danh gia hieu qua dieu tri benh ly moyamoya bang phuong phap bac cau dong mach nao trong va ngoai so

DAI HOC Y DuOC THANH PHO HO CHI MINH 2015

LUAN AN TIEN SI Y HOC

DANH GIA HIEU QUA DIEU TRI BENH LY MOYAMOYA BANG PHUONG PHAP BAC CAU DONG MACH NAO TRONG VA NGOAI SO

CHUYEN NGANH: NGOAI THAN KINH - SO NAO -MA SO: 62720127

NCS TRAN MINH TRI - HDKH PGSTS TRAN QUYET TIEN - PGSTS NGUYEN THI HUNG

Ky thuat mo vi phau bac cau dong mach trong va ngoai so la phau thuat tao duong thong noi giua dong mach thai duong nong, hoac dong mach canh ngoai voi dong mach nao giua. Phau thuat nay duoc chi dinh trong cac benh ly tac nghen dong mach canh trong dua den giam ap luc tuoi mau nao: Benh ly moyamoya, tac dong mach canh trong, hep dong mach nao do xo vua, hoac nhung benh ly can phai that dong mach canh trong: Tui phinh khong lo, u san so.

Benh ly tac dong mach canh trong, hoac tac nghen dong mach nao do xo vua la nhung benh ly dua den benh canh lam giam ap luc tuoi mau nao, benh nhan se co trieu chung cua thieu mau nao thoang qua va ve lau dai se dan den tinh trang dot quy, doi voi benh ly voi moyamoya, benh nhan se bieu hien dot quy do nhun nao hoac xuat huyet nao. Doi voi tinh trang xuat huyet nao la do co su vo cua nhung mach mau nho tang sinh bat thuong o vung hach nen (nhung mach mau tang sinh bat thuong nay duoc goi la mach moyamoya, duoc tao ra de bu dap tinh trang thieu mau nuoi cua nao vung hach nen).

Trong benh ly tui phinh dong mach khong lo hoac u san so, viec phau thuat kep tui phinh hoac lay u gap rat nhieu kho khan, trong mot so truong hop khong the thuc hien duoc neu khong lam tac dong mach canh trong doan trong so, vi the phai tao cau noi mach mau nao khac nham bu dap lai luong mau nao khong di qua dong mach canh trong.

Ngay nay mac du co nhieu nhung tien bo trong can thiep noi mach than kinh, cung nhu ky thuat mo vi phau trong dieu tri benh ly mach mau nao vabenh ly u san so, nhung van chua dieu tri hieu qua duoc mot so benh canh da mo ta tren, nen viec ap dung ky thuat mo bac cau dong mach la phuong phap dieu tri duoc cho la thich hop va co hieu qua. De thuc hien duoc ky thuat nay doi hoi phau thuat vien phai co kien thuc ve cac loai benh ly tren, va phai thuan thuc ky thuat mo vi phau noi mach mau nao. Voi nhung phuong tien chan doan hinh anh ngay cang hien dai nhu chup mach mau xoa nen bang ky thuat so, cong huong tu, chup cat lop vi tinh, cat lop vi tinh da lat cat co tai tao mach mau nao, cong huong tu co tai tao mach mau nao, xa hinh danh gia tuoi mau nao co diamox test giup viec chan doan chinh xac tinh trang hep hoac tac nghen mach mau nao, cung nhu danh gia duoc tinh trang thieu mau nao tram trong va mat kha nang bu tru, nham chon lua benh nhan va chi dinh mot cach day du va chinh xac truoc khi phau thuat. Tuy nhien theo cac tai lieu da tham khao trong va ngoai nuoc, mac du phuong phap nay duoc nghien cuu va ap dung rong rai tren the gioi, nhung hien nay o nuoc ta chua co mot nghien cuu day du va chi tiet ve chan doan va dieu tri phau thuat bac cau dong mach nao doi voi benh ly moyamoya.

Xuat phat tu nhung van de tren nen viec thiep lap mot nghien cuu chi tiet ve ap dung phuong phap phau thuat nay la can thiet. Day cung la van de dat ra cua chuyen nganh Phau thuat Than kinh.


MUC LUC

DAT VAN DE

Chuong 1 TONG QUAN TAI LIEU

1.1. BENH LY MOYAMOYA

1.2. LICH SU NGHIEN CUU PHAU THUAT BAC CAU DONG MACH NAO

1.3. GIAI PHAU DONG MACH NAO GIUA

Chuong 2 DOI TuONG VA PHUONG PHAP NGHIEN CUU

2.1. DOI TuONG NGHIEN CUU

2.1.1. Doi tuong

2.1.2. Tieu chuan loai tru

2.2. PHUONG PHAP NGHIEN CUU

2.2.1. Thiet ke nghien cuu

2.2.2. Co mau

2.2.3. Noi nghien cuu de tai

2.2.4. Phuong phap thu thap so lieu

2.2.5. Phuong phap khao sat trieu chung

2.2.6. Khao sat hinh anh hoc

2.2.7. Bien so chan doan xac dinh

2.2.8. Bien so lien quan den phau thuat

2.2.9. Dieu tri phau thuat

2.3. XU LY SO LIEU

Chuong 3 KET QUA NGHIEN CUU

3.1. DAC DIEM LAM SANG

3.1.1. Tuoi

3.1.2. Gioi tinh

3.1.3. Phan bo gioi va tuoi

3.1.4. Thang diem Glasgow (GCS)

3.1.5. Trieu chung lam sang

3.1.6. Tuong quan trieu chung lam sang va xuat huyet nao

3.1.7. Tien su benh

3.1.8. Tuong quan giua thoi gian nhap vien va xuat huyet nao

3.1.9. Lien quan giua nhom tuoi va xuat huyet nao o benh moyamoya

3.1.10. Tuong quan giua diem Glasgow va tinh trang xuat huyet nao

3.1.11. Tinh trang benh theo thang diem Rankin cai tien

3.1.12. Trieu chung lam sang truoc phau thuat

3.1.13. Tinh trang tri giac truoc phau thuat

3.2. HINH ANH HOC

3.2.1. Hinh anh vi tri xuat huyet nao

3.2.2. Xa hinh tuoi mau nao

3.2.3. Dac diem chup ky thuat so xoa nen

3.2.4. Chup cong huong tu

3.2.5. Lien quan giua muc do hep dong mach trong benh ly moyamoya vaxuat huyet nao

3.3. KET QUA DIEU TRI PHAU THUAT

3.3.1. Cac dac diem chung cua phau thuat

3.3.2. Thoi gian kep tam mach mau

3.3.3. So luong cau noi

3.3.4. Phau thuat 2 ben ban cau nao

3.3.5. Ket qua lam sang sau dieu tri phau thuat

3.3.6. Bien chung sau mo

3.3.7. Chan doan hinh anh sau phau thuat

3.3.8. Ket qua theo doi dai han

Chuong 4: BAN LUAN

4.1. CAC DAC DIEM LAM SANG VA HINH ANH HOC

4.1.1. Tuoi va gioi

4.1.2. Trieu chung lam sang

4.1.3. Dac diem hinh anh hoc

4.2. KET QUA DIEU TRI

4.2.1. Dieu tri noi khoa

4.2.2. Cac dac diem dieu tri ngoai khoa

4.2.3. Ket qua theo doi sau phau thuat

4.2.4. Ket qua dieu tri chung

4.2.5. Ket qua hinh anh hoc

4.2.6. Ket qua lam sang sau mo

4.2.7. Ket qua lam sang 3 thang sau xuat vien

4.2.8. Ket qua lam sang 12 thang sau xuat vien

4.2.9. Tinh trang lam sang benh nhan theo doi sau xuat vien

4.2.10. Lien quan giua tien su benh voi tinh trang benh cua benh nhan

4.3. BIEN CHUNG

KET LUAN

KIEN NGHI

CAC CONG TRINH NGHIEN CUU LIEN QUAN DEN LUAN AN

TAI LIEU THAM KHAO

PHU LUC

- Benh an minh hoa

- Mau benh an benh nhan phau thuat bac cau dong mach nao

- Danh sach benh nhan

DANH MUC CAC CHU VIET TAT

CHT Cong huong tu

CLVT Cat lop vi tinh

CMMNXN Chup mach mau nao xoa nen

(EDAM) Encephaloduroarteri-osynangiosis Ky thuat dua dong mach mang nao len vo nao

(EDAMS) Encephaloduroarteriomyosynangiosis Ky thuat dua co thai duong, dong mach mang nao, dong mach thaiduong nong len vo nao

(EMS) Encephalomyosynangiosis Ky thuat dua vat co len vo nao

GCS (Glasgow Coma Scale) Thang diem danh gia tri giac benh nhanmRS (Modified Rankin Scale) Thang diem danh gia tinh trang lam sang benh nhan

Spect Scan Xa hinh tuoi mau nao

BANG DOI CHIEU CAC THUAT NGU ANH - VIET

Basic fibroblast growth factor (BFGF) Yeu to tang truong te bao soi co ban

Cerebral blood flow (CBF) Luu luong tuoi mau nao

Cerebral occlusive disease Benh ly tac nghen mach mau nao

Cerebral vascular reserve Kha nang ton luu mau nao

Extracranial-Intracranial bypass Phau thuat bac cau dong mach trong va ngoai soInternal carotid artery occlusion Tac dong mach canh trong

Middle cerebral artery Dong mach nao giua

Middle cerebral artery stenosis Hepdong mach nao giua

Moyamoya disease Benh moyamoya

Single positron emission tomography Xa hinh tuoi mau nao

Transforming growth factors beta (TGF a) Yeu to tang truong hinh thai beta

Vascular endothelial growth factor (VEGF) Yeu to tang truong noi mo mach mau

DANH MUC CACBANG

Bang 1.1: Phan loai muc do hep mach mau nao cua Suzuki

Bang 1.2: Tieu chuan chan doan benh moyamoya

Bang 2.1: Thang diem Rankin cai tien

Bang 3.1: Phan bo gioi va nhom tuoi theo ti le %

Bang 3.2: Bang tuong quan ly do nhap vien va xuat huyet nao

Bang 3.3: Thoi gian tu luc khoi benh den luc nhap vien

Bang 3.4: Lien quan nhom tuoi va tinh trang xuat huyet nao trong benh lymoyamoya

Bang 3.5: Tuong quan giua diem Glasgow va xuat huyet nao

Bang 3.6: Trieu chung lam sang benh nhan truoc khi phau thuat

Bang 3.7: Diem Glasgow truoc phau thuat

Bang 3.8: Lien quan muc do hep dong mach nao va xuat huyet

Bang 3.9: Lien quan giua nhom phau thuat 1 cau noi va nhom 2 cau noivoi ket qua theo thang diem mRS sau mo

Bang 3.10: So luong phau thuat 2 ben ban cau

Bang 3.11: Dien tien diem Rankin cai tien theo doi dai han

Bang 3.12: Tinh trang lam sang theo doi dai han

Bang 4.1: So sanh ti le xuat huyet nao o benh moyamoya

Bang 4.2: So sanh ti le theo phan loai Suzuki

Bang 4.3: Nhung nghien cuu danh gia hieu qua phau thuat bac cau dongmach nao

Bang 4.4: Nhung nghien cuu phau thuat bac cau dong mach nao

Bang 4.5: So sanh ti le noi thanh cong cau noi

Bang 4.6: Ghi nhan mRS truoc va sau phau thuat

Bang 4.7: Ghi nhan cai thien diem Rankin cai tien sau qua trinh theo doisau mo

Bang 4.8: Danh gia ket qua lam sang theo thang diem Rankin cai tiencua tac gia, so sanh voi nghien cuu nay

DANH MUC CAC BIEU DO

Bieu do 3.1: Phan bo benh moyamoya theo nhom tuoi

Bieu do 3.2: Phan bo gioi tinh

Bieu do 3.3: Phan bo thang diem Glasgow luc nhap vien

Bieu do 3.4: Ly do nhap vien

Bieu do 3.5: Phan bo tien su benh

Bieu do 3.6: Tinh trang benh nhan theo phan loai Rankin cai tien

Bieu do 3.7: Vi tri xuat huyet nao trong benh ly moyamoya

Bieu do 3.8: Muc do hep dong mach theo phan loai Suzuki

Bieu do 3.9: Bieu thi thoi gian kep tam trung binh

Bieu do 3.10: Tuong quan giua thoi gian kep tam voi ket qua mRS sau mo

Bieu do 3.11: Tinh trang benh nhan sau phau thuat theo thang diem Rankincai tien

Bieu do 3.12: Hinh anh hoc sau phau thuat

Bieu do 3.13: Danh gia tinh trang benh nhan theo thang diem Rankincai tien sau 3 thang

Bieu do 3.14: Danh gia tinh trang benh nhan theo thang diem mRSsau 1 nam

Bieu do 4.1: Ti le nam-nu trong benh ly moyamoya cua tac gia

Bieu do 4.2: Tuoi trung binh benh ly moyamoya so voi tac gia

Bieu do 4.3: So sanh tinh trang benh nhan truoc va sau mo

DANH MUC CAC HINH

Hinh 1.1: Hinh anh xuat huyet nao that va hach nen

Hinh 1.2: Hinh anh cong huong tu nhoi mau nao o benh ly moyamoya

Hinh 1.3: Hinh anh chup ky thuat so xoa nen benh moyamoya

Hinh 1.4: Hinh tuoi mau nao o thi nghi va thi co diamox

Hinh 1.5: Duong mo tran thai duong

Hinh 1.6: Duong mo hinh chu Y ngay tren mach mau

Hinh 1.7: Hinh anh mo ta ky thuat mo EMS

Hinh 1.8: Phau thuat EDAS

Hinh 1.9: Phau thuat EDAMS

Hinh 1.10: Ky thuat mo lo khoan so

Hinh 1.11: Hinh anh phan bo dong mach nao giua nhin tu truoc

Hinh 1.12: Cac dong mach nao giua nhin truoc, va tren mat phang dungngang

Hinh 1.13: Giai phau dong mach nao giua doan M1

Hinh 1.14: Giai phau dong mach nao giua doan M1 va dong mach dau van

Hinh 1.15: Giai phau dong mach nao giua doan M2

Hinh 1.16: Giai phau dong mach nao giua doan M3

Hinh 1.17: Hinh anh cac vung cung cap mau nuoi cua dong mach goc

Hinh 1.18: Giai phau dong mach vo nao doan M4 va vung cung capmau nuoi

Hinh 2.1: Boc tach donh mach thai duong nong

Hinh 2.2: Hinh anh cat co thai duong hinh chu Y

Hinh 2.3: Hinh anh cat co thai duong va mo nap so

Hinh 2.4: Hinh anh boc lo dong mach nao giua

Hinh 2.5: Hinh khau noi tan ben dong mach thai duong nong va nao giua

Hinh 4.1: Duong mo truc tiep tren dong mach thai duong nong

Hinh 4.2: Duong mo tran thai duong

 DANH MUC CONG TRINH NGHIEN CUU

1. Tran Minh Tri (2015), “Ket qua phau thuat bac cau dong mach nao dieu tri benh ly moyamoya”, Tap chi Y hoc Thuc Hanh, So 1 (949), tr. 82-84.

2. Tran Minh Tri (2015), “Dac diem lam sang va hinh anh hoc benh ly moyamoya”, Tap chi Y hoc Thuc Hanh, So 1 (949), tr. 155-157.

TAI LIEU THAM KHAO

Tai lieu tieng Viet

1. Nguyen Quang Quyen (2004), “Cac dong mach nao giua”, Bai giang giai phau hoc, Nha xuat ban Y hoc, Thanh pho Ho Chi Minh, Tap 1, tr. 376-379.

2. Tran Minh Tri (2011), “Phau thuat bac cau dong mach nao dieu tri benh moyamoya”, Tap chi Y hoc thuc hanh, so 779+ 780, tr. 499-505.

Tai lieu tieng Anh

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