tim 4%o Tap van dong, cham ciiu, xoa bop, dieu tri ly lieu Tien trien va tien lirdng Neu dieu tri sdm, tich ciic, san soc ho ly tot thi benh nhan cd the hoi phuc mot phan Da cd triidng hdp cd di chiing bai hoac liet hai chi diidi, roi loan cd vong hoi phuc tot, nhUng 110 cung co trUdng hdp khong hoi phuc dUdc NhUng benh nhan tu vong la suy kiet va boi nhiem III VIEM TUY LEO CAP (HOI CHL/NG LANDRY) Viem leo cap (Landry) co dac diem lam sang khdi phat giong viem ngang cap, nhUng tien trien nhanh chong hang hang gid, lan dan tti thap len cao va co the thUdng ton len hanh nao, gay tti vong nhanh suy thd, truy tim mach Tien lUdng de dat, ty le tti vong cao Lam sang Khdi phat thudng thudng ton d lung, vdi bieu hien liet mem hai chi dudi, vong mot vai liet len hai chi tren Benh nhan trd liet mem tti chi, cd the thay phan xa benh ly bo thap d hai chi dudi Mtic mat cam giac cung lan dan tti chan len bung, ngUc, len chi tren va len cd Roi loan cd vong kieu trung Udng, ltic dau thudng la bi dai tieu tien, sau dai dam ng&t quang Ddi thudng ton hai ben khong dong deu, ben nang hdn ben hoac sdm hdn ben kia, tao nen mot hoi chting kieu Brown - Sequard Sau dd benh tiep tuc tien trien: benh nhan dau d co, gay roi liet cac cd d co, thUdng ton day than kinh hoanh, bieu hien kho thd; thudng ton nhan day than kinh IX, X, XII, bieu hien: noi kho, nghen, sac, mat phan xa hong - hau, liet van dong lUdi Cuoi cung roi loan nhip tim va benh nhan tti vong truy tim mach Mtic liet va roi loan cam giac luc dau cang nang thi tien trien cang nhanh va tien lUdng cang xau, benh nhan cd the chet vai Ill Nhiing trUdng hdp nhe, miic thudng ton khong n&ng, dUdc ciiu chiia kip thdi, benh nhan khong tii vong thi sau 10 - 15 bat dau trieu chiing hoi phuc mot phan, da so de lai di chiing, thUdng de lai di chiing bai hoac liet ciing hai chi dudi O chi tren co the phuc hoi tot hdn, co the di chiing liet hai chi dudi kieu trung Udng ket hdp bai hai chi tren hoac mot chi tren kieu ngoai vi (do thudng ton d phinh co), bieu hien: liet m em , teo cd, m at phan xa gan xUdng, hiem gap liet ngoai vi d hai chi dudi (thudng ton phinh that lung) Roi loan cd vong co the dUdc phuc hoi, benh nhan dai tieu tien chu dong dUdc Rat hiem trUdng hdp hoi phuc hoan toan khong de lai di chiing gi Dieu trj Dieu tri viem leo cap giong nhu dieu tri viem ngang cap Dieu can chu y d day la phat hien sdm the benh nay, cd kho thd thi phai ho trd ho hap kip thdi, hoi siic tich ciic cho benh nhan IV VIEM TUY THj THAN KINH (BENH DEVIC) La mot the dac biet cua viem ngang cap Bieu hien cua viem ket hdp day than kinh thi giac vdi viem ngang The benh ve lam sang, phat trien va dieu tri tUdng tii nhu viem ngang cap Thudng ton dac hieu la thoai hoa bao myelin cua sdi than kinh, gap d day than kinh thi giac chu yeu d giao thoa thi giac Trong nhieu trUdng hdp day la giai doan dau cua bieu hien xd nao rai rac Thudng ton bat cii ndi nao cua song, nhUng phd bien nhat la song nguc 112 Benh chu yeu xuat hien le te nhUng cung co nhiing ddt dich bung phat III BENH CAN ChUa ro rang, so benh nhan triidc dd - tuan da bi benh giong nhii mot benh cam cum nhiem virut dudng ho hap tren hoac ia chay hay kiet ly nhUng da thoai lui roi trieu chiing than kinh mdi bat dau xuat hien Mac du chua xac dinh dUdc nguyen nhan dich thiic nhUng ngUdi ta da tim dUdc moi lien quan giiia hoi chiing Guillain Barre vdi: Nhiem khuan Campylobacter, Mycoplasma va benh Lyme Khoang 25 - 38% cac trUdng hdp hoi chiing Guillain Barre da xuat hien sau nhiem vi khuan Campylobacter jejuni Dac diem benh canh lam sang cua cac trUdng hdp la rat nang ne va thUdng ton giai phau benh la sii huy hoai sdi true vdi hien tUdng thoai hoa Waller, dd hien tUdng huy myelin lai khong dang ke Nhiem virut: hoi chiing Guillain - Barre cd lien quan mat thiet vdi nhiem virut Epstein - Barr, Cytomegalovirus, virut dau mua, virut vaccinia va virut lam suy giam mien dich (HIV) Hoi chiing Guillain - Barre thudng xuat hien giai doan sdm cua nhiem HIV vao thdi diem phan iing huvet HIV chuyen dUdng ti'nh NgUdi ta nghi ngd hoi chiing cd lien quan ca vdi nhiem virut Varicella - zoster va virut sdi - Nhiem doc (vi du nhu sulfamid) - Di iing sau tiem cac loai protein (vacxin serum) Bien chiing sau chung phdng dai 186 Viem da re - day than kinh xay sii man cam doi vdi mo nao chiia vacxin, cO che tifdng tif nhif viem nao thiic nghiem (experimental encephalo myelitis) gay tren nao dong vat - Roi loan chuyen hoa IV CO CHE BENH SINH Co hai cd che benh sinh: Cd che cd ban nhat la mot phan ilng mien dich nguyen phat tan cong triic tiep len mang cua te bao Schwann va myelin Mot phan Ofng mien dich nguyen phat tan cong len cac epitopes cua mang sdi true gay thudng ton nguyen phat d sdi true Nhiing roi loan mien dich hoi chiing Guillain - Barre diidc tien hanh qua trung gian te bao nhifng cung co the la he qua cua cac phan iing mien dich dich the (dieu da dUdc chiing minh vi ngiidi ta da thay co sii hien dien cua khang the anti - GM l ganglioside - la mot phan cau tao cua sdi true) va liidng khang the thi bien dong theo tien trien d phan ldn cac triidng hdp hoi chiing Guillain - Barre the sdi true vdi benh canh liet cap V GIAI PHAU BENH - Cd hien tifdng huy hay mat myelin tifng doan kem theo cd hien tiidng te bao viem ddn nhan (chu yeu la te bao lympho va dai thiic bao, tham nhiem quanh cac tieu tinh mach mo lien ket cua noi mo than kinh (endoneurium) va bao ngoai bo than kinh (epineurium) moi cau true cua he than kinh ngoai vi (nhif cac day than kinh so nao, cac re day than kinh song, cac dam roi va cac day than kinh, cac chuoi hach giao cam) cd the bi thifdng ton nhiing triidng hdp nang 187 Cac thiidng ton sdi true thii phat nhiing trUdng hdp hoi chiing Guillain - Barre nang Cac trUdng hdp hoi chiing Guillain - Barre co lien quan vdi nhiem Campylobacter jejuni, thudng ton chinh va ndi bat nhat cua cac sdi than kinh van dong va cam giac lai la hien tUdng thoai hoa Waller (rat it hinh anh viem cung nhu hinh anh huy myelin kem theo) Hinh Hinh anh giai phau benh qua trinh viem da re - day than kinh A Sii bien dang vd di chuyen te bao lympho ngoai mach B Mat myelin d doan tang bach cau dctn nhan C vd D ThiiOng ton lam gay sett true (Theo AK, Asbury vd Coll) 188 Cac thifdng ton tren lam cho cac re than kinh va nhat la cac day than kinh bi cat doan (hinh tren) - Thifdng ton co the lan tran den: + Mang nao: co hinh anh viem quanh cac tinh mach khoang difdi nhen + Nhan cac te bao van dong d sting trUdc va nhan cua day than kinh so nao + Thoai hoa myelin cua cot sau, difdng gai tieu nao, cac mach mau chat trang cua ban cau dai nao VI TRIEU CHITNG LAM SANG A th £ c b i£ n Dau hieu bao trUdc Vai tuan trifdc dd mui hong bi viem nhiem hoac cd tiem chung phdng benh Khdi phat Thifdng khong sot, cd di cam kien bo d ngon chi hoac quanh mdi, giam cac giac cac chi, liet xuat hien nhanh va lan toa Giai doan cap Thifdng gap la hoi chting liet ngoai vi doi xting, cd hay khong cd roi loan cam giac va giam hoac mat phan xa gan xifdng - Liet thifdng bat dau d hai chi difdi, sau dd lan len tren, nhifng cung cd trifdng hdp bat dau d mat hay tay roi lan xuong hoac liet van nhan hay liet mat ngoai vi 189 - Liet cd than: liet cd bung, cac cd ho hap (cd gian siidn hoac cd hoanh) gay tinh trang suy ho hap Liet cac day than kinh so nao: day VII thudng liet ca hai ben; liet day IX, X gay liet hau hong kem theo liet nhanh quan cua day than kinh quat ngiidc (bieu hien lam sang giong noi khan), liet day am mot hoac ca hai ben Day V va day XII it bi hdn - Roi loan cam giac + Chu quan: di cam d ngon chi cam giac kien bo, moi cd, te cong, hiem gap dau kieu re + Khach quan: giam cam giac nong d ngon chi, roi loan cam giac sau (mat cam giac tii the, mat cam giac rung) Giam hoac mat phan xa gan xiidng d vung bi liet Roi loan cd that: 10 - 20% triidng hdp co roi loan cd th it thoang qua (thiidng la bf dai, giam hoac mat cam giac di tieu - 10 sau thi hoi phuc) Roi loan than kinh thiic vat diidi dang thieu nang hoac ciidng giao cam hay can giao cam: thiidng gap mo hoi nhieu d mat hoac ngon chi, phu ne tai cho liet, tang hoac tut huyet ap, loan nhip tim (nhip nhanh xoang, nhip cham xoang, ngiing tim) B cAc b i£ n th £ c Qa h i c h C tng GUILLAIN - BARRE Hoi chumg Miller Fisher Diidc phat hien nam 1956 Lam sang gom cd: liet van nhan toan bo, mat dieu hoa (ataxia) tii the va mat toan bo phan xa gan xiidng 190 The sdi true Hai the thudng ton sdi true cua hoi chiing Guillain - Barre co lien quan mat thiet vdi viem ruot Capylobacter jejuni la: - Benh than kinh van dong cap the sdi true (acute motor axomal neuropathy) - Benh than kinh van dong - cam giac cap the sdi true (acute motor - sensory axomal neuropathy) Dac diem cua hai hoi chiing la bieu hien lam sang d mile nang: liet nang, de suy ho hap, di chiing nhieu va phuc hoi kem Cac bien the lam sang khac Liet hai chi dudi kem theo dau that liing (de nham vdi viem tuy) Lie* cd h iu hong - co - canh tay Sup mi mat ddn doc - Liet mat ngoai vi kem theo di cam - Liet day VI hai ben kem theo di cam - The cam giac ddn thuan - The roi loan than kinh thiic vat ddn thuan - The lam sang bien chiing sau tiem chung phong dai Co ba the lam sang bien chiing la viem nao, viem ngang va viem da re - day than kinh cap tinh Trong thiic te lam sang, hai the co thiidng ton trung lidng co cung xuat hien tren mot benh nhan nen diidc goi la viem nao lan toa cap (acute disseminated encephalomyelitis) sau tiem chung phong dai The benh viem nao sau tiem phong dai da dtfdc Uehimura va Shiraki mo ta tii nam 1957 Day la mot the benh mat myelin (demyelination) lan toa, tram 191 Bien chiing than kinh xuat hien 1/800 den 1/2000 trUdng hdp sau tiem phong dai va 25% trUdng hdp co nhung bien chiing nang, co the d in tdi tu vong VII CAN LAM SANG Can lam sang then chot hoi chiing Guillain - Barre gom xet nghiem dich nao va ghi dien cd Xet nghiem djch nao Dich nao phan ly dam - te bao, protein tang (chu yeu la IgG) thudng xay tuan thii hai cua benh do neu choc song that lung sdm (trong tuan dau) cd the ket qua am ti'nh (theo Guillain dam tang cao nhat la tii 25 - 45), theo Thieffry tii thii 10 den 20, dam d khoang 175mg% 300mg% Mot trUdng hdp ca biet Gutierry va Mendoza thay 1600 mg%) Nhung lUdng dam tang cao hay thap khong ndi len tien lUdng cua benh Dam trd ve miic binh thudng rat cham, cd the vai thang sau hoac vai nam sau Tieu chuan ve te bao dich nao phu hdp cho chan doan hoi chiing Guillain - Barre la dudi 10 - 20 te bao lympho/mm3 (neu sd lUdng te bao tren 50 te bao/mm3 thi rat cd kha nang la mot benh khac, dac biet la hoi chiing viem da re day than kinh nhiem HIV) Dien cd Neu bi huy myelin d day than kinh, thdi gian tiem xa (distal latencies) keo dai, tdc dan truyen cua cac day than kinh cham lai, dan truyen mat myelin tiing doan, thdi gian tiem cua song F keo dai Neu cd thUdng ton sdi true thii phat (thudng xuat hien sau den tuan) thi dien cd dd se xuat hien hoat dong dien tu phat dudi dang fibrillation 192 Ure huyet: co the tang Dien di protein huyet thanh: gamma globulin tang Cong thurc bach cau: eosinophile tang Nude tieu: co dam vet Trong huyet cd khang the khang gangliosides: khang the anti - GMl thudng gap nhiing trUdng hdp hoi chiing Guillain - Barre co lien quan vdi Campylobacter jejuni Khang the anti - GQlb la dac trUng cua hoi chiing Miller Fisher V III TIEN TR IEN Tien trien qua giai doan: Phat trien Khdi phat thudng la ban cap ti'nh, 90% trUdng hdp co benh canh toan phat sau den tuan tien trien va thoai lui sau dd Rat hiem trUdng hdp tiep tuc nang len sau benh da phat trien dUdc mot thang Cac the cd roi loan ho hap, roi loan nuot, tien lUdng de doa cuoc song, can dUdc can thiep ho hap co dieu khien, md khi' quan, tranh tii vong ngat va tac quan Cd the gap mot sd" bien chiing khac ket hdp: roi loan tim mach, roi loan huyet ap, viem mach, cd nguy cd bi tac dong mach phoi Cd nhiing trUdng hdp benh nhan bi chet cac bien chiing lien quan den hoi siic keo dai, cac the nguy kich ty le tii vong khoang 16% On djnh Tii - tuan 193 Lui benh Benh thiidng hoi phuc dan tii tuan thii tu keo dai tii - 18 thang, benh co the hoi phuc hoan toan Nhiing triidng hdp co thudng ton sdi true, sii hoi phuc se keo dai hdn va khong hoan toan Theo so" lieu cua Ropper thi 15% cac trUdng hdp hoi phuc hoan toan, 70% bi di chiing nhe, 10% bi di chiing nang va 5% til vong bien chiing nhu hoi chiing suy ho hap cap, viem phoi hit sac, un tac phoi va roi loan chiic nang thiic vat IX TIEN Ll/ONG Yeu to tien I uong Tuoi benh nhan Mile liet ban dau Thdi gian on dinh Cac bien chiing d giai doan cap Cac yeu to tien luong xau Cac yeu to' tien lUdng xau hoi chiing Guillain Barre gom: - Tuoi gia - Mile liet ban dau nang - Benh tien trien nhanh Hoi chiing Guillain - Barre xuat hien sau ia chay Campylobacter jejuni - Roi loan than kinh thiic vat nang X CHAN DOAN Tieu chuan chan doan hoi chumg Guillain • Barre Theo Ho Hiiu LUdng, co tieu chuan: 194 1) Liet hai chi diidi (hoac liet tii chi, co hoac khong kem theo liet day than kinh so nao) kieu ngoai vi, doi xiing hai ben cd the 2) Dich nao co phan ly dam - te bao (dam tang cao khong tUdng ilng vdi tang te bao) 3) Benh tien trien den khdi Chan doan phan biet 2.1 Viem da day than kinh: dich nao binh thudng 2.2 Chen ep cap tinh Cd the liet mem hai chi dudi Ranh gidi giam hoac mat cam giac ro rang Roi loan cd vong nang Khong cd dau hieu nao d tren cho chen ep 2.3 Benh Heine • Medin (viem s in g trUdc cap ti'nh) Liet xuat hien giai doan cdn sot - Tien trien rat nhanh ThUdng ton khong doi xiing Khong cd roi loan cam giac chu quan va khach quan - Trong nhiing dau thudng khong cd phan iing te bao dich nao 2.4 Benh porphyrin cap Benh ly than kinh lan rin g vdi Uu the van dong (vd benh ly than kinh sdi true) Phat benh thuoc, ket hdp vdi dau vung bung, co giat 19; 2.5 Viem 2.6 Cac viem da r i - day than kinh khac - Viem da re - day than kinh sau bi ve dot: + Co ban lan rong, dau dut doi d khu vUc re, thiidng ton khong ddi xilng + Tang te bao dich nao + Xet nghiem huyet Barreliose - Viem da re - day than kinh SIDA XI D IEU TRj Chu yeu nhim du phdng cac bien chiing cua suy ho hap cap va cac roi loan cua he than kinh thiic vat, thudng la Khong doan trUdc dUdc va khong lien quan den mute liet, cd the dan tdi tu vong Roi loan than kinh thUc vat (hoat dong qua mile hoac ilc che giao cam cung nhu can giao cam dan tdi cdn kich phat ve huyet ap), loan nhip tim (nhanh hoac cham, song T det hoac dao ngUdc dien tam do), tang tiet d phe quan va phoi, liet ruot cd nang, bi tieu tien Cac bien phap dieu trj 1.1 Nang toan than va d if phdng cac bien chung liet Bao dam sU thong tot, dat noi quan chdm de doa suy ho hap (khi kha nang thong gang siic dudi 15 - 20ml/kg) Du phdng bien chiing tac mach - Du phdng cac bien chiing khac: viem phoi, loet Nuoi dudng d iy du 2.2 Thuoc Thuoc khang sinh (oxytetracyclin - 2g/ngay, uong 10 196 hoac Biomycin Prednisolon (hydrocortancyl) tiem vao dich nao tuy, cach lan 1ml (30mg) tiem tat ca 10 lan (nen rut 1ml dich nao trUdc bdm thuoc de benh nhan dd bi nhtic dau) - Vitamin nhom B lieu cao Vitamin B l 0,025g x 10 ong/ngay Vitamin B6 0,025g x ong/ngay Vitamin B12 1000 microgam x ong/ngay Ly lieu phap, phuc hoi churc nang Xoa bop, tap van dong cac chi, bam nan Mot vai trUdng hdp cu the - Dieu tri tang huyet ap kich phat bang nhiing thuoc giam ap co thdi gian tac dung ngan - Tut huyet ap thti phat sau giam liidng mau tinh mach trd ve tim gian mach ngoai vi, do cac benh nhan thd may rat de bi bien chting Dieu tri bang truyen tinh mach de nang huyet ap Doi phai dung den thuoc van mach - Cac roi loan nhip tim nang doi diia den tti vong co the xuat hien qua trinh dien bien, do phai theo doi sat benh nhan Cac cdn nhip cham dap ting tot v6i atropin, nhien sti dung atropin phai than vi cac cdn nhip cham thifdng chi xay mot khoang thdi gian ngan va atropin co tac dung phu nguy hiem - Difa di hoi stic cap ctiu neu: + Roi loan nuot + Vifdng ddm dai + Kho thd 197 TAI LIEU THAM KHAO R.D.Adams, M.Victor, A.H.Ropper - Principles of Neurology, International Edition - 1997 Brain abscess complicating dental disease G.C.Andrioli; R.Datti 11th I.C.N.S (International Congress of Neurological Surgery) Amsterdam, 1997, p 1665 Barnett H.J.H., J.P.Mohr (1998), Spinal cord ischemia, Stroke, Churchill Livingstone, pp 751 - 766 Bradley W.G., Daroff R.B., Fenichei G.M., (1996) Neurology in clinical practice, Butterworth - Heinemann Problem in the treatment of intraventicular hydatid cysts I.B.Copley; J.J.Snyman 11th I.C.N.S Amsterdam 1997, p 1677 Cue Quan y - Chan doan va dieu tri benh truyen nhiem NXB QDND, 1998 Greenberg D.A., Aminoff M.J., Simon R.P (1996), Motor deficits, Clinical Neurology, Appleton & Lanpe Harrison’s - Priciples of internal medicine - 14th edition, 1998 Le D ie Hinh - Benh bai liet tre em Tap huan ve ky nang giam sat va xac dinh benh bai liet ChUdng trinh tiem chung md rong toan benh bai liet quoc gia - Bo Y Te, 1993 10 Intracranial subdural empyema diagnostic and therapeutic problems K.M.Jha and A.Raja 11th I.C.N.S Amsterdam 1997, p 1673 198 11 Vu Hung Lien, Nguyen Hung Minh Dang Dinh Nam dieu tri 878 trUdng hdp chan thudng so nao qua nam (19931996) tai khoa Phau thuat than kinh- Vien Quan y 103 Cong trinh nghien ciiu khoa hoc 1995 - 2000, NXB Quan doi nhan dan Viet Nam, trang 220 12 Nhan xet bien chiing viem mu mang nao - nao qua dieu tri 166 thudng binh vet thudng so nao Vu Hung Lien, Tran Manh Chi Tu lieu Y hoc quan sU tap 6, 1980, trang 15 - 18 13 Ho Hiiu LUdng - Benh hoc than kinh, NXB Y hoc Ha Noi, 2002, trang 88 -127 14 E Pilly - Maladies infectieuses - 1997 15 Samuels M.A., Manual of neurologic Lippincott William & Wilkins (1999) therapeutics, 16 M.Takishita; K.Takakura Management of brain abscess in patient with congenital cyanotic heart disease 11th I.C.N.S Amsterdam 1997, p 1669 17 Le Van Thanh, Hoi chiing va benh hoc than kinh, NXB Y hoc (1984) 18 Le Xuan Trung Ap xe noi so Benh hoc ngoai khoa than kinh tap I 1997 Trang 335 - 364 19 TrUdng Quang Trung Dieu tri ap xe nao tre em Tom tat hoi thao chuyen de ngoai than kinh TP HCM 1997 Benh vien Chd Ray Trang 107 - 109 20 Vien Ve sinh dich te hoc - Hoi thao khoa hoc Viem nao Nhat Ban va du phong bang vacxin - 1998 199 NHA XUAT BAN Y HOC n h i I m k h u a n h e t h a n k in h Chju trach nhiem xuat ban HOANG TRONG QUANG Bien tap: BS DINH TH! THU SCra ban in: BS DINH THI THU Trinh bay bia: CHU HUNG In 1000 cuon, kho 14.5x20.5cm tai Xi/ong in Nha xuat ban Y hoc Can cCfke hoach xuat ban so: 372-13/XB-QLXB 10/01/2005 In xong va nop lifu chieu quy IV nSm 2005 [...]... giang mai than kinh nhiing trong 131 vong 10 nam tit 19 82 den 1991 da phat hien diidc 92. 587 benh nhan mac giang mai (Vien Da lieu, 19 92) Mot ty le nhat djnh trong so benh nhan do sdm muon se co bieu hien cua giang mai than kinh I DAI ClfO NG VE GIANG MAI THAN KINH 1 Nguyen nhan Nguyen nhan gay benh giang mai la xoan khuan Treponema pallidum Xoan khuan giang mai thiidng xam nhap vao he than kinh trung... vao cuoi nam thil hai, he than kinh chua bi xam pham (qua chiing minh bang phan ilng am tinh trong dich nao - tuy (DNT)) thi 1 /20 so benh nhan van tien trien thanh giang mai than kinh; neu vao cuoi nam thil 5 phan ilng van am tinh trong DNT thi ty le do se la 1/100 2 Lam sang 2. 1 Viem mang nao La bieu hien dau tien cua nhiem giang mai than kinh, co the xay ra theo ty le 25 % doi vdi moi triidng hdp mac... liet 121 Giai doan xam nhap va tang sinh cl than kinh trung Udng: virut tti cac noi tang vao mau (lan 2) va vao he than kinh trung ifdng, chu yeu la cac neuron van dong d sting triidc tuy song Ddi vdi the khong dien hinh (khong cd liet), virut chi xam nhap tdi cac hach bach huyet, niem mac difdng tieu hoa hoac tdi mau ma khong vao he th in kinh trung ifdng, sau dd bi dao thai ra ngoai theo phan 2 Giai... tuy song, xd hoa to chiic dem va thanh mach Tuy nhien, da so" cac thiidng ton diidc phuc hoi va cac chtic nang than kinh cung cd the dUdc phuc hoi sau 1 - 2 thang Mot so" neuron bi thifdng ton nang khong hoi phuc (tren lam sang the hien b in g cac di chting) 122 Cac cd quan ngoai he than kinh cung co the bi virut tan cong nhu ho hap, tim , gan, than, tieu hoa v.v nhUng cac thUdng ton thUdng nhe va nhanh... dieu quan trong hdn la cac di chiing than kinh rat kho hoi phuc ve mat van dong nen 114 chien ludc cua To chtic Y te the gidi la tien tdi thanh toan benh nay tren toan the gidi 2 Lam sang Benh khdi dau giong nhiem khuan cap, 25 % trUdng hdp cac trieu chting khdi phat mat di sau 36 - 48 gid, sau dd benh nhan thay stic khoe hoi phuc 2 - 3 ngay Tiep theo la sot ddt 2, kem theo hoi chting mang nao: dau dau... trieu chting ve nao: dau dau, roi loan y thiic nhe, cd the cd co giat kieu dong kinh, cd khi la dong kinh tuy song (co cting 2 chi dudi, dau ddn) 2 Xet nghiem Xet nghiem DNT: da so' la trong gidi han binh thudng, so it cd tang albumin nhe 3 Tien trien Ket qua dieu tri tUdng doi kha quan sii phuc hoi trUdc tien la day than kinh thi giac dudi tac dung cua corticoid Mot so de lai di chting giam thi liic,... co the nang hdn vdi bieu hien liet day than kinh so, dong kinh, cdn dot quy (do ket hdp vdi thudng ton mach mau) hoac cac trieu chiing cua ap liic qua cao trong so Loai viem mang nao nay cd khi keo dai am tham nhieu nam va sau cung gay thiidng ton nhu mo nao; tuy nhien mot so triidng hdp cung cd the khdi him 2. 2 Dien bien lam sang Moi the giang mai than kinh deu khdi dau vdi benh canh viem mang nao... th in kinh co thiidng ton nhu mo than kinh Cac thiidng ton giai phau triidc kia tiidng la dac biet cua giang mai than kinh thiic ra chi la nhiing phan ling man tinh cua mang nao: vi du viem va tac cac dong mach diidi nhen, viem mang nao - nao, viem mang ong noi tuy, viem mang nao - tuy, hay thay trong thiidng ton do giang mai than kinh deu cd the gap trong cac the man tinh cua viem mang nao 2. 3 The... phan lap virut tu! phan benh nhan va sii cd mat cua khang the trong huyet thanh 126 2. 2 The nhe (abortive poliomyelitis) Chiem 4 - 8%, bieu hien bang trieu chiing viem long dudng ho hap tren, roi loan tieu hoa va mot so' trieu chiing giong cum (sot, dau khdp) Chan doan cung phai dUa vao phan lap virut va phan iing huyet thanh 2. 3 The khong liet (non paralytic poliomyelitis) Chiem 10%, benh nhan co cac... tang cao hdn lan thii nhat Dich te: tuoi de mac benh (2 - 8 tuoi) va cd nhieu tre trong mot tap the ciing bi tUdng tu 2 Chan doan phan biet 2. 1 Thai ky tien liet Benh cum va nhiem virut diidng ho hap do virut khac: sot cao lien tuc tdi 4 - 7 ngay, thiidng cd ret, nhiem doc nang hdn, dau dau dii doi, benh dien bien nhanh trong vong 7 - 1 0 ngav 127 - Viem mang nao mu: hoi chiing mang nao xuat hien sdm