Các yếu tố tiên lượng liên quan đến nguy cơ tăng chảy máu và đánh giá kết quả vi phẫu thuật của dị dạng động tĩnh mạch não

B GIO DC V O TO B Y T TRNG I HC Y H NI Lấ VN BNG CáC YếU Tố TIÊN LƯợNG LIÊN QUAN ĐếN NGUY CƠ TĂNG CHảY MáU Và ĐáNH GIá KếT QUả VI PHẫU THUậT CủA Dị DạNG ĐộNG - TĩNH MạCH NãO LUN VN TT NGHIP BC S NI TR H NI 2015 B GIO DC V O TO B Y T TRNG I HC Y H NI Lấ VN BNG CáC YếU Tố TIÊN LƯợNG LIÊN QUAN ĐếN NGUY CƠ TĂNG CHảY MáU Và ĐáNH GIá KếT QUả VI PHẫU THUậT CủA Dị DạNG ĐộNG - TĩNH MạCH NãO Chuyờn ngnh: NGOI KHOA Mó s: NT 62720750 LUN VN TT NGHIP BC S NI TR Ngi hng dn khoa hc: TS Lờ Hng Nhõn H NI - 2015 LI CM N Trong quỏ trỡnh thc hin v hon thnh lun tt nghip Bỏc s ni trỳ, tụi xin trõn trng cm n: ng y, Ban giỏm hiu, Phũng qun lý o to Sau i hc, B mụn Ngoi - Trng i hc Y H Ni Ban giỏm c Bnh vin Vit c, Phũng k hoch tng hp cựng Trung tõm phu thut thn kinh bnh vin Vit c Tụi xin by t lũng bit n sõu sc ti Thy: Tin s Lờ Hng Nhõn, ó hng dn khoa hc v tn tỡnh ch bo tụi ton b quỏ trỡnh nghiờn cu v hon thnh lun tt nghip ng thi, tụi cng xin trõn trng cm n cỏc Thy Cụ B mụn Ngoi - Trng i hc Y H Ni ó to mi iu kin thun li v truyn t kin thc cho tụi quỏ trỡnh hc Tụi cng chõn thnh cm n cỏc anh ch em bỏc s ni trỳ Ngoi ó luụn bờn v h tr tụi quỏ trỡnh hon thnh lun c bit tụi xin kớnh trng by t lũng bit n sõu sc ti B, M v gia ỡnh ó luụn ng h, ng viờn tụi hc tp, phn u v trng thnh cuc sng v s nghip H Ni, ngy 15 thỏng 11 nm 2015 Lờ Vn Bng LI CAM OAN Tụi l Lờ Vn Bng, hc viờn bỏc s ni trỳ khúa 37, Trng i hc Y H Ni, chuyờn ngnh Ngoi khoa, xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca Tin s Lờ Hng Nhõn Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp thun ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim v nhng cam kt ny H Ni, ngy 15 thỏng 11 nm 2015 Lờ Vn Bng BNG CC CH VIT TT Angio : Chp mch CHT : Cng hng t CLVT : Ct lp vi tớnh DDTMN : D dng ng tnh mch nóo M, /m : ng mch GFB : Gii phu bnh HA : Huyt ỏp Nidus : Phn trung tõm ca DDTMN DNT : Dch nóo tu TM, t/m : Tnh mch MC LC T VN Chng 1: TNG QUAN 1.1 S LC TèNH HèNH NGHIấN CU DDTMN TH GII V VIT NAM 1.1.1 Th gii 1.1.2 Vit Nam 1.2 S HèNH THNH H THNG MCH NO THI K PHễI THAI V C CH BNH SINH CA DD TMN 1.2.1 S hỡnh thnh ca h thng mch nóo thi k phụi thai 1.2.2 C ch bnh sinh ca DD TMN 10 1.2.3 Gii phu v c im hỡnh nh hc ca DDTMN 11 1.3 C CH BNH SINH CA DDTMN 23 1.3.1 Nhng ri lon v huyt ng DDTMN 23 1.3.2 Sinh lý bnh ca bin chng chy mỏu nóo DDTM nóo v 27 1.4 C IM CC YU T LIấN QUAN TI KH NNG TNG NGUY C CHY MU CA DDTMN 28 1.4.1 Yu t c a 28 1.4.2 Yu t gii phu ca DD TMN 29 1.4.3 Yu t huyt ng hc 31 1.5 IU TR NGOI KHOA 32 1.5.1 Ch nh iu tr ngoi khoa DDTMN 32 1.5.2 Ch nh iu tr ngoi khoa DDTMN cp cu 32 1.5.3 ỏnh giỏ kt qu iu tr 33 Chng 2: I TNG V PHNG PHP NGHIấN CU 34 2.1 I TNG NGHIấN CU 34 2.1.1 Tiờu chun chn bnh nhõn 34 2.1.2 Tiờu chun loi tr 34 2.2 PHNG PHP NGHIấN CU 34 2.2.1 Phng phỏp nghiờn cu 34 2.2.2 C mu 34 2.2.3 Ni dung nghiờn cu 35 2.2.4 X lý s liu 44 Chng 3: KT QU NGHIấN CU 45 3.1 DCH T HC LM SNG 45 3.1.1 Gii 45 3.1.2 Tui 46 3.1.3 Tin s bnh lý 46 3.2 C IM LM SNG 47 3.2.1 Tỡnh trng tri giỏc ca bnh nhõn trc m 47 3.2.2 Biu hin lõm sng vo vin 48 3.3 C IM GII PHU KHI DDTMN 49 3.3.1 V trớ DD TMN 49 3.3.2 V trớ nụng sõu ca DD TMN 49 3.3.3 Kớch thc DD TMN 50 3.3.4 Phỡnh mch phi hp 50 3.3.5 T l gia /m cp mỏu/ t/m dn lu 51 3.4 IU TR PHU THUT 51 3.4.1 Bng phõn loi DDTMN theo Spetzler- Martin 51 3.4.2 Cỏc bin phỏp ỏp dng m 52 3.4.3 T l khụng ly ht DDTMN sau m 52 3.5 KT QU SAU M 53 3.5.1 Tri giỏc bnh nhõn sau m 53 3.5.2 Bin chng sm 54 3.5.3 Kt qu gn 54 3.5.4 Kt qu xa 55 Chng : BN LUN 56 4.1 YU T C A CA DDTMN 56 4.1.1 Gii 56 4.1.2 Tui 56 4.1.3 Cỏc bnh cú liờn quan n tng kh nng chy mỏu DDTMN 57 4.2 C IM GII PHU 59 4.2.1 V trớ DDTMN 59 4.2.2 V trớ ca DDTMN gia cỏc vựng 60 4.2.3 V trớ nụng sõu ca DDTMN 61 4.2.4 Kớch thc DDTMN 62 4.2.5 Phỡnh mch phi hp 63 4.3 YU T HUYT NG HC 64 4.4 KT QU VI PHU THUT 64 4.4.1 Kt qu iu tr vi phu thut 64 4.4.2 Tri giỏc bnh nhõn sau m 68 4.4.3 Bin chng sau m 69 4.4.4 ỏnh giỏ kt qu sm 69 4.4.5 ỏnh giỏ kt qu xa 70 KT LUN 73 TI LIU THAM KHO PH LC DANH MC BNG Bng 1.1 Phõn loi ca Nataf.F 17 Bng 1.2 Bng 3.1 Phõn loi Spetzler-Martin 1986 23 Phõn b theo gii 45 Bng 3.2 Bng 3.3 Bng 3.4 Phõn b bnh nhõn theo nhúm tui 46 Phõn b ca tin s bnh lý 46 Tỡnh trng tri giỏc ca bnh nhõn trc m 47 Bng 3.5 Cỏc biu hiờn lõm sng bnh nhõn vo vin 48 Bng 3.6 Bng 3.7 Phõn b v trớ DDTMN 49 Phõn b v trớ ca nidus theo mc nụng sõu 49 Bng 3.8 Bng 3.9 Phõn b kớch thc ca nidus 50 Phi hp phỡnh mch nóo 50 Bng 3.10 Phõn b t l /m cp mỏu/ t/m dn lu 51 Bng 3.11 Phõn loi DDTMN theo Spetzler- Martin 51 Bng 3.12 Cỏc bin phỏp ỏp dng m 52 Bng 3.13 T l khụng ly ht DDTMN sau m 52 Bng 3.14 Tỡnh trng tri giỏc bnh nhõn sau m 53 Bng 3.15 im Glasgow trung bỡnh trc m v sau m 53 Bng 3.16 Cỏc bin chng sau m 54 Bng 3.17 B np s xng sau m 54 Bng 3.18 Phõn loi kt qu gn 54 Bng 3.19 S lng bnh nhõn n khỏm li 55 Bng 3.20 Cỏc di chng sau m 55 Bng 3.21 Kt qu phu thut sau m bng chn oỏn hỡnh nh 55 Bng 4.1 Cỏc bin phỏp ỏp dng m 66 Bng 4.2 Bng 4.3 Kt qu ly d dng ca tỏc gi nc ngoi 67 T l khụng ly ht DDTMN sau m 67 Bng 4.4 Bng 4.5 Phõn loi kt qu gn 70 Kt qu sau m ca cỏc tỏc gi khỏc 70 DANH MC BIU Biu 3.1 Phõn b i tng nghiờn cu theo gii 45 Biu 3.2 Tỡnh trnh tri giỏc bnh nhõn trc m 47 Biu 3.3 Cỏc biu hin lõm sng bnh nhõn n khỏm 48 Biu 3.4 Phõn b kớch thc ca nidus 50 Biu 4.1 Liờn quan gia tui v biu hin lõm sng 57 Biu 4.2 Tri giỏc bnh nhõn trc m v sau m 68 72 nhõn v cỏc nguy c cng nhng phi cho bnh nhõn nhp vin khoa phũng ang quỏ ti Qua phõn tớch kt qu chp kin tra chỳng tụi thy cú 50/56 bnh nhõn sau chp thy ó ly ht DDTMN (chim 89,3%), cũn li 6/56 bnh nhõn cũn mt phn d dng ng tnh mch nóo (chim 10,7%) (bng 3.21) So sỏnh kt qu ny vi cỏc tỏc gi nh Deruty [17] 9% khụng ly ht, Yarsagil [13] 9,4% khụng ly ht, Castel J P [18] 10% khụng ly ht dng ng tnh mch nóo Chỳng tụi nhn thy t l khụng ly ht d dng ng tnh mch nóo ca chỳng tụi tng t cỏc tỏc gi trờn 73 KT LUN Qua nghiờn cu 70 trng hp DDTMN v c m ti khoa Phu thut thn kinh Bnh vin Vit c t thỏng 9/2010 n thỏng 9/2015 chỳng tụi rỳt kt lun sau: Kt qu iu tr vi phu thut: - Bnh nhõn c ỏnh giỏ tri giỏc trc v sau m, nghiờn cu im Glasgow trung bỡnh ca nhúm sau m (14,44 im) l cao hn ỏng k so vi trc m (12,87 im) - Cú 51/70 bnh nhõn ó c ly ht DDTMN (chim 72,9%) - T l gp bin chng viờm mng nóo l cao nht chim 11,4% - p dng cỏc ch nh m, phng phỏp m vi phu v cỏc ỏnh giỏ theo tỏc gi Deruty, Spetzler v Yarsagil chỳng tụi cú kt qu sm sau m: Tt 84,3%, trung bỡnh 15,7% v khụng cú trng hp no t vong - Kt qu xa c tớnh sau m ớt sau thỏng, chỳng tụi thu c kt qu tt chim 84,6%, trung bỡnh chim 15,4% - Di chng sau m ph bin nht l lit 1/2 ngi chim bnh nhõn s 10 bnh nhõn cú di chng (chim 8,5% nhúm bnh nhõn nghiờn cu) - Cỏc bnh nhõn sau m c chp li kim tra nht l vi cỏc DDTMN m nghi ng khụng ly ht DDTMN Chỳng tụi cú 56 trng hp c chp kim tra vi kt qu: Ly ht d dng t 89,3%, khụng ly ht d dng chim 10,7% Cỏc yu t tiờn lng lm tng nguy c chy mỏu DDTMN - Tui trung bỡnh ca bnh nhõn l 33,113,9 tui, hay gp nht l tui t 11-50 - Gii nam chim a s vi t l nam/n t 3/1 74 - Trong cỏc bnh nhõn cú 21,4% l cú tin s bnh lý liờn quan trc ú (bao gm: Bnh lý tim mch, chy mỏu c, thai sn), ú tin s chy mỏu c l cao nht chim 15,7% - Khi DDTMN hay gp nht vựng thỏi dng chim 50%, sau ú n vựng trỏn 21,5%, chm 17,1%, vựng nh v h sau ớt nht cựng vi 5,7% - Trong nhúm nnh nhõn c nghiờn cu hu ht cỏc nidus nm nụng 91,4%, ch cú mt s ớt DDTMN nm sõu c m - Cỏc DDTMN cú kớch thc nh di 3cm chim a s vi 80% bnh nhõn, nhng DDTMN ln hn 6cm ch chim 5,7% - Cú 14,3% bnh nhõn cú DDTMN cú phỡnh mch phi hp nhúm bnh nhõn dc nghiờn cu - T l nhúm cú DDTMN cú t l gia s ng mch cp mỏu trờn tnh mch dn lu ln hn hn so vi nhúm cú t l < TI LIU THAM KHO Lờ Xuõn Trung v cng s (2003) D dng ng tnh mch nóo, Bnh hc phu thut thn kinh, Nh xut bn Y hc, H Ni c Cng (2006) Nghiờn cu hỡnh nh chp ng mch nóo s húa xúa nn chn oỏn d dng ng tnh mch nóo, Trng i hc Y H Ni, H Ni Nguyn Vn ng (1999) Tai bin mch mỏu nóo, Nh xut bn Y hc, H Ni Kiu Vit Hựng (2001) Phõn tớch hi cu 56 trng hp DDTMN, Cụng trỡnh khoa hc hi ngh phu thut thn kinh ln th II, ch biờn, Bnh vin Vit c, H Ni Vừ Vn Nho v Kiu Vit Hựng (1998) iu tr ngoi khoa trng hp thụng ng tnh mch nóo, Tp y hc Vit Nam 6,7,8, 149 1544 Barrow D L (1990) Intracranial vascular malfomation, AANS Da Costa L, Wallace C, Karel G, OKelly C, (2009) The natural history and predictive features of hemorrhage from brain arteriovenous malformations, Stroke, 40, 100-105 Lanzino G, Jensen M.E, Cappelletto B, Kassell N.F (1994) Arteriovenous malformations that rupture during pregnancy: a management dilemma, Acta Neurochir, 126, 102-106 Graf C.J, Perret G.E, Torner J.C (1983) Bleeding from cerebral arteriovenous malformations as part of their natural history, J Neurosurg, 58(3), 331-7 10 Nguyn Thng Xuõn v Phm Gia Triu (1961) Nhõn trng hp m u mch, Tp y hc Vit Nam, 2, 97 - 103 11 Pritz M B (1994) Ruptured supratentorial arteriovenous malformations associated with venous aneurysms, Acta Neurochir (Wien) 128(1-4), 62-150 12 Al-Shahi R, Warlow C (2001) A systematic review of the frequency and prognosis of arteriovenous malformations of the brain in adults, Brain, 10, pp 1900-1926 13 Da Costa L, Wallace C, Karel G, OKelly C, Willinsky R.A, Tymianski M (2009) The natural history and predictive features of hemorrhage from brain arteriovenous malformations, Stroke, 40, 100-105 14 Fults D, Kelly D.J (1984) Natural history of arteriovenous malformations of the brain: a clinical study, Neurosurgery, 15(5), 658-62 15 Batjer H and Samson D (1986) Arteriovenous malformations of the posterior fossa, Neurosurgery 64 (6)(Clinical presentation, diagnostic evaluation, and surgical treatment), 56-849 16 Deruty R, et al (1993) The neurosurgeon's role in the treatment of cerebral arteriovenous malformations, Neurochirurgie 39(4)(A study of a series of 100 cases and review of the literature), 24-212 17 Castel J P and Kantor G (2001) Postoperative morbidity and mortality after microsurgical exclusion of cerebral arteriovenous malformations Current data and analysis of recent literature, Neurochirurgie 47(2-3 Pt 2), 83-369 18 Heros R C and Morcos J J (2000) Cerebrovascular surgery: past, present, and future, Neurosurgery 47(5), 33-1007 19 Jomin M, et al (1993) Natural history and spontaneous prognosis of cerebral arteriovenous malformations, Neurochirurgie 39(4) (discussion 1-210), 10-205 20 Michael T Lawton (2014) Seven AVMs Tenets and Techniques for Resection 2014, Geor - Thieme, New York 21 Harrigan M.R, Deveikis J.P (2009) Diagnostic cerebral angiography Handbook of cerebralvascular disease and neurointerventional technique, Springer, 87-115 22 Hamilton M.G, Spetzler R.F (1994) The prospective application of a grading system for arteriovenous malformations, Neurosurgery, 34, 2-6 23 Yashar M, Kalani F, Robert F Spetzler, Peter Nakaji (2015) Neurovascular Surgery, 2nd, ed, Geor - Thieme, New York 24 Centre de Neuroradiologie de l'Hụpital La Pitiộ Salpộtriốre, Malformations artộrio-veineuses 25 Spetzler R F, et al (1978) Normal perfusion pressure breakthrough theory, Clin Neurosurg 25, 72-651 26 Spetzler R F, et al (1987) Surgical management of large AVM's by staged embolization and operative excision, J Neurosurg 67(1), 17-28 27 Al-Shahi R, Stapf C (2005) The pronosis and treatment ofarteriovenous malfomations of the brain, Practical neurology 5, 194-205 28 Steinmeier R, et al (1989) Evaluation of prognostic factors in cerebral arteriovenous malformations, Neurosurgery 24(2), 193-200 29 Talanov A B, et al (2010) Structural features of cerebral arteriovenous malformations according to the data of optic microscopy and scanning electron microscopy of corrosion specimens, Zh Vopr Neirokhir Im N N Burdenko 4(discussion 31), 27-31 30 Stapf C, Al-Shahi R (2005) The pronosis and treatment ofarteriovenous malfomations of the brain, Practical neurology 5, 194-205 31 Duong D H, et al (1998) Feeding artery pressure and venuos drainage pattern are primary determinants of hemorrhage from cerebral arteriovenous malfomations, Stroke 29(6), 76-1167 32 Ghossoub M, et al (2001) Characteristics of epileptic sezures asociated with cerebral arteriovenous malfomations, Neurochirurgie 47, 76-168 33 Nataf F, et al (2004) Bleeding after radiosurgery for cerebral arteriovenous malfomations, Neurosurgery 55(2), 298-305 34 Salgado H, Albert P, et al (1990) A study of the venous drainage of 150 cerebral arteriovenous malfomations as related to the hemorrhagic risks size of the lesion, Acta Neurochir, 103,30-35 35 Alexander E, Maciunas R J (1999) Advanced Neurosurgical Navigation, Geor - Thieme, New York 36 Nguyn Thanh Bỡnh (1999) Nhn xột 35 ca d dng mch mỏu nóo v chn oỏn v hng iu tr Trng i hc Y H Ni, H Ni 37 Crawford (1986) AVM of the brain: Natural history in unperated patient, J Neuro-neurosurgery 49 38 Brown R.D, Wiebers D.O, Forbes G.S (1990) Unruptured intracranial aneurysms and arteriovenous malformations: frequency of intracranial hemorrhage and relationship of lesions, J Neurosurg, 73, 859863 39 Langer D.J, Lasner T.M, Hurst R.W (1998) Hypertension, small size, and deep venous drainage are associated with risk of hemorrhagic presentation of cerebral arteriovenous malformations, Neurosurgery, 42(3), 481-6; discussion 487-489 40 Komatsu F, et al (2009) Ruptured tectal arteriovenous malformation demonstrated angiographically after removal of an unruptured occipital lobe arteriovenous malformation, Neurol Med Chir (Tokyo) 49(1), 2-30 41 Steinberg G K, et al (1996) Surgical resection of large incompletely treated intracranial arteriovenous malformations following stereotactic radiosurgery, J Neurosurg 84(6), 8-920 42 Meisel H.J, et al (2000) Cerebral arteriovenous malformations and associated aneurysms: analysis of 305 cases from a series of 662 patients, Neurosurgery 46(4)(discussion 2-800), 793-800 43 Lờ Hng Nhõn v Nguyn Th Ho (2004) S phi hp gia tỳi phỡnh ng mch nóo v DDTMN, Tp thụng tin y hc 10, 29 - 32 44 Garresson HD (1995) Vascular malfomation and fistular intracranial arteriovenous malfomation Vol II, Grune-Stattron 45 Hartmann A, Mast H, Mohr J.P, Koennecke H.C, et al (1998) Morbidity of intracranial hemorrhage in patients with cerebral arteriovenous malformation, Stroke, 29, 931934 46 Young W L, Kader A, Pile-Spellman J, et al (1994) The influence of hemodynamic and anatomic factors on hemorrhage from cerebral arteriovenous malformations, Neurosurgery 34(5), 807-808 47 Castel J P and Kantor G (2001) Postoperative morbidity and mortality after microsurgical exclusion of cerebral arteriovenous malformations Current data and analysis of recent literature, Neurochirurgie 47(2-3 Pt 2), 83-369 48 Michael T Lawton (2006) Controversies in neurological surgery neurovascular diseases, Thieme, New York 49 Jomin M, et al (1993) Natural history and spontaneous prognosis of cerebral arteriovenous malformations, Neurochirurgie 39(4)(discussion 1-210), 10-205 50 Meisel J and Brock M Mansmann U, et al (2000) Factors associated with intracranial hemorrhage in cases of cerebral arteriovenous malfomation, Neurosurgery 46(279-81), 272-279 51 Nataf.F, et al (2003) Radiosurgery of cerebral arteriovenous malfomations in children: a series of 57 cases, Int J Radiat Oncol Biol Phys 57(1), 95-184 52 Lờ Hng Nhõn (2002) Nghiờn cu chn oỏn v iu tr phu thut DDTMN tng trờn lu tiu nóo, Trng i hc Y H ni, H Ni 53 Lờ Hng Nhõn (2010) Nghiờn cu c im lõm sng, chn oỏn hỡnh nh, yu t tiờn lng, kt qu phu thut DDTMN, Trng i hc Y H ni, H Ni 54 Grip A Nornes H (1980) Hemodynamic aspects of cerebral arteriovenous malfomations, J Neuro-neurosurgery 53, 456-464 55 Nguyn Quang Quyn (1999) Atlas gii phu ngi, Nh xut bn Y hc, H Ni 56 Deruty R, et al (1993) The neurosurgeon's role in the treatment of cerebral arteriovenous malformations A study of a series of 100 cases and review of the literature, Neurochirurgie 39(4), 24-212 57 Spetzler R F, et al (1978) Normal perfusion pressure breakthrough theory, Clin Neurosurg 25, 72-651 58 Spetzler R F, et al (1987) Surgical management of large AVM's by staged embolization and operative excision, J Neurosurg 67(1), 17-28 59 Garcia Monaco R, et al (1990) Posterior fossa arteriovenous malformations, Neuroradiology 31(Angioarchitecture in relation to their hemorrhagic episodes), 5-471 60 Steinmeier R, et al (1989) Evaluation of prognostic factors in cerebral arteriovenous malformations, Neurosurgery 24(2), tr 193-200 61 Batjer h and Samson r (1986) Arteriovenous malformations of the posterior fossa, Neurosurg 64 (6)(Clinical presentation, diagnostic evaluation, and surgical treatment), 56-849 62 Willinsky R A Stefani M A, Wallace M C, et al (2002) Large and deep brain arteriovenous malfomatins are assiociated with risk of future hemorrhage, Stroke 33, 1220-1224 63 Phm Minh Thụng v cng s (2004) Nghiờn cu mt s c im hỡnh nh d dng ng tnh mch nóo v kt qu bc u iu tr bng phng phỏp gõy tc lũng mch, Tp y hc Vit Nam 301, 212 - 217 64 Horton J.C, Chambers W.A, Lyons S.L, et al (1990) Pregnancy and the risk of hemorrhage from arteriovenous malformations, Neurosurgery, 27, 867 65 Phm Vn Lnh v cng s Trn c Thỏi (2008) iu tr d dng ng tnh mch nóo bng gamma knife ti bnh vin i hc Y Dc Hu nhõn 56 trng hp, Y hc thc hnh s chuyờn 635 636, 314 - 324 66 Deshpande D H and Vidyasagar C (1980) Histology of the persistent embryonic veins in arteriovenous malformations of brain, Acta Neurochir (Wien) 53, 36-227 67 Kader A, Young W.L, Pile-Spellman J, Mast H (1994) The influence of hemodynamic and anatomic factors on hemorrhage from cerebral arteriovenous malformations, Neurosurgery, 34(5), 801-7; discussion, 807-808 68 M.C Yasagil (1987) Microneurosurgery, New York: Geor - Thieme 69 M.C Yasagil (1987) Microneurosurgery, New York: Geor - Thieme BNH N MU I Phn hnh chớnh: 1.H v tờn: 2.Tui .3.Gii:Nam/N 4.a ch: 5.S in thoi 6.Ngy vo vin: 7.Lý vo vin: Ngy vin Mó s bnh ỏn: II Tin s: Tin s chung - Cao HA - Tim mch - Thai sn Tin s gia ỡnh: -Trong gia ỡnh cú b bnh: + Tai bin mch nóo + U mch trờn da + U nóo + Cỏc bnh khỏc ca h thng thn kinh III.Lõm sng: 1.Khỏm lõm sng: M: l/p, HA: mmHg Triu chng lõm sng: Ri lon ý thc: Cn ng kinh: Yu, lit na ngi Hi chng tiu nóo Nụn v/hoc bun nụn Ri lon ngụn ng Gim th lc Cỏc du hiu khỏc: Trc m: Tri giỏc (im Glasgow) Lit ng kinh triu chng khỏc Sau m: Tri giỏc (im Glasgow) Lit ng kinh triu chng khỏc 2.Chn oỏn hỡnh nh: - CLVT hoc CHT xỏc inh: * V trớ ca mỏu t: Trỏn Thỏi dng .nh .Chm Chy mỏu khoang di nhn Chy mỏu nóo tht *V trớ ca DDTMN Trỏn Thỏi dng .nh Chm Nụng Sõu *Kớch thc DDTMN: 6cm *Tn thng xung quanh DDTMN Teo nóo Nang dch Phự nóo -Chp ng mch nóo: *Kớch thc DDTMN: 6cm *V trớ DDTMN : Trỏn Thỏi dng nh Chm H sau Nụng Sõu *ng mch cp mỏu: /m nóo gia /m trc /m nóo sau *Tnh mch dn lu: Nụng .Sõu (tờn v s lng) *Cỏc d dng mch kốm theo: Phỡnh ng mch Lon sn thnh mch 2.Phõn loi Spetzler I .II III .IV V III iu tr: 1.Trc m: 2.M: V trớ mỏu t: Trỏn Thỏi dng .nh Chm Nụng Sõu V trớ DDTMN: Trỏn Thỏi dng .nh Chm Nụng Sõu Kớch thc DDTMN: 6cm ng mch cp mỏu- s lng: /m nóo gia /m trc /m nóo sau Tnh mch dn lu- s lng: Nụng .Sõu Cỏch thc m: Ly ton b Ly mt phn Kp /m cp mỏu hoc t DDTMN Ly mỏu t Dn lu nóo tht 3.ỏnh giỏ kt qu sau m: - Kt qu gn + Khụng ly ht DDTMN: VựngV trớ nụng sõuKớch thc + Bin chng sm: Thiu mỏu nóoChy mỏu nóoViờm mng nóopxe nóo + B np s: CúKhụng +Kt qu gn theo phõn loi ca Deruty Tt: Ci thiờn triu chng lõm sng Trung bỡnh:Khụng ci thin triu chng lõm sng Xu :Nng lờn v triu chng lõm sng hoc t vong - Kt qu xa(cỏch viờn thỏng tr lờn) + Kh nng ly ht DDTMN (Da vo chp kim tra): Ly htKhụng ht + Di chng: Ri lon tri giỏcLit ẵ nging kinh +Kt qu xa: Da vo kt hp c kt qu lõm sng v chp kim tra ỏnh giỏ.Tiờu chun ỏnh giỏ nh tiờu chun ca Deruty ó nờu trờn (Tt Trung bỡnh Xu ) Ngi lm bnh ỏn Lờ Xuõn Trung v cs (2003), D dng ng tnh mch nóo, Bnh hc phu thut thn kinh, ed, Nh xut bn Y hc c Cng (2006), Nghiờn cu hỡnh nh chp ng mch nóo s húa xúa nn chn oỏn d dng ng tnh mch nóo Nguyn Vn ng (1999), "Tai bin mch mỏu nóo" Kiu Vit Hựng (2001), Phõn tớch hi cu 56 trng hp DDTMN, Cụng trỡnh khoa hc hi ngh phu thut thn kinh ln th II, ch biờn, Bnh vin Vit c Vừ Vn Nho and Kiu Vit Hựng (1998), "iu tr ngoi khoa trng hp thụng ng tnh mch nóo", Tp y hc Vit Nam 6,7,8, tr 149 - 154 Lờ Hng Nhõn v cs Nguyn Th Ho (2000), "ỏnh giỏ kt qu trờn iu tr phu thut d dng ng mch nóo nhõn 16 trng hp m ti bnh vin Vit c t 1-1999 n 1-2000", Ngoi khoa 6, tr 34 - 37 et al Phm Minh Thụng (2004), "Nghiờn cu mt s c im hỡnh nh d dng ng tnh mch nóo v kt qu bc u iu tr bng phng phỏp gõy tc lũng mch", Tp y hc Vit Nam 301, tr 212 - 217 Nguyn Quang Quyn (1999), "Atlas gii phu ngi" Phm Vn Lnh Trn c Thỏi , and v cs (2008), "iu tr d dng ng tnh mch nóo bng gamma knife ti bnh vin i hc Y Dc Hu nhõn 56 trng hp", Y hc thc hnh s chuyờn 635- 636, tr 314 - 324 10 Nguyn Thng Xuõn and Phm Gia Triu (1961), "Nhõn trng hp m u mch", Tp y hc Vit Nam 2, tr 97 - 103 11 Adam I Lewis Alexander Y Zubkov, David Scalzo (1999), "Transluminal angioplasty and intra-arterial papaverine for the treatment of cerebral vasospasm after ruptured arteriovenous malformations", Surgical Neurology 51(1), tr 75 - 80 12 Pritz M B (1994), "Ruptured supratentorial arteriovenous malformations associated with venous aneurysms", Acta Neurochir (Wien) 128(1-4), tr 62-150 13 Yasagil M C (1987), Microneurosurgery, Vol IIIB, Geor - Thieme, New York 14 Yasagil M C (1987), Microneurosurgery, Vol IIIA, Geor - Thieme, New York 15 Yasagil M C (1987), Microneurosurgery: New York: Geor - Thieme 16 Batjer H and Samson D (1986), "Arteriovenous malformations of the posterior fossa", Neurosurgery 64 (6)(Clinical presentation, diagnostic evaluation, and surgical treatment), tr 56-849 17 et al Deruty R (1993), "The neurosurgeon's role in the treatment of cerebral arteriovenous malformations", Neurochirurgie 39(4)(A study of a series of 100 cases and review of the literature), tr 24-212 18 Castel J P and Kantor G (2001), "Postoperative morbidity and mortality after microsurgical exclusion of cerebral arteriovenous malformations Current data and analysis of recent literature", Neurochirurgie 47(2-3 Pt 2), tr 83-369 19 Heros R C and Morcos J J (2000), "Cerebrovascular surgery: past, present, and future", Neurosurgery 47(5), tr 33-1007 20 et al Jomin M (1993), "Natural history and spontaneous prognosis of cerebral arteriovenous malformations", Neurochirurgie 39(4)(discussion 1-210), tr 10-205 21 M.C Yasagil (1987), Microneurosurgery, Vol IIIB, Geor - Thieme, New York 22 M.C Yasagil (1987), Microneurosurgery, Vol IIIA, Geor - Thieme, New York 23 M Yashar S Kalani Robert F Spetzler , Peter Nakaji (2015), Neurovascular Surgery, 2nd, ed 24 Centre de Neuroradiologie de l'Hụpital La Pitiộ Salpộtriốre, "Malformations artộrio-veineuses" 25 R F Spetzler v cỏc cng s (1978), "Normal perfusion pressure breakthrough theory", Clin Neurosurg 25, tr 651-72 26 et al Spetzler R F (1978), "Normal perfusion pressure breakthrough theory", Clin Neurosurg 25, tr 72-651 27 et al Spetzler R F (1987), "Surgical management of large AVM's by staged embolization and operative excision", J Neurosurg 67(1), tr 17-28 28 Al-Shahi R Stapf C (2005), "The pronosis and treatment ofarteriovenous malfomations of the brain", Practical neurology 5, tr 194-205 29 et al A B Talanov (2010), "Structural features of cerebral arteriovenous malformations according to the data of optic microscopy and scanning electron microscopy of corrosion specimens", Zh Vopr Neirokhir Im N N Burdenko 4(discussion 31), tr 27-31 30 Stapf C Al-Shahi R (2005), "The pronosis and treatment ofarteriovenous malfomations of the brain", Practical neurology 5, tr 194-205 31 Duong D H et al (1998), "Feeding artery pressure and venuos drainage pattern are primary determinants of hemorrhage from cerebral arteriovenous malfomations", Stroke 29(6), tr 76-1167 32 Ghossoub M et al (2001), "Characteristics of epileptic sezures asociated with cerebral arteriovenous malfomations", Neurochirurgie 47, tr 76-168 33 Nataf F et al (2004), "Bleeding after radiosurgery for cerebral arteriovenous malfomations", Neurosurgery 55(2), tr 298-305 34 Salgado H Albert P, et al (1990), "A study of the venous drainage of 150 cerebral arteriovenous malfomations as related to the hemorrhagic risks size of the lesion", Acta Neurochir 103(30-35) 35 E Alexander v R.J Maciunas (1999), Advanced Neurosurgical Navigation, Thieme 36 Nguyn Thanh Bỡnh (1999), "Nhn xột 35 ca d dng mch mỏu nóo v chn oỏn v hng iu tr" 37 Crawford (1986), "AVM of the brain: Natural history in unperated patient", J Neuro-neurosurgery 49 38 c Cng (2006), Nghiờn cu hỡnh nh chp ng mch nóo s húa xúa nn chn oỏn d dng ng tnh mch nóo 39 Nguyn Vn ng (1999), Tai bin mch mỏu nóo 40 et al F Komatsu (2009), "Ruptured tectal arteriovenous malformation demonstrated angiographically after removal of an unruptured occipital lobe arteriovenous malformation", Neurol Med Chir (Tokyo) 49(1), tr 2-30 41 et al G K Steinberg (1996), "Surgical resection of large incompletely treated intracranial arteriovenous malformations following stereotactic radiosurgery", J Neurosurg 84(6), tr 8-920 42 et al H J Meisel (2000), "Cerebral arteriovenous malformations and associated aneurysms: analysis of 305 cases from a series of 662 patients", Neurosurgery 46(4)(discussion 2-800), tr 793-800 43 Lờ Hng Nhõn v Nguyn Th Ho (2004), "S phi hp gia tỳi phỡnh ng mch nóo v DDTMN", Tp thụng tin y hc 10, tr 29 - 32 44 Garresson HD (1995), Vascular malfomation and fistular intracranial arteriovenous malfomation Vol II, Grune-Stattron 45 Kiu Vit Hựng (2001), " Phõn tớch hi cu 56 trng hp DDTMN", Cụng trỡnh khoa hc hi ngh phu thut thn kinh ln th II 46 Young W L Kader A, Pile-Spellman J, et al (1994), "The influence of hemodynamic and anatomic factors on hemorrhage from cerebral arteriovenous malformations", Neurosurgery 34(5), tr 807-808 47 J P Castel and G Kantor (2001), "Postoperative morbidity and mortality after microsurgical exclusion of cerebral arteriovenous malformations Current data and analysis of recent literature", Neurochirurgie 47(2-3 Pt 2), tr 83-369 48 et al M Jomin (1993), "Natural history and spontaneous prognosis of cerebral arteriovenous malformations", Neurochirurgie 39(4)(discussion 1-210), tr 10-205 49 Meisel J and Brock M Mansmann U, et al (2000), "Factors associated with intracranial hemorrhage in cases of cerebral arteriovenous malfomation", neurosurgery 46(279-81), tr 272-279 50 et al Nataf.F (2003), "Radiosurgery of cerebral arteriovenous malfomations in children: a series of 57 cases", Int J Radiat Oncol Biol Phys 57(1), tr 95-184 51 Lờ Hng Nhõn (2002), Nghiờn cu chn oỏn v iu tr phu thut DDTMN tng trờn lu tiu nóo 52 Lờ Hng Nhõn (2010), Nghiờn cu c im lõm sng, chn oỏn hỡnh nh, yu t tiờn lng, kt qu phu thut DDTMN 53 Lờ Hng Nhõn (2010), Nghiờn cu c im lõm sng, chn oỏn hỡnh nh, yu t tiờn lng, kt qu phu thut DDTMN, Trng i Hc Y H Ni 54 Grip A Nornes H (1980), "Hemodynamic aspects of cerebral arteriovenous malfomations", J Neuro-neurosurgery 53, tr 456-464 55 Nguyn Quang Quyn (1999), Atlas gii phu ngi 56 et al R Deruty (1993), "The neurosurgeon's role in the treatment of cerebral arteriovenous malformations A study of a series of 100 cases and review of the literature", Neurochirurgie 39(4), tr 24-212 57 et al R F Spetzler (1978), "Normal perfusion pressure breakthrough theory", Clin Neurosurg 25, tr 72-651 58 et al R F Spetzler (1987), "Surgical management of large AVM's by staged embolization and operative excision", J Neurosurg 67(1), tr 17-28 59 et al R Garcia Monaco (1990), "Posterior fossa arteriovenous malformations", Neuroradiology 31(Angioarchitecture in relation to their hemorrhagic episodes), tr 5-471 60 et al R Steinmeier (1989), "Evaluation of prognostic factors in cerebral arteriovenous malformations", Neurosurgery 24(2), tr 193-200 61 H.Batjer and D Samson (1986), "Arteriovenous malformations of the posterior fossa", Neurosurg 64 (6)(Clinical presentation, diagnostic evaluation, and surgical treatment), tr 56-849 62 Willinsky R A Stefani M A, Wallace M C, et al (2002), "Large and deep brain arteriovenous malfomatins are assiociated with risk of future hemorrhage", Stroke 33, tr 1220-1224 63 Phm Minh Thụng v cng s (2004), "Nghiờn cu mt s c im hỡnh nh d dng ng tnh mch nóo v kt qu bc u iu tr bng phng phỏp gõy tc lũng mch", Tp y hc Vit Nam 301, tr 212 - 217 64 Trn c Thỏi., Phm Vn Lnh v v cs (2008), "iu tr d dng ng tnh mch nóo bng gamma knife ti bnh vin i hc Y Dc Hu nhõn 56 trng hp", Y hc thc hnh s chuyờn (635 636), tr 314 - 324 65 Phm Vn Lnh v cng s Trn c Thỏi (2008), "iu tr d dng ng tnh mch nóo bng gamma knife ti bnh vin i hc Y Dc Hu nhõn 56 trng hp", Y hc thc hnh s chuyờn 635 636, tr 314 - 324 66 D H Deshpande and C Vidyasagar (1980), "Histology of the persistent embryonic veins in arteriovenous malformations of brain", Acta Neurochir (Wien) 53, tr 36-227 67 Vừ Tn Sn Vừ Vn Nho (2013), Phu thut thn kinh, 1, ed, NXB Y hc, 68 M.C Yasagil (1987), Microneurosurgery, New York: Geor - Thieme 69 M.C Yasagil (1987), Microneurosurgery, New York: Geor - Thieme ... TO B Y T TRNG I HC Y H NI Lấ VN BNG CáC YếU Tố TIÊN LƯợNG LIÊN QUAN ĐếN NGUY CƠ TĂNG CHảY MáU Và ĐáNH GIá KếT QUả VI PHẫU THUậT CủA Dị DạNG ĐộNG - TĩNH MạCH NãO Chuyờn ngnh: NGOI KHOA Mó s: NT... nóo Song song vi cỏc tỏc gi ca bnh vin Vit c, cỏc tỏc gi ca bnh vin Ch Ry Vừ Vn Nho, Kiu Vit Hựng [5] cng thụng bỏo kt qu phu thut ỏng khớch l i vi bnh ny iu tr nỳt mch v iu tr quang tuyn [9,... nidus Theo Nataf.F i vi cỏc phỡnh mch lon sn thnh mch (khụng liờn quan ti dũng chy ca DDTMN) cn thit phi iu tr cựng vi DDTMN cũn i vi cỏc d dng nm trờn cựng /m cp mỏu, liờn quan vi dũng chy thỡ ch