CHN ON & IU TR T QU

L Minh,
B Mn Thn Kinh, i Hc Y Dc Tp HCM; Phn Khoa Thn Kinh, Bnh Vin i Hc Y Dc Tp HCM.

NH NGHA T QU & CN THONG THIU MU NO

t qu (Stroke) l s xut hin t ngt ca cc thiu st thn kinh cc b vn ko di hn 24 gi, v vi nguyn nhn khc khng do mch mu c loi tr(n WHO) Cn thong thiu mu no (transient ischemic attack, TIA) c nh ngha tng t nhng vi thi gian ko di ca triu chng thiu st ngn hn 24 gi, thng l ch vi pht.

NH NGHA T QU & CN THONG THIU MU NO

Xut huyt di nhn (Subarachnoid haemorrhage, SAH) thng khng c du thn kinh nh v, do l mt ngoi l so vi nh ngha nu ca WHO v t qu Mt s nh ngha v t qu v TIA c cha thm yu t hnh nh hc no b (da trn cc c im CT v MRI ca nhi mu no v xut huyt no)

DCH T HC CA T QU

t qu l nguyn nhn t vong hay gp ng hng th ba (sau bnh mch vnh v ung th) v l nguyn nhn chnh ca ph tt t qu l nhm bnh a dng vi nhiu nguyn nhn khc nhau: 85% l thiu mu no, 10% l xut huyt no, 5% l xut huyt di nhn (s liu cc nc phng ty; Nht v Trung Quc c t l XHN cao hn)

DCH T HC CA T QU

T l mc bnh mi (incidence) thay i theo tng vng: - 4,2 n 6,5/1000 dn/mi nm (s liu ca phng ty) 20% bn t qu cht trong vng 1 thng v 30% cht trong vng mt nm u tin 1/3 bn t qu b ph tt, 1/3 bn phc hi hon ton hoc c tr li kh nng sinh hot c lp

DCH T HC CA T QU

Xut huyt no v xut huyt di nhn c mc t vong cao trong 30 ngy u (khong 50%) v gy nhiu ph tt bn sng st

CHN ON T QU & CN THONG THIU MU NO (TIA)

Chn on t qu/TIA uc da ch yu trn bnh s v thm khm thn kinh c th phi hp vi s h tr ca kho st hnh nh no b loi tr cc bnh gy chn on nhm khc MRI diffusion weighted imaging (DWI) c th pht hin phn ln cc t qu thiu mu trong vng vi gi u ca t qu

CHN ON T QU & CN THONG THIU MU NO (TIA)

Chn on t qy cn c khn trng thc hin v cn thit cho cho s quyt nh sm v ng phng thc iu tr t qu Chn on TIA cn c thc hin khn trng nhm xc nh c ch bnh sinh ca TIA v c tc ng ngn chn kp thi (phng nga din tin thnh t qu)

CHN ON T QU & CN THONG THIU MU NO (TIA)

Bnh s S xut hin, khi pht t ngt (abrupt onset) ca thiu st thn kinh cc b (focal neurological deficit) l c im then cht ca t qu. S xc nh thi im khi pht ca t qu/TIA l ht sc quyt nh i vi s chn la cch iu tr ph hp i vi t qu cp. Trong xut huyt di nhn khng c du thn kinh cc b. c im chnh l au u d di v t ngt, v thng c s nh sng, bun nn v cng gy i km.

CHN ON T QU & CN THONG THIU MU NO (TIA)

Du thn kinh thc th Du thn kinh cc b tng ng vi mt vng ti mu ca mt ng mch c th Nhng triu chng gi cc bnh gy chn on nhm l t qu - l ln - ni ngng nghu - chng mt n c

CHN ON T QU & CN THONG THIU MU NO (TIA)

Du thn kinh thc th t qu c c t trc, ri lon nhn thc c sn t trc khin chn on kh hn

t qu c c bnh cnh tr nng do mt bnh ton thn mi xy ra (nhim trng, ng kinh)

CHN ON T QU & CN THONG THIU MU NO (TIA)

Thm d cn lm sng : Chn on phn bit t qu vi cc bnh khc Chn on xc nh nguyn nhn ca t qu

Bng 1: Cc cu hi t ra trc mt t qu cp
1. 2. 3. 4. 5. 6. 7. 8. 9.

Nguyn nhn ca hi chng no cc b v cp tnh? (mch mu, vim nhim, u, v.v) Nu l t qu: thiu mu cc b hay chy mu? Nu l t qu nhi mu th l bnh ca tim, ng mch, tnh mch, mu? L huyt khi, thuyn tc, phnh tch hay vim ng mch? Bnh gy ra hi chng t qu c th cn tip tc l nguy him hn na cho chc nng no b hay khng? Phn no ca no b b tn thng? Th tch no b tn thng? Bao nhiu m no b hoi t? C ch no hin nay ang tip tc gy nguy him cho cu trc v chc nng no

Bng 2: Bnh khc c th lm chn on nhm l t qu

ng kinh cc b Vim no mng no H ng huyt, tng ng huyt, h natri huyt Khi chon ch ni s (apxe, u no) Ngt Bnh tin nh ngoi bin Migraine Mu t di mng cng X cng ri rc Lit thn kinh ngoi bin

XC NH LOI T QU V V TR TAI BIN

Khng c c im lm sng no tin cy phn bit c chc chn nhi mu no vi xut huyt no do bt buc phi c kho st hnh nh no b tr gip. Cng c th c nhm ln trong chn on gia cn thong thiu mu no vi mt xut huyt no nh hay mt bnh khc vn c bnh cnh ging nh TIA do kho st hnh nh lun l cn thit trong cn thong thiu mu no.

XC NH LOI T QU V V TR TAI BIN

Chn on xc nh nhi mu no MRI l kho st hnh nh no b tt nht cho t qu nhi mu no cp: - hnh DWI cho thy ngay tn thung thiu mu trong vi gi u tin (tng tn hiu) - hnh nh MRA cho bit tnh trng ca cc mch mu ni s v mch mu vng c - nhc im: thc hin lu, kh p dng cho bn khng hp tc hoc bn c tnh trng lm sng jhng n nh

CT scans thng l bnh thng trong nhng gi u tin ca nhi mu no cp: - gip loi tr xut huyt no - bt thng hnh nh CT xut hin r khi thi gian tri qua/khi th tch nhi mu ln

XC NH LOI T QU V V TR TAI BIN

Chn on xc nh nhi mu no Nu hnh nh CT no bnh thng lc u th: - chp MRI - chp li CT sau 3-7 ngy

Phn loi lm sng nhi mu no: - phn loi ca Oxfordshire Community Stroke Project (TACI, PACI, LACI, POCI) Chn on v tr nhi mu no da trn hnh nh hc: - nhi mu trong vng ti mu ca cc nhnh ng mch ln (thuyn tc) - nhi mu l khuyt (huyt khi ca ng mch xuyn thu)

Bng 3. Phn loi t qu do thiu ti mu (Oxfordshire Community Stroke Project )

Loi TACI (total anterior circulation infarct) c im lm sng Lit na ngi v/hoc mt cm gic na ngi v ri lon chc nng thn kinh cao cp (mt ngn ng, bn manh ng danh, b st na khng gian) Nguyn nhn & tin lng Nhi mu no rng trong vng ti mu ca MNG do thuyn tc; sng l thuc, d t vong

Bng 3. Phn loi t qu do thiu ti mu (Oxfordshire Community Stroke Project )

Loi PACI (partial anterior circulation infarct) c im lm sng C hai trong ba thiu st ca TACI hay thiu st chc nng thn kinh cao cp n c hay thiu st vn ng/cm gic khu tr ( mt chi hay mt v bn tay) Nguyn nhn & tin lng Nhi mu nh nhng c nguyn nhn ging nh ca TACI, phc hi tt hn nhng nguy c ti pht cao

Bng 3. Phn loi t qu do thiu ti mu (Oxfordshire Community Stroke Project )

Loi LACI (lacunar infarct) c im lm sng Yu lit na ngi n c Mt cm gic na ngi n c Yu lit v mt cm gic na ngi Yu v tht iu na ngi Nguyn nhn & tin lng Nhi mu nh v su do tc ng mch nh, tin lng tng i tt

Bng 3. Phn loi t qu do thiu ti mu (Oxfordshire Community Stroke Project )

Loi POCI (posterior circulation infarct) c im lm sng Du hiu thn no hay tiu no khng c du thp km theo, hay bn manh ng danh n c, hay phi hp c hai Nguyn nhn & tin lng Nhi mu phn sau ca bn cu no, thn no, tiu no do bnh ca ng mch ln, ng mch nh hay thuyn tc t tim; tin lng dao ng

XC NH LOI T QU V V TR TAI BIN

Chn on xc nh xut huyt no CT v MRI c nhy cao i vi xut huyt no cp (MRI pht hin mu tt hn t qu din ra nhiu ngy) Chp hnh mch no (DSA) c ch nh trong phnh ng mch v d dng ng-tnh mch

Bng 4. Nguyn nhn ca xut huyt no

Nguyn nhn V ng mch tn su trong no b c im lm sng Xut huyt su (hch y, i th, tiu no, thn no) Thng do tng huyt p Tui 45 Xut huyt thy (hay nhiu xut huyt) Tui 70 t khi c tng huyt p i km

Bnh amyloid mch mu no

Bng 4. Nguyn nhn ca xut huyt no

Nguyn nhn D dng mch mu no hay u mch hang Ti phnh ng mch c im lm sng V tr a dng Hnh nh bia trn MR Thng tui 45 V tr c th ca phnh mch Xut huyt di nhn Thuc khng ng Thuc chng kt tp tiu cu Thuc tiu huyt khi Gim tiu cu Thiu yu t ng mu

Ri lon ng mu

Bng 4. Nguyn nhn ca xut huyt no

Nguyn nhn U no c im lm sng Di cn ca melanoma, ung th phi, ung th thn, choriocarcinoma, carcinoma tinh hon; u sao bo IV Xut huyt trn hai bn xut huyt thy thi dng Xut huyt di nhn hay xut huyt di mng cng Dp no lan ta Bnh s chn thng

Chn thng

Bng 4. Nguyn nhn ca xut huyt no

Nguyn nhn Huyt khi tnh mch ni s c im lm sng Thng l n au u, co git Nhiu xut huyt Triu chng ton thn ca nhim trng Ru Amphetamine Cocaine c im lm sng ca hi chng no cp do tng huyt p, suy thn cp, sn git

Vim ni tm mc nhim trng Thuc

Cn tng huyt p cp

XC NH LOI T QU V V TR TAI BIN

Chn on xc nh xut huyt di nhn 85% cc trng hp do v ti phnh ng mch

CT l k thut chn on rt nhy (95%) i vi xut huyt di nhn trong 24-48 gi u, s tr thnh m tnh cc ngy v sau Chc d dch no ty l cn thit trong trng hp CT m tnh (dch vng, c bilirubine, nghim php 3 ng nghim)

CHN ON NGUYN NHN CA T QU

Phn loi TOAST (Trial of ORG 10172 in Acute Stroke Treatment): Huyt khi v thuyn tc ng mch ln (35%) Thuyn tc do tim (24%) Bnh mch mu nh (18%) Khng bit nguyn nhn (18%) Nguyn nhn him (5%)

Nguyn nhn him gp ca t qu

Phnh tch ng mch Vim ng mch (Takayasu, vim ng mch t bo khng l, polyarteritis nodosa, vim mch d ng, lupus ton thn, vim a khp dng thp Huyt khi tnh mch ni s CADASIL (cerebral autosomal dominant arteriopathy with subcortical ischaemic stroke and leukoencephalopathy) Vim ni tm mc nhim trng Hi chng antiphospholipid Cc tnh trng tng to huyt khi khc

IU TR T QU

IU TR CN THONG THIU MU NO (TIA)

Thuc khng kt tp tiu cu (aspirin) l thuc c la chn u tin Heparin TM trong 24-72H t APTT = 1,5-2,5 gi tr bnh thng: - ch nh cho cc cht hp nng ca ng mch cnh hay ca ng mch t sng-thn nn, - gi tr tht s? Endarterectomy sm i vi cht hp nng ca ng mch cnh

IU TR T QU CP

t qu l mt khn cp ni khoa 3 phng thc can thip c chng minh l c hiu qu: - stroke unit chm sc tt c cc loi t qu (.tr 20/nga 1 t vong hay ph tt nng) - aspirin trong vng 48 gi u tin ca t qu thiu mu (.tr 77/nga 1 t vong hay ph tt nng) - alteplase (tissue plasminogen activator) trong vng 3 gi u tin ca t qu thiu mu (.tr 10/1 t vong hay ph tt nng)

Stroke unit (S.U.)

Ci thin r rt kt cc ca tt c cc bnh nhn t qu (thiu mu v xut huyt) Cc tnh cht hu ch ca stroke unit: - chm sc a chuyn khoa - ph trch tng vng a d - quyt nh l ca kip lin chuyn khoa - c phc hi chc nng - o to lin tc cho cc thnh vin ca S.U.

IU TR T QU THIU MU NO CP

Aspirin cho t qu thiu mu

Aspirin 150-300 mg (ung, t hu mn, TM) cho trong 48 gi u ca t qu thiu mu. L bin php hu hiu cho phn ln cc trng hp (t tai bin, r tin)

Tiu huyt khi bng alteplase hay r-tPA (thrombolysis)

Ca s iu tr 3 gi Mi 5 pht chm tr a n gim 5% c may c c mt kt qu tt Tng liu l 0,9 mg/kg TM, phn b nh sau: - 10% TM bolus - 90% cn li TTM trong 1 gi S dng r-tPA c lin quan vi xut huyt no 67% cc trng hp (tng gp 3 ln). Yu t d on xut huyt no khi dng alteplase l: - hnh nh bin i sm ca nhi mu no trn CT - kim sot km tnh trng tng huyt p

Phu thut trong t qu thiu mu no

1. 2.

Nhi mu tiu no Nhi mu do tc hon ton ng mch no gia

Phu thut trong nhi mu tiu no

Nhi mu tiu no c bin chng ph no trong 48-72 gi u tin ca tai bin H qu l: - chn p thn no - trn dch no tht cp tnh Theo di da trn bin i ca thc-tri gic Phu thut khn trng h sau + dn lu no tht

Phu thut trong nhi mu no ln do tc hon ton ng mch no gia

Bin chng quan trong nht ca tc hon ton MNG l ph no ln gy tng p lc ni s, tt no v t vong. Phu thut m mt na hp s (hemicraniectomy) c th cu sng nhng trng hp nhi mu no ln ca tc hon ton MNG.

IU TR XUT HUYT NO

Cn c thc hin mt stroke unit i vi nhng xut huyt no ln c hn m bnh nhn ln tui, iu tr ch mang tnh nng v kt cc ni chung thng km. Cao huyt p ng k lc mi khi pht tai bin (HA m trung bnh > 120 mmHg) c lin quan vi s pht trin to ra ca khi mu t v kt cc xu. Do cn kim sot huyt p tch cc trong trng hp xut huyt no (duy tr < 160/90 mmHg)

Phu thut trong xut huyt no

Khng nn thc hin phu thut ly khi mu t thng quy Phu thut c th hu ch v c ch nh trong: - xut huyt c xc nh l do v phnh mch - xut huyt tiu no ang gy chn p thn no v no ng thy Cng c th ch nh phu thut cho nhng trng hp xut huyt no nng v mi bt u tr xu i vi xut huyt ca u mch hang (cavernoma), thng l khng can thip phu thut, hoc nu c th l phu thut ly mu t.

NGUYN TC CHUNG CA X TR T QU CP

Quan st v theo di tnh trng thn kinh v cc sinh hiu gip pht hin mi tr xu lm sng, v gip c c kp thi bin php x tr thch hp Cn theo di st mi gi mt ln trong giai on u Tnh trng tr nng v thn kinh thng c gp (40% cc trng hp)

iu chnh cc thng s sinh l

1. 2. 3. 4. 5. 6. 7.

ng huyt Cung cp oxy Truyn dch Nui dng X tr nut kh X tr st Kim sot huyt p

iu chnh cc thng s sinh l

ng huyt - tng ng huyt c lin quan vi kt cc xu - cn iu tr tnh trng i tho ng - khng dng dung dch glucose trong giai on sm ca t qu Cung cp oxy - c th cn c ch nh

iu chnh cc thng s sinh l

Truyn dch - nhm duy tr tnh trng ng th tch - cn truyn dch sm cho bnh nhn t qu ang b mt nc hoc kh c th ung bng ng ming Dinh dng - nui n qua tube Levine cn c thc hin trong tun u (i vi bn nut kh) - gastrostomy i khi cn thit cho trng hp c bit

iu chnh cc thng s sinh l

X tr st - tng thn nhit c lin quan vi kt cc xu sau t qu - dng thuc h nhit - x tr nguyn nhn gy st

iu chnh cc thng s sinh l

Kim sot huyt p - trnh h p trong giai on sm ca t qu (v c th gy thiu ti mu cc vng tranh ti tranh sng) - c th tip tc thuc ung h p m bnh nhn ang s dng trc khi b t qu - i vi bn c cao huyt p nng v ko di ( 230/120 mmHg) hoc c cao huyt p i km vi tn thng cp ca c quan ch (vd suy tim tri, phnh tch ng mch ch) c th cn iu tr h p ngay trong giai on sm ca t qu cp:

iu chnh cc thng s sinh l

Kim sot huyt p (tip theo) + h p thn trng (10-20%) kt hp vi theo di tnh trng thn kinh + nn dng thuc h p theo ng tnh mch (d kim sot hn) + nn dng labetalol, sodium nitroprusside, glyceryl trinitrate + trnh dng thuc khng calci v ACEI di li (v d gy tt nhanh HA)

IU TR PHC HI TRONG T QU

Phc hi chc nng bnh nhn t qu (ni tr, ngoi tr) c ci thin kt cc ca t qu Chng trnh, k hoch iu tr phc hi cho mi bn ty thuc vo nhiu yu t khc nhau: - tnh p ng ca c s ti ch - mc nng nh ca t qu - s thch ca bn v ngi iu tr - kh nng h tr ca gia nh

IU TR PHC HI TRONG T QU

iu tr c nh hng chc nng v c mc tiu c th iu tr chng mt ngn ng rt kh khn v thng km hiu qu

IU TR PHNG NGA TH PHT

Bng. Yu t nguy c ca t qu
Yu t khng thay i c Tui Gii tnh Yu t di truy Yu t sc tc Yu t c th thay i c Tng huyt p Ht thuc l Rung nh i tho ng Ung ru nhiu Hp ng mch cnh Mp ph Bnh tim Tng cholesterol mu Thiu hot ng th lc

Bin php phng nga th pht

1. 2. 3. 4. 5. 6.

iu tr khng kt tp tiu cu iu tr khng ng iu tr h p iu tr h cholesterol mu Kim sot i tho ng Carotid endarterectomy

iu tr khng tiu cu

Thuc khng tiu cu dng trong phng nga th pht c lm gim nguy c t qu / nhi mu c tim / t vong do s c mch mu bn b t qu hay TIA trc : - aspirin - clopidogrel - aspirin + dipyridamole

iu tr khng tiu cu

Aspirin liu thp (75-150 mg/ngy) c hiu lc nh aspirin liu cao, nhng t tc dng ph hn 10% bn khng dung np aspirin do tc dng ph v tiu ha ca thuc Aspirin (50 mg x 2/ngy) cng vi dipyridamole (200 mg x 2) c hiu lc cao hn aspirin n c trong phng nga ti pht t qu; phi hp ny khng c hiu qu phng nga ti pht nhi mu c tim. Clopidogrel (75 mg/ngy) c hiu lc phng nga ti pht t qu ging nh aspirin (v c th tt hn mt t). Thuc t tc dng ph v d dy nhng li gy tiu chy v mc hn.

iu tr khng ng

Cn iu tr khng ng warfarin cho tt c cc bnh nhn t qu nhi mu v bn TIA c rung nh. Bnh nhn t qu c rung nh cn cng cn c iu tr khng ng. iu tr warfarin cho bn c ch nh khng ng cn c duy tr sut i. Bn t qu cp c van tim nhn to v c rung nh cn c iu tr bng aspirin 100 mg/ngy cng vi warfarin (INR 3,0-4,5)

iu tr h p

iu tr h p cho Bn t qu hay TIA bng perindopril 4 mg + indapamide 2,5 mg hoc ramipril 10 mg/ngy c lm gim t l ti pht t qu, nhi mu c tim v t vong do bnh mch mu, bt k l huyt p c th ch bng 130/70 mm Hg. iu tr cao huyt p bng thuc khc c th cng cho li ch tng t. Khi no th khi ng iu tr cao huyt p: - i vi BN huyt p bnh thng, nn ch cho ti khi bt u c xut hin du hiu phc hi - i vi Bn sn cao huyt p, nn bt u iu tr sm hn.

iu tr gim cholesterol mau

Cc th nghim lm sng cho thy vic dng statin cho Bn nhn au tht ngc v Bn nhi mu c tim c lm gim nguy c t qu Ch c bng c gin tip cho thy statin c lm gim nguy c ti pht t qu Bn TIA hay b t qu. Statin c lm gim cc s c thiu mu c tim Bn t qu Nn ch nh statin (vd, simvastatin 40 mg/ngy) cho tt c cc bn b TIA hay t qu. Cn lu tc dng ph quan trong ca statin l bnh c v bt thng chc nng gan.

Carotid endarterectomy

Cn xem xet vic ch nh carotid endarterectomy cho Bn c TIA hay t qu nh c cht hp ng mch cnh cng bn vi bn bn cu no b thiu mu. Phn ln Bn c cht hp ng mch cnh 70% cn c thc hin carotid endarterectomy. Bn c cht hp 50%-69% cng c th cn carotid endarterectomy nu mng x va b lot

Ti liu tham kho

Adams HP, del Zoppo G, Alberts MJ et al (2007). Guidelines for the early management of Adults with ischemic stroke. Stroke, 38: 1655-1711. Biller J, Love BB, Schneck MJ (2008). Ischemic cerebrovascular disease. In Walter G Bradley, Robert B Daroff, Gerald M Fenichel, Joseph Jankovic ed Neurology in Clinical Practice, 5 th edition, vol 2, Butterworth Heinemann-Elsevier, p 1165-1223. Broderick J, Connolly S, Feldmann E et al (2007). Guidelines for the management of spontaneous intracerebral hemorrhage in adults. Stroke, 38: 2001-2023. Dewey HM, Chambers BR, Donnan GA (2006). Stroke. In Charles Warlow ed The Lancet Handbook of Treatment in Neurology, Elsevier, p 87-116.