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 hoi t
Vng thiu mu
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
Th chai
Thy nh
No tht IV
Sng trc
no tht bn
Sng sau no
tht bn
Mng mng
mch
Nhn u
Cnh tay sau
bao trong
i th
Sng trn no
tht bn
Nhn ui
Vch trong sut
B trn tiu no
Thy nhng
Thy chm
Sng trn no
tht bn
Nhn ui
Nhn u
No tht III
Khe Sylvius
Thy o
C trung no
B c trung no
Tiu no
Tay trc bao
trong
Khe Sylvius
Cng Sylvius
Thy trn
Khe lin bn cu
No tht III
B lin cung no
Cung no
Tiu no
Lim no
Thy trn
Khe Sylvius
B trn yn
Cu no
Lu tiu no
No tht IV
Tiu no
Khe Sylvius
Thy thi dng
Lim no
Lng yn
Thy thi dng
B trc cu no
Xng chm
No tht IV
Tiu no
Thy trn
Tuyn yn
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
Nhn u
Bao trong
u nhn ui
i th
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
M2
M3
M4
M5
M6
I
C
L
T
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
B trn yn
B c trung no
F: frontal U: Uncus Po: Pons
Hnh nh b trn yn v b c trung no
Cung no
B c trung no
B trn yn
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
Rnh lin
bn cu
B trn yn
B m no gia
B gc cu tiu no No tht IV
Rnh quanh
cung no
Khe Sylvius
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
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 g trn hnh ny
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
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 g trn hnh ny
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
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 g trn hnh ny
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
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 g trn hnh ny
Ph no
Kn nc
CT Scan c cn quang
Ph no
Lch ng gia
Kn nc c
tng quang vin
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
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 g trn hnh ny
Thy trn
Thy thi dng
Nhn nn
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
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 g trn hnh ny
No tht IV
No tht III
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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