Vim thn kinh tin nh

PGS.TS.BS Cao Phi Phong

Gii thiu
Vim thn kinh tin nh(vestibular neuritis), vim m o(labyrinthitis),
vim m o thn kinh(neurolabyrinthitis) hay bnh l tin nh ngoi bin
cp( acute peripheral vestibulopathy). y l bnh l lnh tnh, t gii hn
v hi phc hon ton trong hu ht bnh nhn tuy nhin cc triu chng
chng mt , bun nn , nn v ri lon dng i c th gy kh chu trong
thi gian ngn. Vim thn kinh tin nh c cc triu chng ging vi cc
bnh l khng lnh tnh, c bit cc tn thng do mch mu h thn kinh
trung ng, cn chn on phn bit trnh t vong.
Sinh l bnh
Vim thn kinh tin nh xy ra sau nhim siu vi hay vim hu nhim siu
vi h thng tin nh ca dy thn kinh s VIII, c ch sinh l bnh cha r,
trn phn na bnh nhn khng c tin cn nhim siu vi
Lm sng
Bnh khi pht nhanh vi triu chng chng mt kiu quay nng n km
bun nn v nn, dng i lo o. Thm khm c cc du hiu ca tin nh
cp.
1. Git nhn cu tin nh t pht(nystagmus): git nhn cu mt bn,
ngang hay ngang-xoay, c ch khi nhn c nh, khng thay i hng
khi nhn chm ch, chiu nhanh i bn tn thng
2. Test xoay u nhanh dng tnh: xoay u nhanh v bn tn thng,
bnh nhn khng duy tr nhn c nh. Trong nghin cu hng lot,
82% bnh nhn vim thn kinh tin nh cp c test xoay u dng
tnh, tuy nhin khng loi tr tn thng trung ng
3. i khng vng, kh nng i li vn cn, nu ng thng ng v bn
tn thng.
4. Cc du hiu thn kinh khc: nhn i hay lch trc theo chiu dc
ca mt c th hin din do mt phn x si tai-nhn cu(otolithic-
ocular), mc d s xut hin thng c nghi bnh nhn c t
qu.
5. Trong vim thn kinh tin nh chc nng thnh gic khng nh
hng, khi hi chng ny kt hp mt thnh lc mt bn, gi l vim
m o(labyrinthitis).
(trong mt nghin cu 101 bnh nhn, 3 du hiu lm sng phn bit vim
thn kinh tin nh v t qu: s hin din ca test xoay u nhanh bnh
thng, lch trc theo chiu dc ca mt hay thay i hng git nhn cu
chn on t qu vi nhy 100% v chuyn bit 96%.
Chn on phn bit
Nhiu nguyn nhn gy chng mt, chn on phn bit chnh i vi bnh
nhn chng mt cp l phn bit tn thng mch mu h thn kinh trung
ng nh hng n tiu no v thn no. c bit cc bnh nhn c yu t
nguy c mch mu, kh nng cao ti pht t qu.
Xut huyt hay nhi mu tiu no:
Trn 25% bnh nhn trn 50 tui chng mt cp nhp cp cu l nhi mu
hay xut huyt tiu no. Cc du hiu sau y gip chn on phn bit vi
vim thn kinh tin nh;
- git nhn cu khng c ch khi nhn c nh, khng git ngang hay
ngang-xoay v c th thay i hng khi nhn chm ch
- bnh nhn thng khng th ng hay i mt mnh. Hng ng
khng nht thit phi i bn hng git nhn cu
- c th c lon tm chi, ni kh hay au u
- test xoay u bnh thng
- bnh nhn ln tui c yu t nguy c x va mch(cao huyt p, i
tho ng, ht thuc).
Tuy nhin s phn bit khng phi lc no cng r rng, chn on hnh nh
cn thit khi khng xc nh chn on.
Nhi mu thn no:
Hi chng t qu thng gy chng mt nhiu nht l hi chng
Wallenberg (nhi mu no vng hnh tu bn)
- hi chng Horner cng bn
- mt cm gim gic phn ly(mt cm gic au v nhit mt cng bn
v chi v thn i bn)
- vn ng mt bt thng
- mt phn x gic mc cng bn
- khn ting v nut kh
- tht iu chi cng bn
Tn thng khu tr thn no, ch nh hng cc t chc tin nh c th
biu hin lm sng tng t vim thn kinh tin nh. Phn ln l do bnh l
ng mch nh lin quan n tui, cao huyt p v i tho ng. iu tr
lu di bao gm iu tr cc yu t nguy c x va ng mch v chng kt
tp tiu cu,
Chn on
Chn on vim thn kinh tin nh da vo cc du hiu lm sng, khng
c cn lm sng c hiu. Chn on hnh nh c ch nh khi c yu t
nguy c t qu, cn loi tr cc tn thng trung ng. Bnh nhn tr
chng mt cp, khng c triu chng thn kinh v khm git nhn cu ngun
gc ngoi bin khng cn chn on hnh nh nu ci thin trong 48 gi.
Cng hng t no v mch mu no(MRI v MRA)c th pht hin nhi
mu h sau trong ngy u, MRA c nhy v chuyn bit n 95% trong
chn on hp hay tc tun hon sau.
Chp ct lp no(CT scanning) khi khng thc hin c MRI, CT thng
bnh thng trong nhng gi u sau nhi mu, tuy nhin cc trng hp
xut huyt trong nhu m hay ph n chn p no tht t c th pht hin
khn cp.
D hu
Bnh nhn vim thn kinh tin nh thng c triu chng tin nh nng
trong mt n hai ngy v gim dn cc triu chng v phc hi thng bng.
Bnh cp tnh t khi ko di qu nhiu ngy n vi tun, bnh c th li
mt thng bng v chng mt khng in hnh nhiu thng. S ci thin cc
triu chng phn ln l do s b tr t trung ng.
iu tr
iu tr bnh bao gm: corticosteroids, khng virus, iu tr triu chng v
phc hi chc nng tin nh.
- iu tr giai on cp: iu tr corticosteroid trong giai on cp ci thin
s phc hi chc nng tin nh ngoi bin bnh nhn vim m o cp.
Mt nghin cu ngu nhin c i chng so snh iu tr trong 4 nhm:
placebo, methylprednisolone, valacyclovir v
methylprednisolone+valacyclovir
1. iu tr methylprednisolone theo di trong 12 thng ci thin r chc
nng tin nh so vi plcebo.
2. iu tr valacyclovir 1000mg 3 ln /ngy trong 7 ngy khng ci thin
d hu
3. iu tr phi hp methylprednisolone +valacyclovir khng hiu qu
hn methylprednisolone n thun
Mc d d hu c nh gi bng ci thin p ng nhit, nghin cu
khng nh gi thi gian triu chng nng nh mt thng bng, mt nh
hng trong khng gian mn tnh, do iu tr corticosteroid cha r rng
lm gim triu chng lu di. Mt phn tch gp 4 nghin cu ngu nhin
(149 bnh nhn) nh gi hiu qu ca corticosteroid vn cn nhiu kin
khc nhau, tuy nhin iu tr corticosteroid trong vim m o cp l hp l
(60mg prednison trong 5 ngy, 40mg ngy th 6, 30mg ngy th 7, 20mg
ngy th 8, 10mg ngy th 9 v 5mg ngy th 10.
- iu tr triu chng; iu tr triu chng chng mt, bun nn, nn trong
nhng ngy u vim thn kinh tin nh, cc thuc chng nn, khng
histamine, khng cholinergic v benzodiazepine, khi u liu thp v tng
dn khi cn thit. Rt t bng chng cho thy nhm thuc no c hiu qu
hn. Nhm khng histamin v khng cholinergic t gy bun ng hn
benzodiazepine. Cc thuc c ch hot ng tin nh lm nh hng s b
tr ca trung ng, ko di thi gian hi phc.
- Phc hi chc nng tin nh: cc bi tp tin nh gip y nhanh hi
phc v ci thin tn tt bnh nhn tn thng thng trc.

TM TT V KHUYN CO

1. Vim thn kinh tin nh c cho l do vim siu vi cp hay ri lon

vim hu nhim siu vi h thng tin nh ca dy thn kinh s 8.
2. Vim thn kinh tin nh biu hin khi pht chng mt cp tnh km
bun nn, nn v tn thng dng i
3. Triu chng vim thn kinh tin nh trng lp vi tn thng mch
mu thn no v tiu no, thm khm lm sng gip chn on phn
bit
4. Khng c xt nghim chn on xc nh vim thn kinh tin nh,
tuy nhin MRI no cn thit cho bnh nhn chng mt ko di, thm
khm khng ph hp vim thn kinh tin nh, ln tui(trn 60 tui),
hay c au u, du thn kinh khu tr hay yu t nguy c mch mu.
5. Bnh nhn vim thn kinh tin nh v khng c chng ch nh
corticosteroid c th dng corticosteroid v gim dn, thuc hiu qu
trong thi gian ngn, lu di cha r.
6. Dng thuc c ch tin nh v chng nn gim triu chng trong
24-48 gi, ngng iu tr triu chng sau 48 gi nu cho php v cc
thuc ny can thip s b tr ca trung ng
7. Phc hi chc nng tin nh sm sau khi triu chng cp thuyn
gim, gip y nhanh s hi phc c bit thng bng.