Chng I

NHNG IM C BN V VT L V K THUT
Gio s Hong c Kit

Chng I NHNG IM C BN V VT L V K THUT

I . Nguyn l c bn Nm 1979, gii thng Nobel v y hc c trao cho hai chuyn gia vt l hc l Cormack (M) v Hounsfield (Anh) v nhng ng gp ca hai ng cho s thnh cng ca phng php chp ct lp vi tnh (CLVT). S kin ny ni ln nhng cng hin to ln ca vt l hc cho y hc ng thi cng th hin gi tr ca phng php chp CLVT trong chn on, iu tr v nghin cu khoa hc y hc. Ngy 04/02/1991, chic my chp CLVT u tin nc ta bt u hot ng ti Bnh vin Vit - X. Qua 15 nm, hin c hn 120 h thng chp CLVT c a vo hot ng trn ton quc, li ch ca phng php chp CLVT c khng nh trn thc t lm sng nc ta. 1. Lc s Radon (c) nm 1917 t c s l thuyt u tin cho phng php ton hc nhm ti to cu trc ca mt vt th 3 chiu trong khng gian da trn v s tn cc hnh chiu ca vt th . Bracewell (c) nm 1956 ln u tin p dng l thuyt ny trong quang ph. Cormack nm 1963 thnh cng trong vic ti to trn nh cu trc ca mt s vt th hnh hc n gin nh mt ngun bc x ca c ban 60. Hounsfield nm 1967 thit k c mt thit b dng tia X o nhng vt th th nghim lm bng cc cht nhn to v lp c chng trnh my tnh ghi nh v tng hp kt qu. Ngy 1/10/1971 Hounsfield cng Ambrose (Anh) cho ra i chic my chp CLVT s no u tin - Thi gian chp v tnh ton cho mt quang nh lc ny cn 2 ngy. Nm 1974 Ledley (M) hon thnh chic my chp CLVT ton thn u tin "Whole body CT Scanner ACTA" - Thi gian chp v tnh ton cho mt quang nh vi pht vn cha thun tin cho vic ng dng trong lm sng. Cho ti nm 1977 mi c loi my chp CLVT vi thi gian chp mt quang nh 20 sec trn th trng th gii, loi my ny cn mang tn my chp CLVT th h 1. Hin nay c my chp vi thi gian di 1 sec v my siu nhanh c th chp 0,1sec hoc chp xin CLVT dng trong chn on tim mch. 2

2. Nguyn l k thut 2.1. Nguyn l to nh Chp X quang ct lp qui c da trn nguyn tc l lm r cc cu trc mt mt phng nh trc v xo i hnh chiu ca cc mt phng khc trn quang nh . Phng php ny cho php phn bit s chnh lch t trng ca cc cu trc trn cng mt mt phng cao nht l 5%, hin t dng v liu x cao v phn gii nh thp. Da vo l thuyt v ti to nh cu trc ca mt vt th 3 chiu Hounsfield thit k mt my chp CLVT gm mt h thng pht x QTX v nhng u d (detector) t i din vi bng X.quang. H thng ny quay quanh mt ng trn ti mt mt phng vung gc vi trc c th (hnh 1a). Chm tia i qua mt ca s hp (vi millimet) qua c th b hp th mt phn, phn cn li s c u d ghi li. Kt qu ghi c rt nhiu v tr khc nhau ca bng X quang (cng c ngha l nhiu hnh chiu ca mt lp ct c th) s c chuyn vo b nh ca mt my vi tnh phn tch. Phng php ny cho php phn bit cc cu trc c th trn cng mt mt phng c chnh lch t trng 0,5%. Hnh 1b v mt vt th hnh vung gm 8x8 n v th tch. Nu cho mt ngun QTX I0 chiu qua t 2 hng, ta s c kt qu thu c 2 pha i din t Ix1 n Ix8 v Yy1 n Yy8. Hai nhm kt qu ny khng tnh ra c tr s hp th QTX ca tng n v th tch ca vt th ni trn. Mun c 8x8 = 64 gi tr hp th ca 64 th tch phi ghi c 64 nhm kt qu. Trong h thng my chp CLVT s ln o quyt nh s n v th tch ca mt lp ct v nh vy mt lp ct cng chia ra nhiu n v th tch bao nhiu th nh ca n cng c phn gii khng gian cao by nhiu. S n v th tch ca mt lp ct trong ton hc gi l ma trn (matrix). My chp CLVT c nhiu loi ma trn: 256 x 256, 340 x 340, 512 x 512 v 1024 x 1024. 2.2. K thut my V k thut cho n nay hnh thnh 4 th h my da trn 4 nguyn tc k thut v pht tia X v ghi kt qu khc nhau. a. Th h 1 (hnh 2a) My chp c mt u d (detector), ng dng nguyn tc quay v tnh tin. Chm QTX di 1o chiu qua c th ti 1 u d thu nhn kt qu. Bng QTX phi quay quanh c th 1800, khi quay c 100 th li tnh tin mt khong bng chiu rng c th v pht tia o. Mt quang nh phi mt vi pht. 3

b. Th h 2 (hnh 2b) My chp c nhiu u d, quay + tnh tin: Chm QTX c gc m rng khong 100 i din vi mt nhm t 5 - 50 u d. My cng hot ng theo nguyn tc quay + tnh tin nh trn nhng do chm QTX rng hn nn gim c s ln qut ngang. Thi gian chp 1 quang nh t 620s. c. Th h 3 (hnh 2c) My chp c nhiu u d dng nguyn tc quay n thun, chm QTX c gc m rng hn, trm ht phn c th cn chp; 200 - 600 u d ghp thnh mt cung i din vi bng X quang. Bng QTX va quay va pht tia, dy u d quay cng chiu vi bng v ghi li kt qu. Thi gian chp 1 quang nh t 1- 4 s v dy lp ct t ti 2mm. d. Th h 4 (hnh 2d) My chp c h thng u d tnh, g c nh vo 3600 ca ng trn, s lng u d c th ln n vi ngn b. Bng QTX quay quanh trc c th pht tia. Thi gian chp 1 quang nh c th di 1 sec rt thun li cho khm xt cc tng c chuyn ng. 2.3. n v th tch, n v nh, t trng Mt lp ct chia ra nhiu n v th tch - hnh 1 th hin s n v th tch ca na lp ct, trong a=b l cnh vung y ca mt n v th tch thng t 0,5 2mm, d l dy ca lp ct ng thi l chiu cao ca n v th tch (t 1mm n 10mm). Mi n v th tch s hin ln nh nh mt im nh, tng cc im hp thnh 1 quang nh (Volume element - Picture element). hp th tia X ca tng n v th tch c b nh ghi li, cu trc hp th cng nhiu tia X th t trng cng cao, v vy ngi ta cn gi phng php chp CLVT l chp ct lp o t trng (Tomodensetometrie). Da vo kt qu o suy gim tuyn tnh cu chm QTX, ngi ta tnh ra t trng ca cu trc theo n v Hounsfield qua cng thc:

N (H) =

( x ) ( H 2 O ) xk H 2 O

N(H)

: Tr s t trng tnh bng n v Hounsfield ca cu trc X

(x) : h s suy gim tuyn tnh ca QTX khi xuyn qua n v th tch X.
H2O k : Nc tinh khit : H s 1000 do Hounsfield a ra v c chp nhn

Theo cng thc trn, nu X l: - Nc (H2O) c trng khi 1,000g/cm3 = 0 n v H. - Khng kh c trng khi 0.003g/cm3 = -1000 n v H. - Xng c c trng khi 1.7000g/cm3 = +1700 n v H. 2.4. nh chp CLVT, ca s v bc thang xm phn tch c nhng s o ca cc cu trc c th trn mt lp ct cn bin chng thnh nh. V mt thng ch phn bit c di 20 bc thang xm t en n trng, nn nh chp CLVT t 14-16 bc xm khc nhau. Nh vy, nh CLVT khng phi l nh trc tip ca tia X ln phim m l nh to li t b nh ca my tnh v vy phng php chp CLVT cn c tn gi l chp ct lp ti to nh (Tomographie par reconstruction) thy s chnh lch t trng bn trong. Mun nhn ton cc t xng n phn mm cn m rng ca s. im gia ca ca s thng t vo s o trung bnh ca cu trc bnh thng m ta cn khm xt; th d no: 35, gan 50, phi 700, xng +200. Hnh 4 v s m ca s trn gii Hounsfield v cc s o trung bnh ca mt s cu trc trong c th. Mi nh chp Hounsfield u c ghi ca s theo k hiu sau: W (width): rng ca ca s L (Level): Mc gia ca ca s (c my thay ch L bng ch C: Center).

S ca s trn di n v Hounsfield v h qu mnh th tch

2.5. Cc yu t gy bt li cho nh a. H qu ca mnh th tch (Partial volume effect) Nh ni trn nh chp CL-VT l s th hin s o trung bnh ca cc n v th tch qua bc thang xm, v vy gii hn ca cc vng c t trng khc nhau s khng hon ton trng hp vi thc t m s b bin i mt phn do gii hn b

bin dng theo cc n v th tch (Hnh 1). H qu ny c khc phc dn cc th h my 3, 4 do s lng ca ma trn lp ct tng ln cng c ngha l n v th tch v n v nh thu nh li. b. Cc nhiu nhn to (artefact) Nhng nguyn nhn sau y c th to nn nhng hnh nh gi trn nh: - in th qua bng QTX khng thch hp vi dy c th. - Phn c th cn chp chuyn ng trong lc my qut. - Di vt kim loi hoc cht cn quang trong c th, trong qun o bnh nhn Nhng nhiu nhn to trn nh s lm cho nh khng c gi tr chn on 3. Nhng tin b ca cng ngh chp ct lp vi tnh. T thit b chp ct lp vi tnh u tin n nay, cng ngh chp ct lp vi tnh lun lun i mi nhm vo hai mc tiu chnh l: - Rt ngn thi gian qut ca bng X quang cho mt vng quay 3600 quanh c th ngi bnh. - Rt ngn thi gian to nh v ci thin cht lng nh thng qua vic nng cao phn gii i quang thp v phn gii khng gian ca nh.

3.1. Cng ngh chp xon c l mc quan trng nht v tin b cng ngh chp ct lp vi tnh; cng ngh ny bt u c ng dng trn lm sng t nm 1991. Trong chp CLVT qui c, cp cao p cp in cho bng X quang cun mt vng khi bng X quang quay mt ng trn 360o v s phi quay ngc chiu 360o cp in cao p khng b xon; lp ct tip theo c thc hin sau khi bng dng li v quay ngc chiu quay ca lp ct trc . Thi gian ngh gia hai lp ct khong trn 10 giy nn bnh nhn khng th nhn th cho nhiu lp ct . Nh cng ngh tip in qua vng trt (slip ring) v b bin p t ngay cnh bng Xquang trong khi quay nn bng Xquang c th quay lin tc cng chiu, khng cn thi gian ngh gia hai lp ct . Bn bnh nhn c tnh tin lin tc theo mt hng vi tc u to nn hnh qut ca chm QTX trn c th l mt ng xon lin tc khng khp kn (hnh 3a v 3b) .

Hnh 3a

: S cu trc h thng chp xon c

Phn quay gm bin p cao th bc II, bng X quang, loa t quang, dy u d v b thu nhn d liu DAS . Phn tnh gm bin p cao th bc I, my tnh v b nh Cng ngh chp xon c cho php bng X quang quay v pht tia X lin tc t 10 n 30, 60 giy v 90 giy. Nh vy nu mt vng quay ca bng cn 01 giy, ta c th qut hp s, lng ngc hay bng m ch cn bnh nhn nhn th t 20 n 25 giy. Khm xt c th thc hin c rt nhanh, nhng quan trng hn l: - D kin thu c t khm xt mang c im ca th tch mt vng c th c tnh lin tc, khng phi l cng d kin ca nhiu lp ct. - Gim c lng thuc cn quang tim vo c th bnh nhn m cht lng nh thu c li c nng thuc cn quang trong mch mu v t chc cao hn. - nh khng gian 3 chiu (3D) dng li t cc d kin c sn t c cht lng cao v khng b khong phn cch gia cc lp ct, do nh chp mch mu, chp xng c gi tr chn on cao hn. Trong chp CLVT xon c, mt tr gi cn quan tm l t s ca bn (bnh nhn) chuyn ng i vi mt chu k quay ca bng Xquang 360o gi l Pitch : Pitch = V(mm/s) x t (360o) w Pitch = di chuyn ng bn BN trong mt chu k quay ca bng

 m ca chm QTX (mm) Th d : Nu bn bnh nhn tnh tin c 5mm / mt vng quay 360o ca bng Xquang v m chm tia X rng 5mm, ta c Pitch = 1.0 v thut ton ngoi suy tuyn tnh lc ny l 360o Nu bn bnh nhn tnh tin c 10mm/mt vng quay 360o ca bng trong khi m chm tia X vn l 5mm, ta c Pitch = 2.0 . Pitch = 2.0 ng ngha vi cc vng qut khng cn lin tip nh trong trng hp Pitch = 1.0 na . Khi s dng Pitch >1.0, hu ht cc h thng chp ct lp xon hin nay u t ng chuyn sang thut ton ngoi suy 180o gim mo nh v chp nhn tng t l nhiu cng nh gim phn gii i quang .

Hnh 3b

: Trong chp xon c, Pitch th hin mc bao ph ca

chm tia X trn phn c th c khm xt : (A) Pitch = 1:1 ; (B) Pitch = 2:1 3.2. Mc tin b thi s hin nay v chp ct lp vi tnh l cng ngh a dy u d (Multidetector CT-Scanner theo ting Anh hoc Scanner multibarettes theo ting Php). Loi my ny bt u xut hin trn th trng t nm 1992 vi h thng to c 2 lp ct cho mt vng quay ca bng X quang (Twin hoc Dual CT Scanner) . Nm 2001 c my 4 lp ct cho mt vng quay 0,5 giy hay cn gi l my 8 lp ct/giy. Hin nay, cc hng sn xut nghin cu thnh cng loi my 8, 16, 32 v 64 lp ct cho mt vng quay ca bng X quang vi thi gian di 0.5 giy. Cng ngh mi ny cho php chp vi dy lp ct di 1mm, nng cao phn gii nh, kh nng ti to 3D v kh nng chn on ca chp ct lp vi tnh ln rt nhiu, c bit trong lnh vc chn on tim mch . Th d vi my Dual (hai lp ct/vng quay bng Xquang), nu em so snh vi my xon c n lp, ngi s dng c th t c phn gii khng gian 10

dc gp i (5mmx2 thay cho 10mmx1) nu gi nguyn tc tnh tin bn bnh nhn, th tch khm xt v cng dng in qua bng . Nu gi nguyn phn gii khng gian dc, th tch khm xt v dng qua bng, my Dual gim c 50% thi gian qut (15giy thay cho 30giy) . Nu gi nguyn phn gii, tc bn bnh nhn v dng qua bng, my Dual cho php khm xt mt th tch gp i (60cm thay cho 30cm) .

Hnh 4 : So snh my n lp v my hai lp ct : Gi nguyn mA, tc chuyn bn v th tch vng khm xt, my hai lp gim 1/2 dy lp ct v do tng gp i phn gii dc 3.3. Chiu X quang ct lp vi tnh cng l cng ngh mi xut hin t nm 1997. Do yu cu thc hin cc chc d sinh thit vng su trong c th, nht l nhng khu vc m siu m gp kh khn (th d phi, xng); mt s hng sn xut to c cng ngh chiu ct lp vi tnh vi 6 n 8 nh/giy v lng mA thp (10-30mA). Cng ngh mi ny cho php lm sinh thit di hng dn ca ct lp vi tnh vi chnh xc cao. 4. ng dng chp ct lp vi tnh trong lm sng 4.1. Chp CLVT khng dng thuc cn quang Hu ht cc khm xt CL-VT u bt u bng chp khng c thuc cn quang. Da vo cc du hiu lm sng, X quang v siu m... chn vng a vo chp ct lp. Mi khm xt CLVT u ct lp vung gc vi trc chnh c th th tr s no c th ct theo mt phng ng ngang nu cn thit. dy ca lp ct thng dng 8 - 10mm vi bc chuyn bnh nhn 8-10mm. i vi nn s, h yn, xng , thng thn phi dng lp ct mng hn: 2 hoc 5mm. C th dng 11

bc chuyn nh hn dy ca lp ct khng b lt bt thng ni tip gip gia hai lp. Ti hin nh nhng mt phng khc (Reformating). Sau khi c d kin ca nhng lp ct trong b nh, ta c th dng li nh theo nhng mt phng do thy thuc t chn th d ng dc, ng ngang, chch... Hin nh theo khng gian 3 chiu: Nhng my sn xut t thp k 90 thng c ghp chng trnh ny. C th yu cu my cho nh 3 chiu vi nhng khong m t chn (Tridimensional dissplay), cc nh ny c bit qu cho cc phu thut vin s no. a. nh gi cu trc trn cc lp ct thng l gi ra s o trung bnh theo t trng Hounsfield nhn xt. Da vo s o trung bnh ca m lnh, ta c 3 loi cu trc da theo t trng: - Tng t trng hoc tng m (Hyperdense): Vng cn o c s o cao hn m lnh ca cng c nhn . - Gim t trng hoc gim m (Hypodense): kt qu thp hn m lnh ca cng tng, cng ngi. - Cng t trng hoc cng m (isodense): kt qu ghi c tng t nh m lnh ca tng trn cng ngi . i vi cc bt thng tng hoc gim t trng, nu nm vng c th hc ct lp ngang ta c th nhn bit khng kh khn nhng vic nhn bit cc bt thng ng m nhiu khi rt phc tp: phi da vo cc du hiu gin tip v nh s tr gip ca thuc cn quang. b. Nhng bin i chnh v bnh hc hnh thi: Cc cu trc trong c th sng khng th xem xt nh mt vt th tnh c. Chng phn ng li vi cc tc nhn nh chn thng, nhim trng, sinh u v bin i chuyn ho bng nhng cch khc nhau. Nhng bin i ny c th thy c mt phn trn nh chp CLVT. - Dch trong kn, dch vim, dch thm Trong c th c th gp kn nhiu tng. Dch trong khoang kn ca kn c t trng gn vi nc (H2O). T trng ny ph thuc nhiu nht vo lng protein trong dch. Dch kn l mt khoang v mch nn t trng s khng i nu ta a thuc cn quang vo mch mu. Dch tit hay dch vim c lng protein trn 30g/lt c th t t trng 20-30 n v H. 12

Dch thm t protein hn, t trng gn vi nc. - Mu - mu t T trng ca mu ph thuc nhiu nht vo lng protein ca cc phn t hu hnh, nu ly ht cc phn t hu hnh i, t trng ca mu s gim t 55 n v xung 15-20 n v H. Mu cc trong mu t c t trng cao hn hn mu tun hon. Qu trnh tiu mu t, tiu si huyt v cc phn t hu hnh cng nh hin tng c th hp th li Anbumin ca mu t lm cho t trng mu t gim dn; hin tng tng t trng tn ti t 1 n 2 tun sau chy mu tu theo khi lng ca mu t. Sau t trng tr nn cn bng vi t chc ht (phn mm) v sau hn 2 tun t trng c th thp hn m mm. Ti cc mu t ln c th hnh thnh mt bao do t chc to thnh. T trng gim dn theo s gim Anbumin trong bao v cui cng ta c th c mt kn dch. Giai on tng t trng ca mu t rt qu trong chn on v n rt c hiu. B qua tun l u, chn on s kh khn hn nhiu v phi loi tr nhng qu trnh khc c t trng tng t. - p xe ho Qu trnh vim khng hi phc dn n s hnh thnh p xe. T chc hoi t, dch vim v cc bch cu cht l thnh phn chnh ca m. Trng hp iu tr tt, mt p xe s t tiu v trn nh chp CLVT s thy mt kn m dch kn giu Anbumin. Thng thng m c t trng 30 n v H. T chc ht bao quanh p xe rt giu tun hon nn khi a thuc cn quang vo tnh mch ta s c mt bao tng t trng bc quanh p xe, th hin trng hp ca mt p xe mi hon chnh. Cc p xe mn tnh c v hin r trn nh chp CLVT khng tim thuc cn quang. T trng m cha trong p xe theo thi gian c th gim xung gn vi nc. - Nhng bin i khc Hin tng vi ho hoi t hoc vi ho protein rt thng gp trn phim X quang cho thy mt t trng rt cao trn nh chp CLVT: tu theo mc thm vi, t trng ca bnh xut hin cao hn mu t cho n t trng ca xng cng. Thoi ho knh v thoi ho bt cha Anbumin trong t bo hoc trong t chc k khng cho thy s thay i t trng. Cc hoi t tri li th hin gim t trng r rt trong qu trnh dch ho t chc. Ta gp cc ny trong vim khng hi phc v trong cc u pht trin nhanh do thiu oxy t chc hoc chy mu trong u.

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4.2. Chp CLVT c p dng cht cn quang Hai hnh thc chnh a thuc cn quang vo c th l: a vo khoang t nhin v a vo lng mch. a. a thuc cn quang vo khoang t nhin. Cc khoang t nhin nh ng tiu ho, cc tng rng hay cha dch, khoang dch no tu u c th a cn quang vo lm r hn hnh dng, ng b, cc thnh phn cha bn trong v mi lin quan vi cc cu trc ln cn. Khc vi vic p dng thuc cn quang trong X quang quy c, cht cn quang dng trong chp CLVT cn c nhng tiu chun sau: - Dung dch phi c cn quang n nh: cht cn quang phi c ho tan trong dch, khng c hin tng lng, kt ta... - Dung dch cn quang cn c p lc thm thu cn bng vi c th (330 mosmol/kg) trnh hin tng c c hoc ho long thuc cn quang do trao i dch vi c th. - cn quang ca dung dch khng c cao qu trnh cc nhiu nhn to trn nh ging nh trng hp kim loi trong c th. cn quang thch hp ca dung dch l 150 - 200 n v H. b. a thuc cn quang vo lng mch. - Hnh thc ch yu l tim vo tnh mch loi thuc cn quang thi tr qua ng thn. Da vo nhng hiu bit v dc ng hc ca thuc cn quang trong c th quyt nh lng thuc, tc bm v thi im chp CLVT so vi thi im bm thuc (chi tit xin xem phn II) . 4.3. Lng nhim x trong chp CLVT Liu nhim x ti vng c th chp CLVT tng ng vi liu ti ch ca mt ln khm i trng hoc chp thn tim tnh mch (2-3 rad) . Cc th h chp xon c hin c thm b phn iu chnh mA t ng theo dy ca vng khm xt kt hp h thng u d cht rn c nhy cao nn gim c liu x so vi nhng my sn xut c . Liu sinh dc: do cu trc ca my bo v tt nn thng thp hn nhiu so vi khm X quang qui c nu khng chp CLVT trc tip ti vng c c quan sinh dc.

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4.4. Ch nh chp ct lp vi tnh trong lm sng u th ca chp ct lp vi tnh trong pht hin cc cu trc bt thng so vi X quang qui c l nh phn gii i quang thp; nu s khc bit v m cu trc trong c th c th thy c trn X quang chun l 5% th chp ct lp vi tnh cho php pht hin s khc bit t trng ti mc 0,5%. Nh chp ct lp vi tnh cho php o t trng ca cc cu trc trong c th, c th d on cu trc bt thng l m, dch, m mm, mu t hay thm vi, khng kh. Hin nay chp ct lp vi tnh c ch nh rt rng, di y l nhng ch nh chnh trong lm sng. a. S no Cc cu trc bn trong hp s, X quang qui c, X quang mch mu v in no thng khng thm d, nht l v hnh thi. Chp ct lp vi tnh s no, do l ch nh hay dng nht i vi cc bnh l ni s. - Chn thng s no Cc mu t ngoi mng cng do chn thng c v xng thng khng kh khn trong chn on lm sng. c bit c ch trong cc mu t ni no, cc mu t di mng cng, nht l cc mu t mn tnh, khng c v xng s. Cc mu mn tnh thng c t trng bng hoc thp hn t chc no, i khi phi p dng thuc cn quang tnh mch lm hin r chng. Cc mu t ng thi c hai pha i din ca hp s, hoc nhng vng khng gy chuyn dch v tr ca ng mch no thng khng th pht hin c chp ng mch. - Cc tai bin mch mu no Trn nh ct lp vi tnh c th d dng phn bit mu t do chy mu vi nhng gim t trng do nhi mu hoc tc mch no. Pht hin tc mch no gy nhi mu trn nh chp ct lp vi tnh thng t c sau t qu t 12 n 24 gi. Chp ct lp c bit c ch cho iu tr phu thut sm cc trng hp chy mu - t mu. - Cc tn thng do vim Ni chung cc tn thng vim no lan to thng kh pht hin trn nh ct lp vi tnh. Cc vim khu tr hoc di chng ca vim no nhiu khu tr cho thy nhng gim t trng no. Bnh vim no ty - cht trng cng cho thy nhng hnh nh c th phn bit vi vim no lan to. Cc p xe no do nhim trng d dng pht hin bng chp ct

15

lp vi tnh nht l i vi p xe mn tnh. Tim thuc cn quang vo tnh mch kt hp chp ct lp vi tnh c th lm hin r bao ca p xe . Cc tn thng khu tr thnh trong no do k sinh trng cng l mt ch nh ca chp ct lp vi tnh. - U no Chp ct lp vi tnh cho php xc nh v tr, ln v d on cu trc ca u. d on bn cht ca u thng phi tim cn quang tnh mch nh gi li tun hon trong u. Tuy vy vic phn bit mt u no, p xe no v nhi mu bao gi cng phi kt hp vi bnh cnh lm sng. Chp ct lp vi tnh cn gip pht hin nhng d tt bm sinh ca cc cu trc bn trong s. b. Chp ct lp vi tnh ton thn C 2 loi ch nh khm ct lp vi tnh chnh: - Khm pht hin, chn on v chn on phn bit. l nhng trng hp m cc phng php thm d khc nh X quang qui c, xt nghim sinh ho huyt hc, siu m.... khng a li c chn on dng tnh. Ni chung cc thm d khc thng i trc chp ct lp vi tnh. - Chp nh gi s lan rng ca bnh nhm xc lp phng php iu tr thch hp nht, an ton v tit kim cho bnh nhn. i vi cc nhn phi kch thc t 3 - 10mm, X quang v ct lp qui c ch c th pht hin t 20 - 40%, chp ct lp vi tnh cho php pht hin c 80% cc nhn phi. i vi phu thut bng v ngc, chp ct lp vi tnh cn gip cho phu thut vin gim c ng k nhng bt ng trong m v lp c chng trnh m thun li v n cho thy c mi lin quan ca bnh vi cc tng ln cn, phn bc TNM tn thng. c. Bng ghi tm tt cc ch nh chp ct lp vi tnh ton thn: Tn c quan v loi bnh H mt: U Vim gi U, vim Chn thng U Vim U p xe thnh hng U nguyn pht Khm xt i trc X quang

Mt v nn s: C: Trung tht:

X quang X quang X quang 16

U th pht Vim trung tht Bnh l ng mch ch ngc Hch trung tht v rn phi Phi: U nguyn pht X quang Di cn Lao phi Gin ph qun Gin ph nang Tim: Bt thng c tim v mng ngoi tim X quang Gan: Chn thng Siu m U nguyn pht v th pht p xe Thoi ho m ng mt: ti mt: Chn on v tr v nguyn tc mt, u ng Siu m mt Tu tng: U Siu m Vim cp, vim mn p xe tu Gi kn tu Thn v khoang quanhU, kn Siu m thn: Teo, km pht trin Thn nc Si thn - niu qun Chn thng Vim, apxe, lao Tuyn thng thn: U tuyn Siu m Qu sn tuyn T cung - bung trng: Cc khi u Siu m Bng quang, tuyn tinKhi u Siu m lit: Ph i lnh tnh Khoang phc mc: U cc tng trong khoang phc mc Siu m Apxe Ct sng: Chn thng X quang Thot v a dm Lao, u ct sng C xng khp: U nguyn pht v th pht X quang Chn thng II. Thuc cn quang dng trong chp ct lp vi tnh 1. Cc loi thuc cn quang iode tan trong nc Cc cht i quang iode tan trong nc, cu trc, nht v tn gi

Cu trc phm

Tn hot cht nht 37oC

p lc thm thu*

Tnthng

( 300mg iode/ml)

17

Ionic monome

Iothalamate

1500-1600

Conray Vasoray

Metrizoate Amidotrizoate

Isopaque Urografin Angiografin Gastrografin

Ioxithalamate

Telebrix

Ionic dime

Ioxaglate

600

Hexabrix

Non-ionic monome

Iohexol Iopamidol Iopromide Ioversol Iobitridol

500-700

Omnipaque Iopamiro Ultravist Optiray Xenetix

Non-ionic dime

Iodixanol Iotrolan

10

300

Visipaque Isovist

nht tnh theo n v cP

thm thu tnh theo mOsm/kg H2O

c tnh ca cht i quang iode c th l tng hp ca 3 yu t : c tnh ho hc ca cc phn t cht i quang, c tnh do p lc thm thu cao ca dung dch v c tnh do gy mt cn bng ion . Do , nn chn cc dung dch i quang iode tim c thm thu thp, gn vi thm thu ca c th v cht i quang dng khng ion khi s dng cho bnh nhn c nguy c cao b tc dng khng mong mun. 18

Tc dng khng mong mun (ADR) : Cc cht i quang iode dng ion v khng ion u c th gy ADR khi tim vo mch mu . Tn xut chung ADR ca cc cht i quang iode dng ion dng qua ng tim vo mch mu khong trn 3% . Theo mt bo co ca u ban an ton v s dng cht i quang Nht bn vi s lng bnh nhn trn 160.000 cho mi nhm (c ion v khng ion) th tn xut ADR gim c 3/4 nu dng cht i quang khng ion . C th xp ADR theo 5 nhm : 1. Phn ng tng nhy cm cho n chong dng phn v 2. Phn ng tim mch 3. Suy chc nng thn 4. Ri lon ng mu v tn thng ni mc mch mu 5. Phn ng ca h thn kinh trung ng v i khi km theo m mt hoc c hai mt V mc phn ng, c th phn loi nh (thng gp), va (t gp) v nng (him gp) Nh : cm gic nng theo ng tnh mch t v tr tim lan ln c v mt, nga, ni m ay, bun nn, nn, ri lon v gic, ht hi, lo u . Ho v kh th . au dc theo tnh mch tim . Va : cc du hiu k trn mc cao hn, c bit l ni m ay, nn, kh th v lo s . Co tht ph qun lm tng thm kh th, h huyt p . Mc phn ng ny gp khong 0,5-1% cc trng hp tim cht i quang iode . Nng : Cc du hiu m t trn mc rt cao, c bit l kh th, co tht ph qun, tt huyt p, co git ton th . Ri lon thc, ph thanh mn . Tru tim mch c th xy ra cng vi ph phi; lon nhp tim dn n ngng tim . T l gp phn ng nng khong 0,2% cc trng hp tim thuc i quang iode . T vong : Mt s rt t bnh nhn c th b t vong d cp cu tch cc v kp thi . Nguyn nhn t vong hay gp l suy h hp v tun hon nng, ph phi cp v tc ng th do co tht ph qun nng . Mt vi trng hp t vong kiu chong tim cn gp rt sm sau tim cht i quang m khng c triu chng bo trc . Cha c t l t vong chnh xc nhng hi cu a trung tm vi s lng bnh nhn ln cho thy hai nhm kt qu : nhm 1 t 1:15.000 -1:17.000 v nhm 2 t 1: 40.000 n 1: 80.000 . Cc thuc cn quang thng dng trong chp ct lp vi tnh l :

19

+ Cc thuc cn quang n phn t c ion: -Radioslectan 60%: 300mgI/ml - Radioslectan 76%: 380mgI/ml -Tlbrix 35 v 38: 350 v 380mgI/ml Cc thuc cn quang trn c p lc thm thu cao hn p lc thm thu ca huyt tng ti 5-6 ln +Thuc cn quang c ion cha hai phn t gn 6 nguyn t iod Hexabrix 320: 320mgI/ml + Thuc cn khng ion: c cc gc di hn v c i nc cao hn. - Ultravist 300 : 300mgI/1ml - Iopamiron 370: 370mgI/ml - Iopamiron 300: 300mgI/ml - Pamiray (c cng gc ho hc vi Iopamiron) - Xenetix 300 : 300mgI/ml - Omni paque 300: 300mgI/ml - Optiray 300: 300mgI/ml Cc thuc ny c p lc thm thu ch cao hn p lc thm thu ca huyt tng rt t, chng c s dng rng ri trong x quang tit niu, x quang mch mu v chp ct lp vi tnh , mt s c th bm vo khoang di nhn tu sng v cc khoang khc ca c th theo hm lng thch hp . 2. phng cc tai bin lin quan n thuc cn quang: - Cc yu t nguy c: bnh tim, mc bnh mch mu, suy thn, i ng, mt nc, tim thuc cn quang cc ln qu gn nhau, c a d ng, ngi c chng lun lo lng... - Dng cc thuc d phng: nht thit phi dng thuc d phng cho mt s trng hp nht nh ( c a d ng, c phn ng vi thuc cn quang...), cc trng hp c nguy c phn ng thuc . - Cc cch dng thuc d phng: .Atarax100mg: 1 vin /ngy trong 3 ngy trc khi lm th thut . Tim 2 ng solumdrol 40mg trc khi tim thuc cn quang . .Dng thuc cn quang c p lc thm thu thp 20

.Tn trng liu dng thuc cn quang .Khi c nguy c v thn, cn m bo c th khng thiu nc .Trong mi trng hp cn theo di st bnh nhn v lun gi ng tnh mch. 3. Chun b bnh nhn khi dng thuc cn quang tnh mch Hi k tin s d ng vi thuc, thi tit, thc n, hen ph qun Khm xt loi tr suy thn, suy tim mt b Tr cp cu, bnh nhn phi nhn i trc 6gi Khng cn lm test v khng c gi tr d phng t ng truyn tnh mch v lu kim t nht 15pht sau tim

4. Cc biu hin lm sng ca ADR v cch x tr: 4.1- Biu hin nh: -Biu hin nh thng lun km vi cc bnh nhn qu lo u, nn lun phi gii thch r bnh nhn yn tm v hp tc khi lm th thut. -C th c cc biu hin ng h hp( ho, tc th), biu hin ng tiu ho( nn v bun nn), biu hin thn kinh( hong s, au u). Cc biu hin ny c th n c hay phi hp +X tr: cho bnh nhn ht th mnh vi ln trnh cng thng cng c th lm mt cc triu chng, c th phi chun b 1g hydrocortison pha dch truyn truyn cho bnh nhn khi khng . 4.2 - Cc biu hin nng, sc phn v (theo thng t hng dn ca B y t s 08/1999-TT-BYT ngy 04/5/99) Triu chng :

- Cm gic khc thng nh bn chn, lo u, hong s - Mn nga, ban , my ay, ph Quincke - Mch nhanh nh, tt huyt p c khi khng o c - Kh th, nght th (kiu hen, ph thanh qun) - au qun bng, a i khng t ch - au u, chng mt , i khi mt thc - Chong vng, vt v, giy gia, co git

21

X tr

A- X tr ngay ti ch - Ngng ngay thuc cn quang ang tim - t bnh nhn nm ti ch, u thp, chn cao v m cho bnh nhn, nm nghing nu c nn . - Thuc : Adrenalin l thuc c bn chng sc phn v : Adrenaline dung dch 1/1.000 (ng 1ml =1mg) tim di da ngay sau khi xut hin triu chng vi liu nh sau : + 1/2 - 1ng cho ngi ln + Tr em : ho long 1 ng 1ml vi 9ml nc ct ri tim 0,1ml/kg cn nng ca tr . + Tip tc Adrenaline liu nh trn 10-15pht mt ln cho ti khi huyt p tr li bnh thng . + Nu sc qu nng e do t vong, c th pha long 1 ng 1ml vi 9ml nc ct v tim tnh mch . B- Tu theo iu kin trang thit b y t v trnh chuyn mn ca tng tuyn c th p dng cc bin php sau : - X tr suy h hp Tu mc kh th c th s dng cc bin php sau : + Th Oxy ng mi - thi ngt + Bp bng Ambu c oxy + t ng ni kh qun, thng kh nhn to . M kh qun nu ph thanh mn + Truyn tnh mch chm Aminophylline 1mg/kg/gi hoc terbutaline 0,2microgam/kg/pht . + C th dng Terbutaline 0,5mg 1ng di da ngi ln v 0,2mg/10kg c th tr em . Tim nhc li nu sau 6-8gi khng kh th . + Xt hng terbutaline/sabutamol . - Duy tr huyt p : Truyn tnh mch adrenaline duy tr huyt p : 0,1microgam/kg/pht, iu chnh tc truyn theo huyt p, ti a 2mg adrenaline/gi cho ngi ln 55kg . - Cc thuc khc 22

+ Methylprednisolon 1-2mg/kg/4gi hoc hydrocortisone hemisuccinate 5mg/kg/gi tim tnh mch ( c th tim bp tuyn c s) . Dng liu cao gp 2-5 ln nu sc nng + Natriclorua 0.9% 1-2lt ngi ln, khng qu 20ml/kg tr em . + Diphenhydramin 1-2mg tim bp hay tnh mch Ch - Theo di bnh nhn t nht 24 gi sau khi huyt p n nh - Nu khng ly c tnh mch khuu tay, cng tay nn tn dng ng tnh mch i . - C th truyn thm huyt tng, albumin hoc dung dch cao phn t nu cc bin php trn khng nng c huyt p . - iu dng/k thut vin c th s dng adrenaline 1ng1mg di da nu bc s cha kp c mt - Chun b sn sng hp thuc cp cu sc phn v trc khi tim cn quang iod 4.3 - Cc biu hin khc: .Co git; x tr : thng ht sau khi tim 1 ng gardenal /tnh mch , hay valium 10mg/tnh mch .Cn ttani: iu tr bng tim tnh mch calciclorua

Ni dung hp thuc cp cu chng sc phn v ( km theo thng t s 09/1999-TT-BYT ngy 04 thng 5 nm 2003) A- Cc khon cn thit phi c trong hp thuc cp cu : 7 khon 1. Adrenaline 1mg - 1ml 2. Nc ct 10ml 3. Bm v kim tim v khun 10ml 1ml 2 ng 2 ng 2ci 2ci

4. Hydrocortison hemisuccinate 100mg hoc methylprednisolone ( Solumedrol 40mg hoc Depersolone 30mg) 2 ng 5. Phng tin kh trng: Bng , bng, cn , gc 6. Dy gar

23

7. Phc chng sc phn v B- Tu theo iu kin trang thit b v trnh chuyn mn, cc c s c s dng thuc cn quang iod nn c cc thit b v thuc nh sau : 1. Bm xt sabutamol hoc terbutaline 2. Bng ambu v mt n 3. Dng c t ni kh qun - C th dng loi cn quang Iode tan trong nc c ion hoc khng ion. Loi khng ion (omnipaque, iopamiron, ultravist) c u th rt him gy phn ng ph nhng gi thnh cao. Loi c ion (Tlbrix, Urografin, Diatriazoate) gi thp hn nhng gy phn ng ph nhiu hn nn c khi lm gin on khm xt . T l ngi bnh phi tim thuc cn quang trong chp ct lp rt cao, v vy nn chn thuc cn quang mt cch c cn nhc; c th dng loi cha ion cho ngi ln, th trng tt v khng nghi ng tin s d ng; loi khng ion ginh cho nhng ngi bnh c nguy c cao phn ng vi thuc cn quang nh ngi gi, tr em, ngi c bnh gan, tim, thn, bnh phi gy gim chc nng h hp. - Lng thuc cn quang thng dng l 1 1,5ml/kg c th, loi c hm lng Iode 320 350mg/ml, khong 50 120ml cho ngi ln. - C ba cch a thuc cn quang vo tnh mch. + Truyn tnh mch nhanh dung dch thuc cn quang pha long vi mt lng tng ng nc ct hoc glucoza ng trng; kiu ny c a chung vi cc my chp ct lp quy c thng dng v thi gian khm xt tng i ko di nhng m cht cn quan trong mu b hn ch, hin khng dng v cho cht lng chn on thp. + Bm tnh mch hai th: kiu bolus (2-3ml/s) na liu thuc, phn cn li bm chm (1ml/s) v bt u chp ct lp vo thi im thuc cn quang c mt phn c th cn khm xt (d on theo thi gian tun hon). Kiu ny thch hp vi cc my qut nhanh, qut xon c v cho m cn quang trong mu cao hn cch (1). + Bm ton b lng thuc cn thit kiu bolus v bt u ct lp tnh theo thi gian tun hon. Kiu tim ny hay dng cho cc khm xt c kt hp nghin cu ng hc thuc cn quang (dynamic scanning) ca bnh. Bng thi gian tun hon (tham kho) tnh t thi im bt u bm thuc tnh mch nn cnh tay cho ti mt s tng cn khm xt theo N. Schad vi tn s tim 75 ln/pht. 24

Cnh tay Cnh tay Cnh tay Cnh tay Cnh tay Cnh tay

Tht phi Tht tri

4 sec 11 sec 12 sec 13 sec

ng mch ch ngc ng mch ch bng ng mch chu No 15 sec 13 sec

- Thuc cn quang ung. - C th dng cht cn quang Iode ho long hoc Bari Suynfat ho long nhng Iode c a chung hn nhiu v khng xy ra lng ng to ra hin tng cn quang khng ng nht. - Nhng ngi bnh nghi ng c thng ng tiu ho hoc chun b phu thut tiu ho khng c cho ung bari suynfat. - Thuc cn quang iode thng gy tng nhu ng rut, i khi c th gy a chy nhng s t khi sau khi tho ht thuc. - t c dung dch c m 150 200 n v Hounsfield (HU) c th pha long 3ml thuc cn quang ionic c hm lng Iode 370mg/ml vi 100ml dung dch Manitol 4% hoc Sorbitol 4%. L do s dng Manitol hoc Sorbitol l to cho dung dch ung khng cn v ng ca thuc cn quang v lm cho p sut thm thu ca dung dch gn vi p sut thm thu ca huyt tng, do trnh c hin tng c c thuc cn quang trong ng tiu ho khi pha bng nc n thun. - Ngoi ra, nc tinh khit cng c th dng nh mt cht i quang m tnh trong ng tiu ho. - C ba kiu s dng thuc cn quang ng tiu ho l. + To i quang vng bng trn: Cho ngi bnh ung 400ml dung dch cn quang ngay trc khm xt tu tng, thng thn v.v khm d dy cn cho ung 500 600ml d dy gin t mc c th nh gi ng dy ca thnh d dy. + To i quang ton b ng tiu ho: Lng thuc cn thit t 1200 1500ml, bt u cho ung 60 pht trc khm xt chia lm nhiu ln ung cch nhau 10 pht; ung ln cui cng ngay trc lc ngi bnh ln bn khm xt.

25

+ To i quang trc trng Sigma trong khm xt tiu khung: Bm qua ng thng hu mn 250ml dung dch cn quang ni trn ngay trc thi im chp ct lp. C tc gi cn bm thm 50ml khng kh sau khi bm thuc cn quang to hnh i quang kp trc trng. - t tm-png m o: Dng vi mnh gc v trng t vo m o trc khi khm xt vng tiu khung ca ngi bnh n cho php d nhn bit mi tng quan c th hc bng quang - m o - trc trng trn cc lp ct. - Chp ct lp vi tnh cho tng phn c th phi lm theo nhng k thut ring bit nn phn ny s c trnh by di y theo vng gii phu .

III . Hng dn qui trnh k thut chp ct lp vi tnh 1. Chp s no 1. Chun b ngi bnh. - Nhn n trc 4 gi nu d kin c th phi tim thuc cn quang. - Ngi bnh cn yn tm khi khm xt. 2. T th ngi bnh : nm nga, u t trn gi s; mt hi ci to t th thoi mi v gim s lp ct qua thu tinh th. 3. Cc thng s qut : - To nh nh khu hng nghing . - Cc lp ct t song song vi ng l tai ui mt v lin tip ln ti nh s. C gng trnh tia X chiu trc tip ln thu tinh th. C th gim c nhiu nh do khi xng nn s gy ra bng cch ct nhng lp mng hn hoc t lng mA cao hn cho vng h sau. - dy lp ct: 3 - 5mm i vi h sau v 7-10mm cho phn cn li ca hp s. Khi khm tr em di 6 thng cn dng chng trnh s tr em gim liu x cho tr. - Khong cch gia cc lp ct: bng dy lp ct theo vng khm xt - Trng nhn (FOV) 24cm. 4. Thuc cn quang: Tim nhanh tnh mch bng tay hoc bng my (2-3ml/giy) 30 50ml thuc cn quang iode tan trong nc v ct lp li ngay sau khi tim ht thuc. i vi

26

ngi c nguy c cao b phn ng vi thuc cn quang, nn dng loi thuc khng cha ion (non ionic). Ch nh tim thuc tu theo bnh cnh lm sng. 5. t ca s - Ca s no: - Vng h sau: - Ca s xng: WL (hoc WC) WL WL = +35 - 40 = +40 = +300 WW = 80 ( 100 HU WW = 120 ( 150 HU WW = 2000 ( 3000)

- Cn t ca s thng nht d so snh vi nhng ln chp sau. 6. Da theo bnh cnh lm sng - Chn thng s no: Chp khng tim thuc cn quang, cn chp nh vi ca s xng thy c hnh v xng. - T mu di mng cng mn tnh: Nu nghi ng mu t ng t trng, tim thuc cn quang c th lm hin r mu t khng ngm thuc v mng ngn ca t mu ngm thuc nhiu. - Chy mu no: khng tim cn quang. - Nhi mu no: Chp sm nhm phn bit vi chy mu no. Tn thng nhi mu no thng hin nh mun hn chy mu t mu. Thuc cn quang c ion (ionic) c th gy tn hi thm cho vng no b nhi mu trong tun l u, v vy nu cn tim thuc cn quang phn bit vi cc nguyn nhn khc, nn chn loi khng ion. - Vim no: chp trc tim v chp sau tim thuc. - Vim mng no: chp trc tim v chp sau tim thuc. p xe no: chp trc tim v chp sau tim thuc. - U no: chp trc tim v chp sau tim thuc. - U di cn: chp c tim thuc cn quang ngay, nu cn s chp khng tim thuc b sung thng tin. - U no vng h yn: ct lp ngang thng quy khng tim v c tim thuc; Nn b sung hng ct ng ngang (coronal) nh khu gii phu thun li hn. - X cng ri rc chp khng tim thuc, chp c tim thuc c th pht hin cc thng tn ang hot ng. - Sa st tr tu: chp khng tim thuc, nu nghi ng c tn thng nhu m no s chp c tim thuc.

27

- ng kinh thi dng: chp khng tim v chp sau tim thuc. Nn ct theo hng chch v pha chn 20 to nh thu thi dng t nhiu hn.

2. CHP NG TAI TRONG, NN S 1. Chun b ngi bnh: Nhn n trc 4 gi. 2. T th ngi bnh - Ct axial: Ngi bnh nm nga, u da trn gi s, cm hi ci nh t th khm no. - Ct coronal: Ngi bnh nm xp, cm da trn gi s hoc nm nga u dc nh chp Hirtz. 3. Cc thng s qut : - Nn ct c hai hng. - Hng axial: to nh nh khu theo hng nghing, t khung my nghing sao cho mt phng ct song song vi nn s (-20 ). - Vng ct lp: t b di xng chm cho ti nh xng . - Hng coronal: To nh nh khu theo hng nghing, hng ct vung gc vi xng (khung my thng nghing -20 ). - Vng ct lp: t b trc ng tai ngoi cho ti b sau xng . - dy lp ct: 1mm nu cn xem cc tiu ct. 3 5mm nu ch khm nn s. 4. Khong cch lp ct : bng dy lp ct - FOV: 24cm, nu cn thit c th Zoom tng bn. - Dng chng trnh phn gii cao (Ma trn 512 x 512) 5. t ca s - Xng - No WL = +300HU WL = +35 40HU WW = 2000 WW = 100 120

6. Thuc cn quang: Tim tnh mch 40 50ml kiu bolus v ct lp ngay sau khi tim gim liu x v s lp ct. 3. CHP H MT

28

1. Chun b ngi bnh: Nhn n trc 4 gi nu d nh tim thuc cn quang. 2. T th ngi bnh: Nm nga, hai tay t xui, u da trn gi s, cm hi ci nh trong khm s no. 3. Cc thng s qut : - To nh nh khu theo hng nghing. - Ct axial: cc lp ct phi song song vi giy thn kinh th gic, do mt phng ct i qua gc ngoi h mt v mm yn trc; khung my thng chch 10 15 v pha chn. Trong lc ct lp, ngi bnh cn nhn ln dui thng giy thn kinh th lin tc. - Dng chng trnh phn gii cao. - dy lp ct: 3-5mm. - Khong cch lp ct: bng dy lp ct, lin tc. - FOV: 16cm. - Ct coronal: thng p dng khi khm cc khi u h mt. Mt phng ct i qua b trc xng trn v xng hm trn, lin tip v pha sau cho ti xoang tnh mch hang (b sau h yn). i vi trng hp nghi bnh tuyn gip h mt, ch cn ct coronal khng tim cn quang l . Chng trnh khm h mt gy liu x trc tip trn thu tinh th nn cn ghi nh ch t s lp ct ti thiu cn thit. 4. Thuc cn quang: Tim tnh mch 40 50ml v ct lp ngay sau khi tim ht thuc, nh vy c th nhn bit cc u trong h mt m khng cn ct lp hai ln. 5. t ca s: WL = +40HU WW = 400

4. CHP S MT 1. Chun b ngi bnh: Nhn n trc 4 gi nu d kin tim thuc cn quang. 2. T th ngi bnh - C hai hng ct c th p dng: ct ngang v ct coronal.

29

- Ct ngang: ngi bnh nm nga, cm hi cao, u t trn gi s. To nh nh khu hng nghing, khung my thng ng. Cc lp ct bt u t b trn xoang trn cho n ht cung rng hm di. - dy lp ct: 5mm. - Khong cch gia 2 lp ct: 5mm, lin tip nhau. - Trng nhn (FOV): 16 n 18cm. 3. Thuc cn quang: t dng. 4. t ca s - Phn mm: Phn mm Xng WL = +40 WL = + 300 WW = 400 HU WW = 1600 HU

- Ct coronal: nn p dng nu tnh trng ngi bnh cho php v nh khu gii phu hc thun li hn. - Ngi bnh nm sp, cm da trn gi s. - To nh nh khu theo hng nghing. - t khung my nghing sao cho cc lp ct vung gc vi h trc ca hp s. - dy lp ct 5mm, khong cch lp ct 5mm, lin tip nhau. - Vng ct lp: T trn n b sau xng hm di. - Ca s khm nh trn. - Da theo bnh cnh lm sng. - Chn thng : ct c hng axial v coronal, khng tim cn quang. - Khi u: ct axial v coronal; cn chp nh c tim thuc cn quang nhn nh tnh cht khi u v lm r cc hch bch huyt to nu c. - i vi cc u vm hng cn khm xt c nn s. - Bnh l xoang mt : nu l bnh lnh tnh ch cn ct coronal l . Nu nghi ng u c tnh nn ct c axial v coronal. - Nn t ca s rng (WW = 3200) thy c ng thi c xng v nim mc.

5. CHP VM HNG

30

1. Chun b ngi bnh: Nhn n 4 gi trc khm xt. 2. T th ngi bnh: Ngi bnh nm nga, u t trn gi s. Hng dn ngi bnh th nh v khng nut trong khi khm trnh nhiu nh. 3. Cc thng s qut - Ct axial: to nh nh khu theo hng nghing, khung my thng ng; vng ct lp chon t nn s n xng mng. Nu ngi bnh c nhiu rng gi kim loi, t khung my chch loi tr nhiu kim loi. - dy lp ct: 5mm. - Khong cch gia hai lp ct: 5mm, lin tip nhau. - FOV: 16 hoc 18cm. 4. t ca s - Phn mm - Xng nn s WL = +40 WL = +300 WW = 400 WW = 2000

- Thuc cn quang : 40 - 80ml tim tnh mch nhanh 3ml/giy T th coronal: c th b sung mt s thng tin qu. Vng ct lp hng ny trong khm xt cc u vm hng thng khu tr t b trc h yn ti b trc ng tai ngoi. - dy lp ct 5mm, khong cch lp ct 5mm, ca s t nh t th axial.

6. CHP THANH QUN 1. Chun b ngi bnh: Nhn n 4 trc gi nu d nh tim thuc cn quang. 2. T th ngi bnh: Nm nga, hai tay t xui, u t trn mt bn trnh nhiu kim loi ca gi s chiu ln vng c cn khm xt. Hng dn ngi bnh th nh v khng nut trong khi chp. Nu mun nh gi s hot ng ca giy thanh, cn bo ngi bnh pht m khi cc lp ct i qua thanh i. 3. Cc thng s qut : - To nh nh khu theo hng nghing, khung my thng ng; ct lp lin tc t gc hm ti h trn c. - dy lp ct 5mm.

31

- Khong cch gia hai lp ct: 5mm, lin tip. - FOV: 16 hoc 18 tu theo ln ca c. 4. Thuc cn quang tnh mch - Khm chn thng thanh qun khng cn thuc cn quang. - i vi ung th thanh qun, tim thuc cn quang d phn bit mch mu vi cc hch to nu c. Dng 40 80ml thuc cn quang Iode tim nhanh tnh mch 3ml/giy hoc 1/2 liu kiu bolus (3ml/sec); phn cn li tim chm (1ml/giy) trong khi ct lp. Ngoi cc chng ch nh chung ca thuc cn quang, i vi bnh l thanh qun cn c chng ch nh ring l kh th nng. Ngoi nh trc tip ca cc lp ct, cn to thm nh coronal v nh 3D. - Ct lp xon c c u th v c th dng c nh nhiu mt phng . 5. t ca s: WL = +35-40 WW = 360 400

7. CHP C 1. Chun b ngi bnh: Nhn n trc 4 gi nu d kin tim thuc cn quang. 2. T th ngi bnh: Ngi bnh nm nga, cm t cao, hai tay xui theo ngi. Trong lc ct lp yu cu ngi bnh th nh v khng nut trnh nhiu. 3. Cc thng s qut : - To nh nh khu theo hng nghing. Vng ct lp t gc hm cho ti h thng c, khung my thng ng. - dy lp ct: 5mm. - Khong cch gia hai lp ct: 5mm hoc 7mm tu theo bnh cnh lm sng. - FOV: 16 hoc 18 tu theo ln ca c ngi bnh. Nn t lng mA tng hn mc khm xt thanh qun gim nhiu nh vng c vai, nht l i vi ngi c ngn. 4. Thuc cn quang. - Nn tim thuc cn quang d nhn bit hnh mch mu v hnh hch to nu c. Liu lng thuc t 40 80ml, bm nhanh tnh mch 3ml/giy hoc tim nhanh 1/2 liu, phn cn li bm chm hn (1ml/giy) trong lc ct lp gi nng cht cn quang n nh trong thi gian khm xt. 32

- i vi U cun cnh, ch cn khu tr vo vng quan tm. 5. t ca s: WL = 35 40 HU

8. CHP BNG 1. Chun b ngi bnh - Nhn n trc 4 gi sch thc n ng tiu ho on trn v chun b iu kin nu cn tim thuc cn quang. - Cho ngi bnh ung thuc cn quang nhm d phn bit d dy v tiu trng vi cc cu trc khc trong bng. Nn pha thuc cn quang bng dung dch manitol 3% hoc nc ngui vi thuc cn quang Iode (loi tim tnh mch) sao cho c c mt dung dch cn quang 1,5% (t 150 n 200 HU). Cng c th dng dung dch cn quang t pha bng barisuynfat c nng 1 1,5%. Cn chn hn hp barisuynfat c treo rt tt cc ht barit khng b lng trong qu trnh khm xt. Tng lng thuc cn quang ung 600 800ml s chia lm 3-4 ln ung, cch nhau t 10 15 pht; bt u khm xt ngay sau ln ung cui cng c cht cn quang trong d dy v t trng. 2. T th ngi bnh: Nm nga, hai tay gi ln u. Ct lp vo thi im ngng th sau th th ra hoc th vo mt cch thng nht v tr cc tng t b thay i v tr. Nu my c chng trnh ct nhm (cluster scanning) cng cn lm cc nhm qut nh trn. Nu my c th qut xon c, nn lp chng trnh qut tu theo kh nng nhn th ca ngi bnh. 3. Cc thng s qut : - To nh nh khu theo hng nghing, khung my thng ng; vng ct lp t st trn vm honh ti st mo chu (c th m rng hay thu hp tu theo bnh cnh lm sng). - dy lp ct: 8 10mm. - Khong cch gia hai lp ct. - 8-10mm nu c nh hng r trn lm sng. - 15mm nu ch l khm thm d. - FOV: 32 40cm tu theo ngi bnh. - di vng ct lp nu ch khm xt phn bng trn: 30 40cm. - Nu lp chng trnh x tr thng phi khm c bng: 40-50cm.

33

4. Thuc cn quang: Cch tim thuc cn quang tnh mch v thi im bt u ct lp tu thuc rt nhiu vo bnh cnh lm sng v cu hi chn on. Trng hp cn c nh cc mch mu trong khoang bng ngm thuc (th d phng ng mch ch bng), tim nhanh kiu bolus 50ml thuc cn quang, sau bm chm hn (1ml/giy) 50ml tip theo. Nn bt u ct lp vo thi im 15 n 20 giy tnh t lc bt u bm thuc. Nu chp vi my qut xon c, tim 80-100ml vi lu lng 3ml/giy v khi ng qut ty theo yu cu chn on . Khi c yu cu qut ng (dynamic scanning), chng trnh tim thuc phi cn c vo chn on v ch nh ca bc s chuyn khoa. 5. t ca s - Thng thng c th t: WL =+30 40HU WW = 300 400

- Ti vng y phi c th to thm nh ca s phi. - i vi gan c th thu hp WW ti 200 d pht hin thay i m . 6. Da theo bnh cnh lm sng a. Ung th d dy: C th dng nc thay thuc cn quang nh mt cht i quang m tnh. Lng thuc cn quang hoc nc cn 600 800ml ung ngay mt ln trc khi khm xt d dy gin t mc c th nh gi ng dy ca thnh d dy trn nh. Nn dng thuc gim trng lc d dy cho ngi bnh (20mg Buscopan tnh mch) i vi cc my c thi gian qut mt giy mt lp ct. b. Lymphoma - Thuc cn quang ung: nh khm bng. - Thuc cn quang tim: 80-100ml tim tnh mch 3ml/giy - Vng khm xt: T vm honh ti khp v. - dy lp ct: 10mm. 10mm.

- Khong cch lp ct

- Nu qut xon c c th t Pitch 1,5 c. Teratoma tinh hon: Ging nh cc thng s khm Lymphoma bng.

9. CHP GAN 1. Chun b ngi bnh - Nhn n trc 4 gi.

34

- Khng cho ung thuc cn quang trc khm xt gim nhiu nh v d pht hin si gan, mt, tu nu c. Nn cho ung nc to i quang m tnh d dy-rut . 2. T th ngi bnh - Nm nga, hai tay gi cao hai bn u. - Nn lm cc lp ct thng nht sau th th vo. Nu c iu kin nn qut xon c trnh b st tn thng do gan chuyn ng theo nhp th. 3. Thng s qut : - To nh nh khu theo hng thng, lp chng trnh ct lp t nh vm honh ti ht mm gan hoc ti t sng L5 tu theo bnh l v yu cu chn on. - dy lp ct: 7- 10mm. - Bc chuyn bn: 7- 10mm. - FOV: 32 hoc 40. 4. Thuc cn quang tnh mch - Nn bt u bng chp khng tim thuc, nhm d nhn bit tnh trng gan nhim m hoc ng hemosiderin. - i vi cc khi u gan cn chp li c tim thuc v di y l mt s chng trnh gi . 5. Bnh cnh lm sng - Tn thng chon ch trong gan bao gm u gan nguyn pht, u di cn v cc nguyn nhn khc: 80 100ml thuc cn quang tim tnh mch nhanh mt th (3ml/s). Nn bt u ct lp 25 giy sau thi im bt u tim c c hnh ng mch ngm thuc, c hnh tnh mch ca ngm thuc, ct lp 60 giy sau tim . Nu ct lp xon c s cho php rt ngn thi gian qut v gim c lng thuc cn quang tim tnh mch . - Nghi ng u mch mu gan cn ct lp ng (dynamic scanning): tim kiu Bolus 80 100ml thuc cn quang v ct lp vng nghi u mu lc 1 pht, 2 pht, 5 pht, 10 pht sau khi bt u tim thuc v c th ko di hn nu thy cn thit. Khong 50% cc u mch mu c hnh gim m khi khng tim thuc, sau ngm thuc m t ngoi vo trung tm v tr nn ng t trng cc nhm qut mun. - CT angiography (portography): L k thut tt pht hin cc tn thng nh di 1cm trong gan: t ng thng chc lc vo ng mch mc treo trn sau chuyn ngi bnh ti phng chp ct lp. Bm thuc cn quang pha long 35

t hm lng 200mg/ml, tng liu 100 200ml qua ng thng vo ng mch mc treo vi lu lng 2ml/s trong 10 giy, sau chuyn lu lng xung 1ml/s v bt u ct lp lin tc 10mm t nh vm honh phi ti ht b di gan. Khng nn t ng thng vo ng mch thn tng hoc ng mch gan v khm xt c th khng t kt qu do bt thng gii phu ca ng mch gan tng i hay gp. 6. t ca s nh: WL = +40 WW = 400

Thu hp WW xung 200HU c th lm tn thng hin r hn. Nn chp nh gan theo hai ca s khc nhau ni trn so snh. 7. Qut xon c ba th sau tim cn quang: ng mch, tnh mch ca v th cn bng : - Vng khm: ton b gan, nh nh khu hng trc sau. - Thuc cn quang ung: 800ml chia nhiu ln ung trong 45 pht. - Thuc cn quang tim: 100 120ml loi cn quang khng c ion. - Hm lng 300 320mg/ml. - Lu lng tim tnh mch: 3-4ml/s. - Chp th ng mch: 25 - 30 giy sau thi im bt u tim. - Chp th tnh mch ca: 60 70 giy sau thi im bt u tim. - Chp th cn bng : 180 giy sau thi im bt u tim thuc. - Thng s qut: 120kV, 175 300mA, ma trn 512, sau th vo. - Vng qut: ton b gan, dy lp ct 5mm, pitch 1:1 n 1,5:1. - Ti to nh: 4mm, ca s m mm. - Ghi ch: + K thut qut xon c ba th cho php pht hin c hai loi di cn ngho mch v giu mch t u t bo thn, u sc t, ung th v v t cc u ni tit, u gan. + Ung th gan nguyn pht a s giu mch nn hin nh r trong th ng mch v c th tr nn ng m trong th tnh mch ca. + Cc u mu c th thy c vi kch thc trn 1cm vi kiu ngm thuc t ngoi vo trong. + Tuy ti to nh 4mm nhng khi chp nn chn lc mc 8mm/1 nh thun li cho c phim. 10. CHP TI MT

36

1. Chun b ngi bnh: Nhn n trc 12 gi, khng ung thuc cn quang trc khi chp. 2. T th ngi bnh - Nm nga, hai tay gi ln t hai bn u. - Cc lp ct lm thng nht sau th th ra hoc sau th th vo. Nu c iu kin nn qut xon c sau th th ra. 3. Thng s qut : - Vng ct thng thng t b trn t sng L1 cho ti mm gan l . Nu thy cha ht ti mt s qut b sung. - dy lp ct 3- 5mm. - Bc chuyn bn 3- 5mm. - FOV: 24cm. 4. Thuc cn quang tnh mch: Cn thit khi lm sng nghi vim ti mt. 5. t ca s: WL = +40HU WW = 400

- Nn cho ngi bnh ung 400ml nc to i quang m tnh ca d dy. - Tim tnh mch 50 100ml thuc cn quang theo hai bc nh khm tu, lch v bt u ct lp 25 giy sau thi im bt u tim cn quang. - Nn qut xon c vi dy lp ct 3mm v Pitch 1:1

11. CHP TY TNG 1. Chun b ngi bnh - Nhn n trc 6 gi. - Nn bt u bng khm xt cho ung nc v khng tim thuc cn quang d pht hin si mt, vi ho tu, vim tu, xut huyt 2. T th ngi bnh. - Ngi bnh nm nga, hai tay gi ln t hai bn u. Cc lp ct lm thng nht sau th th ra hoc th vo, nn qut xon c nu c iu kin. - Trng hp khng lm r c gii hn gia u tu v t trng, c th cho ngi bnh ung thuc cn quang v ct lp t th nm nghing bn phi t trng cha thuc cn quang, d nhn dng u tu trn nh. 3. Cc thng s qut : 37

- V tr thng gp ca tu t L1 n L2 nhng do mi lin quan bnh l ca tu nn thng phi khm xt t vm honh n ch phn i ng mch ch bng. - dy lp ct: 10mm lin tip. - Bc chuyn bn: 10mm. - Ct lp thng nht vo sau th th ra hoc th vo. Nn qut xon c nu c iu kin. - Trng hp cn nh chi tit hn c th t dy lp ct 5mm v bc chuyn bn 5mm. - FOV: 32 hoc 40cm tu theo ln ca ngi bnh. 4. Thuc cn quang tnh mch: 80 100ml. Tim nhanh 3ml/s, bt u ct lp 20 25 giy sau thi im bt u tim thuc. Nn b sung thm th tnh mch ca 60 giy v th cn bng 180 giy sau tim thuc trong chn on vim tu hoi t. 5. t ca s: WL = +40HU WW = 400

6. Bnh cnh lm sng a. Vim tu: ct lp t vm honh ti ch phn i ng mch ch bng, c th thp hn na nu thy cn thit. Cc dch ca vim tu c th lan xung tiu khung hoc lan ln ngc. nh gi kh nng hi phc ca tu vim bng ct lp c tim cn quang tnh mch nh ni trn. b. U tu: cn ct lp c tim cn quang v nn qut 5mm lin tip nhm xem cu trc trong u, tnh trng xm ln b mch mc treo trn. Vng ct lp cn chon ton b gan pht hin di cn trong gan v m rng ti ch phn i ng mch ch bng tm hch bnh l. 7. Qut xon c - Qut khng tim thuc cn quang: 120kV, 75 150mA, sau th vo. - Qut xon c vi dy lp ct 10mm v pitch 2:1 t vm honh n L4 chn vng qut giai on c tim thuc. - Qut c tim thuc: 100 120ml cn quang khng ion, hm lng 300 320g/ml, lu lng tim 3 4ml/s. - Khi ng qut: 25 giy sau thi im bt u tim thuc (th ng mch), 6070 giy sau thi im bt u tim thuc (th tnh mch ca) v th cn bng 180 giy sau tim thuc

38

- Thng s qut: 120kV, 175 300mA, ma trn 512 sau th vo. - Nn qut 5mm vi Pitch 1:1 ton b vng nghi ng trn nh chp trc tim thuc

12. CHP LCH 1. Chun b ngi bnh. - Nhn n trc 4 gi. - Nn bt u bng ct lp khng ung thuc cn quang pht hin si, vi ho trong bng hoc trong lch. 2. T th ngi bnh - Nm nga, hai tay gi ln t cnh u. - Vng ct lp: t vm honh tri ti b di ca lch. Cc lp ct lm thng nht sau th ra hoc th vo, nn qut xon c nu c iu kin. - lm r ranh gii lch v phnh v c th cho ngi bnh ung 500ml nc, to nh i quang m tnh ca d dy. 3. Thng s qut : - dy lp ct: 10mm.

- Bc chuyn bn: 10mm. - FOV: 32 n 40cm. 4. Thuc cn quang tnh mch: lm r cc t mu mn tnh di bao lch, nhi mu lch, p xe lch, u lch v cc hch cnh ng mch ch bng, nn tim thuc cn quang t 80 100ml vi lu lng 3ml/s. Bt u ct lp 25 giy v 60giy sau thi im bt u tim thuc lm r lch v tnh mch ca. 5. t ca s: WL = +40HU WW = 400

13 . CHP THC QUN 1. Chun b ngi bnh: Nhn n trc 4 gi khng c thc n trong d dy. 2. T th ngi bnh - Nm nga, hai tay gi ln t cnh u. - Vng ct lp t nh phi n b di gan. 39

3. Cc thng s qut : - dy lp ct: 10mm lin tip. - Bc chuyn bn: 10mm. - FOV: 32 n 40cm. 5. Bnh cnh lm sng a. Ung th thc qun: Cn cho ung trc 400ml thuc cn quang c thuc trong phnh v v t trng. to lng thc qun cn quang, da theo tnh trng lu thng thc qun cho ung thuc cn quang. - Nu nghn nhiu, ch cn cho ung vi ngm thuc khi bt u nm trn bn. - Nu khng nghn nn cho ngi bnh ngm ng ht ni vi mt cc thuc cn quang d iu khin ung thuc trong lc khm xt. - Cn ct lp xon c 5mm c tim thuc cn quang tnh mch nh gi lin quan ca u vi cc mch mu ln trong trung tht v d pht hin cc hch thm nhim u. b. Gin tnh mch thc qun: Cn kt hp tim thuc gim trng lc ng tiu ho. 14. CHP TIU TRNG 1. Chun b ngi bnh - Nhn n trc 6 gi. - Cho ung 1000 1200ml thuc cn quang chia 4-5 ln ung, cch nhau 10 pht. Lm khm xt ngay sau khi ung ln cui cng. - Nu my c thi gian qut di (> 1 giy) nn dng thuc gim trng lc trc (20mg Buscopan tim tnh mch). 2. T th ngi bnh - Nm nga, hai tay gi ln t cnh u. - Cc lp ct lm thng nht sau th th ra. - Nn qut xon c nu c iu kin. - Vng ct lp: t t sng L1 n khp v. 3. Cc thng s qut : - dy lp ct: 10mm lin tip

- Bc chuyn bn: 10mm. 40

- FOV:

32 hoc 40cm.

4. Thuc cn quang tnh mch: Trng hp nghi khi u tiu trng hoc u ngoi tiu trng xm ln ng tiu ho cn cho ung nc y tiu trng hoc t ng thng t trng bm nc v tim 100ml thuc cn quang tnh mch vi lu lng 3ml/s v qut xon c sau khi bt u tim thuc 30 giy.

15. CHP I TRNG 1. Chun b ngi bnh - Nhn n trc 12 gi. - Tht tho trc khi khm xt. - C hai kh nng a thuc cn quang vo i trng. - Cho ung 1400 1600ml thuc cn quang 1,5-2% trong khong 30 pht v khm xt bt u 30 pht sau khi ung ht thuc. Bng cch ny c th xem c tiu trng v i trng phi . Bm qua ng thng hu mn 800 1200ml thuc cn quang ngay trn bn my v lm khm xt ngay sau khi bm ht thuc. Cch ny thun li cho khm i trng, nht l vng trc trng Sigma. C th bm 800ml nc vo trc trng v chp sau tim cn quang tnh mch . 2. T th ngi bnh - Nm nga, hai tay gi ln t cnh u. - Vng ct lp t vm honh ti khp v. 3. Thng s qut : - dy lp ct: 10mm lin tip. - Bc chuyn bn: 10mm. - Nn qut xon c nu c iu kin. - FOV: 32 hoc 40cm. 4. t ca s: WL = +40HU WW = 400

16. CHP TIU KHUNG 1. Chun b ngi bnh Nhn n trc 6 gi.

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Thuc cn quang ung: 800- loooml chia 4 ln ung cch nhau 10 pht trc khi khm xt. - Bm thuc cn quang vo trc trng nu cn thit. - i vi bnh nhn n nn t tm bng thuc cn quang vo m o, nht l khi khm xt u t cung, phn ph. 2. T th ngi bnh - Nm nga, hai tay t ln ngc. - Nu cn khm xt c bng: Gi cao hai tay t cnh u - Vng ct lp: T khp v ln ht mo chu. Nu khm ton bng, ct lp tip ln trn ti vm honh. 3. Cc thng s qut : - dy lp ct: 10mm lin tip - Bc chuyn bn : 10mm i vi vng tiu khung - Nu cn khm tip ln cao, c th p dng bc chuyn bn 15mm. - Nn qut xon c nu c iu kin. - FOV: 32 hoc 40cm 4. Thuc cn quang tnh mch: Tim cht cn quang d phn bit cc mch mu chu vi cc hch to trong tiu khung. Tng liu 80-100ml, tim na liu kiu Bolus, sau tim 1ml/s duy tr nng thuc cn quang trong huyt tng. Bt u ct lp 25-30 giy sau thi im bt u tim thuc thuc cn quang kp ti cc mch mu chu hng. Nu qut xon c, tim 100ml thuc cn quang tnh mch 3ml/giy v khi ng qut 30 giy sau thi im bt u tim thuc . 5. Bnh cnh lm sng - K thut chp ct lp tiu khung ni trn c th p dng cho cc khi u trc trng, t cung, bung trng v bng quang. Nu nghi ng u bng quang cn nhn tiu hoc bm nc y bng quang trc khi chp . - Nu cn tm hch v di cn ti cc tng bng, phi ct lp ln n vm honh. - i vi cc u tin lit tuyn cn ct lp lin tip 5mm c nh chi tit hn v nn m ca s rng hn khm xt xng v, xng chu. 6. t ca s: WL = + 40 HU WW - 400. 42

17. CHP THN 1 . Chun b ngi bnh Nhn n trc 4 gi. - Cho ung thuc cn quang nh khm bng. 2. T th ngi bnh Nm nga, hai tay t cnh u. Ct lp thng nht vo sau th th ra hoc th vo ca ngi bnh. 3. Cc thng s qut : - To nh nh khu theo hng thng. - Nu ch khm thn, ct lp t t sng T12 n L3 - Nu khm ton b bng, vng ct lp m rng t vm honh ti ch phn i ng mch ch bng. - dy lp ct: 10mm. - Bc chuyn bn: 10mm lin tip - FOV: 32 - 40cm 4. Thuc cn quang tnh mch - Tng liu 50 - 80ml c th tim theo hai cch ty theo bnh cnh lm sng. - Tim nhanh 3ml/s v ct lp 20 giy sau thi im bt u tim thuc; bng cch ny d nhn bit cc u nh trong thn v ranh gii tu - v ca thn hin r. - Khi cn khm i b thn v niu qun, ct lp li sau vi pht tu theo tnh hnh bi tit cht cn quang ca thn. Nn b sung phim chp bng nh chp UIV. 5. Bnh cnh lm sng a. Si tit niu - Ct lp khng tim thuc trc trnh b st si khng cn quang. - Tim thuc kiu Bolus v bt u ct li 30 giy sau tim thuc nh gi c nng thn, hnh thi i b thn v niu qun. Nu cn lm r niu qun cha thuc cn quang, c th ct lp mun sau tim thuc t th ngi bnh nm xp. Qut xon c khng tim cn quang c th gip chn on hi chng tc cp ng bi xut.

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b. U thn - Ct lp khng tim thuc trc trnh b st phn cu trc m bn trong u. - Tim thuc nhanh 3ml/s, qut xon c 5mm, Pitch 1:1, 20 giy sau tim. Dng li nh 3mm v nh MPR tm huyt khi tnh mch thn v tnh mch ch di . - Ct lp rng xung ch phn i ng mch ch tm hch cnh ng mch ch. c. Chn thng thn: Ct lp khng tim v sau tim thuc kiu Bolus. Nn qut xon c nu thit b cho php, dng nh a mt phng MPR.

18. CHP BNG QUANG TIN LIT TUYN 1. Chun b ngi bnh Nhn n trc 6 gi. - Cho ung thuc cn quang Iode vi dung dch Sorbitol hoc Mannitol 7% to dung dch c p sut thm thu cao v rt ngn thi gian lu thng rut thuc cn quang c th ti c trc trng. Cho ung loooml dung dch ni trn chia 4 ln 250ml cch nhau 15 pht. Bt u ct lp 15 pht sau khi ung cc thuc cui cng. - Yu cu ngi bnh nhn tiu t nht 2 gi trc khm xt c c bng quang y nc tiu. - Cn bo trc cho ngi bnh bit sau khi ung thuc cn quang c th b a lng v s ht ngay sau khi tho ht thuc ra ngoi. 2. T th ngi bnh - Nm nga, hai tay gi cao t cnh u. - Ct lp thng nht sau khi th ra hoc th vo. - Nn ct xon c nu c iu kin. 3. Cc thng s qut : - To nh nh khu hng thng. Vng ct lp t khp v ln ti gia thn; m rng ln c honh nu nghi ng gan c lin quan. - Ct lp 5mm tin lit tuyn. Bng quang v phn cn li ca bng ct lp l0mm lin tip. - FOV: 32 hoc 40cm.

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4. Thuc cn quang tnh mch Thng thng khng tim thuc v nc tiu trong bng quang l mt tc nhn i quang tt v nu bng quang cha y nc tiu cn quang c th che lp cc u nh thnh bng quang. C th tim thuc cn quang tnh mch khi cn phn bit mch mu v hch chu. 5. Bnh cnh lm sng - U tin lit tuyn: Cn m rng vng ct lp xung di khp v c nh ton b tuyn. To thm nh ca s xng tm tn thng xng v, xng chu. - U bng quang: Nu u nh, cn ct lp bng quang vi dy lp ct 5mm lin tip trnh b st u. ph n cn t tm bng thuc cn quang trong m o d nhn bit bng quang trn nh. 6. t ca s: WL = +40 HU WW = 400

19. CHP TUYN THNG THN 1 . Chun b ngi bnh - Nhn n trc 4 gi. - Cho ung 300- 400 ml thuc cn quang 10 pht trc khi khm xt to i quang ca phnh v v tiu trng vng bng trn. Nu phnh v khng c cht cn quang s d nhm vi tuyn thng thn bn tri. 2. T th ngi bnh - Nm nga, hai tay t ln ngc. - Nu cn khm xt c bng: Gi cao hai tay t cnh u. - Vng ct lp: T vm honh phi n gia thn phi. Nu cn tm u t bo a chrome ngoi thng thn, phi m rng vng qut n ch phn i ng mch ch bng. 3. Cc thng s qut : - dy lp ct: 5mm lin tip - Bc chuyn bn: 5mm

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- Nn qut xon c nu thit b cho php; p dng dy lp ct 5mm v khong chuyn bn 5mm (pitch 1 : 1). - FOV: 32 hoc 40cm. 4. Thuc cn quang tnh mch - Nn qut khng tim thuc trc - Qut c tim thuc: 80-100ml thuc cn quang khng ion vi lu lng 3ml/giy. - Khi ng qut 30giy sau thi im bt u tim thuc. Ch : Cn c sn thuc phentolamin tim tnh mch (Regitin) cp cu cn tng huyt p do tim cn quang kch thch u tu thng thn gy ra. 5. t ca s: WL = +40 HU WW = 400

20. CHP NG MCH CH A. Phng ng mch ch ngc 1. Chun b ngi bnh: Nhn n trc 4 gi. 2. T th ngi bnh - Nm nga, hai tay t ln cnh u. - Ct lp thng nht sau th th vo. - Tt nht l qut xon c, c th ct lp lin tc v hng dn ngi bnh th chm, nh trong lc khm nu khng c iu kin qut xon c. 3. Cc thng s qut : - To nh nh khu theo hng trc sau - Ct lp t trn quai ng mch ch cho ti c honh. - M rng vng ct lp xung bng nu ti v tr c honh vn cn thy phng ng mch ch. - dy lp ct: 10mm. - Bc chuyn bn: 10mm, lin tip.

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- FOV: 24cm nu ch xem ng mch ch, 32cm nu cn xem ton b lng ngc. 4. Thuc cn quang tnh mch - Tim nhanh kiu bolus 40-50ml thuc cn quang vi tc 3ml/s v sau bm tip 40-50ml vi lu lng 1ml/s nu khng qut c xon c. Bt u ct lp thi im 15giy sau khi bt u tim thuc . Nu qut xon c tim 100ml thuc vi lu lng 3-4ml/giy v khi ng qut 20 giy sau thi im bt u tim thuc . dy lp ct 5mm v Pitch 1 :1 . Ti to nh 3mm v dng nh MPR, 3D b mt, 3D th tch d phn tch tn thng . - Nn dng my bm thuc cn quang t lu lng cao ban u. - Nn dng thuc cn quang khng ion trnh phn ng d nh ca ngi bnh lm gin on khm xt. 5. t ca s: WL : +35 HU B. Phng ng mch ch bng 1. Chun b ngi bnh - Nhn n trc 4 gi. - C th cho ung 400ml thuc cn quang 30 pht trc khm xt nu nghi ng mi lin quan ca phng ng mch ch vi ng tiu ho. 2. Cc thng s qut : - Vng ct lp t vm honh ti ch phn i ng mch ch (L5) v c th m rng ti khp v nu cn lm r hai ng mch chu gc. - dy lp ct: 5mm. - Bc chuyn bn: 5mm, lin tip. - Cn ti to nh 3mm v dng nh MPR, 3D lm r mi lin quan ca ti phnh vi ng mch thn hai bn l mt ch tiu quan trng t ch nh m . 3. Thuc cn quang tnh mch: nh ng mch ch ngc. 4. t ca s: WL = +40 HU WW = 400 WW : 400

C. Phnh tch ng mch ch 1. Chun b ngi bnh Nghi phnh tch ng mch ch l mt khm xt cp cu nn khng i hi chun b trc.

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Nu thi gian cho php : nhn n trc 2 gi. 2. T th ngi bnh: Nm nga, hai tay gi cao t cnh u nu sc kho ca ngi bnh cho php, nu khng c th t xui hai tay. 3. Cc thng s qut : C hai kiu khm xt la chn tu theo loi my s dng, tnh trng ngi bnh v thi quen ca bc s. a. Ct lp 10mm vi bc chuyn bn l0mm t cn xng c ti vm honh, khng tim thuc cn quang thm d; sau tim thuc cn quang 100ml chia lm hai th 1/2 liu tim kiu Bolus, cn 1/2 liu tim chm lml/s v khi ng qut sau thi im bt u tim thuc 15 giy. b. Qut xon c c tim cn quang ngay. - dy lp ct: 5mm, Pitch 1:1 - Vng qut nn m rng t quai ng mch ch ti chc ba ch chu v ti to nh 3mm, dng nh MPR v nh 3D lm r im bt u bc tch , im kt thc cng nh mi lin quan ca lng gi vi cc ng mch tng . 4. Thuc cn quang Tim l00-120ml thuc cn quang khng ion vi lu lng 3ml/giy v bt u qut 20giy sau thi im bt u tim thuc. - Nn dng loi khng c ion khm xt c thun li. - FOV: 32cm 5. t ca s: WL = +40 HU WW = 300

21. CHP LNG NGC 1. Chun b ngi bnh: Nhn n trc 4 gi. 2. T th ngi bnh - Nm nga, hai tay gi cao t cnh u. - Ct lp sau th th vo, hng dn ngi bnh lm nhiu ln th vo vi mc ht vo ging nhau c c v tr lin tip trn cc lp ct. - Nn ct lp xon c nu c iu kin. 3. Cc thng s qut : - Vng ct: t nh phi n gc sn honh trn nh nh khu theo hng thng.

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- dy lp ct: 8-10mm - Bc chuyn bn: 15mm nu khm thm d. 8- 10 mm nu nh hng c bnh trong lng ngc trn phim ngc chun. - FOV: 32-40cm tu theo rng ca ngi bnh. 4. Thuc cn quang tnh mch: Khi cn phn bit hnh mch mu vi hch hoc bnh l tim 100ml thuc cn quang tnh mch vi 50ml tim nhanh kiu Bolus, sau tim chm lml/s v khi ng qut 15 giy sau thi im bt u tim. C th tim mt th vi lu lng 2-3ml/giy v khi ng qut 30 giy sau thi im bt u tim thuc. 5. t ca s - Ca s trung tht: WL = +'35 WW = 400 Ca s nhu m phi: WL = 'lgoo WW = 1200 6. Da theo bnh cnh lm sng a. Ung th ph qun-phi - Nn ct t nh phi ti thng thn tm di cn thng thn. dy lp ct: 8 l0mm ; v tr ca ph qun gc - rn phi nn ct vi dy 5mm trnh b st bnh. Qut xon c mt ln nhn th l tt nht. - Thuc cn quang: 100ml tim tnh mch nhanh (3ml/giy) , khi ng qut 30 giy sau thi im bt u tim nh gi c mc tun hon ca khi u . b. Di cn ung th ti phi - dy lp ct: 8-10mm. - Bc chuyn bn : 8 - 10mm. - Khng cn tim thuc cn quang. c. U trung tht - Vng ct lp m rng t nn c n gc tm honh c th phn bit bu gip chm vi u trung tht. - dy lp ct: 5 - 8mm - Bc chuyn bn: nh dy lp ct d. Tng sn tuyn c - Vng ct lp t b trn cn xng c ti rn phi. - dy lp ct: 5mm 49

- Bc chuyn bn: 5mm e. Gin ph qun, gin ph nang, bi phi v cc bnh t chc k. - Ch nh chp ct lp phi i vi cc bnh l nhu m phi, ph qun ngy cng m rng vi k thut chp ct lp phn gii cao (HR(T) theo nhng thng s k thut di y: - dy lp ct nh di 2mm. - Thi gian mt lp ct di 2 giy. - Ma trn 512 , 120kv , 50 - 100MA. - Bc chuyn bn: 10 hoc 15mm. 7. Thuc cn quang tnh mch: khng cn thit 8. t ca s: WL = -750 n -800 WW = 900 n 1200

- C th m thm ca s trung tht khm xt vng trung tht. Cn ch nu chp phn gii cao s hn ch pht hin hch trung tht, v vy c th p dng qut xon c nu cn pht hin hch. - Qut xon c: + Vng qut t trn xng n cho ti gc sn honh + Thng s qut: 120kV, l00-150mA, qut sau th th vo + FOV : 24-32cm + dy lp ct 8 mm , khong di chuyn bn 8mm (pitch 1 : 1 ), c th nng pitch ln 15 : 1 rt ngn thi gian qut nhng c th s kh pht hin nhng nhn phi di 4mm. + Thuc cn quang: 100ml loi khng ion, 3ml/giy. + Khi ng qut 30giy sau thi im bt u tim thuc. + Ti to nh ct ngang c dy 4mm vi 2 ca s phi v xng. - Chp ng mch phi trong chn on nhi mu phi: + Ct lp xon c vi dy lp ct 5mm v pitch 1 : 1 + Vng qut rng 12 cm t b trn quai ng mch ch tr xung hin nh cc ng mch phi t cp 2 n cp 4. + Thuc cn quang: l00-120ml loi khng ion, 300mg Iode/ml. + Tc bm 4-5ml/sec qua tnh mch nn.

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+ Khi ng qut 15 giy sau thi im bt u tim thuc. + Ti to nh vi dy 3mm. + Theo Remy-Jardin, chp ct lp theo k thut ni trn c th t nhy 100% v c hiu 96% i vi tc mch phi ti cc ng mch t cp 2 n cp 4.

22. CHP CT SNG 1. Chun b ngi bnh: Khng cn nhn n 2. T th ngi bnh: Nm nga, hai tay t cho trc ngc nu ct lp ct sng tht lng. 3. Cc thng s qut : To nh nh hng nghing d xc nh v tr t ct sng v mt phng ca a m. - dy lp ct: 2mm, 3mm hoc 5mm - Bc chuyn bn: bng d dy lp ct - Ma trn : 512 - FOV : 16cm ; nn dng chng trnh Zoom. 4. Thuc cn quang tnh mch: Ch cn s dng trong bnh l xng hoc khm xt sau phu thut thot v a m. 5. t ca s: WL = +60 HU WL = +200 a. Ct sng tht lng - Thot v a m: t hng ct song song vi bn xng tn cng ca t sng theo tng khoang lin t. Ct lp lin tip t cung t trn n cung t di. Nn ct lp t nht ba khoang lin t cui cng ca ct sng v l v tr hay gp thot v nht: L3/L4 ; L4/L5 v L5/S1. - Hp ng sng: t hng ct song song vi bn xng tn cng ca t sng nh ni trn. mi t sng ct mt lp qua cung sng v 2 lp qua a m. V tr ct lp t L2 n S1 . cc thng s k thut nh trn. - Chn thng: Nn t hng vung gc vi mt bn v qut xon c lin tc d ti to nh 3D v cc mt phng cn thit khc. WW = 400 cho phn mm WW = 3000 khm xng

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- Sau bm thuc ng sng: Nn ct lp hng thng nh trong chn thng hoc hng chch nh thot v a m ty theo bnh cnh lm sng. Vng khm xt thng rng nn gim liu x cho ngi bnh, nn p dng dy lp ct 5mm lin tip. - t ca s rng hn d pht hin cc bt thng trong ng sng. b. Ct sng c: Chp ct lp ct sng c ch lm i vi chn thng, khng ch nh cho thot v a m. Khi cn tm thot v a m hoc khi chon ch trong ng sng c phi bm thuc cn quang vo ng sng trc khi chp. - Nn qut xon c nu thit b cho php v dng nh 3D thun li cho chn on.

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