CT Scan trong tai bin mch mu no

Bs L Vn Nam

Mc tiu bi ging
Pht hin c cc xut huyt trong s ( no, mng no, mu t ) M t nm triu chng sm ca nhi mu no Pht hin c huyt khi trong lng ng mch Chn on c ng mch tn thng Xc nh c mc tn thng Pht hin triu chng thot v thy thi dng

Gi tr chn on ca CT Scan
Thm khm lm sng khng phn bit c nhi mu no v xut huyt no CT Scan pht hin ngay cc hnh nh xut huyt no, mu t , xut huyt mng no ( 95%) CT Scan c th pht hin cc hnh nh bt thng trong vng 3 gi sau khi nhi mu no ( 50% ) Xt nghim gip chn on nhanh, chnh xc, an ton v sn c trong cc trng hp tai bin mch mu no

The Nobel Prize in Medicine 1979

Allan M. Cormack Tufts University Medford, MA, USA

Godfrey N. Hounsfield Central Research Laboratories, EMI London, United Kingdom

Sinh l bnh
hp thu tia X c o trn CT scan bng n v Hounsfield ( Hu ) Nc : 0 Hu Xng : 1000 Hu Khng kh : -1000 Hu Cht xm : 35-40 Hu Cht trng : 20 Hu Xut huyt : 40-90 Hu Vi ha : >120 Hu

Sinh l bnh
m ca CT scan ty thuc vo t trng ca m no ( hp thu tia X ) Hin tng thiu mu gy ph t bo no v lm tng lng nc cha trong m v gim m Ch cn thay i 1% lng nc trong nhu m th CT s thay i t 2.5-2.6 n v Hounsfield Mt thng c th nhn thy s thay i 1 Hu nn c th nhn thy c tn thng.

Cc thay i ca CT Scan
Hin tng gim m xut hin v tng dn theo thi gian thiu mu no S gim m thay i ty theo vng tn thng v nng ca tnh trng thiu mu Lu lng mu < 9 ml/100grams no/pht Hoi t = ph no = gim m Cc vng chung quanh vng hoi t l vng thiu mu nhng cn c kh nng hi phc

Vng thiu mu

Vng hoi t

K thut CT Scan
Lp ct dy 2 mm, ca s nhu m (do kh nng phn bit m nht ca mt) Khong cch hai lp ct l 4 mm vi h sau 2 mm vng h yn 8 mm bn cu Kho st khng dng thuc cn quang

Lim no

Trung tm bu dc

Thy trn

Sng trc no tht bn

Th chai
Thy nh

Mng mng mch

No tht IV Sng sau no tht bn

Sng trn no tht bn Nhn u Cnh tay sau bao trong i th Nhn ui Vch trong sut B trn tiu no

Thy nhng

Thy chm

Sng trn no tht bn Nhn ui Tay trc bao trong Khe Sylvius Cng Sylvius C trung no Nhn u No tht III Khe Sylvius Thy o

B c trung no
Tiu no

Thy trn

Khe lin bn cu

No tht III B lin cung no Cung no Tiu no

Lim no
Thy trn

Khe Sylvius Khe Sylvius B trn yn

Thy thi dng

Cu no
Lu tiu no No tht IV Tiu no

Lim no Thy trn

Tuyn yn

Lng yn Thy thi dng B trc cu no Xng chm

No tht IV
Tiu no

Cc bc n gin c CT Scan
C xut huyt hay khng ? C cc vng nhi mu c hay nhi mu yn lng khng ? C du hiu huyt khi trong lng ng mch hay khng ? Cc du hiu sm ca nhi mu ? nh gi rng ca tn thng

Pht hin xut huyt

Xut huyt l cc vng tng m v c th thy trong cc bnh l: T mu ngoi mng cng, T mu di mng cng Xut huyt mng no Xut huyt no tht Xut huyt trong no Phn bit ho vi v xut huyt nh vng nhn nn Phn bit xut huyt cu no vi artfact

C xut huyt hay khng ?

C xut huyt hay khng ?

Xut huyt mng no

Mu t ngoi mng cng

Mu t di mng cng

Phn bit xut huyt v vi ha

Vi ha i xng, khng c hin tng ph no v khng c hiu ng chon ch Xut huyt khng i xng, c ph no chung quanh v c hiu ng chon ch o mc cn quang (ROI: region of interesting) Vi ha > 120 Hu Xut huyt = 40-90 Hu

Xut huyt hay vi ha ?

Xut huyt hay artefact ?

Tm du hiu huyt khi trong ng mch

Du hiu tng m ca ng mch do huyt khi trong lng mch mu, gp ti : ng mch no gia v cc nhnh ( Dot sign ) Ni tn cng ng mch cnh trong ng mch thn nn y l mt triu chng tin lng nng v vng nhi mu ln Tuy nhin cn lu trong trng hp triu chng xut hin i xng hai bn ( vi ha ), bn c huyt khi phi tng quang nhiu hn.

Hnh nh tng m ca ng mch no gia

Dots sign: hnh nh tng m ca cc nhnh ng mch no gia trong khe sylvius

Hnh nh tng m ng mch no gia kim chng bng DSA

Cc triu chng sm ca nhi mu

Cc triu chng sm ca nhi mu no xut hin do hin tng ph no gy ra v ph no cht xm nhiu hn cht trng do nhu cu bin dng y cao hn Xa m nhn u Du ru bng thy o M rnh Sylvius M cc rnh v no Gim m nhu m

Xa m nhn u
Nhn u c cn quang l 35 Hu Vng di v c cn quang 20 Hu nn bnh thng c th phn bit r nhn u Khi nhn u b ph do thiu mu th cn quang gim bng vng di v nn khng phn bit c Ty mc tn thng hin tng xa m c th mt phn hay ton th nhn u

u nhn ui

Nhn u

i th

Bao trong

Du ru bng thy o
y l lp v no ca thy o ( insula ) Bnh thng thy lp ny r do pha trong l lp cht trng, c cn quang thp hn, v pha ngoi l dch no ty trong khe Sylvius c mu en Khi v no vng thy o b ph n th gim m v khng cn phn bit c.

M khe Sylvius
Khe Sylvius c nhn r trn hnh CT nh cha dch no ty Khi thy o b ph n th lp dch ny gim b dy hay mt hn nn khng cn phn bit c Du hiu ny thng i km du m nhn u v du ru bng thy o

M Khe Sylvius
Khe Sylvius

Khng thy

M rnh v no v gim m nhu m

Hin tng ph lm cht xm ( 30 Hu ) gim m ging nh cht trng di v ( 20 Hu ) Cc rnh v b ph s kh phn bit do gim lng dch no ty ti cc rnh ny y l hai du hiu thng xut hin chung v rt quan trng v gip nh gi c rng ca vng nhi mu.

M rnh v no v gim m

Xc nh thi gian nhi mu

Phn bit nhi mu mi v c Gim m t : vi gi Gim m d nhn thy : vi ngy Gim m nhiu : mt ti hai tun Nhuyn no : trn mt thng Fogging effect: hin tng ng m vng nhi mu ngy 14-21 do tng thc bo hoc xut huyt vi th, khi vng nhi mu rt kh nhn thy. Mt s trng hp c hin tng tng quang do xut huyt trong vng nhi mu vo sau ngy th ba.

Tin trin ca s gim m

105 pht sau tai bin

Tin trin ca s gim m

Ba ngy sau tai bin

Fogging Effect

24 gi

11 ngy

4 thng

Xut huyt sau nhi mu

Xc nh mc tn thng
Tn thng do nhi mu c th b ton b vng chi phi ca mt ng mch no hay ch mt phn Trong nhi mu do c ch cung lng thp th nhi mu s b ti vng ranh gii ca cc nhnh chnh hay ti nhnh tn cng (watershed infarction ) Chn on mc tn thng rt quan trng trong iu tr bng rTPa hay khng ng phng nga trong cc thuyn tc t tim

Vng phn b ng mch

No trc

No gia

No sau

Vng phn b ng mch

Nhi mu vng nui ng mch no trc

Nhi mu vng nui ng mch no gia

Nhi mu vng nui ng mch no sau

Nhi mu watershed

Borderzone infarction

Nhi mu watershed

Terminal infarction

Mc tn thng ng mch no gia

Thng s dng trong trng hp tc ng mch no gia Vng no b tn thng < 33% vng chi phi ng mch no gia > 33% vng chi phi ng mch no gia Hin nay p dng thang im Aspects chnh xc hn quy tc 1/3

Vng chi phi ca ng mch no gia

Vng chi phi ca ng mch no gia Di 1 thy <33%, trn 2 thy > 33% (Von Kumar)

<33%

>33%

>33%

Alberta Stroke Program Early CT Scoring (ASPECTS)

p dng ti Foothills Hospital, Calgary, Alberta nh gi vng tn thng do tc ng mch no gia Da vo hai lp ct trn CT Scan chun Lp ct th nht ngang vng i th-nhn nn Lp ct th hai pha trn lp th nht v pha trn nhn nn ( khng thy nhn nn ) Vng phn b ca ng mch no gia c chia lm 10 vng

Alberta Stroke Program Early CT Scoring (ASPECTS)

Bn vng di v - Nhn ui - Caudate (C ) - Nhn u - Lentiform (L) - Thu o - Insular (I) - i th - Thalamus / internal capsule (T).

Alberta Stroke Program Early CT Scoring (ASPECTS)

Su vng v M 1,2,3 Tng ng vng ca nhnh trc, gia v sau ca ng mch no gia M 4,5,6 Vng tng ng vi cc nhnh trn nhng cao hn Bnh thng 10 im Tn thng mi vng tr mt im

Alberta Stroke Program Early CT Scoring (ASPECTS)

M1

M4
C M2 I L T M3 M6 M5

Cch tnh thang im ASPECTS

Gi tr thang im Aspects
p dng trong iu tr vi rTPa Nu Aspects di 7 th khng s dng Theo nghin cu Ecass1 (European Cooperative Acute Stroke Study) th tn thng trn 1/3 ng mch no gia s c nguy c xut huyt cao khi dng rTPa Trong nhi mu do thuyn tc t tim th nu tn thng trn 1/3 th cng khng dng ngay thuc khng ng

Pht hin thot v thy thi dng

Hin tng thot v thy thi dng gp trong nhi mu hay xut huyt bn cu ln C th pht hin trn CT scan bng triu chng mt b trn tuyn yn hay mt b c trung no L triu chng cn lu trong cc trng hp nhi mu ln do tc ton b ng mch no gia hay xut huyt no

S - suprasellar cistern

Po - pons
P - cerebral peduncles (midbrain) M - medulla C - quadrigeminal plate (superior and inferior colliculi) V - fourth ventricle Q - quadrigeminal cistern

Hnh nh b trn yn v b c trung no

F: frontal U: Uncus Po: Pons

Cung no

B trn yn

B c trung no

B trn yn B c trung no

Thot v thy thi dng giai on sm

Thot v thy thi dng giai on nng

Kt lun
CT Scan l cng c hu ch trong chn on tai bin mch mu no CT Scan gip chn on xut huyt no, xut huyt mng no, mu t ngoi hay di mng cng Trong nhi mu no CT Scan cho thng tin v V tr nng Kch thc vng nhi mu CT Scan gip pht hin thot v thi dng

Bnh n minh ha
Sau y l mt s bnh n km hnh nh CT scan, MRI Cc bn hay quan st v tr li cc cu hi

Trng hp 1 Ph n 60 tui nhp vin sau khi b lit t ngt na ngi bn tri 3 gi trc CT Scan thc hin lc nhp vin

Thy g trn hnh ny

A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Trng hp 1 Chn on : Nhi mu no do tc nhnh gia ca ng mch no gia

Trng hp 2 Bnh nhn nam 50 tui, t qu v hn m 1 gi 30 pht trc khi nhp vin Nhp vin trong tnh trng vt v Gy cng

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

B trn yn

Rnh lin bn cu B m no gia

B gc cu tiu no

No tht IV

Khe Sylvius Rnh quanh cung no

Knh Sylvius

Dn no tht

Mu trong no tht III

Trng hp 2 Chn on : Xut huyt mng no v no tht

Trng hp 3 Bnh nhn n 43 tui nhp vin v lit na ngi tri trc 2 gi Bnh nhn c tin cn m thay van hai l v c iu tr khng ng Bnh nhn t ngng thuc khng ng Xt nghim ng mu bnh thng CT Scan thc hin lc nhp vin

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Du hiu tng m ng mch no gia

Du hiu xa m ruban thy o v nhn u

 Bnh nhn c iu tr vi rTPa CT Scan c thc hin ln hai sau 26 gi

Trng hp 3 Chn on : Nhi mu no do thuyn tc (embolie) ng mch no gia

Trng hp 4 Bnh nhn nam 73 tui nhp vin sau khi bi yu t ngt na ngi bn tri trc 1 gi 55 pht Bnh nhn tnh to, yu na ngi tri, tim c rung nh CT Scan c thc hin

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Tng m ng mch no gia

Tng m ng mch no gia

Mt phn bit cht trng v xm

Trng hp 4 Bnh nhn c iu tr vi Activase Sau 10 gi tnh trng tri gic xu hn CT ln hai

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Gim m vng trn v thi dng

Mu trong no tht III v no tht bn

Lch ng gia

Xut huyt vng nhn nn

 28 gi sau bnh nhn c lm CT Scan ln th ba Hnh nh ph no nng v c tt no thy thi dng v tt no di lim Bnh nhn t vong

Trng hp 5 Bnh nhn n 34 tui nhp vin trong tnh trng l ln v hi kch ng Bnh nhn c mt cn co git sau khi b chn thng u do tai nn Khng c triu chng thn kinh nh v no khc CT Scan

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Trng hp 5 Hnh nh CT Scan bnh thng Bnh nhn c xut vin sau vi ngy theo di Chn on : ng kinh sau chn thng s no

Trng hp 6 Bnh nhn n 58 tui nhp vin v nhc u bn tri t 2 tun nay 6 thng nay bnh nhn c yu nh na ngi bn phi CT khng cn quang

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Khi u tng quang

Trng hp 6 Chn on : Phnh ng mch thn nn

Trng hp 7 Bnh nhn n 54 tui, nhp vin v c cn co git ton thn trc 1 gi Bnh nhn khng c tin cn co git Khm : bnh nhn c v hi l ln nhng khng c triu chng nh v no khc CT Scan

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Vng tng m

Rnh v no b xa m

Trng hp 7 Chn on : D dng ng tnh mch

Trng hp 8 Bnh nhn n 83 tui nhp vin v l ln Bnh nhn c tin cn rung nh v nhi mu vng chm tri 6 nm trc CT Scan

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Nhi mu cp vng ng mch no gia bn phi

Nhi mu c vng ng mch no sau bn tri

Trng hp 8 Chn on : Nhi mu no

Trng hp 9 Bnh nhn n 38 tui nhp vin v nhc u d di xy ra trc 3 gi CT Scan

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Khi chon ch tng m

Trng hp 9 Chn on : Phnh ng mch thn nn

Trng hp 10 Bnh nhn n 43 tui c tin cn ung th bung trng di cn v vim ni tm mc nhim trng nhp vin v yu na ngi tri trc 6 gi Tin cn lit mt tri 6 thng trc hi phc Khm: Yu na ngi tri sc c 2/5 CT Scan

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Thy o

Nhn nn

Thy trn

Thy nh Nhi mu c

Trng hp 10 Chn on: Nhi mu vng chi phi ca ng mch no gia bn phi C cc vng nhi mu kiu lu lng thp c hai bn cu (watershed infarcts )

Trng hp 11 Bnh nhn nam 62 tui nhp vin v ni kh v yu na ngi phi tng dn CT Scan

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Ph no

Kn nc

Ph no

Lch ng gia

Kn nc c tng quang vin

CT Scan c cn quang

Trng hp 11 Chn on bng sinh thit Astrocytoma

Trng hp 12 Bnh nhn n 83 tui nhp vin v lit na ngi phi 8 ngy trc khi nhp vin Bnh nhn lit hon ton na ngi phi v mt ngn ng CT Scan

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

Thy trn

Nhn nn
Thy thi dng Thy chm

Trng hp 12 Chn on : tc ng mch no trc, no gia v no sau bn tri

Trng hp 13 Bnh nhn nam 43 tui t nhin xut hin cn co git ton thn v hn m Khi nhp vin bnh nhn c huyt p cao Hi chng mng no CT Scan

Thy g trn hnh ny A Mt phn bit cht xm cht trng v/hay gim m B Dn no tht C Xut huyt D Khi chon ch E D dng ng tnh mch F Khng c g bt thng

No tht III

No tht IV

u nhn ui

No tht bn

Trng hp 13 Xut huyt u nhn ui lan no tht do cao huyt p

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