Nghiên cứu chẩn đoán và điều trị phẫu thuật túi phình động mạch não vỡ

i
LỜI CẢM ƠN

              
 - Khoa 


c, Kt Tn kinh,
- 


- 


nguyên Phó ch           

 

Tôi xin           
 



 
   
T
               

 t


.
i, ngày 14 



ii
LỜI CAM ĐOAN




Tác giả


Vũ Minh Hải



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MỤC LỤC


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
 i
 ii
 iii
 vi
 vii
 ix

 x
ĐẶT VẤN ĐỀ i
CHƢƠNG 1: TỔNG QUAN 3
1.1. Lịch sử nghiên cứu chẩn đoán và điều trị túi phình động mạch não 3
 3
 5
1.2. Giải phẫu mạch cấp máu cho não 7
 7
 8
1.3. Đặc điểm bệnh lý túi phình động mạch não 9
 9
 9
 10
 11
 15
1.4. Chẩn đoán túi phình động mạch não 15

iv
 15
 17
1.5. Các phƣơng pháp điều trị túi phình động mạch não vỡ 27
 27
 29
 31
CHƢƠNG 2: ĐỐI TƢỢNG VÀ PHƢƠNG PHÁP NGHIÊN CỨU 35
2.1. Đối tƣợng nghiên cứu 35
2.2. Phƣơng pháp nghiên cứu 36
 36
 36
 37

2.3. Các phƣơng pháp khắc phục sai số 52
2.4. Xử lý và phân tích số liệu 53
2.5. Đạo đức trong nghiên cứu 54
CHƢƠNG 3: KẾT QUẢ NGHIÊN CỨU 55
3.1. Đặc điểm lâm sàng và hình ảnh học 55
 55
 61
3.2. Kết quả điều trị phẫu thuật 72
CHƢƠNG 4: BÀN LUẬN 86
4.1. Đặc điểm lâm sàng 86
 86
 86
 87
 88
 89

v
 não 91
4.2. Hình ảnh học 93
 93
 95
 97
4.2.4. So sánh giá tr
 98
4.3. Điều trị phẫu thuật túi phình động mạch não vỡ 101
 101
 103
 104
 112
 113

4.3.6. Bi 115
 116
 119
KẾT LUẬN 123
DANH MỤC CÁC CÔNG TRÌNH CÔNG BỐ
KẾT QUẢ NGHIÊN CỨU CỦA ĐỀ TÀI LUẬN ÁN
TÀI LIỆU THAM KHẢO
PHỤ LỤC

vi
NHNG CH VIT TT TRONG LUN N

Ting Vit
BN
CHT
CLVT
CMDMN
CS
DNT
M
MN
(Stent)
PTTK
THA
VXKL (Coils)

Ting Anh
95%CI
DSA : Digital Subtraction Angiography

GOS : Glasgow Outcome Scale
(Thang phân loại hồi phục sau mổ)
ISAT : International Subarachnoid Aneurysm Trial
(Thử nghiệm quốc tế điều trị
phình mạch não vỡ có chảy máu d-ới màng nhện)
MIP : Maximum intensity projection
(Tái tạo c-ờng độ tối đa)
MPR : Multiplanar reconstruction (Tái tạo đa mặt phẳng)
OR
TCD :
TOF : Time of flight (Hiệu ứng thời gian bay)
VRT : Volume rendering technics (Tái tạo 3D)

vii
DANH MỤC CÁC BẢNG

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1.1:  28
2.1: -Hess (1968) 38
2.2:   39
2.3:  41
2.4:  42
2.5:  51
3.1:  55
3.2:  56
3.3:  56
3.4:   57
3.5: 

 59
3.6: -
 60
3.7:  61
3.8:  62
3.9:  63
3.10:  63
3.11:  64
3.12: 
 65
3.13:  66
3.14:  
 67

viii
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3.15:  68
3.16:  69
3.17:  69
3.18:  70
3.19:  71
3.20:  71
3.21:  72
3.22:  73
3.23:  74
3.24:  75
3.25:  75
3.26:  76

3.27:  76
3.28:  77
3.29:  77
3.30:  78
3.31:  79
3.32: Liê
 81
3.33: 
 83
3.34: 
 84
3.35: 
 85

ix
DANH MỤC CÁC BIỂU ĐỒ

Biểu đồ
Tên biểu đồ
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3.1:  55
3.2:  57
3.3:  58
3.4:  58
3.5: -Hess 61
3.6:  62
3.7:  64
3.8:  66
3.9: 
 72

3.10: -Hess 73
3.11:  74
3.12:  78
3.13:   80
3.14:  80
3.15:   81
3.16:  82


x
DANH MỤC CÁC HÌNH ẢNH

Hình
Tên hình
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1.1:  7
1.2:  10
1.3:  14
1.4:  15
1.5:  
 18
1.6:  19
1.7: 
 21
1.8: 
 21
1.9:  23
1.10:  24
1.11: 
 25

1.12:  30
1.13: 
 30
1.14: 
 31
1.15:  33
1.16:  33
1.17:  34

xi
Hình
Tên hình
Trang
2.1:  46
2.2:  46
2.3:  47
2.4:  48
2.5:  48
2.6:  48
4.1: 
 94
4.2: - 
 94
4.3:  94
4.4: 
 94
4.5: 
n). 96
4.6: 
  99

4.7: 
 100
4.8: 
 101
4.9:  106
4.10:  107
4.11:  
 108

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4.12: 
 108
4.13:  109
4.14:  110
4.15: 
 110
4.16: 
 110
4.17: (a), (b) 
não  
 111
4.18: 
 (b) 112
4.19: 
 113

1
ĐẶT VẤN ĐỀ

Phình  i h 
 não m
thành   [32].   phình  ch não  -8% [24],
[131]. 90% túi           
 màng  [31], [73]. túi 
 hàng nm trung b  trong 100.000 dân
[130]. Vtúi   

 - 
   cao.

 máu
 6 tháng là 50- 
3].
a phình , 
 tri giác [14],[18].

n oán xác  
   
túi    .          là
 . H   là
 ít   
. P
              
[36], [38], [42], [68], [86], [123], [125].

2

ích  túi  là c
 phình
phình 
 phìnhphình qua 
 (coil).
, túi  
  
  kinh.

 (  
) và     ã thúc
túi phình  cho 

  
 ,  h , Xquang
  
i phình  t (ISAT 2009
[27]), còn  .
 "
túi   hai :
1. Mô tả đặc điểm lâm sàng, hình ảnh cắt lớp vi tính và chụp
mạch số hóa xóa nền túi phình động mạch não vỡ.
2. Đánh giá kết quả điều trị vi phẫu thuật túi phình động mạch
não vỡ.


3
CHƢƠNG 1
TỔNG QUAN

1.1. LỊCH SỬ NGHIÊN CỨU CHẨN ĐOÁN VÀ ĐIỀU TRỊ TÚI PHÌNH
ĐỘNG MẠCH NÃO
1.1.1. Trên thế giới
ng
)  ,
 
báo cá 


 não khi m
(DNT) .

   
CMDMN) 






 (CLVT) 
an toàn.
) 

4

         

.
            

.
.

 

Alaa, Li, Scoville,        


 [23], [57], [81], [118], [130].
 

   
112].
            
            s
(Guglielmi Detachable Coils).

 






5
 
 

[94], [116].
1.1.2. Ở trong nƣớc

cs) 
 
nghiên 

Hinh và cs [6], [14], [15], [18].

 
 [4].
, 

              

 (2008),  
8Lan (2009), 

 5].
 

         20].    

22].

6

 

m Hòa Bình và cs báo cáo ti hi ngh khoa hi hi
ngoi khoa ln th X: Phu thung ht qu tt,
2 t vong, 1 tàn ph.
n Th Hào và cs báu tr ngoi khoa v túi

ph ng hp.
ng s báo cáo vi phu thung
hng clip Sugita; kt qu tt 93%, t vong 7.
h

[1].

   
7,512].

 


           
16].


 vong [19].



7
1.2. GIẢI PHẪU MẠCH CẤP MÁU CHO NÃO

 (vòng Willis) [9],
[105], [113].
1.2.1. Hệ động mạch cảnh trong






yên
.


[113].
 

 n các thành
tr


8
 

 

+ 
- yên trên trong chui qua
. 
               

105].
- 






 
nên các phình  
 [10].
- 
              

1.2.2. Hệ động mạch đốt sống thân nền
+ 



  




9
+ :
- 

-  



  vùng 
sau,  [70].
1.3. ĐẶC ĐIỂM BỆNH LÝ TÚI PHÌNH ĐỘNG MẠCH NÃO
1.3.1. Nguyên nhân bệnh sinh
Nguyên nhân còn 
+    :       ,  


  

sau. [18], [47].
+ Nguyên nhân : là do 
  





 
 ) [47].
1.3.2. Cơ chế hình thành túi phình động mạch não
Do do
 :
+ 
phình 
          


10

-
11], [13], [18].
+ 
lên t 
        
         
vòng 

[18], [83].
1.3.3. Phân bố vị trí túi phình động mạch não


-


126].



Hình 1.2: 
 (2002) [126].

             
- 90%-35%)
- 5-
Túi phình ĐM
thông trƣớc
Túi phình đỉnh
thân nền
Túi phình
ĐM sống nền
Túi phình
ĐM tiểu não
sau dƣới
Túi phình ĐM
tiểu não trên
Túi phình
ĐM não giữa

Túi phình
ĐM thông sau

11
n hoàn sau


 [3], [13], [109].
1.3.4. Sinh lý bệnh vỡ túi phình động mạch não
  
   tâm lý      
[14], [19], [78].
theo 
 gây nên CMDMN



 gây 14],
[78], [90].
* 
Nga
     
h
c, não
nên 18], [19], [35], [76].
* : 
            
do :
+ Y





12


23], [29].
+  viêm: sau CMDMN 
    
interleukin, E-secretin, collagen type
là p [40], [78], [98].
CMN,
, là nguyên nhân chín 
M 

 




[38], [42], [53], [86].




              

 [120].

thá




13
. Theo Roos Y.B. và cs 
107].
 

* Giãn 
+ Giãn



115]. Theo Jacques S. và cs
(2005) 

60].
+ Giãn


* : , theo Roos
Y.B. và cs , 


 
  
   có     


t 107]. (Hình 1.3 a,b).