Cao DSng Y te Phu Tho - Tlur vi§n

K M . 0 0 71 2 6
JACQUES CLARISSE
NGUYEN THI HUNG
PHAM NGOC HOA
• •

H I N H A N H H O C

SON AO

X q u a n g c a t la p d ie n t o a n
C o n g h a a n g tCf

\J J NHAXUiT BAN YHOC

C h u b ien :

- J. CLARISSE
G iao su bac si H inh anh hoc, D ai hoc Y khoa L ille
N guyen T ruong khoa Bo m on H inh anh hoc B enh vien R oger Salengro - D ai hoc
Y khoa L ille, Phap

- NGUYEN THI HUNG

B ac si y khoa, T ien si Y hoc
G iam doc B enh vien N guyen Tri Phucmg, TP H o C hi M inh
Pho chu tich H oi T han K inh H oc TP H o C hi M inh

- PHAM NGOC HOA

Bac si y khoa, T ien sT Y hoc
T ruong khoa Bo m on C han doan hinh anh, V ien T ru o n g C h o R ay - D ai hoc Y D uoc,
TP H 6 Chi M inh
C hu tich hoi C han doan hinh anh TP Ho C hi M inh

N g ir o i d ic h :

- PHI ICH NGHI

N guyen G iao su thinh giang , D ai hocY khoa H enri Poincare - N A N C Y , Phap
T ruong khoa C han doan hinh anh B enh vien FV, TP H6 C hi M inh

V o i sir con g tac cua :

- LE T U PHUCKNG THAO
Bac si Y khoa, T ien si Y hoc
G iang vien Bo m on T h in kinh Dai hoc Y khoa Pham N goc T hach (T T D T B D CBYT)
T ruong khoa ThSn kinh, Benh vien N han dan G ia D inh, TP H 6 C hi M inh

- HA THJ THANH TUYEN

Bac si Y khoa, T hac si Y hoc
Bac sT chuyen khoa C han doan hinh anh B enh vien 115, T P H o C hi M inh

H ie u dl'nh : NGUYEN THI HUNG, PHAM NGOC HOA

h in h An h h o c s o n a o• •

X Q U A N G C A T L O fP D I $ N T O A N

C Q N G H lJ d N G TLf

TRUONG
CAO DANG
Y T§'
PHU T H O

•THU V IE N
so

_____ cHO/iol/
 LCH G i a i THIEU

Vcri circmg vi la C hu tich Hoi Chan doan hinh anh T hanh pho Ho Chi M inh tir nam 1995
den 2005, cho phep toi dugc co doi Idi to bay long ton kinh voi G iao su Jacques C larisse ve nhirng
viec ong da lam cho tat ca chiing ta, nhirng bac si chan doan hinh anh. bac si noi than kinh va
ngoai than kinh cua V iet Nam.

Tir khoang m irdi hai nam nay G iao su Jacques Clarisse cua C H U De Lille da danh nhieu
tinh cam , thoi gian cho V iet N am cung nhu ong da su dung phucmg tien cua chinh ong de den
Viet Nam giang day ve Hinh anh hoc than kinh trong khuon kho c h uong trinh dao tao FFI va
chuong trinh dao tao lien tuc FM C ve hinh anh hoc y khoa dirge to chuc bcri G R E F va Dai sir
quan Phap phoi hop voi Dai Hoc Y Ha Noi va T rung Tam D ao Tao Boi Ducmg C an Bo Y Te.

C huong trinh FFI ve hinh anh hoc y khoa da dat nhieu thanh tiru Ion voi hang tram bac sT
Chan doan hinh anh V iet N am dugc dao tao tai Phap FFI cap 1, FFI cap 2, Pho G iao su hay G iao
su cong tac. Ho hien tai xay dung nen nganh C han doan hinh anh hoc V iet Nam.

C h uong trinh dao tao lien tuc ve hinh anh hoc y khoa ma G iao su Jaques C larisse la ngucri
ggi y dau tien da giup ich rat nhieu cho cac bac si V iet N am , du noi tieng A nh, cung tan dung
duoc co hoi d u g c dao tao cac kien thirc m oi ve Hinh anh hoc Y khoa boi cac giao su va bac si
chan doan hinh anh Phap.

N goai hai c h uong trinh tren, G iao su Jaques C larisse con den V iet N am n h u m ot ky si don
thuong doc m a tir 7 nam nay, moi nam it nhat 2 lan den V iet N am de giang day ve H inh anh hoc
than kinh o TP H o C hi M inh, Hue va Ha Noi.

Dac biet, tai benh vien C h g Ray tat ca cac bac si chan doan hinh anh, bac si noi than kinh va
ngoai than kinh m ien nam V iet N am ai cung deu biet den G iao su Jaques Clarisse.

N am nay, vao thang 4 G iao su Jaques C larisse d u g c U y ban N han D an T hanh pho trao Bac
dau boi tinh vi su nghiep cong hien cua ong cho V iet Nam.

D ieu lam toi an tu o n g nhat a ong la su trung thuc, loi song d o n gian, su thang than va them
vao do la ly luan hgp logic cua ong trong chan doan hinh anh hoc, do la dieu lam toi n h d lai cau
cham ngon cua M ontaigne : « M ot cai dau co to chuc thi tot hon m ot cai dau chira day kien
thirc ».

N h o vao cac c h u o n g trinh nay ma trinh do chan doan hinh anh hoc V iet N am , dac biet la
trinh do chan doan hinh anh hgc than kinh, tien bo nhieu trong vai nam vira qua.

N hirng bai giang cua G iao su Jaques C larisse d u g c hieu dinh m oi nam va hien thoi dugc
xuat ban trong quyen sach Hinh anh hoc than kinh voi su tham gia cua Bac si Pham N goc Hoa,
Nguyen Thi H ung va Phi Ich Nghi.

Dai dien cho Hoi C han doan hinh anh T hanh Pho Ho C hi M inh toi bay to long biet o n sau
sac den G iao su Jaques C larisse va gidi thieu quyen sach nay den tat ca dong nghiep va sinh vien
y khoa.

T oi xin cam doan voi quy dong nghiep rang quyen sach nay co the giiip ich rat nhieu trong
chan doan benh ly than kinh.

BAC S i NGUYEN QUY KHOANG

V
 X in c h a n th a n h c a m o n :

- JP FRA N CK E
Bo m on G iai phau hoc
D ai Hoc Y K hoa Lille - V ien Dai Hoc L uat va Y Te LILLE

- JP PRU V O va cong sir

K hoa X quang T han Kinh, T rung Tam V ien Trucrng LILLE

- G SA LA M O N
Dai Hoc Y K hoa M A R SE IL L E

- N G U Y E N Q U Y KH O A N G TP HO CH I M INH

- N G U Y E N AN THAN H

- N G U Y E N T H A N H THUY

- HO H O A N G PH U O N G

- N G U Y E N BA T H A N G

- N G U Y E N THI KIM H U O N G

- N G U Y E N THJ CA M TU

- t r An DU G si

VI
 LOfI NOI DAU

Day la m ot quyen sach nhap m on ve hinh anh hoc than kinh va cung la m ot « so tay thirc hanh »
hinh anh hoc. Sach bao gom 3 phan :
Phan nhac lai m ot so diem can luu y ve giai phau va giai phau benh can thiet
Phan gicri thieu ve ky thuat tien hanh khao sat
Phucmg phap doc va ly giai hinh anh

M uc dich chung toi giai thieu sach nay la de cac ban co the tham khao cac sach kinh dien, dac biet
hai quyen sach m ai cua A nn O sborn

So tay bac si X quang / nao bo / 100 chan doan thuong gap

(Pocket radiologist / brain / lop 100 diagnoses / O sbom / A myrsis editions)

Hinh anh hoc chan doan / nao bo

M uc tieu cua sach la :

1 / T hiet lap m ot ngan hang hinh anh d u lieu

- N h u tat ca cac loai hinh anh khac, hinh anh hoc y khoa chira dung n hung thong tin m a
khong the dien dat bang tir n g u de doc gia suy dien ra hinh anh ... nhieu thong tin se bi bien doi
hoac that lac trong qua trinh chuyen doi hinh anh - tir n g u - hinh anh.

- C hinh vi the can cho doc gia nhieu thong tin nhin thay dugc qua « ngan hang d u lieu » do
ca nhan tu thu thap va luu tru thucrng xuyen. Sach nay la m ot quyen sach ve hinh anh giiip doc gia
nhin vao do m a lien he lai voi ngan hang dir lieu ca nhan cua m inh.

' tram n g h e k h o n g b a n c m at thav "

2 / X in d u g c trinh bay voi doc gia m ot « kirn chi nam » trong viec ly giai cac hinh anh thSn
kinh so nao.

CAC TAC GIA

 BANG CHU VIET TAT

ADC Apparent Diffusion Coefficient - He so khuyech tan bieu kien ADC

BJ Dong kinh Bravais Jacksion

CHT Cong hirong tif

CHT-MM Cong hirong ti> mach mau

DM Dong mach

DNET Dysembryoplasic neuroepithelial tumor - U bieu mo than kinh loan san phoi

DNT Djch nao tuy

DSA Digital Substraction Angiography - Chup mach so hoa xoa nen

gado Gadolinium

IR Inversion Recovery - Ky thuat hoi phuc dao ngu’O’c

MIP Maximum intensity projection - Ky thuat MIP

MPR Multiplanar reformation - Ky thuat tai tao nhieu mat p h ln g

PNET Primary neuroectodermal tumor - U bieu mo than kinh nguyen phat

T1 Fat Sat T1 bao hoa mo

T1 SE Chuoi xung T1 Spin Echo

T2 FLAIR T2 Fluid attenuated inversion recovery - Chuoi xung hoa tin hieu cac dich

T2 SE Chuoi xung T2 Spin Echo

T2* T2 Echo Gradient

TE Temps d'Echo - Thoi gian phan am

TK Than kinh

TOF Time of flight - Ky thuat mau sang TOF

UH Unites Hounsfield - D on vi Hounsfield

XQCLBT X quang c l t lop dien toan

V III
 MUC LUC
Lfri gioi thifu

Lai noi dau

Bang chfr viet t i t

NHCrNG DIEU C A N BIET KHI THVTC HIEN KY T H U A T H IN H A N H HQ C 1

- 1/ G IA I PH AU VA GIAI PH A U X Q U A N G : 3

- Hop so - M ang nao va khoang m ang nao - N ao bo - D ong m ach - Tinh m ach 3

- 2/ KY T H U A T V A HIN H A N H : m at dp tren X Q C L D T , tin h ifu tren C H T 25

- X Q CLD T ky thuat, m at do, tuong quan giai phau 25

- CHT ky thuat, tin hieu, tuong quan giai phau 35

i6i 1 - CA C C H U O I C H IN H
- T1 Spin Echo 39
- T2 Spin Echo : 1° echo ( mat do proton ) 39
2° echo 39
- T2 Inversion R ecuperation : T2 FLA IR 44
- T2 Echo G ra d ie n t: T2 * 45
- H inh anh hoc khuech tan : b 1000, ban do AD C 46
- T1 G A D O LIN IU M 53
2 - C A C C H U O I D A C B IET
- H inh anh hoc . D ong m ach co, dong m ach nao : dong, gado 57
. Cac tinh m ach nao : dong, gado 67
. D ong dich nao tiiy 71
- T1 Inversion R ecuperation, T1 Fat Sat, T1 gado bii dong 73
- Phan giai rat cao : C ISS 75
- H inh anh hoc trong tir cung ... 76
- H inh anh hoc khuech tan : gadolinium 77
- H inh bo than kinh : hinh anh hoc sue c&ng khuech tan (tenseur de difusion) 80
- H inh anh hoc chuc nang nao Echo Planar Im aging 81
- Phep do pho C H T 82

- 3 / D QC V A LY GIAI : 81

. A / D O C hinh anh :
- DSu hieu ton th u o n g (dau hieu true t ie p ) :
1 - M uc do ve m at do hoac tin hieu; tu o n g quan voi loai cau true 81
2 - Vi tri cua ton th u o n g , giai phau - X quang, tuong quan voi dau hieu lam sang : 83
roi loan v an dong, roi loan cam giac, roi loan chuc nang cao cap, day than kinh so
3 - H inh thai va vi tri co goi y m ot vung tuoi dong m ach khong? (xem trang 145)
4 - C4u true ben trong nao co con nguyen ven khong? khoang V irchov R obin con nguyen ven ? 100
5 - T on th u o n g duy nhat hay nhieu ton th uong? 101

- C ac hau qua cua ton th u o n g len cac cau true binh th u o n g (dau hieu gian tiep) :
6 - Phu 103
7 - D ay lech cac cau true lan can : ranh vo nao, d u o n g giua. ban trong ... 105
8 - T hoat vi : the chai, moc thai duong, thuy nhong phan tren, hanh nhan tieu nao 105
9 - G ian nao that : 109
. Do tac nghen D N T trong nao: bj u dong, lo M onro, kenh Sylvius, nao that IV, lo M agendie 109
. Do tac nghen D N T ngoai nao : viem m ang nao, tran dich nao that ap lire binh thucmg 114
. Do teo nao; phoi hop voi : gian cac khoang V irchov - Robin, thoai hoa chat trang 116
. D o di dang nao 1 18

IX
. B / C ac dau hi?u ggi y C A N N G U Y E N

1 - U trong nao :
- B enh than kinh dem u te b a o d e m 119
- M o than kinh PN E T, D N E T 129
- M o tao m au lym phom , u lircri m ach 131
- Di can nao theo duomg m au, d u o n g ducri nhen 133
- T ru o n g hcrp dac biet u trong nao that, u quai 136
gia u : u m ach d ang hang, phinh dong m ach 140
hoi ch u n g can ung th u 140

2 - Tai bien m ach m au nao :

- N hoi m au nao : vung tuoi d o n g m ach, m at do va tin hieu, can n guyen 143
- X uat huyet nao, xuat huyet m ang nao 174
- U m ach dang hang, u m ach tinh m ach 191
- V iem tac tinh m ach nao 199

3 - B enh ly viem : X o cu n g rai rac, benh chat trang cap tinh, benh saccoit 208

*4 - N hiem trung : - N hiem vi trung : ap xe, chan d o an cac ton th u o n g " dang nang " 218
tu mil, viem m ang nao, viem day m ang nao
- N hiem virut : viem nao herpes, H I V ,... 231
- N hiem ky sinh trung, nhiem nam 235

5 - B ?nh ly thoai hoa : benh P arkinson, teo nao da o he thong, b en h A lz h eim er ... 239
x o cu n g hai m a 245
6 - B enh ly nhiem doc : rucru, m a tuy, o x y t c a c b o n ... 247
7 - B enh ly bien d u o n g : loan d u o n g chat trang thircmg than, tang m u c opolysaccarit, L eigh ... 249

- TO N T H U O N G N G O A l N A O : tuy theo VI TRI

8 - V om so : - ton th u o n g xucmg, ton th u o n g m ang nao khu tru 250

- ton th u o n g so lan toa, ton thucrng m ang nao lan toa : viem day m ang nao 260
- bien doi hinh the hop so : dinh khcrp hop so, hop so kho n g can x u n g 262
9 - N en so - tang tru o c ( khong ke hoc m a t ) 265
10 - T uyenyen 270
11 - V iing ho yen : ton th u o n g tren yen, b en yen va ducri yen 283
12 - Phan tru o c d u o n g g iu a : the chai. vach, the tam giac 296
13 - Phan sau d u o n g g iu a : tuyen tiing , goc liem ldu . 16i th^ chai 299
14 - H o sau : goc cau tieu nao, doc yen, th an n en ... 301
( ngoai trir xucmg d a ) dau nhan phSn n in 310

- TO N T H U O N G TR O N G N A O V A / H O A C N G O A I N A O

15 - C han th u o n g so - nao 312

16 - Di dang nao, dj dang m ang nao : 324
17 - B enh than kinh-da : benh u x o T K , x o nao cii, Sturge W eber, V on H ippel / u lucri m ach 335

- M O T SO T H U A T N G U THLTONG D U N G T R O N G C O N G H U O N G T l j SO N A O 340

* : V iet ch ung v a i B ac si N guyen Thi H ung

X
 NHU’NG DIEU CAN BIET KHI T H U t HIEN KY T H U AT H i N H ANH H OC

C *ch viet giay YEU C A U K H A O SAT :

- L oai k h a o sat n a o ? ... X Q C L D T ? C H T ? ... c o c h o n g c h i d jn h C H T h a y k h o n g ?
- T h irc h ie n to i k h a n ? tircmg d o i k h a n c a p ?
- C a c tie n c&n
- C a c d a u h i? u lam s a n g : c a c d a u th a n k in h c h u c n a n g , k h a m th a n k in h , k h a m to n g q u a t
Luu y . D ie n tie n : k h a i p h a t d o t n g p t ? tie n trie n th e o g io , n g a y , th a n g , n a m ?
. Vj tri c o th e c u a to n th u o n g n e u lam s a n g n g h i n g o
. N g u y e n n h a n c o th e : di c&n ? x o c u n g rai ra c ? ...
- K e t q u a c u a nhum g k h a o sat c u : h in h a n h , sin h h o a , n g h ie m p h a p c h u c n a n g th a n k in h

CHI D IN H :
- XQCLDT - K h a n c a p th a n k in h - C h a n th u o n g so
- T a i b ie n m a c h m a u n ao
- T a n g a p n o i so c a p
- H in h a n h h o c v u n g m a t : T ai m u i h o n g ( T M H ) , n h a n k h o a , k h o a m ie n g
- N g o a i le X Q C L D T m o i b o s u n g c h o C H T : d o n g vo i ? k h a o sat n e n so ?
- CHT - T a t c a c a c b e n h ly th a n k in h k h o n g k h a n c a p :
. N g h i n g o b e n h ly . U , n h ie m tru n g , v iem , n h ie m k y s in h tru n g
. T h o a i h o a , n h ie m d o c , di d a n g
. L a m s a n g k h o n g y nghTa : D o n g k in h , n h in d o i, n h u c d a u , s a s u t tri tu e ...
- C H T b o su n g ch o X Q C L D T : C h a n th u o n g so v a X Q C L D T k h o ly g iai ,
N h o i m a u n a o , k h o i m a u tu : b o s u n g th o n g tin
- T r u o n g h o p k h a n : N g h i n g o n h o i m a u n a o scrm ducri 3 g io : th irc h ie n ly g ia i h u y e t k h o i ?
V ie m ta c tin h m a c h n a o , v ie m n a o d o h e rp e s
M at thj g ia c d o t n g o t ...

DQ C V A LY G IA I :
. P h a n tic h to n g th e :
- D u lie u la m s a n g : tu o i, tie n ca n , d a u h ie u lam s a n g , d ie n tie n to n t h u o n g th e o th o i g ia n
- K e t q u a k h a o sat h in h a n h c u v a c a c k h a o s a t c a n lam s a n g kh ac
- D o c h in h a n h tre n m a n h in h , xur ly h in h a n h n g a y k h i do
- T o n g h o p ta m then c a c th o n g tin :
. V i tri to n th u o n g , k ic h th u o c , h in h th a i, so lu o n g ; tu o n g h o p v o i c a c d a u h ie u lam s a n g
. M a t d o tre n X Q C L D T , tin h ie u tre n C H T , v a d o i c h ie u v o i lo ai c a u tru e g iai p h l u
. C a c y e u to h in h a n h g o i y v e m o t c a n n g u y e n d a c b ie t
. V ie t tu o n g trin h k e t q u a : 1 / D o c h in h a n h
2 / C a c y e u to g o i y c a n n g u y e n

G U I CAC T H O N G TIN den bac si lam sang :

- K e t q u a v ie t v a g h i h in h a n h len p h im / ta t c a h in h a n h h a y k h o n g ? c o c h u th ic h k h o n g ? s o d o ?
- G u i n h irn g g i ? D e nghi :
. Thoi g ia n p h o n g d in h : c a n guri c h o b a c sT lam s a n g n h u sa u :
- T o a n b o h in h a n h in tre n d ia C D R
- M p t p h im v o i c a c h in h c o y nghTa : c h u o i T 2 F L A IR c a t n g a n g
- B e n h ly " d o n g ia n ” : g u i 1 p h im v o i 12 - 2 0 h in h y n g h la v a 1 d ia C D R
. K h a o s a t b e n h ly , to n t h u o n g n h ie u k h a n a n g p h a u th u a t : c a n giri c h o b a c sT lam s a n g :
- T o a n b o h in h a n h tre n C D R
- T o a n b o c a c c h u o i h o a c 4 - 6 c h u o i c o y nghTa
C ho phep . T h a m k h a o , k h a o sa t d e d a n g
. T r e o p h im tro n g p h o n g m o , th o n g tin ro ra n g v o i b e n h n h a n , ho i c h a n ..

.C H T / N H A N SV V A K H O A :
. B ac s i - T h e o d o i k h a o s a t tie n h a n h : th a y d o i c a c h th irc h ie n ? c a n tie m h a y k h o n g tu y k h o n g d u tru ?
- C h u a n bi k h a o sat tie p th e o :
. C o d a t d u o n g tru y e n tin h m a c h k h o n g ?
. C h a m s o c b e n h n h a n ra s a o ?
. C a c h th irc h ie n : c h u o i n a o ? c a t th e o m a t p h a n g n a o
- L y g ia i c a c k h a o sat c u v a th irc h ie n k h a o sat
- T ie p n h a n y k ie n c u a d o n g n g h ie p v e c h i d jn h k y th u a t, ly g iai
. K y th u a t v ie n : - N a m ro c a c c h o n g c h i d in h c u a C H T
- D a t d u o n g tru y e n tin h m a c h n c u c a n
- T h u c h ie n k h a o sat
- S a o c h e p le n C D , in p h im

1
 CH T S Q - NAO TlTONG TRINH KET QUA / TIT KHOA
TEN NGAY :

N a o b $ , .... T uy£n yen, ... D o n g m ach vung co

C H I DJNH

KY T H U A T - Loai chuoi : hinh anh T l . T 2 Spin E cho 1° ech o , 2° echo. T2 F L A IR , T 2 *, kh u ech tan b 1000
va ban d o A D C . T l gadolinium
- trucm g hg p dac b iet : hinh anh hpc d o n g m ach , tinh m ach : do n g , g ado
T l In version R ecu p eratio n , T2 C ISS, T l Fat Sat, ...
hinh anh tu o i m au , hinh bo th£n kinh, h in h anh ch u c n ang, p h ep do pho
- C at ngang ( hucmg nao ? C A - C P , th eo su n g thai ducm g ), m at ph an g tran, m at p h an g d u n g dpc________

LY G IAI
. A / D Q C hinh anh : m o ta dau h if u, ly giai du a theo v| tri, cau tru e giai p hau , so lu v n g
D au hi?u ton th u o n g : dau hieu tru e tiep
1 - Tin hieu trong m oi chuoi k h ong tiem ? tin hieu sau tiem ?
K et q u a :. T on thucrng : phu, ton th u o n g dac
. X uat huyet, voi hoa, m o
. D ang nang : tin hieu cua d ich thay do i th eo n o n g dQ p ro tein
. D o n g nhanh, dong cham ...
. Bat hay k hong bat gadolinium
. T o n th u o n g d o n g nhat ? k hong d o n g n hat ,
2 - Vi tri ton th u o n g : thuy nao, ducm g giu a, ho sau, nen sp ... C o tu o n g hgrp v6 i d au h i?u lam sang khong ?
3 - H inh thai va vi tri ph u hp p voi v u n g tucri dQng m ach k h o n g ?
4 - T on trpng, k hong thay doi cau true ben tro n g nao bo ? C ac k h o an g V irch o v R obin k h o n g bj anh hucm g?
5 - T on th u o n g du y n hat hay n h ieu to n th u o n g ?
- T ac d p n g cua ton th u o n g len cac cau true b in h thucrng lan can : d au h ieu g ian tiep
6 - Phil ne
7 - D ay cac cau true lan can : cac ranh vo nao, ducm g g iu a, ban tro n g xucm g so ...
8 - T yt nao - T o n th u o n g tren leu : tut the chai , m oc thai ducm g, h anh n h a n tieu n3o
- Ho sau: thuy n h o n g tren, h anh nh an tieu nao
9 - G ian n o nao that Do tac ng h en D N T : tac nghen tro n g n ao ? h ay ng o ai n ao ?
- Do teo nao
- Do nao k h o n g p h at trien : dj d ang

B / C4c dau hieu gyi y CAN NGUYEN tuy theo . Tien can, lam s&ng, khao s&t khac, dien tien
. Doc cac dau hi£u tren CHT
TON TH U O N G TRONG NA O
1 - U tro n g nao : - T han kinh dem u te b ao d em
- M o than kinh u n g u y en b ao tuy, D N E T
- M o tao huyet ly m p h o m , u lucri m ach
- Di can nao th eo d u o n g m au , th eo ducm g ducri n h en
- T ru o n g h o p d ac b iet: u q u ai, u tro n g nao th at, hoi ch u n g can un g th u
Tai bien m ach m au nao : - nhoi m au nao: v u n g tucri d o n g m ach , m at d o v a tin hieu , can n guyen
- x u a t hu y et nao, x u at h u y et m an g nao
- u h ang, u m ach tinh m ach
v iem h u y et khoi trnh m ach nao
3 - Benh ly viem x o c u n g rai rac. b enh ch at trang n ao cap , b en h s a c c o i t ...
4 - B ?nh ly nhiem trung n h iem vi tru n g : ap xe, tu m u, v iem m an g nao
6 - B enh ly nhiem virut b enh n ao do h erpes, H IV , ...
5 - N hiem ky sinh trung b en h g ao , ...
6 - B enh ly th o ai hoa b enh P ark in so n , teo n h ieu o h? th o n g , b e n h A lz h e im e r ...
7 - Benh ly nhiem doc rucru, m a tuy, o x y t cacb o n ...
8 - Benh ly b ien d u o n g loan d u o n g chat tran g th u o n g th an , tan g m u co p o ly sa cc a rit, B en h Leigh ...
- T O N T H U O N G N G O A I N A O : u va g ia u tu y theo vi tri
I 9 - V dm so
10 - N en so : tan g tru o c, tu y en y en . vung y en . d u o n g g iu a. ho sau
TON TH U O NG TRONG NAO - - NGOAI NAO
11 - C h an th u o n g so-nao
12 - Di d ang nao, di d a n g m an g nao. di dan g so
Di d ang toan nao tru o c , vo sinh. di n g u y en . u m a . u qu ai, C hiari
. N ang m an g nhen. th o at vi m an g nao
. D inh lien khcrp so
13 - Hoi ch u n g th an k in h -d a : u x o T K . xcr cim g n ao cu. S tu rg e W eb er. V o n H ippel L in d a u d a u lucn m ad
- DT nhien co the th ao luan n h ieu can n guyen cac kha n an g ? do c h ac ch an ?
T uv y kien d o n g n g h iep co hucmg \ u tri : k h an '1 k hao sat h in h a n h khac? k h ao sat can lam san g k h ac'1
KY TEN
 GlAl PHAU va GlAl PHAU X QUANG

T A l L IE U : - J P F R A N C K E , X D E M O N D IO N
B p m o n G ia i p h a u
D a i h p c Y k h o a L ille - V ie n D a i h o c L u a t - Y te - L ille 2

- G SALAM O N :
D a i h o c Y k h o a M A R S E IL L E , D ai hoc U C LA USA
A tla s g ia i p h iu c l t la p , N X B S a n d o z

XQCLDT : 120 lat, be day 1 mm, tai tao be mat

1 ho m £t 8 lo b a u d u e 1 x u ’a n g h a m tre n 7 d a u xu 'cm g h a m d ip a i
2 x u ’a n g s a n g 9 lo ra c h 2 cung go ma 8 16 g a i h a y lo c a n h
3 m g t tre n th a n x u ’a n g b u a m 10 d in h x u ’a n g d a 3 m o m c h a n x u ’a n g b i/ a m 9 m au nen
4 c a n h Idm x u -o n g b ir o m 11 lo o n g ta i tro n g 4 c a n h x u a n g h a m d u ’a i 10 lo c h a m Io n
5 m a u g iu ’o n g tru ’a c 12 d o c y e n (c liv u s ) 5 lo ra ch 11 d o t d oi
6 cu yen 13 ra n g d o t tru e 6 lo b a u d u e 12
7 ho yen 14 16 c h a m la n

3
 CAC BAO CUA NAO BQ HOP SO VA CAC KHOANG MANG NAO QUANH NAO

da va
mo te bao d ira i da : ma
hop so ban ngoai : xu’ang dac
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIHI' tuy : mo
ban trong : xu’ang dac

khoang ngoai mang cim g: boc tach dupe

mang cim g
khoang d iro i mang cirng: ao, boc tach du
mang ngoai cua mang nhen
khoang d ira i nhen: co thuc, dich nao tuy
(D N T )
mang trong cua mang nhen
dinh vao mang nuoi

khoang Virchow Robin

dong mach nho, tinh mach nho. Dfd

da, m o du'O’i da
doi khi co the thay nai bam cua cor nhai

ban ngoai
tuy (diploe)
ban trong

mang cim g dinh vai ban trong

khoang d u 'O ’i mang cifn g ( bi bong ra :
khi a tren xac

mang nhen : la trong

la ngoai
khoang dLfai nhen : DNT
mang nuoi khong thay d irg e
vo nao : chat xam
chat tr§ng

CHT sau tiem

4
MANGCUNG : LI6M 0AI N A O -L £ U T l£ U NAO

M£ng ci>ng c6 vai trd ca hpc thiet y&u,

cung v6i he thong dich trong khoang duoi nhen va cac nao th a t:
hpp s q cimg ch3c, mang cung chlic trung binh, lap djch dem bao ve
M£ng cimg ^n dinh pham vi ba khoang trong s q :
ho nao phai, ho nao trai, ho sau
Mcing cung tao nen thanh cua cac xoang tinh mgch

L ie m d a i n a o v a le u tie u n a o
K h a n a n g th o a t vi (tu t) n a o :
- thoat vi the chai duoi liem dai nao
- th o a t vi thai du’O’ng vao lo bau due
- th o a t vi h a n h n h a n tie u n a o v a o lo c h a m Io n

5
 HE THONG n a o t h A t , c A c k h o a n g m A n g n A o QUANH NAO
D|CH NAO TUY
. Bai tiet - cuon mach mac, mai mach mac nao that III
- dam roi mach mach nao that IV va dam roi ngach Luschka
. Dong - nao that III, kenh Sylvius, nao that IV, lo Magendi
- cac khoang ducri nhen quanh nao
. Hap thu - cac hat Paccionni / xoang tinh mach doc tren, xoang ben

Vai trd ca hpc, vai tro tham thau, vai tro nuoi du&ng

1. si>ng tran, 2. sung thai ducrng, 3. moc thai du'cng, 4. than nao that, 5. nga tu> nao that
6. sung cham, 7. ho ben hay thung lung Sylvius, 9. thuy dao

- C a c d a m roi m a c h m g c c u a n a o th a t b e n lie n tu c v o i m a i m a c h m a c c u a n a o th a t III

- N a o th a t IV lie n tg c v o i o n g n pi tu y c u a tu y s o n g

- T ra n d jc h n a o th a t k h o n g th o n g t h u o n g 1 d o ta c n g h e n D N T ta i c a c n a o th a t b en ,
c a c 16 lie n n a o th a t, k e n h s y lv iu s , n a o th a t IV h a y lo M a g e n d i
- T ra n d jc h n a o th a t th o n g t h u o n g ' d o t ^ c n g h e n D N T ta i c a c k h o a n g m a n g n a o q u a n h tie u n a o , lo b a u d ue .
c a c ra n h b e n , c a c k h o a n g m a n g n a o c u a p h a n lo i b a n c a u n a o h a y c a c h a t P a c c io n n i tro n g c a c x o a n g tTnh m a d -

6
 DAM R 6 l MACH MAC : hinh thai binh th im n g va cac bien the

D£m r6i Lushka D£m roi cua sung thai duong Hinh 3nh T1 sau tiem

V| TRl
. Cu0n mgch mgc : . nga tu nao thlit ben, san cua cac than nao that
. lo lien nao that Monro, mai mach mac cua nao that III
. dam roi lan den dau mut phia truftc cua cac sung th&i duong
. khong co dam roi mach mach trong cac sung tran lan sung cham

. D£m roi mgch mgc O’ ho sau : cac ngach ben cua nao that IV
Id Lushka, goc cau tieu nao
MAT 0Q, TlN HiEU : - thuong co hien tuong hoa nang va dong voi
- b it manh chat tuong phan

T2 FLAIR T1 gadolinium T2 Spin Echo

B ie n th e c u a d a m ro i m a c h m a c : h o a n a n g o b e n p h a i. v o i h o a a b e n tra i

7
NAO BQ
1 dau nh§n duoi
2 beo sim
3 phan n go ai cua cau nhat
4 p h a n tro n g c u a c a u n h a t
5 n h a n tru ’f r c t i l i n g
6 bao ngo3i
7 b a o tro n g
8 c 3 n h ta y tru -o c c u a b a o tro n g
9 c 3 n h ta y s a u c u a b a o tro n g
1 0 ,1 7 th e ta m gicic
1 1 ,1 2 ,1 3 c a c n h a n d o i th j
14 d o i c h a m c u a d o i th j (p u lv in a r)
19 p h & n id i th e c h a i
20 duoi nhan duoi
2 1 d a m ro i m a c h m a c
2 3 n g a t i f n a o th a t
2 4 g o i c u a b a o tro n g

1 dau nhan duoi

2 b eo sam
3 cau nhat
p h a n tro n g

4 n h a n tru ’crc tip d n g

5 bao ngoai
6 b a o c i/ c n g o a i

8 c a n h ta y tru ’crc
c u a b a o tro n g

10 m e p t r l n g tru c rc
11 n a o th a t III
12 ha d oi
13 d a i th j

16 th a n th e c h a i
17 h o i d a i (g y ru s c in g u la ire )

20 d o n g m a c h th a n n e n

24 th e h a n h n h a n (a m y g d a lo id e )
cua h oi hai m a
 1 than kinh thj 15 the g6i trong
2 giao thoa thj giac 16 h£i m3
3 dai thj 17 the hgnh nhin
4 ha doi 18 nao th lt ben: sung du6i hay sung th£i duang
5 nao that III, ng£ch tuyen yen 19 h6i hoc mlt-tr£n
6 the vu 20 ho b£n cua nao hay thung IQng Sylvius
7 be thj-giao thoa thj gi£c 21 dong mach nao giua hay dm Sylvius
8 be lien cuong 22 dong mach nao sau
9 nhan do 23 doi chlm cua d6i thj (pulvinar)
10 chat den phiin dac 24 the goi ngoai
11 chat den phln ludri 25 khe ngang cua nao hay khe Bichat
12 bo vo-gai hay bo thap 26 hoi canh hai ma
13 trung nao : chat xam 27 d£i khuu
14 cong nao

1 th^n nhin dudi

3 b6o s5m
5 - 1 0 ccic nh3n d6i thj
11, 12. 13. 16 bao trong
14 li&m den
15 nhin d6
17 c£u n§o
20 th& chai
21 c£c try cua th i tam gi£c
24 th in nSo that ben
25 n3o thcit III
26 ch6 dinh li£n doi thi

10
 ph An b 6 c u a c h At t r A n g v A c h At xA m

- C a c b ^ n c i u d a i n § o : gidri h a n ro giCra c h a t trS ng v i c h i t x a m

- C £ c n h in x £ m tru n g t i m : c £ c v £ n c h i t t r in g tro n g n h a n x a m , g g i y te n g p i la th e v a n
h $ q u a : k h i n £ n g h i$ n d i$ n to n th u o n g m i t m y e lin b e n tro n g c a c n h a n x a m tru n g ta m

Ho sau : . than nao : - chat xam : chat lu’O’i, nguyen uy thu-c s u cua cac day than kinh so
- chat t r in g : bo vo-gai, bo gai-vo
cac cuong tieu nao : chat trang va nhan rang
cac ban cau tieu nao va thuy giun : thanh phan chu yeu la chat xam. c h u a rat nhieu te bao
 TO CHl>C B£N TRONG CUA NAO BQ

- C a c c o n g trin h g ia i p h a u X q u a n g c u a V irc h o v R o b in v a c u a S a la m o n c h o th a y to c h u c c u a n § o b<> tu y th e o

c a c tru e m a n g n a o -m a c h m a u : c a c k h o a n g m a n g n a o c h u a d jc h , c i c d p n g m a c h n h o v i c i c tTnh m a c h nh 6 .

- T o c h u c n a o n h u 1 v a y d u p e th a y tre n h in h a n h C H T th i T 2 d p p h a n g ia i c a o :
. ta n g tin h ie u c u a c a c c a u tru e v o i s u t u o n g p h a n d ic h : D N T + c& c tTnh m a c h n h o c o d o n g c h $ m
. c a c tie u d o n g m a c h , n h o h o n , k h o n g th a y d u p e

- T o c h u c n a y c h o p h e p h ie u d u p e m o t s o h in h a n h C H T th i T 2 d p p h a n g ia i c a o :
- g ia n n o c a c k h o a n g m a n g n a o -m a c h m a u tro n g t r u o n g h o p te o n a o lie n q u a n d e n tu o i h a y d o t 6 n thuo^ng lam
o c h a t t r ln g , h in h a n h c a c to n t h u o n g m a t m y e lin d p c th e o c i c trg c n iy ,
- g iu n g u y e n s u p h a n b o c a c tru e n a y tro n g n h o i m a u n a o , x i o trp n c a c c i u tru e n a y tro n g b e n h ly u.

- H in h a n h T 2 d u p e q u a n s a t tre n m a n h in h q u a c u a s o ra t h e p

c a c k h o a n g V irc h o v R o b in

12
G. SALAMON tiem vao cac mau gi^i phllu, cat nhieu lat lien tiep va chyp X quang lat c it mong

13
 CAC 0Q N G MACH NAO

Dong mach nao Dong mach nao giOa Dong m$ch n3o
truo’C hay dong mach Sylvius sau

D a g ia c W illis :
dong m ach nao tm a c
d o n g m a c h th o n g t r i/ a c

x ip h o n g c a n h

d o n g m a c h n a o giO a
d o n g m a c h th o n g sa u
d o n g m a c h n a o sa u

th a n n en

14
D p c h e th 6 n g d $ n g m a c h tro n g m a t p h in g c i t n g a n g : c a c d o n g m a c h c a n h , he d o t s o n g -th a n n en .
0 Qng m a c h c 6 tin h ie u th a p d o h ie u i/ n g d o n g

15
 C A C TTNH M A C H M A N G N A O , C A C X O A N G TTNH M A C H

Cac tTnh mgch nao sau

2 xoang th in g
3 xoang doc dira i
4 bau Galien
5 tTnh mgch nen Rosenthal
6 tTnh mach nao trong
8 tTnh mgch doi thj-th& van
9 tTnh mach v^ch
10 tTnh mach tripac trung tam
11 tTnh mach thuy nhpng trSn

CAC XOANG TlNH MACH cua vom sq va nkn sq

1 xoang ngang
2 xoang doc tren
3 xoang th in g
4 xoang ngang du'O’i
5 tTnh mach Labbe
6 xoang da tren
7 xoang da du o i
8 xoang hang
9,16 dam roi tTnh mach chan bu’dm
10 tTnh mach nao giCra nong
11 tTnh mach Trolard
12 xoang sigma
13 tTnh mach canh trong
14, 15 tTnh mach hoc m ilt

T 1 g a d o lin iu m
8 0 la t c h o n g n h a u ,
d a y 1 m m tro n g ta i ta o M P R

16
X oang hang

- tTnh mach m it
- xoang vanh
- xoang hang
- xoang bu’di'm

- xoang da tren
mao xu’O'ng da
- xoang da dim i
mat doc (clivus)

- xoang ben
- xoang nen
- xoang cham
- hop Ilfu xoang sau

- xoang doc tren

Moi lien quan giD-a

da giac Willis
va giao thoa thj giac:

. p h a n tru 'o c c u a d a g ia c W illis

nam 6 tre n g ia o th o a th i g ia c

. p h a n s a u c u a d a g ia c W illis
n i m b e n d u o i g ia o th o a th j g ia c
 hO sau

- than nao: chat trang

v i chat xim
- tieu nao : it chat tring
- cuong tieu nao giua va nhan rang
- hanh nhin tieu nao

- phan loi ciia the chai

- cu nao sinh tip

- cuong tieu nao

- cau nao
- hinh tuy hay tuy keo d ii

- thuy giun phan duoi

- hanh nhin tieu n io
- be Ion
- lo Ion hay lo cham

Tieu chuan binh thu’O’ng cua ban le so-cot song

- tie u c h u a n n g a n g : d u o n g C h a m b e rla in
tip k h a u c a i c u n g d e n b o s a u
c u a lo c h a m k5rr
m a u ra n g b e n d u o i d u c rn g n a y

- tie u c h u a n tru c rc -s a u : d u a n g n e n .
la d u o n g k e o d i i c u a m a t d o c (d ivu s)
m a u r i n g n i m tru c rc d u o n g n a y

18
 le tam giac

Di thj
nh mach nao trong
ay tTnh mach Galien

>ng thai duong, hai ma

j nao sinh tu

jo n g tie u n a o tre n
jo n g tie u n a o g iu 'a
„J o n g tie u n a o duoi
an c a u tie u n a o

anh tuy hay tuy keo dai

»Ion hay 16 cham

19
 - t £ n GOI - L O S O N O I D A Y T K 01 R A - lA m s Ang

1 th a n k in h kh ipu g ia c m anh sang m it m ui

II th a n k in h thj o n g thi n h in m o , m il m a t

III th a n k in h v a n n h a n kh e o m i t tre n s u p m i,
( hay van nhan chung) h a y k h e b ip o m g ia n d o n g t u \ le m i t ra ngoai

IV th a n k in h ro n g ro c kh e o m i t tre n n h in d oi

V th a n k in h s in h ba d a u th a n k in h V 6 m at
- th a n k in h m i t W illis k h e o m a t tre n (tra n , le , m u i)
- th a n k in h h a m tre n 16 tro n (h a y 16 tro n Io n ) d a u th a n k in h V 6 m it.
c o t h i t ni>a m a t
- th a n k in h h i m d u o i 16 b a u d ue d a u th a n k in h V 6 m a t

VI th a n k in h v a n n h a n n g o ii k h e o m i t tre n le m i t v i o tro n g

V II th a n k in h m a t v a T K tru n g g ia n (V II b is ) lo o n g tai tro n g h a y o n g ta i tro n g Net m a t n g o a i b ie n

V III th a n k in h tie n d in h -o c tai 16 o n g ta i tro n g h a y o n g ta i tro n g d ie c m o t b e n

c h o n g m a t, u tai
IX th a n k in h th ie t h au 16 c a n h ro i lo a n vi g ia c
X th a n k in h la n g th a n g h a y p h e vj lo c a n h k h i u c i i m e m ( m in k h a u cai)
XI th a n k in h phu lo c a n h te o c o th a n g

XII th a n k in h ha th ie t o n g ha th ie t te o n i>a Iif o i

A TLAS C U A G. S A L A M O N tie m v a o c a c m a u g ia i p h iu , c i t n h i§ u la t lie n tie p v a c h u p X q u a n g la t c i t m o n g

21
1 th u y tra n 6 th u y d in h 1 lie m d a i n a o 5 n a o t h l t IV 9 h a n h tu y
2 ra n h ben 7 ra n h d in h -c h a m 2 th e ch a i 6 le u tie u n a o 10 p h a n lo i t h i chai
3 ra n h t r u o c tru n g ta m 8 th u y th a i d u o n g 3 tu y e n ye n 7 cuong nao 11 le u tie u n ao
4 ra n h tru n g ta m 9 th u y c h a m 4 n a o th a t III 8 cau nao 12 h a n h n h in
5 ra n h sa u tru n g ta m 10 b i n c a u tie u n a o tie u n io

1 m a u tra m 1 m a t d o c (c liv u s ) 5 v o i th in h g ia c
2 T M c a n h tro n g 2 tra m h a n h tu y 6 n ga ch hau
3 D M c a n h tro n g 3 th a p h a n h tu y 7 b a n c a u tie u n a o
4 loi c a u x u o n g c h a m 4 h a n h n h a n tie u n a o

1 x o a n g s ig m a 4 xoang da d u o i 1 n g a c h s a u b e n c u a n a o th a t IV 5 c u o n g tie u n a o g ift

2 T K th ie t h au 5 c u o n g tie u n a o d u o i 2 m ai m ach m ac 6 th a n k in h m i t
3 T K la n g th a n g 6 p h a n th a p n h a t c u a n a o th a t IV 3 cau nao 8 T K tie n d in h -o c ta i
h a y tk p h e vi 4 n h a n ra n g
 1 th u y d a o 4 g ia o th o a thj 1 cau nhat 4 b a o tro n g 1 k h e s y lv iu s 5 m ai m ach m ac
2 hoi hoc m it 5 c u o n g tie u n a o 2 th e ta m g ia c 5 th u y d a o 2 beo sam 6 th e c h a i
3 hoi th in g 6 s u n g cham cot tru o c 6 nga tu n a o t h it 3 s u n g tra n 7 cu0n m ach m ac
(G iru s re c tu s ) 7 cupn m ach m ac 3 n a o t h i t III 4 lo M o n ro
lo lie n n a o t h i t

1 th u y th a i d u o n g 4 b a o tro n g 1 v a c h tro n g s u o t 1 x o a n g d o c tre n

2 ra n h b e n h a y 5 nhan duoi 2 th e c h a i 2 lie m d a i n a o
th u n g lOng S y lv iu s 6 d o i thi 3 n a o t h i t b en 3 tru n g ta m b a n b a u d u e
3 beo sam 7 th e ta m g ia c 4 nhan duoi 4 ra n h tru n g ta m h a y ra n h R o la n d o
5 ra n h t r u o c tru n g ta m

1 s u n g tra n 2 s u n g th a i d u o n g 3 m o c th a i d u o n g 4 th a n n a o t h i t 5 nga tu nao t h it

6 su ng cham 7 th u n g lu n g S y lv iu s 8 th u y d a o 9 s u n g th a i d u o n g 10 h ai m a

23
 X QUANG CAT LOP DIEN TOAN (XQCLDT) VA CONG HIKING TU’ (CHT) :
_____________________ CAT THEO m a t p h A n g n A o ?____________________
1/ Mat p h ln g CA - CP (mep tr ln g tru a c - mep tr ln g sau)

Mat p h ln g doi chieu

c A
m6 p trSng tap6 c
commissure
blanche ant6 rieu

C P
m6 p trln g sau
commissure
blanche
post&rieuse

B ie n th e : m a t p h in g n o i h a i th e c h a i
tiep tuyen . vdri mo the chai
. va v 6 i loi the chai
m$t p h in g nay gan giong mat p h in g CA - CP
va d i dang djnh vj han

- 2 / C ac m at phang khac

- LOM (ligne orbito meatale) - Mat p h in g VIRCHOV - Mat p h in g CAC SU N G THAI DUO N G
du’drng hoc m it lo tai ngoai va th in g goc vai mat p h in g n&y

bd1 ngoai hoc m it / bd 1du-ai hoc m it / song mui dau d u a i /

ong tai ngoai ong tai ngoai ong tai ngoai

m$t p h ln g tifa n g t y mat p h in g CA-CP mat p h in g co tinh chat " Ijch sir khao sat hoi hai ma / benh canh sa sut tri tue
th in g goc vai than nao mat p h in g nay ti/a n g t i/ mat phang than kinh
hoc m it
dung trong XQCLDT
dau sao cung chi phong chung
vi djnh vi bo ngoai hoc m it
khong ro rang tren trim n g quan sat
(scout view)

25
 XQ C LD T : Ky thuat, mat do

0 6 d £ y la t ca t 0.5 den 5m m Tia X : p h a t ra. h ^ p thu . kh ue ch t in

C o 100 - 5 00 so d o tir 4 0 0 • 1.000 <JAu d6
tro ng m oi v o n g xo ay
tu nhO ng so do nay, tai tao cac co n so cu a m a t do cua ti>ng d ie m kh 6 t

Chuyen doi cac con so thanh cucrng do s£ng

2.000 m uc m$t do UH Unites Hounsfield
don v| Hounsfield

Cua so hep : chpn 100 don vi trong s6 2 000 UH

va chinh xac hon la 1 0 0 mat d 6 tuong Cmg
vfri nao bp

May tinh tai tgo c£c con so cua m$t dp cua tung diem
C£c khai niem : ma tran (thi du 256 h£nq / 256 hana). pixel : be mat. voxel (diem khoi) the tich (pixel x do dav cua lat cat)

120 la t / 1. 2 m m / tai tao :

Tro n g tru o n g h o p kho ly giai tren cac lat

ca t d a y 5 m m th u o n g lam , can th y c hien lai
m o t ch*JOi thu- hai v o i 100 l£t m ong theo
m a t p h in g c i t n ga ng va tai tgo the o mat
p h ln g tran va d u n g doc

26
 XQCLDT MAT OQ / U H (do-n vj Hounsfield)

- xirong d$c

- v 6 i hoa

MAT 0 0
CAO

- iot
+ 100 UH - cu c m au d ong

c u c m iu dfing

©ONG + 30 UH c ^ a t xam
M A T 0 Q + 1Q UH Ch a t t r ln g

- phu
- O NT

- mo

MAT 0 0
THAP

27
 MAT DQ CAO

- XUONG + 1.000 UH
- VOl HOA

- cue m Au o Ong
nhieu h 6 ng c iu
X o n§o cu Boum eville M£u ty ngodi m dng cung

- T i§ m lO T x lp xi v 6 -i 100 UH

- m 6 N H lE U T £ B AO + 60 UH
u m £ng nao, u d a y tha n kinh, u lym ph o ...
U mdng n3o g6c lifem dgi nflo- lAu tiAu ndo.
____________khftng va c 6 tiflm ________________

- m^u luu th 6 ng v&i HEMATOCRIT cao (trd em)

Dj dgng dQng-tinh m ^ch

kh6ng ti6m vS c6 tifim

- P R O TE IN nong dp tren
5 gam I lit

U nh&y x oang tr^n Nang th& k eo n§o thAt III

o O n g m a t DQ

- ch At xA m + 30 UH : nude 7 0 /100, m a 8 /100, protein 2 2 /1 00

c 6 kha nang co ton th u o n g d on g m a t dp : ch a n d oa n a m gia tre n X Q C L D T neu

n h u kh on g co hieu c h u n g ch oa n cho

- CHAT tr Ang + 15UH : nub'c 80/100, m a 15/100, protein 5/100

m at do THAP : 4 m uc

- PHU " th u a n tu y "

... hay phu va te b&o u Phu hai b3n cku sau khi ngt>ng tu4n ho^n
nh£n xSm va ti&u n§o tr ln g g i i n h i/ m ^t d$ cao

- DN T
... va xu at huye t m ^ n g nao
kh on g co ege m £u dong

- MCf

- KHi - 1.000 UH
Nang dang t>i kyste Oermotde) G3y t5ng tn/oc O ">& so
 - T h u th§p: b& d a y ca c ISt ca t tu y th e o m a y: ti> 1 den 4 mm.
B A O N H l£ u L A T C A T ? . T ^ j ( ^ 0 v(^j d a y 4 h o 5 c 5 mm
- H 6 sau : 16 den 20 l£ t do d a y 4 m m sat nhau

- T a ng tren leu : 16 den 20 lat do d a y 5m m

T u o n g q u a n g ia i p h lu
xem trang 2 0 , 21

XQCLDT sau tiem

29
 Cua so

CCra s6 hep. a /a s6 rOng

T^i tdo kiAu VRT

Volum e Rendering T e c tn q u t

-1 / Cu-a s6 " mo m&m " : 1 / chon dung b& rpng cira so

21 sau <36 Xcic djnh mire s^ng

100 UH 60 50

40 30 20

con s6 thay ddi tuy theo logi m£y

- 2 / Q ua n s£t m p t c£ch he tho n g, tgi ban dieu khien, toan bp cac l£ t cat
q ua c u a s 6 rpng, c u a so x u o n g ... c i c th o n g tin d o i khi co tin h ch at q u ye t d jnh

+ 1.000 U H / O S

C u a s 6 rpng
« xuong »

+ 60 UH 4
c u a so hpp
mo m em "
20 UH i

I 000 UH KHI
 Tai tao nhi^u m at phlng, r i t h&u ich de xac dinh vj tri ton thirong

1/ Tai tgo ti> 30 lat cat ngang c6 be day 4mm

2/ XQCLDT nhi&u hang d 6

. tai tao tu1 1 2 0 lat cat ngang be day 1 mm ... c h it lu’p’ng cao hon h§n
. trong tr u in g hpp kh 6 xac djnh vj tri t 6 n thu-ong, l$p ti>c th yc hi?n chuoi lat cat thi> 2 r£t mong

Xipong da : cac lat cat ngang, dp day lat cat : 0.8mm

i
 T a i ta o d a m a t p h ln g

h& u ich cu a m ^ y X Q C L D T tro ng tru o n g h a p kh on g c 6 m ay C H T

th i dg : ton g ke kh ao sa t tie n p h lu m o t u m a n g n ao cu a leu tieu nao

. h in h th e va vj tri cu a ton thu ’a n g
. kh ao s a t d a c b ie t tin h th o n g th o a n g cu a xo a n g ben sau khi tiem

120 l£ t . be day 1 mm

T£i tgo dCmg ngang : mode MIP 0 ^ o nghjch c^ c tircrng ph£n

Maxim um Intensity Projection ^ ich n h l/ ^ 7
d&y 40mm

Tat sq nghieng hop so bat xCrng do hien tu-pmg hoa x i/o n g va dinh khdrp
som mQt ben, dong som d i/o n g khop vanh ben tra'
hinh anh tong ke tn /a c dieu tn

32
XQCLDT mgch m£u cac d<?ng mach co, XQCLDT- mach mau cac dong mach nao

- C h i d jn h :

- dOng m g c h c 6 : sau khi l£ m d o p p le r, l£m t6 n g ke k h 3 o s£ t ccic tn /fr n g h o p h e p v£ h u y e t kh 6 i dOng m a ch co,

djnh lu-Q^ng m ire dO hep
- dOng m g c h n a o : t6 n g k§ kh d o s£ t h in h t h i c 3 c t r u i n g hQ-p h ep v £ huy&t khoi c a c dOng m a ch nao
t6 n g kg k h ^ o s£ t h in h th e c 3 c p h in h m g ch t n /a c khi lam th u ye n t i c

- C 6 s i/ cgnh tranh gi&a XQ CLVT mach m£u va CHT mach m£u

c6 khuynh h i/ 6 ng chuOng CHT- mach m3u hen nhfr nhOng ti&n b$ ky thu3t. khong c in ti§m iot va khong nhiem tia x

- K y th u ^ t :

- XQCLDT- mgeh mSu thy-c hi§n trong 10 gieiy, ti§m 80 cc c h it c^n quang 300 mg / lit, 3 - 4 cc moi giay
- xi> ly hinh in h tu in ty tu1 dOng m?ch c6 r6 i dOng mach n3o, d#c biet 13 da gi£c Willis
- xi> ly . mode MIP : Maximum Intensity Projection
. mode VRT : Volume Rendering Technique, d$c bi$t trong trucrng hp-p v 6 i h6 a dOng mach

- To ng ke kh a o sa t tru crc khi d ie u trj tui p h in h m ach

. phinh mgeh dau tan cua DM than nen

. hinh £nh va p h in day cua phinh mach
. dOng mgeh nao sau x u it phat ti> tui phinh mach
- H # d o t s 6 ng - tha n n en b in h th im n g . phinh mach nho doi ben o- dpng mgeh nao sau ben phai

Lat c l t n g u yen thuy T a i ta o th e o m o d e M IP

 XQCLDT tu o i mau
C h i d inh :

1 / Lp*i ich tro n g vie c q u y e t d jn h ly g iai h u ye t kh 6 i,

. d a c b ie t neu kh on g the th u c h ien C H T n g a y tu c thi
. the tich kh ao s a t : 30m m , vi va y ta p tru n g c a c lat 6- vu n g d on g m gch n§o g iu a

2 / L o i ich tro n g ton g ke kh a o sa t u n ao : vu n g u h oa t d p n g co h in h 3 nh tan g tu & i m au

. djnh vj sinh th ie t nao
. lap luan g iup p han b ie t u n g u yen b ao d em va ca c u k h a c : u lym ph o
. u tai p ha t d u p e tu-di m au nhie u h o n vu n g h ogi ti> do t£ c d y n g cu a tia xa

- K y thu a t :

. X Q C L D T nhie u hang dd : 16 hang

. tiem 4 0 cc ch at tu’o n g phan iod v o i toe d o 6 cc/g ia y, iod 3 0 0 m g /lit
. th u c hien ch uo i lat ca t c u m oi 0,5 g ia y tro ng v 6 ng 4 0 g ia y

- L y g ia i:

. sau khi x u ly h in h cinh :

. d o d a c h in h 3 nh : D S C : lu u lu p n g m a u n3o, V S C : th e tic h m au n§o, T T P : th fri g ia n d a t d inh
. vu n g khong t u b i m au, vu n g giam tu o i m au, vu n g tip o i m au b inh th u o n g , v u n g ta n g tiF<fyi m au

U nao :
. hinh anh tu’b’i mau
. khcio s^t nhieu t h i tich dich
... sinh t h iit cac vung tang tvrd'i m6 u

Chi dinh dac biet cua XQCLDT- mach mau: chan doan chet nao
. tru oc khi lay tang
. de quyet djnh ngung hoi sue

- D ien n ao do : « p ha ng »

- X Q C L D T tu’o i m au: X Q C L D T co the se th a y the han c a c tie u ch u a n cu a d ien n a o d o va X q u a n g m a ch q u y u 6 c

tro ng ch an doan ch e t nao

. X Q C L D T nhie u hang do
. tie m tin h m a ch va thu th a p tro n g vo n g 60 g iay
. ch an doan ch e t nao:
- n g u n g tua n h oan tai ca c vj tri x ip h o n g ca nh h o a c d o a n n ga ng cu a D M n §o g iu a
- ca c tieu ch ua n nay hien d u o c m o rpng ra nhu 1 sau:
tha y xi-ph on g ca c dong m a ch ca n h va d oa n n ga ng cu a d p n g m a ch n ao g iu a n h u n g :
. kh on g th a y d oa n xa cu a d on g m a ch n a o giO a
. kh on g th a y ca c tin h m ach nao sau cu ng nhu 1 tTnh m a ch n a o n on g

34
 HiNH A nh c o n g hif & ng T ir
Ky thuat, tin hieu

C£c lo?i song: dai sdng, t i n so Tiromg tac giu»a m pt loai song vo»i m pt cau true giai p h iu

3 (H z) 3 m th a n h n g h e d u v c

6 sb n g si§ u 3 m s i£ u A m

7 hinh in h CQ NG H l/Q N G TLT

s 6 ng vi ba
s6ng cao t i n / ti> tru’drng

8 s 6 n g ra d io
b . Idm n6ng c£c m6
. c in c6 khung F araday G am m e radio FM

9 s 6 n g tru y e n h in h , rada

12 tia h o n g n go ai

£ n h s£ n g th a y du’Q’c kham lam s£ng: quan sat

16 tia e y e tim

17 tia X : R o e n tg e n X quang QUY U O C , chgp m ach m ^u tr6n X Q C LDT

tia G a m m a NHAP NHAY B O d6ng vj. PET scan

22

1 - CAC CHU O l C HlNH :

T1 Spin Echo
- . T2 Spin Echo: 1 °e ch o = mat do proton
2° echo: "T2 th y c s y "
. T2 FLAIR: fluid attenuated inversion recuperation
. T2 *: echo gradient
. Hinh anh khuech t3n : b1000 va ban do ADC : he so khuech tan bieu tn/n g

T1 GADOLINIUM: thu thap b in g Spin Echo ho$c Echo gradient (mpr)

2 - CAC C H U O l DAC BiET:

- hinh anh hpc . d$ng mach: dong d$ng mgeh TO F 3D, chyp mach b in g CHT: gado
. tinh mach: dong tTnh mach TO F 2D, T1 gado
. dong DNT

- T 1 inversion recuperation
- dp phan giai rat cao: T2 CISS
- h inh anh nhanh: trong tuyen yen, hinh anh hoc trong ti> cung, .

- hinh anh tu o i mciu: gadolinium

- hinh bo than kinh: hinh anh si>c cang khuech tan
- hinh anh hpc c h irc nSng nao Echo P lanar Imaging EPI
- phep do ph 6 b ln g CHT
 2 /C A C S 6 N G C A O T A N : 1 /p h a t c a c s o n g c a o ta n 2 / n g a n g c a c s o n g c a o ta n -> 3/phfc
1 / TLf T R U IN G

djnh hu’6 ,ng neu tan so cac song cao tan giong va i tan so xoay cua proton H
c£c proton HYDROGEN nhOng proton n^y, do cpng h ira n g , se tich tg n3ng I^Q-ng

-C A O T A N : 3 logi CHU O l
- SE Spin Echo
- IR Inversion Recuperation
- EG Echo G radient
moi chu&i bao gom c£c dac tinh:
TR Tem ps de Repetition th a i gian I3p Igi
TE Tem ps d ’ Echo th a i gian phan hoi
Tl Tem ps d ’ Inversion th a i gian dao nghjch

Tan so xoay cua cac proton H

tuy thuQC vao moi tru a n g xung quanh cua chung
H 20 , CHOH, COOH, protein, chuyen dOng ..

- C H O N G C H l D |N H C P A C Q N G H U ’O’N G TL f:

. 1 / C h o n g c h i d jn h le n q u a n t a i ti> tru a n g :

. ch o n g c h id jnh tu y e t doi:
- m a y ta o nhjp , va n tim b ln g kirn lo a i th e h e cu,
- lu’O’i lo c tTnh m a ch ch u m a i d at, s te n t d o n g m a ch c a n h m a i d a t ... d u o i 2 tu a n
- clip cu tren p h in h m a ch , tre n 15 nam
- m a n h kim lo ai tro n g h o c m a t ca n p hai di kh a m b a c sT,
nhCmg tru a n g h a p n a y ca n th u ’c h ie n X q u a n g q u i u a c s o n ao .
- va n nao th a t-p h u c m a c d ie u c h in h b ln g ti>, tru ’ khi d u n g ta m m o t lo a i d ie u c h in h m a i tro n g th a i g ia n ng£n
- bo p ha n c a y o c tai, ca c o n g th o n g tro n g p h ir a n g p h a p k ic h th ic h d ie n n a o sa u (b e n h P a rk in s o n )
- b a m tie m t y d on g

. kh o n g ch o n g c h i djnh :
- bo phan ghep kim loai: cot song, hang, chi
- bo phan g h e p ra n g c o d jnh ... nhipng la y§ u to g a y n h ie u h in h a nh
- bo p ha n g h e p d on g m a ch cu , lu a i lo c tTnh m a ch c h u cu

. 2 / C h on g c h i d jn h lien q ua n ta i h ie u u n g ca o tan: h ie u u'ng lam n o n g le n th e o k ie u "s o n g vi b a"

- han che tuy theo nha san xuat cam slf dgng m ot so chuoi nhat djnh a nhu nhi va tre em

. 3 / C h o n g ch i d inh lien q ua n t a i b en h n ha n:
- benh nhan s a n lm trong mot hop kin. benh nhan kich dong: can dung thuoc tru a c ?
- nen thu-c hien cac chu6i co th a i gian n g in , trong vong 1 phiit, b i t dau b ln g cac chuoi cho nhieu thong tinrfl

. 4 / C h o n g ch i d inh lien q u a n t a i c h a t tu a n g p ha n: (lu u y: b en h n h a n kh o n g ca n p hai n hjn d o i)

- tru'ang hap rat ngoai le dj ung vai gadolinium
- kh o n g ca n d u n g th u o c t r u a c t r u khi g hi n ha n co tie n ca n di i>ng

36
-OAI HlNH ANH thi&n T 1 .T 2 : thdri gian d l c^c proton tr6 Igi th£ng b in g
2 logi hinh 3nh c 6 t h i thu nh$n du’O'c trong 3 logi chu 6 i khac nhau
Spin Echo, Inversion Recuperation, Echo Gradient

AT C A T - tru-drng (FOV, Field Of View), ma trgn: 256 ?, 512 ?, doi xtrng ?, b it doi xi>ng ?
- dO d£y ( 1 - 5 mm)
- s6 Icpong l£t c i t (20 - 150)
- kich thu’d'c d ilm 3nh? D ilm kh 6 i?

d A T PHANG : m$t p h in g c i t ngang, m$t p h in g tr£n, dung dpc

HO l GIAN :4 - 8 chu 6 i trong trung binh 3 phut

Logi may

Lat c it
m u c (niveau)
do day
tru an g
ma tran
do nghieng

Ci>a so
be rong
m i/c (hauteur)

37
 T1 S p in E cho T 2 SE 1° E C H O T 2 SE 2° E C H O T 2 F L A IR
m$t dO proton

CAC CHUOl
TRONG CHT

l' \ V
- it n h it
15 lo ai h inh 3nh

- tro n g 3 m $ t p h ln g

T2 * E ch o G ra d ie n t k h u e ch ten b 1 0 0 0 b i n (36 ADC

. . r it nhi&u
q u y trin h
k h ^ o s3 t

fT \
' v ^ ^
\-u U v

T1 SE g ad o dOng mgch
■ tinh mgch
dbng DNT

trircrng h op d$c bi$t 11

IR T 1, CISS, fat sat
t6n thu an g loai u
CH T tircri m£u
sinh th ilt: hinh bo t h in kinh
u te b&o gai it nheinh ph 6 p do p h i
ph§n dO II CHT c h irc n£ng

- 1 I 0 Q C V A L Y G iA l T IN HIE U C ac ti> khoa

- TIN H IE U : c u o n g d o : tha p , d o n g , ca o ? b i t g a d o lin iu m h a y kh o n g ?
tu o n g u n g v a i lo ai ca u true g ia i p hau:
ton th im n g dac? phu? xuat huyet? m&? voi hoa? dang nang? dong c h |m ? dong nhanh? / ddng n h it 9
- 1 : T1 -2 : T2 - 3 : T2 - 4 T2 - 5: T2 * - 6: k h u ic h tein - 7 T 1 GADOLINIUM
Spin Echo Spin Echo Spin Echo FLAIR Echo G radient .b1000
1°echo 2°echo b£n do AD C
m$t dQ proton "T2 th yc"

- 8: hinh 3nh d$ng m a tfi

- 9: hinh anh tTnh maefi
- 10:hinh £nh dong DNT

-1 1 : Inversion R ecuperation T1
- Vj T R I? to n th u a n g th u y tra n ? th u y d in h ? , ... ph3n giai r i t cao CISS
hinh 3nh hoc trong cung
h o sau, tu y e n y e n ? ...
tu a n g u n g d un g v a i ca c d au h ieu la m sa n g ?
- 12: hinh £nh hoc ti/on mau
- ro i lo a n v a n d p n g , ca m g i3c, m a t tie n g noi, c h u c n a n g c a o ca p , tri n h a . 5aoo*mium
- c a c th a n kin h s q v a n d<?ng h a y c a m g ia c
- d o n g kin h B ra v a is Ja c k s o n ... - 13: hinh b<b th in kinh
size c5ng < r tin

- H iN H T H £ g ^ i y : th e o vu n g t u a i cu a d o n g m a ch ?
- 14: hinh anh hoc ch u c n£ng

- C A U T R U C : g iu 1 n g u ye n ca c ca u tru e n ao b o? - 15: ph6p do phA bang CHT

■ S O L lfC ^ N G c a c t o n t h u o n g : ton th u a n g d u y n h a t? n h ie u to n th u a n g ?

- 2 / CAC LAP u nhoi mau, xuat huyet-7 ap xe7 xa cung rai rac-7 nhiem ky sinh tn jn g ? n h ilm d$c? c n i r tr^/cr^g j
L U A N H l/ Q N G V £ n3o? h u y it khoi tinh mach nao7 benh ly roi loan chuyen hoa’ thoai hoa? d| dang? so n £ c ')
CAN NG UYEN?

38
 C 3 c tin hi$u tr§n S pin E cho T1 v3 T2

Spin Echo T1 SE T2 echo thCr 1 SE T2 echo thi> 2

■ P7 T
* 5 - K ■ '

v
T in thuang phu: nh 6 i m^u bao trong bSn ph3i: tin hi§u tr§n T1 th lp , T2 echo thu11 tSng, T2 echo thur 2 tang

Spin Echo T 1 SE T2 echo thi> 1 S E T 2 echo th ir 2

T 6 n thuang x u it huyet: m&u ty dr nhSn d$u ben phdi v^o ng^y thu 7: tin hieu a T1 tang. T2 echo thu -1 t£ng, T2 echo thu 2 tang
vi6 n xung quanh giam tin hieu do hemosiderine.

Tin hieu T u a n g im g 1 S PIN E CHO SPIN ECHO SPIN E CHO

giai p hau I T1 T2 e c h o th i> 1 T2 e c h o th i> 2
m at do proton
tin hieu cao A
cuc m £u dong cuc m au dong
ro ret
nong do p rotein cao | ^ nong do protein
= t r ln g
m a , m elanin cao

g a d o lin iu m T1 phu
nang
it protein
tin hieu cao
hogi ti>
trung binh
= xam sang
DNT

d 6 ng tin hieu
= x£m v ir a

phu
ton thu-ang phu
tin hi0 u thap
nang
tru ng b inh it p rotein
= xam sam
hogi tCr

xu’a n g
tin hieu thap v 6 i hoa xu o n g
ro ret dong dong m gch voi hoa
= den m pt so dong dong d on g m gch,
tTnh m gch dong tTnh m gch
hem osid e nn hem osid e nn
khi ▼ T khi

39
 CAC TiN Hlgu C A O tren S pin Echo T1

- 1 / C y c m ciu d o n g

- 2 / N o n g dQ p ro te in ca o : nang the keo n ao tha t III

? \

n h o i m a u n g & y thi> 1 0
hogi ti> v 6 n§o dang I6 p

-3 1 Mo
nang dang bi tin hieu cao 6 d inh x u o n g d£: m a b inh thub-ng cua tu y x u a n g s q ? p rotein?
cho tha y Ipi ich cua chuoi bao hoa m a

T1 F at S at mfj

- 4 / M e la n in

d i ca n cu a u h i e to

T1 khong tiem

- 5 / B e n h i> d p n g c h a t d o n g : b e n h W ils o n , b e n h lp d p n g m a n g a n : n u o i d u o n g q u a d u o n g tTnh m a c h

- 6 / D o n g . tTnh m a c h : tin h ie u th a y d o i
tre n T 1

... tin h ie u co th e ta n g
d o h ie n t u p n g d i v a o la t c l

. th e o vj tr i d p n g m a c h : d o n g d o n g m a c h c h a m ? (h ie u ipng di v a o la t c i t )
... k h o ly g ia i tro n g tr u o n g h o p p h in h m a c h d o n g m a c h b| h u y e t k h o i m o t p h a n

- 7 / G a d o lin iu m

di can u h lc to
- 2 di can thuy tran ben trai
. tang tin hieu t u phat
. sau khi tiem ton th u a n g co kich th ira c la n h an
b i t gadolinium m ot phan

- 1 di can d u a i la p n<?i m ac nao t h i t ben

. co tin hieu thap t y phat
. bat gadolinium

40
 CA C T lN H lg U tr6n Spin Echo T2: echo th u n h lt, m gt dp protons

L g i ich: 1/ NSo b<>: . tu a n g phan r 6 g iu a . c h it tr ln g c 6 tin hi$u t h lp , DN T dong tin higu

. ton th u a n g p h ii co tin higu cao
. chu 6 i n3y kh 6 ng tao nhieu 3nh gia a ho sau n hu ng khong cho nhieu thong tin h a n chu 6 i O' T2 FLAIR

T2 SE echo thi> 1 T2 SE echo thi> 2 T2 FLAIR

T1 T 2 S E e ch o th u 1 T 2 SE echo th u 2 T2 FLAIR T1 g ado

X a ci>ng r3i rac: nhieu ton th u a n g m a t m yelin nhieu n ai m ang tin hieu cao tren T2 echo th u nhat
L uu y: mOt ton th u a n g d u d i npi m a c nao tha t ke can nga tu nao tha t ben ben phai m ang tinh chat "dang hoat d pn g" tren T 1 gado

. 21 C hudi nay h u u ich de khao sa t cac nhan xam trung tam / benh Parkinson:
chat t r ln g co tin hieu tha p ro rgt, nhan xam co tin hieu cao

I C u a so hep co the m ang lai Igi ich vi D N T co hien tu a n g dong tin hieu hay tin hieu tang nhe

41
 CAC TIN HIEU tren Spin Echo T2. echo thi> 2, T 2 th y c s i/ '

Lo-i ich - dQ phan giai khong gian r i t tot

chuSi d<jic biet hOu ich de kh ao sat

. h 6 c m it
. t h in kinh thj va g iao thoa thj giac c3 c lat c i t s3 t nhau d dy 3mm/ m at p h in g tran
. tuye n yen, cac xoang hang

. vung m§t ca c la t c i t sat nhau d a y 4 hay 5 m m / m at p h in g tran

. h 6 sau

- t h iy r i t r 6 ca c dQng m ach va xoang tTnh m ach, vQ-i tin hi$u t h i p rQ r$t

anh gia cua d 6 ng DNT : "it tang tin hieu h a n " ... iQ i ich v ! m $t tri$u ch u n g hoc d l danh gia tin h linh dQng cua DN'

Luu y: . tren T2 Spin Echo echo th u 1 va echo th u 2: viec chinh ca c h inh anh a cua so hep tren ban d ieu khien la r i t q ua n trpng
. mQt tin hieu rat m gnh tren T2 co the che k h u it mQt ton th u a n g ... do do can th iet s u dgng c u a so r i t hep

T2 FLAIR

ton th u a n g co ve n h ir dang nang. c h u a djch ... ... t6 n th u a n g d 3 c

T2 SE, echo th u 1: cu a so rong "b in h th u a n g ' C ira so hep nhoi m au doi thi p hia sau hai b e'-

42
 T n /b 'n g h<?p d $ c bi$t; tin hi£u cua c£ c c£u true chi>a protein tren spin echo

P. SOM : R A D IO LO G Y . 1989, 172. 5 15-520

-0 - 1g/l
T 1 S pin E cho T2 echo th tr 1 T2 echo thi> 2
DNT: 0,20g/l

A .

m
fg j W m
T1 T2 echo thi> 1 T2 echo thu 12
- 1 - 15g/l

nang cua u
phu

- 1 5- 30g/l T1 Spin E cho T2 echo thi> 1 T2 e ch o thi> 2

eye m£u dong CA0

nang cua u
. . d Ong
nhieu protein

ege m£u dong

T1 Spin Echo

- 3 0 - 4 0 g/l

nang the keo

nang dgng bi

m$t s6 nang nhay

nang n h ly ciia dinh xi/a ng d3

T 1 Spin Echo T2 echo thi> 2

- tr§n 40g/l

mOt s6 nang nhay

u qu£i

43
 CA C TIN HIE U tren T2 FLAIR

. Fluid A tte nu a ted Inversion R ecup e ra tion : h inh anh 1 2 n h i/n g cho tin hi£u DNT 'd e n '
. la chuoi cho nhieu thong tin nhat

-1 / T u o n g phan ro r$t g iu a ton th u o n g co tin hi#u ca o (phu) va DNT, d $ c bi$t 6 nhOng p h ln \6\ cua W n c iu dai nSo

* r K ^

( \ v ' - •> : 7
* )
/« '

12 SE echo thi> 1 12 SE echo thi> 2: t6n thi/o n g ?? T2 FLAIR

nhAi mau vo ndo

- 2 / L u u y: nang, djch c 6 n 6 ng dp protein c = "it tSng tin hi$u "tr§n T2 FLAIR

S inh thiet: u te bdo sao it nhdnh

dang nang dQ II

T2 SE echo thi> 1

M pt ngu y c o sai s6 t tren T2 FLAIR:

. Trong dien tien cua nhoi m au nao: doi khi co the g$p vie c chuyen d in dan tU m pt ton th u o n g logi phu co tin hi$u cao
sang m pt hoc nao, co tin h ch a t djch, tin hieu thap ... qua m pt giai doan djch c h u a pro te in dong tin h*6 u
. Hg qua: q uan s3t ky c£c chuoi tren T1 : ton th u o n g co tin hieu thap

12 FLAIR ------- ------------------- SE

T 2 F LA IR "binh thucrng" ton th i/a n g dau nhan duoi ben p hai kh o n g th a y d u p e

44
 CA C TIN H l£ U trdn T 2 *

- ch u fii E cho G ra d ie n t: giSm tin hi$u cua m d

vd vi v$y c 6 hien tu p n g Qi^m tin hi$u cua c h it trln g ,
- c6 3nh gia Ii6 n quan d in c£c c lu true x u a n g vd s i/ hi$n di$n cua khi trong cac xoang
- c 6 s i/ deinh gid trQi h a n so v 6 i th i/c t l t h i t(ch t 6 n th u a n g
n h u n g d 3 y |& ch ufii r i t c6 y nghTa;
v l n 6 m ang Igi nh& ng thdng tin m3 chu 6 i T2 Spin E cho v3 T2 FLAIR khong cung cap d u p e :
h inh 2 nh hem osiderin, v6 i h 6 a

1/ HEMOSIDERIN : m £u ty? x u lt huyet m 3ng nao? nhoi m£u x u lt huyet?

u mach hang? chan th u a n g ? ...

- V i d y: m at ngon n g u d ot ngOt a m pt benh nhan thuan tay phai c3ch nay 4 ngay :

. Chuoi T1 v3 T2 Spin Echo, T2 FLAIR ... khong co nhoi mau

. K h u lc h t£n: nhoi mau, phu nao hai thcii d u a n g chu yeu ben phcii
. C huoi T2 * chan doan . co nhoi m 3u thcii d u a n g trai
. nhoi m au m ang tin h chat xuat huyet
... c h i chuoi nay m d i cho phep chan do£n d u y c n h u v§y

T2 SE echo thi> 1 echo thi> 2 T2 FLAIR khuech tan b 1000 T2 * kh6i mdu ty
NhOng hinh anh n£y kh6ng cho th ly du’O'c ton thirong th£i duang b§n tr£i

T1 T2 SE echo thi> 1 echo thi> 2 T2 FLAIR T2 *

M 3u tu n h o a n h a n d au b en trai, khong nhgn ra d u a c n h u n g vi x u a t huyet kh a c N hieu ton th u a n g gi3m tin

hieu dang cham tro n g b$nh
canh nao do ca o h u ye t £p

Thanh phan xuat huyet cua nhoi mau

vung dong mach nao giua va nao trudc
chi thay d u a c tren T2 '

T 2 FLAIR

45
 T1 T2 SE 2° echo T2 FLAIR T2 •

V 6 i h 6 a nh3n duoi b£n tr3i, kh 6 c h in doan tren T 1 , T2 SE, T2 FLAIR

C h u 6 i T2 * 13 rat g o i y:
. khong n hu ng t h i y voi hoa nhan duoi tr3i
. m 3 c6 n t h iy c3 vi voi hoa ben phai v3 g iup k h in g djnh c h in do3n, loai bo mQi n ghi ngdr b$nh ly u
... benh FAHR

CHT: h inh anh h<?c K H U E C H TAN

- Nguyen t ic : . d $t m $t g ra die n t bo sung de dao pha: bO, b500, b 1 .000 (m illi te sla s/m m 2)
. d p i roi d £t mOt g radient hoi pha tu a n g tu
. n iu c3c ph3n tu nu’d’c c 6 chuyen dQng gi3m (khuech t3n hgn c h i) , g ra die n t h 6 i pha c 6 hieu qua:
tin hi$u cao tren T2 van ton tgi
neu c3c ph3n tu n u ^ c c 6 chuyen dpng nhieu: n i/a c , DN T (khuech tan tang),
hoi pha khong hoan to3n = m at tin hieu: DN T v3 djch tu do c 6 tin hieu t h ip tren blOOO
- K h3o s3t tin h chuyen dQng tu do cua ca c phan t u n u 6 c ben trong mQt m oi tru-ang :

- djch chuyen d§ng tu do: djch nao tuy, djch cua nang trong u cua tui chUa D N T, c 6 it te b3o
linh dQng r 6 , k h u lc h t3n nhi&u :
- khuech tan b1000: DNT, nang: "den", tin hieu thap
- ban do A DC: DNT, nang: "trin g " , tin hieu cao
- djch it chuyen dQng tu do h a n / thanh te bao :
c h it x3m v3 c h it trin g , nhoi m au cu, u nao ...
- c iu true "xam ", dong tin higu tren khuech tan b 10 00 v3 ban d 6 ADC

- djch it c h u y in dQng tu do h an nOa :

phu dQC te bao (nhoi m au rat m a i): te bao tang kich thu’a c
m il trong 3p xe: dai th u c b3o, te bao da nhan bien doi
- ton th u a n g c 6 tin hieu cao tren khuech tan b10 00 va tin hieu t h i p tren ban d<i> ADC

C ac chi djnh chinh

- 1 / N hoi m 3u nao :
. chan do3n mQt hay nhieu vung nhoi m au m ai. co the n im g iu a nhOng ton th i/a n g cu
ly gi3i huyet khoi? h inh anh khuye ch tan xac djnh dQ lan rong cua vu ng phu dQC te bao kh on g h 6 i phg c d u t/c nOa
- 2 / L y gi3i mQt ton th u a n g dgng nang:
. khuech t3n han che: ap xe
. khuech t3n gia tang: u hogi tu (u nguyen bao dem . di c3n)

- 3 / C 3c Igp lugn g o i y tin h c h it cua mo:

khuech t3n hgn c h i: u nhieu te bao (lym phom , u nguyen bao tuy, u d3y than kinh, u m 3ng n3o)
. khuech t3n gia tin g : u it te b ao (u te bao dem )

46
-K9 thu$t c h u ii 2 0 lat trong vbng 30 gidy,
cb t h i 2 c h u ii 2 0 lat c i t t£p trung vdo vung h 6 sau roi den 2 ban cau dgi nao

phan giai v i mgt khdng gian k 6 m/ma tr^n nho

p hfin g iii v i m at tin hi$u tuy$t h5o tr£n k h u ic h tan b 1 0 0 0 , tu a n g phan "ton th u a n g tr in g tren n in den"
. tr 6 n ban d i AD C , dpc kh 6 han : " t in th u a n g den tren nen trin g "
- c6 t h i do h$ s 6 : c6 l|ip mOt vung t 6 n th u a n g va m pt vung doi x u n g m o lanh
- so sanh: khac bi$t tr§n 20% g iu a ca c hg so khuyech ten bieu tru n g la co y nghTa
n iu t6 n th u a n g khbng bao gom thanh phan voi h 6 a hay x u it huyet tr£n T2*
- bieu hi§n s 6 do b in g 10-3 m m 2/g ia y D N T = 3 ; c h it t r in g = 0,7
- Kitqui :
. (H inh ^n h sau khi si> d ung m ^ t trudrng tr 6 ng, b = 0
. h inh in h T2 tu a n g t y nhu 1 h inh in h T2*
. khbng c 6 ich ly i trong c h in doan; n 6 g iup tinh toan cho ban do A D C )

. (H inh in h sau khi s u d yn g m pt tru b n g b 500: d i khao sat nao bo, it la i ich h a n b1000 trong khao sat nao bd)

. Hinh £nh sau khi s u d yn g m it tru a n g b1000: 2 logi h inh in h , bo sung cho nhau:

. 1/ K h u ic h ten: h inh anh hon h op : m pt phan la hinh anh T2 (gpi la "T2 xuyen qua"), m pt p h in la h inh anh khuech ten
teng tinh hi$u tr§n T2 SE hay FLAIR, tru-ang h y p th u b n g gap, se d u a den tang tin higu tren b1000 do higu i>ng cua T2
v i va y tang tin hieu tren b 1 0 0 0 khong n h it thiet dong nghTa v a i khuech ten hgn che
can d o c ban do A D C ("khuech ten th u c s y ) : tim s y giam tin higu ro r?t c iia khuech ten hgn c h i

. 21 Ban d 6 A DC: "h g so khuech ten bieu trim g " c 6 du-p’c b in g cach tinh ti> bO va b1000
. logi t r y thanh phan T2 cua hinh anh: h inh anh "th y c s y " cua khuech ten
. dpc b in g cach so sa nh "bang m at th ira n g " g iu a ben lin h va ben bgnh
hoac c 6 the do d g c D N T = 2 den 3, c h it tr in g : 0,3 den 1,2; lu-u y s y so sanh b in g phan tram g iu a p h in lanh
va phan bgnh la c h ic c h in han cac so do tuye t doi
- h inh tr in g va den: A D C giam = den, do nhay gia tang:
nhoi m au m a i, ... va ca m au tu r i t m a i, ap-xe
A D C teng = trin g , djch chuyen dong: DNT. n ang cua khoi u
- h in h mau: A D C giam = xanh d u a n g
A D C tang = do

KH U E C H TA N trong th y c hanh

- Lam sang gp-i y nhoi m au nao r i t m b -i/1 den 3 gib-:

. X Q C LD T va C H T b inh th u a n g
. H inh anh k h u ic h ten g y i y nhoi m au r i t m ai:
- b1000: nhoi m au co tin higu cao do khuech ten / khong the nham lan v&i hi£u u n g T2 ch u a x u it hign
- b in do A D C : tin higu th ip : co the do: g iim 20 - 50% so v<fri vu ng m o binh thub-ng
. L uu y: ngu y c a n ham lan v& i m au ty r i t m 6 i: teng b 10 00 va giam A D C ... X em T 2 F LA IR va T2*

- Lam sang gp*i y nhoi m au da 3 gib 1 - 6 ngay: nhoi m au m 6 i, d a n thuan hay trong n h u n g vung nhoi m au cO
. X Q C LD T va C H T benh ly: m a t do t h ip tren X Q C LD T, tang tin hieu tren T2 FLAIR
. H inh in h khuech ten co y nghTa ve nhoi m au m a i: teng tin hieu tren b 1000, ban do A D C : giam tin higu
(L u u y: tren b10 00 co the nham v a i hieu u n g T2; sau 3 g ia vie c dpc them ban do A D C la can thiet

-T in th u a n g "dgng nang" tren CHT:

1/ T in th u a n g cb tin higu ca o tren b1000 va tin hieu thap tren A D C = khuech tan hgn che = ap xe : bgch cau da nh^n, protein
21 C h it c h u a ben trong ton th u a n g tha y doi tin hieu "theo tin hieu cua DNT": t h ip b1000, cao A D C = u hogi tu
( u nguyen bao d em h ay di can)

- C ac l§p lugn go-i y tin h c h it cua m o :

. U nhieu te bao (lym ph o m , u nguyen bao tuy, u d a y than kinh, u m ang nao, nang dgng bieu bi)
= khue ch ten hgn che: tang b 1000, giam ADC
. U it t i bao (u te b ao dem ) = k h u ic h ten gia tang: giam b1000, tang AD C , tin hieu giong n h u dich nao tuy

- Cac ngu yen nhan nham lin :

. Ton th u a n g co T A N G TIN HIE U T2, dong tin hieu b1000, tru a c tien n g h i ta i m ot tin h trang khuech ten b inh th u a n g
... d iu sao cung kiem ch u n g Igi tren ban do A D C : ton th u a n g giam tin higu tren ADC do khuech tan hgn c h e 7

. Ton th u a n g khong dong n h it: thanh phan x u it huyet, voi hoa, m a co tin hieu t h i p tren khuech ten va ban do A D C j
... kho ly giai ca c ton th u a n g khong d ong n h it tren khuech ten

47
 KHUfzCH TAN GlAM

T2 FLAIR KHUECH TAN b 1.000 b3n <36 ADC :

Apparent Diffusion Coefficient
-1 / Phu trong hay ngo£i t l bao :
- k h u ic h ten gi£m "= tr in g "
- b in d6 ADC “= den*. "giAng n h u T2 FLAIR"

phu trong t l bao do d$c t l bao. khdng h & p h yc ducrc

= nh6i m ^u r i t mdri
13m sang: nh6i m au d ir6 i 3 gifr trd lai
c6 the c6 c h i djnh ly gidi h u y lt khAi ...

lu u y: eye m au d6ng r i t m 6 i cOng teng tin h i#u tr§n b1000

.. xem T2 F LA IR va n h it Id T2*

phu ngoai t l bao phu v$n m ach, c6 t h i hAi p h yc d u p e

= nhAi m au dOng m ach sau 3 g iir
= t i t c3 c£c t i n th u a n g phu "d a ng hoat d$ng "
i - u t l bao dgm phSndO cao
- x a c u n g r^i rac / t i n thucrng m fri
I - nhAi m au tin h m ach

TANG

- tang tin hieu b 1000 khuech tan giam

Nhoi m au nao :
dien tien tin hieu ng£ y 6 nga y 60
tren khuech tan
AD C k h u ic h ta n b in h th u frn g
tr a ve binh th u ’drng hay
k h oang n g ^ y th u 6 k h u ic h ta n gia tang
... I^ i ich cua vig c tin h n g a y x3 y ra n h li m au nao ( g iln g n h u D NT)
- giam tin hieu / ban do ADC
trong tarOng hop h6c n3o

- 2 / D q n h ly teng: mu tro ng ap xe
T2 FLAIR k h u £ c h t A n b1000 BAN DO ADC ... k h u ic h tan giam
TANG tA n g GiAM

k h u ic h ten gi3m vi :
A n - n h ilu t l bao: bach c lu da nhan
- t l bao phi dai: phu tro ng t l bao
do doc t l bao

(ngoai le:
ap xe d o toxo p lasm a, c h it chi>a ben tro ng hoai tu
tin hieu tu a n g t y n h u cua u hoai tCr)

- 3 / Nhieu t l bao
... k h u ic h ten g i^m . Lym p h o m
( p h a n b*gt vtri u
n g u yg n b do dgm)
T2: giam tin hieu k in dao
U n g u yg n b ao tuy
khoang co chi>a it djch : n h ilu t l bao
(ph a n t> gt vdn u mang
k h u ic h tan b 1 0 0 0 : ta n g tin h igu r6
6 n g nfy tuy)
khong the giai th ich bang h igu u n g T2 tru n g binh
DNET
sinh t h ilt: lym phom nao
(va kh d n g phai Igc chfi
c h i t xam)
. U m ang n io
T2 F LA IR : ta n g tin higu U dg y t h i n kinh
. k h u ic h ta n b 1000 tang kh fin g r6 N ang d a n g bi
tang tin h igu d o higu u n g T2
hay d o hgn c h i s i/ k h u ic h tan? Cac Igp iu3n kh6 ng 06
ban d 6 AD C tin h k h ln g Sinh
tin higu th a p ro 'g o i y d 4 n '
d o hgn c h i k h u ic h tan c l n so s a n h vb i
sin h thiet: lym p h o m nao ca c d l u khac
khuech tan b 1000

48
| KHUECH TAN GIA TANG | djch ■ ti/ do *

-1 / N ude = DNT, h6c n io

T2 FLAIR K H U fC H TAN b 1 000 BAN DO ADC
nang m £ng nhgn

- 2 / K hoang ngoai b£o = c h £ t c h u a b e n tr o n g n a n g

r$ng c u a k h 6 i u:
u te b ^ o d g m , d i c 3 n
= p h £ h u y t6 b £ o :
x a c i> n g r ^ i r£ c
to n th u a n g cu
= n h 6 i m £ u cu:
tS n g s in h tb d g m ,
h6c n§o
trung t3m hogi ti>
th Ap

T2 FLAIR I K H U eC H TA N b 1.000 B£n d6 ADC

- 3 / G ia ta n g d o n h a y v d i ti> tin h
£ v t d a u h ie u p h i> c tg p tre n k h u e c h ta n : h e m o s id e n n
W - m a u ty (b a n c a p )

' ‘ v V

' '

Trung tSm THAP THAP t h Ap

- 4 / Ky nude / m a
u m a , u quai

xem tin h ie u m a d u d i d a th a i d u a n g
T1 T2 FLAIR KHUECH TAN b1000 b3n d6 ADC

( ' J

- KHI
KHCNG KHUECH TAN
- V C l HO A

KHUECH TAN b1000

m -

■ K - . V '

XQCLDT v6i h6a

49
 LQ I ICH C U A K H U E C H TAN: 9 thi dy

- Nghi n g d nhA« rrteu mdn

- H inh in h khuAch ten b 1 0 00 tin hi$u cao

bdn dA A D C tin hifcu thAp

... nhAi nteu m d i vu ng dm n £o g iua

n fing vd sSu

- Tr§n khuAch ten thAy nhAi m £u lan r^n g han

tr6n T 2 FLAIR

T2 khuech tin : b 1.000 b3n do ADC

DNT c6 tin hieu th^p DNT cd tin higu cao
"n h i/ tr6n T2 FLAIR" "nhi/ tren T2 Spin Echo *

^ 3

Sfci.
m$t dO protons T2 echo thi> 2 kho6cti tin b 1000
Nhi&u h in h dnh dgng khuyet trong v6 n§o: khuyet h ay nhAi m £u ngo? t6 n th u a n g mGi ha y cu ? c5 n n guygn?
K h u ic h ten ch o thdy: . d£u la t6n th u a n g m ai: tin higu cao trgn b1000, t6n th u a n g cO c6 tin higu d6ng
. d 6 Id n h u n g nhoi m £u dudri v6 c h ir kh6ng phdi lA kh u yg t d o thodi h 6a lypoh ya lin
. nhAi m du m 6i, da phdn ngm ben trdi trgn khuech tdn: c6 th g d o thu yg n td c tir dgng m g ch c
L u u y: c d c chuAi kinh d ien T1 va T2 Spin E ch o khong ch o nhigu thgng tin ;
ph6i h a p v 6 i d ay ban trong x u a n g trdn

- Nghi ngdy nhoi m au m ai:

chan dodn m pt hay nhieu ton th u a n g m a i g iu a n hu ng hinh khuyet nao cu

T 2 FLAIR: t6n th u a n g m 6 i? cdi nao? tra k ri ..k h u A c h td n b1000, ban dA AD C

k h u e c h ta n b 1 000 ban (36 ADC

nhoi m au m 6 i c6 tin higu cao nhAi m du m o i c6 tin higu thAp

T1 T2 FLAIR
H ai nhoi m au d g n g kh uye t ke can nhau: m ot to n th u a n g m a i7 cat n a o 7

50
 5/ B $nh nhan 6 khoa h6i si>c / lam t6ng k6 tdn th u a n g , ti£n lu p n g ?

. b$nh nhan h6n m § sdu sau nh6i m au co- tim tu 6 ngay tru d c
sang; kh6ng c6 tripu ch u n g than kinh m pt ben

T1 T2 SE echo thi> 1 echo thCr 2 T2 FLAIR T2 *

. c h it t r in g phu ne lan toa, doi xi>ng, dong tin hipu tren T1

. tin hi$u cao 6 v6 nao tren T2 FLAIR ? xoa cac ranh vo nao, sau nay xac djnh la chat xam phu ne

khuech tan b1000 ban d6 ADC

tSng tin hieu toa n bo ch a t xam tren khuech tan b1000, tin hieu hon h p p cua vo nao tren ban do ADC
ton thu-ong n ao do giam lu u lu p n g m au tram trpng va keo dai; tien lu p n g khong kha quan

6/ A p xe hay u hoai tu (u ngu yen bao dpm , di ca n) ?

Ap xe

khuechtan b1000 ban do ADC

. c h i co th e d p c ly giai ch a t c h u a ben tro n g nang

. kh o n g ly g iai d u p e tin hieu b en tro n g to n th u a n g d a c ... hinh anh khuech ta n khong m ang lai th o n g tin
ve ph an d o cu n g n h u ve logi u te b ao dem , cu n g n h u chan d o a n phan biet g iu a u te b ao dem v a i ung th u
. n h u n g h in h anh k h u ye ch tan co th e g iup co n h u n g Igp luan ve tin h ch a t nhieu te bao, xem benh an tie p theo.

U hogi tu

khuechtan b1000 ban do ADC

51
 C ic Igp lugn tren khuech tan giup tiep can c h in doan giai p h iu b$nh cac u:

- 1/ Ton th u a n g nhieu te bao: lym phom , u nguy§n bao tuy, DNET. u d ay t h in kinh, u m ang nao
= khuech tan han che, tin hieu cao tr£n b1000
-2 / Ton th u a n g it te bao, "co tin h phu ": u te bao dem nao, di can
= khuech tan b inh th u & n g , dong tin hieu tren b1000

. ngoai cac yeu t6 lam sang va h inh thai.

. ton th u a n g dong tin hieu T2 echo th u 2

vi vay day ia khoang c6 tinh c h it dich b« hgn c h i
. k h ln g dinh tren h inh anh khuech tan: tin hi£u cao
khong the g iii thich b in g hi$u u n g T2
... co kha nang ton th u a n g nhieu te bao

sinh thiet: lym phom nao

k h u & c h te n b1 00 0

T1 T2 FLAIR T1 gado khuech t£n b1000

cha n doan u m ang nao tren T 1 . T 2 FLA IR (khoang co tin h ch a t dich yeu), va T 1 gado
lap lu$n bo sung tren khuech tan: tang tin hieu b 1 000 do khuech ta n han che, ban d o A D C it co y nghTa

- T on th u a n g nam a nhan dau ben phai, b p ro. co ve ia ton th u a n g trong nao

it cac d a u hieu g ia n tie p : da y nhe th u n g lung S ylviu s ra ngoai. g i n n h u ton tro n g bao tro n g va d u a n g g iu a
n h u n g d ay nhan dau ra tru a c : khong co phu ke can : g a i y ton th u a n g ngoai nao
- K hao s a t c a c tin hieu :
g ia m T 1, tan g T2 SE, giam T2 FLA IR , tang T 2 * ton th u a n g co thanh p h in m ang n h ie u tin h c h a t d|C h
c h an d o a n na ng m an g nhen khong d u p e nghT den vi
h in h th e va vj tri khong dien hinh
c h i t c h u a ben tro n g ton th u a n g khong dong n h a t tren T1 va T2
ta ng tin h ie u dgng vgch th in g a ngoai vi tren T1 T2 m o co nhieu protein
kho ng b i t g ad o lib iu m
. ta ng tin hieu ro tren k h u e c ta n b 1.000 va giam tin hieu kin dao tren ban do AD C khuech tan bi han ch e 1
to n th ira n g nhieu te bao, nhieu vach ngan

T o m lai chan d o a n nang d ang bieu bi (kyste e p id e rm o id e ) iu ha t ng o c) ia gan nhu rat dung
C h in doa n kh on g d u p e kiem c h u n g lai. benh nhan khong m o C o th e kiem tra d ien tien b in g C H T th u c hien v o i th o i gia"- -

52
T 1 G A D O L IN IU M

- C H l D |N H T l£ M ? lu-u y H A N G R A O M A U N A O

- CHT kh O n g T I£ m k h o a n g 4 0 / 1 0 0 c ^ c k h a o sa t

- tai b iln m g ch meiu n3o

- v$ n dOng b i t th u d n g , P a rkin so n
- c h in th u a n g
- kh 2 nSng dj d g n g n a o -m ^ n g n ao
- n gh i n g p v ie m n io d o h e rp e s
- r6i lo g n tri n h d , sa s u t t r i tup

- C H T C 6 T l£ M 6 0 /1 0 0

- n g h i n g d u n a o ... u te b a o d e m , lym p h o m , di can

- &p xe
- x a c u n g r£ i r£ c, A ID S

- tai b ie n m a ch m a u nao: . c h g p m g ch b in g C H T (C H T -M M )
. nghi n g d v ie m h u y e t kh oi tTnh m a ch nao
. h in h a n h kh o n g d ien h in h t h i y tre n c a c c h u o i kh o n g tiem

- la m s ^ n g k h o n g ro ra n g ... d p n g kin h, n h in doi

n h u c d au : h oi b en h s u cu a b en h n ha n ; neu kh o n g d ien h in h : tiem

- c£ c k h a o s a t C H T kh o n g tie m d a th u c h ipn c o k e t q ua kh o ly giai

G hi ch u: th e o n g u y e n t i c an to a n , m a n g th a i la m o t ch o n g c h i d jn h tie m g a d o lin iu m

- k Et q u A

C A U T R U C B lN H T H L r tl'N G kh o n g b lit g a d o lin iu m b at g a d o lin iu m

- n a o bp - m a n g nao
- d p n g m a ch : d o n g n ha nh , tin h ieu th a p - d a m roi m a ch m a c
(tru khi c h u 6 i b a o h o a d o n g d u p e si> d u n g ) - tu y e n yen
- tTnh m a ch

T O N T H U m iG kh o n g b a t g a d o lin iu m b a t g a d o lin iu m

- u te b ao dem : kh o n g tu a n g u n g
- p hu n ao : q u a n h u
g iu a p ha n d o u va d o b i t tu a n g phan
v ie m nao
- di can
- m o t s o u te b a o d e m , p ha n d o th a p
- lym p h o m
- n ho i m a u m o i, n h o i m a u cu u m a n g nao. u d a y th a n kin h
- kh oi m a u tu
- m o t so n h o i m a u sa u 6 n g a y
- dj d a n g n a o - m a n g n ao
ch u vi q u a n h kh o i m a u tu
- u q ua i
- a p xe, tu m il
- x a c u n g rai ra c (m a n g d a n g h o a t d o n g )

53
 T 1 g a d o lin iu m : k y t h u a t th u t h a p

-1 / T h u th ^ p T 1 S p in E c h o : 2 0 la t c i t d a y 5 m m , c 3 c h q u ^ n g 2 h a y 3 m m , tro n g 3 m $ t p h ln g

- t r u d c ti§ n t h y c h ie n c h u o i tre n m a t p h ln g d u n g dQC v £ tr£ n , v £ s a u d 6 , tro n g c h u i i cuA i c u n g , trfen m £ t p h l n g c a t ngana.

d iiu n £ y c h o phe p - ta n g th d i g ia n t u lu c tie m d e n k h i t h u c h i$ n c £ c l£ t c i t n g a n g , ia t c i t n h i^ u th 6 o g b n n h it
- g ia m I n h g ia o h 6 s a u Ii6 n q u a n t d i g a d o lin iu m lu u th ftn g tro n g c i c x o a n g tTnh m g c h bAn
- 3 m $ t p h l n g , d $ c b i$ t Id m a t p h ln g d u n g d p c p h a i d u o c t h y c h i£ n th u d rn g q u i ... Ip i ic h c h o p h 5 u th u £ t

T 5 n g tin h i$ u d o t i I? p ro te in ta n g v a d o e y e h u y l t k h 6 i

- c h u o i t r u b ’c v a s a u tie m g a d o lin iu m : v l n d e v e d ie u c h in h c u a s o
. k h i b i t t u o n g p h a n y e u : n e n d u n g c u a s o n h u n h a u g iiip s o s a n h c a c h in h 3 n h c 6 d p t u o n g p h a n g»6ng n h a u
. tu y n h ie n k h i t u o n g p h £ n t r u o c tie m ro re t, h o £ c k h i b i t m a n h g a d o lin iu m , k h d n g t h i n a o g iu c h u n g c u a s i

- 2 / T h u th g p T 1, m o d e 3 D

. 100 iat d a y 1 ,4 m m ; th u th a p tro n g m a t p h ln g d u n g d p c (e c h o g ra d ie n t),

h a y 1 8 0 la t de»y 0 .9 m m ; th u th a p tro n g m a t p h ln g c i t n g a n g (T1 in v e rs io n r e c u p e r a tio n )
. sau d6 tai t g o tr e n m g t p h ln g n g a n g va v a m a t p h l n g tra n th a n h 2 0 la t d a y 5 m m
- k y th u g t n a y d u p ’C s u d y n g s a u tie m g a d o lin iu m d e c o d u p e c a c c h u o i tro n g 3 m a t p h ln g s a u m p t la n th u th a p ,
d $ c b ie t la ceic d o n g m g c h va tTnh m a c h c o tin h ie u c a o ro d o h ie u u n g h o n h p p : d o n g + g a d o lin iu m

- s o s a n h g iu a . 1 / h in h a n h th u th a p tre n s p in e c h o , m o d e 2D

thp'i gian 3 x 3 phut = 9 ptiut

hinh anh t i t v e m at tin hi£u

trong 3 m at p h ln g

thu th ap tron g m £ t phan g ca t ngang, d u n g dpc. tran lat cat da y 5 m m

21 h in h a n h th u th a p tre n T 2 * m o d e 3D
th in gian 1 x 4 phut
♦ tai tao

. h in h ^ n h khdng g ia r kem hem

khi tai ta o tr6n
m at p h ln g tran va d -m g doc
d0 phan giai v& m a t b n h i& j th ip
- phan bi$ t c h i t r t n g
chat xam
- gado lin iu m

th u th a p 0 .9 m m tro n g m $t p h ln g c i t ngang roi tai tao tro n g m at p h ln g cat ngang tran va d u n g d o c lat c i t da y 5 mm

54
- Di&m chii y :

1 / Lp'i ich quan trcpng cua ccic chu6i sau tiem de chan doan ton thuong

T1 gadolinium

.21 Lp’i ich cua chu6i sau tiem trong vi?c phan do u te bao dem

T1 gadolinium

- ton thu ’O'ng tha m n h ie m ke c^n nga t u nao tha t b e n p h a i, lan d e n th e chai day len den nga tu- doi ben
- b a t g a d o lin iu m k in d a o n h u n g c h i c c h i n c o b i t , c o c a c tTnh m a c h d an lu u
- s in h th ie t: u te b £ o g a i it n h a n h ( o lig o d e n d ro g lio m e ) d o II h a y d o III: hien tu o n g oat g ad olin ium xep ton th u o n g thanh do III

55
 3 / Khong nen giai han the tich khoi u chi a ton thuang co b it gadolinium

- ton th u a n g co th e kh o n g d o n g n ha t, n h a t la u te b a o d g m tro n g d o m p t p h in c 6 t h i th u ^ c p h in d p t h ip . khd>ng b i t gadolinium

va m p t p ha n k h a c p h a n d o ca o , b i t g a d o lin iu m
- c o th e sai so t tre n X Q C L D T : kh o n g c h in d o a n d u p e p h a n u t h i m n hi& m v i d 6n g m $ t d<> t r i n X Q C L O T
- cOng co th e sai so t tre n C H T : ly g ia i v u n g kh o n g b i t tu a n g p h a n n h u v u n g p hu n i o p ha n u n g tro n g khi th u c s u
lai la v u n g u th a m n h ie m v a i h an g ra o m a u -k h o i u k h o n g bi p ha v a .

- d o d o s in h th ie t p h ii kh d o s a t kh o n g n h u n g v u n g b i t g a d o lin iu m m i c a n h u n g v u n g I3n c£ n kh 6 n g b i t c h i t tu a n g p h in

X Q C L O T sa u tiem CHT: T1 T1 g a d o T 2 m i t dO proton

T o n th u a n g th a i d u a n g g iu a tro ng
K h ln g d jn h to n th u a n g th a i d u a n g g iu a tro n g
- n h u n g ton th u a n g c u n g la n t& i h oi h a i m § v a c u e t h i i d u a n g
- h in h th a i k h o n g g a i y mQt phu p h in u n g , vdri t6 n th u a n g
th u a n g a tru n g ta m n h u n g la mOt u te b a o d $ m kh 6 n g d6ng nh^t
- sin h th ie t n h ie u c h o k h ln g d jn h s u la n rp n g c u a u d i n t o i n bO thuy
th a i d u a n g

56
 C Q N G H l/d N G T L f cac 0 Q N G M A C H va T IN H M A C H C 6 va T R O N G S Q

- 1 / DOng m g ch c 6 : - A / b o c ta c h ? T1 F a t S a t - B / C H T - m a ch m a u (C H T -M M )

- 2 / DOng m g c h n i o : -A / T1 v a T 2 - B / T O F 3D
-C l C H T -M M -D I c h u p m g ch so hoa xo a nen
- 3 / K h a o s a t d 6 n g th d i dOng m g ch va tTnh m g c h : M P R g a d o , T O F 3D sa u tiem

- 4 / K h a o s d t c d c tTnh m g ch tro n g sq : T O F 2 D ,T 1 g a d o , tu o n g p h a n pha

- 1 1 CHT CAC DQNG M ACH CQ

A / B 6 C TA C H C A C DQNG M A CH CO ? T1 Fat Sat, mat p h ln g ngang

- LSm sang: tai b iln mgch mau nao thoang qua hay <33 hinh thanh
- cb t h i trifb c <36 cb (3au vung co t y phat
- ho$c khbi phat do c h in thirang tryc tilp ho3c gian tiep: thu thu3t xoa bop CQt s6ng, xoay dau dot ngot
- C ln thyc hi$n c h in doan kh ln. d l quyet djnh d ilu trj khang dong

- K hlo sat cac dbng mach c£nh trong va dpng mgch dot song:
. 15 I4t trong m$t phlng c it ngang, cac iat c it ngang thi T 1 bao h6a mb’ (Fat Sat). ti> ngang dot song C5 d in nen so
. 3 bflo h6a - bao h6a ma de c h in doan tin hi$u cao cua eye mau dong dirai lap ngoai mac cua mach mau so vai mb vung co
- bao hba dbng tTnh mach ti> tren di xuong de loai tri> nhOng hinh anh c6 t h i c6 cua dbng tTnh mach binh thi/bng tang tin
hi$u tren T1... hien tuang di vbo iat c it
- bao h6a dbng dbng mach tu dubi di len, n lu dbng bj cham lai. co t h i tang tin hi$u tren T1.

. lat c it ngang khong tiem, T1 va 3 hieu i>ng bao hba:

tang tin hieu "hinh liem" cua eye mau dbng
dual nQi mac dbng mach canh

- bao hoa m d
- bao hoa dong dong mach di len
cac lat c i t phia d u d i

- bao hoa dong tTnh mach di xuong

cac iat cat phia tren
Boc tach cac dong mach canh phai va trai
. eye mau dbng co tin hieu cao "hinh liem"
dbng dong mach co tin hieu th ip

57
 0 nh&ng b$nh nhan tre, nen tim boc tach dOng mgch tr£n T1 Fat Sat c it ngang m$t c ic h th u a n g qui
. dau vung c6 khong th u a n g x u y ln
. cdc d lu hi£u hep dpng mach thay tr§n CHT-M M c6 t h i r i t it ho$c khPng c6
. p h li th y c hien chuoi T1 Fat Sat truO c khi l£m CHT-MM vPi gadolinium

T 1 Fat Sat: boc tach d u P i npi m ac dpng mgch dot song ben phai
... b6c t£ch t y phat, phat hien nhP dau nh6i mau trong vung tu 6 i cua dpng mgch t ilu ndo sau duPi b6n phdi

CHT-MM: d$ng mgch dot song ben phgi c6 k h lu kinh hep v£ khong deu
... c h in do£n boc tach dong mgch khong the c6 d u p e neu khong th y c hi$n chu6i T 1 Fgt Sat cat ngang

T 1 Fat Sat: b6c t£ch d u P i n$i m gc dOng mgch c£nh trong bdn phli
(luu y: x6a dbng tinh mgch chu-g dgt y§u c£u)

CHT-MM: dpng mgch cgnh trong c6 k h lu kinh g in n hu binh thud-ng

c h in do£n b6c tech dpng m gch khong the cb d up e n lu
khong c6 chu6i T 1 Fgt Sgt c i t nggng

C6 the s u dgng gnten be m$t vung co: dp phgn giai khong gian va do phan giai tin hieu tot nhat

Mgc dich: . 1 / t h iy d u p e ege mdu dong cug boc tach dpng mgch
. 2 / thay d u p e cau true mang x a vu a :
mdng xa ? lipit? ege mau dong nho? voi hoa nho hay lan?

Anten be mat
vung co

H Ngu6n X Lederc

58
 B / CHT-M M cAc DQNG M A CH VUNG CO iat c i t theo mat p h ln g tran sau khi tiem gadolinium

- 5 0 d 6 n 7 0 Idt / d $ d d y: 0 .7 - 1 m m / m $ t p h ln g tr£n
- tifim g a d o lin iu m , d £ n h m 6 c th d i g ia n khi c h i t tu a n g p ha n d e n q ua i d o n g m g c h chu
- thdri g ia n t h i/c h i$n c h u fii 34 giS y
- xCr ly h in h 3 nh : xo £ n&n, M IP , tg o vi&n cA c d o g n d o n g m a c h d a n g ch u y, tg o h in h x o a y

chinh ta m : lat cat sau cung n£m m$t ia t cat ch6ng 5 0 iat cat I6n nhau
dr sau cung sau cua d6t d§i

chong 50 lat c i t len nhau tren mode MIP

. sau do tao vien true dong mach canh ben phai
trong m at p h ln g tran va d un g doc.
. loai bo cac doan dong mach khong y nghTa

loan san c o sai:

. dong mach to va dai n g o ln ngoeo
. cac tiii phinh mach di ch un g cua boc tach
. nguy c o thuyen tac va nhoi mau nao
. dieu tri khang dong

CHT-m ach mau kiem tra

khi nao ngung dieu tn khang dong7

59
 X a vu a dQng mgch c ln h : hep? huyet khoi? mang x a vu a loet?

T f
V

Mang x o vfra lodt

Hinh 3nh d£nh gi£ hep qu3 mire so vOi thi/c t l:

. hinh 3nh gi£ t ic dpng mgch do khdng c6 tin hi^u

li§n quan tdri tSng cao t6c dO ddng,
tin tai ddng dpng mgch 6 phia trfen

. tin hi£u th ip ben trong c3c d$ng mach c3nh chung vd

canh trong do cung hi$n tuang dpng nhanh

ao de s s u s de la sien ose

- hep dQng mach canh trong do x a vu a

- do be mat c i t ngang dQng mach
sau khi tai tao theo m $t p h ln g c i t ngang t£r kit
qua thu thap cua mat p h ln g tran

d u d i cho hep 1030 mm2

tai cho hep 560 mm2
tren cho hep 840 mm2

- la i ich cua viec do n&y?

tren th u c hanh, danh gia m ire dQ hep b3ng m it

Khong co q u y lt djnh dieu trj n&o c6 t h i d u a tren

khao sat duy nhat ia CHT-m ach m£u co bem gado

Quyet dinh phai d u a tren s i/ tong hap g iua

dau hiQu lam sang: am thoi? thieu sdt than kjnh?
k i t qua khao sat Doppler?
. m u c dQ hep: tren 70/100?

| Co t h i dieu tri ngoai khoa?

Sieu 3m doppler Nong gian qua d u d n g nQi mach?

60
- 2 I C A C D Q N G M ACH NAO:

2 k 9 thu$t khfing tidm gadolinium , 2 ky thu$t c6 tifim gadolinium

-A/ O qc c ic chufii kinh d iln T1 v i T2 dQng mgch kh6ng c6 tin hiQu do dong chay nhanh

- B / K hdng tifim gadolinium TOF 3D, hinh Snh ddng, 60 l i t tren m$t p h ln g c i t ngang, d iy 0,8 mm

- C / T ifim gadolinium echo gradient / 50 l i t c i t tr§n m $t p h ln g tr in , d iy 1 mm

gi6ng n hu chyp mgch c ic dQng mgch vung co ... tic h bigt dong mgch n io ra
• D / Tifim gadolinium DSA: Digital Substraction A ngiography (chyp mgch so h6a x6a n&n)

A / O p c c*ic chufii kinh <Ji6n T1 v i T 2

• J H L
r * m

Dbng DM c in h trong b6n phii:
tin hi$u th ip cua dogn trong hang do dbng d$ng mgch binh thuang
- Huy^t kh6i DM c in h trong b6n tr£i: tin hi§u cao v i. khbng c6 dbng c h iy
. eye mau dbng
Nhbi m3u DM n3o giua ben tr3i trubc trung tam
do h u ylt kh6i D M canh trong
. xiphong D M canh trong doan xoang hang ben trai cb tin hi§u cao
. xiphong D M cin h trong doan xoang hang b£n phai binh thi/bng.
tin hieu thap

T1 T2 FLAIR T1 gado CHT-mach m3u/gadolinium

Kh6ng c6 tin higu thap cua dong chay a xiphong D M canh ben phai -> kiem chung tren T 1 gado va CHT-m gch mau: huyet khoi
hoan toan DM canh trong ben phai

61
 BI K h o n g tiem ga do lin iu m : hinh anh d on g d p n g m ach: TOF 3D

- 50 - 100 iat c it ngang, day 0,7 -1 mm, thbi gian thu th$p: 5 d&n 7 phut
- "hOp" kh£o sat bj gi6*i hgn vbi be day 50 den 70 mm ;
toan b$ tu in ho3n DM nao cb the khao sat trong 2 chuoi libn tiip nhau ... 6 phut
- thu thap trong m$t phing c it ngang, th in g goc vbi tryc DM c3nh v£ than n&n

- hinh £nh ho3n h3o d6i vb i cac DM co dong chay nhanh

- hinh anh doan xa cua cac D l^ c b the dupe c3i thi$n neu trubc db cb tibm
d ii chi "mpt gipt gadolinium "
- nhu-ng . hinh 3nh cb the thay doi b cac DM cb dbng ch^y trung binh va c h |m ... c£c nhanh xa cua DM nao giOa?
cb th& hinh £nh khbng ro b mat sau cac xiphong dpng mach c3nh
... bb sbt tui phinh mach kich thi/b c dirbi 2 mm
chyp mach m3u quy u-bc v in ia c in thi&t trong tong ke khiio sat cbc tnrbng h<7p x u it h u yit mang ndo

. eye mau dbng cb tin hieu cao trbn T1 iam c3n trb vi^c ly giai c3c tiii phinh mach
. ki&m tra sau khi iam thuybn tic : cb the cb anh giei liSn quan den coil

chbng cac iat cat: 1 trong so 50 lat c it ngang tbi tao trbn m$t phin g trdn
mode MIP bbc tach 2 xiphong DM canh h u y it kh6i DM nao giCra b6n ph^i do thuydn tic
cue mbu dbng dubi npi mac DM cbnh ben phai b it s3n DM nao tn fb c b6n ph3i
 C I CHT-mgch mau: chyp mgch m£u bing cpng huang ti>

c3c iat c it tr6n m$t phlng tran k6o dai 30 giay dupe thyc hiQn 20 giay sau khi tiem gadolinium
. ky thu$t tuang ty nhu- chyp mach mau cac DM vung co
t^ch biet cac DM nflo ra, sau 66 xu ly hinh anh.

- l/u d ilm : k9 thu$t nhanh, khdng bj ch lng hinh anh cac tTnh mgch nao
■ Khuylt d ilm khao sat bj hgn c h i trong mQt dQ day 50 mm tr6n mat phlng tran
. doan xa cua DM trong nao it tuang phan va sau d6 khdng th iy du’p’c nOa
. bQnh nhan c6 than hinh dai: kh6 bao trum tru’d-ng khao sat ti> quai DM chu cho d in toan t h i sq nao

I f

X lp ly h in h anh

X6a cac doan DM khdng y nghTa

sau d6 khao sat cac DM nao duPi
n hilu ch ilu vj tri khac nhau
r ~ '■
. thuyfin t ic ti> tim dr mQt tr£ bj liQt nCra
ngi/iri trai dQt ngQt
. vung khao sat: cac DM nao
. tai tao hinh anh trong m$t phlng c it ngang

t ic gan nhi/ hoan toan DM nao giOa bSn phai

f >

{ \

. thu thap . chQng 50 lat c it len nhau

m
l I3t c it theo mp tran . tach biQt cac DM nao b in g cach .tai tgo / xoay mpi hucrng
xoa bo cac DM vung co

- Chit lupng hinh anh DM dang dua c cai thiQn nhung hiQn nay chua du de c6 the thay the chyp mach mau quy ucrc hay XQCLOT-mach mau
trong tong kfe x u lt h u y lt mang nao.
- Ngoai ra. bj han che boi mot "hop "co do day 50 d in 70 mm: khong the khao sat toan bo he thong DM trong so
• Chit lupng khi§m t6n ho$c khong th iy dupe cac nhanh DM xa.

63
 0/ CHT - DSA : Digital Substraction Angiography

ti§m 6 cc gadolinium trong vong 4 giSy + 20 cc djch d in g tru a n g

chuoi r i t nhanh, 16 pha, 1 gi3y
1 iat c it: d&y 8 cm, 2 thu thap
xi> ly sau: 20 phut
chi djnh: iam t6ng ke / k iim tra dj dgng dpng-tm h m gch

IRW DSA
NguAn: JY GAUVRfT

chyp m^ch mdu quy i/6c

L uu y C H T c6 t h i tot h a n chyp m gch m3u quy u 6 c trong vi$c k iim tra theo ddi c3c dj dgng dOng-tTnh mgcti sau khi da 1dm thuyf
t i c v3/ ho$c xg trj, dg c bi^t khi dbng chay r i t ch$m:
... hinh the "binh thud-ng" tr§n chyp m gch m 3u vi d<> tu a n g ph3n y iu v£ c h it tu a n g ph£n i6t d in t r i
... hinh 3nh b it th u ic t r i c£c tTnh m gch tr§n T1 gadolinium
C H T-M M c6 thay t h i ky thugt chyp m gch m 3u d i k iim tra theo d6i

- 3 / K H A O S A T D Q N G T H O I c a c D Q N G M A C H v a T IN H M A C H :

A I TO F 3D sau tie m : thu th^p d u p e trong m$t phSng cSt ngang / lat cSt 2mm

. Lpi ich cua k9 thu$t n&y khi 13m s£ng khong n ghi den chi djnh k h io s3t c3c dQng mgch hay c3c tTnh mgch
. Luu y: kheio Scit toan bO tuan hoan nao dong mach v£i tTnh mgch, tu l6 c h im Idn d in dinh v6m sq

100 lat c a t ngang

dp d£y 2 m m
m a tr|in 154 - 256
4 phut 30 giay

tai tgo trong cac "hop" day 60 m m trong 3 m gt p h in g

64
 B / H in h Anh h y c d d n g dQng m g ch TO F 3D c 6 ti§ m g a d o lin iu m

T O F 3 D khO ng tifim x T O F 3D c o tie m

th u o c tro n g d p n g m a c h va tTnh m a ch

- L pi ich tro n g to n g ke dj d a n g dQ n g -tm h m g ch

v d i m g c d ic h d jn h ranh g id i n h a n dj d an g

- TOF 3D khdng tifim - TOF 3D sau ti§m, 1 iat cat

dbng d$ng mgch dbng O M + thu6c trong nhan va tTnh mgch

ch6ng nhau 20 iat cat

X
■L

- T O F 3D sau.tiSm, 20 iat cat

d6ng D M + thuoc tu o n g phan trong nhan va

tTnh mach
co the tai tao trong 3 m at p h in g

65
^ C I MPR g a d o : 120 Idt c i t 1 mm

- Mat p h ln g thu th£p: - th u a n g Id mat p h in g d irn g dQC r6i tdi tgo trong m$t p h in g trdn vd m ^t p h in g d i/n g <Jqc
- c6 the c i mat p h in g c i t ngang d i k h io sdt d $c bi$t da gidc Willis

Ky thu$t ndy it dung ho-n hinh dnh ddng TO F 3D khong tiem gadolinium vi cb s i/ chAng I6n cua cdc tTnh m ^ch
Ky thuat c6 ich trong vi$c khdo sdt s i/ cung c ip mdu nudi cdc u trong hay ngodi ndo ho£c cdc dj dgng dQng-tTnh mach

thu th^p trong mp dung dpc x ip chAng 30 trong s6 120 l£t c it tdi tgo trong m$t p h in g trdn
1 trong s6 120 d in 200 iat c it c£c l£t c it v6i d$ d dy thay dt»
dOng mgch + tTnh mgch

- thu th£p 120 Idt c i t c6 dQ ddy 1 mm

- chpn mQt "hQp" c6 15 d in 30 Idt c i t = 15 den 30 mm
- khao sdt cdc c iu true d$c biet, trdnh nhOng cho chong hinh, b in g cach tjnh tien cdc Idt c i t li/a chQn ti> phdi qua trdi,
ti> tren xuong d u d i
- dQ phdn gidi kh6ng gian tuy^t hdo
- iQi ich: khdo s^t mQt b§n xoang hang, d u d n g giCra, ton thu’O'ng dinh sq ...

_ f. ; • S ' ~-
> s y
9 T 7 ’I t , ' * ' ■ \

: > J

, *« * *

* • '
- y • ^ P .fJ a • : • • - \ '
- 4 / CH T cdc TTNH MACH NAO

2 myc dich: - A / c h in doan huyAt khAi tTnh mgch nao

- B / khao sat trudc phSu thu$t tinh thdng thoang cua cac xoang tTnh mgch k6 can v6i mQt u mang nSo

- A / ChAn d o a n h uyA t khA l tTnh m ? c h n go I xem thSm chu-ong nay

- A 1 / C h u 5 i T 1, kh d n g ti6 m :
. cac tTnh mgch binh th u a n g c6 th& tin hieu cao t u phat tren T 1: hien tu p n g di vao lat cat
nhung mOt tin hi$u cao rd r§t, d6ng nhdt, 6- xoang tTnh mgch la benh ly: eye mau dong

tin hieu cao: eye mdu dong

- tang tin hieu xoang b£n
di kdm dj dgng xoang tTnh mgch
- huyet khoi tTnh mgch nao

:3V vV r vit > '

1 I r \I
V ' hi

v .
Tang tin hi$u do ddng binh th u o n g hay do cuc mdu dong? ' Tang tin hieu tren T2 SE echo th u 2 va T2 FLAIR:
T1 khdng y nghTa ... dQC hinh anh T2 gp'i y huyet khoi xoang tTnh mgch dpc trdn

A 2 / C h u 5 i T 2 : chuoi kinh dien T2 Spin Echo 6 echo th u 2, hay T2 FLAIR

cdc chuoi ndy cung cho thong tin n h u cac chuoi dong tTnh mgch hay cac chuoi co tiem gadolinium

binh th u o n g huyet khoi tTnh mach

f t -f V \ / / _ \ t V

k ( m ,

T2 SE T2 FLAIR T2 SE T2 FLAIR

binh thu d ng = xoang doc tren co tin hieu thap huyet khoi tTnh mach nao = xoang co tin hieu cao

2 ly do: khong co dong chay

. cue mau dong

67
 -A 3 / H in h a n h d o n g tTnh m a c h kh o n g tie m g a d o lin iu m : T O F 2D

. hinh anh he thong tTnh mach co c h it lu pn g

. nhung co nguy c o sai s6t: khi xoang tTnh mach nam trong m $t p h in g lat cdt, thi du m$t p h in g cdt ngang. r>6 cd thA dAng tin hi$u
... khong thay doi lat c i t = dong tTnh mgch khbng phdt hi$n d up e
... so sdnh v o i hinh dnh sau tiem Id cdn thiAt

ho$c thu thgp m$t chuoi theo mgt ho$c tot hon, thu thdp mOt chuAi 120 Idt c i t ddy 2mm theo m dt p h in g ngang
p h in g trdn rAi tdi tgo d un g doc vd d un g d oc rAi tdi tgo theo cdc mdt p h in g khde

TOF 2D T1 gado

TOF 2D: hinh anh nhim lin vbi huyAt kh6i tTnh mgch xoang t>6n b6n trti
T1 gado: xoang ben bbn tr£i c6 d6 d iy thu6c, dudng kinh nh6 nhung thdng thoAng

TOF 2D: hinh Snh n h im l5n vbn huyAt khAi

tTnh mgch xoang b6n b6n trdi
T1 gado: xoang b§n b6n tr£i c6 dA ddy thuAc
T1 gado

- 1 / H inh anh dong: "khong thay" xoang ben ben trai 2 / Chuoi T 1 gadolinium thu thdp trong m dt phdng d u n g dQC
bat san? huyet khoi tTnh mgch nao? 100 Idt c it , tai tgo trong mdt phdng tran
xoang ben ben trai gidm sdn, n h u n g con hoat ddng

ca 2 chuoi, dbng tTnh mgch va T1 gadolinium MPR, phai d u p e thu c hien mot cach th u o n g qui trong tru o n g h pp
nghi n g o huyet khAi tTnh mgch ndo

TO F 2D: dong tTnh mgch

- Huyet khoi tTnh mgch nao

xoang tTnh mgch doc tren
xoang ben ben phai

- Dan lu u tTnh mgch nao qua

cdc tTnh m ach vo ndo
vdnh dai tTnh mach d u o *-’'—sytvius
cdc tTnh m ach vung e r a '-
 - A 4 / H in h a nh T iN H M A C H tffri gado:
. Thu th$p theo mode MPR: 110 iat cat day 1 .4 mm trong mat phang d irn g doc va tai tao

Thu thap theo mode 3D : 200 iat c^t day 0.8 mm trong mat phang dCrng doc va tai tao

thu thap theo mode 3D, ch6ng anh theo mode MIP v6 i dp day thay doi tai tao trong mat phang tran

Khao sat cac tTnh mach vo nao theo MPR gado

. thu thap c i t ngang, 110 lat c i t

do day cac lat c it : 1 mm
tcii tao: chong nhau 30 lat c it

. cac tTnh mach doi xu ng

Huy^t khoi tTnh mgch nao . xoang tTnh mgch doc tren
xoang ngang phai
b it gadolinium tgi thanh cac xoang tTnh mgch: thanh viem, day len
... s i/ day len nay cua thanh cac xoang co the d ua den sai sot trong ly giai
m ot xoang tTnh mach bi huyet khoi ma thanh day len do
hien tu o n g viem bi ly giai thanh mot xoang thong thoang

. toan bo m ang cu n g va dgc biet la liem dai nao: n h u c dau d u doi

vi£c doi chieu v d i hinh anh dong tTnh mgch khong gadolinium , TO F 2D. la can thi§t

- A 5 / H in h a n h h p c d o n g tTnh m g c h b in g tu o n g p h a n pha

. ITu diem cu c mau dong co tin hieu thap

. Khuyet diem : can chpn tru o c toe do dong se do, toe do tTnh mach 30 cm giay
th o i gian thu thap dai
hinh anh cac dong xoeiy?

69
 - B I Khao s£t tru>6»c phau thugt tinh thong thoang cua cac xoang tinh mgch ke c$n m$t u m*ng nao

. U mang nao dinh v6m sq ; bam vao xoang tinh mach doc tren
. Cau h6i: tang tin higu cua xoang do dbng hoac do xam lln cua u?
- X3m lin vao xoang? co the l l y bo xoang tTnh mgch, cat b6 toan b<> u mang nao
- Xoang tTnh mach thong thoang? khong l i y bo xoang, c i t u khdng trpn vgn

1/ Hinh anh T1 gadolinium : khong c6 cau tra Idi cho cau h6i ... do la d6ng tTnh m gch? hay u mang nao?

J
2/ Hinh anh d6ng tTnh mgch ... c6 cau tra Idi: khong c6 dong tTnh mgch, gian n o cac tTnh mach k& c^n ... phai giO nguySn
xam lln cua u vao xoang tTnh m gch dQC tren

Cau h6i tu*ong tu*:

Xoang tTnh mgch dpc tren c6 thong thoang khong?

hay bj xam lan b o i u mang nao?

1/ T1 gadolinium : khong co cau tra Idi

- 2 / H inh anh dong tTnh mach: tra Idi:

. dong tTnh mgch binh thu d ng ,
. khong c6 xam lln cua u
vao xoang tTnh mach doc tren

70
 D 6 N G D|CH n a o t u y

Lpi ich cua vi$c khao sat d6ng cua DN T:

-1 / . gian n d ba nao th it: c6 hay khbng hep kSnh Sylvius?

. m d b l nao t h i t III b in g pha san nao t h it III: k iim tra h$u p h lu ; vi$c m d be hogt dQng tot khong?
nang mang nh$n . .. c6 thbng th u a n g vd i cac khoang mang nao lan cgn khong?

- 21 c h in doan anh gia cua dQng DNT trSn T2 FLAIR

... hinh thai d iln hinh cua hinh anh tin hieu cao cua dbng tr§n T2 FLAIR

n hir vay - khbng n h lm lln g iua I n h gia vdi hinh I n h cgc mau dbng do x u lt huyet mang nao
. khbng ly giai tin hi^u cao cua x u lt h u y lt mang nao n hu la mQt hinh anh binh th u d n g cua DNT

- K y th u $ t:

4 ^ 1 / Khao sat T2 Spin Echo . dbng chay nhanh cb tin hieu t h ip ty le v d i toe dQ cua dbng
" . thi dg: dbng DNT ngang nao t h i t III, kenh Sylvius, nao t h it IV
be tru d c song, tru d c hanh tuy va b l lien cubng

Ghi chu: tang the dbng DNT cb t h i ia

mQt d lu hi$u cua tran djch ndo
t h it ap lu c binh th u b n g

Dj dgng Chiari: thoat vj mang nao sau phau thugt

- hep do u d kenh Sylvius
Cdu hbi:
- m d b l nao t h it
. Thoat vj m ang nao nay cb thong th u a n g v d i cac khoang d u d i nhgn khbng?
- kiem tra tinh thbng thoang
. Vj tri cho thbng th u a n g ?
- T2 Spin Echo:
. viec m d be hogt dbng t6t
. cb dbng DNT giua nao t h it III
va be lien cuong

\ r
T2: cua s6 binh th u d n g ; thbng th u o n g g iua DNT va thoat vj mang nao?

71
 2 / Khao s^t tren T2 FLAIR dong DNT:

- kh6ng c6 dong: tin hi^u th ip

thi dy: nao t h it ben

- dbng "trung binh": tin hipu cao

6 . cac lo lien that
. nao that III va nao that IV
. cac be nen sp
. g6c cau tieu n3o:
"anh gia" cua nhjp d ^p DNT
tgo ra b bi nhjp dgp cua cac

- dbng nhanh cua DNT: tin hieu th ip

lifu y:
kenh Sylvius cb tin higu thap anh gia cua dbng
it thay tren T2 SE hon
 C A C C H U O l D A C B IE T

T1 in v e rs io n re cu p e ra tio n

- Leri ich : . P h a n b i$ t c h i t x£ m va c h it t r in g :
d $ c bi£t ia k h ^ o sat vb nao, h in h th a i g ia giai p ha u cu a n ao bO

- K ^ th u $ t : . H in h a n h T1 d $ c b i$ t ... (JO tu a n g p ha n th a y d oi th e o s o lo gi ch uo i va th e o lo ai m a y
- C a c c i u true x u a n g bj xo a h in (IR ) h a y xo a mOt p h in (T u rb o In v e rs io n R e c u p e ra tio n )
- D b n g d p n g m g ch kh o n g tie m c b tin h ieu ca o
- C a c c i u tru e c b tin h ip u th a y d o i d a c b ie t la ca c ton th u o n g p hu va c a c e ye m a u d o n g :
... d o d b, c h u o i n a y kh o n g th e th a y th e T 1 S p in E cho

- Chi d jn h : . N g h i n g d dj d g n g n ao , kh a o sat tro n g ba m a t p h in g

. DOng k in h d n g u b i tre : D N E T ? , x o h ai m a ? Igc ch o c h a t xa m ?

T1 Spin Echo T2 Spin Echo

mgt do proton

Xo» h a i m a

- T u rb o In ve rsio n R e cu p e ra tio n :

- T o n th u o n g h ai th u y thai d u o n g
c b tin h ie u ca o

- T u o n g p h a n tre n T IR tu o n g tu
n h u tu o n g p ha n tre n T 2 F L A IR

D o n g k in h th a i d u o *n g

N h ie u d i d g n g vo n ao
. d c a c b an ca u n ao va c a c hoi hai m a
. d b an ca u tie u n a o tra i

- O e k h a o s a t c a c n h a n x a m tru n g tam , d a c b ie t la d oi thi va c a c n h a n d u o i d o i (b e n h P a rkin so n , c a c va n d on g b a t th u o n g )

C h u b i T1 In v e rs io n R e c u p e ra tio n da d u o c s u d u n g n h u n g ke t q u a d a n g th a t vo n g . X e m tin h ieu ye u cu a n ha n xam
tru ng ta m b e n tre n . D ie u n a y th u c ra la d o c a c n h a n x a m tru n g tam cu n g cb th a n h p h a n ca c va n c h a t t r in g m a tin h ie u ca o
cu a c a c v a n n a y c h e l i p tin h ieu t h i p cu a c h i t xam

- C a c n h a n xa m tru n g ta m d u o c k h a o s a t to t h o n tre n T 2 SE, e c h o th u 1. m a t do p ro to n , h in h a nh r i t tu o n g p ha n

73
 H inh anh co d o phan g ia i cao : T2 CISS

- 6 0 Icit, <30 d a y 0 .7 m m ,
khcio sSt g id i h gn tro n g mOt d 0 d a y 4 0 m m
m a tr$ n c a o : 3 2 0 / 5 12
- T h u th £ p th e o m ^ t p h in g c a t n g a n g h o g c m a t p h in g tra n
- D ie m kh 6 i n h 6 h o n 1 m m 3 :
. ta i tg o tro n g 3 m $ t p h a n g va m p i th e ch e ch
. tai tg o t u 6 - 1 2 ia t cu a v u n g c h in h o in k h a o sa t
- T in h igu ca o r5 r$ t tgi c a c kh o a n g dich
n h u n g dO p ha n g ia i kh o n g g ia n kern :
kh o n g p ha n b ig t d u p e g iu a c h a t t r in g v a c h a t xa m
- C h i d jn h :
. b $n h ly g 6 c c i u t i i u n ao
. tim c a c v a ch n g a n b en tro n g c a c to n th u o n g co d jch: T2 CISS T 1 gadohnium

c h in d o a n p ha n b ig t g iu a mOt n a n g m a n g n hg n u day t h in kinh ben trong 6ng tai trong

t6n tgi DNT giOa mao t iin dinh
v a mOt u c h o le s te a to m ... d e m o
va u day t h in kinh
Ipi ich cho ky thu$t cuOc m6 vd i
d ird n g vao phau th u ^t xuyfen m6 10
chufii CISS cung cung c ip
nhi&u thdng tin n h i/ chufti
T1 gado

K ha o s a t ta i g i& a
. c h u 6 i C IS S th u th £ p th e o m ^ t p h in g tra n
. ch 6 n g n ha u cu a 30 iat

C h it lu p n g p ha n g ia i khOng g ia n :
. ti&n d in h , 6 c tai,
. c a c o n g ban k h u y § n ...

T1 g a d o lin iu m v6»i ky th u a t bu do ng

- N g u ye n t i c : b 6 su n g mOt g ra d ie n t xo a bo h ig u u n g d on g
... c a c dOng m g c h h ign len v o i tin h ig u c a o sa u k h i tie m g a d o lin iu m

- L p i d ie m : ky th u g t n a y ia m g ia m d a n g ke c a c a n h g ia d h o sa u lien q u a n d e n g a d o lin iu m tro n g c a c x o a n g b en

Ip i d ie m c o th e c o d u p e : t h i y d u p e he th o n g dOng m g c h ( tre n th u c te kh o n g d u n g v i c a c la t c i t d a y 5 m m va
cach q ua ng 2 mm)

- T rig u c h u n g :

- T 1 s p in e c h o kh o n g bu d o n g : c a c dOng m g c h kh o n g t h i y d u p e ;
c h u n g c 6 tin h igu t h i p b e n tro n g DNT c u n g c o tin h ieu t h i p
.... h ig u u n g tro n g cu a d o n g lien q u a n d e n d o n g " c h d " g a d o lin iu m

- T 1 sp in e c h o v d i bu d o n g : d on g m g ch c o tin h ieu ca o
. c6 th e s u d y n g mOt each th u d n g q ui ky th u a t n a y ch o t i t ca ca c
ch u o i T1 g a d o lin iu m

. K h u y e t d ie m :
- th o i g ia n thu th g p 3 - 4 p h u t
- tro n g to n g k e k h a o s a t d i ca n va to n g ke b g n h x o c u n g rai ra c
h ign tu p n g " t h i y q u a ro d o n g m g ch " co th e g a y k h o kh a n tro n g ly giai:
c6 b i t b i t th u d n g g a d o lin iu m kh o n g ?

74
 T1 va bao hoa m o -: T1 Fat Sat

L p i Ich - k h £ o s£ t h 6 c m i t +++
- h in h 5 n h kh ftn g d iln h in h cu a n&n sp

T2 Spin Echo

T in h i?u ca o d d in h xu -o ng d£ m p t b en th a y tre n T1 va tre n 1 2 b e n tr£i:

L y g ia i : m d tu y x u o n g s p ? U h a t v ie m (n o n g d p p ro te in ca o ) ?

T1 F a t S a t : tin h ieu t h i p
p ha n m d n h 6 l§ n th u § c tu y x u o n g sp

T1 F a t S a t : tin h ieu th a p ... n a n g d a n g bi

75
76
 CHT : H inh anh hoc TLFCN MAU

- N g u y in t i c : t iim g a d o lin iu m v i k h io s i t n g a y d p i th u o c tu o n g p ha n di q u a d au tie n : s i/ s y t g ia m n h a n h tin h igu

th d n g tin v l t h i tic h m iu . c i c d p n g m g ch va c a c D M nho, roi ca c m a o m g ch , ca c tin h m g c h n ho
. r6 i d e n c i c tTnh m a ch nao

- C h f d jn h : - dT n h iin h in h i n h h p c tu d i m i u c 6 th e l i can th ie t de d u a ra c h i d in h ly giai h u y e t kh o i b in g d u o n g tTnh

m a ch tro n g vo n g 3 g io sa u khi co th ie u s o t th a n kin h
- c i c c h f d jnh k h ^ c : x i c d jn h tin h c h it cu a kh oi u ?
p h in dp c i c u ? d jn h vj n o i sin h th ie t d n h u n g vu n g ton th u o n g t u o i m a u ?

- Ky th u $ t: - t i i m n h a n h , 5 c c m o i g iiy , b in g m a y tiem
- khi p h it h i£n lieu g a d o lin iu m d e n q u a i d p n g m a ch chu
th u c h ign c h u o i 1 2 - 2 4 l a t 'c it n ga ng m o i 2 g ia y tro n g v o n g 4 0 g ia y
- T1 S p in E c h o h a y T1 E ch o d e G ra d ie n t / e c h o P la n a r Im a ging
- k h io s i t m u c s y t g ia m tin h ig u ty Ip v d i n on g d o g a d o lin iu m
- x u ly h in h i n h d v u n g q u a n tam

- K i t q u i : d in h g i i t h i tic h m i u d p n g m a ch n h o -m a o m a ch va d o n g d o n g m a ch n h o -m a o m a ch :
- g ia m t u d i m i u khu tru : th e tic h v i d on g g iim
- t in g t u d i m i u kh u tru : th e tic h b in h th u d n g , d o n g tan g
- u tr$ tTnh m a c h : th e tic h tan g v i d o n g b in h th u d n g

- L y g i i i c 6 th e kh 6 n go ai t r u n h u n g tru d n g h o p « d ien h in h »... c i c n g u ye n n ha n sai s o t co the do

- clp d p n g cu a b g n h n h in
- c h a t lu p n g c u a lie u g a d o lin iu m ? .. s u y tim ? hep d oi xU n g h o a c kh o n g d o i x u n g c i c d o n g m a ch c in h ?
- n ho i m i u : . k h i n in g g ian m g ch d o ligt c6 th e x i y ra s d m h o n l i m o c 6 g io th o n g th u d n g
. kh a n an g h in g r i o m i u n a o th a m m g n h, n g a y la p tu c , g a y kh o kh a n c h o v ig c ly g i i i

T r in th u c te, n eu n h u h in h a n h k h u e ch t i n d u p e th u c h ign ch o ta t ca c i c kh a o s i t C H T , th i c h i d jn h C H T tu-di m iu

h ign n a y va n l i hiem .

H in h i n h K H U E C H TA N H in h anh TU'O 'I M A U

b 1000 Ban do ADC

G adolinium lam cho
- Nhoi mau m oi tran cue trai tu 36 g id theo lam sang
sut giam tin higu
- Nhoi mau dinh cham phai cO________________________

14 giSy sau tiem 16 giay 18 giay 30 giay

V d i g ia th u y e t m a n h o i m i u tra n c u e c o th e la ra t m o i, chi dinh ly giai huyet khoi kh o n g d u p e d u a ra vi

c o su g io n g n h a u g iu a d p lan rp n g to n th u o n g tre n k h u e c h tan va tre n t u o i m au
... kh o n g c o v u n g tra n h toi tra n h s a n g "

77
 kh u £ch t An v A t l t Cti m Au

N h o i m a u n a o ra t m o i, d u o i 4 g io : c o th e c h i d jn h ly g ia i h u y e t kh6i
X Sc d jnh vu n g " tra n h toi tra n h sa n g c 6 kh a n a n g h oi p h y c d ir p c nhdr ly g i i i h u y ^ t k h &
lam p h e p trip giO a k h u e ch tan v £ t i/ d i m £ u

V S C : v o lu m e s a n g u in c e re b ra l = th 4 tic h m 3 u n ao
. " p h a n ben tro n g *’ d ip d n g bi&u diSn

M T T = m e a n tim e tra n s it
th o i g ia n x u l t h i£n g a d o lin iu m

C B B = c e re b ra l b lo o d flo w = I ip u li/ p n g m £ u nao

. th e tic h th e o ti>ng d o n vj th d i g ia n
. h i$ n tip o n g h oa i ti> n eu < 18 c c / 1 p h u t c h o m6« 100 g a m nhu md
. v u n g tra n h toi tra n h Scing n e u d u d i 3 0 cc

thdri gian . t jm e t0 p e a |< = thdri g ian d e n c u a g a d o lin iu m khi d g t td i n d n g dO t6i da

T hdi gian dat nong dO toi da
so s£ n h giCpa n hO ng v u n g q u a n t£ m

K h u e c h tan = V u n g tra n h to i tra n h sa n g

L i$ t ni>a n g u d i trcii d p t n g p t : C H T g io thi> 2 : “ ch e n h lg c h " giCpa v u n g h og i tip tre n k h u e c h ta n v a v u n g g ia m tir d i m^u

Dbng dpng mgch TOF 3D K huech tan b 1000

S au ly g ia i fib rin tro n g d pn g

m g ch v a o 3 g io 30 p h iit

Dong dpng mgch TOF 3D K huech tan b 1000

tai tu d i mau DM nao giua nhirng nh6i mau lai tram trong her-*

78
C H T T l/ d n M A U : L p i di&m tro n g t6 n g k§ u n 3o
- x a c <3jnh tin h c h lit u ?
- PhSn <30 u ?
- D jn h vj d e sin h th ie t nhO ng v u n g to n th u o n g ta n g t u o i m a u ?

Khuech tan b 1000 Ban do ADC TuOi mau

. H in h a n h T 1 , T 2 , T1 g a d o : ra t c o th e la u te b a o d gm
. C a c lg p lu #n gp-i y u te bao d $ m tre n h in h a n h k h u e ch ta n : kh o n g co hgn ch e k h u e c h tan
. H in h a n h t u d i m a u : t u d i m a u u kh 6 n g d 6 n g n ha t
vj t r i s in h t h i e t : tim v u n g ta n g t u d i m au

79
 H inh bo tha n kin h : H inh anh s ire cang khuech t i n

- K h u e ch tan th ie n ve c a c c h a t d ich th e o h u d n g c iia c a c s o i try c th a n kinh

- T h d i g ia n thu th a p 6 p hu t, g ra d ie n t bo s u n g b 1000
- H i^ n n a y co n it s ir d u n g ky th u a t n a y tre n la m s a n g n h u n g c u n g co m o t so Ip i ich n h i t djnh :
tu o n g q u a n g iu a k h o i u v d i b o v o -g a i c h ln g h an
- L o i ich to Id n tro n g kh o a h p c c o b an : g ia i p h a u , s in h ly, k h a o s a t tre n c o th e s o n g (in v iv o ) v& c £ c b d c h i t t r in g

T a i lieu : R iv is ta N e u ro ra d io io g ic a

80
 CHT CHl/C NANG

- N guydn t ic :
. 1/ H o g t h 6a c h u c n a n g v$ n d pn g, ca m g iac, tri tue
. 2 / T 3 n g d a n g k£ d d n g m a u n ao tro ng v u n g c h u c n a n g . n ha n len g a p 10 lan
. 3 / Du- th u a d a n g ke oxy. va vi vg y su* m a t b a o hoa o x y kh o n g du
. 4 / H a u q u a : ta n g d a n g ke n 6n g dp d e s o x y h e m o g lo b in e c o tin h c h a t ca n ti>
. H i^ u u n g B O L D ( b lo o d o x y le v e l d e p e n d a n t) d u o c do
. K et q u a ch 6 n g h in h len v d i m p t h in h a n h k in h d ie n T1 h o a c T2

- K y th u g t : n g u d i ch U ng h o a c b gn h n ha n th u c h ien
- n h ie u lan m p n h Ipnh: va n d p n g , noi, lam v ie c tri o c
- h o a c d u o c d a t d u o i m o t kic h th ic h la p d i la p lai v e thi g ia c, th in h g ia c
... v u n g c h u c n a n g se d u o c h o a t hoa

- C h i d jn h :
- D jn h vj c a c vu n g c h u c n a n g t r u d c khi p ha u th u a t, d a c b ie t ia v u n g va n d p n g : d a y le ch, x a m la n ?
- N g hien c u u c o b an : n h ie u n g h ie n c u u ve s in h ly, ta m ly, ta m th a n ...

- K y th u a t k h a c : P E T s c a n : tie u th u o x y g e n , d u d n g

H o a t h oa b an ta y tra i : ta n g tin h ieu vu n g R o la n d o b en pha i, va ca b en tra i

ta n g tin h ieu ca n h d u d n g g iu a

V ig c g p i len tro n g y tu d n g v e m o t c u d o n g s£ ia m ta n g lu u lu o n g m a u tu o n g t u n h u ta n g lu u lu o n g m a u khi th u c s u

th u c h ie n va n d o n g a y

T o n g ke v e m a t c h d c n an g t r u d c khi
D ie u tri p h lu th u a t m o t u n ao

D in h vi v u n g v a n d p n g

Tai lieu LEH ERICY Pans

Journal of N euroradiology

81
 CHT / PHEP DO P H 6

- Kh£o s^t c iu true sinh h6a cua mpt s6 phan tu tan trong n u d e : phan tich c h u y ln djch h6a hoc d iln hinh cua cac ph£n tu nay sau khi
loai bo tin hieu cua n ud e va t h ilt lap mOt ti> tru d n g bo sung.

- Thu th$p di> li£u theo m$t p h ln g c i t ngang ; thdi gian thu th£p 5 - 1 0 p h u t; xi> ly hinh anh va ly giai 5 phut d in 1 g«P

- Do cac pho d cac vung quan tam : cac d ilm kh6i cua 1 the tich nhd /1 cm3 : khao sat n h ilu d ilm khAi cua m$t khdi u phai luu y
loai ra ngoai vung quan t§m t i t ca cac c iu true c6 t h i tgo ra anh gia : xu o n g v6m sq hay n ln sp, khi kh6 khao sat cac t&n th u o n g v6
nSo, anh gia do hien dien cua khi, cuc mau ddng, vdi h6a ...
- Trinh bay cac pho qua hinh anh nhu-ng d ud ng b ilu d iin : dinh cao ho$c d u d i dang ban dA cua m fii c h it b iln duP n g pang cach d£t
c h ln g cac c iu true binh th u d n g vdi cac d u true b£nh ly

- Cac ph6 khac nhau tuy theo th d i gian phan h & i:

-T E d a i, 135 ms, khao sat . choline : c h it danh d lu mang t l bao va n h u v£y li§n quan s u tang sinh t l pao
. creatine : chi diem nang lu p n g , lip it : hogi tu , la c ta t: hogt d^ng y lm khi
. N Acetyl A spartate : c h it danh d lu naron / chf d ilm s u t h it thoat noron
. m yo in o sito l: c h it danh d lu t l bao d£m, taurine : u nguy&n bao tuy

- TE n g ln , 35 ms, khao sat cac c h it b iln duP ng tr§n va cac lactat, lipit. glutam in - g lu ta m a t...
- 0 o ph6 d u p e th g c hi$n trong lln kh^o sat d lu , ho$c thdng th u d n g d u p e b6 sung trong t6ng k§ sau d6

- Chi djnh :

- T6n th u a n g cua logi u

- Ph6 : cac c iu true duP ng giua ? lan sang d6i b§n ?

- B $c d ilm tang cholin, giam N acetyl Aspartate, tang ty l$ tu a n g d6i

- S p lan t6a cua u vao m6 : . u mang nao phSn d$ th ip hay phan dO cao, PNET hay DNET ?
. u nguySn bao tuy ? ap xe ( lactat) hay u hogi tu ?

- Tai phat hay hogi tu do xg ... It c h it b iln duP ng

- Sinh t h ilt hay p h lu thu£t d lu sao v ln c !n t h ilt d l c6 c h in doan giai p h iu b$nh

- Cac nghifen cuu dang t iln hanh : cac b§nh b iln dua ng , b$nh ly vi6m, benh ly c a , b$nh ly tim ...

Tong k§ kh ^o sat s y xam lln cua rr>dt u thudc

logi u nguySn bao d$m

- Dinh vj n h ilu t h i tich dich theo 3 'n at p h ln g

- Khao sat pho - giam choline
- tang NAA
- Sinh t h ilt : u n3o r6 rang thu0c k>a t l bao d |m
- Khong lan sang d6i ben theo ph<5 n |

- Sinh t h ilt hay p h lu thugt d lu sac ^ |n d n th ilt

d l co d u o c c r\|n doan

82
 C A C D A U H IE U T O N T H L fa N G

- C £ c d lu hi$u t i n th u a n g ( d lu hi$u try c t ilp )

1 - 0 $ m dO tr6n X Q C LD T , tin hi$u trfin C H T : giam , dong, tang
d i i c h ilu gi& a d£m d | h ay tin h i|u v d i logi c iu true giai p h lu (xem "ky thu £ t va h inh anh" tra ng 26 - 82)
2 - Vj tri t in th u a n g / giai p h lu x quang, d6i c h ilu v d i d lu h i^u iam sa ng (trang 83 - 99)
3 - H inh thai va vj tri phu hQ-p vung tu d i m au d |n g mach ? (" n h ii m £u nao " tra ng 145 - 155)
4 - C iu true b§n trong cua nao b | ? cac khoang V irch o v Robin c6 bj anh h u d n g ? (trang 100)
5 - T in th u a n g d u y n h it h ay n h ilu t i n th u a n g ? (tra n g 101 . 102)
- Tac d |n g cua t i n th u a n g len cac c iu true b in h th u d n g I3n can ( d lu higu g ian t ilp ) :
6 - Phu , 7 - Di l$ch , 8 - T h oa t vj nao (tyt nao) , 9 - G ian nao t h i t (trang 1 0 3 - 1 1 8 )

CAC BAN CAU DAI NAO : 10 VUNG GlAl PHAU

21 V! TRI T 6 N T H l/g N G

- thuytr An
1 T in th u a n g tru d c trung tam
2 T in th u a n g tran g iu a
3 T in th u a n g c u e tran

THUY OlNH
4 Ton th u a n g sau trung tam
5 T in th u a n g d inh

THU Y CHAM
6 T in th u a n g c h lm

C h ilu lln N G A BA N A O T H A T
7 T in th u a n g n ip cong hay nga ba nao ... ranh g id i ?

- THUY THAI D l/Q N G

8 Ton th u a n g thai d u a n g sau : 1/3 sau
9 T in th u a n g thai d u a n g g iu a : 1/3 g iu a
10 T in th u a n g cu e thcii d u a n g : 1/3 tru d c

- 1 SAN S Q T R U Q C : x u a n g tra n, xoang

m ang nao, t h i n kinh kh u u Ol/QrNG GlCTA : 6 VUNG SAU
- 2 VONG HO Y £N
. tu y ln y in
. g iao thoa t h j , san n ao th a t 3
. xoang hang, xip hd n g d |n g m gch canh
. than x u a n g b u d m , m au g iu d n g

- 3 PHAN T R l/Q C D U ’OrN G G lfr A

. lil m dgi nao, vu ng tra n - v a ch - v 6m nao - the chai

- 4 PHAN SAU D l/Q N G G IL/A

. tu y ln tung, l l i th e chai
. lilm dgi nao, l l u t ilu nao, b dng G alien

-5 HQ SAU
. D ie y in (c liv u s ), be tr u d c c i u nao, D M tha n n ln
. thSn nao, nao t h i t 4, th u y nh$ ng (giun), t ilu nao
. x u a n g da , g 6 c c iu - tie u nao
. ban l l s q - cQt s in g ____________________

-6 C A C n h A n X A M T R U N G TA M
. n h in d ufii, d i i thj, n han b eo (nhan d$u)
. thuy dao, bao tro ng

83
 T o n th u 'O ’ n g t r u ’O’C r a n h t r u n g t a m ? t o n t h i w r n g s a u r a n h t r u n g t a m ?

V j tri ca c d u d n g van dpng : R anh trung tam h a y ranh R olando

B o vo - gai hay bo thap
- Thieu s6 t v$n d Q ng (yeu Met), d on g kinh c u c bo van d on g : hoi tru d c tru ng tam
- M i t th y c d y n g : v u n g v $ n d Q n g p h u

^ 4 ,
H inh c h ie u cu a chi tren
v& chi d u d i nga n g mi>c
"ia t c i t cuoi cung"
N ip

<r
rolan d o

. 1 / Q uye t d jn h mOt c u d Q ng : toan bo nao b§ ■ . 2 / T h y c h ien mQt c u dong

- T h ong tin th ln h giac, thj giac, tri n hd
- Theo k ilu y th u c h ay phan xa
- Hoi ty cac lu ong than kinh td i vung tran g iu a va c u e tran
- D an tru y e n ta i v u n g tie n v a n d Q n g :
" kich hoat ” c u dQng / yeu liet = m i t d ieu hoa (that dieu ) v$n d$ng
V ung vgn dQng phu
- D an tru y e n ta i v u n g v a n dQ ng : liet mQt chi, Net ni> a n g u d i
- Bo vo - g a i h a y bo th a p :

s ? *< v

V j tri cua bo vo -g ai

. Tro n g m g t p h in g tran
. Trong m a t p h in g c i t ngang

84
 - Ojnh vj ranh trung t3m hay ranh Rolando

D jnh vj r5nh trung tSm hay r3nh R olando r i t quan trpng :

- V ung c h u c nSng v$n dOng ?
- X 3 c djnh d u d n g v£o d i sinh t h i it ho$c p h iu t h u ^ t : di tu- p hia t r u o c ? di t i r p hia sau ?
K hfing t h i x ^ c d jnh m $t c^ ch ch inh x^ c vj tri cua ranh trung t3m trong c ^ c m at p h ln g d u n g dQC va m at p h in g tran
Trong m $t p h in g c i t ngang, v£ n iu t h i y d u p e c3c ranh v6 nao d iin h inh ( 9 5 / 100 tren C H T , 5 0 / 100 tren X Q C LO T )
N aidich da m d t i c3 c tidu c h u in d ^n g tin c^ y

Trong m $t p h in g C A T N G A N G : ti§u c h u in N A IDICH

3 d i u h igu c h in h

- 1 : D a n g h in h m o c d g c b ig t

- 2 : R a n h tr£ n tre n k h o n g di t d i ra n h tru n g ta m

- 3 : V u n g v ^ n dQng de>y h o n v u n g c a m g i£ c

2 d iu h igu p h g , k h o n g t h u d n g g a p

- 4 : H oi n a o tre n v ie n
= ra n h d a i m 6 tro n g , p h ia s a u ra n h tru n g ta m
- 5 : R a n h s a u tru n g ta m c h ia d oi
v& c h ie u n g a n g u n g v d i h o i tre n v ie n

D in h vi ra n h tru n g t§ m t u la t c i t tr§ n c a o ro i la n th e o ra n h n a y t u tre n x u o n g d u d i:

ra n h tru n g t§ m c h e c h x u o n g d u d i v& ra t r u d c

85
 - C 3 c tie u c h u a n k h £ c g iu p d jn h vj ra n h tru n g ta m : s o vo-i m a t p h ln g D l/ N G D Q C d d u d n g g iu a
ro i m a n g le n m a t n go cii n a o bp
C d c tie u c h u in n £ y k h o n g c h in h x a c b in g tie u c h u in N a id ic h n h u n g c u n g c o ic h kh i c a c ra n h v o n a o c o h in h theii khfing
d ie n h in h h o a c k h i k h o n g th a y d u a c c a c ra n h v o n a o : n h a t la X Q C L D T c u a tre e m h a y c u a n g u d i tre .

- 1 / P h u a n g phtep Talairach : so v d i d u d n g CA - CP
p h u o n g phap d u p e sip dung tren C H T / m at p h ln g d u n g d p c d d ip d r
ve d u d n g CA - CP , ccic d u d n g th in g goc va "d u d n g cheo sau ", roi chieu d u d n g n&y len ca c mgt d p c canh d ud ng giua

R anh tru n g ta m : m ui ten

-2 / PhiFcmg p hap O livie r dung tren c h yp mgch m au n h u n g cho

ca tr§n C H T - 3 / R anh cua d on g m ach ch ai-vie n, doan tan cu a D M quanh
I . D u d n g n6i : . Mo the chai ( hay DM nao tr u d c ) the chai : ranh cong. sau . tha y ro tren CH T
. Loi the chai ( hay bong G alien ) R anh n£y 1a ranh sau tru ng tam
I . Ranh trung tam te " d u d n g cheo cua phan tu th u 3 p hia sau" . Ranh tru ng tam n lm n g a y p hia tru d c

86
. T i n t h i r o n g t h u y trA n 7 Hay T 6 n t h ir o n g th u y th a i d i r o r g ? C a n x e m ra n h b e n h a y ra n h S y lv iu s

Ton thu’O’ng thu y dinh hay thu y c h a m ?

- Vj tri cua he ngo£i thap ca c ct> dpng b i t th irirn g , run khi chu y. tang tru o n g li/c
- V j tri c£ c trung tam ngon ngO : m£t ng6n ngu1

Primary auditory
cortex

- M i t ngdn ngi> g i i c quan : . V ung W E R N IC K E : h ilu t iln g n6i

. P h in sau cua hoi t h i i d u a n g thi> 1
. V u n g W ernicke d p h ia sau d u d n g thuy d i o

- M at ngon n g u hon h a p : • Lien ket g iu a vung B roca v i v iin g W ernicke

. M $t ton th u a n g cua n i p cong ha y cua th u y d in h cd
th e d i n ta i m i t ngdn n g u h6n h a p
. K i t h a p v d i d l u hi£u k h ic : m it nh£n th u c s d ( m it
khoi h in h th g iic ) , m i t nh£n th irc b$nh...
- M i t ngdn n g u vgn dpng : V u n g B R O C A : " k h d i d$ng " t iln g n6i
. C h in hOi t r in th u 3
. O jnh vj d u d n g thuy d i o : v iin g B roca d p h ia tr u d c
d u d n g n iy
( K hd ndi : rdi loan v |in d p n g c i c c a v iin g m i t )
A tla s cu a S A LA M O N : tuang tu g iu a c i c dudng lien k i t tro n g nao v i t6 c h u c h0
th o n g dQng m gch nho / k h oang V irch o v Robin

- C6c c h u c n§ng cao d p : m i t ngOn n g u h6n h o p , m i t nh£n th u c d m g iic s o , m at nh$n th u c benh,

m il d p c (kh o ng h ilu c h u v ilt) , m at nhg c nang (khong cam th y dup-c am n h a c ) ...

Lfim s£ng : b in d u u u the, h0« ch u n g G ertsm an ; b in d u khong u u the, hOi ch u n g B abinski A nton
VCing n ip cong : m $t n g o ii cu a nao bO u n g v d i vj tri c h ilu len cua nga ba nao t h i t ... khdng co g id i han ch inh xac

89
 Tri nho1 : the c h a i, vbm nao , hai m a kh£i n i^m v6ng P apez cbn dang d u v c ban c3i

Ceic try cua vbm nao ThSn cu a vbm nao

C a c d u a n g lien ke t v b i m 6p t r in g tr u b c C 3 c tin h m gch nao tro n g b n g a y b6n d u d i

C£c l£t c it trong mgt p h ln g qua sung th^i duang

v3 c£c l^t c it th in g g6c vbi mgt p h ln g n£y

than cua vbm nao ca c d u d n g li§ n k 4 t g iu a vb m n a o va m3

4 sung th^i duang

T 5 h6i th^i d i/a n g thU 5 <r <r
1 hai ma
- te o <~hon Iq c d£u - .^ e im e r
2 hoi cgnh h i i ma 5 dubi nh3n du6i
- xa hba h^i ma va dong kjrr
3 the b a (fim bria) 6 thuy dao

90
 - Ceic ducrng th j gtec trong nao :

. Nhin mdr, ruAi bay , lo giac , can d<J>ng kinh BJ thj giac , mu tam thin
. Ph6p do thj trudrng : g6c manh , ban manh dAng danh m0t b§n

- M$t phlng c ! t : djnh vj c a c d a y th in kinh thj g ia c b in g chuAi ca c iat c i t - G ia i han giO a th u y thdi d u a n g va th u y c h lm : ranh th in g g6c
dirng dpc r in h c y a phan chia th u y c h lm tro n g m at p h ln g c i t ngang
M$t phlng CA - CP kh6 ng thu an Ip i tro n g v i£ c khao sa t ca c du-d-ng thj giac

cac duang thj giac phan bo - Phia trong va phia ngoai sung thai duang
- Phia tren va phia duai cua sung thai duang
B0nh nhan c6 the khong biet minh bj ban manh va goc manh , ghi nhan « nhin ma »

mu
mpt mit

ban manh
thai duang hai ben

ban manh
dong danh ben trai

goc manh

ban manh
dong danh ben trai
mil tam than
vung phoi hap

91
 - Hpi c h im g tie u nao
- B£nh ly cac day than kinh sp

v6m

lAi th£ chai

n3o th4t III

gia o thoa thj

hA y6n
cAng n flo s
cu6 ng n3o
bA gian cuAng
c ii ndo sinh tir

xoa ng da sdu
dOng m ach thd

clivus : ph£n r
p h in

cAu ndo

hdnh tu y ---------------
hanh nhdn tiAu nao

bA 16m -----------------
ban l& sp-cOt sAng
mAu r a n g -------------

tu y sAng

t £ n g q i t h A n k in h s q l O r a k h Oi h q p s q LAM SANG

1 : d ii (hay thin kinh) khCru manh s^ng m it khi>u giac (m it mui)

II than kinh thj ong thj giac nhin mdy, mu

III than kinh vgn nh§n khe o m it tren syp mi

( hay vgn nhan chung) hay khe bi/crm gian dong tCr, le m it ngodi

IV than kinh rbng rpc khe o m it tren nhin doi

V than kinh sinh ba dau th in kinh V cr m$t

- than kinh m it Willis khe o m it tren (tr£n, le. mui)
- than kinh ham tren lo tron ( lo tron I6n) dau th in kinh V a m^t.
- than kinh ham duoi lo bau dye co thSt nCra m§t /cac c a nhai
VI than kinh van nhan ngoai khe o m it tren le m it trong

VII than kinh mat va TK trung gian (VII bis ) lo ong tai trong (CAI ) liet m$t ngoai bien
co th it nCra mat /mi mit

VIII than kinh tien dinh-oc tai lo ong tai trong diec mot ben
( TK thinh gi^c va than kinh tien dinh) 16 ong tai trong chong mj-it, u tai

IX than kinh thiet hau 16 canh roi loan vi giac

X than kinh lang thang (TK phe vi) lo canh khau cai mem
XI than kinh phu (than kinh song) lo canh teo 00- thang

XII than kinh ha thiet ong ha thiet teo ni>a li/ai

92
93
 Cap thu* I : Cac than kinh khtru

LS m s £ n g • p h iu

M it m ui - Ceic s<7i k h tru / m ^ n h s£ n g

D Q ng k in h B J c 6 ti& n trie u khi> u gieic - H einh k h u u v 3 t h i n k in h k h ir u
C h £ y d jc h q u a m ui
N h ^ ceic m u i - N oi lie n v a i h o i h a i m a 13 t£ n c u n g m 6 p tr u d c

m iu m ao ga
m 3 n h s3 n g

ta m p h ln g xu ’a n g b u d m
m iu g iu d rn g tr u d c

l6i c u h 6 y £ n

XQCLDT

- II : Cac than kinh thj giac

Giao thoa thj giac
Dai thj, cac duong thj giac

94
 - Ill : Th£n kinh v$n nhan ho$c than kinh van nhan chung
L6 ngocii, g i£n dAng t ir . syp mi

Khe butim ---------------------

Xoang hang -------------------------

Dfly III . LO trinh trong

b i gian cuOng n§o ------
nguyfin uy do
. LO trinh trong cuOng ndo

Nhfln cuOng nSo : nguySn uy thyc

B §nh nhdn gi£, sgp m i khi thi>c ddy T 1 .T 2 FLA IR , T 1 g a d o : n hoi m du tru n g nao (cu6ng nao)

-V I : Than kinh van nhan ngoai

L6 trong

- Kich th ird c nho, ft khi th a y difo-c tre n h inh anh hoc

- LO trinh hu’d’ng len
giOa ranh hanh - cau v£ xoang hang

95
 V : than kinh sinh ba

- V 1 : than kinh m i t W illis d au vu ng tr^ n , le, m ui : kh e o m i t tr6 n

- V 2 : t h in kinh h ^ m tren d au vu ng m at, lo tr6n ( l6 tr6 n I6 n )

co t h i t nCra m $t ( d c c a n h a i)

- V 3 : t h in kinh h im d u ^ i d au v iin g mat, lo b lu d gc

III

D ay V : LO trin h a m a t n g o li cau n§o H6 M eckel

nhi&u n h£ nh ch ia cua TK sinh ba

K hao sa t d l y V :
Leri ich cua d c l i t c i t the o m § t p h ln g t r ln 4 m m n6i ti4p nhau,T
do phan giai cao ti> g o c m ui den ban c iu t)4u n3o

Ho M eckel: khong n h ^n ra d i/ p c than kinh sin h ba

.... nhieu s p i t h in kinh
Hgch G a sse r n lm tren dinh x u a n g da

T h in kinh sinh ba

96
-VII Th&n kinh m$t
• VIII T h in kinh thlnh g iic , th in kinh ti&n dinh Bo thin h g iic - mat

97
 - XII : Than k in h ha th ie t lo>n : N hai kho
Teo nCra Icpo’i

Ong l6i c&u tru'd’c

Va • T j f l

v v V \'
Hi
H pi c h u n g C la u d e B e rn a rd H o rn e r

. L£m s^n g : co d6ng tin ph£n i>ng , lom m i t ( m it thu t ra sau), hep khe m i m i t

. T6n th u a n g he g iao c3m h iro n g nao

. T im m p t ton th u a n g dpc suot chuoi g iao c3m :

- Hgch sao vu ng n g y c / hoi c h u n g P ancoast Tobias
- C huoi giao cam co quanh dong m gch canh : u g i£p , u cu $n c2nh
- X oang hang : u m&ng n§o, u day than kinh ; benh ly vifim : h0i c h irn g T o lo sa H unt
- Than nao : nhoi m £u , x o c im g r£i r£c, u t l b£o d$m ....

Hpi ch u n g C laude B ernard H o m e r do khoi u tan sinh 6 d inh phoi

98
 Tuy song : Cic duang v$n dong

” B6 v6 gai b6 ngoai th^p:

hQi tg v& " mOt t& b3o " 6 si>ng tru’d c tuy s6ng

B6 tien dinh - gai

Bo - gai
Mdi - gai

hach gai

giac nong lanh. dau So mo, nhan biet tinh te

b it cheo di th in g C H T co T2 echo g radient

99
 4 I CAU TRUC BEN TRONG cua ton thirang
C H T cho phep biet d u o c cau true ben tro ng cua ton thu-ong , n h it Id 6 T2 , c u a sA hep ve> trfen h in h anh diffu sio n

1 / Lyi ich trong viec phan biet u te bao dem va nhoi mau nao :
- U te bao dem ph£ h uy cau true nao : n ha t la u te bao dem do ac cao

- N hoi m au nao g iu nguyen cau true nao :

. C hat xam va chat tr in g phan bo deu dan tren T2 , khao sa t b in g c u a so hep neu can
. G iu nguyen hinh thdi cdc vung tu d i mau the o d png mgch

Nhoi mau n§o trong vung tird i mdu cua dong mgch tieu ndo sau d uoi (P IC A ); ngoai yeu to hinh thdi vd vj tri giO nguyen d u true ti6u ndo

Ban do ADC

T 1 . diffusion b 1000 : hinh th a i" dien hinh * cua mau tu sau
... T6ng ke vd dieu tri mot khoi mau tu 7
Ton thucrng khong dong tam
Ton trong cac cuon nao thuy dao va cdc vdn ben trong cua era', tam
Giam tin hieu dang xuat huyet cb khia nhoi mau xudt h uy& ta c 36ng mgcti
Tong ke va dieu tn nhoi mau nao x u it huy4t

100
 5 / S 6 LIT^NG : T6n th iro m g duy nhat ? Nhieu t o n thiP O » ng ?

T in th u a n g thdi d u a n g p h li cd t h i tu-ang u n g v d i m pt u nguySn b£o d$m T u a n g t y : t i n th u a n g th u 2. trdn trdi

t6n th u a n g th u 2, th3i d u a n g tr£ i ... di cSn

. D png kinh BJ v$n dpng bSn tr£i, c a n d lu ti&n, khdng cb t iin c3n
. T h u a n g ton a h i i tru d c trung tSm b§n p h li :
u te b£o d0m ? di cSn ? ...
. T h iy d u p e t i n th u a n g th u 2. t ilu nao p h li

. Di cSn da 6 ...
th a y d6i t in g kS tru d c d iiu trj v£ cdch d iiu trj

... S u c in t h ilt cua dp ph3n giai t6t trong khdng gian v£ tu a n g

phan

T h ua n g t i n d u y n h it h a y nhieu th u a n g ton? Kha nang bo s6t m ot th u a n g ton nho vi hien tu p n g " t h i tich b£n p h in "
■ R it c ln th y c hien chuoi xung T1 co gado tro ng 3 m gt p h ln g

Tien can co u tan sinh :

ton th u a n g tieu nao tr£i
r i t nhie u kha nang la di can

-IN
iat c i t 1
5 mm ^ ¥ 5 mm
1 Idt c it

c«ich quang
2 mm

Nguy ca bo s6t
m$t t6n thuang
kich th u d c 5 mm
do hi£n tuang
■ t h i tich b£n p h in " T in thuang thu hai. kich thu d c 3 mm. thay ro tren mat p h ln g c it ngang va dung doc
khong thay ro tren mat p h ln g tran di can nhieu nai

101
 . U nguyfen bcio dem vung nhSn duoi , d6i thj , p h in trong th£i duong U nguyen b^o d$m c£c nh£n xam trung tAm
. Thuang t6n duy n h it nhung c6 t h i b it chat tuang phan n h ilu ch6 lan sang d6i ben r6 ret do thSm n h ilm t h i chai
tdn thuang hai b§n nhung lai la duy n h it

B it g ad olin ium nhieu noi

ben tro ng m o t ton th u o n g l&n
khong d ong nhat

Ton th u o n g nhieu n oi : ton th u o n g 6 ca hai ban cau

Sinh th ie t ton th u o n g thai d u o n g :

u t l bao sao it nhanh do II

Rat co the la u t l bao dem nhieu noi

102
 H A U Q U A C U A C A C T H U a N G T 6 N LE N C A C C A U T R U C B iN H THUCTNG
( c ic d iu hieu g ia n tie p )

1 - PHU
1 -1 : Phu "p h in irn g " d k i c$n th u a n g t i n n g u y in nhan
1 - 2 : Phu "do u " : c h in (Jo in phu bao g6m c i tin h trgng t h im n h ilm cua ca c te b io u :
u t l b io <J$m dO i c t h ip d k i c in u dO i c cao

2 - DA Y L £C H c i c c iu true li n c in : c ic n io t h it, c i c r in h v6 nao, b in trong cua vbm sq

3 - TH O A T V| N A O (TU T N A O ) : - T h o it vj the chai d u d i liem dai nao

- T h o it vj phan m 6c t h i i d u a n g v io lo bau due
- T h o it vj p h in tren thuy g iun (thuy nhQng) vao lo b iu dye
- Thoat vj hanh nhan tieu n io v io lo c h lm

4- G lAN CAC K HO AN G MANG NAO : gian c i c n io t h it, c i c r in h vo n io , c i c k h o in g V irchov Robin

4 - 1 : G lA N NAO THAT do t i c nghen d u d n g lu u thong djch TR O N G nao

. G ian c ic nao t h it, cong sylvius, l6 Magendi = Tran djch nao that "khong th6ng th u a n g "
. T6n th u a n g + phu + t h o it vj n io + tac nghen DN T = H inh thanh "v6ng lu ln q u in "

4 - 2 : G lA N NAO TH A T do t i c nghen d u d n g lu u thong djch N G O Al nao

. Gian cac be nen so, lo bau dye, c i c khoang m ang nao vung vom nao = tran djch nao t h i t "thong th u a n g "
. T ru d n g h o p d ie biet : t r in djch nao t h i t i p ly c b inh th u d n g .
. T ru d n g h o p d £ c biet : h in h in h h oc v i dan lu u DN T . C ac van d in luu
. Thu thuat m d thong be djch nao - tuy q ua da
4 - 3 : TEO NAO : . G ian nao t h it, gian thung lung sylvius, cac ranh vo nao
G ian cac k h o in g V irch ov Robin,
. B enh ly c h it t r in g nao
4 - 4 : Dj DANG : G ian n ao tha t d o nao khong phat t r iln / t i t khong hinh thanh b in c iu nao, Chiari ...

- 1 / Phu :
1-1 : Phu "phan i>ng” ke c?n m pt thu’O’ng ton co bat chat tiro'ng phan

Phu d c h it t rin g , khong anh h u d n g c h it x im

. Lan r0ng dang ”ng6n ta y m ang g in g " den t i n vo nao
. Phu dap u ng v d i dieu tri b in g corticoid, vd i cac djch u u tru a n g
C6 t h i bieu hien ro tren iam sa ng do th u a n g ton + phu = hieu u n g c h o in cho

T2 FLAIR T1 gado

Di c in : phu phan ung U m in g nao x im lan : phu hon h op

Tham nhiem do u + phu phan u ng
U + phu = hieu u n g choan cho

- Ap xe nao
c h it ben trong tang tin hieu
d b1000 do g iim chuyen dong

- Phu phan i/n g d ngoai vi

t in g tin hieu tren hinh diffusion
do hieu u ng T2

T2 F LA IR T1 gado Diffusion b 1000

103
 1-2 : Phu va thu’O’ng ton te bao d^m tham nhiem

Kho chan doan phan biet g iu a phu "thuan tuy" vd phu bao g6m cd cdc t l bdo u rdi rdc
... dieu quan tam chu y lu cua cac p h u a n g phdp d iiu trj

T uy nhien, co "n h un g dau hieu nho" g o i y phu do u thdm n h ilm ( chu y lu Id u t l bdo d$m dQ d c t h ip )

- Phu co it hoac khong co hieu i>ng choan cho g o i y tru d c tien td i u thdm n h ilm
- Phu c6 g ia i han ro, khong phat t r iln rQng dgng ngon tay m ang gdng vdo cd c h6i ndo. g o i y tru d c ti^n td i u thd m n h ilm
- Phu hai ben, lam d ay t h i chai, la do u tham nhiem
- Phu dong tam , g id i han ro, g a i y tru d c tien td i u tham nhiem
- Phu lech tam, g a i y tru d c tien ta i u tham nhiem

- Can th y c hien phep ky thuat C H T pho

. Phu "thuan t u y " : pho binh th u d n g
. Phu + u : . choline tdng
. N acetyl a spartate giam

- T h u a n g ton kh6ng d6ng n h it

. B dt gado dang u
. Khong b at gado :
. G idm tin hi$u T1, tdng tin hi£u T2
. Phu phdn u n g ?
. T in g tin hieu d in g tdm g id i hgn rO

- S inh t h ilt :
. T iln t r iln m $t p h in thdnh u nguyftn bdo d$m
. U t l bdo sao it nhdnh g rade II

Todn bO cdc th u a n g t i n d lu c6 dang u

- U t l bdo dem tham nhiem , hai ben, d t h i chai, dgng "canh b u d m ’

U nguyen bdo dem (glioblastom e)

- T h u a n g ton tham nhiem, lan toa, sinh t h i l t : u t l bdo sao d0 d c t h ip

Toan bQ cdc ton th u a n g d lu cd dang u

U nguy§n bdo dem thodi hda d c tinh

t ir mQt u t l bdo sao thd m nhi&m dd II

Sinh t h ilt: th u a n g ton k l c ^ n giam tin hi$u T1,

tang tin hi$u T2 Id u

G hi chu: th u a n g ton tham n h ilm ton trong vung

tu d i m du "hdnh la ng" cua d ong mach ndo trudc

X Q C LD T co tiem can quang / Phu "lech tdm " = u

P h iu th ug t u t l b ao sao khong dong nhat. do ac cao. d phia tr u d c va u te bao sao d$ dc t h ip d p h ia sau

104
 2 / P ly c^c cau true lan cgn

D £ y l$ch cac nSo thdt

X 6a mb' cac ranh v6 nflo

ca c thung IGng Sylvius

Cac dau hi$u t6n thu-ang x i/a n g

6 k& c£n

Nang mang nhen vung vbm nao :

Vbm sq bi m6ng di

- 3 1 Thoat vj nao (tyt nao)

- Thoat vj the chai diro'i liem d?i nao

Bien dang cac nao that ben : hinh thai tren mat p h ln g cat ngang

Bien chung hiem gap cua thoat vj nao :

Khoi mau tu a the chai
. hoac do c a che chan thuang : ba ty do cua liem dai nao sac
. hoac do chen ep dong mach nao truoc :
nhoi mau xuat huyet

Chan thuang sq nao

Mau ty duo'i mang cung, phu nao
Neu benh nhan con song: roi loan tri nhb, hoi chi>ng Korsakof

105
 - Thoat vj moc thai du’cng

M 6c th ^ i d u o n g thodt vj vdo be quanh cuong ndo

... "kh&ng con thay d u o c " be quanh cuong nao
tr§n X Q C LD T hoac CH T Id m pt dau hieu benh nang

C hdn dp ho$c d iy lech cuong nao :

Ldm sdng : . Li$t n u a n g u o i doi ben th u a n g ton do chen ep cuong ndo
. Gidn d6ng tu cung ben th u o n g ton do chen ep TK III
. Nhjp tim chdm do tang ap npi sq

Neu c6 chdn dp cuong nao doi ben

. Li$t n ua ngud-i cung ben v 6 i th u o n g ton

B in h thu’d’ng : tu a n g quan g iu a hoi n ao T 5 cua thuy thai du-ang v6-i b e q u anh cu6ng ndo

Phu nao sau ch£n th u o n g

Mdu ty d u o i mdng cu n g phia b o tu do cua leu tieu nao
T hodt vj m 6c thdi d u o n g ben phai
X uat huyet du6-i nhen / cd c khoang djch quanh cuong nao
Chen ep cuong nao I _________________
X ua t huy&t li ti 6 cuong nao

U m ang nao vung pterion Nang m ang nhen 6 thung lung S ylvius
T hoat vj m 6c thdi d u o n g M oc thai d u o n g phai thoat v; man tinh

106
- Thoat vj phin trdn thiiy nh^ng ti>du6i I6n tr£ n v d o tro n g lo b a u d u e d o m p t th u -o n g to n 6 h o sa u

Thoat vj p h in tr§n th u y nhpng : . T h o a t vj ban cau tieu nao phai va phan tren thuy nhQng
. Gi&m tin hieu T1 vd tang tin hieu T2 cr phan tren th iiy nhpng do phu
. B ien dgng cuong nao, cdc nao th£ t ben gian vu a phai
. G iai phau benh : u nguyen bao tuy (m edulloblastom e)

C h in h khoi u cung thoat vj vao lo bau dye

gian nao that, xoa ca c ranh vo nao

- U te bao sao d gng long co nang : U o thanh tiet ra dich

- Leu tieu n ao hcri bien dgng : leu co dgng th in g ngang vj tri khoi u
- T h oa t vj phan tren thuy nhpng . Xoa cac khoang m ang nhen quanh cuong nao
. D ay cuong nao ra tru o c
. T i c m pt phan lu u thong djch nao - tu y trong nao : Nao thdt gian v u a phai
Xoa cac ranh vo nao
- N guy c o tro ngng d pt ngpt do thoat vj nao ngng h on nhat la trong tru o n g h o p th u c hien dan lu u nao that ben

107
 - Thoat vi hanh nhan tieu nao

L am s a n g : C d c d a u h i? u c h e n e p h a n h tu y
- N h jp tim c h $ m
- R o i lo a n h u y e t a p
- N g lit ... ti> v o n g d o t n g o t

Vj tri b inh th u a n g cua

hanh nhan tieu nao

X 6 a toan b0 cdc khoang dich cua lo cham

Hinh dnh "chgc ba" dgc tru ng , diem giam tin hieu a trung tdm
g iua hdnh tuy vd cdc hgnh nhdn tieu nao
Hanh tu y bien dgng h inh tam gidc : dau higu ndng

Chan doan phan biet thoat vj hgnh nhan tieu nao : hanh nhan tieu nao dai. tron
- Xoa be la n , e ye d u a i cua hanh nhan tieu nao ndm ben d u a i m at phdng cua lo cham
- N h ung . Con ton tgi cdc khoang dich quanh hanh tu y ... khong bien dang hanh tuy do chen dp
. Khong bien dang nao that IV, khong co ton th u a n g choan cho a ho sau cung n h u a tang tren leu

B inh th u o n g C han doan phan biet thodt vi hanh nhdn di d ang C h ia n II

- Khong co hoi ch u n g choan cho a ho sau
- Hanh nhdn tieu nao nhpn
- N a i noi hanh tuy - tuy song ngang d ot tryc

108
 4 / Gian nao that
4 -1 Do t i c
cac d u d n g djch lu u thdng TRO NG nao
.
C ac nao th it, cdng sylvius, l6 M agendi = tran djch nao that khong thong th u a n g
.
Thu-ang t in + phu + thoat vj nao + t i c DN T = khai niem "vong luan quan
. 4-2 : Do t i c
cac d u d n g djch lu u thdng NG O Al nao
= tran djch nao t h i t thong th u a n g
. T ru d n g h ap dac bi$t : tran djch nao that ap lu c b inh th u a n g
. T ru d n g h ap d£c bi$t : hinh anh hQC va d in lu u DNT : van dan luu, m a thong nao that vao be
djch nao - tuy qua da
. 4 - 3 : D o teo nao : tu 6 i, ru y u , c h in th u a n g , ca c nhoi m £u nao lo khuyet
. 4 - 4 : Do dj dgng . gian nao t h i t do khdng phat trien / tat khong hinh thanh ban cau n a o , C h ia ri...

4 -1 : Gian nao that do t i c nghen cac d u o n g lu u thong dich TRONG nao :

- Tran djch nao t h i t dang hogt d 0 ng "khdng thong th u a n g "
. G i3n ca c nao th it, cac su n g nao t h i t c 6 dgng tr 6 n, hinh thai "tang ap lu c"
. DNT t h im xuydn vao nao : chenh Igch ap li/c g iu a ca c khoang trong va ngoai nao
. X 6 a cac ranh v 6 nao
- Can nguydn : u, hep cong S ylvius bam sinh hogc m ic phai

C ac dau hieu d a c b ie t tu y th e o v| tr i tac nghen DNT

A - "O’ d p n g " tro n g s u n g th a i d u a n g

U cupn m ach m gc : u nhu cua dam roi mgch m gc ? u m ang noi tuy ? u m ang nao ? di can ?
giai p h iu benh ly : u m ang noi tuy (ependym om e) do II

- Chan doan phan b ie t : nang m ang noi tuy; cu a so hep cho phep thay d u a c thanh nang

109
 B - Lo g ia n n a o th a t m o n ro
T r^n djch nao that "dang hogt don g" ch i
Cac n3o t h i t c6 dgng tr 6 n, "tang ap ly c "
C 6 th4 c6 cac d lu hi$u DNT th lm xuy 6 n vao nao
XPa ca c ranh v 6 nao
6 mpt nao that Tran dich nao t h it "dang hogt dOng" dr hai nao th£t

Nang the keo cua nao t h i t III

T ic nghen cac 16 gian nao that U m ang npi tuy

chu yeu ben trai (ependym om e)
Phau t h u a t: U te bao it nhanh 6 vach dp II

C - T i c n g h e n c o n g S y lv iu s h o a c cr n a o th a t IV :
gian cac nao that ben va nao that III

- 1 : H e p b a m s in h c o n g S y lv iu s

Bieu hien d gc tru n g v fti s y hien dipn cua rat nhieu lo thung co kich th u a c d u a i 1 mm thay the cong b inh thuO ng

. Chan doan a tre s a sinh hogc nhu nhi : tran djch nao that khong thong th u a n g tien trien

. N h ung cung c 6 khi chan doan tre, a thieu nien hoac a n g u o i la n . T h i du : C H T trong benh canh vo kinh ngu yen phat
- Nao that 3 gian ro r e t ; m anh vuong rut n g ln Igi ch u n g to bj hep da iau
- K hao sat T1 va T2 c i t d un g d pc xem hinh the cua cong, cua cu nao sinh tu , tuyen tung, bong G alien
de logi tru nguyen nhan hep do u : cu nao sinh tu la n a i th u a n g gap cua u te bao dgm it nhanh
- Khong the chan doan phan biet g iu a hep bam sinh vcri hep th u phat sau nhiem trung hoac xuat huyet neu ti 6 n can
khong ghi nhgn n hu ng benh nay

Chup nao that v o i iot / choc d c '■ £ 0 th it

110
 - 2 H ^ p cdng n3o do u khdng bat Gado

U cua cu nao sinh tu-

Sinh thi6 t U t 6 bao d$m It nhanh dd

K hdng nhey v d i tia xg
. K hdng nhgy v d i h 6 a trj
. Khdng ph5u thu£t

D in li/u DN T bang cach m d thdng nao

thdt III vdo b& giao thoa

T1 gado

- 3 : Hep cong nao do u b at G ado Sinh t h ie t : U te bao m am cua tuyen tung

- 4 : U gay tac nghen nao tha t IV

- U lam t i c nghen nao tha t IV / p h lu thuat : u m ang npi tuy

- Cac nao tha t cb dang tron, giam dam do quanh nao that do DN T tham xuyen vao nao xoa cac ranh vo nao

- U m ang n 0 i tuy

111
 D : LO MAGENDI
gian c£c nao that b&n, nao th£ t III ndo thekt IV

U hanh nh§n tieu n§o : G i^i phau benh : u m ^ng n0i tuy
L uu y : Di c£n qua d u o n g d u d i nhen be gian cuong, be tren thuy nhQng

T1 T2 SE T2 FLAIR

Tac nghen lo M agendi :

. c a 4 nao t h i t gian Ion

. Nao tha t 3 gia u thu n g ln m anh vuong, cong S ylvius gian va n g in lai
. G iam tin hieu 6 cong S ylvius do hieu ung dong chay cua DNT
c 6 lien quan to i chuyen dpng cua D N T do dong m ach than nen phong len o thi t£m thu gay bi<
. Khong co h inh anh dong chay 6 lo M agendie : m ang nhen can nguyen khong d u o c xa c dinh

. Cac ng£ch Luschka cua nao tha t IV, nao tha t ben, cung khong thong ;
. 6 1 T2 FLAIR c 6 anh gia do nhjp dap cua DN T trong nao that IV

. Di ch u n g viem m ang nao ? dj dang m ang nao ? di d ang loai Chian ?

112
 T6n th u a n g + phu ♦ tho£t vj n5o + t3c nghen DNT - khai niem vong luan quan_________

2 vi dg :
1 / Ch4n th u a n g sq nao -> X u4t huyAt va phu nao -» Thoat vj nao. gian nao that -> "N ao bj ton thu-ang" -> Phu nao

M yc dich : DiAu trj nguyfin nhan n£u dirQC : mau ty ngoai m ang cu ng , u ...
va / hoac di&u trj h$u Qua : ch 6 ng phii nao, khi c iin co the m o so giai ap

Ch£n th u o n g SQ-nao : mau ty d u o i m ang cu n g vung vom nao va leu tieu nao, phu nao

xu a t huyet d u o i m ang nhen, xuat huyet trong nao t h a t : nao that ben, cong sylvius

Thoat vj the chai, m oc thai d u o n g , hanh nhan tieu nao, ...

Gian n3o t h i t ben ben trai do ta c nghen DNT, can lu u y gian nao that nay vi co yeu to can bang cac cau true d u o n g g iu a

2/ Di can nao

Dau hieu try c tiep : Di can g a y nghen lo gian nao that ben trai
Di can thuy d inh cham ben phai

Dau hieu gian tiep : - G ian nao tha t p hia ben trai do tac nghen DNT
- Phu nao ban cau phai: hieu u n g choan ch 6
- Dan lu u nao tha t ben trai de giai ap co the lam
benh nhan nang them

113
 4 - 2 : Gian nao that do TAC NGHEN cac dircrng liru thong djch NGOAI n3o

- C£c b i n in thung IQng Sylvius, cac khoang mang nh$n vung v 6 m nao
sq ,
= tran djch nao t h it "dang hoat dong" thdng thuang

- Gian d iu d$n ca 4 n io th it
kh&i d iu x6 a cac r§nh v 6 nao, sau do dien tien tdi gian nao th it do teo nao
khdng c 6 d iu hi$u t i c nghen cac dudrng luu th 6 ng djch trong nao
DNT khdng th im xuySn vao nao
- D iin tiin : . tSng tin hi$u quanh nao th it do b^nh ly c h it trin g c6 li£n quan d in "ton thuang nao"
. sau d 6 gian nao th it h&n hap : t ic luu thong djch va teo n3o

- Can nguy§n : viSm mang nao, x u it h u y it d u 6 i nh$n, tg djch d ud i mang cung

T 1 gado

k ; vt^m mdng nSo

do vi trung

T ru ’O’n g h o p d a c b ie t : T ra n d jc h n a o t h a t a p ly e b in h t h u a n g
- H0i ch u n g gap o’ n g u 6 i gia, khong ro nguyen nhan, hiem gap sau viem m ang nao hoac xuat huyet m ang nao
- Roi loan hap thu DNT do cac hat P accionni / xoang tTnh m ach giam c h u c nang
- Lam sang : tam ch u n g AKIM : sa sut tri tue. roi loan dang di, roi loan c a vong

- Tren X Q C LO T cung n h u tren CHT, khong co dau hieu nao co y nghTa ch u n g to tran djch nao that ap ly e b inh th u o n g
. Lam s in g nghi n g a chan doan
. Chan doan d y a vao chQC d o tuy song rut d jch ra nhieu lan :
neu lam sang cai thien ro, co chi djnh dan lu u nao that

- X Q C LO T va C H T :
. G ian ca c nao that, thung lung S ylvius va cac ranh vo nao
tu a n g t y n h u trong teo nao
. Khong co gian chon loc su n g thai d u a n g hoac su n g tran g a i y den benh A lzh eim er hoa c benh Pick
- C H T : Mpt dau hieu g a i y n hu ng khong c h ic c h in cua tran djch nao that ap lu c b inh th u a n g :
Tang toe dong chay DN T gan cac lo gian nao that, a cong S ylvius va a nao that IV
thay tren T2 Spin Echo, PD, hoac tren T2 FLAIR
xem CH T / cac chu 6 i xung chinh / tin hieu cua DNT

- Mpt can nguyen dac b ie t : "h0i ch u n g bua" : benh canh tran djch nao that ap lu c binh th u a n g lien quan tai
. N hip tam thu cua ap ly c trong nao that
. X ay ra do dong mach than nen dai va la n lam bien dang san nao tha t III.

"H oi ch u n g bua" D ong mach than nen to va dai. gian nao that, cac ranh vo nao g ia '- 1
Nao that 3 va cong sylvius giam tin hieu do dong chay DN T tan g : 6 c

114
 4 -1 v a 4 - 2 H in h g n h h p c v a d i£ u trj g ia n n a o th a t d o ta c n g h e n lu u th o n g d jc h n a o tu y

-1 / D in lu u nao th it-p h u c n . Tr^n djch nao t h it kh 6 ng thong th u o n g

. Tran djch n3o t h i t thong th u a n g

- Myc ti§u : D in thoat DNT v i khoang phuc mgc d i d u o c h ip thu

- Dyng cy : 3 thanh p h in : - C atheter nao t h it

- Van sau tai
- C atheter d u d i da cho d in phuc mac

- C3c b iin ch u n g d 6 i h6 i kh2o sat h inh anh hpc :

- XQCLOT ho$c CH T trong t r u in g h o p n h u c dau, 6 i m u a :
giam ho$c tang ap ly e n$i sq ? ... cac d iu hieu lam sang tu o n g t y
X Q C LO T ho$c CH T : xem kich th u d c c£c nao t h it
chf djnh d$t lai dyng cy dan lu u ? vj tri nao ?
- C 6 t h i c in X quang quy u d c d i k iim tra ba th^n h phan c 6 cdn lien tuc khong
- S iiu Sm byng, th ^m ch i X Q C LO T byng, _
trong t r u in g h o p tao cac vach ngan ho$c nang trong phuc mac
- C in t iim qua van d i xa c djnh nguyen nhan khong hogt dQng

» * »
Djnh vj c3c catheter trong nao t h it b in g C H T ... c 6 tru in g hop kh 6 x^c djnh

Dan luu nao t h i t lau ngay

N h u c d iu kinh ni§n

O
X Q C LD T trong tong ke :
- V an khong hoat dQng, nao t h i t gian ?
- HQi ch un g giam ap ly c npi sq do "van hoat dQng qu3 tot"?
. Xep nao th it, dac biet hai su n g tran xep nho
H . Thieu nien : vom sq phi dai lan toa do m i t ap ly c tu nao

-2 1 M d thdng nao t h i t vao be dich nao - tuy qua da : tran djch nao t h i t khong thong th u o n g

- Myc ti§u : tgo mQt lo g iu a ngach pheu cua nao t h i t III, dang bj gian, vo i be gian cuong nao dang binh th u o n g ;
. Ky thugt nay chf co c h i djnh tro ng tru d n g hQp t i c nghen DN T trong nao : cong S ylvius, nao t h i t IV
. D 6 ng th d i can phai co
. Tang ap ly c nao t h i t nhieu
. Ap ly c binh th u d n g d cac be nen so
. H ip thu DN T b inh th u d n g d ca c xoang tin h mach
= T£i lap lu u thong D N T ben trong, h o p v d i sinh ly
■ Ky thugt: P h iu thuat t h in kinh qua npi soi: lo khoan sq vung tran, tham chi xuyen the chai

T1 g a d o Hieu qua cua vie c dieu tri nao th a t g ian :

T ic nghen c6n g na o d u d n g m d va o be g ian cuong thong th u o n g
do u cua cu na o sinh tu T2 S E : D N T co tin hieu thap vi co dong chay 6 n o i m d vao be

115
 4 -3 : Gian nao that do teo nao

T h o a i h o a c h i t t r in g (le u c o a ra io s e ), c a c k h o a n g V irc h o v R o b in g ia n n d g ia n an g
- N h ie u n g u y e n n h a n :
. " M it sinh d u a n g " (abiotrophie) lien quan td i tuoi Teo nao ia m pt hien tu p n g Iu 6 n Iu 6 n c 6
nhu ng thay doi tu n g u d i nay sang n g u d i khac tu o n g t y n h u hien tu o n g da n g u d i gia, th$n
n g u d i gia ...

. Mpi ton th u o n g nao deu co the d in td i teo nao :

- R u p u , oxyt cacbon, ma tuy, hoa tri, xg trj
- Bgnh c h it tr in g lan toa do m ach m au : phoi hpp nhieu nh 6 i m au nao dgng 16 k h u y lt / tn jn g tam ban b lu dye
teo nao khu tru trong tru d n g h o p di ch un g sau n h & m au vd ndo
- Nhuy&n c h it t r in g quanh nao t h i t chu sinh
- Tran djch nao t h i t ap lu c binh th u d n g / hien tu o n g p h u c tap :
ket h o p roi logn h ip thu va teo th u phat sau cac r6 i logn nay
- C h in th u o n g sq nao
- H£u qua (ma khdng Id nguyen n han) cua trgng thai dong kinh (D K li£n tyc)

- H in h th a i g ia i p h a u h in h a n h h p c :
. Ton th u o n g c h it t rin g , c h it x3m nguyen vpn :
- T eo d u d i v 6 , vd kh 6 ng teo v 6 nao
- C ac ban c iu tieu nao c iu tgo chu yeu ia
c h it xam nen it bj anh h u d n g

. C h it t r in g :
Trong giai dogn d iu , gian n d cac khoang V irchov Robin
Sau d 6 ton th u o n g lan t 6 a : giam dam d0 lan t 6 a tr§n X Q C LO T
giam tin hi§u T1 vd tang tin hi£u T2 tr£n CH T . Trgng thai d 0ng kinh
. Phu nao lan t o i
va p h u c h$ : bien doi ty le n u d e / m d
. C ac th u o n g t 6 n d ban c iu n3o trai
hang rao mau - m o th im t h iu b i t th u d n g d iin tien thanh teo nao nhi&u
cac khoang V irchov Robin gian thy dong

- C a c h a u q u a c u a te o n a o le n c a c kh o a n g m a n g n a o k h o n g p h a n b ie t n g u y e n n h a n n a o :

1 / G ian cac nao t h i t ben, nao t h i t III. thung lung S ylvius va ca c ranh v 6 nao
2 / Gian cac khoang V irchov Robin d cac nhan xam trung u o n g , cac thuy d io , ca c e y e thai d u o n g
3 / Thoai hoa c h it t r in g : tang tin higu lan toa quanh nao t h it
. Thong th u d n g la hau qua thoai hoa h yalin-m d d cac dong mgch tan, bgnh ly thoai h 6 a khac v d i m ang vu a
. Tuy nhien h inh thai cung tu o n g tu n h u trong teo nao nhieu do gian n d cac khoang V irch ov R obin

116
GiSn cac khoang Virchov Robin Thoai hoa chat tr in g

*
Vv A
Teo ndo ngu6n g6 c n h ilm <J0c G idn n d cd c khoang V irchov R obin
d mOt n g u d i trd : n h ilm <30c ru a u . Phu m o ke
gian todn bp cdc khoa ng V irch o v R obin
... th$m c h i cd th iiy thdi d u o n g

T ru d n g h o p d g c b ie t : c a c k h o a n g V irc h o v R o b in cua hai bdn cau nao gian n d gia nang

Phdt hien tinh c d .... C H T trong tong ke chong mat d m0t phu n u tre

Gidn hai ben, chu yeu ben trai, cac nao that ben gian v u a phdi

Cdn nguyen ? . Di ch un g cua nhuyen nao quanh nao that chu sinh ?
. Di ch u n g cua thieu m au nao hai ban cau tu trong bao thai ?
. Logn d u d n g chat tr in g : the khdng bieu hien iam sang ro cua benh H urler ?

y v

■»' t
_ O '

117
 4 - 4 I Gian nao that do dj dang nao

Gian n3o t h i t do nao khong phat trien

C ac nao t h i t I6 n dj dgng : t#t khong h inh thanh ban cau nao, t$t co khe cat ngang ban cAu
Kh 6 ng c 6 tang tin higu quanh nao that
Thung lung S ylvius va cac ranh vo nao gian va c 6 the bien dang
C 6 the di k 6 m ca c d lu higu t i c nghen D N T : hep cong nao bam sinh, dj dang A rnold Chiari

Dj dgng khong hinh thanh ban cau nao the vo thuy: gian nao that do nao khong phat trien
san nao that III khong phinh vao be quanh cuong d ira i dgng "cai d a y 2 tui (en besace)"

118
 U TRONG NAO Hinh anh hpc

- C a c T H £ 0 | £ n H lN H : C d c d l u h i$ u 13m sa ng va h in h a n h h o c gcri y c h a n d o a n u nao

-A U t h i n kin h d £ m : c d c u t l b a o d$m : u t l bao sao, u te b a o it n h a n h , u m a n g noi tu y, u n g u ye n b ao d em
1 C d c y l u t 6 gp'i y c h in d o a n g i i i p h lu benh
2 : C d c 6 $ c d ilm c u a u t l b ao d 0m d nao
2-1 : Khai n i$ m d 0 d c (g ra de )
2 -2 : Khai n i$ m h in h t h i tro n g kh d n g g ian
2 -3 : M oi tu a n g q u a n g iu a dQ dc va b i t iod h a y b i t g a d o lin iu m
2 -4 : Lan r0 n g cu a ca c u te b ao dem
2 -5 : C d c u d g n g nang
3 : C d c tr u d n g h y p d $ c biet
3-1 : U t l b a o d e m n h ilu n a i
3 -2 : U te b a o d $ m lan toa
3 -3 : U t l b ao d e m tha n nao
3-4 : U t l b d o d e m d n g u d i Id n tuoi
4 : D iffu sio n va th u crn g to n it t l b ao , v a th u a n g ton n h ie u te b ao
5 : C a c u m a n g n0i tuy
6 : H in h a n h h<?c sa u d ie u t r j : n $ i kh o a , p ha u th u g t, xg trj
- B . U cd n g u 6 n g o c T K : - P N E T : u b ilu m o T K n g u y e n p h a t : u n g u y e n b a o tuy, u th a n te b a o T K , u d em h g c h T K
- D N E T : u b ieu m o th a n kin h lo g n s a n p hoi
- C . L y m p h o m nao
- D . U lu d i m a ch m a u
- E . (C a c) d i ca n : b in g d u a n g m a u , b in g d u d n g d u a i n he n
- F . T ru d n g h y p d a c b i g t : . U tro n g n a o th a t : u m a n g n oi tu y, u n hu , u m a n g nao, n a n g m a n g n0i tuy
. U h a y g ia u 6 n g o a i n a o p h a t trie n v a o tro n g nao
U m a n g n a o a th u n g lu n g sylvie n , n a n g b i, u m g ch d gn g h an g, tui p h in h d o n g m g ch
. H 0i c h u n g c a n u

C ac T H £ K H O N G B i£ N H iN H : C a c d a u h ig u iam sa n g va h in h a n h hQC kh o n g du g y i y c h in d o a n u nao

... kh o n g c h ic c h in ... sin h th ie t ? d ieu trj th u ? c h d vd kie m tra Igi ?
- T h u a n g ton dgng nang h a y h ogi tu : u te b a o d g m h a y di ca n ? h a y a p xe ?
- T h u a n g t6 n "p h u " : u te b a o d g m th a m n h ie m hay nhoi m au nao ?
- M a u tu

- LAM S A N G : n gh i n gd ” u n a o :
- T h ilu sd t t h i n kin h n $ n g d a n "th e o v e t d au lo an g "
- D 0 ng kin h : ... ch f 4 / 1 0 0 c a c c a n d a u tie n co n g u o n g o c u
- T a ng ap n0i sp
- Tien can c 6 kh oi u ta n s in h ?

- HlN H A N H H Q C :
- N eu co m a y C H T :
. X Q C L O T kh o n g c o la i t r u tru d n g h y p c l p c u u : ta n g ap lu c n oi sp ca p tin h ... ca n dan lu u n a o th a t ?
. T h y c h i$ n X Q C L O T kh d n g tie m ; k h d n g ca n tie m vi tro n g th d i g ian n g ln n u a se p hai t h y c h ien C H T
- N lu kh d n g cd m a y C H T : X Q C L O T
. C a n p h a i c d X Q C L O T t r u d c tie m v a sa u tie m
N h it ia neu X Q C L O T k h d n g tie m b in h th u d n g ... c d kh a n a n g cd u d o n g d a m d o va kh d n g g a y h igu u n g ch o a n ch o

X Q C LD T khong tiem .... binh th u d n g Sau tiem Lym phom nhieu o

119
 - C a c h tie n h a n h k h a o s a t C H T : - T1 S E
Ti£ m Gadolinium n g ay sau chuAi xung T1
- T 2 F L A IR cat ngang
- T 2 * c i t ngang
- K huech tan (diffusion) b 1000. ban dA A D C
T1 g a do d u n g ngang, T1 gado d u n g dQC. T 1 ga<Jo cat n gang
Ghi chu :
- T1 cSt ngang t 6 t han 1 chuoi xung T1 d un g doc (djnh vj) d l cb t h i so sanh chuAi T1 khdng ti6m vd cd t)^m trong cung mdt m$t ph4ng
- T1 gado: 3 m$t p h ln g ; ket thuc bang chuoi cat ngang
. de kdo dai thdi gian giu-a luc ti£m vdi thdi diem cat ngang, chuAi cho nhilu thdng tin
. d l giam anh gia d ho sau c6 li§n quan tdi nong dd gado trong cac xoang tTnh mgch b€n
- ChuAi T2 Spin Echo cat ngang ? K it qua chuoi T2 Spin Echo tu a n g t y v d i T2 FLAIR
... chuAi T2 * cd y nghTa han : hemosiderin ? ddng vdi ?
... bQ chuAi xung : T1, T2 FLAIR, T2 * tren th y c t l cho n h ilu thdng tin han bO chuAi xung: T1, T2 FLAIR. T2 Spin Echo
- Hinh anh hoc tu d i mau ? H ilm khi th y c hi0n ;
Lai ich : . Djnh vj vung ton thu-ang chinh, tang tu d i mau, giup xac djnh n ai c£n sinh t h ilt
. Tai phat / tang tu d i mau hogc hogi tip do tia / giam tu d i mau
- Ph 6 p do pho? Xem ch u a n g "ky thugt"

/ T »
■<

Ban dA ADC

T h u a n g to n u sa u ra n h tru ng tam
s in h th ie t ( h ucrn g s a u -tru d c )

C h a n d o a n : u n g u y e n b a o dem

T in h c h a t da d a n g cu a u te b a o d e m n a o : . T o n th u a n g d ac, d a n g n a n g , d a n g keo, x u a t h u y e t, v o i h o a ...

To n th u a n g d o n g n h a t, to n th u a n g kh o n g d o n g n h a t ...
T o n th u a n g k h u tru , to n th u a n g la n to a

D o m o t ca ch he th o n g kic h th u a c 3 c h ie u cu a u d e s o sa nh
 A/ U T g B A O D E M C lIA N A O :

1/ C a c y e u to qg*i y c h a n d o i n g ia i p h a u b g n h d g c b ie t

- U t l bSo sao dang I6ng: u t l bao d#m duy nhat d$ I, u te bao dem d u y nhat co tien Itrong tot lau dai
tr6 em h o jc th ilu nien
v j tri : g in d u b n g g iu a : thd n n ao , b a n ca u tie u nao
ddc, khd n dn g c 6 lin g d o n g h e m o s id e n n b n g o a i vi : co th e n h a m v o i u hang
. b i t c h it tuo-ng p h in , n g a y ca d o d c th a p
c 6 the d ang nang : tim u tre n th d n h n a n g tro n g ba m a t p h ln g
. d ie u trj p h lu thu # t: Idnh benh

- U t l b d o s a o th d m n h ie m : . to n th u o n g c h i t t r in g
. c h i m $ t cu 0 n nao, to a n bo m o t th u y, th a m c h i ca m o t b an ca u n do
. h o i c h u n g u k in d a o n h u n g co th u c : m 0 t c u 0 n n ao Ion , b a o tro n g Io n ...
. t 6 n th u o n g d o n g n ha t, d o n g d d m d o, d o n g tin hieu T 1 , ta n g tin h ieu T2
. kh o n g b i t g a d o lin iu m h o g c b i t it : c o kh a n dn g la yeu to c i n th ie t d e p hd n do a c neu n gh i n g b
. g ia i p ha u b e n h : kh o n g b i t : d o II; co b i t : d o III
. d ien tie n ra t ch g m ; p ha u th u g t v u n g kh o n g c o c h u c n dn g
. to n th u o n g it n h a y v d i tia xa, kh o n g n h a y h oa trj n g o a i t r u u te b d o s a o lo ai a n a p la siq u e
. p h e p d o p h o : c h o lin e tan g , N A c e ty l A s p a rta te g ia m , ty le c h o lin e / cre a tin e tdn g

- U t l b do sa o -h g t va n g : . ch a n d o a n g ia i p ha u benh
. c o th e gp'i y c h a n d o d n n d y tre n h in h i n h tro n g tru o n g h o p u tre n leu, b n g u b i tr§
. u v u n g v o nao, n a o v a m a n g n do
. n o t 6 m d n g n ao , "d a u h ie u d u o i m a n g c u n g ", c o th e la m v d i u m a n g n ao

- U t l bdo it n hd nh : . u th u y trd n h o a c d in h , Ibn , d ien tie n ch am

. d b n g v o i kh o n g d o n g n h it , d g n g "d d m m a y kh bi t h u o c " ... kh b n g th a y tre n C H T ;
. kh o n g h o a c co it d a u h ie u g id n tie p
. u v u n g v o nao : kh a n an g Idm b ie n d g n g b an tro n g h o p so "d g n g m $ t k in h d 6 n g hb"

- U m dng 6 ng n<?i tu y . u tro n g n a o th a t n h u n g cu n g c o th e tro n g n do , th a m c h i c h i tro n g n ao

. c o vj tr i tre n leu b n g u b i Ib n , d u b i le u b tre em
. u "m e m " p h a t trie n tro n g n ao tha t, th e o c a c n g a ch n ao tha t
. to n th u o n g d ac, b i t c h a t tu o n g p h a n , d g n g n a n g , vo i h oa , cb k h i c b x u l t h u ye t
. c b kh a n a n g di ca n d u b i m a n g n h e n , p ha i tim m o t ca ch he th o n g :
c a c b e n e n s q , c a c ranh vo n a o vu n g vb m nao; vj tri tro n g m d n g c u n g b o ng so ng

- U nhu ; la u c u a d d m ro i m g ch m g c : n ga ba nao th a t, n d o th a t III, n d o th a t IV, be g o c cau - tie u nao

d a n an g nho, g a p b n hu nhi, cb kh a n dn g p h a t trie n t u tro n g b un g m e
cb kh a n a n g th a n h ca rcin o m a

- T dng sin h m b d e m n ao : to n th u o n g u lan toa , it n h i t 3 th u y n ao , kh b n g c b dau h ieu g id n tie p , tie n lu g n g x lu

- U ngu yen b do d em : d o IV, d o d ie n tie n t u m o t u te bdo d em t r u o c d o, h o a c d o IV n g a y t u d au

d iin tie n n h a n h ; th b i g ia n so n g tru n g b in h : 16 th d n g
va o th b i d ie m c h a n d o a n u cb th e Ib n h o a c nho, tu y th e o m oi lie n q u a n v b i ca c v u n g c h u c n dn g
u k h b n g d o n g n h a t : d ac, n a n g , x u a t h u y e t ; kh b n g cb h o a c c b it vb i hoa
ca c v u n g lan ca n cb d o a c th a p , n h u v a y k ic h th u b c u kh b n g p hai c h i Id vu n g b i t c h i t tu o n g p han
kh b n g d u g c xe m n h u n g v u n g b i t c h i t tu o n g p ha n la n can n ha u n h u Id cb n h ie u u ke n hau
r i t h ie m d i ca n th e o d u b n g m a u : pho i, g an , x u o n g
c b th e p h a u th u a t v u n g k h b n g c h u c n dn g n h d m g ia m th e tic h u tr u o c khi tia xg

T6n thuong tham nhiem nhan dau-bao trong-d6i thi phai CHT T2 SE cho nhieu thong tin hon
XQCLDT sau tiem Ton thuorig lan sang h6i truoc trung tam
O iy nao th it 3 vua phai
Giai phau benh u t6 bao sao tham nhi£m <30 II Giam d$m do nhe truoc ranh trung tam ben trai Sinh thiet duong vao hucmg tardc-sau
u te bao sao do II

121
 71 Oar. diem cac u than kinh dem a nao

U te b a o s a o
2-1 / K hS i n ie m d o i c
U te b a o g a i it n h a n h P h 3 n lo g i d a n g ia n h 6 a
U m a n g o n g n o i tu y
U nguyen bao dem

U te bao sao. u te bao g ai it nha nh , U m a n g o ng noi tuy U nguyen bao d£m

BOJ DO II °0 III DO IV

P hau thuat Tien lu y n g : 10 nam Tien lu y n g 2 - 3 nam Ti§ n Itrgng : 18 thing

Trj khdi benh
P h iu thu a t neu l i vu n g kh d n g c h u c n an g, h o ic sinh thi^t
X a trj, h oa trj tu y th e o g i i i p h iu b$nh

2 -2 / K h a i n ie m h in h th e tro n g k h o n g g ia n : P han loai D aum as - D u po rt d y a tre n s in h th ie t n h ie u tan g

T h e not T h e hon h o p T h e t h im n hie m

Ton th ira n g g id i han ro Ton th u o n g g io i han ro

Te b io tham nhiem rai r i c Te b io tha m n hie m rai r i c
Y eu liet "vet dau b a n g ” Y eu liet h o a c d on g kinh D o n g kinh, kh on g ye u liet

C o khi co phu o’ vu ng lan can N o t b i t tu o n g p h in K ho n g b i t tu o n g p h in

B i t iot, gado T h im n hie m te b io u
khong b i t tu o n g p h in

P hau thu g t G iim the tic h u b in g D ie u trj ?

n g o ii vu ng c h trc n in g
phau thuat, xa trj, hoa trj
U te b io sa o th a m n h ie m 6 $ a c th ip :
- T o n th u o n g c h a t t r in g
kh o n g to n th u o n g c h it x im
- K ho n g co h in h thai d a n g nh 6 i m iu
th e o vu n g t u o i m a u d o n g mach

- Tro n g tru o n g h y p ton th u o n g n ot d u o c bao q ua nh l i m o t vu n g d im do th a p h o a c t in g tin h ieu T2, h in h i n h h y c kh 6 ng th£

x i c d jnh d i y la vu ng phu “p h in u n g " l i n can h a y l i vu n g t h i m n hie m c i c te b io d e m ... t h | t sai la m n eu n h in d inh u
l i vu ng n ot b at tu o n g p han va xem vu ng g iim d am d o h a y tan g tin hieu T2 l i vu n g "phu p h in u n g ’
- K ho n g co tu o n g quan g iu a do i c v i h inh t h i i tro ng kh on g gian l i d an g not. t h im n hie m hoa c h 6 n h o p
- K ho n g co tu o n g quan g iu a do i c v o i hien tu o n g b i t c h a t tu o n g p h in .
n go ai tru u co do i c kh on g c h ic c h in tren g i i i phau benh : ton th u o n g kh on g b i t = do II. co b i t tu o n g p h in = d o III

122
 2 - 3 / C 6 m 6 i t u a n g q u a n g iO a <30 d c c iia u v d i m u c d p b i t t u a n g p h a n k h o n g ?

K h d o sd t g id i p h iu b$nh Id "tidu c h u in vdng"

. U t i b ^ o sa o dang Idng (pilocytique), d 0 I, b i t gadolinium
. U t i b d o it n hd nh (o lig o de nd ro g lio m e ) dO III c 6 t h i kh fing b i t g ad olin ium
. T u y nhidn, n iu gidi p h iu b$nh nghi n g d g i& a dO II vd dO III, u b i t g a d o lin iu m d u g c xep va o dO III
C h fnh vi t h i v in p hdi ddnh gid ch inh xdc d lu hi£u b i t tu o n g phan b in g cdch ly a ch pn c h in h xd c c u a so h iin thj.
N iu ci>a s 6 qud rOng, h inh hi$n Idn "qud xdm ", c 6 th e xo a m i t d iu hieu b i t g a d o lin iu m nhe

w -4 r i
& f \

T on th u o n g thdm nhiem
ke c ^ n nga ba n ao t h i t ben phai
lan r 0 ng qua l6 i the chai
den nga ba ndo doi bdn
C h ic c h in co b i t g a d o lin iu m du b i t nhe

Sinh t h ie t :
U te b do g ai it nhanh, d 0 II ho$ c III
Xep dO III do u b i t c h it tu o n g phan

2 -4 / P Q la n rp n g c u a to n t h u a n g lo a i te b a o d e m

. Khong d u g c n h im lan g iu a d iu h ieu b i t g a d o lin iu m v d i the tich khoi u

- U t i bdo dem th u d n g kh on g d o n g nhat, m ot phan d0 d c ca o vd m o t phan d0 d c thap
- T 6 n th u o n g d0 d c ca o th u d n g 1a m 0 t phan n ho cua u te b do d em do d c t h i p d ien tien cham
- T 6 n th u o n g d0 d c th a p kh on g trip u c h u n g ... c h i can m 0 t phan nho chuye n thanh d 0 IV cu n g du d an td i s y x u it hien
tri$u ch u n g Idm sd ng
- O dnh gid u nho h o n s y th $ t th u d n g xa y ra tre n X Q C L D T : phan u thd m n h ilm d on g dam d0 h o g c giam d gm dO, d u g c
ly gidi n h u Id vu ng phu ne "p h a n u n g "
C ung c 6 the g dp tren C H T : ly gidi vu ng khong b i t tu o n g phan tang tin hieu tren T2 n h u 1a vung phu ndo
tro ng khi co m 0 t vu n g u thd m nhiem m d hang rao m du - nao khong ch o c h it tu o n g phan t h im qua
. DT nhidn phai th y c h ien sin h th ie t n g a y tgi ton th u o n g co b i t tu o n g p han vd ca vu ng lan can d p c the o m 0 t hay nhieu
h u d n g sinh t h i e t ; th o n g tin d u o n g nhie n khong toa n ven vi u d u g c kh ao sa t c h i th e o m o t h u d n g .
ch in h v i the , ca n xd c d jnh ranh g id i cu a ton th u o n g b in g p he p do p ho C H T hoa c C H T -tu d i m du
. X em p h in phu n do : tra n g 103, 104

XQCLDT sau ti£m CHT T2 mat do proton T 1 gado

T 6 n thu o ng p h in trong thuy thai duo ng g iua P CHT khang djnh ton thu o ng 6 phan trong thuy thai duo ng giua ben
nhung cung cho thay ton th u o n g lan rQng den hai ma va cue thai duong
hinh thai khong giong phu phan ung
Sinh t h iit n h ilu tin g k h in g djnh u lan r6 ng k h ip thuy thdi d uo ng : U te bao sao do III b phan sau
do II o phan truoc

123
 2 -5 / B i t c h i t t im n g p h a n g a d o lin iu m d th a n h c a c u d g n g n a n g
. P hai q ua n s i t tro ng ba m a t p h in g :
- B it tu a n g phan : can tie n hanh l l y b6 t h in h cua u nang
- K hong b i t tu a n g p han : g iu n gu yen t h in h nang
C o the p h ii khao sat giai phau bgnh ti>c th i, n g a y tro ng khi m6, qua sinh t h i lt t h in h n ang n lu h in h i n h h o c n g h i n g d
X em the m trigu c h u n g hQC / tru d n g h y p d a c b ig t : c h in d o in t6n th u a n g b i t c h it tu a n g p h in d gn g v ^ n

T1 Gado : b it gado T 1 Gado : b it gado T 1 Gado / 2 m it phing u 6 thinh nang

nhung thinh nang kh6ng b it tucmg phin

3/ Tripdng hyp dgc b ig t:

3 -1 / U te b i o d g m n h ie u o :
. T on th u o n g 6 hai th u y hog c hai ban cau k h ic n ha u, khong noi lien nhau
. K ho ch an d o in c in ngu yen neu c h i d y a tren h in h in h hQC : di c in ? n h ilu o nh 6 i m iu ? xo cung r i i r ic ?

. S inh th ie t ton th u o n g e y e thai d u o n g t r i i : u te b io it n h in h dQ II

. N hieu kha n in g t 6 n th u o n g ranh trung tam p h ii, kh on g sin h t h i lt d u y c (cu p n n io tru d c r in h tru n g t i m ), l i 6 u t l b io d$m
t h u hai

3 -2 / U te b a o d g m v a u n g u y e n b a o d g m la n to a : ca mQt thu y ? c i mQt b in c iu n io ? lan sa ng d6i b$n ?

T on th u o n g hai ben
Phi dai loi cua the chai
C o t h i l i u te bao dgm h o # c lym phom
U t l b io sa o it n h in h dO II
L y i ich cua C H T k h u y lc h tan d iffu sio n :
. Ton th u o n g it t l bao? u t l bao dgm - Lan d in l6 i t h i chai r 6 i d in
tang tin higu tren h inh b 1 0 0 0 n ip co n g d b£n trai
. T on th u o n g g iau t l bao? lym ph om
tin higu b in h th u d n g tren b 1 0 0 0 - C h in d o in tr§ n T 2 FLAIR
- C 6 c h i dinh d o ph 6
L y i ich cua p he p do pho
T y le ch oline / N A A tang
... n h u n g " b it b u 0 c" sinh t h ilt:
U t l bao gai it n h in h do III

T 1 gado T1 gado T2 FLAIR

N hi/ co nhieu ton thu a ng thay tren T 1 gadolinium
U nguyen bao dgm hai ben ... ton thuang duy nhat
that ra la u te bao dgm tham nhiem dQ th4p c h ilm toa ' 1 b in ciu
u dang "canh buam "
nao ben phai. dong thoi chuyen dc tinh. do IV da 6

124
 T1

V
-i f ; > .

\ ‘ V * V

T1 gado
- U d $ c kh on g d o n g n h a t ; x u a t h u y e t tro n g u g a n d ay, tre n d u d n g giCra, va x u a t h u y e t m a i, p h ia n go ai
- U tham n hie m toa n b p th a n n a o ; b a o q u a n h d o n g m a c h th a n nen
- Gian ca c n ao th a t b en , x o a c a c ra n h v o nao
- C 6 the sin h th ie t nga tra n c h o d e n n o i noi h an h tu y v d i tu y so n g

3 -4 / U n g u y e n b a o d e m d n g u d i g ia

- Chan d oa n u n g u y e n b a o d e m n g a y ca n g n h ie u d o tu o i th o n g a y ca n g ca o v a tie n bo c iia h in h a n h hpc

- Khong co tin h c h a t d # c h ie u n h u n g ra t g g i y : to n th u o n g co du’d n g b d kh o n g d eu , b at g a d o lin iu m ra t m a n h , d a n g tha m
nhiem, kh on g p hu h o a c p hu it, tie n trie n ra t n ha nh
- Song tru n g b in h : 6 th a n g

T 1
g ad olin ium

B e n h n h a n g ia : to n th im n g t r u d c ra n h tru n g ta m b en tra i, kh o n g sin h

th ie t
d u g c , kh o n g m o d u g c
... C h a n d o a n u n g u y e n b a o d e m d u a tre n tie n trie n ra t n h a n h cu a u

U n g u y e n b a o d # m p h a t trie n
d o c th e o c a c kh o a n g V irc h o v R o bin

125
 4/ D iffusion va thu’O’ng ton it te bao, va th ifg n g ton nhieu te bap ?

diffusion b 1000 ban d 6 ADC

U n g u y £ n b&o d em h a y lym p h o m ? - T1 va T 2 kh o n g c 6 y nghTa

- T1 g a d o lin iu m : to n th u o n g kh o n g d o n g n h it , h o a i ti> tru n g tam , g o ' y u nguyS n b£o d$m
- H in h a nh k h u e ch tan
. b 1 0 0 0 : tin h ieu c a o kh o n g ly g ia i d u o c neu k h d n g c 6 b an d o A D C
.... tin h ieu ca o n a y c o th e lie n q u a n td i h ie u U n g T 2 g £ p tro n g T 2 FLAIR
B an d o A D C : ton t h r o n g d o n g tin h ieu
... ly m p h o m c o tin hieu th a p / to n th u o n g d a te b&o

51- U mang ong npi tuy : d<? II h o a c III

- T o n th u a n g c o the b en tro n g n ao tha t, h o a c h on h o p : tro n g n ao th a t v a tro n g n ao , h o a c n g o a i le c h i tro n g nao

- U kh o n g d o n g n h a t : d a c, n a n g , vo i hoa, xu a t h u ye t
- U m a n g o n g n pi tu y la n h u n g u m e m co the "c h a y " ben tro n g h o a c ra n g o a i he th o n g n a o th a t
- Cy tre e m , g a p u d ho sau
- P ha i tim m o t ca ch he th o n g ca c di ca n d u d i m a n g n he n . Q u a n h n ao , tro n g n §o tha t
. C o t so n g : g ie o r i c th e o d u d n g D N T

U m em .
T h o a t vi v a o lo ch a m

126
 6/ Hinh anh hoc sau di4u trj : p h iu thuat, xg trj, hoa tri

K 9 th u $ t c $ n g h i/d n g t ir giAng n h a u ch o t i t c& c a c l i n k iim tra : c u n g c h u o i xu n g , c u n g m a t p h in g . c u n g th d n g s6

. 1/ . K iim tra n g a y sa u k h i m 6 b in g C H T , m 0 t each h$ t h in g , n g a y th u 2, t r u d c va sa u tie m

. C i t b d to a n b$ ? c i t b 6 m p t p h in ? ia kh a o s a t th a m kh a o d e so s a n h ve sa u, p ha n b ie t g iu a u tai p h a t va u c d n d e lai
. Vj tri th u d n g g £ p cu a u cd n d i lai h o ^ c u tai p h a t : g id i h an tro n g cu a vu n g m o, v u n g c h d c nang

-2 / K hdng kh a o s a t h in h a n h h o c tro n g k h o a n g n g a y th u 4 d e n th a n g thip 3 : h a n g ra o m a u - u c h o th u o c tu o n g p ha n tha m

q ua d o c 6 li§n q ua n d e n c u q c m o
N g oa i tru * : ta n g a p l y c n pi so c i p tin h

- 3/ S au khi ke t th u c d ieu trj n g o a i kh o a , xa trj, h 6 a t r j :

. K ho n g kiem tra t r u d c 3 th a n g : v ie m n ao d o tia xa "b in h th u d n g ", co th e co d a u h ieu ta n g a p ly c npi so
. K ie m tra va o th a n g t h u 6 n e u ia u te b a o d e m d p a c ca o , h o a c s d m h o n n eu co d au h ieu lam s a n g tie n trie n trd lai
. K ie m tra va o th a n g t h u 12 neu ia u te b a o d e m d o a c th a p
. S a u d o kie m tra m oi n am : c o kh a n a n g u tie n trie n t r d lai n h ie u n a m sa u k h i d ie u trj
. Khi tai phat, u co d p a c c a o h o n so v d i u te b a o d e m b an dau

K et q ua : tie u ch u a n M a c D o n a ld : d o 2 du’d n g k in h Id n n ha t, n ha n d oi hai d u d n g k in h n a y v a so sa n h :

- K e t q u a to t : u "b ie n m a t" h o a c m a t 9 0 / 1 0 0
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- N ang h on : ta n g tre n 2 5 / 1 0 0

Kha nang to n th u o n g d o d ie u trj lie n q u a n td i d o c tin h c u a h o a trj : . T a n g tin hieu , kh o n g b i t g a d o

. T e o n a o kh u tru h o a c lan toa
. V o i h oa sa u d ieu trj b in g m e th o tre x a te

-4 / S au d ie u trj b in g tia xa, h o a c p h a u th u a t v a tia x a :

. L y giai : D iu h ie u tai phat d i u h ieu h oai t u d o tia

- D iu h ieu la m s a n g tie n trie n K h o n g co h o a c c h i c o v a i d i u h ieu lam sa ng

- T a i p h a t s d m : v a i th a n g H o ai t u d o tia . toi th ie u sa u 6 th a n g
. n g o a i le c o th e sa u 24 th a n g
- T o n th u o n g d a c K et h o p to n th u o n g m o d a c va d a n g nang
- T a i ranh g id i v u n g l i y bo T ro n g vu n g xa trj
- T ro n g v u n g c h u c n an g
- C o h ieu u n g c h o a n ch o K h o n g co h ieu u n g ch o a n ch o, n g u o c lai c o th e bj "c o keo"

- D iu h ieu b i t tu o n g p h a n g a d o lin iu m v a p hu n e q u a n h to n th u o n g kh o n g c o y nghTa

- T ru d n g h o p n g h i n g d :
. P h e p d o p ho
- T a n g h am lu p-ng ch o lin e - P ho d o b in h th u d n g h o a c b ien d oi it
- G ia m h am lu o n g N A A

P E T s c a n , h a y xa h in h v d i s e s ta m ib i / b ie n th e cu a te c h n e tiu m
M y c tie u : k h a o s a t m a t d o te b a o c u a to n th u a n g
N e u tai p ha t, ty la p th e b i t c h a t d o n g vj p h o n g xa
T h o n g tin n a y tin c a y h o n v ie c k h a o sat h a n g ra o m a u - u, kh o n g co y nghTa nhie u

- 5 / U m a n g o n g noi tu y . u n g u y e n bao tu y : K h a o sat he th o n g o n g s o n g tro n g m a t p h in g d u n g d oc. T 1 g a d o lin iu m :

K ha n an g co d i ca n d u d i m a n g n h e n th e o d u d n g dich

127
 H in h a n h 6 th a n g sau khi k e t th u c d ie u trj

/ — ~ N

f #V &] 1
T2 SE

echo 1 v ^ 2

T o n th ir o n g k ic h thirdrc 4 mn
b i t g a d o lin iu m

C 6 n s 6 t u h a y u tai p ha t ?
... c iin k ie m tra
n g a y sa u p h iu thu$t
de c o th e s o sanh

H in h a n h 1 n am sa u k h i ket th u c d ie u trj :

- L y giai : d au h ie u g o i y h oai ti> d o tia xa, xe m p ha n tre n

- L o i ich H in h d iffu s io n d iffu s io n (c h u y e n d o n g cu a n u o c ) kh o n g bi h an ch e
X a h in h P E T sca n kh o n g co ty la p th e .. k h o n g bat d o n g vi p h o n g xa
. P h e p d o p h o p h o b in h th u o n g
- ... S in h th ie t h o a c ca n th ie p lai

128
BI U N G U 6N GOC THAN KINH : PNET, DNET

- H iim h a n u t i b d o d$m
- G $p d t r 6 e m h o $ c n g u d i tr 6
- U p h d t s in h t ir c£ c t i b a o n g u in g i c t h i n Kinh
- H in h a n h h p c kh 6 ng ch o p h 6 p c h in d oa n c h in h x a c c h ic c h in

1/ PNET : p r im a r y n e u ro e c to d e r m a l t u m o r : U b ie u m o t h a n k in h n g u y e n p h a t

- U n g u y in b a o tu y
: . T o n th u a n g d ^ c , d o n g n h it
n h iiu t i b ao : . ta n g d a m d o t r u d c tie m
. d o n g tin h ie u T 1, ta n g tin h ie u n he T 2 vi kh o a n g d ich bi h an ch e
. d iffu s io n : ta n g tin h ie u tre n b 1 0 0 0 v i kh o a n g d ich b j h an che
. B i t c h it tu a n g p ha n d a n g d a m (d a n g k h o i)
. T h u d n g g a p di ca n d u d i m a n g n h e n . tro n g n a o va tro n g o n g so ng

- U te bao d $m h a ch : . O 0 n g kin h d n g u d i tre ; th u d n g g a p d th u y thai d u a n g

. U Id n , kh o n g d o n g n h i t : d ac, d a n g n a n g , v o i hoa
. H ie u u n g ch o a n c h o : d iu h ieu de p ha n b ie t v d i D N E T

- U te bao th a n kin h : . U h ie m , g a p d n hu nhi h o a c tre e m

. V j tr i : d u d n g g iu a , p h a t trie n tro n g n a o th a t
. T o n th u o n g Id n , kh o n g d on g n h it , da th u y l da n a n g , co th e voi hoa
. B i t c h i t tu a n q p ha n it

U nguyen bao tu y (m e d u llo b la s to m e )

XQCLOT khong tiem Diffusion b 1000 : Tang tin hieu T1 gado Tang tin hieu
T3ng dgm dp do met do te bao cao n u d e chuyen dong han che do mat do te
bao cao, d iu hieu phan biet va i u mang ong
npi tuy, it te bao

U te bao d #m ha ch (g a n g lio g lio m e )

T2 T 1 gado

T o n th u a n g lan ro n g, kh o n g d o n g n h a t : n o t d a c, b a t c h i t tu o n g p h a n . n a n g d o tie t dich

H ie u u n g c h o a n ch d'*K d i u h ie u p h a n b ie t v d i D N E T

129
 2 I DNET : D y s e m b ry o p la s ic N e u ro E p ith e lia l T u m o r - U bi6u m d th£n kin h lo an s£ n phfx

- M o te b a o d e m - th in kin h ; to n th u o n g la n h tin h , tie n t r il n ra t ch $m

- D p n g kin h d n g u d i tre
- H in h § n h hQC kh o n g d a c h ieu : to n th u o n g d a c h o a c n a n g , tin h i£u r4 t m g n h trd n T2
b a t c h a t tu o n g p h a n d a n g kh oi h o a c b i t O' n g o a i vi cu a n an g, c h i tro n g 1/3 c a c tr u d n g h<7 p h«^m kh i v d i hda
- Y l u t 6 g g i y : to n th u o n g c h ie m to a n bo h o a c mQt p h in th u y d ao , g id i h an rd. ia m d a y v d n ao
khdng cd hoac cd vai dau hi$u gian tiep : khdng d iy cac c iu true ian c$n, khdng phu r>£
ton thuong vd nao : kha nang day ban trong h0p sq dang "m$t kinh d6ng hd"
cd the cd kern cac o lac cho chat xam

T h e nang
T 2 tin hieu ta n g m a n h
B at g a d o d n g o a i vi

12 FLAIR T1 gado b it dang viAn

. The dac
. P h i d g i c h i t xam
. T 2 ta n g tin h ie u rd
. D a y v a o b an tro n g so

1 2 SE m^t (36 proton

. T h e d a nang
. T a n g d gm dQ tre n X Q C L D T :
v d i hda
. T 2 tin h ie u ta n g rd
. K h d n g b i t g a d o lin iu m

. H ie u u n g ch o a n ch o i t :
d u d n g g iu a kh d n g di lech
. V o m s q m d n g di
1 2 FLAIR T1 gado

P h i d ai c h a t x a m th u y d a o
K h d n g xo a th u n g lung S ylv iu s
K h d n g b i t g a d o lin iu m

To n th u o n g tu o n g t u

130
 C l LYMPHOM NAO

. B $nh nhS n ca o tud i, tiAu d u d n g , d inh d u d n g k 6 m, A ID S , d iiu tri ch o n g th a i g h e p

. TAn th u a n g nhiA u tA b a o dAng nhA t : - TSng d $m d 0 tr£ n X Q C L D T d o c o n h ie u te b ao

- D A ng tin h i$ u T 1 , ta n g tin h ieu v u a p h a i T 2 , ta n g tin h ie u tre n d iffu s io n b 1000.
g i£ m tin h i$u tre n b an d o A D C d o m a t d p te b ao cao
- B i t c h i t tu o n g ph£n
- D a ng th a m n h ie m : kh o n g c o h o ^ c c o h ieu u n g ch o a n c h o it
- T h u d n g nhie u ton th u o n g : . n h a n xa m tru n g tarn, th e ch ai, tru n g ta m b an b au d ye
. co kh a n an g co to n th u o n g v o n ao

. L ym phom tip A , B ... c i n s in h thiA t d e xd c d jn h ch a n d o a n va q u y e t d jn h lo ai hoa trj

. DiAu trj co rtico id ia m hAi p h y c ta m th d i h an g ra o m a u -u ; k h o n g d u o c d u n g c o rtic o it t r u d c khi s in h th ie t

XQCLOT sau tiem

Lym phom d lAi thA ch a i

L y m p h o m d ie n h in h : kh on g c o d iu h ieu c h e n e p h o a c c h i c h 6 n 6 p nhe ;
TAn th u o n g c 6 v£ k h o n g dA n g n h it
g iu n g u y e n h in h th a i ca c s u n g n ao th a t va n h it ia d u d n g g iu a
TAn th u o n g tiAu th u y ca n h tru n g ta m b §n p hai

XQC LD T sau ti 6 m lym phom da A trong nao va lym phom phat tnen trong nao that

131
 Dl U L i r a i MACH hay U NGUYEN BAO MACH (HEMANGIOBLASTOME)

- T ie n cSn : b e n h V o n H ip p e l L in d a u , m p t va i tr u d n g hp-p le te h ie m g £ p \& u m d i t i/ d i u ('d e n o v o ")

- N h ie u ton th u a n g : h o sau, v o n g m a c, tu y s o n g / 1> d jch tro n g tiiy
T o n th u a n g g ia u m a c h nuo i, k ic h th u o c th a y doi
th u d n g c 6 d g n g n a n g d o u tie t djch
- C d c th e c 6 trie u c h u n g d u o c d ie u trj n g o a i kh oa

- K h o n g tie m : to n th u o n g d a n g n a n g , n g h i t r u d c tie n t d i u, d t i i u n § o tr£ i

- C 6 tie m : n a n g tie t d jch, to n th u o n g n o t n h o d sau n g o a i, to n th u o n g k h a c d th a i d u o n g tro n g b e n tra i

- N e u kh o n g h 6 i b en h s u , ton th u o n g n h u v # y c o th e tu o n g u n g v d i u te b ao s a o hoeic u m £ n g o n g n pi tu y d a n g nang

C hgp m gch m au
n h ie u to n th u o n g . g ia u m a c h nu 6 i
T o n th u o n g n h ie u n o i: - h o sau
v o n g m ac
tu y so n g / u d ich o n g s a o tu y d o t i c n g h e n o n g m a n g n oi tu y
h o a c d o m o t h a y n h ie u vi tri u k h a c d tu y so n g

132
El CAC Dl CAN :
T in h c h a t d a d a n g c u a d i c3n
E-1/ Di cdn ndo theo dircrng mdu
- N h in c h u n g , to n th u a n g . d ^ c , d o n g n ha t
. b i t c h a t tu a n g p ha n
. co phu bao quanh
- N h u n g c u n g c o th e g a p
. T h e h oa i t u
. The nang . c h u a dich
. c h u a th e ke o
. T h e x u a t h u y e t . m a u tu la n ca n
. m £ u ty tro n g u
. H ie m g 3 p di ca n vo i hoa
. N g u y c o b 6 s o t di can
. di Ccin x u o n g vb m s o h o $ c d ^ y s o (s a n so )
. h o c m i t / l6 i m it ?
. tu y e n yen
X e m th e m : D lu h ieu ton th u o n g / m o t h a y n h ie u t 6 n th u o n g ?
tra n g 1 0 1 , 102

Di ca n th e k e o t u m p t u n g th u p h o i Di c a n t u u ng th u v u ; h oa i tip tru n g ta m
T o n th u o n g t h u h a i ' N h ie u to n th u o n g

133
 Lam sang va hinh anh hoc : K h a n a n g la d i c a n , c a u h o i vd hudng xi> tri
- 1/ C o b ie t c 6 ung t h u n g u y e n p h a t k h o n g ? da sin h th ie t c h u a ? da m 6 chua?
- 2 / U n g t h u n g u ye n p h a t d a d u o c kie m s o a t h a y c o th e k ie m s o a t d u o c k h d n g ?
... lo i ich c u a v i$ c d ieu trj m o t h o a c c a c di c a n n a o n eu u n g u y§ n p h a t c h u a d u o c k iim so a t
- 3 / Di c ^ n d o n d o c ? - Cy v u n g kh o n g c h u c n a n g : p h a u th u £ t h a y d a o g a m m a
- Cy vu n g c h u c n a n g : d a o g a m m a
N h ie u to n th u o n g : . 2 - 3 to n th u o n g : d a o g a m m a va xa tri bo s u n g to a n th4
. tre n 3 to n th u o n g : xa tri to a n the

T r u d c tie m S a u ti§ m

T a n g tin h ip u t u n h ie n tre n T 1 lie n q u a n td i . m e la n in

. hoac do cac 6 x u a t huy& t li ti
Di ca n t u u h l c to (m e la n o m )
- K h o n g p ha i m p i d i ca n d eu ta n g tin h ip u T1 : c 6 1 to n th u o n g c 6 g ia m tin hi$u
- S au tie m , c a c to n th u o n g d eu Id n h o n : v u n g c 6 h o a t tin h d n g o a i vi

Di ca n t u u h a c to

K ie m tra sa u xa tri da ch u m

H ie u q u a tre n to n th u o n g th u y tra n g iu a b e n tra i

..... N h u n g p h a t trie n th e m 2 di c a n k h a c

T2 SE m a t d o p ro to n

Chan doan phan biet cac di can nao :

N h o i m ^ u n a o m o i m a ia m s a n g kh o n g n ha n ra va co b a t g a d o lin iu m
. N h oi m a u v o n a o : ton th u o n g c h a t xa m d a n g th a n g ta n g tin hieu t u n h ie n va b a t G a d o
. N e u ch a n d o a n kho, nen th u c h ien C H T lan 2 ca ch l l n d au kh o a n g 4 tu a n le

T 1 G ado

T ie n ca n ung t h u : C H T to n g ke m u c d o xa m la n t r u o c khi d ie u tri to n th u o n g n g u y e n p h a t

T1 g a d o lin iu m : T o n th u o n g v u n g vo n ao . h in h a nh d a n g th a n g d c h a t xam
D i c a n ? n h o i m a u n ao p h a t h ien tin h c d 9
C o th e la n hoi m a u nen th u c h ien C H T k ie m tra lan 2 c a c h la n d au kh o a n g 4 tu a n le

134
E-2/ Di cdn theo d i/frn g dtrfri nh?n

- CSn n g u y 6 n : - U m d n g 6 ng nOi tu y
- U nguy& n b a o d £m
- U n g u y fin b ao tuy

- Vj tri t 6 n th u o n g
- T ro n g n a o t h i t
- D u d i nhpn
- T u y s 6 ng
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.... C H T n a o va 6 n g s 6 ng

- C 6 kha n an g c 6 m p t h o a c n h ilu di can tro n g 6 ng X Q C L D T kh o n g ti 6 m

s6 ng T a n g d am d p q u a n h n a o t h i t : n h ie u te b do
g o i y p h a i tim u n ao

- Tidn lu o n g : tip v o n g sa u v a i t u l n

D i can
. T ro n g n a o t h i t
. O cac b l DNT

T1 T2 FLAIR

X Q C LO T kh 6 ng ti£ m c 6 tie m
Di ca n d u d i n hp n
C a th e te r tro n g c o n g S ylv iu s

T1 qado

T1 T2 SE T2 FLAIR T1 gado

T o n th u o n g thai d u o n g p h a i c o v e n h u tro n g n ao
Di c a n d u d i n h p n th u o c th u n g lung S ylv iu s va n h ie u to n th u o n g di ca n d u d i n he n k h a c
Di c a n ia to n th u o n g ra t n h ie u te bao, d o n g tin h ip u , th a m c h i g ia m tin hieu tre n T 2 S p in E c h o va T 2 F L A IR
T o n th u o n g m a n g n ao . n g o a i n ao . kh o n g g a y p h u n ao

135
 F/ U TRONG NAO : t ru c rn g h o p d a c b ip t

A . U trong n io t h it
B . P h it trien vao trong nao ti> u ho$c gia u n g o ii n io
u m in g n io thung lung Sylvius, nang dgng bi, tui phinh d$ng mgch
C . H0i chung c#n ung th u

F-1/ U trong nao that

1 : U d ie : u m a n g n ao , u n hu , u m a n g o n g n $i tu y ..

- T 6 n th u o n g d a n g u, d n ga ba n a o th a t tr£ i
. "O ’ d o n g " d s u n g thdi d u o n g : n g h e n D N T d u o c tie t ra t u ca c d a m ro i m a c h m a c
. H in h anh h o c cu n g n h u g ia i p ha u b en h d ai the kh o n g g iu p x a c d in h cd n n g u y e n :
u m d n g n ao , u n hu , u m a n g o n g n oi tu y ...?

- C h a n d o a n g ia i p h iu b en h ... u m a n g o n g n pi tuy

U tro n g nao t h a t : u m a n g o n g n oi tu y ? U n hu ?
T u d n g trin h p ha u t h u a t : u n hu d im ro i m a ch m a c n a o th a t 4

T2 SE T1 gado

T o n th u o n g d a n g u tro n g n a o th a t : u m a n g nao, u n h u , u m a n g o n g n oi tu y 7

X Q C L O T co y nghTa h o n C H T : u c u o n m a c h m a c
C h a n d o a n tro n g khi m o va g ia i p h a u b en h : u m a n g n a o c u a d a m ro i m a c h m a c

136
 2 : N a n g m a n g 6 ng nOi tu y

M ^ t (30 vd tin h i$u tu a n g t y n h u D N T n h u n g kh d n g c 6 h in h anh d o n g c h a y tre n T2

. T h iy d u a c th a n h n an g 6 c u a s 6 hep
. N h in c h u n g , kh d n g cd ta c dOng Idn d dn g c h a y D N T ... kh d n g c d d au h ieu la m sa n g , d u p e p h a t h ie n tin h c tt

- C d kha n an g ta o s u e c a n g va c h e n e p le n c a c ca u tru e lan ca n : to n g ke ca c tru o n g h a p n h u c d au

137
 F-2/ Tien trien trong nao cua u hogc gia u ngoai nao:

1 : U m^ng nao thung lung Sylvius

C h in d o in p h in b»|t
U t l b i o d | m n h d n x i m tru n g u ong

- T i n th u o n g d in g n h it , g id i h a n ro, vo i h 6 a tru n g tam

- T i n th u o n g n h ilu t l b i o ... kh o n g t i n g tin h i$u tre n T 2 F L A IR
- P hu la n c£ n : u m in g n i o " x im lan"

T1 gado T1 gado

•Tl
i f P V T \

\ t
Diffusion b 1000 Diffusion b 1000 B in do ADC

U m in g n io lie m n io : U n g u y e n b a o d e m v o m n i o - v ic h tro n g s u o t - t h i ch a i d a n g ’ c a n h budm *

N g o ii yeu t 6 vj tri v i hinh t h i i g p i y Phan trung tam u co tin higu nhu cua m ^t u it t l b io t iln t n ln ter hoai h> :
T in hi£u cho thay t6 n th u o n g thu$c loai nhieu te bao T in g tin hieu T2
. It tin hi^u T2 FLAIR Diffusion tin g Giam tin hi£u b 1000.
. Diffusion hgn che : tin g tin hieu b1000 T in g tin hi$u tr§n b in d 6 ADC
Tin hieu vung ngoai bien thuoc loai "co hogt tinh*. nhieu t l bao

138
 2 : U q u a i, n a n g d g n g b i

MG m d , v d i h 6 a n g o g i b idn
D iu h i$u g id n t i i p k h d n g c d h o $ c cd it

M d di d p n g tro n g s u n g th d i d u o n g phdi
do n a n g v d
M y c n dm n g a n g m d - djch
Khd n d n g v id m m d n g n d o vd tru n g n eu v d vdo
cd c kh o a n g d u d i n h$ n
Xem th d m t 6 n th u a n g trd n l&u

XQ C LD T T1

X Q C LD T

X Q C L D T sa u tie m : to n th u a n g

T in h ieu kh o n g d o n g n h a t tre n T1
G ia m tin h ipu ro tre n T 2 lie n q u a n td i n ong
p ro te in ca o , x e m tra n g 43

T ie n trie n ra t c h a m
. K h o i p h a t tu 1 tro n g b un g m e ?
. K h o n g tu o n g x u n g g iu a th e tic h u Idn
v a c a c d a u h ie u g ia n tie p it
. K h o n g phu lan can
. T h o a t vi v a o lo b a u due
khong chen ep cuong nao nhieu
C H T d oi v d i n h u c d a u m d i :
. G ia n v u a p h a i n a o th a t d oi d ie n
. X oa c a c ra n h v o n ao
- N a ng d a n g b ieu b i -

3 : N a n g d a n g b ie u b i h o g c u h g t n g o c : xem trang 52 va trang 307

Thuong ton tien trien rat cham. tang tin hieu T 2 S E , c h u a n h ie u d ich . ich lo i cu a h in h d iffu sio n

139
 T2 SE echo thi> 1 Hinh dnh dbng chdy d$ng mg<*i TOF 3D

4 : Tui phinh dQ ng mgch gia u :

V j tri, h in h th d i vd tin h igu gQi y tu i p h in h dQng m g ch c 6 huy

kh oi b en tro n g :
.T 2 : g id m tin h ip u d o h e m o s id e n n e
. T O F 3 D : h u y e t kh oi to d n b p dQ ng m a c h cd n h trong
d o a n tro n g vd n g o £ i sq

v d d 0 n g m a c h n d o giCra trdi
. M a ndp sq : ta o th o n g n 6 i g iu a
. D p n g m a c h th d i d u a n g vd d p n g m a ch n do giOa
. Nhdr ta o h in h b d n g tin h m a c h h ie n tro n g
khi th o n g n oi th o n g th u a n g : dQ ng m a ch n do g iu a
T2 SE echo thi> 2
g ia m tin h ip u d o c 6 d b n g c h d y

F - 3 : Hoi chung can ung thu5

- H ie m g dp
- MQt h o o a c nhie u ton th u a n g th o d i h oa m ye lin : hai m d, th u y trd n , th e ch ai v d h oi d a i (h o i v ie n )
- B p n h t u m ie n d o p h d t trie n kh a n g the
- T o n th u a n g n g u ye n p h d t : u ng t h u p ho i te b a o n h o ... h o d c kh o n g b ie t c o u n g u y e n p h d t
u n g u ye n b d o d p m n ao vd to n th u a n g a h a i h ai m a
- L am s d n g kh o n g d d c bipt, d ie n tie n ch a m
- T o n th u a n g td n g tin h ipu T 2 , tu a n g t u n h u vie m n a o d o h e rp e s, co it h o a c kh o n g c 6 h ip u u n g c h o a n ch o , k h d n g bdt
g a d o lin iu m . L u u y : n eu 1a to n th u a n g ca n u, kh o n g c o th a n h p ha n x u a t h u y e t
- C h an d o a n b an g C H T , X Q C L D T th u a n g b in h th u a n g
- K et h o p v a i b pn h th a n kin h n g o a i bien
- T o n th u a n g n g u n g tie n trie n sa u khi d ieu trj to n th u a n g n g u y e n p h d t

R o i lo a n ta m th a n / . B e n h n h a n c o c a c x in o m p hoi te b ao n h o
. T h e ch a i ta n g tin h ie u lan d e n hoi d ai (h o i vie n )

140
- B$nh nhdn Nam 52 tudi
- DOng kinh BJ chi tr6n vd chi d u d i b6n trdi, / • M

Li$t vdn dOng vua phdi

- TAn th u a n g thdm n h iim hdi tru d c trung tdm * V j
bfin phdi
- Tdng tin hi0u . Hdi md hai bdn
T h u y d d o vd trd n n in b £n trdi
/

- D iin tien sau 2 th a n g : b p n h n a n g h a n CHT

... U ngu yen bdo d p m t r u d c vd sa u ra n h tru n g ta m b e n p hai
- Hdi c u u :
. C d c t h i d p n g k in h c u a v ie m n a o h e rp e s th u d n g h iim
. C u ng h iim g a p c d c to n th u a n g v 6 ;
. K hd n g s 6 t, k h 6 ng c 6 k h a n g th e d $ c h ipu
. K ho n g c 6 d a u h ipu x u a t h u y e t tre n T 2 *
-> C h in d od n v ie m n a o h e rp e s kh o n g c h d c ch d n
... Tro n g tr u d n g h g p v ie m n a o h e rp e s kh o n g d iin h in h ,
c in th u c h ie n c d c h in h sa u tie m g a d o lin iu m T1 gado

Phoi hop cac b$nh ly u n g u y e n b d o d e m da m o vd xa trj, y i u ch i d u a i b en tra i tro n g vo n g 24 g id

X Q C L D T v d C H T n g a y th u 4: n h o i m d u n a o vu n g t u d i m a u cu a D M n a o t r u d c b en p hai

XQCLDT
khdng
ti§m

C H T . T1 g a d o
. D iffu s io n b 1 000
. Ban do A D C

- X Q C LD T g g i y chan doan
n hoi m d u n a o m d i
- C H T d iffu s io n k h d n g d in h
chan doan

141
 G - T ru o n g h o p dac bie t : cha n do an cac VOI H 6 a a ndo

C h in d o a n v o i h 6 a, v a c 6 kh a n a n g ch a n d o a n cd n n g u y e n :
. D e tre n x quang quy u6c va X Q C L D T , ci>a s o h e p vd cua s 6 r0ng
XQ C LD T vuQt trpi hon C H T trong ch in dodn cdc voi hod
. Kho tren C H T neu khong co chuoi xung T 2 * : gidm tin hi£u T1 vd T 2 S p in E ch o h a y F L A IR do k h d n g c b p ro to n
- G id m tin h i?u n d y bj n h a m l l n v 6 i c d c g ia m tin h i$ u k h d c n iu v 6 i h o d "d a n g d $ c ‘
- G id m tin h ieu th u frn g bj x o d mdr d o td n g tin h ipu c a o cu a cd c th d n h p h in p ro te in tro n g tAn th u a n g :
c d c t 6 n th u o n g kh d n g d o n g n h it , m p t p h in Id m 6 m im , td n g tin hi$u , mQt p h in v fii hQa. g id m tin hi$u
- C h u 6 i x u n g T 2 * r i t n h a y ■■■ b i t b u $ c
- C in p ha n biQt g id m tin h ip u d o vd i hod v 6 i c d c g id m tin h i$ u d o Idng d p n g h e m o s id e n n d y a vd o Idm
sd n g , h in h th d i, v j tr i ... n h u n g k h fin g c 6 b d n g c h u n g c h i c ch d n
- T u d 6 ru t ra m o t d ie m ye u c u a C H T s o vb'i X Q C L D T :
1 / M a t th o n g tin d e c h in d o d n ca n n g u ye n
th i d y : . V o i h oa "d a n g d d m m d y kh 6 i" r i t g o i y d e n u t i b d o it n h d n h
. V o i h o d cu a u s o h iu r i t c 6 g id trj tro n g c h in d o d n m Q t u tro n g h 6 y§ n
2 / K h o n g d u th o n g tin c u n g c i p c h o c h i d jn h vd k y th u d t s in h t h i i t n do :
S in h th ie t t h i t b g i ; th a o ta c kh 6 , th $ m c h i n g u y h iim

CHT : voi hoa dong tin higu CHT : voi h 6 a dong tin hi$u

T2 FLAIR T2 ’ : vo< fx>a

Chuoi xung duy n h it y nghTa

Can nguyen

V o i h oa b in h th u o n g : - T u y in tun g , d d m ro i m a ch m a c
- L iim dai n ao . leu tie u n ao
V o i h oa b en h ly :
V o i hoa mQt n o i - U .. u te b a o it n h a n h , u s o h au , u q u a i, u m o c u a t h i ch a i
- S au c h a n th u o n g : m a u tu d u o i m d n g c u n g d o n g voi
- M a ch m a u : m a n g v u a d o n g m a c h , d i d a n g dong-tTnh m a c h : sen tin h m a ch
V o i h o a n h ie u n o i : - B e n h t h i n kin h -d a x o c u n g n a o cu B o u m e v ille . b e n h S tu rg e W e b e r K rabbe
xem : B p n h th a n kin h -d a
- N h ie m tru n g : n h ie m to x o p la s m a
- T h o a i hoa : b en h F a h r x e m : B p n h ly th o a i h oa

142
 TAI b i£ n m a c h m a u n a o hinh anh hpc

T ru d c m<?i b $n h nhdn n ghi n g d bj tai b iin m ach m du ndo, luon luon th y c hien X Q C L D T n ao kh on g tie m ca n q ua ng k h in cap
XQ C LD T : - X d c d jn h T B M M N th u 0 c loai t h iiu m du h a y x u a t huye t
- X d c d jnh 0 6 i v d i t i n th u a n g : vj tri, kic h th u d c , so lu a n g ...
D 6 i v d i cd c c iu true Idn can : tin h tra n g g ian nao that, th o d t vj nao 7
. Bdc s i Idm sdng s§ c 6 tro ng ta y cdc k i t qud :
. Ldm sd ng : - T h iiu s 6 t t h in kinh v in t i n tai? tho d ng q ua ? tin h tra n g tri g idc, liet ban than, m a t n gon ngO, ligt ca c d a y sq
- T u ii? t in g tra ng ? t iin cdn : cao h u ye t dp, t i i u d u o n g , vie m dQng m a ch chi d u a i, n hoi m du c a tim ?
. X Q C LD T , cd c x 6 t n g h i^ m sinh h 6 a c a bdn
Todn bO thdng tin tr§n ch o phdp : . L |p t in g ke ton th u a n g
. X d c d jnh cdn ngu yen
. C h o c h i d jn h - K iim tra n ao bQ s a m b dng C H T n iu co the
- C 6 t h i kdm sieu a m D o p p le r D M vu ng co, D o p p le r xu yen th y c quan
. Q u y it d jnh d iiu trj
. T ie n lu a n g d y hau .
TrSn th y c t i , n iu c h in d oa n X Q C L D T 1a :
Nhoi m au n ao (N M N ):
. C ho ch i d jnh sie u am D o p p le r cd c m a ch m du vu ng co
. N eu d o p p le r b inh th u d n g h a y n iu d o p p le r c h o th a y h ep d on g m a ch d u a i 50 / 100 : lam C H T nao
. N iu d o p p le r c h o th a y h gp tre n 50 / 100 : c h i d jnh C H T d on g m ach co va C H T n ao bQ
... C H T th y c hipn 1 lan h a y n iu co t h i th a n h 2 lan : C H T nao roi C H T m a ch co : co b o c tach kh on g? , C H T -m a ch m au
To ng hQp : - Lam sa ng ( a m thoi m a ch ca n h ? ) + d o p p le r + C H T m ach co ( h ep tren 70 / 100 ) tu a n g u n g nhau :
q u y it d jnh p ha u th u a t h o a c nong g ia n d on g m a ch : dQng m g ch ca nh , dQng m g ch song
- K i t q ua kh o n g tu a n g u n g nhau : . C o t h i th y c hign X Q C L D T -m a ch m au / m ay da hdng do
. Lam lai sieu a m D o p p le r do 1 b a c s i co kinh ngh ig m
K h ii ty m du sau a n g u d i g ia : n g u n g ; kh on g lam C H T, kh on g c h y p m ach m au; the o doi d ie n t i i n b in g X Q C L D T
K h ii m du ty a thu y, x u it h u y it m ang nao, khoi m du ty sau a n g u d i tre ;
C h y p m a ch m du dong m a ch ca n h vd d ong m g ch so n g -th an nen, cd t h i lam C H T
MOt tru d n g h g p d $ c bigt cd c h i d jnh ly g iai h u ye t khoi khan.
I - Hinh dnh hQc: X Q C L D T may da hang do : chyp mgch mau bdng X Q C LD T , X Q C L D T tudi mau,
! h o ^c, vd tot h a n , nen th y c h ien C H T
| - Khi dd cd c ky th u a t n a y p h a i th y c hien rat k h in tro n g vo ng 3-6 g id sau khi x u a t h ign trig u c h u n g dau tien

Nhoi mau nao H inh anh hpc

-1 / VI T R l V A H iN H T H A l N H O l M A U N A O : cd c vu n g tu d i m du d on g m ach

- D p ng m ach nao tr u d c - D o n g m a ch m a ch m ac tr u d c
- D o ng m g ch n a o g iu ,a - D o n g m ach tha n nen, c a c d on g m a ch t iiu nao
- D p ng m g ch n do sau
- N hoi m du vu n q tie p q iao
I -2 / d iE n t i £ n T H E O T H Cy\ G IA N C U A n h O i m A u N A O

4 g id d in 5 n g a y : P hu n gu on g o c m a ch m du
D iu hieu tre n X Q C L O T , D a u h igu C H T : T1, T2, d iffu sio n

N g a y th u 5 d in n g a y th u 6 0 : . H o at d on g cu a dgi th y c bao = phu, m a o m ach th a m t h iu

H au q ua : - "H ieu u n g s u a n g m u" tre n X Q C LO T kh dn g tie m ; b inh th u d n g
- C d t h i cd nhoi m au phu - xu a t huyet
- C d t h i cd b i t ch at tu a n g phan
- C d t h i cd h oai t u v d ndo d an g la p m dng
- C d t h i cd g ian m a ch ; tu d i m a u "xa xi” ("de lu xe")
T ru d n g hap dac b ie t : N M N va benh dang tinh bQt, benh mach do cao huyit ap,
b enh m a ch p ha n sau cd hoi phuc. cada sil

V i lau d a i : - N h oi m a u d an g Id k h u y it, te o nao, th o a i hod c h i t t r in g , g idn n d ca c kh o a n g V irc h o v Robin

- C d t h i xay ra : tdn g sin h t i bao d e m se o hda, h o c k h u y it nao

N g a y sau tai b ien : ly giai h u y it kh oi kh an ? C h u p tro n g vo n g 3 g id sau khi cd dau hieu Idm sang

-3 / H iN H A N H H Q C V A can N G U Y E N C U A N H O l M A U : tim , d on g m a ch chu va d on g m gch co. d ong m a ch nao

DQng mach co mang vu’a? logn san SQi-ca dong mach? hau qua : boc tach? hep ? huyet khoi7
Dong mach ndo nhoi mau vd tui phinh dong mgch, nhoi mau va boc tach dong mach nao. benh dang tinh bot
viem dong mach do viem : lupus, benh Gougerot

143
 QUI TRiNH THUC HIEN KHAO SAT BANG CHT
Nhoi mau nao <5a hinh thanh tren lam sang hay tai bi&n thieu m ^u thoang qua

1 / C6 t h i Idn chuang trinh th y c hipn 2 khdo sdt CHT cdch nhau 1 hay n h iiu ngdy :

- Khdo sat thu n h i t : NAO BQ •

- T1 SE c i t ngang
- diffusion b1000 va ban do ADC
- T2 FLAIR c i t ngang
- T2 * c it ngang
- T2 SE c it dung ngang. echo tre
( - H iim khi T1 gado : chi th y c hien trong mpt vdi tru d n g h op h iim , khi c in can thi$p trdn b$nh cdnh hep ddng mach
khong tien hdnh p h iu thudt neu nhdi mdu cd th im th iu hdng rdo mdu - ndo )

- Khdo sdt th u hai : DQNG MACH CO VA DQNG MACH NAO :

- T h yc hi$n lai chudi T1 SE va T2 FLAIR c i t ngang neu : nhoi mdu tiin triin v i mdt gidi p h iu ?
- B6c tdch cdc dpng mach co? T 1 fat sat (xod m o ) c it ngang vung c6 t u C5 d in ddy sp
- Khdo sdt da gidc W illis : dong chdy d$ng mgch bdng TOF 3D, xCr ly hinh dnh
- CHT-mach mdu : chyp mach mdu cdc dpng mgch c6 vd dpng mach ndo. 50 Idt cdt d ung ngang. xu ly hinh dnh
- Ndo bp : chu6i cdt ngang T1 gadolinium, khdng th y c hipn trong khdo sdt th u n h it
cd th im th iu hdng rdo mdu - nao ?

- 2 / T huc hi$n 1 lin khdo sdt CHT cho cdc thong tin

. Ndo bp : 5 chufii cdn bdn :

- T1 SE c i t ngang - diffusion vd ban do ADC cdt ngang - T2 FLAIR c i t ngang - T2* c it ngang - T2 SE
dung ngang echo tre
Sau d6
- Ldm sdng nghi ngd bdc tdch : T1 Fat Sat tu C5 den ddy sp
... tru d c khi tidm gadolinium
- Khdo sdt da gidc W illis n iu d up e : TOF 3D ... tru d c khi tiem gadolinium
- Nghi ngd hpp DM canh hay DM song (tai bien thoang qua, dm thoi, b£nh nhdn bdnh n h iiu dOng mach. doppler cd y nghTa )
CHT-mach mdu : chuan bi tru d c khi chyp CHT / d ud ng truyen tTnh mach
50 Idt dung ngang, day 1 mm, trong 30 gidy, xu ly hinh anh dpng mach c6 vd dpng mach ndo
- Neu dd thyc hi£n CHTmach mdu : ndo bp, T1 gado cdt ngang : tinh trang hdng rdo mdu ndo?

3 / T ru d n g h g p d a c biet : nghi n g d nhoi m du d u d i 4 g id / cd c h i d jin h ly g iai h u y e t kh oi ?

Kha ndng - 3 - 1 : Khdng cd sdn may CHT :

XQCLDT khdng tiem, hodc neu d up e XQCLOT khdng tiem + XQCLOT-MM + XQCLDT tu d i mdu
- 3 - 2 : Cd s in may CHT : khdo sdt CHT, nhieu thdng tin han XQCLDT

3 -1 . Hodc qui trinh "dpn gian" : Idm sdng + XQCLDT khdng tiem ( cd c h it lu pn g ) :
. Quyet djnh ly giai huyet khoi chi dua tren Idm sdng + XQCLOT, phdi b iit r i t ro cdc tidu c h u in an todn
. Cdch x u tri it ton kem va khong m it thi g id : khong Idm CHT

- Tieu c h u in lam sdng : Khiem khuyet van dpng dpt ngpt, m it ngon ngu, lipt cdc ddy TK sp ... Idm sdng khdng t y cdi thi$n
. Rat nhieu kha ndng tai bien mach mdu ndo : tuoi, tien cdn bpnh ly dpng mach
. Khdng cd tien cdn nhu c nua dau, khong c h in thu a ng , khdng cd d iu tdng dp nd« sp
. Khdng cd tien cdn gai y huyet khoi tTnh mach ndo
- Sinh hda k h in : loai tru ha d ud ng huyet, nhiem dpc

- XQCLDT khdng tiem : . Binh thudng, nhat la Khong cd tdng dam dp t y phdt / mdu ty
. Khdng cd giam dam dp / nhoi mdu phu dd hinh thanh
Loai tru mdu tu d u d i mdng cung, mpt "khdi choan cho* u. dp xe
Xoang tTnh mach binh thu d ng ... van nghi ngd, tidm: h u y it khA» tTnh mach 7
Hodc phu ndo md the tich khdng qua 1/3 the tich vung tu d i mdu cua dpng mach ndo g iua ty gidi h u y it khdi
Hodc phu ndo md the tich Idn han 1/3 the tich vung tu d i mdu cua dpng mach ndo g iua dung

3- 2 Neu cd san may XQCLOT da hang do XQCLOT cdt ngang ♦ XQCLOT tu d i mdu + XQCLOT-mach mdu
Binh thu d ng hodc vung giam dam dp gidi han
X Q C LD T-tudi mdu vd XQCLOT-MM Cdc dpng mach cp cd thdng tdt? huyet khoi dong mach nao g iua 7
Luu lu p n g mdu tdi ndo. the tich mdu ndo : vung tranh to« tranh sang ?

3 -3 . Hodc tot hgn, th yc hipn CHT ngay tuc thi :

Scout view vd T1 SE cdt ngang, hay T 1 SE c it dung doc Idm moc
Hinh anh hpc diffusicn b1000 va ban do ADC
T2 FLAIR cdt ngang
T2 * cdt ngang
Dong chay dpng mach vdi TOF 3D da giac W illis, huyet khoi dong mach ndo g iua ?. dpng mach thdn n e r ">
Cd the tim ludn boc tdch dpng mach vung co T 1 Fat Sat cdt ngang. tu C5 den ddy so ( tru d c khi bdr- gadolinium )
Hinh anh hoc tu d i mdu va xu ly hinh anh
Hinh tu d i mdu tru hinh diffusion = vung tranh toi tranh sdng (p h in chenh Idch) = nhdi mau cd t h i *>6 ohuc
sau ly giai h u y it nh6 >
Dau sao hipn nay van con nhieu tranh cai ve vung tranh toi tranh sdng

144
CUA NHOl MAU NAO : Cac viing tu>cri mau dong mach

DQng m gch n §o giOa D 0 ng m g ch n §o sau

D o ng m g ch n go tru o c

D o ng m gch n go g iu a

D o n g m g ch ngo sgu

N hoi m au x u a t h u ye t vu n g tu o i m au D M nao g iu a
K ho n g anh h u o n g vu n g tu o i m au cua d on g m ach nao t r u o c va nao sau
Di c h u n g : tan g sin h te b ao d em nao, hoc kh uye t nao

145
 1 - 1 V ung tu rn mau cua do ng mach nao tri/o c

- N hoi m £u n g £ y th u 8 , T1 gado, ton th u a n g " n h u h ^ n h la n g ” canh d u ^ n g g iu a , g ia i han ngoai r 6 n ga ng d in h nSo t h it

tro ng tru frn g hQ-p ton th u a n g nho, c a c tieu ch ua n vj tri r i t c 6 Ipi de phan b i$ t g iu a n h 6 i m £u v£ t 6 n th u a n g u

Lam sa n g : Li?t d o t n go t m o t chi, yeu m o t chi h a y d on g kinh BJ cu a chi d u 6 i doi ben

- V un g c h u c n an g van d o n g d u a c g ia i han ch i a cu<?n n ao (h o i) tr u o c tru n g t3m
- V un g n a y khong ke o xu on g den the chai
- V un g n a y ch i tu a n g u n g v a i kh oa ng 5 / 1 0 0 vu n g tu o i m a u cua d on g m a ch n£o tru 6 c
... phan Ion nhoi m au vu n g tu o i m au d on g m a ch n ao trud'C kh o n g co tne u ch u n g

N h o i m a u h o i d a i (h6i v i6 n ) :
n&u ton th u o n g m<>t b6n
kh o n g cb h o ^ c c6 it d lu hi$u
la m s ^n g

D in h n a o th a t b en
x a c d in h gicn h an ngodi
cua v u n g tu o t m au thuOc dOn9
m a c h n a o ta rcrc

D o ng m ach n ao tr u o c : . C a c d ong m ach xu yen va d on g m a ch H e u b n e r d en n uoi d a u nhan d uoi

. C a c dong m a ch n a y p ha t sin h tu d oa n A 1, d oa n n lm n g a n g cu a d o n g m a ch n ao tr u a c

T1 g ad o : nhoi m au nga y th u 10. b at g a d o lin iu m tu o n g u n g d u n g v a

vu n g t u a i m au cu a d on g m a ch nao t r u a c va n ha t la cu a ca c d o n g ^ a c h xuy§n

1 46
 1 -2 V iin g tirfri mau cua dyn g mgch nao giu»a
. T o dn bO vu n g tudri m £u c iia dOng m gch n3o g iu a ... hi$u u n g ch oa n cho, t£ c m o t phan ca c d u o n g lu u th o n g dich

Lpi ich cua vi$ c n3m ro

ceic vung tudei meiu dQng m ach

2 tru d n g h o p lam sa ng :
. Khi6 m khuyet d iin tien trong 24 h
. Lu lln h6 n m 6

1/

. T in h i$u tu o n g t u n h u n hoi m a u phu ... n h u n g h in h th a i va vi tri kh on g phu h o p th e o vu n g tu o i m au cua d on g m a ch

Luu y - T ru o n g h o p th u nhat: ton th u o n g hai ben
- D a c b ie t c 6 ton th u o n g ca c th u y dao
- H ai m a co tan g tin hieu : vu n g tu o i cua d o n g m a ch n ao sau
- 6 T 1 . tro n g tru dyng h g p th u 2, ton th u o n g xu at h u y e t it 6 cu o n nao T5 ben trai
. C h a n d oa n : V ie m n a o h erp e s tro ng ca hai tru o n g h op .

147
 D ong mach nao giOa
V un g n on g : ye u liQt, d o n g kin h BJ vu n g m a t v& / hoSc chi tren

- V un g sau, c £ c dQng m ach va n : li?t n u a ngu’dyi h oan toa n , kie u ton th u o n g bao tro ng
Nhoi m £u va o g ib 36 : ton th u o n g chu yeu b ch at xa m , n ha n duo i, n ha n b 6 o (nhcin d a u )

T2 SE T 2 * : N h o i m au xu a t h u y e t m Q t ph a n D iffu sio n b 1 0 0 0 : D iffu sio n h an ch £

148
 - V un g s£u : vu n g xa cu a c ^ c dQng m ach vSn

T2 Spin Echo

B$nh c£ nh 13m s£ n g cu n g la liQt n u a n g u o i

k ilu t 6 n th u a n g b ao tro ng

T 6 n th u o n g to£ n bQ b 6 vo - gai

T ru d n g h o p d $ c b iQ t: c a c dQng m a ch nuoi th u y d ao
- Thuy d 3o la m $ t th u y cu a d o a n n ao

149
 1 - 3 Vung tu>cyi mau cua dong mach nao sau
L3m sang : - B an m a n h, g o c m anh
- C o n BJ thi g iac
- C 6 th e co dau kieu d oi thj do di c h u n g
V u n g chi ph 6 i : a *
- 4 / 5 tr u d c cua cu $n n §o T1 v& T2 '- j
kh on g tu d i m £u e y e th a i d u o n g
- T h u y c h lm : g id i han n go ai t h in g / d inh s u n g c h lm
*
- T h u y d in h : vu n g tu d i m au cu a dpng m a ch n ao sau
lan len tre n tran ca c nao t h i t ben
- 2 / 3 tro n g v£ sau cu a doi thj
- C u on g nao : . C h it den
. K ho n g tu d i m £u bd v d - gai

M 12 FLAIR T1 Gado
N h oi m au x u lt h u ye t vu n g t u d i m a u cu a d o n g m a ch n a o sau

T2 F LA IR

. N h oi m a u cu d a n g l6 khuy 6 t
. C d ton th u crn g m d i khdng ?

D iffu sio n

N h oi m au m c r vu n g tu d i mau
d o n g m a ch n a c sau ben trdi

G hi chu V u n g tu d i m au d phan xa (p h an t | n ) d on g m a ch n ao sa u th u o c th u y dinh

H in h ch ieu “ rat ca o" cua vu n g xa nay, p h ia tre n t r ln ca c n a c t h i t ben

150
DOng m gch m ach m a c sau : nha nh cua <J0ng m ach nao sau

1 - 4 Nhoi mau vun g tie p giap do giam lu»u lu a n g mau :

T h iy t 6 n th u o n g d ranh g id i cu a hai vu n g tu d i m £u

- N h oi m au vu n g tie p g ia p d o g ia m cu n g lu o n g m au G iu a ca c vu ng tu d i m au cua d on g m a ch n ao g iu a
va d on g m a ch n ao tru d c

G iu a ca c vu ng tu d i m au cua d on g m ach n ao g iu a
va d o n g m a ch nao sau (m ui ten)

- D o n g m a ch ca n h tro n g bOc tach tu p ha t d m o t phu nu 1 tre

- L ie t n u a n g u d i ben p hai tien trien n ha nh ; d ie u tri kh an g d on g hoi p h u c van d on g kh on g h o a r toan
 1 - 5 V iin g tir<yi mau cua dong mach mach mgc tru»<yc
- 1 / T u d i m au ch o ca n h tay sau cua bao tro n g : lie t n u a n g u d i ki&u t 6 n th u a n g b ao trong

T2 SE echo thu' 1 / m |t do proton Diffusion Ban do ADC T2 FLAIR T2 SE

N hoi m a u m o i p ha n n g o £ i d oi thi
va n hoi m a u p ha n sau ca nh ta y sau b a o tro ng

- 2 / D o n g m a ch hai m a va hoi ca n h hai ma

. R oi loan tri n h o
. T on th u o n g g a y d ong kin h -r

Ph3n b6 dong mgch nudi

vung c u c th£i duang

DM mm trudc
Dpng macn
nao giOa
DM nao sau
- 3 / D o n g m ach cua tha n va duoi nhan duoi

| D iffu sion b 10 00 N h oi m au m d i / D o n g m a ch m a ch m a c tr u o c

. 1 V u n g t u d i m a u cu a d o n g m a ch hai m a phan tren c u a - a m a

p h§ n d u d i d o d o n g m a ch n ao sau
2 P h4n sau cu a ca nh tay sau b ao tro ng
3 P ha n sau cu a n ha n duoi
* ■
Di c h u n g cu a nhoi m au vu n g tu d i m au D M n ao g iu a n o r g .a sa u 6 k£ can

152
 1 -6 Hg th o n g dQng mach cQt song - than nen : vun g Upom mau cua cac dong mach tieu nao

- DOng m g ch tid u n do sau d u 6 i (P o ste rior Infe rio r C e re b e lla r A rte ry ) : P IC A h a y dQng m a ch tieu n ao d u 6 i

- HO' ch un g W allenberg: nh 6 i m du vu n g tu'6 'i m du cua D M ho ben h dn h tuy N hoi m d u d o n dQC v u n g tuQ-i m d u
c u a d Q n g m a c h c u a h o b e n h d n h tu y
- PICA trdi t h i y d u g c / mGi tSn ; P IC A phai kh o n g th a y d u g c
- KhOng dnh h u d n g v iin g tu d i cua D M tieu nao t ru a c - d u d i
gi6 i han n ga ng d ien h inh giOa ca c vu ng tu b 1! m au cua P IC A vd A IC A
- P IC A : tird 'i 8 0 / 1 0 0 bdn c iu t ilu ndo

. V un g tu d i m au cu a P IC A ben p hdi :
nhdnh bdn c iu d u d i

. N hoi m du d an g tam g ia c do t i c mQt n hd nh

cu a P IC A trai

. K hong a nh h u o n g vu n g tu d i m du cua
A IC A , tru o c

1 '/ ■ 7 * / ■
/

. f

______ y
W & - » - i

T2 Spin Echo T2 FLAIR Diffusion b1000

T2 Spin Echo

2 d lu h i$u n h o i m a u : - 1 / H in h the V u n g tu o i m a u cu a n ha nh tre n cua d on g m a ch tie u n ao sau d u o i ben p hai

. K ho n g a nh h u o n g vu n g t u o i m au cu a d on g m a ch tieu n ao tr u o c ducri
2 / C a u true kh o n g lam th a y d o i h in h th e cua c h a t xa m va c h a t trd ng ,
phai tim d au h ieu n a y b dn g c u a so hep
U khong ton tro n g s u phan bo d eu d an cua ch a t trd n g vd c h a t xam

153
- D o ng m ach t i l u nao tr u a c d u d i (A n te ro In fe rio r C e re b e lla r A rte ry ) : A IC A , h a y dOng m a ch t i l u n do giOa

D p ng m a ch th in h g i£ c tro n g la m o t n ha nh cu a A IC A : ch dn g m $t, d ilc d $ t ngOt mQt b6 n

N h 6 i m £u phu vu ng tu d i meiu D M tieu n ao sau P IC A T2 FLAIR

N h oi m ^ u phu v iin g tu d i m du D M t i l u n flo giOa

T1 T2 SE T2 FLAIR T1 gado
N h oi m au n a i t ilp g ia p g iu a vu n g tu d i m ^ u cu a P IC A v& A IC A

- S up e rio r C e re b e lla r A rte ry : S C A

h ay d §ng m a ch t ilu nao tren

Ni>a thuy nhong phia tr£n

- V un g tu d i m au cua ca c d on g m a ch xu yen cu a d on g m a ch tha n nen

1 54
 N h 6 i m du d o t 6 n th u a n g Di c h u n g nhoi m au n a i tiep g iap g iu a v iin g tu d i m au cua
cdc dOng m gch xu y£n n uoi cu o n g nao . D o ng m a ch nao sau, d m e ngoai ,
. C a c d on g m a ch xu yen cua tha n nen d m e trong

Cdc dpng m ach c iu n ao tren : h u d n g xu on g, g id i han tro ng d n g a y du’d n g g iu a

. Nh 6 i m £u ca c D M vo n g cu n g n g ln . kh on g a nh h u d n g vu ng tu d i m au cu a cac D M vo n g cu ng dai, d ben ngoai

C a c d o n g m a ch ca u n ao d u d i : h u d n g len, g id i han d n g a y d u d n g g iu a
. U th u d n g kh o n g to n tro n g ca c tie u ch u a n v e vi tri va h in h the
. H u y m ye lin tru ng tam ca u n ao kh o n g ton tro ng ca c tie u ch ua n ve vi tri va h inh the

T 1 G a d o : PP bu tru d on g ch ay
ca c d on g m a ch tan g tin hieu

- Nh 6 i mciu kh on g lau lam vu n g tu d i m au d on g m a ch n ao sau ben phai

n h o i m a u co m o t phan xu a t huye t
- Nh 6 i m 3u cu o n g n ao hai ben. vu n g t u d i m au cua ca c d on g m a ch xu yen
- N g uyen nh£n rat co th e do c u c th u ye n t i c :
C a c ye u to h in h the va vi tri

T i c ta m th d i no'i tan c u n g d o n g m g ch tha n nen sau do co tai lap tua n hoan lai m o t phan

155
 - 21 d i^ n t i £ n t h e o t h o i g ia n c u a N H bl m a u

2 -1 4 gio» d e n 5 n g a y P hu n gu on g o c m a ch m du

. H in h anh - X Q C LD T : D au h ieu lu c k h a i p ha t
- CHT T 1 , T2, d iffu sio n g iup k h ln g djnh bdn c h it m d i xdy ra cu a n h & m d u

N hoi m au n ao . T ru a c tie n Id b en h ly cu a c h a t xam

. K e do la benh ly cua ch at xam vd ch at t r in g
. S au cu ng Id benh ly cu a c h it tr in g

N h 6 i m d u cu, 6 th d n g

T a n g tin h i$ u cu a c h i t t r in g
. T in h i$ u c u a c h i t xdm
tr d v i b in h th u a n g
Si>ng tr3 n g ian d o te o n do

Nh&i m ^ u m<5ri, 2 n g d y .

. C h i t xa m ta n g tin h»$u
. C h it t r i n g ta n g tin ht£u n h irn g k6m hon

Nhoi mau / 24 h
Tang tin hieu a chat xam

Nhoi mau nao :

- Tro n g n h u n g g id d au : P hu nhiem d o c te bao, roi sau do -> tro n g vo n g 3 d en 6 g id , phu t 6 n th u a n g c h it xd m c 6 n g u in
g o c m a ch m au -> sau n u a la phu c h it xa m va c h it t r in g
- S o lu g n g va h in h thdi kh ac n hau cua c a c tieu d on g m a ch tan d c h it xdm
T h ie u m du n ao : tang q ua m u c tin h t h im t h i u hang rao m au - n ao cua c h it xdm
- Hau qua : N h oi m du = phu = giam d am do ...
d lu h ieu dau tien tren X Q C L D T la cdc c iu true cu a c h it xd m bi xoa m d : vo nao, d a i c h i t xd m th u y d ao . n h d n d$u (b io )
- T on th u a n g d a c biet cua c h it xd m hien ro t u n g d y th u 8 :
. B it g a d o lin iu m ch on loc tre n cdc c iu true nay
. C o the tien trie n td i nhoi m du vo nao d an g la p m ong

N hoi m du v o nao m d i vu ng tu d i m du d on g m a ch n ao g iu a H in h th d i k h a c n ha u cu a ca c t>eu D M d

T on th u o n g d ai ch at xa m thu y d a o vd d vu ng tan cua c d c DM d au - va n / m ui ten . C h it xdm
N h oi m du co m o t phan xu a t h u ye t a ch at tra ng . C h it t r in g

156
 XQ CLDT : C<ic dau hi$u s d m cua nh&i mau nao
- 1 / 0 6 n g dam do d c h it x£m : "xoa m d " hign tuQ-ng tan g d am d o b in h th u d n g cu a ch at xam

M i t ngd n n g u d 0 t n gpt X Q C L D T g ia th u 6
D i in tie n sau 4 8 g ia
B £n trai: g iiim da m d p d c h i t Xcim th u y d a o

X Q C L D T g ia th u 6 D ien tie n sa u 36 g id 1
Ben p h d i: gi&m d gm d<? d c h a t xa m vu n g vo th u y tra n va th u y d a o Tai lieu cua Cl Manelfe

- 2 / Tren X Q C LD T , th a y tru e tie p cuc m au d on g tro ng d on g m ach : " D lu d a y th u n g "

C y c m au d on g tro n g d on g m a ch nao g iu a ben trai

C ue m au d on g tro n g m p t n ha nh xa
c iia d on g m a ch n ao g iu a trai

N h 6 i m au th u o c vu n g tu d i m au c iia . 2 d on g m ach n ao tr u d c
. D o ng m a ch n ao g iu a trai
Do h u y it khoi d o n g m a ch ca nh tro ng ben trai
va b at san d oa n n g a n g cua dong m ach nao tr u d c ben phai

C y c m a u d on g tro ng d o n g m ach nao tr u d c ben trai

157
 CHT I C a c d a u h ie u s a m c u a n h o i m a u n a o xem them : hinh in h hgc khuActi tar (affusion)
a/ Phu nao

T2 SE echo th u -1 2° echo T2 FLAIR

Diffusion b 1000 Bein do ADC

N hoi m au dau - van b§n phdi g ia th u 6 :
D o ng tin h ieu T1. tan g tin hieu T2, tan g tin hieu / d iffu sio n b 1 0 0 0 , g id m tin h ieu / ban do A D C , T1 g a d o : kh 6 ng bat
G hi c h ii : N hoi m au m a i va n hoi m au cO bieu hien cu ng tang tin h ieu tren T 2 ... kh o n g th e th ie u h in h d iffu sio n
T h i du : nhoi m au dau - van cu ben trai, d an g lo k h u y e t / m ui ten : tin h ieu b in h th u a n g tr§ n h inh diffusion

T2 Spin Echo, 2° echo T2 FLAIR T2 Echo Gradient

Diffusion b1000 Ban d& ADC T2 S{*n Ecfo

Nhoi mau a 3 giai doan khac nhau :

1 - Nhoi m au m a i. g ift thu’ 4, tru a c trung tam ben trai : dong tin hieu T 1. tang tren T2, tang tren diffu sio n b 10 00 giam trdn
ban do ADC
2 - Nhoi m au cu, 5 thang, tru a c trung tam ben phai dong tin hieu T1. tang tren T2. d ong tren diffu sio n b 10 00 d 6 ng trfen
ban do ADC
. gian n a than nao that ben
3 - Nhoi mau rat cu, tu 1 nhieu nam tru a c . thuy d in h phai giam tin hieu T 1. tang tren T2, giam tren d iffusion blOOO tdng trfen
ban do ADC tu a n g u n g v a i tin hieu DNT
gian ro ca c ranh vo nao
. tang sinh te bao dem seo hoa khong thay d u a c

158
 (J giai d oan r£ t s ftm , tru ftc g ift thi> 3 ho$ c 4, h inh dnh X Q C L O T va C H T th u ftn g q u y d eu b inh th u ftn g hod c kh o ly giai
.... h inh 3 n h h p c khud ch tan (d iffu s io n ):

1/ G iu p ch £n d oa n :

- T2 FLAIR

nh 6 i m au ?

- D IF F U S IO N

n hoi m au

Tro n g tru ftn g hp,p kh on g co tang tin hieu co y nghTa tre n T2 F L A IR ,

Ta ng tin hieu tren d iffu sio n blOOO co y nghTa ia m o t n hoi m au n ao m fti ;
... C o the hien tu g n g n a y kh on g lien q ua n d en hieu u n g T2

2 / X ac d jn h m ire lan rong cu a ton th u o n g

Diffusion b1000

~ \ > \
^ \ ■
r \

■ tr
T2 FLAIR T2 SE echo thCr 2 Diffusion b1000 Ban do ADC

l$nh nh 3n n a m 5 6 tuo i. c a o h u y § t ap , h on m e d p t n g p t, "h p i c h u n g kh o a tro n g ”

Ih6i m au tie u n a o ph ai k h o n g g ia i th ic h d u p e hpi c h u n g na y N hoi m a u ro n g o cu o n g n a o g ia i th ich "h o i c h irn g kh o a tro n g "

ihong n h a n ra h o ^ c n h $ n tha y n h o i m au cu o n g n a o kho n g d a n g ke

159
 CHT C a c dau higu s a m kh ac g p i y nhoi m du nao

- b / Tang tin higu tro ng dong m ach tren T 2 S E : do khong cQ d 6 ng ch ay va do c6 eye m au d dn g tro n g k in g d ftn g m g c h
TSng tin hi$u tro ng dong m a ch tren T 2 F LA IR : do d on g ch ay b j ch ^m lai nhi&u hod c do cg c m au <36og

. N hoi m au d |u - van ben trai

. Ddng ch dy D M canh trong ben phai b in h th u a n g , g ia m tin hieu
. TSng t in hieu d o eye m au d o n g tro n g d ong m ach ca nh tro n g trai a o n g d Q n g m ach ca n h va a xo an g hang

Cac dau hieu gian tiep ciia nhoi mau nao

Hau qua cua n hoi m au len ca c cau true lan can ... T h oa t vj nao, tac nghen cac d u a n g lu u tho n g d jch tro ng n§o

Diffusion b 1000 Bar'd 6 ADC T2 FLAIR

- N hoi m au n ao D M nao g iu a rong men tren d iffu sio n tang tin h ieu tren d iffu s io n b10 00 . giam tin h ieu tren s a ^ 36 A D C
- D au h ieu g ia n tie p : . T h oa t vj the ch ai d u a i liem dai nao. th o a t vi m oc th u y th a i d u a n g ben phai
C h en e p c 6 ng S ylviu s va n ao th a t III g ia n nao th a t doi ben
D a y g iao thoa thi g iac va ch en ep dai thi ben phai

160
 2 - 2 / Ngdy thi> 5 den ngay thu* 60 :
Dai th y c b d o h oa t dOng = hdm lu p n g protein cao va cdc m ao m ach tha m thau
H$u q ud 1- "H i$ u i>ng s u a n g m u" trdn X Q C LD T
2 - N h 6 i m du phu - x u lt h g y lt
3 - B i t c h d t tu a n g phdn
4 - H o ai tu v 6 n do d an g Id p m 6 ng
5 - G id n m a ch : tu d i m du "xa xi"

A / H dm lu p n g pro te in cao : t i n th u a n g dong d am do, tha m c h i tan g dam d o tren X Q C LO T

- G id m d dm d<? Ii§n q ua n td i phu nguon g o c m ach m du bien m a t : "h ie u u n g s u a n g m il"
T 6 n th u a n g trd nen d in g d am dp ... ngu y c a b 6 s o t n hoi m au tren X Q C L D T khong tiem
- S au d 6 t i n th u a n g co t h i trd nen tan g d am do t u p h a t : xem hoai tip v o nao d an g la p m ong

B/ H dng rdo m du n do thd m t h lg b a t th u d n g : hong cau, ch a t tu a n g phan

- B1 - K hd n dn g b iln doi n hoi m du phu thanh n hoi m du phu - xu a t huye t
... T ii n t r iln x u lt h u ye t nay xa y ra ra t s d m , th a m c h i tu c th i ... n hoi m du xu a t h u ye t n g a y lap tu c
- B2 - B dt c h it tu a n g phdn
1 / N h u vd y, sau 5 n g d y d ien tie n lam sang, n iu X Q C L D T "b in h th u d n g " p hai bo su n g the m h in h co tiem
cdn qua ng ... c h a t can q u a n g iot se g iiip ch o ch an d odn
2 / K h u y it d ilm : d o "h ie u u n g s u a n g m il", vd n iu khong co benh canh lam sang, vie c b dt ch a t cdn q ua ng
io t co t h i lam sai la c ch an d oa n g iu a n hoi m du va u nao

1 I "Hi#u ung sucyng mu" tren XQCLDT

XQCLDT kh 6 ng tiem
5 ngdy sau khi c6 cac X Q C L D T co tiem
D iu hi$u Idm sdng

N h o i mciu v u n g tu rn m au
XQCLDT binh thudng cu a 2 d o n g m ach n a o sau

Khodng ngdy thu* 5,

XQCLDT khdng tiem co
t h i trd v i binh thudng

XQCLDT khdng tie m n g a y t h u 6 X Q C L D T co tiem

Gidm ddm dp nhe th iiy c h a m phai N h oi mdu

ly giai ra sa o ? dong m a ch nao sau

B dt ch dt tu a n g phan
X Q C LD T khong tie m n g a y t h u 7
T o n tro ng h inh t h i cd c v iin g
t u d i m du d o n g m ach
. T on th u a n g chu yeu
th u o c c h a t xam
X Q C LD T b inh th u d n g

2 / N h o i m a u p h u - x u a t h u y e t / xe m th e m : c h a n d o a n m a u tu tro n g n a o

T 1 gado T2 SE

. H inh a n h "m d u tg sa u " tre n T 1 ... n h u n g h in h thai ton tro ng d un g the o v iin g tu d i m a u cua ca c D M van ca tro ng 3 m a t pha ng
- T 1 : C g c m au d o n g : h in h th a i gion g n h u cu a n hoi m au ca c d on g m a ch van. xem tra ng 148
- T 2 : C g c m au d o n g + p h ii lan can, m au tg tga n thu d un g h inh t h i v iin g tu d i m au cu a ca c d on g m a ch van
G id i han n dm n ga ng n ga ng m u c tran cua than n ao that
. T u a n thu ca c d o n g m a ch th iiy d ao va ca c d on g m a ch d a u - v a n . c a c n h a n h " d o a n n a o " c iia d o n g m a c h n a o g iu a
. N h oi m a u p h ii-x u a t h u ye t D M nao g iu a sau th y c hien ton g ke c a n n g u y e n c iia n h o i m a u n a o c h u k h o n g c iia k h o i m a u tu
... D a so c a c "kh d i m a u tg sag d n g u d i khong ca o hgye t a p d e u la n h o i m a u x u a t h u y e t h o a c n h o i m a u d a x u a t h u y e t

1 61
 3 / H o a i tip v o d a n g la p m o n g : Tu- nga y th u 8 , hod c n g a y t ir ngd y thu 3 tro ng tru g n g h o t) m ^ u r0ng

X Q C L D T kh o n g tiem X Q C L D T c 6 ti6m

. T a ng d am do t y p ha t nhe
a cd c ranh v o nao
H d ng rao m d u n do th£m thiu
do tan g h am lu g n g
a vi tri c h ^ t xdm
. T a c d pn g cua dai th y c bao

T1 T2 FLAIR T2 * T1 Gado

N h oi m au tro n g vu ng tu a i m au cua hai d on g m a ch n ao t r u a c ti> 12 n g a y :

- T1 : H oat d on g cua d ai th y c b ao lam tan g tin h ieu co lien q ua n ta i s y gia tdn g hdm lu a n g p ro te in
- T2 * : T in hieu tang tren T1 khong p hai d o n hoi m au ch uye n d an g sa n g xu a t h u ye t
... K hong co h e m o sid e rin e tren T 2 *
- T1 g a d o : K ho n g bdt . .. khong co s y tu a n g d on g g iu a . s y gia tan g ham lu g n g pro te in
. tin h tha m tha u cu a h dn g rd o m du n do
- Ton th u a n g c h i g ia i han a ch at xdm

H o ai tu vo nao it co tdn g tin hieu d o tan g hdm lu g n g pro te in T u a n g t u / b dt g a d o lin iu m ro ret

. K ho n g co chuye n d an g xu d t h u ye t tren T2 * G hi c h ii : m dng n a o d d y len m a i chQc do tiiy s6 r*g
. B dt g a d o lin iu m

T in h ieu tan g tren T1 Tang tin h ieu tren T2 B at g a d o - un

H o ai tCr vo n ao d an g la p m ong ton th u a n g g iau pro te in h an g rao m a u - a ; •.-a~

162
 4 / Bat c h i t c i n q u a n g i6 t h o d c g a d o lin iu m

- N h 6 i m du n a o n g d y th u 9 n a i tie p gidp
. O pn g m g ch n do g iu a
. D o n g m a ch n ao sau ben tra i

- N h 6 i m du phu
. K hong c h u y ln d an g x u it huye t
. K hong tie n trie n tha n h hogi ti> v 6 ndo d gn g Ibp
m ong

T1 gado B i t g a d o lin iu m m gnh, g id u

X Q C LO T
T2 F L A IR T 1 gado
Di ch un g nh 6 i m du D M n ao g iu a ben phai
- T ir khi co c h uo i xu ng d iffu sio n
Dj cdm m dt - ca nh ta y ben pha i, h$i c h u n g G ertsm an
ch uo i xu ng T1 g ad o kh on g g iu p ich nhieu
Khfing c 6 t 6 n th u a n g vu n g n ga ba n ao t h i t ben trdi
- N h oi m d u n a i tie p g idp d in h -c h a m trd i g iu a c d c vu n g tu fti
H irdn g x u tri :
m du cu a d on g m gch n ao g iu a vd dpng m g ch n do sau
. 1/ H ogc X Q C LO T c o tiem
... nh 6 i m du m 6 i h a y cu?
. 21 Hay to t h a n la lam C H T :
- Neu kh on g c6 h inh d iffu sio n, tiem g a d o lin iu m c o the g iup
. D iffu sion
x d c d inh bdn c h it m a i cua n hoi m du d in h trd i
. Neu kh on g co d iffu sio n : Idm T1 gado

B d t g a d o lin iu m : T h e g ia u cu a nhoi m d u nao

Trigu c h u n g hQc ch o p he p p ha n b ie t g iu a u vd n hoi m du d u a tre n c d c yeu to h inh th d i v a vj tri ton th u a n g ton trong
theo vung tu fri m du cu a d p n g m gch, c d c n hd nh cua d oa n M1 cu a d pn g m a ch n ao g iu a _______________________________

5/ Gian mgch do liet mach

N h oi m au nao
. G ian m g ch Igi ca n g n h ie u h a n khi vu n g n hoi m du rong d on g m g ch n ao g iu a
n g d y th u 7
. G ian dQ ng m gch, tTnh m g ch , d dm roi m g ch m g c

r i ■ J
\ 4n

Diffusion b1000 Ban do ADC T 1 gado Diffusion b 1000 Ban do ADC T1 gado
Nh6 i mau DM nao giu-a vung nong ngay thu- 2 : Ii0t mgch vu-a phai Dien tien vao ngay thu 4. nhoi mau lan rong. liet mach nhieu

163
 TriFcrng ho»p dac bi$t

- 1 / B g n h d a n g tin h b o t

T ich tu pro te in tro ng thanh d on g m ach

c d c yeu to th u a n Ip-i : su y than, tie u d u d n g , b en h n han ca o tu 6 i
Y eu to g a y sa su t tri tue
T on th u o n g : xu a t h u ye t va nhoi m au
- M p t / nhie u m du tu a th u y ; neu q u y e t d jnh can th ie p n go gi kh oa ... cd khd ndng mdu tg tdi phdt ngay l$ p tuc
- N hoi m du vo nao, nhie u cho, phu vd p h u -x u a t huye t
n hoi m du cd the c h i cd x u a t huye t
D d nh gid tien trie n cu a b enh bdng C H T : cd c ton th u o n g lan rong deu dan
K hd n g cd tieu ch ua n ch a n d od n n do tre n C H T .... cu ng n h u bang cd c p h u o n g tie n cd n Idm sd n g khac
C h i cd the g o i y benh d an g tinh bot, kh dn g th e kh dn g djnh

B$nh nhdn dang chgy th$n

... sa sut tri tu$ tdng d in

N h iiu 6 nh6i mdu phu

d- nai t iip gidp c h it xdm
. c h it trin g
r it cd t h i Id b$nh dgng tinh bOt

B $nh n hd n t iiu d u d n g

N h ie u o m d u tg ...h a y dung han Id

nhie u o nhoi m d u x u it h u y it

r i t cd t h i Id b ^ n h dang tinh bOt

- 2 / B e n h ly m a c h m a u d o c a o a p

- Nhieu o xu a t h u ye t li ti, doi x u n g

- V j tri : n hd n xdm tru n g u a n g , n a i tie p g ia p c h a t xd m - c h a t trd ng

- 3 / B e n h ly m a c h m a u p h ia s a u c o th e h o i p h u c : p o ste rio r re ve rsib le e n c e p h a lo p a th y sy n d ro m e : PRESS

S an giat, n hie m d o c thai ky, n g h ie n m a tuy, u c ch e m iin dich

N hoi m au p hia sau hai ben ; cd the b d t ch at tu a n g phan h an g rdo m du nao m a t kh a n dn g d ieu ch inh
C H T -m a ch m au h a y ch up m a ch m au : co thd t d on g m ach
T ro n g vo ng 2 tha n g, cai thien Idm sa ng vd h in h a nh h p c trd lai n h u b an dau

X Q C LD T
G ia m d d m d o d o i x u n g
d hai th u y ch a m

164
 T1 T2 F L A IR T1 g ad o kh ech tan b 10 00

. N h oi m au hai th u y ch am , doi x u n g , n g a y th u 10 ; d iffu sio n han che

. D ien tie n td i h oai t u vo n ao d an g la p m o n g ; b i t g a d o lin iu m
. G ian nga ba n ao tha t

T 2 F L A IR T1 g ado
Benh ly m gch p h ia sa u hoi p h u c d im e : the n an g, co the g a y ti> vo ng
... to n t h u a n g la n to a h o n : tie u n a o , th u y c h a m , tr u n g ta m b a n b a u d y e
T1 g a d o : . H a n g r a o m a u n a o k h o n g th a m th a u b a t th u ’O’n g
. L oai tr u m o t ca ch c h ic c h in huye t khoi tTnh m a ch nao

- 4 / C a d a s il

- "C erebral a u to so m a l d o m in a n t a rte rio p a th y w ith su b co rtica l in fa rcts a nd le u ke n ce p h a lo p a th y”

(bgnh ly dpng m g ch , di tru ye n n hi§ m s i c the troi, kern nhoi m au d u a i vo va b enh ly c h a t t r in g nao)
- Di tru yen n hie m s i c th e th u a n g th e troi
- Sa s ilt tri tue s a m a n h u n g b en h n han kh on g co n g u y c a ve b enh ly m gch m au
- Ton th u a n g ca c tie u d o n g m g ch xu yen :
. N h oi m au sau, hai b en : tru n g tam ban bau due, th u y th a i d u a n g , tha n nao, c a c ban cau tieu nao
. K hong n hoi m a u v u n g vo nao

165
 2 -3 I Ve lau dai
- Nh&i mau n ao IS k h u y e t: hien tu a n g d a y m6 s p i-h y a lin & c ic dong mgch t j n (6 xa) v i c ic A nhAi m iu n hd
- B#nh chat tring : tang tin hi§u quanh nao th it i>ng vdri tinh trang teo n io do nhiAu nguyfin nhin, b«nh ly 04ng mach
n h u n g cu ng co th e d o ch a n th u a n g , ngd d o c ...
- Di c h u n g n h6i m du v iin g vd n ao : . T a n g sin h te b a o dgm , te o ndo
. H oc k h u ye t nao

1 - Cac nhoi mau nao lo khuyet: nhoi mau vung xa ; kich thu dc du&i 15 mm
- C h in d od n de khi c d d au h igu Idm sang : tuoi, tie n can ve bgnh ly m gch m du, Id d lu hi$u g a i y
- C han dodn cd th e kho neu thieu d u kign lam sang, n ha t Id bgnh nhan tro n g kh od ng 40 d £n 6 0 tuAi

C d c y lu t6 h in h d nh g g i y nhoi m du d gn g lo khuye t C d c yeu to h in h a nh g g i y x a c u n g rdi rdc

. T on th u a n g cd ch xa c d c n do that . T on th u a n g d u d i m dng noi tuy

D oi xung K hd n g doi x u n g
. K hd n g dnh h u d n g c d c bdn cau tieu nao . T o n th u a n g lan toa: cd c bdn c iu ti£u ndo, cu d n g t»4u ndo,
cd c th u y thdi d u a n g c d c th u y th d i d u a n g

. T o n th u a n g g id m dgm d o n hg tren X Q C LO T . M o t h o a c nhie u ton th u a n g , g id m tin h igu nhi&u trd n T1 "l6 den"
tan g tin higu nhe tren T 2 C H T ho d c tdn g tin h i$u r i t ca o trd n T2

. Ton th u a n g "lam tam " d c u a so hep . T on th u a n g d o n g n h it h o d c d gn g vi&n

. Ton th u a n g dgng trdn h o d c bau d g c . T on th u a n g d g n g bau d gc, th e o c h ie u cd c T M nhd: v»dm quanh TM

. K hdng b i t chat tu a n g phdn . B i t c h it tu a n g p hd n d gn g vie n h o d c toa n bd d m p t h a y nhi&u tdn

T ru ngogi Ig : l6 kh uye t rat m d i tro n g tru d n g h a p c a c m d n g n a y d an g h o g t dOng

. K et h a p v d i nhoi m du vd n ao cO h o d c m d i K et h a p v d i ton th u a n g g ia o tho a thi g idc, ton th ira n g tuy sdng

Vi tri ton th u a n g kh dn g d a c higu

- Ton th u a n g d u d i vd
- T on th u a n g th e chai
- T on th u a n g tha n ndo

- T u o i : 50 tuoi, khdng cd tien cdn d a c bigt

- Lam sd ng tu a n g t u : dj ca m chi tren ben phdi gan d dy, th o a n g qua, tdi di tdi Igi

Nhoi m du
d an g lo k h u y it X a cu n g
rai rdc

166
2 - B $ n h c h £ t t r in g : Td ng tin h i£u q ua nh ndo t h i t u n g v 6 i tin h tra ng teo nao
d o nhi&u ngu ydn nhdn, b#nh ly dpng m gch n h u n g cu ng co the do ch a n th u a n g , ngo d p c ... xem tra n g 116, 117
3 - Di c h u n g nh6i m du v6 ndo : . Tdng sinh t& b do d$m , te o ndo
. h 6 c kh uye t ndo

Di ch un g n hoi m du v6 ndo K et h a p h oc k h u ye t ndo vd ton th u a n g se o te bdo dem

T6n th u a n g nhieu n a i d ai ndo. tie u ndo C H T T2 S pin E cho : kh o n g t h i y h o c kh uye t nao
. Nhieu khd ndng do nhieu cu c ngh en m a ch nhieu vd ch ngdn ton th u a n g se o te b do dem

X Q C L D t co tiem tu a n g p hd n: Di ch u n g n hoi m du D M ndo g iu a bdn trdi

- T on th u a n g kh on g tu a n g u n g v a i mQt h a y nhi&u h o c kh uye t nao

. G idm d am do n h u n g khong gidm nhie u n h u ddm dQ D N T
. C 6 di c h u n g nao vd m g ch m du
= T a ng sin h te bdo dem ro ret ... co d am do gion g n h u D N T

T1 g a d o Ti
T u a n g tu
T d n g s in h te b do d em ro ... tin h ieu tu a n g tu n h u cua DN T

T2*

Hinh th d i d a c b ie t c iia di c h u n g n hoi m du : h in h thdi c d c vu ng tu a i m a u d on g m ach Di c h u n g m au tu

- N h 6i m a u ddu - va n : tie n tn e n ta i h o c k h u ye t nao, kh on g co v d ch n gd n te b ao d em T ru e tru a c - sau thd n g d u n g
H e m o sid e n n

167
 2 - 4 I Tru’d’ng ho*p dac b ie t : phai ly giai huyet khoi kh£n ?
Toi khan, thuc hign khao sat hinh anh trong v6ng 1 d in 4 gift sau khi cd d iu ht£u &m sang
- M g c dich G iu p d on g m a ch kh on g co n t i c m o t cd ch k h in c ip
T h o i g ian la ye u to q u ye t d jn h : . G ia m thcri g ia n th y c h i$n C H T
. X Q C L D T th a y t h i C H T n iu n h u kh d n g c6 n g a y m d y C H T

G iii p hd ng ch 6 t i c m $ t c&ch t y nhiAn

d d pn g m g ch nSo giCra vdo ngdy th ir 5
... qud t r i ... Ii$t nCra ngudri kdo ddi

- L u u y ve "d o n vj d ieu trj d o t quj"

... cd c b d c s i c a p c u u , b d c s i noi tha n kinh, b a c sT h in h d nh hpc, b a c s i xd t n g h ig m , 24 g id / 24
- K y th u d t : . X em c h u o n g X Q C L D T : C d c Idt c i t kh on g tie m , X Q C LO T tud-i m du ndo
X Q C L D T -m a ch m du cd c d on g m g ch v iin g co, cd c d on g m a ch n£o
X em c h u o n g C H T : . T 1 , T2, T O F 3D, C H T -m a ch m du c d c d pn g m a ch v iin g c6, cd c d d n g mgch ndo
. K y th u a t tie n h d n h , tra ng 144 ; toi th ie u : d iffu s io n , T 2 F L A IR . T2*
- T rigu c h u n g hpc : . X Q C L D T b in h th u d n g , n ha t Id khdng co d iu higu cu a kh di m a u tg
tru d n g h o p nhoi m a u -ph u , the tic h v iin g n a y phdi d u d i 3 0 /1 0 0 the tic h to a n bo v iin g t u d i m d u cu a D M ndo gi&a
. C H T : T 1 , T2 FL A IR , T2*. T O F 3D . d dn g ch ay D M n ao g iu a ?. cd th e tim d iu b d c tdch.
. C H T -m g ch m du co vd nao ... xe m cd c d iu h igu s d m c iia n h d i m du n d o tre n C H T
- K et q ua : L o i ich c iia ly g idi huye t khoi k h in : « - G id m ty le t u vo ng / so ng phg th u d c t u 62% xu d n g 5 6.4%
- N gan n g u a 56 t u vo n g / so n g phg th u d c tro ng 1 000 b£nh nhdn
- C in d ieu trj 18 n g u d i d e c u u 1 n g u d i »

X Q C L D T T L /O 1! M A U ( kh dn g tu o n g d u o n g v d i C H T d iffu sio n )

C B F : ce re bra l bloo d flo w - lu u lu o n g m au nao CBV c e re b ra l bloo d v o lu m e - the tic h m d u ndo

L u u lu o n g m du. the tich m du :

D a n h g id v iin g tra nh toi tra nh sa n g bdng ca ch kh ao sd t ty Ig tu o n g doi g iu a lu u lu o n g m a u vd th e tic h m a u

- V iin g tra nh toi tra nh sa ng lu u lu o n g m au t h ip . the tich m d u van cd n d u y tri

- H o gi t u : lu u lu o n g m au thap. the tic h m au t h i p

168
 Hinh in h KH UtC H TAN Hinh anh T l/ a i MAU

V *
16 g iay 18 g ia y 20 g iay 24 g iay

CHT : d iffu sio n (khuech tan) va tu’O’i mau

Nhoi mdu nao v u a m a i xa y ra, d u a i 4 g ia : co the co ch i d jnh ly giai h u ye t khoi

vung "tranh toi tra nh sa n g " d u a c x a c d jn h b in g cach lay h inh t u a i m au tru h inh d iffusion
... Id p h in n hoi m au co kh a n an g hoi p h u c sau ly giai huye t khoi
Luu y r£ng quan niem ve v u n g tra n h toi tra n h sa ng h ien v i n con nhie u ban cai

binh thudng___
K hao sa t the tich m au nao :
"p h an ben tro ng " d u a n g b ieu d iin
b$nh ly \ \ \
M T T = m ean tim e tra nsit

PfPr th a i gian xu at hien g a d o lin iu m

C B B = c e re b ra l bloo d flow

JF i th e tich ch o tu n g d a n vj th a i gian
H o ai t u neu d u a i 18 c c /p h iit /1 0 0 g ra m m o nao
V u n g tra nh toi tra nh sa ng neu d u a i 30 cc.
Vung
tranh toi
tranh sSng

Gidm tin hieu lien q u a n v a i luc g a d o lin iu m den

C h i d jn h ly g ia i h u y e t k h o i la d u n g
Khong co chi dinh ly giai huyet khoi

169
 L ie t ni>a ngi/cri trai d<?t ngpt CH T v£o thdri <Ji£m 2 g ift

170
 •3/ HiNH A n h HQC VA CAN NGUYEN CUA N H 6l MAU - 4 / CAC DQ NG M ACH NAO BQ ?
- C H T d on g c h a y TO F 3D +++
Xem : C H T / K y th u # t / K h io s i t cSc dOng m ?ch cd - C H T -m a ch m du g ad o
K hdo sdt cdc d Q n g mach nao - X Q C L D T -m a ch m du
- C h gp m a ch m du q u y udrc?

- M dng x o v u a
- B oc tdch dQng m a ch d o loan san
- Lupus, B. B eh ce t, HC M oya M oya

- 3 / CAC DQ NG MACH V U N G CO ?
- Lam sdng : a m thoi
- D o p p le r +++
- C H T -m a ch m du g a d o +++,
b oc tdch T1 Fat S at
- X Q C L D T -m a ch m du ?

- M ang v u a
- Loan san s g i-c o
- V ie m dQng m ach, hiem g ap

■2 / TIM ?
- Ldm sdng
- ECG
- X q ua ng n g u c
- S ie u am tim
S ieu am qua ngd th y c quan

- Roi loan nhjp, rung n h i

- N hoi m du c a tim
- B en h O sie r
- B en h ly va n tim
- U nha y
- T h u ye n td c ngh ich dong

• 1 / BEN H TO N G Q U AT
- R oi loan d on g m du
- C a c hoi c h u n g A n tip h o sp h o lip id e s

- N g uye n n h a n tim :
Nghi n g o tren : - Lam sa ng
- C H T : n hoi m a u da o, hai ben, m a i, th a y tren C H T diffu sio n
. 1 t i * *
Diffusion b1000

A - B e n h ly d o n g m a c h v u n g c o : . X a v u a ? L oan san d Q n g m ach SQi-ca? V ie m d o n g m a ch ? ...

. H au qua : B oc td ch ? H ep ? H u ye t khoi ?
. 1 / X a vua d o n g m a ch :
T iin C H T t r o n g v i e c x d c d j n h b a n c h a t c u a m a n g v u a th u Q C l o a i :
bQ c u a
mo dac, nhie u lipit, x u a t h u y e t : ta o h u ye t khoi, d on g voi ... can anten (co il) be m at
. C H T : d an h g id m ire d o h ep : "b d ng m a t" h a y q ua d o d a c
ghi chu : . d an h gid q ua m u c do h ep tren 9 0 / 1 0 0
... h in h thdi gia h u ye t kh oi d o kh on g co tin hieu vi toe do tua n h oa n tdn g n ha nh
. X Q C L D T -M M : d an h g ia to t n h u n g c h i rat hep
. K ie m tra hau p h iu : anh g ia d o m o t so sten t
. H u y e t kh oi h oa n toa n / danh g id ch a t lu a n g tai lap tua n h oa n nao q ua da g ia c W illis? b o c tdch ?
/ kh a o s d t hoi c h u n g D M d u a i d on c u n g : h u ye t khoi d on g m a ch d u a i don.

.2 1 - L o a n s a n s y i- c a
C han d od n d i tre n ch up m a ch mdu,
C han d o d n k h o t r e n C H T -M M / k h o n g d u dQ p h a n g id i
________________________ tr o n g k h o n g g ia n

H§i ch u n g D M d u a i don c u n g ; huye t khoi D M d u o i

(J6n trdi, d a o c h ieu d ong chay D M cot song ben trai ;
I
hep n h iiu d ong m ach . 3/ - H ie m g a p . v ie m d o n g m a c h : benh T a k aya sh u

171
 . 4/ - B oc tic h c a c d ong m ach co xem tra ng 57
- B enh n han tre ,c6 yeu to n g u y c o d pn g m ach, tie n cd n C H A , d au vu ng cA t y p h d t h a y sau m p t ch d n tfu n m g rd t n h 6 .
th e nh? h a y th e ndng cua benh loan sa n s g i-c o , b pn h M arfan, bpnh E h le rs D anlos
- V j tri b o c tdch : d oa n d u a i x u o n g d d cu a d pn g m a ch ca n h tro ng , d pn g m a ch cp t sPng n ga ng C 2 . C 3 . C4
- C H T : - 1 / D p n g m a ch g ian do b o c tdch
- 2 / C y c m d u d on g tro n g th a n h :
tin h ipu tre n T 1 th a y doi, tu y th e o kh o a n g th fri g ian t u luc b 6 c td ch tfri khi Idm C H T ; d a n g h in h li£m
- 3 / B oc tdch m o t b en h o d c hai ben
- 4 / L6ng d pn g m ach le ch tam : tin h ipu tu y th e o toe d p d on g c h d y / khPng c6 tin h i$u n £u d o n g c h d y nhanh
kha ndng c6 h u ye t kh oi D M ca n h , cu c m du d on g lan n g u p c d bn g d6n n a i ch ia dPi dPng m g c h cd nh
- 5 / C o the bj n hoi m du nao d o g ia m lu u lu a n g m du h o a c d o e ye n gh en m a ch
xe m tra n g 57, 58
- X Q C LO T , kh do sd t X Q C L O T -M M : IPng d on g m a ch h pp Ipch tdm

Dien tie n cu a b 6 c tdch dpng m ach vu n g co : NhPi m d u n ao vd

T h e o d oi bdng C H T -M M de co q u ye t d jnh n g u n g th u o c ch on g d on g h a y kh on g c h lm th u a n g d p n g mach
- T rd v& b in h thu d m g n h u ban dau
- H u y e t khoi d p n g m pch
- H in h thd n h tui p h in h dpng m ach do boc tdch : kha ndng g a y th u ye n td c nao

C H T -m a ch m d u vi d au vu n g co D ien tie n sau 4 th a n g

Tu i p h in h d p n g m a ch d u a i x u a n g dd v a i co tui ro n g, d o b o c tach
D iin tie n sau 4 thd n g : h pp d on g m a ch canh, T u i p h in h d on g m a c h c a n h tro n g b6n trdi
Tu i p h in h m a ch kh on g tu a n g phan nhieu d oa n d u d i x u a n g da
do d on g ch ay? d o cue m a u dong tro n g tui p h in h ? do v e t th u a n g b dn g d a c
... T ie p tu c d ieu tri kh an g d o n g , d ieu tri b dn g d u a n g noi m a ch 7 G id m kh a u k in h d p n g m a ch

172
 B - Bfrnh ly dpng mgch ngo :
. 1 / Tu i p h in h (JQng m g ch vd nhPi m du n d o ;

NhPi m d u lidn q ua n td i h u y it kh 6i m p t phdn tro n g I6ng tui phin h

... n h & n g c g c thu yd n td c m g ch li ti

NhPi m d u thi> p h d t sa u co thd t dpng m gch

. NhPi m du sau d iiu trj

T1 gado, bu tn> dbng chay
hai DM nao giOa bdt xi>ng

. 3 / Vidm dQng m g ch n d o ;

XQCLOT vd C H T d lu t h i lu s 6 t tro ng
Chdn dodn vid m d pn g m a ch n ao :
Khdo sdt "b in h th u d n g "? p hu n ao lan toa?
• Vidm dOng m gch d o lu pu t, h pi c h u n g G o u g e ro t S jogren
- Vidm dOng m gch t i i n t r il n vP cd n : hpi c h u n g M o ya M oya
. V idm dOng m gch d o v id m kh on g ro n g u ye n nhan
thdy d trd em n h u n g ca o’ n g u d i Idn
. Vidm dOng m g ch tdn g s in h Idm td c d og n g in d pn g m g ch :
D a g id c W illis,
D ogn A1 vd M1 cu a c d c d p n g m g ch nao
. Hinh thdnh m g n g lu d i th o n g noi q ua cd c dQng m g ch vdn

- B0nh h iim :
. NhPi m du dQng m g ch n a o g iu a d ngudi tre
. Tdng tin h i$u hai b dn d T 1 .. c h u khong d T2
d o i x irn g / n h a n x d m tru n g u o n g
/ h in h th d i kh o n g d g c higu
. T e o ndo
. C h in d od n : b pn h t l b do ty Igp t h i

• 4 / Cdn lu u y "co th d t cd c d p n g m g ch n a o " :

. C hdn d od n kh 6 : h e p d o m a n g v u a ?
hdu q u d cu a g ia m lu u lu o n g d o c y c th u y d n td c ?
. Nguydn nhdn n h u c n u a ddu ?
■ Nguydn nhdn n ha n tg o : d u n g d an xu d t cua c u a m g ch ?
. N g uydn n hd n n h ilm d p c ?
T ru d n g h p p d d c b ig t : co th d t vd x u d t h u y it m dng ndo
... c h y p m g ch m d u q u y u d c vd n cd n th iet d e c h in d od n co th d t d pn g m g ch

173
 TAI Bl£N MACH MAU NAO XUAT HUYfcT
m A u Tg, x u A t h u y £ t m A n g n Ao

X Q C LO T k h in kh6ng ti6m

20 / 100 : X U A TH U Y £T 80 / 100 n h O i m Au
Mau ty sau ? mau ty d thuy? Nh6< m iu phu n l?
X u lt h u y it mang nao ? N h it m iu p hu -xu lt huyit?

-1 / T in thuang : - Vj t r i : - Mau ty sau, x u lt h u y it trong nao th it

- Mau ty d thuy, x u lt h u y it nao - mang nao, mau ty d u d i mang cung di k6m
- X u lt h u y it mang nao th u ln tuy
- 0$m d$ tr§n XQCLDT : d iln tiin v l d$m d0
Tin hi£u tr£n CHT : d iln tiin cua tin hi$u tr§n T1, T2 SE, T2 FLAIR, T2 *, diffusion

- 2 / D lu hi§u hinh anh gpi y can nguySn .

2-1 -M a u ty s a u "ty phat", mau ty than nao NGUNG ... Khdng th yc hign CHT, khdng th yc hi$n chyp mgch mau
b§nh nhan cao h u y it ap : v d cac vi tui phinh dOng mach
b$nh nhan h u y it ap binh thudng: nh6i mau x u lt h u y it vung tu d i mau DM van? “n h li mau x u lt h u y it da ti>ng x u lt h uyit’
2-2 - Mau ty b thuy, va m<?i k h ii mau ty, d sau hay d thiiy, b ngudi tr£ :
- Logi tru nh6i mau x u lt h u y it nguon goc dOng mach: vung tu d i dQng mgch hay n g u ln g lc tinh mgch: h u y it kh6i tTnh mgch nflo
- NguySn nhan mgch mau : tui phinh dQng mgch, dj dgng dQng-tlnh mgch, u mgch dgng hang, b£nh dgng tinh bdt
- Nguy6n nhan u : u t l bao dgm, di can ( than, u h lc t l , ... )
- NguySn nhan c h in thuang, c6 tien can c h in thuang hoac khong cb tien can c h in thuang

QUI TRINH khao sat CHT

• 4 c h u o i x u n g tro n g m g t p h ln g c i t n g a n g : T1 SE, T2 FLAIR, T2 * c i t ngang, diffusion va ban do ADC

1 c h u o i xu n g tro n g m # t p h ln g d u n g n g a n g : T 2 S E d p p ha n g ia i ca o

■ S au d o ... tru d n g h a p d g c b ie t tu y th e o la m sa n g va ke t q ua cu a c a c c h u o i t r u d c d 6 :

Mau ty sSu t y phat : bgnh nhan gia, cao HA, tieu d ud ng , bgnh nhan dang dieu trj khang dbng, hdn me ...
- NG UNG
- Luu y : Khong iam hinh anh hQc dong chay dQng mgch, khong T1 gado, khong chyp dOng mgch
T ru tru d n g h ap h iim c6 mau ty sau d n g u d i tre khong tien can dac b i$ t :
TO F 3D, CHT-mgch mau, thgm chi chyp dQng mgch qui u d c

Lam sang, XQC LD T va nhung chuoi xung CHT d lu tien g a i y tui phinh dQng mgch :
NG UNG , vi can th y c hien chup mgch mau c£ 4 tryc dQng mgch nuoi nao

Nghi ngd dj dgng dQng-tTnh mgch :

- D d n g c h a y dQng m g c h TO F 3D m g t p h ln g c i t n g a n g , "hQp" 70 m m , tai ta o d u n g n g a n g va d u n g d o c
- T1 gado? c6 lp-i trong khao sat d in lu u tTnh mgch, th y c hign MPR ( 100 iat d un g dQC va tai tao )

Chan doan u mgch dgng hang tren T2 *

- T2 * dung ngang
- T2 * d u n g dQC
- MPR gado de chan doan u mgch tTnh mgch k i t hop

Kha nang mau ty do u : tien can ung thu, mau ty k£m phu ne :
- T1 g a d o c i t n g a n g , d u n g n g a n g v a d u n g dQC ; kh o so sa n h v d i ta n g tin h i$ u c u a m iu ty tre n T1 k h o n g ti£ m Gado

Hinh thai g ai y nhoi mau xuat huyet :

. DQng mgch : xem them nhoi mau / tong ke cac dQ ng mach co. d o n g mach nao
. TTnh mgch : "mau ty" da o : xem them huyet khoi tTnh mgch / d o n g chay tTnh mgch
TO F / 2D hay Phase Contrast, MPR gado d u n g dQC

174
 1 / Cac ton thu’O’ng

1.1 Kh6i m iu tg
- Vj tri, kich thu’d'c, sA lu g n g , d$m <30t r in X Q C LO T, tin hi£u tr§n CH T
- T i c dOng cua khAi m iu tg : phii I3n c in ? t h o it vj n io ? t r in djch nao tha t dp tin h do t i c n gh en DNT?

XQCLDT : mdu tg nhdn ddu

XQCLDT
- Mdu tg nhdn ddu - Mdu tg thuy trdn d6 vdo c ic nao th it
/£i bao trong - Cgc mdu dong tdng ddm d0
- Cgc mdu dong trong vung th ip cua nao t h it - Cgc mdu ddng trong vung th ip cua ndo th it
- Nghen cdc d uo ng lifu thong djch - Xuat huyet mdng ndo vd mdu tg d iro i mdng cung lien bdn c iu
- Cgc mdu dong tren dam roi mach mac bdn trdi - Tdc mpt phan cong Sylvius : gidn ndo t h it

- XQCLOT : (Jam do khoi mau tu ooooooooooooo

ooooooooooooo
ooooooooooooo
ooooooooooooo
TANG DAM DO ooooooooooooo
ooooooooooooo
4 0 - 150 UH thodt huyet tu’ong
- cg c MAU DONG tap trung r i t nhieu hong cau

thieu mdu, khdng dong

= cgc mdu dong c6 it dac hon

- Chat xam ■30 UH

+ 30 UH MAU LU’U THONG d On g b Am do

- Chat tr3ng ■15 UH

mdu binh thiFong : huyet tirong + hong cau

-DNT 0 UH DAM DO
thAp

DNT vd vai hong cau BI ly giai

XUAT h u y £ t m a n g n a o KH O N G CO MAU cgc choc do tuy song xuat huyet
= XQCLDT binh thirong nhung XQCLDT binh thuong
= Chpc do tuy song

175
 X Q C L O T v £ C H T : tin h i$ u c u a kh 6 i m £ u tu

| XQ C LO T CHT

T1 Spin Echo T2 Spin Echo T2* y*JVO r b*na6

T2 FLAIR 8 1000

R&t cAp tinh d6ng oxyhemoglobine ding tin hi$u T1 tdng tin hi$u T2 trung tdm tdng tin tdng On ding Onl i
0 - 3 gid sau 66 tdng d^m d i viin gidm tin hi§u c6 th i nhim v&i ♦♦♦ viin ngoai vi nhv/ m$t -Vxr mOi
nhoi mdu ndo giim tin hi$u nhi( mdu ndo 1 rr»*u r&O '

C6p tinh tdng d$m dp desoxyhemoglobine ding tinhi$uT1 gi^m tin hi$u T2 gidm tin hi$u T2 * trung tdm p&m d in f l h o * *
4 gidr - 3 ngdy ch4t thufin tir khdi <3hu v iin tdng viin hemosidenne t*ng k M d o fl

Bdn c£p s6m tdng d$m dO methemoglobine tdng tin hi$u T1 tdng tin hi$u T2 tdng tin hi$u T2 trung tim gidm ding ho«c
ngay 4" - 7" trong t i bdo ti> ngo^i biin viin hemosidenne v'An tdng
vdo trung tdm

Bdn c£p tr& tdng methemoglobine tdng tin hi$u T1 tdng tin hi$u T2 tdng tin hiiu T2 tdng tin h«$u ding ho|c f t r
ngay 7° - r6i ding ngodi t6 bdo
tuAn thi> 4 r6i gidm d$m d{> v iin gidm tin hi$u viin gidm tin hi$u
hemosidenne hemosidenne hemosidenne
ngoai bi6n

Man tinh binh thu’dng, Dinh thi/irng binh thirdrng binh thi/dyng gidm. hemosidenne tdng hodc dAng ding hodc giir
tr6n 1 thdng ho$c d ing d^m d$
hay hemosidenne v i Idu ddi

hi6m, l6 khuyet ndo DNT gidm tin hi$u T 1 tdng tin hi$u T2 SE tdng tin h iiu T2 gidm tin rw$u tdng tin hi$u
= gidm d$m d i giim tin hi$u T2 FLAIR nr»J DNT nhir DNT

L umj y : tin hi$u cu a m au tg khong luon luon g io n g nhu- tro n g b a n g tre n ddy; n g u ye n d o vi cd c kh o i m du tg kh 6 n g g i6 n g nhau
b ie n d o i th e o H em a tocrit, co th e co th u o c khang do n g , tin h tra n g n d o Idn cdn : b$nh n h d n trd ? teo n d o ? kh d n g d 6 n g ’’
. X u i t dQ chay m au lai : m au tu hai th i, b a th i; ch a y m du lai tre trdn n en di c h u n g m du tg
. M du c g c th o d t va o tro n g n ao th it , tro n g cd c rdnh v6 ndo m du tg du'Q'C D N T "rU a sach"

X Q C LD T / gid1thu* 4° CHT / g ig th u 5° :
. T a ng tin hieu T 1 , m o t p h in , 6 tru ng tdm , tien t r iin
. G iam tin hieu T2, n h it la T 2 *
tren X Q C LD T va T2*. the tich m au tg giong nhau, tren cd c ch u6 i kh dc thu crn g ddnh gid nh6 hon

diffusion b 1000 ban d6 ADC

XQ C LO T: T a ng tin hieu T 1
G iam tin hieu T2. ro. m oi chuoi
C gc m au dong t iic thi kich th u o ’C n ho h on
T2 * g iup xac d inh the tich th a t s u zCa ~.au tg
tan g dam do tren X Q C LD T

176
CHT / m^u tg gifr thir 6 d£n gifr thir 48

, t \ z

T2 S pin E cho echo 1

TSng tin hi$u dg ng vi6n

T2 * diffu sio n b 1000 ban do A D C

- D i§ n tie n b tru n g tSm m £u ty, d o n g tin hi§u sau d o tang tin hi§u
G hi chu: tru n g t«im m £u ty tSng tin hieu tr§ n b 1000 va giam tin h i^u tren ban d 6 AD C n h u nhoi m au nao
- N go g i b i§n : . V i&n h e m o sid e rin e bat d lu trgn T2 *
. P hu "p h ^ n ipng" nhe cua m 6 n§o k l c ^ n m au tu tr§n T 2 FLAIR

CHT / g ifr thu- 4 8° va sau do ;

/ i \

T2 FLAIR T2 * T 1 g a do
gi6ng T2 SE Vi&n hemosidenne dien hinh

177
 - C H T n g £ y thu* 8 ° , va tro n g nhieu thang, m ^ u tg c6 tin hi$u cao ir trung tam
vi&n giam tin hi$u b ao q u anh : hem osidenn

T1 m

- Dien tien m £u tg
luc 1 th£ng :

. T h ^ i g ia n d e m £u tg ly
g i^ i th a y d6i

b in (36 ADC

S au nhieu thang
. H o ac t ra ve nhu1b in h th u a n g ta r o c day
. Hoac, hiem h a n , h em osid e nn m a n g nao
. H o gc khoi m au tg nho lai
n h u n g van ton tgi h inh anh "ve t xam " X ua t huye t li ti va tich tg h em osid e rin e
d o hem osiderine
tai . M ang nuoi cua n ao bo
. T h an kinh so v£ c p t song

G h i c h u : vj t r i k in h d ie n c u a m a u tu s a u :
v u n g y e u " c a h p c " giO a:
. N h a n b e o , th u p c m e te n c e p h a le
. v a th u y d a o , th u p c d o a n n a o

2 th i d u u m a c h d a n g h a n g v a tic h tu h e m o s iC e '-~ nao

178
 1.2 Xuit huyet mang nao (xuat huyet dw&i nh$n)

- Nhuc d iu dOt ng^t, dO ddi. hQi chung mang nao

- Can nguydn : . Tui phinh d$ng mgch, dj dang dOng-tTnh mach. u mach dang hang, u x u it huyet hiem gap
. C h in thuong sp nao, cd t h i khdng b iit rd
HQi chung x u it h u yit

- XQCLDT k h in
n iu binh thudng : chpc dd tiiy s in g
- Sau dd chyp mgch mau 4 ddng mach nudi nao : n h iiu tui phinh dong mach? co that dpng mach xa cho phinh mach?
- Khdng chi djnh CHT tru- khi D iu hi$u iam sang va XQCLDT khdng tuong xung
N h iiu tui phinh dpng mach: tui phinh nao x u it huyet?

XQCLDT

Xuat huyet mang nao dien hinh :

Tang dam do
. d cac be nen day sp
d thung lung Sylvius
d cac ranh vd nao
chu yeu ben trai

Kha nang cd tui phinh dpng mach

d dpng mgch thdng sau
hoac xiphdng canh b§n trai

CHT v a x u a t h u y e t m a n g n a o

C h in doan . tren T2 F LA IR

. tren T 2 * +++

T2 *
hemosiderin

T 2 F L A IR T ^ n g tin h ieu a be tr u d c ca u n ao va c a c ranh vo nao

V o tu i p h in h d p n g m ach cua d p n g m gch th o n g sau phai
G h i ch u T a n g tin h ieu d ca c be D N T va d ca c ra n h vo n ao tren T 2 F L A IR cung co th e tu o n g u n g v o '
A n h gia cu a dong ch a y / xem th e m d o n g cha> D N T tra n g 72
1 Di can th e o d u d n g d u d i nhen
D au hi£u viem m a n g n a o n h ilm trung

179
 C H T va x u it huye t m ang nao / n g ^ y thi> 2

ir T 1 V *'

. . .

T2 Spin Echo :echo th ir 1

T 2 * : chuoi xung rat nhay : thay du’Q’c c g c m au dong a ca c ranh vo nao ben phai
khong chan doan du’O'c tren ca c ch uo i kh ^ c

\ \ \

T2 SE T2 FLAIR
C h i co chuoi T 2 * ch o thay cuc m au d o n g tro n g phan th a p cua si>ng ch a m phai

180
 2 1 C3c diu hi$u hinh anh ggH y cSn nguyen

[2 - 1 * M au tu sau "tu phat", m au tg than nao N G U N G ... khong iam CHT, khong lam quang mach

B$nh nhan ca o h u y it ap : v d cac vi tui phinh d$ng m gch

B *n h nhdn khdng cao h u y it ap : nhAi m au x u it h u y it trong vu ng tucri m au cua D M va n? nhoi m au la ngu yen nhan cua m au tu

2-2 - M au tg d thuy, va m pi kh6i m au tg, d sau hay d thuy, 6- n g u d i tre :

a/ Logi tn> nh6i m au x u it h u y it ngu6n g 6 c d 0ng mgch : vu ng tucri m au dong mgch,

b/ Logi tn> n h ii m au x u it h u y it ngudn g 6 c tTnh m gch : huye t khoi tTnh m gch nao
d N guyfin nhan mgch m au : tui phin h d png m gch, dj dgng dong-tTnh m gch, u hang, bgnh dgng tinh bot
d/ Nguydn nhan u . u t i bao dgm , di can ( th$n, u h ie to, ... )
e l Nguydn nhan c h in thucrng

2.1 M6u tg s a u "ti/ p h a t”

. B$nh nhan gia, t iiu d u a n g , tong trg ng yeu 61

. C ao ap dOng m gch, benh dgng tinh bQt, khang dong, hoi ch u n g x u it huyet
= X Q C LO T r6 i N G lfN G kh on g C HT, khong ch u p m gch m au
. V j trf: - N han d |u , bao tro ng , d6i thj, trung tam ban b iu dgc
- C 6 kha n ang d o tu c thi va o nao t h i t
- X u it h u y it t h u in tu y tro ng nao t h i t c6 t h i g iin g n h u m au tu sau "da d u g c dan lu u "
- Cd kha nang g a y t i c n gh en m Q t phan ca c d u d n g lu u thong dich va tang ap nQi sq cap tinh:
c in d in lu u D N T c i p cCru ....
. Khdng th y c hi$n t in g ke ch g p m gch m au d n g u d i gia
. Cytrd em va n g u d i trd, ca c kh oi m au tg d sau hiem g£p.
C in khao sat C H T va ch g p m gch m au : dj dgng dQng - tTnh m gch, u m gch dang hang khdng t h iy tren chup m gch mau, u ...

M6u tg d s3u : b$nh nhan gia, cao huyet ap, tieu dudng : gia thiet di dgng dpng - tTnh mach rat it kha nang xay ra

. Lpi Ich vua phdi cua chuoi xung ddng chay TOF 3D
. Chu6i xung CHT-mgch mau gado khong co Igi ich
Gia th u y it dj dgng d$ng-tTnh mach r i t thap -

Ngung; khdng chgp mgch mau 4 trgc dpng mgch nuoi nao \

ARM / gado

- Bdnh nhdn trd : h iim ggp mau ty sdu

= CHT + chgp mgch mau 4 true dOng mgch nudi ndo

Tim : . Dj dgng ddng tTnh mgch

. U mgch dgng hang 1 )
. U ndo

T2 * CHT-mgch mau gado

181
 Can nguyen cua mau tg sau
- 1 / C a o h u y it dp : vo- cac vi tui phin h dgng m gch cr dogn xa cua cdc d$ng m gch vdn

. DT nhidn Id khong t h i thdy d u o c cdc vi tui phinh d$ng mgch trdn XQCLDT vd CHT
. T6ng ke chyp mgch mdu khdng mang Igi loi ich gi doi v6i vi phinh mgch Charcot
tru1dc ngufri d u6 i 50 tuoi khong co tien c^n cao huyet dp de logi tn> dj dgng d<>ng-tTnh mgch (tuy htAm)

- 2 / N hoi m du x u lt huye t tro ng vu ng tu o i cua d ong m a ch van :

"Mdu ty 6 sdu" vj tri, hinh thdi tuan thii chinh xdc vung tu 6 i mdu cua cdc d0ng mgch vdn
ton trong cdc ti&u d0ng mgch ciia thuy dao

Tren XQCLDT va ca CHT cdc hinh anh nay d u o c ly giai nhu la "mdu tu sdu"
Th yc ra d6 la hinh anh nhoi mdu dong mach van, nhoi mdu co xuat huyet ngay tuc thi
Ly do la . Hinh thdi y het nhu hinh thdi cua nhoi mdu phu
. Tren ban do ADC, cau true ben trong ton trong cau true nao bo va nhat 1a cdc cuQn nao ciia thuy dao
Tong ke can nguyen nhoi mau se day du hon tong ke lam cho mdu tu
Du gia thiet la nguyen nhan ndo, cung khong mo lay mau tu

C ac "n h oi m au t y no xu a t h uye t" kh ac v d i cac "n h oi m au da co xu a t h u ye t cu tru o c day"

. T ren T2 * h in h thai khoi m au tu o sau do m o t phan vao s u n g tran cu c m au d on g tro ng n ao tha t tren h in h T2 co ro na l
T ren d iffu sio n b1000 va ban do A D C nhoi m au phu rong vu ng tu o i m au dm n ao g iu a . la n g u yen nhan g dy kh6t m au ty sdu

182
 - M ^t tAn th i/c rn g x u i t h u y it ndm d u n g trong vung tu d i m du ddng m gch. d o la nhoi m au xuat h u y it
- C h in do dn b ao gd m c i n tAng k6 nhAi m du / D oppler. C H T -m ach m au vung co khdng c h y p m ach m du nao

M du ty khd ng d 6 n g n h i t d th u y dao trai

. ChuAi m $t p h in g trdn c d ich : h in h th d i nh6i m du phu vd c6 m pt phan x u l t h u ye t th u d c vung tu'6'i m du sdu d p n g m ach nao g iu a
. K h ln g djnh nhAi m du : h u y it khAi d d n g m ach cdnh : x ip h o n g canh trong xo a n g hang trdi tdng tin h i§u trdn T2

ty thein nao? hay d ung hern la n hoi m au than nao ngay tu c thi co xuat h uyet? : ton th u a n g khong d ong n h a t ,
d$m dO khdng tang n h ilu , try c la n n lm ngang, ton trpng h in h thai chat xam , tAn th u a n g dAi xu n g

2.2 Miiu tu thuy, va moi khoi mau tu O’ n g u a i tre :

- A / Logi tru nhAi m £u d pn g m ach loai xuat h u y it

T on th u a n g xuat h u y it t i l u nao phdi

kh o i m du tu hay nhoi m du x u a t h u y it?

. G ia i han tro n g th d n g vd d u n g th e o d u d n g g iu a
. T u a n th e o vung tu d i cua d d n g m ach t i l u ndo
g iu a
. C au true tren T2 ' ra t khdng d d n g n h it

... N hoi m du
To n g ke can n g uyen nhoi m du 1a can t h ilt

- B/ Logi t r u n h o i m a u tTnh m a c h lo a i x u a t h u y e t : h u y e t k h o i tTnh m a c h n a o

. C h in dod n r i t q u a n tro ng va dT n h ie n kho

. Dgng d iln h in h c u a n ho i m a u tTnh m ach
. N h ilu 6 m du ty , k l c$ n nh au : nhoi m du n ao x u a t huyet
. Cdc xoa n g tTnh m g ch td n g tin h ieu tre n T2

. C an d d n g k in h d i u tie n kh o i m au tu n ho thuy th a i d u a n g giu-a tren T1 va T 2 F LA IR

. h u y it k h di tTnh m a ch n ao ta n g tin hidu rd rg t d xoa n g tTnh m ach d oc tren, xoa n g ben ben trai va tTnh m ach canh tra ^d u trdi tren T2 F LA IR

183
 - C / C d c ngu yen nhan m ach m du

C.1 / Phinh mach dQng mach

- V j t r i : da g id c W illis , n a i chia ba cua d $ n g m a ch ndo giO a

d l u td n cu a d p n g m g ch th d n nen, dQng m a ch t i l u ndo sau d u d i
- K ic h t h u d c th a y d 6 i : 2 m m ... vd tu i p h in h dQng m a ch g id u / Idm sdng cd t h i b ilu h i$n n h i/ u
- C o t h i t d 0 n g m ach vd n h li m du ndo di kdm / n g d y th ir 5° d i n n g d y th u 10°
- T h i kho ng c6 bieu hi$n, loan sd n d 0 n g m a ch n he h o d c ndng
- C 6 khi k i t hQ-p vdi d a n a n g th d n ( h iim gdp)
- MOt h o d c n h ilu tui p h in h dOng m ach : c i n x d c d jn h tu i p h in h n do Id tu i p h in h g d y x u l t h u y it d u d i n h $ r

. P h in h m gch n a i ch ia ba c u a d 0 n g m g ch n do g iu a
. V a d d y tu i p h in h m ach

X Q C L D T khd n g tidm : x u l t h u y it m d n g n do n gdy th u 2

. T d n g d d m d 0 lan t6 a 0 k h o a n g m d n g nao
. T d n g d d m dO khu tru d thu n g IQng S ylviu s trdi
c h u n g t6 cd v d mOt tu i p h in h dm ndo g iu a

X Q C L O T : x u lt h u y it m d n g n d o n g d y th ir 9*

- K h d n g tid m : td n g d d m dO v<>a p h i i d th u y th d i d u a n g trdi

m d u tg d a n g h i p th u
c h i djn h t i n g k d c h g p m a ch mdu

S au tidm
...kh d n g Ich Ig i v l ch g p m g ch m ^ u cu n g d p n h ilu thdng tin hon
. ThuO c v d o tu i p h in h d m n d o g iu a
. H in h d n h "d g n g b ia " tu a n g u n g v fri v u n g nhOn n do ngogi
b idn bd t t h u l c tu a n g phdn

C .2 / X u a t h u y e t m d n g n a o = ch gp q ua ng m gch bdn k h in ( 24 g id r)
= chg p m gch m du 2 d m cdnh + 2 dm song m dt cd ch hd th d n g ( kh d ndng cd n h ilu tu i p h in h dOng m a ch )

T d n g kd 4 trg c d d n g m gch

X Q C L O T h u d n g d i n ky th u d t
v d dQC k i t qud td n g kd ch g p m g c h m du

3 g ia i d o a n Idm s d n g cu a x u lt h u y it

M du tu nhdn ddu vd th u n g lung S ylviu s

X Q C L O T c h o t h i y 3 cg c m du d d n g c d tud< k h £ c nhau
. MOt c g c cu, p h ia sau, n g a n g m ire n d m n g a n g
. MOt cg c m d i h a n , d a n g h i p thu
. MOt c g c m 6 i, td n g d d m dd, to tru n g td m a i a c y c th u hai

- C h g p m g ch m du : tu i p h in h d d n g m g ch tgi n o i c h ia ba
cu a dOng m g ch n d o g iu a

- N go gi I# : X u a t h u y e t m dng n ao kern th e o m au tu sau d ien h in h :

b a o trong, nhan xam tru n g u a n g . th a n n do a benh n h d n gid. c a o h u y it dp;
= M au tg sa u "d 6 va o " nao th a t va ca c kh oang d u 6 i nhen : NGLTNG

184
 . Chgp X Q C LO T -m gch m iu h ay C H T -m ach m iu ( d in g ch/5y T O F 3 D. C H T -m ach m iu cd gado )
c 6 t h i th a y t h i c h yp m ach m iu quy U'O'C 4 try c d png m ach khong?
. Chup XQCLDT-mach m iu : tiin b« rS v»i XQCLOT m4y da hSng dd; c4u h6i v in cdn dang d in h g ii
. C H T-m gch m a u kh dn g du:
- T u i p h in h dOng m gch kich th u d c vai m m ?
- V l n d l d $ t ra khi dOng m gch g$p g6c, danh gia c a c dQng m ach d da gia c W illis khi c6 co t h i t dQng m gch?
- K h dn g t h i y h o $ c t h i y khdng rd p h in xa cua c£ c d d n g m gch : tui p h in h dOng m gch 6- xa?
- T ru d n g qu an sdt cu a h inh ddng chay d$ng m gch T O F 3D h o a c C H T -m g ch m au cd g a d o lin iu m kh d n g d u .... 5 0 - 70 mm
- C y c m du ddn g ta ng tin hi$u bao quanh p h in h m gch cd t h i g a y kho khan ch o vi£ c ly giai
- Ly g id i tu i p h in h d d n g m gch cd h u y it k h ii m dt p h in ?

/
T2 FLAIR Hinh Anh ddng chiy dQng mgch TOF 3D

Cgc m iu dflng trong thung IGng Sylvius, tui phinh <Jm n§o gi&a . Khdng du y lu t6 d l quyit djnh d iiu tn

Chf djnh d$c bigt cua hinh a nh hQc :

k h i o s d t h i n h thai c a c t u i p h i n h d Q n g mgch t r o n g t o n g ke tru o c dieu trj : phau thu g t hay g a y t i c m ach?
d $ c b i g t I I ca c t h o n g t i n ve h i n h t h l i cua co tu i p h i n h

CHT ddng chdy, TOF 3D? hay ndn dung XQCLDT-MM

ESSES
CHT-MM cho k it q u a b in h th ucrn g Tui p h in h dQng mgch d n a i tg n cua d o n g mgch than nen :
hinh tai tgo be mat - Nhanh dQng mgch phat sinh tu chinh tui phinh dQng mach
nhung c h it lu’Q’ng kh d n g p ha i lu c n a o cung tdt - Tui phinh dQng mgch thir 2° cd kich th u d c nho han n lm tren d m nao sau ben phai
- Cd kha nang cd hinh anh cua vd tui phinh d day tui phinh

185
 C .3 / D i d a n g d o n g - tTnh m a c h

. Lam sdng : x u lt h u y it nao-mang nao ho$c x u it h u y it mdng nao dan th u in , ddng kinh. th ilu sdt th in kinh. nhuc i» a d£u khdng dlAn hlnti

. H in h dnh h o c :
- Mo ta ton thuang : . DOng mach den, o dj dgng (n id u s ): vj tri, kich thud^c. hinh thai
. Cac mao mach dj dang hinh thanh nhirng v in tuan thu phan bO ciia cac trv»c t iiu dOng mach - mao mgch
. Cac tTnh mach d in luu gian, hiem khi dbng v6i : sdi tTnh mgch
- Ton thuang ket hap : mOt hoac n h ilu tiii phinh dOng mgch do tang luu lu ong mau
- Bien chung : kh6i mau ty? di chung cua mau ty?
- H iim khi co dj dang dOng-tTnh mgch nhieu nai ... bOnh th in kinh-da

- XQCLDT : T in thuang cb hinh thai mach mau dOng dam dO hay tang dgm dO d trd em : mau luu thdng cd hematocrrte cao
Khdng d iy hoac d ly it cac c iu true I3n can ; sOi tTnh mgch
Khdng c in hinh c6 tiem vi se thuc hi$n CHT hoac chup mgch mau
- CHT : Hinh anh 0 cac xung T1, T2 Spin Echo. T2 *, TOF 3D khong tiem va sau tidm ; cd khi chyp ca CHT-mgch mdu c6 gado
- Chyp mgch mau : Cho th iy cac dac diem ve hinh thai va chuc nang cua 6 dj dgng (nidus)

. D ieu trj : - Ngogi th in kinh trong mOt sO trudng hap h iim hoi do mau tg gay chdn 6p
- Gay t i c mgch sau d6 xg trj da chum (chum tia chia nho lilu ) Idn p h in 6 dj dgng khdng gay t ic mgch duo c
- Theo ddi sau d iiu trj b in g CHT : trj khdi bdnh? cdn sdt Igi mdt p h in 6 dj dgng? hogi tu do tia7 c in chgp mgch mdu klAm tra
- Theo ddi d iiu t r j : khao sat CHT mdi 6 thang va chup mach mau k iim tra vao nam th u 2

Trudng hap d$c b i$ t: - Tui phinh ddng-tmh mach d bdng Galien : u mgch mau nhd. gian tTnh mgch rd
- Cac dj dgng dpng-tTnh mgch cd h u y it khdi tu phat cue ky h iim ; c h in doan phan bi$t vdn u hang?
- Trudng hap cd hi£u ung choan chd : cd t h i la u ludi-m geh ... u r i t giau mgch nudi gia hinh thai di dgng mgch mdu

D| d g n g dgng-tTnh m gch d in h c h im trai

. K h d n g xuat h u ye t dong kinh

. G iam tin hieu do d d n g chay
N a o ian can n g u ye n vgn

186
 D iiu trj b in g cd ch gay t i c m ach

- K iim tra b in g XQCLOT : c h it g§y t ic tang d£m db khdng cb mau ty

- K iim tra v l sau b in g CHT-mgch m£u vd chgp mgch mdu quy i/b c
- Sau db kiem tra b in g CHT-mgch m£u dbng chay TOF 3D. T 1 gado

Trudrng h a p d dc bi$t : tui phin h b6ng G alien, p hd t hi§n 6 nhu nhi, trd em va 6 ca n g u a i la n

M ^t dj dg ng dQng-tTnh m gch cu a nhdn xdm tru n g u a n g duQ-c d i n lu u tTnh m g ch tru e t i i p s/do bbng G alien giSn lOn

XQCLOT khbng ti§m

. Xoang tm th in g gian
. Sbi tTnh mgch

XQCLDT sau ti§m M pR

T5ng d$m db dgng mach mdu
Phinh mgch bbng Galien “ t d t d *y 1 mm
M Chong 10 \d\ c5t
Khbng t h i th ilu
Chyp mach mdu quy irb'C

C .4 D o d o n g - tTnh m a c h m a n g ci> ng

- X u lt huyet nao h a y m an g nao, u tai c6 n hjp dgp, loi m i t ...

- D 0ng m gch d i n nu6i : c d c d o n g m gch ca n h n g o d i vd / h o $ c canh tro n g , th o n g noi (sh u n t) nho, mQt h o $ c nhieu shunt. tTnh m gch

ho$c xoa ng tTnh m gch d i n lu u gian

.... c 6 khd nSng bd s 6 t d 6 m dng c u n g tre n C H T

- D in lu u tTnh m g ch ng od i n ao / xo a n g dQC trd n , xo a n g ben

xoa n g c6 t h i b j h u y e t k h ii m p t p h in ho$c to d n b $ : h u y e t k h ii tTnh m gch cu la n g uydn nhdn g a y ra d6?

h ay d in lu u tTnh m g ch q ua c d c tTnh m g ch n ao : c d c tTnh m gch v o nao ... n g u y c a x u i t h u y e t gia tang

- D iiu trj b in g cdch g dy t i c m gch q u a dudrng dQng m g ch ha y tTnh m gch : t i c xoa n g tTnh m gch; c6 th e tdi phat

T2 FLAIR TOF 3D

. X u i t h u y e t li ti th a i d u a n g phai
. N h ii m d u dQng m g c h n a o g iu a nong vd sSu
. D d m d n g c u n g th a i d u a n g phai
. D 6 m d n g c u n g c u e tra n phai / < C
/
D Q ng m g c h d e n n uoi dQng m gch c a n h trong

187
 C .5 U m a c h d a n g h a n g : x e m tra n g 191 d e n 1 98

B?nh nao do cao h u y it £p

- Nhdi mdu hai thuy c h lm do b$nh |y mgch mdu c6 t h i h6i phgc / PRESS; h iim gdp t h i x u lt h u y it
- X u lt h u y it li ti lan t6a; xdy ra n h ilu n h it 6 noi t ilp gidp c h it xdm - c h it trin g

Viem dQng mach do nhiem doc

- T in thuong khdng ddc hi£u

- C h in dodn tuy theo t iin cdn
- MOt hay n h ilu mdu tg nhdn xdm trung u-ang
c6 khd ndng cd hai ben
- Phu ndo lan t6a khdng k iim sodt dua c
... tu vong do qud lieu

C .6 B e n h d a n g tin h b o t, x e m tra n g 1 64

Ldng dong protein trong thdnh d0ng mgch

Suy thdn, tilu dudng, ngudi gid, tong trgng yeu 61, sa sut tri tue ; khdng cao h u y it dp d$ng mgch
Nhdi mdu phu, nhdi mdu x u lt h u yit, mdu tg

T1 T2 FLAIR T2 * diffusion b 1000 bdn d l ADC

- nhoi mdu phu. nhoi mdu x u lt h u y it. mdu tu
- cham trdi, quanh cong nao. thuy dao ben trai, nga ba ndo bdn trai
- x u lt h u y it li ti 6 nai tiep giap chat trdng - c h it xdm

188
 D / M £ u tg tro n g n a o c 6 n q u 6 n g 6 c u :
T h i x u lt h u y it cua cdc u nguyfin bdo d$m vd di cdn : tu u th^n, tu y ln giap u h lc to
Khd c h in dodn vl. tr6n XQCLOT, n h lm lln giua mdu tg vd u, n h it Id sau khi ti6m
Tuang ty cung kh6 c h in dodn trfin CHT, n hlm lln giua tdng tin hi$u cua mdu ty vd b it gadolinium
Ghi chu : mdu tu c6 phu chung quanh Idm chung ta phdi nghi d in di can x u lt huyet
Sau 2 thdng. XQCLOT cung c lp n h ilu thflng tin han CHT : kh6i mdu tu h ip thu boi, u tien trien th6m

- U nguyfin bdo d$m

x u lt h u y it mOt p h in

- Cdc di cdn x u lt h u yit

- Nhuc d lu dQt ngot sau do roi loan tri gidc

- XQCLOT k h in , khong tiem

XQCLOT CHT
- Khoi mdu tu ke can nga tu nao t h it - Tang tin hieu T2 a ngang muc
do mot phan vao trong nao th it nga tu nao that hai ben va a the chai
- Giam dgm dp lan can, do phu ne ? do ton thuang tham nhiem? - Sinh thiet u te bao it nhdnh do III
- Phi dgi the chai. lan sang doi ben

- Mat ngon ngu dot ngot

- U x u lt huyet
Mau tu thuy tran
Mau tu thuy thai duang
- T 1 gado di can lan rpng a
Mang nao lan can

- U nguyen bao dem da dang

igiioblastome multiforme)

T1 T2 FLAIR T2 * T1 gado

189
 E / M a u ty d o c h a n t h ir a n g
- C6 tru in g h yp khdng b iit c6 c h in thuang tru 6c
- Ton thuang to vung "cyc" cua thuy tr£n, thuy th^i duang, thuy ch im

XQCLOT : D£p n3o to c y c tr^n p h ii

Hoi chung tre em bj n guac dai ;CHT co ly i vi giup tim ra nhi&u t6n thuang

Mat y thuc va chan thuang sp nao : tam quan trang cua hoi bgnh sir
- Mau ty trong nao la do chan thuang?
Hay tai bien mach mau nao da gay ra mat y thuc va chan thuang so nao :
va tui phinh dpng mach, thuyen t ic nao, huyet khoi dong mach ...?
- Chan doan quan trpng vi . Neu co xuat huyet m^ng n§o, co chi dinh tong ke chup mach m£u
. Co lien quan van de phap y

Chan thuang so nao mau tu sau chan thuang?

V a tui phinh mach dong mach nao giua ben trai m it y thuc sau d6 Id c h in th u o rg '’

190
 u MACH DANG HANG

. Phat triAn ti> cdc mao mgch b it thudng bj huyAt khdi ngay l$p tire; khdng cd ddng chdy .
. B im c h it b im sinh, cdc thA gia dinh
■ Phdi hop vdi mOt hay nhiAu budu mdu tTnh mgch : d in luu tTnh mgch cd dang kh6ng diAn hinh b im sinh

. 2 logi - 1 / U mgch dgng hang khdng xuAt huyAt : dOng kinh, ph^t hi$n tinh ctj
. OiAu trj : - Khdng diAu trj ? : lin i y nguy ca xuAt huyAt ?
- Ngogi thAn kinh ? : ngan ngua xuAt huyAt
cd thA khdng diAu trj khdi ddng kinh vi lidn quan tdi tang sinh tA b£o ddm phan ung d vung ldn cdn
- Dao gamma : hi$n nay chi djnh nay chua d u o c cdng nh^n ... xg trj vdi liAu giam mdt nua ?

- 2 / U mgch dgng hang xuAt huyA t: thiAu sdt thAn kinh xuAt hi$n ddt ngdt, nhuc dAu, hdn md
. DiAu trj : - Ngogi thAn kinh

- Vj tri : Thiiy tran, thai duang, than nSo, nai tiAp giap gi&a chAt tring va c h it xam
tuy nhidn cOng cd cac u mgch dgng hang ngoai ndo, cac bA nAn so. vi tri trong tuy sdng
Sd luong : Thay ddi, hiAm khi ddc nhAt, cd thA ti> 1 dAn 40

- XQCLDT : . T3ng d$m dd t y phat vira phai, khdng ddng n h it

. Vdi hda li ti
. Khdng cd hi$u ung choan chd; nguQC |gj, gj§n khu tru nao t h it hogc gian khu tru cac ranh vd nao do teo nao
- CHT : Tdn thuang khdng ddng n h it, dgng diAm li ti; hinh anh T2* trong 3 mgt phin g , nhgy han XQCLOT . . thuang tdn nhiAu nai
tang tin hiAu trung tam va giam tin hi$u ngogi vi trdn T1, trdn T2 Spin Echo va T2* do x u it huyAt li ti m di d trung tdm va lin g
dQng hemosiderin
- XQCLDT vd CHT : b it c h it tuang phdn ?
. Trong trudng hap binh thudng, khdng b it tuang phan
. Nhung cd thA cd b it thudc tgi chinh u mgch dgng hang hoac d ngogi bien. B it tuang phdn cd thA lien quan tdi cdc vung nhuyAn nao
hay x u it huyAt li ti tir vai ngay. B it tuang phdn cd thA d u a c ly gidi la d i u higu cua mdt dQ l tiAn then.

- Chyp mgch mau : . Khdng cd chi djnh ... u mgch dgng hang khdng cd mgch mdu tdi nudi
. B udu mdu tTnh mgch d u a c c h in doan b in g XQCLOT hay CHT cung khdng c in chyp mgch mdu.

- Cd trudng hop u mgch dgng hang xdy ra sau diAu trj bdng xg trj.

- 1 /U mgch dgng hang khong chay mau ; dQng kinh, phdt hien tinh ccx...

XQCLOT khdng tidm ; u hang diAn hinh : hinh thdi tdng ddm dQ lim tim , khdng cd higu ung choan chd

The dien hinh cua u mgch dgng hang

. Ddm dQ vd tin hi£u khdng ddng n h it

. Hinh thdi lim t im "mudi tieu "
. Teo ranh vd ndo
. Gian sung tran d ke cdn

XQCLOT khdng tiftm T2 mat dQ proton

191
 U m ach d an g n an g gi£ u
( j nhu nhi

T1 gado ThA t)£n tnAn nha nh

phu & n c£n
. P hdt tn£ n cd c nang

U mgch dgng hang nhieu nai : hinh anh T2 * trong 3 mat p h in g

. Ton thuang dgng not kich thu a c thay doi va ton thuang lan toa a nhan dau v£ bao trong b6n phai

XQCLOT khong tiem

T2 *

U m ach dang h ang da o khong xuat huyet

the d ien h in h tren X Q C L D T va CH T

192
 C 6 b i t c h it ti/a n g p h ln trdn X Q C LO T vd tren C H T khong ?
Trdn ly t h u y l t : khfing b d t ; trdn th i/c t l : c6 k h i ndng c6 b i t = d au h ieu ton th u a n g tien trien

- A / B dt tu a n g phdn bdn trong u mgch dgng hang

T1 T2 FLAIR T2 * T1 gado
3hi chu : hinh T 2* d ^n h gi£ u m gch d a n g hang la n h a n th y c te d o xa o anh (artefacts); the tich c h in h xa c d u a c danh gia to t h a n tren 1 2 FLAIR

- B / B dt tu o n g phan a ngogi vi cua u m gch dang hang

C a n dQng kinh dau tien a m o t thanh nien : u m ach dang hang thuy thai d u a n g
CH T : tang tin hieu tre n T2 F LAIR , bdt g a d o lin iu m : D lu hieu t iin trien va ngu y c a chay mau

Cac vj tri dac b ie t:

U m g c h d g n g h a n g n g o a i n a o ; b e g o c c a u -tie u n a o
R i t c 6 the la u m g ch d g n g hang khong m o b e n h nhan
. T 3 n g tin h ie u a tru n g tSm tr§nT1 ; ham lu a n g p rotein cao
. N h ilm h e m o s id e n n a m £ n g nao g i n u v& a tren leu : ranh vo nao phan vom nao
d o c h a y m a u lim t i m tai di t£ i Igi

193
 u m gch dgng hang h&nh tuy phat tridn vao trong nao tha t 4, ch ay m ^ u m d i

' Mm:v r ^ u m gch dgng hang tuy s6ng

m m n i g w jr j
k jA . Ii£t hai chi d u d i d$t ng$t vd g iim dAn
. chdy mdu trong tAn thi/ong
B K k f l tdng tin hi$u ddng n h it

MUM . cdn th i/c hi$n CHT ndo dd tim

cdc u mgch dgng hang trong ndo kdt hgrp

M
j
T2 * tro n g 3 m$t phdng
3 is a

C a c t h e g ia d in h

- Nao ngu’b'i m e : cdc u m gch dgng hang khong xuat huyet; the g a y dong kinh; tren 30 u m gch d gn g h an g kich thuG c nhd

- N a o con gai ; cac u m gch dgng hang xu a t huyet; tren 40 u m gch dgng hang I6n nho

. Cue thai dirtrng p h d i:

mdu tg moi
nhUc ddu kh6ng d{>ng kinh

Tuydn y£n
vi th h*dm
tdng k£ bdt binh thudng

194
- 2 / U mgch dgng hang x u it hu yit

XQCLOT
- Vi v6i hba
- Mdu ty mOi k6 cdn

T2 *

- U mgch dgng hang

- Mau ty : chay mdu mOi
. Kh6ng c6 vi£n hemosiderin
. Phu Idn cdn

. U mach dang hang da o

. U mach dang hang nhdn xdm trung tdm : mdu ty mOi k& cdn

. T2 * ci>a s6 r i t hep
. Hinh thuc t iin trien cua u mgch dang hang: cdc mao mach bat thu’O’ng co huyet khoi
. Tien trien v6i nhung dot cap khong the d u bdo, ve thoi gian cung nhu ve m uc dp ndng
. Tdng lu ong mdu 61cdc mao mgch Idn cgn ... kha ndng vo mao mgch khi u mgch dgng hang tien trien

C l / ;

U mgch dgng hang : chay mau 2 thi

. Mdu ty cu d ngogi bien
. Mdu ty m 6i 6 ke cgn
Di&u trj ngogi khoa c ip cuu

Lie t nCra ngucri p hai m ot cach do t n g p t 6 n g u o i tre

U mgch dgng hang sau ranh trung tdm M au ty a sa u t u 6 ngay tru a c
c&n djnh v| ranh trung tdm CH T T2 * U m ach d a n g hang da o, kich th u o c n ho d u o i 1 cm
d£ xdc djnh d uo ng vdo khi p h iu thudt U m a ch d a n g hang 6 bao trong va nhan d au trai

1 95
 U MACH DANG HANG : C H A N O O A n P H A N B l£ T

T iin cdn, c a dja, Idm sa ng , h in h thdi vd vj tri cd c t6n th u a n g , n h in chung,

c6 the g iup phdn bi$t u m ach d an g h ang v 6 i cdc t6n th u a n g khdc c6 chCra
hem osiderin.

- 1 / M du tg "tu p h d t " : u h ang k l c | n ?

. khd ndng u mgch dgng hang a ngi/dri tre : kh6 c h in dodn

... n h lm lln giOa mdu ty vd u mgch dgng hang
tim vung gidm tin hi$u khong “logic" dr k l cgn mdu ty
. k iim tra Igi bdng CHT vd XQCLDT sau 2 thdng :
- XQCLDT t6t han CHT, giup phan bigt cdc tdn thu’ang trdn
. v ln t6n tgi hinh dnh u mgch dgng hang
. mdu ty dd h ip thu
- CHT cdn gidm tin hi#u cua mdu ty vd u mgch dgng hang

2 / X uat huye t li ti tu phdt :

cao h u y it dp, tieu du’drng, nh6i mdu di kdm
.... t6n thu’ang dgng lim ch lm , nhin chung d6i xUng
nhdn xdm trung tdm, nai tilp gidp c h it xdm / c h it trdng

- 3 / N h6i m du x u lt huyet, benh d gng tinh bot

. ph6i hap n h li mdu phii vd x u lt h u y it lan hodc li ti
x u lt h u y it nho 6r nai tilp gidp c h it xdm / c h it trdng
c
. b$nh nhdn gid, t h i trgng y lu 61

- 4 / U xu at huyet U ngu yen bdo dgm

Di can tu ung th u vu, tuye n gidp

Cdc di cdn
tu1u hdc to

T1 gado 3 di cdn

T ru o n g h a p d a c b ie t : u te bdo sao dgng lo n g ....... u m g ch dgng hang ?

Mau bgnh p h im
Kho chan dodn
giai phau
n iu khong co a cdc vi tri khdc

- 5 / C d c voi hoa trong sq

Bgnh F a h r:
Cac ton thuang doi xung
a nhdn xdm trung tam
Cdc kha nang . the mpt ben
. t h i lan toa

Xa cUng ndo cu Boumeville hign di^n cac cu d u a i ^nang 6ng n$i tuy

196
 B u d u m d u tTnh m a c h

- T h u d n g k£t h p p b u d u m du tin h mgch / u hang ( 50 / 1 0 0 )

- Dj d gn g d in lu u tTnh m gch n3o : cdc Ang d in tin h m gch khdng d ien h in h n hu ng c iu true thanh tTnh m gch binh th u d n g
- K hdng c6 x u it h u y it di kdm ; n iu m$t b u d u m du tin h m g ch co bieu hign xuat huyet, rat co the xuat huyet ndy Id do v d
mQt u m gch dgng hang nhd khdng b ilt tru d c ndm ke can.

T1 Gado

D6ng tinh mgch r i t ch am : tin higu cua b u d u m du m gch tTnh m ach tu o n g tu v d i tin hieu cua DNT
T1 Gado : b u d u m du tTnh m gch n ga m thuoc; so sanh kinh dien ; dgng "dau N u than M eduse vd m di toe” ("dang d lu su a ")

Ket hop : u mach dang hang va birau mau tTnh mach

T1 Gado

- T h i dien hinh cua u m gch dgng hang vd b u d u m du tin h m gch :

n ao tha t kd can g ian n d, di ch u n g

G hi nhdn :
- T rdn T 2 * : thay d u p e u hang rat^nho cua thuy d in h phai n h u n g khong chan doan d u p e tren cac chuoi xung khac
- C a n th u c hi$n lo g t h in h co tiem iot hay gad olin ium de ch an doan cdc b u o u m au tin h mach

197
 . U m gch dgng hang cuong tieu nao g iu a ben trai
. B u d u m du tTnh mgch

U mgch dgng hang

phdn trong thdi d u o n g trdi
vd b u o u m du tTnh mgch

T1 gado

Gian mao mach

- C a c m a o m gch g ian tu n g dam kich th u o c 1 - 5 m m , d o n d o c hogc da o, nhieu kha n dng khong xu a t h u y it

- Vj tri th u o n g g ap : cau nao

- K hong chan dodn d u o c bang X Q C LD T

tren C H T, ton th u o n g li ti dong tin hieu T1, tan g tin higu T2, khong hign dign h em osid e rin tren T2*

- C o the co b u o u m du tTnh m gch di kern

- C o the do tia xg g a y ra
- K hong co c h i d jnh ch gp m gch mdu
- K hong can dieu trj

T2 SE T1 gaoc

Benh Rendu Osier

Ton th u o n g m gch m du da dang gian m ao m gch, di d an g d on g - tTnh m gch

198
 HUY£T KH6l (VIEM TAC) TINH MACH NAO
C o dja - T iin sdn, hdu sdn +++
- V idm tai, vidm xoang, n h ilm trung rang, phau thu a t tai-m ui-hong
- Tinh trgng tang ddng, d iiu trj b in g npi t ilt , tien can vidm tin h m ach chi d u a i
- N h ilm trung h u y it, tong trgng y lu , bgnh saccoit, benh B e h c e t...
- C h in th u a n g sp ndo

LAm sdng khdng d$c hidu : . N h u c dau keo dai, khdng giam v d i cac thu o c thdng th u d n g
. T h ilu sdt t h in kinh, hon m d ....
Mdi khi th u c hidn khdo sdt X Q C LO T hogc C H T, can phai n g h i td i benh canh lam sang cd t h i lien quan tdi
H u y it khdi tinh mgch ndo ; ket qua X Q C LO T khdng tiem va k i t qua C H T T1 va T2 cd t h i h u d n g tdi
C h in dodn : q u y it djnh th u c hign ngay cd c h inh X Q C LD T v d i iot hoa c C H T v d i G adolinium , va th u c
hidn CHT ddng chay tin h mgch

Hinh dnh hQc : - T h u c hidn khan vi cd chi djnh d iiu trj khdng ddng nga y tu c thi
- N iu cd m dy C HT, nen th u c hign khdng va cd tidm gadolinium , thdng tin n h ilu h an X Q C LD T
- N iu khdng, X Q C LO T khdng va cd tiem :
. XQ C LO T, da hang dd cdng tot
. N iu tren X Q C LO T khdng tidm, nghi n g d h u y it khoi tTnh m gch nao
va n iu sau dd khdng lau, cd the ch up C H T thi khdng cdn t ilp ty c X Q C LO T cd tiem
... C H T cung ca p n h ilu thdng tin h an

Mgc tidu cua khdo s d t h inh dnh :

- 1 / C h in dodn nhdi m du tTnh m gch phu hay x u lt huyet

• 2 1 Chan dodn h u y it khoi tTnh m gch . d m pt h ay n h ilu xoang tTnh m gch, ndng hodc sau
. d cac tTnh m gch vd nao
- 3 / Dau higu vidm d toan bp cac cau true m ang nao
- 4 / Y lu t6 h inh anh g a i y can nguydn viem td c :
. V iem tai, vidm xoang ?
. T ru d n g hp’p d g c bigt: ap xe nao, nguydn nhdn hay hau qua cua h u y it khoi tTnh m gch ?
- 5 / Kiem tra dien t iin bdng C H T sau dieu trj 6 thang, 1 ndm ; d l quye t dinh n gu ng dieu tri khang ddng ?

Xem tru d c : - G iai p h iu tTnh m gch : trang 16,17

- K y thuat : h inh anh cdc tTnh m gch: trang 67

- Cach t iin hdnh khao sa t C H T khi nghi n g d vie m tdc tTnh mgch nao

- T1 SE ca t ngang nhoi m au xuat h u y it (m ot hay n h ilu n a i) ?

- T2 TSE 2 echo , cd t ngang xem xoang tTnh m gch cd b inh th u d n g giam tin hieu. nhoi m au di kern ?
- T2 F L A IR cdt ngang : xem xo an g tTnh m gch cd b in h th u d n g giam tin hieu. nhdi m au di kem ?
- T2 * cdt ngang : hem osid e rin ? nhoi m du tTnh mgch th u d n g xuat huyet
- D iffusion va ban do A D C nhoi m du m d i ?

- D dng ch ay tTnh m g ch TO F 2D, tru d c tiem G adolinium . 120 lat cdt ngang. 2 mm
th u c hign hinh trong m gt phdng d u n g ngang, tai tg o h inh cdt ngang vd d u n g dpc
- T1 g ad o M P R . th u c hien h inh d u n g dpc, tdi tgo hinh cd t ngang va d u n g ngang

C ac chudi xu ng ddng chay tTnh m gch va M P R co gad olin ium bo tu c cho nhau. chuoi nay bo sung thieu sdt ciia
c h uo i kia
- Kha nang sai sdt cua h inh anh ddng chay tTnh mach d u o n g tin h gia cd huyet khoi tTnh mach
tuy theo h u d n g cua xoang tTnh m ach the o mat p h ln g ca t lat
thi dg : khdng thay xoang tTnh mach ben kich th u d c nho du xoang van thong th u a n g
- Kha nang sai sot cua M P R co gado ( h inh anh sai lech cua ddng chay b inh th u d n g i
do bat chat tu o n g phan tren thanh cua xoana t'n n m ach bi viem

199
 XQCLOT va huyet khoi tTnh mgch n§o

- XQCLDT khong tiem

. 1 / C h a n d o a n h u y e t k h o i c u a m o t h o a c n h ie u x o a n g tin h m a c h

. 2 / C h a n d o a n n h o i m a u . Vo nao va / h a y d sau, m pt bSn hoac hai b6n

. Phu, phu - xuat huyet,
. X u it huyet : m p t o m au tg, nhieu 6 m au ty

X Q C LO T khong tiem sau do co tiem neu trong th d i g ian gan khong the th y c hi£n d u p e C H T

N hieu 6 nh6i m au x u it h u y it mOt bAn

Nhi£u 6 nhAi m iu x u it huyAt

hai ben

T a ng d am dO c iia xoang thin$

v ^ xo an g tTnh mgch dpc trftn

- X Q C L D T c o tie m :
- 1 / C h a n d o a n h u y e t k h o i c u a m o t h o a c n h ie u x o a n g tTnh m a c h : d a u h ie u d e lta
- 2 / C han doa n nhoi m au : b i t ch a t tu o n g phan

X Q C L D T k h o n g tie m X Q C L D T c o tie m

. Tang dgm dp d tru d c ranh trung tam ben trai :
kho chan doan nhoi m au xuat huyet neu
khong co tien can ro rang
. C ac xoang tTnh mach "hien len qua ro" cung
kho chan doan : cac xoang tTnh m ach cung tang
d am do trong tru d n g h p p hem ato crite cao. la
b inh th u d n g d tr£ em, hogc do m i t n u d e d
n g u d i Idn
D am do khong doi cua vung nhoi m au ben trai
b i t tiro n g phan bgnh ly ben phai, sau ranh trung tam m ang nao ?
nhoi m au phu v d i hang rao m a u -na o tham t h i u ?
Co d iu delta vi:
- B it tu o n g phan d thanh m ang c u n g d a y do v ^ m
- Khong co iot trong ca c xoang tTnh mgch
cu c m au dong tan g dam do tu p ha t n h u n g t h i p hem
dam do cua thanh xo an g bi viem

- Co the ch yp X Q C LO T- m gch m au bo sung, khong can ch yp neu cac hinh khong va cd tiem can qua ng da ro
70 lat c i t d iy 2 mm trong 30 giay
. Tiem tTnh m gch, c h d 20 giay, ca c lat cat mong. day 2mm
D ac bigt chu y h inh tai tgo d u n g d oc d d u d n g g iu a
Tai tgo iat cat mong, 1mm, vi bat tu o n g phan d thanh xoang co the tao anh g ia ia long xo an g cd thdng th u o n g

200
 C H T v d h u y i t k h 6 i t in h m g c h n § o

1 / Chin do£n tic xoang tTnh mgch

. Hinh T1 : t h i y tn /c t ilp cy c mdu ddng
. H inh T2 : cdc xoang tTnh mach c6 h u y it k h ii tdng tin hipu

T1 T2 Spin Echo 2° echo T2 FLAIR T2 Spin Echo 2° echo T2 FLAIR

BlNH THU'O’NG h u y £t KHOl t Tn h m a c h

T 1 : tin hi$u cao Xoang tTnh mach c6 huydt kh6i tdng tin hi$u
khdng ly gidi d u p e T2 SE FLAIR : xoang tTnh m gch b inh thucrng do khong c6 ddng chdy vd do cyc mdu ddng
hi$n tupng 9 'dm tin hipu Nguyen nhan n h lm Idn: cd thd c6 gidm tin hi$u vdo ngdy
"di vdo Idt c it " thi> 2 do hidn di£n hemosiderine ,
Do d6 cdn c6 chudi xung ddng chdy vd chudi T 1 gado

21 . Chin do£n nhli mau phu, phu-xult huyet

. Chin do£n mdu ty trong nao

j i -

T1 T2 FLAIR
XQCLDT khdng tidm CHT T2 SE
. D lu delta . Tdng tin hipu d xoang doc tren T 1 : Mau tu hoi thai duong giua ben trai ... cdn nguydn ?
Gidm ddm dp vung dinh / . Tang tin hi$u vung dinh 12 FLAIR : huyet khoi tTnh mach xoang doc tren
nh6i mdu phu

T1 T2 SE T2 FLAIR T1 gado
Nhdi mdu phu sau ranh trung tdm hai bdn khdng didn hinh: nguyen nhan dpng mach7 huyet khoi tTnh mach 7
T1 gado : . huydt khdi tTnh mach xoang dpc trdn, mdng cung phi dai ro r$t, dang viem
. tdng tin hipu nhu md nao
... Choc dd tuy sdng : vidm mdng ndo. bidn chung : huydt khdi tTnh mgch ndo

201
 - 3/ D 6ng ch ay tTnh m gch TO F 2D
120 Idt cd t ngang, 2 m m ,
h inh tai tgo d u n g d<?c va d u n g ngang

D 6ng c hdy tTnh m gch : H u y it kh6i tin h m gch xo a n g do c trdn, xo a n g th in g , xoa n g bdn bdn phdi
D in lu’u tTnh m ach n do b i t th i/O n g : gidn v d n h d a i tTnh mach b i/d ro - sytvus
P hi d a i cd c tTnh m ach xuydn x i/o n g so vd d u d i da

- 4 / TTnh mgch vd tidm G adolinium , 100 ia t d u n g doc 1 ,2 mm

tai tgo h inh c i t ngang va d u n g ngang

T1 ga d o lin iu m : h u y it kh6i tTnh m ach xo a n g d o c trdn vd xo a n g nga n g b dn phdi

H in h d nh "d w b n g r l y xe li>a" d o p h i d g i m d n g cU ng; l il m n d o p h i d g i d o vidm
T hdnh m dng cUng cua cd c xo a n g tTnh m gch p h i dgi d o vid m r6 r$t, bdt m g n h g a d o lin iu m
.... gid h in h cua dOng chdy trdn T1 gado
D o d6, c i n phdi th y c hidn m pt cdch hd th 6 n g c h u 6 i xung d b n g ch d y tTnh m gch vd c h u li sa u tidm g a d o lin iu m

T rd n m p r gado : gid h in h thdi cua xoang tTnh m gch th o n g thu’O’ng b inh th i/O n g / thd n h xo a n g tTnh m g ch vidm

T1 gado DOng ch d y tTnh m gch T O F 2D

. G id dOng c h dy tTnh m g ch d o phi dgi th a n h xoang . H u y it kh 6 i tTnh m gch . X oang doc
. L u u y : kh6 ng cO tin hipu tru n g tdm , dau delta . X o a n g bdn bdn p fid i

C d c th fin g tin b6 sung v ! cd n nguydn cua h u ye t kh6i tTnh m ach trdn X Q C L D T vd C H T : vidm xo a n g s d n g vd v id m xo a n g btrdrm

202
 Cdc bi&n th£ gidi ph iu

. 1 / BAt sdn mQt xoang bSn

t

’ d
f * ,/ i
— *

i • /
c
y
DOng ch d y tTnh m gch T O F 2D C hup m gch m du
- X oang d oc trSn n6i t i i p v d i m $t xo a n g b6n d u y n h it, b&n phdi, cung kich th i/O c
d iu hi$u nd y d u o c k iim ch irn g Igi cdc l6 tin h m gch cdnh, khOng d6i x irn g
- N a i chia xoang d p c trdn th d n h hai xo a n g bdn thirO ng ndm trdn d u O ng giOa ;
tro n g tri/O n g h o p b i t sdn, n a i n6i t i l p nd y bj Idch ve bdn xo a n g bdn du y n h it

Cd t h i sai sOt 1
trdn hinh dOng c h dy tTnh m gch T O F 2D

1
J S S V
r f

- DOng c h d y tin h m ach : khong t h i y xoang bdn bdn trdi d o huyet kh6i tTnh m ac ? d o b i t d6i xirn g b im sinh?
- M P R g a d o : xoang bdn gidm sdn, v i n th o n g thu’a n g

.2/ Hinh khuyet ben trong mpt xoang tTnh mach lan

T h o d t vj m dng nhgn vdo tro n g xoang

- T in thu’a n g kh u tru, d g n g tron
kich th irO c 1 0 - 1 5 mm
- K hong d n h h ira n g dOng ch a y tTnh mach

X o a n g ben ben tra i : kh6ng c6 dbng chdy tTnh mgch

Chyp mach mau th i tTnh mach
- H in h a nh t h i y d u o c trdn 1 h o d c 2 Idt
hinh khuyet trong xoang tTnh mach
- B ien t h i b in h th ira n g , ha t P accionni

203
 Huyet khoi tinh mach sau

- N h6i m £u 6 m pt ho£ c hai <36i thi, phu ho£ c x u lt h u y it

- H u y it k h ii cdc tTnh m ach ndo tro ng vd xo an g th in g

XQCLDT khdng tifem XQCLDT sau bdm

Gidm ddm dp 6 d6i thj trai Ddm dp khdng thay doi 6 t in thircrng dAt thi : h u y it k h ii tTnh mgch
Tdng ddm dO V phdt 6 xoang thdng Bdt i6t quanh b6ng Galien
Trong trirdng ho1? ndy, XQCLDT khdng tidm mang tinh quyet djnh

T2 FLAIR
Ton thu’ang phu hai d ii t h j:
n h li mdu tTnh mgch?
Tdng tin hidu xoang doc trdn

The h u y it k h ii tTnh mgch ndng :

xoang dpc tren, xoang th in g , xoang bdn bdn phdi
Dan li/u tTnh mgch ndo qua vdnh dai bi/6m -sytvius vd
cdc tTnh mgch chdn bird'm

204
 T1 gado

T1 gado

- T6n th u a n g phii khong doi x u n g a hai doi thj ; b i t G ad o khong dong n h a t ... the viem t i c tTnh mgch gia u
- Huyet kh6i to£n bQ xoang th in g ; huyet khoi bein p h in dr . X oang dQC tren, phan tran xoang tTnh mgch giSn
. Xoang ben ben p h li
... MQt ton th u a n g doi x u n g hoac khong doi xu n g a d6i thj g a i y chan doan viem t i c tTnh mgch nao

V iem tac tTnh m gch nao nong va sau : the xuat huyet

205
 Viem t i c tinh mgch m0t tTnh mgch v6 n3o

K ho chan do£n vi :
- Nhoi m au tTnh m ach g id i han
- Khong ky thuat h in h anh nao cho chan doan c h ic c h in
V e mQt tTnh mach vo nao khong cd ch a t tu’o n g phan

- MQt tTnh m ach vo nao tang tin higu tren T 1, nhoi m au phu vu ng ranh trung tam tr^i
- C ac xoang tTnh mach Idn tren du’d n g g iu a khong bj anh h u d n g

Kha nang viem t i c tTnh mach vo ... Kho chan doan c h ic c h in

. T 1 gado. MPR, 110 lat

. B e khao sat cac tTnh m ach vo nao, th u c hien ca c h inh trong m at p h in g c i t ngang tot h o n m ^ t p h in g d irn g doc
. Chon 30 lat c i t va khao sat he thong tTnh mach tu d u d i len tren, d a c b ie t cac tTnh m ach vu ng d inh dau

V iem tac tTnh m ach xoang dQC tren :

g ian cac tTnh mach vo nao vung tran ; tTnh m ach dan thoat

206
 The ban cap

- ChAn do£n tr5 .

Thi/c hi$n khio sat hinh £nh trong t6ng k§

nhirc diu kinh niSn
Ho$c theo ddi diSn ti4n th4 c ip tinh

- H uyet khoi m pt dogn xoang dpc tren va xoang th in g

- Thanh xoang va m ang c im g day len
- G ian n 6 . C a c tin h mgch lan can lien ban cau va cac tin h m gch vo nao
. Xoang dpc tren den g o c mui, xoang dpc d u o i

- H uyet khoi mot dogn xoang d p c tren,

huyet khoi xoang ben ben phai, gian cac tTnh m ach vo nao
- Toan bo liem dgi nao day len

Kiem tra viem t i c tTnh mgch ca c xoang ben

sau 6 thang di§n tien :

. Tien trien iam sang kha quan

. V an hien dien h u y it khoi cac xoang ben
. G ian no1xoang dpc tren
. P hat trien cac tTnh mach d in thoat :
- P hia tru o c , gan g oc mui. ve cac tTnh m ach mat
- Hai ben : cac tTnh m gch nao nong
- P hia d u o i. ho sau
. Xoang da sau
. Cac tTnh m ach gian cuong nao va tn/crc c iu nao,
tTnh m ach thuy nhong d ird i

207
 BENH LY VIEM hinh anh hpc

- Bgnh viem m i t m yelin khong ro can nguyen :

. X a c im g r£i ra c ( hay x o hoa da o hay MS m ultiple sclerosis )
v^ . V i£m tu y - than kinh thi Devic
. X a h6a d6ng tam Balo, gia u
. Bgnh S childer a tre em
. B$nh M arburg : dien tien dO dpi

. Bgnh c h it tr in g nao cap tin h rai rac : LEAD I tiln g A nh A DE M

. Bgnh c h it tr in g nao da o tien trien : LE M P / tie ng A nh PML
. Bgnh saccoit nao : u hat viem , benh saccoit m ang nao
. Nhoi m au li ti do viem dong mgch co nguon goc viem / bpnh hg tgo keo : benh G ou g erot S joegren. luput ban d6

- Bgnh ly viem co can nguyen v ir u t :

. Vi&m nao herpes
. A ID S : V i£m nao do virut va ca c ton thu’a n g lien quan t6 i hpi chtpng su y g iam m ien dich

Q ui trin h khao sat CH T : k h io sat nao sau d6 khao sat tuy song

. N ao : th y c hi#n it n h it 6 chu&i xung

- T1 T S E c i t ngang
ti§m gadolinium ngay ti>c th i sau chuoi T1
- T 2 FLA IR c i t ngang
- T2 FLA IR c i t d u n g doc: d$ c biet khdo sdt the chai vd tuy song c6 cho d in CA
- T1 gad o c i t di>ng ngang
- T 1 gad o c i t ngang : chuoi cuoi cung, nhu- vdy it n h it 12 phut sau tiem
- ( c6 t h i th em ) T 2 TSE c i t ngang, m $t do proton vd e cho thi> 2

T rong truO ng h o p co dau hieu lam sang cua viem th in kinh thi sau nhan c iu :
- T 2 Fat S at d u n g ngang 3 m m noi tiep nhau : tir nhdn d u den g iao thoa thj, c6 the ca T1 g a d o Fat S at di>ng ngang

T u y s6ng :
- T r u in g khao sdt 400 m m ( d£» phan giai khong gian kdm n iu dung truO ng 5 00 m m ), Idt dd y 3 mm
- C hu§i xung th u 1 : n g y c - t h i t lu n g , T 2 S TIR d u n g doc tdp trung tgi ch6p cung
- Sau do 4 chu&i xung de khao sdt tuy song co vd n g y c :
. T 1 Spin Echo d u n g doc
. T2 S TIR d iin g do c ( truO c khi ti§m gadolinium )
... tiem gadolinium
. T2 Spin Echo d u n g dQC
. T1 gadolinium d u n g dQC / neu khong t h iy to n th u o n g : ngu n g
. Neu co ton th u a n g : Idt c i t c i t ngang T2 *, nhieu thong tin h a n c h u fii T 1 gado

x a Cl/NG RAl RAC ( SEP )

H in h a n h h p c p h a i tr a lo i c a c c a u h o i s a u :

- C h in dodn cdc ton th u a n g m at m yelin : so lu a n g , vj tri, kich thuO c

- B i t c h i t tu a n g phan ; lu u y benh "dang hoat dong" ... de d ieu tri
- L?p Igi khao sdt :
. Lan rong theo thOi gian : tien trien ve so lu o n g ?
. Lan rpng theo vj tri : phan bo cdc ton th u a n g ?
- Th eo doi ode ton th u a n g tren hinh anh hoc de danh gid hieu qua dieu tri
- T on th u a n g co vj tri da c b ie t : viem than kinh thi sau nhan c iu tuy song ?

4
** I x i.
- 7

7 5 v XQCLOT sau ti§m

th£y m$t ton thuong duy nh£t va chi th iy sau tiem
CHT T2 FLAj R
r^1 nn*^» *Ar TKrang

208
. Vj tri t h u d n g g $ p c u a c £ c t6 n th u o n g

- T in th u a n g quanh nao th it, d u d i m ang 6ng npi tu y v d i chan barn rong

- Trung tam ban b iu d g c : s6 lu o n g t6n th u a n g thay d6i, khong doi xu n g
- ThA chai la i ich cua chuAi T2 FLAIR trong m$t p h in g d u n g dpc
chudi ndy cGng cung c ip thdng tin ve tuy s6ng cho den C4.
- Cudng t iiu nao g iu a va than ndo
- Kha nang cd m0t hay n h iiu tOn th u a n g d nhdn xdm trung tam : the "van" = cac van cua chat t r in g
- It gdp t6n thu-ang d cac bdn c iu t iiu ndo vi c iu tao chu yeu ia c h it xam

. TiSu chuin chin do£n

- Khdo sat CH T c6 gid trj c h in doan tu a n g tu n h u gid trj cua cac d iu hieu lam sang ,
cua khdo sat sinh hoa te bao D N T vd cua cdc nghiem phdp c h u c nang t h in kinh

- T6n th u a n g SEP : - M0t p h in g c i t ngang : ton th u a n g kich th u d c tren 3 mm, khong anh h u d n g vung lanh lan can
- Tu y song : lan theo chieu cao, d u d i 2 than dot song

1 / Lan rpng theo khong gian : tieu c h u in B arkhof / 2005

- Tin hieu - 9 ton th u a n g tang tin hieu T2 ( nao bo va tuy song )
hay 1 ton th u a n g tdng tin hieu T2, b i t gado tren T1
- Vj tri 3 trong 4 tieu c h u in
- it n h it 1 ton th u a n g d u d i leu hay tuy song
- it n h it 1 ton th u a n g can vd nao
- It n h it 3 ton th u a n g quanh nao t h i t

21 Lan rgng theo khong gian : tieu c h u in M ac Donald = lam sang + C H T + co the DN T
- M$t ton th u a n g m d i tang tin hieu T2 x u it hien tren 30 ngay sau m ot khao sdt C H T ch u n g to benh dang tien trien
- Du Idm sdng khong co d iu hipu tien trien, C H T van phai d u p e th u c hipn lai sau 3 thang
cho t h i y cac ton th u a n g m d i ? b i t gadolinium ?
mpt ton th u a n g m d i tang tin hipu tren T2 ho$c c6 b i t gadolinium du de xd c djnh c h in dodn
- Neu lan khdo sdt th u 2 khong ch o them thong tin ndo,
th u c hipn khao sat lan 3 cOng 3 thang sau lan C H T th u 2 ...co ton th u a n g m d i tren T2 ? ton th u a n g b i t g ad olin ium ?

Vj tri va hinh thai dien hinh cua ton thuong xo cung rai tac
. Ton thuong duoi mang ong noi tuy, day rong
. Ton thuong phan bo dang tia / khoang Virchow Robin
Ton thuong cac sgi dang U / mOi ten
. Vj tri chu yeu quanh nga ba nao that
d the chai
... Loi ich cua chuoi T2 FLAIR trong mat phing dung dpc
. B it tuong phan dang vien

209
 D a m d o va tin h i$ u c u a t6 n th u c rn g m A t m y e lin : ti£ n tn 4 n th e o t h in g ia n

-1 / T o n th u ’O’n g m o i . D ong dam dp tren X Q C LO T, giam tin hi$u T1 va tang tin hi$u T2 tr6n C H T
. B it c h it tu o n g phan
. Ton th u o n g co dang tron hay bau dye, theo try c cua khoang V irch ow Rotxn
. Chung co the dong tam hog c co dang "m 6ng n g u a " : t6n th u o n g cac bo cu ng dutfn v6

T1 T2 SE 1° echo T2 FLAIR diffusion b 1000 bdn <J6 ADC T1 gado

- T 6n th ira n g m P i "dang hoat d p n g ” T1 : giam tin hieu ro

T 2 SE : t§ng tin hieu ro
. T2 FLAIR va T1 gado : ton thu’a n g dang vi6n / ph&n h o a t dong cu a m ang
. D iffusion b1000 va ban d o A D C kh6ng c6 y nghTa du t6n th u a n g d a n g hogt dOng

- Ceic ton th u a n g khong mOi I3m lan toa, so lu a n g nhieu, khong b3t gadolinium

T1 T2 FLAIR T1 Gado

C au true cac m ang dang hoat dpng : . G iam tin hieu T 1, tang tin hieu 1 2, bSt g a d o dang vien tren c a c so^ d a n g U

210
 Lgri ich c u a h in h d iffu s io n ?

T1 T2 FLAIR T1 gado diffusion b 1000 ban do ADC

C 3 c m ^ n g d a n g h o g t d o n g c o tin h c h a t th a y d o i tre n h in h d iffu s io n ; t u o n g q u a n g iu a h in h d iffu s io n

v a b i t g a d o lin iu m th a y d o i:
1 / . D iffu s io n h a n c h e : ta n g tin h ie u tre n b 1 0 0 0 , g ia m tin h ie u tre n b a n d o A D C
. m a n g c o v e ra t h o a t d o n g ... n h u n g k h o n g b a t g a d o

T2 FLAIR T1 gado diffusion b 1000

2 / . B i t g a d o lin iu m m a n h ... v a d iffu s io n b 1 0 0 0 h a u n h u b in h th u o n g

-2 / T 6 n th u o n g k h o n g m o i l i m :
- D ong dam do tren X Q C LO T
- M ang g iam tin hieu T1 va tang tin hieu T2 m ot cach tiem an khong that ro n h u tru’a n g h a p tren
- "C ha t t r in g d o " ton th u a n g lan toa trong chat t r in g : nga ba nao, trung tam ban bau due
- Khong b i t ch a t tu a n g phan
- Tien trien dan ta i teo nao

C hat trang d a ”

. T6n th u a n g m i t m yelin lan toa ; ca c ton thu 'a ng quanh nao tha t tu a n g tu n h u benh ly thoai hoa
c h it t r in g (leu co a ra io se ) n h u n g co t6n th u a n g cuong tieu nao g iu a ben phai va a than nao
. Ti£u c h u in B arkov : kho xac djnh dung so lu a n g ton th u a n g trong tru a n g h a p nay

- 3 / T 6n th u a n g cu - G iam dam do tren X Q C LD T do ton th u a n g tien then dan den tao hoc
- G ia m tin hieu T 1: "lo den", tang tin hieu T2 tu a n g tu tin hieu D N T
- C a c m ang m i t m yelin la n va teo nao ro ret

211
 C&c tieu chuan phan biet giua nhoi mau lo khuyet n§o v£ c^c m^ng m it myelin

. C h in d o ^ n d e k h i c o c ^ c d i u h ie u 13m s £ n g rd : tu 6 i, t i i n cSn b $ n h m g c h m £ u
. C h in d o a n c o th e k h o n e u k h o n g c 6 c ^ c d i u h i$ u trd n , n h i t Id tro n g k h o a n g tu6* 4 0 - 6 0

1 / Y e u to h in h a n h g g i y n h o i m a u l6 k h u y e t n a o 2 / Y i u t6 h in h d n h g g i y x a c im g r£i rd c

. T o n th u ’a n g c ^ c h x a th a n h n a o t h i t . T o n th u a n g k h o n g d o i x u n g , d u d i m d n g 6 n g n d ' tu y
D oi xung
K h o n g d n h h u o n g b a n c a u tie u n ao . T o n th u a n g la n t6 a , k h 6 n g d d i x u n g : b d n c i u t i i u nSo,
th u y th a i d u a n g c u o n g tie u n a o , th u y th d i d u o n g

. T o n th u o n g g ia m d $ m d o n h e tre n X Q C L D T . M o t h o a c n h ie u to n th u a n g g ia m tin h ie u r i t n h ii u trd n T1 : T6(Je

ta n g tin h ie u n h e tre n T 2 h a y r i t td n g tin h»$u trd n T2

. T o n th u a n g " l i m t i m " d u a i c u a s o th a t h ep . T o n th u a n g d o n g n h i t h o $ c d g n g v ie n
. T o n th u a n g trd n h a y b au d y e . T o n t h u a n g b a u d y e , th e o h u d n g c u a c a c tTnh m g c h n h 6 :
v id m q u a n h tTnh mgch

. K h d n g b i t c h i t t u o n g p ha n . T r u d n g h o p m 0 t h o £ c n h ii u m d n g d a n g h o a t <30ng,
T r u n g o g i le : o k h u y e t r i t m a i b i t d g n g v ie n h o ^ c b i t to £ n b d m a n g d a n g h o g t ddng

. K i t hp-p ceic n hd i m d u v d n io , cu h o $ c m d i . K e t h g p v d i c d c to n t h u a n g g ia o th o a th j. td n th u o n g tu y sAng

C a c vj tri k h d n g d a c b ie t :
- T o n th u a n g d u d i vd .
- T o n th u o n g th e c h a i
- T o n th u a n g th a n n a o

- T u o i : 5 0, k h d n g c d tie n ca n d a c b ie t
- L a m s a n g n h u n h a u : m d i d a y c d di c a m c h i tre n b en p h a i, th o & n g q u a , ta i lai

N h o i m a u lo k h u y e t

212
 The <5#c bi$t cua cac benh mat myelin

1
B$nh Balo : . X a chai dong tam , h in h d an g "v o h a n h " kin h d ie n , to n thu ’a n g hai th u y d in h , doi x u n g
. Tro n g t r u in g hp-p n ay, th e hoai tu \ g ia m tin h ieu ro tre n T 2 * d o phan xu a t huye t
. Tien trie n den hoai tu
. D ien t iin ia m sa n g xa u di n ha nh ch on g

B$nh S childer

- 6 tr6 em h o $ c n g u d i tre
- HOi ch u n g th a p hai ben, noi kh6
D iln tien td i s u y g id m tri tho n g m inh , m u , d ie c
- CHT : T6n th u a n g kh on g d a c hieu , ta n g tin h ie u a ca c tru n g tam ban b au d ue roi lan sa n g ca c thu y thai d u a n g

B$nh M arburg : T ie n trie n ra m r0 va t u vo n g nha nh

- V j tri tu y s o n g c u a b e n h x o h o a d a o

- Phdi khdo sa t tuy so n g m p t c a ch he tho n g, nghTa la phai kh a o s a t C H T hai lan vi kh on g the n ao tro n g cu n g m p t lan,
c6 t h i kh do sa t d u n g d in v y a nao bo, v u a tu y so n g : xe m tra n g 208

■T6n th u a n g
g io n g n hu 1ton th u a n g a n ao
. cOt sau vd cp t ben, co kh a n an g co ton t h y a n g ch at xam
. kich th u d cton th u a n g va i m m ;
. khfing qua hai tha n so ng , k h a c v a i v ie m tu y c i t n ga ng

■Trong th y c t l :

. Ho$c b$nh nhan bieu hien n h y n g d au h ie u lam sa ng cu a b e n h ly n a o . K ha o s a t C H T n ao bo ch o thay

cac t6n th u a n g x a c im g rai ra c
.... can t h y c h ipn C H T tu y so n g d e d a n h g ia m y c d o lan ro n g cu a ton th u ’a n g th e o kh o n g gian va th d i gian

. Ho$c d lu hipu lam sa n g cu a b en h ly tu y so n g : ye u t u chi kie u lie t c u n g , ro i loan ca m g ia c :

. K hdo s a t dau tie n ia C H T tu y
. Sau d6, tro ng m pi tru d n g h a p ( tu y so n g b inh th u d n g h a y b en h l y ) : kh a o s a t th e m nao bo

213
 T2 E c f o d e G ra d ie n t

T2 Spin Echo T2 STIR

- C in kh a o s a t tu y so n g T 2 S p in E ch o va T 2 S T IR
T 2 S T IR : d o phan gidi tro n g kh on g g ian ke m h o n n h irn g do p ha n g ia i tin h ie u to t h o n :
T d n g tin h ie u O’ C 3 , C 4, C5

. C o th e bo so t ton thu ’a n g do h ieu im g th e tic h ban phan

(e ffe t de v o lu m e p a rtie l)
. 6 tu y so n g , h au n h ir kh o n g th e lap lai c h in h x a c vi tri c a c la t c i t q u a c a c
lan c h g p k h a c n hau

Viem tuy - Than kinh thi Devic

K et h g p vie m tha n kin h thj sa u n ha n cau hai b en va v ie m tu y

K h o n g tie n trie n th e o d p i
T o n thu ’a n g th a n kin h thi va g ia o th o a thi n h im g kh o n g c o m a n g x a a n ao
T re n X Q C L D T v a C H T , c a c to n thu ’a n g tu a n g tu1 nhu- x a c im g th a n h m a n g
T o n th u a n g tu y h o g i ti> va ta o h o c ta n g tin h ieu T 2 ke o d ai it n h a t 3 d o a n n g u y e n so n g
ton th u ’a n g tru n g tam tu y va nhi§ u tan g

214
 B 0 n h c h i t t r i n g n § o c l p t in h ra i ra c : LEAD

- T h ud t ngO t iln g A n h : A c u te D isse m ina ted E n ce p h a lo M ye litis ADEM

- N h ilu tAn thuang vid m cu a c h i t tring do hien tu o n g t y m ien

g $p sau m $ t b£nh n h ilm tru n g tir 2 t u l n din 6 th d n g : s d i, th u y d au , h o a c ch ic h n g u a
-Lim sdng : t h ilu s 6 t t h i n kin h d $ t ng0t, mOt thi, t i i n t r il n tro n g vo n g 1 d en 3 tuan
- T i i n triln th a y dAi : c 6 t h i khdi b #n h, c6 h a y kh o n g co di c h u n g , 3 0 / 1 0 0 ti> vo ng tro ng vdi t u l n

I X Q C LO T vd C H T . N h ilu tAn th u a n g d a n g n o t g ia m tin h i#u T1 vd tan g tin hieu T2, b i t tu a n g phan

“ S au d 6 thdnh tAn th u a n g d a n g v iin
. TAn thu ’a n g m i t m ye lin n h o d u d i 1 cm , tu a n g t u n h u tAn thu ’a n g x a c u n g rai rd c th d n h m a n g ,
N h u n g cu n g c 6 n h u n g tAn thu ’a n g kic h th u d c Idn , 1 - 4 cm , nhie u n a i ; tien trie n th d n h da n an g nho
. TAn th u a n g d an g h o g t d on g tan g tin h ieu tre n d iffu sio n b 1000 vd c6 t h i b i t tu a n g p hd n ;
C h in d oa n p ha n b ie t : lym p h o m / c a d ja k h a c ,
. B i t tu a n g p ha n m g n h h a n va lan to a h a n .
. K ho n g hoai t u d an g nang
. C 6 t h i cd tAn th u a n g tu y so n g : tAn th u a n g nhie u doan
. C 6 t h i t i i n t r il n x u lt h u y e t ... Ig i ich cu a c d c c h u o i e c h o g ra d ie n t
= B §n h c h it t r in g n ao c l p tin h x u lt h u y it H u rst

r 1
4
% i
' - j

i *

T 2 Spin Echo

L w T 1 gado

T2 Spin Echo diffuision b 1000 T 1 gado

B e n h c h it t r in g nao c l p tin h rai rd c :

T o a n bo cd c d lu h ieu : tAn th u a n g k ic h th u d c tre n 1 cm .
. M o t ton th u a n g d a n g h o g t d o n g tre n d iffu s io n / ta n g tin h ie u va b at g a d o lin iu m
D ien t i i n h o g i t u th d n h da n an g n ho

215
 Benh chat trin g nao da o tien trien, LEMP

- T h u $ t ngu1tie n g A nh : P ro g re s s iv e M u ltifo ca l L e u c o - e n c e p h a litis (P M L )

- C £ c ton th u a n g n ao lien q u a n tcri s i/ tai h o a t d on g cu a viru t p a p o va th u d n g t h i y tro n g c h it t r in g n d o b<> va

p h a t thAn tro n g c a c te b ao s a o v a te b ao it n ha nh
- D ie n ti&n t u v o n g tro n g vai tha n g
- C o dja : su y g ia m m ie n d jch . A ID S , tie u d u d n g , lym p h o m , ung th u , b en h b a ch huyAt
. d ie u tri u c c h e m ie n d jch, d ie u tri c o c tic o it ke o dai

- X Q C L D T v a C H T : B an dau, ton th u o n g c h a t tra n g rai ra c, kh on g doi x u n g

Sau d o, to n th u a n g hai ben, ke ca n n ga ba n ao th a t v a c a c s u n g c h lm
C o the c d ton th u a n g d th a n n ao va tie u nao
H igu u n g ch o a n c h o it h o a c kh on g cd, ra t h ie m khi b a t c h a t tu a n g phan
K et qua h in h a nh d iffu s io n ?

- C h an d o a n phan b i e t : n h ie m to x o p la s m a ? lym p h o m ( b at c h a t tu a n g p ha n ) ? co th e p h a i s in h t h i it

T 2S E

A
 Benh saccoit n§o, mang nao

.0 3 b ilt tru d c b $n h saccoit: t6n th u a n g ph6i, hgch p hi dgi

vi§ m m £ n g b6 d£o, vi6m da k h d p
Ho$c khOng b ilt t r u d c c6 b |n h s a c c o it : ch inh t&n th u a n g n ao - m a n g n a o g iu p p h a t h ign b enh

-T in th ira n g n§o : . N h ilu u h gt v ilm , kich th u d c tren 1 cm ,

. O n a i t i l p g idp c h it t r in g / c h it xdm
. B it c h it tu a n g p hd n m gnh

vd / ho0c t i n th u a n g m dng n 3o V ilm m dng n3o n en so

. T h im n hie m c i c c i u true n ao lan ca n : sa n nao th a t 3, cu o n g tu ye n ye n . d di th a o n hg t
. V ilm m in g n §o vu n g vb m n ao : kh a n an g vie m d a y m ang nao, g ia m tin higu T2
. C d c kh 6i n ao v ie m lan cgn

- Mdng c u n g d dy lan t6a, r iln g I I h o £ c k e t h o p v d i c d c ton th u a n g n ao

Kh6 c h in dodn h o £ c kh on g the ch an d o a n tre n X Q C L D T : n h a m lan g iu a ta n g d a m do cu a m a n g n ao vd b an tro n g h op so

T r ln C H T : H in h T1 b in h th u d n g ; tre n T 2 c d c kh oa ng d ich q u a n h nao d d y t u 3 - 5 m m .

C in c6 ch u6 i x u n g sa u tie m : b a t m g n h c h i t tu a n g phan

V ilm m dng n ao d o b gn h s a c c o it ; ch an d o a n d u a tre n c a c vj tri khac, hgch , phoi

MOt y lu to tre n C H T g iu p ch an d oa n : cd c ton th u a n g m a n g n ao tro n g b en h s a c c o it g ia m tin h ieu tre n T2

B$nh saccoit mang nao : hinh thai khong dien hinh tren CHT ; cac ton thu’ang lan rang den doc yen (clivus) va ong song

Cac benh tu mien, benh he tao keo <■

Benh luput ban do, benh Gougerot, benh Behcet

. Ton thuong nao va ton thuong tuy tuong tu nhu ton thuong xo cung rai rac; CHT khong dac hieu
. Cac nhoi mau nao di kern

T2 F L A IR

B en h
G o u g e ro t

217
 BENH LY NHI^M TRUNG : DO VI TRUNG, DO VIRUT, DO KY SINH TRUNG

Hinh dnh hpc kh6ng ddc h i|u d i i v d i cdc tdn thu’a ng n h ilm trung trong vd ngodi ndo
MOt s6 hinh thdi cOng g ai y b$nh ly n h ilm trung nhung chi nhOng xdt nghi$m sinh hpc m di cho phdp khdng <Jjnh chAn dodn xdt nghidm miu.
xdt n g h i|m djch ndo tuy, vd r i t h iim khi phdi sinh t h ilt nao
Cdc t iin bO v l CHT cOng xdc thu c : hinh Anh hQC k h u ic h tan (diffusion), ddc bi$t phdp do phA cho phdp phdn t*dt dp xe vtn u dgng nang h»yu
hogi tu.

Trong th y c t l . Hodc todn bO : tiin can, 13m sdng, XQCLDT, CHT gpi y benh ly n h ilm trung, do virut hay do ky smh tn jn g .
vd co t h i ly gidi nhu1sau " dua theo t iin can, Idm sdng vd tri|u chUng hinh dnh hoc.
c h in dodn c6 the Id......"
cdc xdt nghiOm sinh hQc se giup khdng djnh hodc loai b6 c h in dodn d l xudt
. Hodc todn b0 : tiin cdn, Idm sdng, XQCLDT, CHT khong giup ly g id i: hinh dnh t in thiro ng trbn.
mdng ndo ddy ... khi d6 ly gidi phdi cdn thdn : " d ua theo t iin cdn, Idm sdng vd tndu chUng hinh dnh hpc.
c6 t h i g pi y gia th u y lt b$nh ly n h ilm trung / do virut / do ky sinh trung "
bdc sT Idm sdng se cho thuc hi$n cdc xdt nghi$m sinh hpc, khdo sdt djch ndo tuy

- A / Mo td t in thuang : . Vj tri, kich thu d c, hinh th i, ddm d | vd tin hi$u, tru d c vd sau tidm
... t in th i/a n g ndo, mdng ndo, mdng 6ng n |i tuy, mgch mgc, tinh mgch, xuang
t in thira ng n h ilu nai ?
. Phu quanh t in thu’ang ? thodt vj ndo ? tdc nghen du’dng lu’u thdng djch ?

- B / Ly gidi tim cdn nguydn :

. Nhiem trung do vi trung khdng ddc hi$u : vi trung th i/d n g, hay n h ilm trung ddc hi$u : lao
- 1 / Vidm ndo tru d c khi tgo mu vd dp xe ndo : c h in dodn cdc t in th u a n g dgng v iin sgu tidm
- 2 1 Tg mu d u d i mdng cung hgy ngodi mdng cung
- 3 / Vidm mdng ndo do vi trung / tru dn g hpp ddc b i$ t: c h in dodn vidm ddy mdng ndo

. Vidm ndo do virut, vidm mdng ndo do virut

- 4 / Vidm ndo herpes
- 5 / Vidm ndo do HIV vd cdc t in thu a ng do h |i chung suy gidm m iln djch gdy ra
- 6 / B$nh Creutzfeldt Jakob

. N h ilm ky sinh trung, n h ilm ndm

- 7 / N h ilm cysticercus, toxoplasma, cryptococcus, kdn sdn ch6 echinoccoccus, listeria, s it rdt, sdn mdng shistosom a..

Qui trinh khdo sdt CHT

1 / - T1 SE cdt ngang
tidm gadolinium nggy sgu c h u li T1
- T2 FLAIR cdt nggng
- T2 * cdt nggng
- Diffusion vd bdn d l ADC cdt nggng : . b 1000 : mu tdng tin h i|u / diffusion hgn c h i
. bdn d l ADC : mu giam tin hi$u
- T1 gado SE cdt dung ngang, dung dpc, cdt ngang
- C6 t h i thg c hipn phdp do pho

2 / Tim nguyen nhdn tg mu hodc dp xe

. N iu dp xe thuy thdi d ua ng : Khao sdt x u a n g da chuoi xung T1 c6 tiem gado bdng cdc Idt cdt mdng, c h u li CISS
DT nhien c6 t h i th i/c hien XQCLOT xu’a ng da :
viem tai gida, viem xi/a n g chum, tiin cdn p h iu thudt TMH ?
. Viem tdc tTnh mgch ndo ? hinh anh dong chay tTnh mgch : TOF 2 0, chuoi xung T1 gado

218
 1/ Vidm nao t r im c khi t? o mu va ap xe ; chan doan cac t h u ’O’n g ton vien

1 .1 : V ie m n d o t r ir & c k h i t? o m u : T6n thuang g iim dO lan toa, dang phu. trong 36 se xu^t hi#n v6 dp xe sau ndy

Ap xe khftng phat thAn ti> mOt tAn thucrng c i/c nh6 : ton thuong viem nao tru a c khi tao mu id [an toa trong d6 se hinh thdnh mOt
mdng sinh mu
Ap xe tiip theo <36 se phdt triln d in d in do hogt d$ng cua mdng sinh mu vd tich tu mu
. ( j giai dogn ndy, khdng bdt hodc bdt c h it tuang phan it
. Hi$u ung chodn c h i vi>a phdi
. Sau tidm, c6 d iu hi$u vidm mdng ndo
. Cd t h i binh thud-ng trdn XQCLDT ( giai dogn sd-m )
. C6 t h i khdi n iu d iiu trj khdng sinh hi£u qud
giai dogn ndy kdo ddi n iu d iiu trj chf ddp i>ng m$t p h in

1 - 2 : A p xe :

, Vung gidm ddm dp trdn XQCLDT, giam tin higu T1 vd tdng tin higu T2 tren CHT, ranh gi<fri rd, thdnh mong vd d iu d$n, bdt tu a n g phdn
phu Idn cdn, higu ung choan cho
. Hodc d iin tiin khd quan : trd Igi binh thuang
Ho$c d iin tiin khdng thugn lai : tgo nang, v6 ddy
. V in cdn diffusion hgn che : tdng tin higu b 1000, phu ne giam ;
. Hdng rdo mdu nao tham thau i t : bdt tua n g phan yeu, khdng sinh chi hieu qud mpt phan

Diffusion b 1 0 0 0 T 1 gado

A p xe :

T 1 . c h it ben trong giam tin hi§u vua phai nhieu te bdo

T2 SE : chat ben trong tdng tin higu
T2 FLAIR tdng tin higu vua phai ... nhieu protein

nhung khong chdc chdn neu khong thuc hign hinh diffusion
= diffusion hgn c h i : . b 1000 : mil tdng tin hieu
. ban do ADC mu giam tin hieu

219
 XQCLOT s a u tiAm

Todn bO cdc d lu hi$u cua dp xe xem bdng

T6n thu a ng n6t thuy tran trai chua ap xe h6a
Vidm ndo tiAn tao mu 6 thuy dinh tra>

XQCLDT sau tidm :

Vidm ndo t)An t ^ mu

Ap xe da 6

Ghi chu :
Neu nghi n g6 giua dp xe vd u
Kh6ng dung cocticoit chAng pftfl
Nguy c o dp xe diAn tiAn nharftl

T1 gado :

Ap xe dien hinh a thuy thdi d ua ng trdi

Phu Idn can : phan ung ?
viem ndo ?
Ton th u a n g thdi d a a n g phdi chua dp xe hba
Vidm ndo that, viem ddm r6i mach mac
Gidn ndo th it. xoa rdnh vo n d o tdng dp
n0 i sq khdri phdt

Yeu to ggi y can nguyen cua ap xe

- A / T im t o n t h u ’O’n g nen sq ho a c vung m at ; l a i ic h ch an d oa n va d ie u trj

■ S M
m
T2 SE 1° echo

T l zavz

Viem tai xu an g chOm cap tinh tien trien tu 2 tudn le. didu tri khang sinh roi phau thuat
- Ap xe lan a tieu ndo phai . tin hieu cua mu tua n g tu DNT
bdt gadolinium khong manh Idm tdc dung cua viec dieu tri bdng khang s - -
- Viem tai xu'ang chum ke can
- C6 the viem tac tTnh mach a cdc tTnh mach bdn cau tieu nao Idn cdn. Id trung gian g iua viem tai va ac »e
Tuy nhien, cdc xoang ben ben phai va ben trai thucrng van con thong thuang

- B / A p xe do d u a n g m au vi tri khong he thong, ap xe da o

Nhidm trung huyet. benh Osier 7
Con lo thong lien that 9 ro dong-tTnh mach phoi benh Rendu Osier 7

220
 D i l n t i6 n c u a £ p x e : khi ndo n g u n g d iiu trj khdng sin h ? c d c y lu t6 trdn X Q C L D T vd C H T

- A / D iln t iin khd q uan :

Khdng cdn b it cdn quang dgng v iin
Trdn chufii diffusion, m it cdc d lu hi£u diffusion hgn c h i vd trd lai tin h i|u tu a n g tu nhu DNT
H ie djch dang h ip thu

T1 gado

C h in thu a ng so hd vung trdn hai bdn, chdy DNT

m$c du dd dung khdng sinh, v ln hinh thdnh dp xe ndo d cue trdn

4 thdng sau, d iln tiin Idm sdng khd quan

K huich tdn b 1000
CHT k iim tra :
- T1 gadolinium :
. Thdnh dp xe khdng b it gadolinium
. Tdng tin hidu dgng c h lm vd gidm tin hidu T2 * 6 p h in trong trdn phdi
khong g a i y dp xe
- Hinh diffusion :
Tin hidu ciia thu a ng ton tuang tu nhu DNT
Gidm tin hieu b 1000, tdng tin hidu bdn d6 ADC
Bdn do ADC
... Cdc d lu higu phu hap vdi dien tiin Idm sdng :
Tien trien gidi p h lu -h in h dnh hoc thudn lai

- B / D iin tien kh on g thu g n ly i

m
V ! /
T1 T2 FLAIR diffusion b 1000 bdn dA ADC

T1 gado dong chay tTnh mgch TOF 2D

U nguyen bdo ddm (glioblastom e) sau ranh trung tdm ben trdi da mo
. B iln chung n h ilm trung hdu p h iu : ap xe nao ben trai cgnh dud ng g iua ngang vdi ndp so phau thuat
d iiu trj khdng sinh tu 2 thdng
. CHT k iim tra : T iin th in khong thugn l a i : dp xe hai ben, diffusion hgn che b 1000 va ban do ADC
Khdo sdt xoang doc trdn :
- Chu6i xung T1 gado khdng giup c h in dodn chdc chdn : huyet k h ii 9 mang cung vidm ?
- Chu6i xung TOF 2D g iiip logi trU gid th u y lt vidm tdc tinh mgch ddng chdy tTnh mgch tdng tin higu

221
 1-3 I T ri£ u c h tp n g h p c : C h a n d o a n c a c to n t h i / a n g d a n g v id n s a u ti6 m

-A / C a c dau hieu h u d n g td i dp xe :

Ap xe :
- MQt hay nhieu ton thi/crng dgng tron, " khong c6 dp lu c "
- Nhieu t&n th i/a n g d ke cgn
- D u di cua so hep, khdng thdy vdch bdn trong : mu / hinh dnh gid vdch ngdn khi 2 dp xe kd nhau
- Thdnh ddy ddu : v6 dp xe
- XQCLDT : gidm ddm <30 nhidu hodc it / chdt bdn trong cd d0 protein cao ; bdt tiro n g p>hdn id< manh
CHT : . T1 : mu ddng tin hidu hodc hai gidm tin hidu ... nhidu td bdo
T2 . mu rdt tdng tin hidu T2 SE. tdng tin hidu vi>a phdi trdn T2 FLAIR, thay ddi tuy theo hdm lu ?n g protein
. Diffusion han chd : mil tdng tin hidu b 1000 vd gidm tin hidu trdn bdn <30 ADC ( " n g iro c tin hidu DNT ” )
Ngoai Id : " mu " dp xe do nhidm toxoplasma / AIDS, tu a n g tu tin hidu cua cdc u dang nang
. Phep do phd : Khdo sdt thdnh nang : binh thu d ng ? khdng tdng choline, khdng gidm NAA
Khdo sdt lactat. lipid, glutamine- glutamat...

. Anh hudng Idn cdc cdu true Idn cdn :

- Hidu Ung chodn ch6 : ddy Idch, thodt vj ndo. trdn djch ndo thdt do tdc nghen cdc d ud ng lu u thdng djch
- Cdc cdu true mdng ndo ddy do vidm : lidm dai ndo. leu tidu ndo. ddm rdi mach mac
- Vidm tdc tTnh mach kdt hap ?
- Vidm ndo thdt. cd the cd tdc nghen Id Monro
- Phu nao Idn cdn : ddu hidu khdng khdc b ie t ... phu ti/a n g tu n hu phu quanh u

. Cdn nguydn ? : . Ap xe cd ngudn gdc TMH ? vidm tai ? viem xu’a ng chum ? phdu thudt m di hodc cG ?
. Nhidm trung rdng ? nhidm trung huydt ?

Diffusion han chd :

. B 1000 : mu tdng tin hidu
m il nhdy : bach cdu, dai th i/c bdo. xdc td bdo
. Bdn do ADC : m il gidm tin hidu

Ngoai Id : dp xe do toxoplasma

- B / C a c d au h igu h u d n g td i c h in d oa n u :

- Tdn thu a ng cd hinh dang khdng deu

- Cd vdch ngdn ben trong
- Thdnh ddy khdng deu ; trong tru dn g hap ton thu’a ng dang nang, phdi tim u tren thdnh
- XQCLOT : chat ben trong long cd giam ddm d0
CHT . T2 SE vd T2 FLAIR : tdng tin hieu rd
. Diffusion gia tang : hoai ti> u giam tin hidu 1000, tdng tin hidu tren ban dd ADC, tin hidu g»6ng DNT
. Phep do pho : khao sdt u tren thanh : gia tdng cholin, hg thdp NAA
- Mdng nao binh thudng, khdng viem nao th a t:
U lan theo du’d ng d u d i mang nhen cd hinh thdi khac vdi cdc ddu hidu vidm mdng ndo

U nguyen bao dem hay di can

222
C h in dodn c6 t h i la u
n h irn g kh d n g t h i c h in dodn
logi u

U t i bdo d im dO a c ca o hod c
di can hogi ti> ?

U nguyfen bdo d$m da nang . Di cdn t h i keo thdi d u ang trdi

. Di cdn dang ddc thuy trdn d6i b6n

C 6 kha nang ton thu ’a n g la u h ogi ti> :

Diffusion b 1000
. Ton thu a ng thuy dinh . thdnh ddy khong d iu , phu xung quanh it
. U te bao dem dp ac cao ? di can hogi tu ?
khong the chan dodn c h ic chan n iu khdng co
hinh anh hpc diffusion vd c6 the ca phep do ph6
. Diffusion gia tang : chat ben trong I6ng giam tin hieu / b 1000
dong tin hieu / bdn do ADC .u
. Djnh vj ranh trung tam, tieu chuan Naidich, ton thu a ng sau ranh trung tam
Sinh thiet qua nga sau:
Giai phau benh : u nguyen bao dem
Ban dd ADC

T1 gado

diffusion b 1000

Nhieu ton th u a n g hogi tu k i cgn:

. Co the la u te bao dem dp ac thap, d iin tien chgm, khong co dau hieu lam sang
. D iin tien m ai thanh u nguyen bdo dem dp IV co bieu hien lam sang

C6 t h i logi tru mdt cach chdc c h in gia thuyet ap xe da 6 trong mQt 6 viem nao lan toa nhd vdo hinh anh hoc diffusion
B 1000 giam tin hi§u tu a n g tu DNT. khdng hgn che diffusion

223
 - C / Cac thu’O’ng t6n dgng vien khac :

- X o c im g r i i ra c th ^ n h m a n g : co th e c6 b at tu o n g phan d gn g v iin

/t i > - v « • '
4
'S . *
V,

V * % •r >
^ "V , •
S. v' *_ ^

T2 SE 2 ° echo

/ T - N h ilu tAn thu’a ng dgng m it myelin

A ' > - Trong m$t p h ln g c i t iat ndy : sau tifim h i|n I6n m#
t in thu a ng dgng viin
£ , ; - K h u ic h tan : tin h i|u thay d ii i t :
y* < j . Diffusion b1000 binh thuOng
\ ..A . . H ai tang tin h i|u t r ln b£n d l ADC
I Hinh thai khfing phu h op v6i ap xe

Diffusion b1000 B£n 66 ADC

T1 gado

- B enh n ao ca p tin h rai ra c

- N h ie m ky sin h tru n g : nhiem au trung san ddi heo (cysticercose), nhiem toxoplasma

T ru o n g h g p d g c b ie t tre n X Q C L D T : m au tu d an g h ap thu d on g d g m d p b a t tu o n g p ha n a n g o g i vi
. Nghi v ln tr§n XQCLDT sau tiem, khong co van de tren CHT ( vien hemosiderin c6 y nghTa )
. Khoi mau tg dang hap thu dong dam do
. B it tu a n g phdn 61ngogi vi cua m£u tg, a vung nhuyen nao quanh mau tg

Khoi mau tg : dien tien tu 8 ngdy tru ac

hinh anh “dgng bia"

- Phan con lai ciia khoi mau tu dang hap thu

- V ln con tcing dgm d& a trung tam

- B it tu a n g phan 6/ ngogi vi,

a vung nhuyen nao quanh mau tu

XQCLDT
sau tiem

224
 - 2 / T g m u d i r 6 i m c in g c u n g v £ n g o & i m a n g c ir n g

- T g m il du&\ m £ n g ci> ng

Ld su tich tg mu d u d i ho$c ngoai mang cung

Phdi tim nguydn nhdn trong vung I3n c$n : - Vidm xoang tran, vidm xu an g chum, tinh trgng rang hu
- Nhdi mau tTnh mgch, viem mang nao nen sq

T 1 gado

Ty mu d u d i mang cung o’ vung vdm nao va khoang lidn ban cau ben t r a i; CHT kiem tra sau choc dd
. Mu gidm tin hieu rd
. Cy ben phdi, b it gadolinium dang th in g : hinh anh viem t i c tinh mach vd nao ?
. Vidm t i c tTnh mach di kern ? neu khdng cd chuoi xung ddng chay, khdng ly giai d u a c tang tin hieu cua xoang dQC tren
th^nh mang nao cua xoang dQC tren day ten do viem ? ddng chay tTnh mgch binh th u d n g ?
. Vidm xoang tran : cd the ia nguyen nhan cua tg mu d u d i mang cung

Tg mu ngoai m ang c u n g

XQCLOT khdng tidm T1 gado

Hinh dgng hai mat loi

Khoi tg mu bdc tdch cac xoang tTnh mgch
Nhiem trung cd the lan rong den vdm so va cac cau true d u d i da
Tren XQCLOT, giam dgm dQ vua phdi : ham lu a n g protein cao
B it chat tua n g phan mgnh

XQCLOT sau tiem

- C h in doan phan b id t : . Mau tg d u d i mang cung mgn tinh

Tg djch d u d i mang cung . Chan thu a ng so nao. khoi ty dich khdng bat tu a n g phdn
. Di chung viem mang nao mil d tre em
khdi tu djch vo trung. ddm do tu a n g tu nhu DNT

225
 - 3 / Viem mang nao

C h i d inh cu a h in h i n t i h p c :

. H in h dnh h p c d u n g h an g thi> h a i tro n g vip c ch a n d oa n cu n g nhu- t6n g kd tro n g v id m m d n g ndo

... Lam sa n g g p i y ch a n d oa n va ch a n d od n d ir p c x d c d jn h b in g c h p c d 6 tu y sAng 6 t h i t Iu tk j
. N eu khong co dau h i?u tha n kinh, kh on g co c h i d jn h h in h a n h hpc
C 6 c h i d in h h in h a nh h p c khi co dau hieu th a n kin h : C ic d au t h iiu s6 t t h i n kinh, nhCrc d iu d£>
C a c d iu tdn g i p lu c npi sp

. N eu co the , n en lam C H T , neu kh on g, co the th u c hipn X Q C L D T

. K h o n g th e th ie u c i c ch uo i sau tie m : neu kh o n g tie m , kh a o s i t c o th e ch o ke t q u i b in h th i/P n g

- X Q C L D T kh o n g tidm : c a c be nen so d on g d am do n en kh o ly giai, h o d c h in h X Q C L D T l i b in h th ird m g

- C H T kh on g tie m : X oa c i c ranh v o n ao tre n T 1

tren T 2 S E e ch o 1 v i e c h o 2 co th e n h im l l n g iu a . T d n g tin h idu c iia D N T b in h th irP n g
. C ic d iu h ipu vie m c iia m d n g ndo
tren T 2 F L A IR : ta n g tin h ieu cu a c i c kh o a n g d u 6 i n h e n , p hu n ao lan cdn
- X Q C L D T va C H T sau tiem :
T o in bo ca c ca u true m a n g n ao b i t tu a n g p ha n m p n h v i lan t6a :
. D a y k h o a n g d u b i n hd n v i m a n g c u n g

C
. K ha nang co v ie m n a o th a t va v ie m cd c d am roi m a ch m a c

. B ien c h u n g ? - T i c n gh en c a c d u o n g lu u th o n g djch n g o ii n ao : tra n djch n a o th a t th d n g th u a n g

- A p xe ndo, vie m t i c tTnh m a ch ... n g u yen n h in h a y h$u q u d cu a vie m m d n g n d o ?
- H ie m khi co vie m d on g m a ch n h ie m tru n g vd n hoi m iu nao

. C a n n g u yen ? Dau hipu - V ie m tai giO a, vie m x u a n g ch um , vie m xo a n g t r i n va x o a n g bu’d m ,

- N h ie m tru n g rang ...
- C han th u a n g so nao, co khi kh on g h a y b ie t ? c h a y nu’P c m u i ?

. C han doan phan b ig t neu kh o n g co du d u lipu lam sa ng :

G ie o rd c u a m ang n ao do di can the o d u a n g d a a i n h$ n : u m d n g ong noi tu y, u n g u y e n b ao tu y

V ie m m d n g nao

T1 g a d o

/T f c .

& • */•

T2 SE T2 FLAIR

- NhUc dau nhieu. roi loan tn gidc roi hon me

- Kho ly giai neu CHT kh6ng tiem

G o' y c h in doan : nhoi mdu v6 nao do gian- tru 1_rong mdu

CHT sau tiem khong the thieu

Dau hi#u viem khoang mang n§o d i/o i nhd«-
Phu nao lan can vai cac ton th ira n g nhier- -nang n§o

- Choc do that lirng viem mang ndo do lien cdu

T1 gado

226
 T1 gado

CHT : . Cdc hinh khong tiem : Tang tin hieu a nhan duoi va b6o s lm ben phai : nhoi mau nao khong dien hinh ? chan doan khac ?
Gian ndo that, cac ranh vo nao binh thu’ang tren T1, gian tren T2, ly giai ?

. T1 gado :
- Todn bo khoang d u a i nhen tang tin hi£u va day lan toa
c h in doan hi£n nhien Id viem mang nao .... trong tru a n g hop khong tiem co the bo sot chan doan viem mang nao
- Tdng tin hieu O' cac xoang tTnh mach sau tiem lien quan tai dong chay tTnh mach binh thu a ng hoac viem thanh xoang
do viem t i c tTnh mgch ; co the thu c hien mot chuoi xung dong chay tTnh mach TOD 2D de xdc dmh chinh xdc tinh
trgng thong thu a ng cua cac xoang : xoang doc tren, xoang th in g

Liru y tdng tin hieu tren T2 a nhan duoi ro rang la nhoi mdu trong vung tu a i mau cua cac dong mach van do viem dong mgch nhiem trung
gian ndo t h it Id m$t tru an g h ap trdn djch nao t h it thong thu’a ng do t i c cdc d uo ng dich quanh nao

DNT : ViSm mdng nao do phe cau trung

227
 Trirfrng ho-p d£c bi£t: chin do£n " vi6m d£y mdng n§o

a / - T in g kd c h u n g n h u c d iu m an tin h dO d0i. kh dn g ch ju d u o c , x u it h i$n khi th a y dAi t i/ t h i

... HQi chi>ng ha d p nQi s q " t y p hd t " h o $ c sau ch Q c dd tu y sd n g :

- " Rf DNT " : rd DNT kdo ddi do nhidu nguydn nhdn khdc nhau
. C h in thu’ang sq ndo, cd t h i nhe vd khdng de y d in , tiin cdn p h iu thudt ndo .
. Cd giai doan m it nude c ip tinh
. Ong sdng : cdc dj dang hiem gdp cua cdc bao r i th in kinh vd dd DNT: CHT n gi/c vd thdt li/n g
. Bdnh Marfan

- CHT : . Hinh dnh hQC T1 vd T2 thu d ng Id binh th u d n g ... cd t h i bd sdt c h in dodn n iu khdng cd chuAi sau tidm
. Cd t h i t h iy v iin djch tdng tin hidu trdn T2 SE, t h iy r6 han trdn T2 FLAIR
. Sau tidm, mdng cUng ddy d iu
. Cdc c iu true du’dng giua sa vdo lo b iu dye vd lo c h im Idn

- DT nhien cd the c in d iiu tri vi nhuc d iu khdng chju d u a c : *

Blood patch : tidm mdu vdo trong bao mdng cung mQt hay n h iiu lin

r r \

t •

<

b / M ang c u n g d d y lan toa , rieng le h o a c ke t h o p v d i ton th u o n g nao

. Khd hogc khdng the chan dodn tren XQCLDT : nham lan g iua . Tang dam dQ cua mdng ndo
. Bdn trong cua vdm sq
. CHT : hinh dnh tren T1 binh thu d ng ; tren T2 cdc khoang djch quanh ndo ddy 3 - 5 mm
c in cd chuoi sau tiem : bdt mgnh c h it tua n g phan

C d n ngu yen :

- b 1 : Tg dich d u o i m a n g cu n g , mot ben hoac hai ben, cd the tim d u a c nguyen nhdn hogc khdng

\ '

1 1

Di chung mdu tu d u d i mdng cUng hai bdn, cd voi hoa mdt p h in

CHT trong tdng ke nhu c dau lau ngdy
Ton th u a n g r i t cu, cd the tu tru d c khi sanh : vom so ben phai mong di. hoi moc (uncus) thdi d u a n g thodt vi "-.a~ : nn

228
 b 2 : V i6 m m d n g n 3o do nhiSm trung hay d o vi6 m : iam sang, choc do that lung

- B$nh saccoit

a n * A

V45 v ■«± t

Vi6m mdng n3o saccoit ; c h in dodn dua tren cdc vj tri ton thira ng khdc, hach, ph&i
MOt y lu t6 CHT giup c h in dodn : t6n thu a ng mang ndo saccoit hien ten dang gidm tin hi$u tren T2

- Vi&m mdng nao ; ti&n c3n : AIDS dang d iiu trj

T 1 gado
Tdi lieu ciia Vai de Grace

TSng tin hi$u to cdc d u true mdng nao ke c$n cuong nao vd cdc th in kinh v$n nhan chung vd than kinh sinh ba.

- b 3 : U m £ n g n ao nhie u n o i lan toa : bgnh d a u s o i tha n kin h tip II

. Tien can : b $n h da u s o i tha n kinh tip II

. T6n thu ’a n g to a n bo m a n g c im g va u m ang n ao x u a n g d a -clivu s ben phai lan den o ng tai trong.
. C in phan b ie t v o i u m a n g n ao nhie u n o i ngan each nhau b o i n h u n g vu ng m ang n ao b in h th u o n g
. P h6i h o p v o i c a c u d a y th a n kin h, c a c u cu o n ca n h nhie u n o i

- b 4 : Di ca n d o g ie o r i c th e o d u frn g d u a i nhen
mang cu ng vd cac khoang du’dyi nh£n ddy lan toa nhung khong deu

229
 T r u o n g h o p d a c b ie t . la o n a o , la o m £ n g n a o

- X u lit hien bdn ca p h o a c m an tin h o m o t n g u b i cb h o d c khbng cb m o t tAn th u o n g lao ngodi n do :

vie m hach, la o phoi, viem thd n so ng - d ia d em ...
- C a c the gidi phau - h in h a nh hpc : . V ie m m d n g nao d o lao, vj tri th u b n g g dp : be d d y thj - g ia o th o a thi
ich lo i c iia ch ub i T2 F L A IR tro n g c h in d oa n v i£ m m d n g n do c ^ c v u n g vb m ndo
. L ao ke nao
. (C dc) u h at - K hb n g cb ba d au (ca se u m ) b tru n g tdm : h inh dnh thu o m g tAn dang ddc
- C b ba dau (ca s e u m ) b tru n g tam : h in h d nh th u o n g tb n d an g viAn
. D ien tien th a n h 1 h o d c nhieu cu lao, n h it Id b hA sa u :
. D ien tie n ban ca p
. H in h anh " vo h a n h " sau d o vbi hba th a n h d d m / tha n h khbi

Vi£m mang nh^n

Be ddy thj-giao thoa

(Cdc) u hat - Khong co ba dau (caseum) a trung tam : hinh dnh dgng thu o ng tAn ddc
- Co ba dau (caseum) o trung tam : hinh dnh dgng vien

T 1 gado ( Vai de Grace t

Vai de Grace)
Cdc cu lao : giam tin hieu T2 do voi hoa mot phan phdi khdng dinh Igi bdng XQCLOT

230
 - 4 / V i§ m n § o , v i§ m m a n g n a o d o v ir u t

a/ Vi6m n§o do herpes :

- Virut herpes sim plex logi HSV1

- Sa n hiim hodc tdi hogt m ^t virut tiim I n tgi cdc hgch Gasser.
- Ldm sdng goi y : moi tuAi, s6t, nhi>c d iu . th iiu sOt th in kinh d iin t iin nhanh
Ho$c Idm sdng khdng rd r 0 t : - T h iiu sOt th in kinh ridng Id vd d iin tiin nhanh, roi logn tri gidc
- Cdc t h i tdm th in
- HOn md trong vdi gib
- Xdt nghi$m sinh hoc cO gid t r j : khdng t h i

- D iiu trj k h in c ip b in g zovirax : 6n djnh cac t in thu’ang v i mdt gidi p h iu , cdi thign cdc d iu higu lam sang

- XQCLOT hodc CHT : . Viem ndo hogi ti> vd cO khd ndng c6 x u it h u y it, tiin triin thdnh nhung t in thu’ang teo ndo vlnh v iin ;
di chung gidi p h iu vd ch uc ndng thu’ang Id tr im trong
. T in thuang . Dgng phu : gidm ddm d i tren XQCLOT, gidm tin hidu tren T1 vd tdng tin higu trdn T2 CHT
. Dgng x u it h u y it : tdng ddm d$ trdn XQCLOT, tdng tin hidu T1 vd giam tin hidu trdn T2 CHT b trung
tdm t in thu’ang

- b / Cdc viem nao khdc :

-Vidm ndo do virut " theo miia " : xudn, hg

virut cum : d iu hi#u Idm sdng cua hOi chung mdng nao, cO the la bgnh canh vidm ndo
- Vidm ndo trong d iin tien bgnh sai, thuy dgu, zona : viem tiiu ndo do virut
- HIV / s a nhiem : c h it trdng, thdn ndo, hgch nen
- Cytomegalovirut : t in thu’ang phu, v iin tdng tin higu quanh ndo t h it
- Vidm ndo nhdt bdn : t in thu’a ng d ii thj hai ben, thdn ndo, tieu ndo
- Enterovirut : h i sau, sUng tru-O’C tuy s in g
- Vidm ndo Nipah : liim den
- Ebstein-Barr v ir u t: t in th u a n g lan toa cdc hgch n in
- Vidm ndo mgn (viem ndo Rasmussen) : Sai : viem tiiu ndo
_______________ t in thu’ang viem vo ndo, teo thuy hay teo bdn c iu mpt ben.________________________

Nghi ngd- vidm n ao : qui trin h kh ao s a t C H T

- T1 SE cdt ngang - T2 FLAIR cdt ngang - T2 * cdt ngang

- T2 FLAIR dUng ngang: tu cue thdi dua ng d in nga ba ndo t h it
- T1 cdt ngang gado
- N iu cO the - T2 SE 2 echos cdt ngang - T 1 gado dung ngang

1 1 Vi§m nao do h e rp e s : vj tri d ien h in h cu a ton thu’a n g : he th o n g vie n (lim b ic)

- a / . Thuy ddo, hdi md, hoi thdi du-ang trong, cac nhan xam trung tdm,
bO trdn cua thung lung Sylvius nhung cung cO vj tri khong g o i y : thuy dinh, th iiy c h im
. T in thu’ang m$t hogc hai ben, khong d ii xung
. Cdc t in thu a ng khdng tuan thu vung tuo-i mau dgng mgch va nhu1the co the phdn biet d a o c vai nhoi mdu
C h in dodn n h ii mau tTnh mgch / huyet k h ii tTnh mach nao co the kho han : nhoi mau phu hay p h u -xu it h u y it
... Trong truOng hop nghi ngcr, khao sdt cac xoang tTnh mgch bdng XQCLOT-Mgch Mau hay CHT-Mgch Mau.
. Hi$u Ung choan c h i thay d ii, m uc do trung binh

- b / Cdc d iu hi$u viem cua mdng nao : liem dgi nao, leu t iiu nao, thung lung Sylvius, mang ndo vung vdm ndo

Y« */'■; I '
s

XQCLOT khdng tiem : . . . . . J.2 Spin Echo .

. Giam dgm dO phan trtjpg thdi du’ang Tdng tin hieu a thuy dao va a hai ma ben trai
. Giam ddm do a thuy dao bdn trdi Tdng tin hieu va phn dai thuy dao ben phai giup cho chan doan
Hieu ung choan cho it

2 31
 NhLKC d lu dO d ii r i i h6n me : vi§m n3o do herpes dien hinh

CHT k h in :
T2 FLAIR : TSng tin hi$u 6- tr£n-theii dipong- thuy dao b§n tr£i
T1 gado : B it chu y lu 6 c h it xam

. TiSu c h u in phdn bi$t gi&a viem n§o herpes n h ii m£u nao :

. T in thu’a ng herpes khdng tuSn thu vung tirOi m£u dOng mach
. Diffusion hgn c h i it, tang tin hi0u b 1000, giam tin hi?u vi>a phai tr§n b£n d i ADC

diffusion b 1000 ban d i ADC

V ie m n ao h erp e s
. Tang tin hi$u a thai dira ng giu’a va c y c thai d i/a n g ben trai : vi tri khong theo vung tu-Oi m ^u dong mach
hon hop giu’a vung ti/a i mau cua dong mach nao giu’a va vung tirOi m£u cua d in g mgch nao sau
. T in thu’ang thuy dao va phan trong thai d uo ng ben phai. p h ii hop dien hinh cua viem n§o do herpes

/ '' y & v

! ■> ' * j p

T1 T2 FLAIR T2 SE
V ie m n ao h erp e s
T 1 : G iim tin hi$u thap phan trong thai ducmg ben trai. ket hap mpt vung nho tSng tin hieu : t in th u a n g co mOt phAr r u l t h u y it
T2 : T in thu’ang phan trong thai d u a n g va phan trong thuy tran 2 b a cua thung lung Sylvius, t in th u o n g d & thi sau

232
 - 5 / A ID S : V i6 m n£o d o H IV vd c£ c t6n th ira n g p h£ t sinh

- Scr nhi&m : viSm nao Ian t6a do virut

. XQCLOT va CHT binh thirdng
. Trdn ly th u y it, c6 the c h in doan tr§n CHT do c3c t6n th i/o n g Ian t6a tang tin hi$u trSn T2
. Khdng thudng xuydn : b#nh nao ban c ip : - Tang tin hi$u 6 c h it trin g / v6ng t h i vu-d6i thj : r& loan nh£n thtfc
- Lui b$nh sau d iiu trj bang 3 th ir thudc

- Cac t6 n th u’O'ng phat s in h do HIV

. T6n th u ’O’ng nhiSm tru n g . Ap xe do vi tru n g th ird n g , ty mu

. Lao k§, u hat, vi§m mang nh$n a cac b i n in so

. T6n thu o ng vi§m : B§nh c h it trin g nao nhi&u 6 tiin triin

- Nga ba nao, trung tarn ban b iu due
- Tang tin hi$u T2 6 c h it trin g
- Kh6ng b it tuo n g phan trir khi t6n thiro ng hogi ti>, b it 6 ngoai bi6n
- Dien t iin ti> vong trong v6ng 3 thang

. Tdn thu o ng v ir u t: Vi£m nao do cytom egalovirut CMV : viem mang 6ng nO* tuy hoai tip, b it ti/o n g p h in

. NhiSm ky sinh trung : - N h iim toxoplasma : . T6n thu o ng dac, t6n th iro n g dgng nang : . No-i t iip giap c h it trin g / c h it xam
. U hat b it ti/crng p h in
. Thud n g gap ... di&u trj khang toxoplasma neu chu’a phan bi$t d irp c nhi£m toxoplasm a vdi lymphom
dap irng di&u trj trong vdng 10 ngay
. Ap xe do toxoplasm a : tru’O’ng hqyp dac bi$t tren diffusion : diffusion gia tang, tin hi$u n h i/ cua DNT
- Nhiem cryptococcus : vidm mang nao, nang gia / khdng b it thuoc tu’ong phan sau t)6m
- Nhiem n im : aspergillus, actinomyces

. Phat sinh u Lymphom nao ... Dien tien nhanh, c in sinh thiet nao
Neu nghi n g d ... khdng dung corticoit vi corticoit iam thu’ang t6n khdng cdn b it thu6c va sinh th iit dm tlnh
- B$nh Kaposi

. Nhdi mau nao thu phat sau viem dong mach nao

- 6 / B $nh C re u tzfe ld t Ja ko b :

- Viem nao t h i x6p c6 t h i lay nhiem

- Cac lo g i: t h i . Ca l£ t6
. Do t h iy thu6c
. Gia dinh

B iin the (1996) : Viem nao the xop & bd

- XQ C LD T : G ia m d $m do d beo sam va phan sau cua doi thj hai ben

-C H T T 1 v a T 2 : Tang tin hi$u

Hinh anh dien hinh cua ton thu o ng : hinh th a i" moc hockey "

234
 - 7 1 Nhi&m ky sinh trung, nh ilm n im
TAn th i/a n g d ii dang giAi phAu x quang : - TAn thira ng n§o dang dac hoac dang nang
. Phu ISn c£n tuy theo hoat tinh cua ky sinh trung
HiAm gSp, viSm mang nao Ian toa hay ton th i/o n g mang nao khu tru

N hiS m Au tru n g s £ n d a i h e o m 6 th £ n k in h : 60 - 80% cac t r u in g hgrp n h ilm ky sinh trung A nao bA

.A u trung san dai heo (taenia solium); ky chu trung gian : heo
Vj trl Nai tiAp giap gi&a chAt trAng-chAt xam, tAn thu-o-ng tr§n va d i/6 i lAu
C6 thA c6 tAn thu-ong trong nao thAt; c6 kha nang gay tran djch nao thAt d p

4 giai dogn : - Cac nang : . Nang bAu dye, thanh mAng, kich th ir6 c trung binh 5-15mm, thAy dAu cua Au trung
. TAn thu-ang c6 kha nang rAt nhiAu va l&n
. NhiAu nang, hiAm khi m$t nang
, TAn th u ^ n g phat triAn ch$m, it hoac kh6ng gay phu; dAu hi£u lam sang trA
- Cac nang thA keo / Au trung thoai h6a : djch tang dam dQ v6i vA bao day, bat tu’ang phan
- Cac nAt dgng u h a t : thM ky thuySn giam; thA tich va bat tiro n g phAn giam
- Cac nAt v6i h6a

Hinh Anh h<?c : . OAm dA va tin hi$u tuy theo giai doan tiAn triAn
. Lu’u y : T2 FLAIR : nAt tang tin hieu, chuAi nay nhay de tim cac nang trong nao thAt

11 gado
T1 T2 SE
XQCLDT sau tifem ,
Cac nang, cac nang the keo

235
 - N hi& m T o xo p la sm a

. Th6 chu sanh (tri/6 c va sau khi s a n h ): t6ng k§ tran djch nao thdt
. Tr§ em, ngiFdri I6n : phat hi^n tinh ci r n h ilu v6i h6a trong nao, d$c bi$t « dgng vAt m6ng tay »
. B$nh nhan HIV + : th& c lp tinh
- Thirfrng nhi&u t6n thira ng , gap chu y&u i r . N oi ti6p giap v6 - d i/6 i v6
. & nhan xam trung tarn
. Nhi&u u hgt vi§m . 12 : Tang tin hi§u nhi^u nai, u hgt trung tam giam tin hi$u hem
T 1 gado : bat c h it tiro n g phan
. Sau d6, c6 kha nang c6 ap xe do toxoplasma : . C h it b6n trong I6ng kh6ng ph^i ia mu / dich hoai tir
. Diffusion b 1000 va ban d& ADC tin hi$u khdng <J»ln hinh,
tiro n g t y n hir tin hi$u cua c£c u dang ra n g . cua DNT
- La nhCmg t6n th i/o n g d n phan bi$t v6i lymphom nao; kh6ng c6 dAu hi$u c h ic chan trdn hinh anh hoc
Oi6u trj thi> : d ilu trj dac hi$u, t6n thu-ong do toxoplasma se giam trong v6ng 2 tu ln

T2 SE T 1 gado
U hat <Ji6n hinh do Toxoplasma ( tdi li$u Val de Grace )

-
O i
N h ie m Listeria :
• •
c a c vdt h6a trong n3o
Tran dtch n3o th lt d3 <Ji6u trj

H6 sau / g6c c lu -tie u nao, tuy s6ng co

T6n thu o ng tham n h iim , it gay phu; tien then thanh mOt hay nhieu ap xe do listeria
C h in doan sinh hpc : khao sat DNT; dieu trj khang sinh, cac ton thu o ng giam nhanh

Tdi I«u
Val de Grace

Y k
1f j o• *•

' 4&

T1 gado

236
 Nhi&m crypto coccus : giSn nd c£c khoang Virchov-Robin, vi§m mang nao

- N h ilm histop la sm a

T in thuxrng t ilu n§o, ton thuong tuy song khong d$c hi#u

- S6t r6t nao :

Phu nao nang, xuat huy&t diem, nhoi mau di k6m

- Nhi§m san mang shistosoma : cac u h?t

- ViSm nao do amip :

Kh6i don d$c hay nhi&u kh6i, bat tiro n g phan dgng vien

- Nhi§m n lm aspergillus, mucormyces

. B iln chi>ng viem nao mang nao cua vi§m xoang tran
. Cac v6i hoa trong xoang

237
 T 6 N TH U ’CTNG n a o d o t h o a i h o a

B$nh Parkinson B$nh Alzheimer - Liet tren nhdn tien trien

B0nh Sydenham B0nh Pick - Teo nao nhieu o tien trien
Mua vd'n Huntington - Benh Fahr

1 - B ?nh P a rkinso n

. Khfing d £t ra v l n d& c h in d o d n h in h d nh d oi v ^ i b en h P a rkin so n h a y hpi c h irn g P a rkin so n . 0 6 Id n hO n g ton thu ’O'ng th o d i h6a.
NhCrng t h l tri$u c h u n g Id n go ai le vd th u b -n g di ke m v ^ i tie n ca n vd c a c d a u h ieu Idm sa n g d d c b i e t :
P arkinson c6 n gu 6n g o c m a ch m du, u, ch a n th u o ’n g ( vd sT q u y e n a n h ), n h ie m d p c ..

N lu th y c hi$n kh d o sd t h in h d nh , k&t q u a Id b in h th u frn g h o d c c h i c h o th a y te o n a o m u c d p tru n g b in h vd Ian toa

MQt s6 t r u in g h p p hi£m , ta th d y :
. MOt d lu hi$u kh6 ly g i d i : d a i td n g tin h ieu tre n T1 n dm g iu a c h a t d e n vd n h d n d o bi m d n g di
. P arkinson tri$ u c h u n g : d d u n hoi m d u d an g lo kh uye t, d au hieu u a c a c cd u tru e dudri doi

Tuy nhidn, hinh dnh v in cdn thiet trong tong ke tru’O’C dieu trj / ddt cac dien cue kich thich than kinh tai cdc nhdn dirdri d6i ;
CHT g iup loai tri> m p t cd ch c h d c ch d n m p t ton th u o ’ng n g u y e n n ha n v d de lo ai tn> c d c d i c h u n g cu a n h o i m a u n d o tro n g v u n g tu,6'i
M lu cua cd c dpng m geh van. K hi do, h in h d n h h o c c h o th a y vd c u n g n h d m cu n g c a p to n g ke v e g ia i p ha u : te o ndo n h ie u khPng ?
DO I6ti cua nao t h l t 3 ?

Tnrd'ng h p p d g c b i$ t : . B e n h S y d e n h a m : to n th u o ’n g td n g tin h ieu T1 vd T 2 a c d c n h d n dau

. M u a vcrn H u n tin g to n : ton th u o ’n g th e va n
KhSo sdt h in h d n h h p c ca n thu ’C h ien t r u a c , khi c o c h i d in h ca n d ie u tri b dn g g h e p n o ro n h o d c d ie u tri g en

• C lc qui trin h kh d o s d t C H T :

. M$t p hd ng cd t n g a n g - T1 S E , m a t p hd ng C A - C P Id b d t bup c, de so sa n h v o i a tla s d jn h vj ba c h ie u (s te re o ta x y )

- T2 F L A IR , ch u ye u m d t p h d n g C A - C P
- T2 TS E 2 e c h o : h in h d n h e c h o t h u 1 d u o i c u a so hep, h in h " tu o n g p ha n "

. Mdt p hd ng d u n g n ga ng - T2 T S E , 2 e ch o , 4 m m , n ha n x d m trung tarn, e c h o t h u 1 ra t tu’O'ng phan

- T 1 In ve rsio n R e c u p e ra tio n ... tu a n g p ha n c h d t trd n g /c h d t xd m 6 v u n g v o n a o to t ho'n 6 vu n g
n ha n xd m tru n g ta m d o ca u tg o h on h p p
- N g o a i le, thu’C h ie n T1 g a d o tro n g ca ba m a t p h d n g n eu to n thu’O'ng kh o n g d ien h in h : u ?

. Trong tu’O'ng lai, h in h a nh d iffu s io n c d c b o s g i than kin h co th e m a n g lai th o n g tin tro n g to n g ke c d c ci> d o n g b a t th u o n g .

Muc d ic h : kic h th ic h th a n k in h c u a p h a n tre n c d c n ha n d u o i doi T1 in v e rs io n re c u p e ra tio n

239
 2 - B£nh Alzheimer

X Q C LD T va C H T cho ket qua khong d a c hi$u, chan doan b#nh A lzh eim er v ln la c h in doan d i/a trftn & m sang
C lc d au hi$u teo nao Ian toa, khong d $ c hi$u, tu’o n g Crng v6\ tu6i cua b ^n h nhan ...
tu y nhi§n chan doan it c h ic c h in neu khong co teo nao tren X Q C LD T hay CHT
ve m $t hinh I n h : kho chan doan phan bi$t vdri tran djch nao t h l t ap ly e b inh th ird n g n hirng ca c d lu h*£u iam sang thl khac nhau

T1 T2 FLAIR T 2 spin echo

3 - Benh PICK : teo thuy tran va thai di/ang

- Tong ke tin h trang sa su t tri tue. roi loan tri n ho \ benh A lz h e im e r: qui trin h khao s i t C H T

- Can nguyen thoai hoa n hu ng cOng co sa sut tri tu? co nguon g o c m gch m au, sa sut tri tu # do nhi£m dOc : rugu

- Chuoi xung nhanh T 1 d irn g doc de dinh vi ca c si>ng thai d iro n g

- T1 c l t ngang trong m at p h ln g ca c s irn g thai d iro n g , spin echo hoa c inversio n recu pe ra tion
= mat p h ln g than kinh - hoc m l t (goc m ui - o ng tai ngoai)
- T2 * c l t ngang - T2 FLAIR c l t ngang - diffu sio n b 1000 va ban do A D C
- T1 inversion re cuperation m at phang d irn g ngang
H oac T2 SE d u n g ngang do phan giai cao. 4 m m . ca c lat c l t vuong goc v o i m a t p h ln g cac sur>g thai d i/a n g
tu’ cu’c thai d u o n g den nga ba nao t h l t

240
4 - Li#t tren nhan tien trien / b en h S teele R ich a rd so n O ls z e w s k i

- Li$t v$n n hd n, sa su t tri tu$

. Chu&i xu n g b6 su n g T 2 6 c h o t h ir 1 m d t p hd ng c d t n ga ng 3 m m q u a cu o n g n a o v a ca u nao

Cdc d£u hi$u c h in h :

- Teo khu tru 6 cu o n g n do

- B& lidn cu 6 n g n o r$ng
- Tdng tin h i§u 6 cu o n g n ao q u a n h c o n g n ao

Cdc d £u hi$u thu 1p h a t :

- T dng tin hieu . C d c ca u n ha t
. C d c lie m d en
- Teo ndo Ian tda p hoi h o p
nh£t Id & trdn vd th d i d m yn g
 5 - B enh te o n h ie u he th o n g (A tro p h ie m u ltifo c a le s y ste m a tise e )

- T e o n ao to£ n d ie n n h u n g ch u yeu c a c to n th ip o n g a cu o n g n § o va c ^ u n §o
- T a i c a c vj tri n ay, tren m a t p h ln g c l t n ga ng , h in h a n h " d a u th ^ p “ d o ta n g tin h i$u T2 c u a c h i t tra ^ g
- G ia m tin hieu ca c n ha n rang
- T e o b e o sam

- T e o tr^ m - ca u - tie u n ao

T e o th a n n a o ro re t C a c n a o th a t b en b in h T j ? - g ^ o a c g ia n nhe
g ia n th u n g lu n g S . . _s j j b phai

242
6 - B$nh FAHR
. BAnh th i/A n g gdp, 6 b$nh nhdn cao tuAi nhung cOng cA thA gdp 6 ngi/cri trA
- KhAng cA twcrng dAng rfl r£t giOa 13m sdng v&i h$i ch im g ngoai thap

. VAi hAa 6 cdc nhdn xdm trung tdm, nhiAu, hai b§n, dAi xi>ng
thdt ra Id vAi hAa A' chdt trdng ngay kA c$n v 6 i c h it xdm
. CA thA g dp thA mAt bAn, c h in dodn khA hern
OAi v6 i cdc thA tiAn triAn, cdc tAn thu’O'ng Ian tAa vd dnh hu’O'ng cd c nhdn rdng vd c h it trdng cua trung tdm bdn bdu due ;
khi cdc tAn thi/o-ng nhiAu, cA thA cA rAi logn nhdn thine d o tAn thu-ong chat trdng

HAi chipng tdm thAn

XQCLDT : cdc vAi hAa o’ chat trdng ngay ke cgn vAi chAt xdm

243
 - Cdc voi h6a trong so nhi&u ncri
. C dc nhdn xdm trung tdm , cdc nhdn rdng
. V 6 ndo : n o i tiep g idp giOa chat trdng vd chdt xdm

- Th& c6 tri^u ch u n g hi£m gdp : h$i ch im g ngoai thap

- Kh6ng ro cdn nguyen

N goai tru* cdc hoi ch irn g F a h r . gia suy can gidp

B $nh Fahr
. C 6 the c6 cdc v6i h6a 6 m pt ben thdy tren X Q C LD T
. C d c voi h6a dr hai ben t h i y tr£n C H T cho phep chan dodn b£nh

* . T . *

’«.
v
O T* * T
/

C d c voi hoa 6 cdc nhan rang

.. . Vd tang tin hieu T1 : protein cao

244
 Xo» ci>ng hai mi

1 HSi ma 4 Si>ng th ^ i d iro n g 7 Beo s3m

2 H6i c$n h3i ma 5 D uoi nhan duoi 8 Dai thi
3 Th& bir (fimbria) 6 T h u y ddo TH Doi thj. NR : nh3n dd

BiAn thd binh thudrng : cdc h6i ndo thdi d iro n g trong T4 vd T5 c6 do ddy th a y d oi / chu yeu 6 chdt xam
H$u qud : Gidm tin hi$u T1, tdng tin hi$u T2 FLAIR dong nhat, hai ben, doi xi>ng, 6 cdc hoi nao T4 vd T 5 ,
C6 khd ndng c6 gidn cd c su n g thdi d iro n g

M S
■ A t*

245
 X o * c i > n g h a i m a : c a c c h a n d o e in p h ^ n b i^ t tr§ n h in h d n h h<?c
c h i n d o a n c ^ c t 6 n t h i r a n g 6 p h lin t r o n g t h ^ i d i/ a n g

C d c d au h i$u t h i n kin h, d p n g k in h m d i
- 1 / N h 6 i m d u v u n g tip 6 i m a u cu a d $ n g m g c h n a o sa u : khdri p h d t d $ t ng£>t, b a n m a n h d 6 n g d an h
- 2 1 V ie m n do h e rp e s : so t, n h ir c d au , ro i lo a n tarn th a n
- 3 1 V ie m n a o hp v ie n : kh oi u tan s in h n g u y e n phat, u te b d o d $m

D § n g k in h lau n g d y
- 4 / X a cCrng hdi m a : d o n g kin h ti> thucr n ho
- 5 / U : u t i b d o d p m hach (g a n g lio g lio m ): d p n g kin h dr ngu'dri tre
- 6 / U m g ch d g n g h an g : th e x u i t h u ye t, p h d t h ie n tin h c a
- 7 / Dj d g n g c h it xd m : la c vj (h e te ro to p ie ), dj d a n g c d c ra n h v 6 ndo __________________________________

-3 1 V ie m n a o h$ v ie n : kh oi u tan s in h n g u y e n phdt, u te b d o d pm

-4 / U : u te b do d p m h a ch (g a n g lio g lio m )
D o n g kin h dr n g ir a i tre

T2 SE T1 gado

-5 / U m a ch d gn g h an g : . P h a t h ie n tin h c a
. T h e kh o n g x u it h u ye t
h o a c co x u i t h u ye t

- 6 / Di d a n g c h i t xa m / v o n ao

Dj d g n g c a c ra n h vo n ao L g c vj c h a t xa m

246
 CAC TON THU’O'NG NAO nguon goc NHliM DOC

N h iS m dC>c rti'p 'u m g n tin h

Teo nao du-dri v6 Ian t6a, d&u d$n, thu’dmg Id ro r e t ; ton thu’O'ng dac biet a phan tren thuy nh<?ng
HOi chtrng G ayet W ernicke : tSng tin hieu T2 a . cuong dgi nao, cac the vii, cdc doi thj.
. chat xdm quanh cong nao
B$nh Machiafava Bignam i : h0i ch un g K orsakoff
- Cdc tdn th u ’O'ng the chai : d£u, than, l6i
- Cdc t6 n th u ’O'ng p h u ; cb th& b i t c h i t t u o n g p h a n
. Hogi tCr h a i b6o s im
. Huy myelin b trung tarn c£u nao

X Q C LD T c6 ti£m T1 Gado

B$nh M achiafava B ignam i : ton th u o n g goi va loi the chai, bat chat tu o n g phan

Benh G ayet W ernicke : tang tin hieu T2

. C ac cuong dgi nao

. C ac the vu, ca c doi thj
. C hat xam quanh cong nao

Teo n ao b n g iro i tre, teo du’d’i vo : gian n o cac khoang V irch ov Robin cua hai ban cau nao

247
 - O x y t c a rb o n : vj tri cdc t6n th i/a n g (y beo nhgt sau d6 d in b6o s lm
cd c t6n th i/a n g giam dam dp tr§n X Q C LD T , tang tin hi$u T1 vd T2 tr6n CH T

- C h a t kh&C : nhiSm d0c kim logi : dong, th ilc / c h it di0t n lm , thuy ngan : t6n thirang 6 tilu nao. chi khdng c6 t6n thi/ang nao
nhi£m dpc cong nghipp : dung m6i : ton thu’O'ng b6o s lm va nhan dudi

- T o n t h r o n g n a o lie n q u a n t o i m a tu y : a m p he tam in, thu 6 c phi$n

. Ton th u a n g cap tinh do viem dpng mgch nao do nhiem d p c : nh6i m au nao phu, nh6i m au nao x u it h u y lt. cac mau tg (j sau
- Vi£m t ilu dong mach cua nhan xam trung tam , benh nao phan p hia sau c6 t h l h6i phyc
- ViSm t ilu dpng mgch cua than nao : tip vong do qua lieu

. Ton thu’o n g Ian t6a m an tin h gay ra teo nao

Ngirdn nghi$n thu 6 c phi$n :

. M au tg n h ilu ch6
. Phu nao Ian t6a

: hon m e sau c a n keo dai ; khong d lu hipu t h in kinh khu tru

. N hoi m au tieu nao, nhieu o nhoi m au a vu ng tiep g iap ca hai ban c£u
benh nao phan phia sau co the hoi phgc
. Khong viem t i c tin h m ach nao

- N h ie m d p c th u o c : - M ethotrexate : cac voi hoa

- H oa tri : viem tac tin h m ach nao
- C yclosporin : bpnh ly phan phia sau co the hoi phgc

248
 BENH LY B|£n DU’O’NG

Cac b £ n h li n g d p n g m u c o p o ly s a c c h a rit : benh H u rle r:

- Teo nSo, gian nhieu cac khoang V irchow Robin
- Phi dai, bat san cac day chang, nhat la o’ ban le so - cot song

- Loan d u a n g c h a t t r in g - th u o n g tha n
Ton th i/a n g mat m yelin gap o loi the chai, sau do 6 vom nao (fo rn ix , roi toi bo vo - gai

B £nh L e ig h : giam tin hieu T 1, tang tin hieu T2, doi xCmg
Cdc hgch nen
Cac doi thj, nhan duoi

Trat dot doi ra tru a c

do bat san day chang
ngang M ac Rae
Hep 6ng song nhieu
. D u o n g clivus c l t ngang
m lu rang

C a c b #n h d o q u a ta i : Q ua nhieu chat d ong : benh W ilson, nuoi an qua d u o n g tinh mach

. Tang tin hieu tu1phat cua cac nhan dau

- Huy myelin do tham thau :

-C dn g<?i Id huy myelin trung tam cau nao ; ton th r o n g Ian toa h en cua chat tr in g : Toan bo than nao
N h un g cQng 6 the chai, cac trung tam ban bau due
-Thip phdt sau cac roi loan bien d u o n g nang : sodium va cac c h it dien giai khac. n lm 6 khoa hoi su e keo dai
 VOM SO, MANG NAO
H in h a nh h pc: - K y th u a t: X q u a n g q u y u o c , X Q C L D T , C H T
- Ly giai: - 1 / V i tri c u a ton thu’O'ng? m a t d o, tin hieu / c 6 tiem thu6c tuong ph^n khdng? kicti thuprc? sA lucmg?
- 2 / C a c yeu to g o i y c a n nguyen: trung ta m cu a t6n thuong cr d£u?
b a n n g o a i, b a n tro n g , tu y x u o n g sq ? m d n g c im g ? n h u m d n d o & n c £ n ?

-1 / T o n th u o n g s p v a / h o a c to n th u o n g m a n g n a o kh u tru:
.1-1 c a c to n th u o n g d o n g d a c: u m a n g n ao , d d y x u o n g trd n b e n tro n g
. 1 - 2 to n th u o n g n g o a i n a o ke c a n v o m sp , h a y to n th u o n g tro n g n d o (u t& b £ o d £ m . di cd n n 3 o )?
. 1 - 3 c a c h in h k h u y e t la n h t in h : . c h o le s te a to m , u m a ch x u o n g (a n g io m e o s s e u x )
. tre e m : u h a t u a e o s in , b e n h H a n d S c h u lle r C h n sb a n
. n g u o i g ia : x o p x u o n g cd g id'i h an ro
. 1 - 4 to n th u o n g h u y x u o n g a c tin h : di c a n x u o n g , da u tu y, s a c c o m , u m a ch t& b £ o q u a n h m a o m 9 ch
(hemangk>p6ricytome)
- 2 / T o n th u o n g toa n bo h o p sp: b p n h P a g e t, b e n h te b a o h in h lie m , b e n h x u o n g h 6 a d a (o s te o p e tro s e )

- 3 / B ie n d oi h in h th e h o p sp: d in h k h o p sp , h o p sp b a t x u n g

da
m Cr di/on da
c6 th4 Id ncn bam c o nhai

m dng cu n g
khoang dir6n mdng cirng (bj bong ra:
khi 6 xdc ch4t)

ban ngodi
tu y v6m s<p
bdn trong

mdng nh£n (Id trong.

la ngodi)
vd khoang dirdri nh$n
mdng nu6i. kh6ng thdy d irp c
vo ndo ; chdt xdm
chdt trdng

XQCLDT vom sp CHT vom sp

m o te b a o d u o i da

x u o n g : b a n n g o a i, tu y x u o n g sp, b a n tro n g

m a n g c u n g , x o a n g tTnh m a c h

XQ C LD T n h ie u h an g d o
- 180 la t c d t
- 0 ,8 m m
- 3 0 g ia y
- L o c m o m e m va lo c x u o n g
- K h a o s a t c a u tru e c a c to n th u o n g
o d u o i c u a s o d a c biet:
. M uc : + 1 50 0 UH
. Be ro n g: h e p / 2 0 0 UH

H in h a n h d o n g d a c: u x u o n g la n h tin h
giu' n g u y e n ca u tru e c a c th o x u o n g

250
Vdm sp: c3c bien the

251
 -1 / Ton thu’O'ng sq va / hoac ton thuo’ng m£ng nao khu tru:
1-1 Ton thu’ona dona dac u mAna nao

Harvey CUSHING

- c a c th e g ia i p h a u -x q ua ng :
. d o n g d a c d o p h a n i>ng ta o x i/ a n g n a i u th a m n h ie m
k h a n an g voi h oa tro n g u, m o t p h ln h o a c to a n bo u: u c £ t m 3 n g n3o
(p sa m n o m e )

- u m a n g nao la nh tin h nhu-ng c6 th e 13 u n g u y e n b a o m a n g n § o dO IV

(m e n m g o b la s to m e d£> IV)
v ie c c h in d o a n th e g ia i p h iu b e n h la q u a n tro n g g iu p q u y e t d jnh c6
th e xg trj sa u p h a u th u g t h a y kh o n g

T1 T2 FLAIR T1 GADO

U m a n g n a o kh o n g x a m Ian:
- tin hieu : ton th ira n g co tin h c h it d o n g n h lt . d 6 n g tin h ie u tre n T1 T 2 = to n th i/a n g to n th ir a n g co tin h c h a t ta n g m at
d o te b ao , b i t g a d o lin iu m d o n g n ha t: u m a n g n a o d ie n h inh
- p h i d ai b an tro n g v a tu y x u a n g s o d o p ha n lin g ta n g x u a n g lie n q u a n t a i s u th a m n h ie m c iia u m a r g - a o
- kh o n g c o p hu n a o q u a n h u___________________________________________________________________________

U m a n g nao x a ~ an

- phu n hu m e .an can,

do chen e c m ach?

- u m ang nac j 2 - m a n g nao

th u y tra n giO a

n h ie u u r r a r g - h z ’ m e n in g io m e s
m u ltip le s ” kh o r-g z ^ a a b e n h u mang
n a o Ian toa ' g io m a to s e d iffuse’
(co tin h t o a r c i/n g tn jn g
g ia n )

252
 U mdng n<Jo dgng mdng:

T1 T1 gado
H in h d nh u m d n g n a o nh6, u x u o n g I6 n : ro rd n g la kh 6 n g c6 thS m n h i£ m u m d n g n§o vd o
tro n g x u o n g n h u n g , v e m a t g id i p ha u b en h, hien d ie n nhie u te b a o u m d n g n 3o

T1 T2 FLAIR T1 gado

U m a n g n ao " r a t xa m Ian ": . th a m n h ie m v d o c d c th u y tra n vd phu n a o nhieu;

__________________. h ie u u n g ch o a n cho: th o a t vj th e ch ai d u o i lie m d a i nao

U m d n g n a o p h a n d o c a o a n hu nhi: b e n h u s p i th a n kin h tip 2

- U m d n g n a o leu tie u n ao Ian len tre n va xu o n g d u o i, va o ho sau
u x u o n g Io n p ha n u n g d o th a m n h iim te bdo u m d n g nao
Ian to a te b d o u den cd c m o te b d o d u o i da
- U m d n g n a o d in h v o m sp xa m Ian v o m sp
c o th e k h a o s a t d o n g tin h m a ch b d n g T O F 2D: d o n g c h a y co b in h th u o n g k h o n g 9
c o x d m Ian xo a n g tin h m a ch d p c tre n k h o n g ?
- T d c n g h e n d u o n g lu u th o n g d jch n a o tu y: g ia n n a o t h l t . D N T th a m v a o n ao

253
 Tang sinh xircyng ban trong xLrcrng tran
b pn h c u a p hg nO I6 n tu o i
c o khci nSng bj nhi> c d £ u v u n g tra n khi c o nhO ng d o i b $n h ti&n tn&n
hOi c h im g M o rg a n i M o re l: ta n g s in h xu ’o n g cu a b3n tro n g x i/ o n g tr£ n , b 6 o p h i, c h im g r$ m Idn g . c d c r6 i lo a n c u a tuy^n

Tcing s in h xu ’o n g g io i h a n & tra i xu ’o n g tra n ; d u o n g g iu a kh o n g l$ ch ; h in h 3 n h 16 ch S u m a i d i6 n h inh

"3 b in xu a n g ”

TS ng sin h xu ’o n g b an tro n g x im n g tran

- the m o hoa

ft m ' j s
t 7 ' 'V

- tien trien thanh

the voi hoa V ^ N u 'y y j

254
 1-2 T 6 n th u ’crng n g o a i nao . ke c a n v o m s o , h a y to n t h r o n g tr o n g n a o (u te b a o d e m . d i c a n n a o )?
Tin thi/ang trong n§o: u te bao (J$m ke can vom so?
- D a y kh 6i u hep
- T ru n g tam khoi u xa vo m so
- G 6 c tie p xu c nhQn
- M ^ n g ci>ng b in h thu-ang
- C h it xa m s a t v o i vo m so
- D p n g va tTnh m a ch bj d a y ra n go ai
- M g t d o te bao it: g ia m d a m d o tren
C T, T1 c o tin h ie u th a p
- T h u o n g kh o n g d o n g n h a t
- it g a y hieu i>ng ch o a n ch o
ton th i/a n g kie u "th a y th e "
n hu m o la nh cu a nao
- P hu d a n g ke
= u?
U te b a o d $ m v u n g c ipc tra n
■ Xu’ong tra n b in h th u o n g . k h o n g d a y m a n g c u n g ke ca n
kh o n g di Ipch c h i t xa m
■ C lu true u kh o n g d o n g n h a t. T 1 co tin h ie u th a p
kh6ng d a y su-ng tra n t6 n th u o n g d a n g th a m n hi§ m
K4t q ua tu 'd n g trin h p h a u th u a t: u tro n g nao, c u c tran
Giai p hau b en h u te Dao sa o it n h a n h (o lig o d e n d ro g lio m e )
p ha n d o ca o
Ton thu ong ngoai nao: u mang nao?
- D a y kh 6i u rong
- T ru n g ta m n g a y tre n vo m sp
- G o c tie p x u c tu
- M a n g c u n g d a y len
- C h a t xa m bi d a y v a o tro ng
- D o n g va tTnh m a ch bi d a y va o
tro n g
- M a t do te b a o nhie u
d o n g d a m d o h o a c ta n g d am di
- Thu'O ng d on g n ha t
- C o h ieu u n g ch o a n ch o ro ret
to n th u o n g " th e m va o
nhu m o lanh c iia n ao
- P hu kh o n g d a n g ke
= p ha n u n g
U m a n g nao
- T o n th u o n g c?a, : -a : xam
- D a y ca c tin h - " a ; 1 vo r a o
- Xuong r^org f
- M ang cu ng * a y <
■
255
 1-3 : C a c h in h a n h k h u v e t s o la n h tin h

Cholesteatom vom so

L a to n th i/a n g lanh tin h . tie n trie n ra t ch a m , kh o n g dau

. x u a t p h a t t i/ tro n g tu y x i/ a n g s q : la m ta c h rp n g b a n tro n g v 6 i b a n n go ai:
co d irO n g vi& n d 6 n g d ^ c n g o a i b i£ n , h in h d g n g “ d a y ly "
. u c h i/a m o h o a c m o h on h o p
. vo i hoa tro n g to n th i/a n g h o a c h ipn d i£ n x i/a n g c h it

. U m ach xu ’O’ng
(A n g io m e osseu x)

La to n th i/a n g h ie m g a p a h o p so ;
. d a u h ie u ti/ o n g tu> n h i/ u m a c h cu a th a n d o t so ng
. h in h th e d g n g tia , to n th i/a n g . co c a u tru e to c h irc ro
. tie n trie n ra t ch a m

n T2 echo 1 T2 echo 2 T2 FLAIR

- V o m s o b in h th i/a n g ... u m a d i/ a i da: d a n g "th a u k in h
. T in h ip u c iia ton th u o n g th e o d u n g n h i/ tin h ie u m o m a d i/ a i da
. M o t n an g c o n on g d o p ro te in ca o se co h in h a n h d o n g tin h ie u o c h u o i T 2 F L A IR

256
 U h g t w a e o s in (G r a n u lo m e e o s in o p h ile )

Khuyet so nhi&u n o i g 3p a tre nhu nhi hogc tren tre em , co tin h c h a t tie n trien
Hi£m khi d ien tien th a n h benh H and S chu lle r C h ristia n n h u n g neu x a / ra thi se tra m trong
- h in h kh uye t "d a n g ban do",
- l6i m l t d o tran h o c m i t bj huy,
- d 3i th a o n ha t d o Ian toa b$nh ly vie m d en sa n n ao th a t III

U hat wa eosin: dien tien trong vong 6 thang Benh Hand Schuller Christian

Hinh anh khuyet sp sau chan thu»o»ng

Ti&n can chan th i/a n g sp nao

ton thu’a n g hon h p p / vie m x u o n g

Cua so
hop so

- X6p xu’a n g g ia i han ro tro n g b en h xo p x u 'o n g S ch u lle r: h in h a nh k h u ye t sp Io n co b a ro d u p e ghi nhan 6 phu nQ’ Ion tuoi

257
 1-4 : Ton th u o n g huy xu’on g ac tinh: di can xu>o»ng, da u tiiy, saccom, u mach quanh mao m?ch
(H em angiopericytom a)
. Di can tuy xipong so:
- c h in d o a n d e tre n x q u a n g q u y i/ o c
- c6 th e c h in d oa n d ir g e tre n X Q C L D T , n e u n h u t h i/c h ipn h in h a nh 6 ci>a s6 h ep
- c h in d o a n k h o tre n C H T ... da s o c a c d i ca n d e n v o m so hoeic n en s o d e u kh d n g d i/ g c n h $ n ra do
tin h ip u kh o n g d o n g n h lt va tin h c h i t chipa m o m p t p h ln cu a tu y x ir a n g sp;
to n th i/a n g co tin h ip u t h l p tre n T1, tin h ipu ca o tre n 1 2 F L A IR v £ b i t g a d o lin iu m

h in h k h u y e t b a kh o n g ro
to n t h i/a n g g ia u m a ch nuoi: H in h 3 n h c h g p X q u a n g Idt c i t
. g ia n c a c ra n h x i/ a n g cua m 6 n g (m ic ro ra d io g ra p h ie )
d o n g m a ch m a n g n ao giO a cu a m $ t m i u b $ n h p h lm :
. th g n trp n g : s in h th ie t c h a y m au
r l t nhie u ... ceich di& n ti&n
to n t h i/a n g n g u y e n ph£t: than, h in h £ n h di cSn
tu y e n vu , tu y e n g iap h u y x i/a n g

T1 T2 FLAIR T1 gadolinium
Hinh anh cua ung thu1phoi da biet / . di cSn nhieu o
. di c3n du’crng kinh 15 mm a x ira n g dinh trai b it gadolinium
... c6 the n h lm Ian va i hinh anh tin h?u cao cua m a trong tuy x i/a n g so; dSy lei c h in doein kh6, chi nghi ngO c h in doein
tren T1 khdng ti§m thu6c tira n g phdn.

h in h a nh h u y x i/a n g
m a n h x i/ a n g v u n tro n g v o m sp tro n g benh
ca n h di ca n (kh o n g th a y c a c m a n h x i/a n g
v y n tro n g t r i/ a n g h g p u m a n g nao )
m a n g c im g bj xa m lln :
. p hu n ao
. xo a c a c ra n h v o n ao

XQCLOT khong tiem XQ C LO T sau tiem

- h u y x i/a n g
- ke d e n d l y m a n g c ir n g v a n hu m d ~a o
T 1 Gado - ke d e n la m d ir t d o a n m a n g c ir n g
p ho i h g p di c a n x u 'o n g v a di ca n m a n g nao - xa m l l n x o a n g tin h m a c h d o c tre n

258
T6n thi/ang nhi&u kh2 n^ng £c tinh ... di can?, u tu y ? , u m a c h t§ b a o q u a n h m a o m a c h (h e m a g io p e r ic y to m e ) ? s a c c o m '

tAn thirang r lt d§ chciy m^u: sinh thiAt blng kim , kh on g sinh th ie t b an g p hau thuat

Hinh einh h uy x i/a n g : b an n g o a i, tu y x i/a n g sp, ban tro n g ; "p h a n t>ng" m a n g n ao Ian rong ra n go ai ton th i/a n g x i/a n g
bat mgnh g a d o lin iu m ... v e h in h a n h h pc, ch a n d o a n d a y la to n th i/a n g a c tin h , kh on g th e c h a n d o a n c h in h x a c h a n

Di Ccin: nhie u h in h k h u y e t so kic h th u ’d c k h a c n h a u , b d k h o n g ro B enh da u tu y: k h u y e t sp da o v o i h in h a nh

_________________________________ ____________________________________________________ "v o n g m o c k h o a " co b a ro net

c h a n d o a n p h a n b ie t c a c h in h k h u y e t a c t in h cua vom so k h u y e t so la nh tinh

cac khuyet sp x u 'O 'n g d in h .c o h in h a n h tu 'O ’n g phan yeu. x a \ ra 6 n g u 'd i gia xop x u o n g giai d o a n dau

259
 - 2 / Ton th u ’O'ng toa n bo hop s o : benh Paget, b^n h hong cau h in h Hem, b^n h n ira n g hoa d i
(o ste o p e tro se )
- B enh P aget

K h o n g c6 h ie n tim n g an lun n en sp C o h ien tu’O’ng a n lu n n e n sp d o x i/ a n g sp trd n 6n mAm

C 6 s i/ phS n ly giCpa:

- d i/c rn g C h a m b e rla in
. kh a u cai c irn g
. b o sa u 16 c h lm l&n

v£

- d ircrn g M a c G re g o r
. k h a u ca i c irn g
. d ie m th a p c u a tra i xin yn g ch im

B § n h T h a l a s s e m i: . n ho i m a u n ao d a o d o d a h o n g cau
. p hi dai v o m so d o h ie n tim n g ta n g sin h h o n g c a u , n en s p t im n g d o i d i/ g c g iir n g u yen

260
-X i/ang hoa da (Osteopetrose): b$nh A lb e rs S ch o e n b e rg

2 61
 - 3 / Cac bien doi hinh the hop sp:
- Dinh khcyp sp hoac hep hpp sp

j \

-r* ' #

# 4
V %L> /

H o p s o b in h thu ’O’ng P la g io c6 p h a lie

"s o nghi& ng"
= b it xirng

- hay dau hinh thap (turricephalie) d inh khdrp s q s<>m

- benh Crouzon: cua khdrp vdnh trfti
- tin g tru d c n g ln , loi m lt
- dau I n lom sp dang ng6n tay, tSng ap npi s q
- kem theo: hpi chi>ng Apert. ti> cht>ng Fallot
S o h in h ta m g ia c
- oxycephalie, dau nho d inh kh 6p so sdrm
cua kh 6p tran

■ S o h in h t a m g ia c H in h a n h X Q C L O T o b $n h n h a n g a y m e to a n th a n , 1 40 la t c o d o d a y 1 m m . tai ta o h in h 2nh

262
T$t sq nghieng: hOp sp khdng d6i xi>ng
dinh khdrp sp mOt b6n ; dong sPm d im n g k h a p v a n h b en trai

263
 Hpp sp bat doi xi>ng

B #n h ly h o p so H 3u q u a cu a m 0 t b $ n h ly n $i so

D in h k h p p s q m o t ben. 1 / Ni>a h p p s p Ion

tg t s p n g h ie n g - b an c ! u n a o Io n - n io u ng th u y m p t bdn n a n g m £ n g n h$ n
tu diet) d i/P i mdng cong

*
di chi>ng T B M M N
o tre em

b en h S tu rg e W e b e r K ra b b e

< - r : ^

’- ■ A '

T e o m o t ni>a h o p s p va n a o tra i

264
 TANG TRirfrC CUA s A n sp

lA m s a n g

- m£t ngCri mui

(J6ng kmh co tien trieu kh iru giac
nhirc d lu vung tran

- ngh^t mui
vi6m xoang t3i di tei Igi
hiAm khi ch ^y nird-c mui
ty mu, vi6m mang nao, ap xe thuy tran

- tdi m5t, nhin doi

hOi chirng Kallm ann - de Morsier:

m it mui, giSm nang tuyen sinh due
(hypogonadisme)

HiNH A n h hqc :

- 1 1 Trung tam cua ton th u o n g a dau?

- 2 / Chan doan can nguyen:

- than kinh khiru giac. m ang cu ng san so

- u m ang nao
- u nguyen bao than kinh kh iru
(e sthesioneuroblastom e)

- xoang sang :
- u bieu bi te bao M alpighi

- xoang tran :
- nang n h ly

- xu o n g tran. tran hoc mat

- u m ang nao
- loan san s g i cua xu o n g
- di c a n

- khoang m ang nao va nao bo

- thoat vi m ang n ao p hia tru o c
do m ui-sang
- u te bao dern c a c tran

3 Do Ian rong cua tAn trsii'ong?

Tinh trang m ang c u n g ' Dir-.h th u o n g kh on g 9 bi xam

Ian khong? nao bo bj day k ^o n g ? co phu khong?
 U mang nao tang truoc
phan loai theo vi tri

- u m ang nao T K k h iiu g iac ---------------------------

- u m ang nao mat tren than x ira n g bipcrm -—
Ian den hoanh yen
den xoang hang
- m !u giu’b’ng triFdc
- c£nh b£ xu’O'ng b im m
- phan ba trong
- phan ba giOa
- phan ba ngoai thop ben tru-dc
- tran hoc mSt

U m ang nao TK kh iru giac Kiem tra h inh anh sau p h lu thu ^t, h £ng nSm r6i m 6i hai n3m
khong co dam dac x iro n g kha nang tai ph£t m& khdng co dau h i£u 13m s&ng
day m ang ci>ng : duoi cua u m ang nao

U m ang n ao cua than kinh kh u u giac

X Q C LD T sau tiem : u m ang nao than kinh kh>_nj g iac

u x u o n g cua mat tre r r a - x ^ a n g bi/crm
«not phong ld n » (b lis te ^ -g i

266
 -Chin do^n phdn bi0t u mdng n§o : logn s3n spi cua xi/ang, benh Jaffe Lichtenstein

- B§nh cua ngi/dri tr£, tien t r iin chgm

- Vdm sp va t in g tru’d c n&n sp: ton th i/a n g nen sq n h i/n g cung co the ton th i/a n g a xoang sang va xoang b i/a m
. t6n th i/a n g dam d£c xi>ang khong dong n h a t : nhieu h inh kh uyet nho va cac ton thu-ang c6 khi (soufflantes)
. t6n th ira n g co the rat quan trong: "c h i/n g x i/a n g m a t su> ti>", loi m lt
- Kha nang c6 cac ton th i/a n g a vom so

- U bieu bi te bao Malpighi

- B$nh ngh& nghipp: ky nghp go
- T6n thi/a n g c6 d ilm kh a i p ha t ti> xoang sang
- C h in doan thi/d-ng la tre
- Sinh th ilt qua d i/d n g xu yen qua mGi

. Hinh anh Ian nhieu va o trong so

. Huy m anh sang

. H inh anh khong Ian vao trong sp

267
- D i c a n XU’O 'ng: tien c5n co ung th i/ th ich di can x ira n g va m ang tin h huy x i/a n g ung th u th£n. vu. t u y in g id p ?

- U nguyen bao than kinh khipu

(esthesioneuroblastome)

- u phat t r iin d g a tr§n c a c t i bao t h in kinh

kh iru giac

- ia ton th u o n g hiem gap

m ang tin h tha m nhiem
Ian den m ang nao ke c£n

- c h in doan nhdr sinh thiet, qua nga TM H

- dieu trj?
- ti§n lu p n g trung binh

- Do mui-sang bam sinh

. C H T du-pc th g c hien trong tong ke m p t u m ach (angiom e cu ta n e) a da vu ng tran va m $t

. khong ch ay n u d e mui
 - N a n g n h £ y x o a n g tra n

XQ C LO T khong tiem X Q C LO T co tiem

tSng dam dp tu p h a t ... nong dp protein cao b at c h it tu o n g phan o cac vj tri

. thanh nang n h ly
di tich xu’o ng : ca c'm a n h x u o n g o thanh sau cua xoang . m ang c u n g ian can
phat trien c i/c ky chgrn: khong c6 phu nao

N a n g n h a y x o a n g tra n k ic h t h im c Io n :

. T6n th u o n g xoang tran Ian den ho nao tru d c ... gia thuyet n g u g c lai it khi xa y ra:
mpt ton th u o n g trong sp khong xam Ian den cac xoang khi
. Hinh anh voi hoa 6 trung tam kho ly giai
. P h lu thuat: ia nang nhay tuy nhien khong dien hinh
. Giai phau benh: nang nhay va boi nhiem nam a spergillus giai th ich h inh anh voi hoa

269
 B $nh ly TR O N G y £ n
TUY£N YEN - VUNG HO YEN t6n th i/a n g d $ c : u tuyAn nh6 (m icro a d e n o * ^ ; cu a tu y6 n y6 n ♦♦♦
hiAm gdp u so h £u tro n g y *o
di Cdn tu y ^ n y4n
v*6m n h t^m tu y ^ n yftn
"n a n g djch " : . u tu y6 n nh6 d a n g nang
. u so hAu trong y6n d a n g nang
nang cua tui R athke
. dp xe tu y6 n y6n
. th o a t vj m dng nh£n tro n g y£ n h6 yftn trdng
. giSn nSo t h l t III
. p h in h d o n g m gch tro n g yfin

B $nh ly T R £ N y £ N :

- u t u y ln to n (m a cro a d e n o m e ) cu a tu y6 n yftn lan I6n tr&n

- u m a n g n ao hoanh y£n, u sg n (c h o n d ro m e )
- u t6 bao d$m di/dxng thj gia c
- u so hau. nang d a n g bi, n a n g d a n g b ilu bi
- u te bao dpm san n ao t h l t III. u t£ b ao m |m . di can
- ham artom ca c c ii v ii
- vi£m m ang nh0n th j-g ia o th o a thj giac. b£nh m 6 b a o X. b$nh saccoit
- p h in h d 0 n g m ach gia u tren y£n

B enh ly B ^ N y £ n :
- u tu y ^ n I6 n (m acro a d e n o m e ) cu a t u y ln y&n lan v d o trong xoang hang
- u m ang n ao cu a xo a n g ha n g , u d a y t h in kinh s in h ba
- u n g uy£n s6ng, di can
- b ^ n h ly viSm , hQi c h u n g T o lo sa H unt
- p h in h m ach d$ng m ach ben ySn, d 6 dOng m a ch ca n h -x o a n g hang
- vi£m xu-ang b ir 6 m , nang nh&y xo a n g b i/d m
- s ir lan r$ng m $t kh6i u tai m ui hong: u bi£u m 6 (e p ith e lio m a ), u so1*
(fib ro m e ) v u n g m u i-h lu

B enh ly D U '6'I Y E N :
- u tu ye n I6 n cu a tuyen y§n lan va o tro n g xo a n g bi/crm
- u n g uyen s6ng, di can
- viem x i/a n g b i/ftm , nang n h£y xo a n g b i/6 m
- s y lan rpng m 0t kh6i u tai m ui hpng: u b i lu m d (e p ith e lio m a ), u s p i
(fib ro m e ) v u n g m u i-h lu

. X oa n g han g d u p e ta o th a n h nhcr s p tach doi cua m ang c i/n g 1 t h i n kin h thj

n en sp 2 g ia o th o a th j gia c
. H in h anh iat c l t di n g ang q ua phan sau cu a h o ye n : 5 ng a ch pheu cu a n a o t h l t III
p ha n sau c ua tu ye n yen a canh d u o n g giO a ben trai 7 k h o a n g p h lu th u a t giCra kjx cu h 6 y&n va
. C a c d p n g m ach p h in h Io n d o loan san d p n g m ach g ia o th o a th j g ia c
8 kh oang g ian cuong
21 d p n g m ach n a o g it/a

- Tu yen yen: lam sang, giai p h iu

- U tuye n cua tuyen yen: - ca c qui trin h ky thuat:

- u tuyen nho, u tuyen Ion

- T ru o n g h g p dac b ie t:
. d p t q u y tu y e n yen
. c a c to n t h u o n g d g n g d jc h tro n g y e n : u tu ye n n ho d a n g nang: u so h au tro n g yen d a n g nang:
n an g cua tui R athke: ap xe tu ye n yen th o a t vi m ang n h e n tro n g yen: h o yen trong: gian n o nao th £ t III
. v ie m t u y e n y e n
. tu i p h in h d p n g m a c h

270
 Leim s&ng
u tuy^n nhd cua tuydn y6n
. 1 1 Cdc d lu hi$u r»Oi t i l t
hy tuy^n y6n
- Tflng t i l t II : thAn kinh thj
- TRH m l t kinh, t i l t s&a III : thAn kinh v$n nhSn
m l t libido d6i v 6 i dan 6ng chung
- GH : horm one than t h l : b£nh to d l u chi ci OM cdnh trong
- ACTH b$nh C ushing d o nguy§n nhSn " tr§n cao" s sp xoang bi^rm

- K h ilm k h u y lt h6c m 6n
- suy nh i/p'c, n h g l nhgt
- hQi ch irn g S hee han h$u s£n
- c h $ m d $ y th i, A i1 * . 5 SP v
b6o phi b tr£ vj thanh ni§n
- dai thao nhat

.2 1 Cdc d lu hi$u thj g iac :

- nhln mb', ban m anh hai th a i diro-ng
- nhin d6i, dan d6 ng ti>, s y p mi

- 3 1 NhCrc d£u sau h6c m lt

trub’ng horp ngoai 1$ chay nub-c mGi

-4 / T in g k§ b#nh da u t u y ln li§n quan n h ilu tuyen noi t i e t :

tu y ln y§n, t u y ln c$n giap,
tuyen tyy, tu y th irg n g than

- Giai phau

- Than x iro n g b iro m , tuye n yen,

- M ang cirn g , c lu true toan the:
tach lam doi . la trong lot than x u o n g b iro m
. la ngoai tao nen thanh ngoai cua xoang hang va hoanh yen
la n ay bao quanh tuyen yen vi va y tuyen yen nam trong m ang cirn g
.. .hien tirg n g chay n i/o c m ui co the xay ra
- T hanh p h ln trong xoang hang: dam roi tin h m ach h inh thanh t ir n h irn g vach ngSn m ang cirn g
. D ong mach canh trong / doan trong xoang hang
. Than kinh: III. IV. VI
D ay T K V (T K sinh ba) : . TK m l t W illis : nhanh tran, 10. mui.
. TK ham tren
. TK ham d iro i
D ay than kinh d u y n h lt t h l y d irg e tren C H T ia d a y III n lm 6 goc tren-ng oa i cua xoang hang
C dc than kinh kh ac d irg e tach ra thanh r l t n h ilu nhanh nho d iro i 1 mm

271
 >- Tuyen yen : hinh anh binh thuong, cdc b iln th4

T1 T1 G ado

- P h ln tien yen d6ng tin hieu tr£n T 1 , bdt gadolinium

- Ph&n h$u yen co tin hi#u cao ( c h it chuyen hoa cua horm on khang Igi nieu), b i t g ad olin ium khdng ddng k&
- Nang nh6 cua tui Rathke, bien the cua b inh thud-ng

T ry c g ian nao - tuye n yen Id m ot t6ng the gidi p h iu -s in h ly

- bdi t i l t horm on
- b i t g ad olin ium ... nhu m o khdc v d i sdn ndo t h l t III
- ghi chu: cu6ng tuyen yen bdm vdo
. hoa c tgi n o i noi giOa tien yen vd hdu yen
. ho$ c tai dogn g iu a cua tien ydn

P han h au yen N ang n ho cu a tiii R athke T a n g tin h i£ u p h ia sau:

h ep h a n ph an tie n ye n phan hdu yen: la la p m o n g p hia sau mfir tu y x ir o n g sp cua m d n h vu fin g
 - U t u y l n c u a tu y e n y e n : c a c q u i t r in h k y th u a t

.XQCLDT

. C hyp X Q C LD T \d xd t nghiem n lu cd th e d u p e thi nen tr£nh kh o n g lam . . nen th y c hien C HT

. X Q CLDT n h ilu hdng dd, I3t c l t d ay 0.8 m m , t£i ta o tren m at p h ln g tran va d irn g dp c
. U t u y ln trong ydn, lan nhe I6n tr§n g idp v d i g iao thoa thj g i^c ; kh o ph3n tic h ca c xoang hang

. CHT

- 1 1 Nghi ngdy u tu y e n n h o / h oi c h u n g m a t k in h tie t s u a

- 3 chu6i khdng the t h ilu : - T1 SE di>ng n g ang 3 m m tai h o ye n - T1 SE d u n g do c 3 m m - T2 SE di>ng ngang 3 m m echo thu- 2
- 2 chufii c6 tinh hO’U ich : T 2 SE c l t ngang vd T 2 SE di>ng d pc

- Ti&m gadolinium k hong? :

. hOi chi>ng m l t kinh tie t sOa : neu I3m sang vd nong d p prolactine r l t g p i y va neu nhu’ng chuoi nay cho thay c h ic c h in c6 u t u y ln nhd
cua t u y ln y§n, c6 the n g u n g th y c hien tie p C H T sau ca c c h u o i T1 va T2
. N&u khdng - T h y c hien 2 chuoi c6 tiem g a d o : T1 S E d im g dp c 3 m m tiem g a d o tren m at p h ln g tr£n vd m $t p h ln g d irn g doc
- L p i ich cu a chuoi "dong" khi chuoi T 2 b in h th u o n g : T 1 G ado nhanh tro n g m at p h ln g d irn g ngang, 3 m m, 6 lat,
th d i g ian m pt c h u o i: 30 - 4 0 giay, chuoi tr u o c tiem ke den chuoi 1, 2, 3, 4 nhanh sau tiem gado

T2 Spin Echo T1 gado 30° giSy T 1 gado tre

hoi p h u c ve lam sang

. P hy nO 26 tuoi, c6 hpi ch u n g m l t kinh t i l t s u a ; . sinh hoa
nong d p prolactine : 130 nanogram . h inh anh CHT
. u tu ye n cu a thuy phai tu ye n yen,
d irP n g kin h 5 m m , c6 tin h c h it phu
. g ia m tin hieu tren T1 tru n g binh, ta n g tin hieu tren T 2 ro
. khdng b i t gado lin iu m

- 2 / N g hi n gd 1u tu y e n la n c u a tu y e n y e n

Chon b ! deiy leit c lt s ir dung tuy theo kich thu’d’c u tuyen Ion th ly dupe tren chudi thir n h a t: 3 mm ? 4 mm 7 5 mm ?

- T2 FLAIR c lt ngan ti> 16 c h lm IPn den dinh vdm so

- T1 TSE dirng ngang tgi h6 yen
- T2 dirng ngang TSE phSn giai cao tai ho yen
- T1 c lt ngang cd gadolinium tgi h6 yen (chudi dong khong co ich Ipi)
- T1 dirng ngang tai h6 yen
- T1 dung dpc tgi h6 yen
• dfli khi cd t h l thi/c hi$n hinh anh ddng dong mach TOF 3D
d ! x3c djnh tn /o c p h lu th$t vi tri da giSc Willis
khi cd chut nghi ngdr ve tui phinh mach: tui phinh mach cd tin hieu thap tren T2 do hieu ung ddng

273
 - G hi chu ky t h u a t : u tuye n n hd : c3 c chudi "ddng" sau tidm ; c3 c c h i djnh

T1 gado

g iay 60 sau tiem 3 p hu t sau tidm

. Chuoi dpng . C h ud i th y c hi$n tr§

th y c hi$n c l t la t trong vo ng 30 giay c6 h i#n tirg n g b inh thu’d n g h6a
60 g i3y sau tiem tin hieu cua u tu y ln
u tuyen nho cua thuy phai tuyen yen
c6 tin hieu t h lp

C huoi th y c h i^n 3 p hu t sau tiem

- C huoi 30 den 40 g iay bao gom 6 lat c l t day 3 mm th d i g ian th y c hien 3 p h iit
tren m at p h ln g tran
dd d £ y la t c l t : 3 mm
dp day lat c l t : 3 mm chuoi T1 S pin E cho
chuoi T1 Spin Echo h ay T1 Echo G radient
- Chudi thu* nhat khdng tiem
- K et quci :
ke den Id ca c chuoi d th d i diem 30, 60, 90, 120 giay sau tiem
. C d s y can b l n g ca c m ir e tu ’O'ng p h ln
- K et q u a : . Neu k h d n g cd c h u d i d d n g ,
. B i t gadolinium d m o tuyen yen b inh thu’d ng
va n e u h in h a n h T2 k h d n g c d g g i y g i c l ,
. B i t g ad olin ium it h on d u tuyen nhd
c h a n d o d n u tu y e n n h d
cd th e k h d n g d i r g e n g h i d e n

U tuyen c6 tin hi§u cao

- U tuyen nhd d ben trai d ird n g kin h 6 m m ... chan doan d y a tren T2 SE
L gi ich cua gad olin ium la g i?
... chudi nhanh sau tiem g ad olin ium b i t thu’d n g nhu’ng khdng ich lg i ... chuoi tre de g a y nham lan

chudi T1 gado nhanh la c ln th ie t... vi chudi T1 gado t r i cung co dong tin hieu

Tren thu-c te : d?t s in dirdng truyen tTnh mach

Neu chudi T2 SE trong mat p h ln g tran cho thay ton thirang tuyen yen va neu nong do prolactin cd y nghTa
- neu nong dp prolactin tren 60 nanogram, cac chudi sau tiem khong phai la b it bupc;
- liic n£y cd the thyc hien them chudi lat c lt T2 trong mat p h ln g c lt ngang de k h ln g dinh t6n thirang
Neu chuoi T2 SE khdng gai y : tiem gadolinium va chu6i “dong' la can thiet

274
 U tu y e n n h o : t ir o n g tr in h k e t q u a

.M6UJ:

. 1 / TAn thu-ang trong tu y ln ygn, thuy trai, kich thutoc (do da c d e danh gia dien ti&n sau dieu tri)
c4u true c6 tin h chat p h ii, T1 tin hi£u h a i th lp , T 2 tin hieu cao, khdng b i t gado lin iu m (it nhat trong giai doan s d m )

- 2 / Cac h£u qua cua tdn thirang : lan r$ng : l§n tren nang hoanh yen; khdng ch6n ep giao thoa thi giac
d l y n he cu6ng tuy&n y6n
. ra ngoai xoang hang cdn nguyen v?n
vao trong da y rat nhe cuong tuyen yen
. xu6ng dip6i lam ha thap san h6 yen ma khong lam m ong vo x i/a n g

K^t lu$n : u tu y ln nh6 cua tuyen yen d ien h inh

S u la n rQng cu a u tu y e n n h o .... u tu y e n Io n

- I§n tr§n : ch6n ep giao thoa thj g iac khong ?

- ra ngodi : day hay xam lan xoang hang ? xem d u a n g noi hai dpng mach canh
- vao trong : day phan tuyen yen b inh th ira n g ? d a y cuong tuyen yen ?
- xu6ng d u d i : ha tha p san ho yen ? lan vao trong xoang b ir^ m ?

D u o n g noi 2 phan D M canh ti> doan

xam lan vao xoang hang tro n g hang d en doan d u a i m ang
nhen cu a D M canh trong

X oang hang ben phai b inh th u a n g

(tin hieu cao m au tTnh m ach /
toe do li/u thong ra t cham )
C o s u xam lan xoang hang ben trai

275
 - 1 / L a n le n tr e n y e n

i t
XQCLDT sau tiem :
. u tu y in khdng b£i t iit T2 SE
c h in dodn rat tre : Giao thoa thj gi£c bi nang l§n, bien
hQi chim g thuy tr£n dang va t£ng tin hieu
u tuyen ton
trong v£ trSn y§n

. c6 phu hai thuy tr£n di k6m

. xoang hang c6n nguyen ven u tu y in Ion xSm lln

. Lan l§n tr&n vd b4n y6n
. X£m lln 2 xoang hang
. Can thi$p qua ngS dirdn tr£n d i lly b6 m$t p h ln
. Trutoc ti§n dinh vj hai xiphong c£nh
va da giac W illis : hinh anh dong TOF 3D;
. Liru y : c6 s y b it san DM thong sau

- 2 / Lan ra ben : xam lan xoang hang

.1 -
- j l

T2 S pin E cho T 1 G AD O

Kiem tra hau p h lu sau can thiep nga xu yen bi/crm

- Vet tich con lai hay tai phat u tuyen Lpi ich cua th yc hien hinh anh kiem tra sorn hau N1 hay N2
dac biet trong truang hpp nghi nga kha nang con vet tich khoi u
- U tuyen v u p t qua duong noi giua doan trong hang
I va doan tren hang cua xiphong canh
- Neu u tuyen bai tiet (lam sang, sinh hoa): co chi dinh xa tn da chum
- Neu u tuyen khong bai tiet theo doi b ln g CHT

276
 - Xdm l i n xoang hang b6n tr£i : s y lan rQng cua kh6i u d u a l doan trong xoang hang cua xiphong canh trong
- O iy thanh trong cu a xoang hang ben phai : xoang co tin hieu dong nhat tren T1 va T2
. T h iy d u y c thanh trong cua xo a n g hang trdn T1 va T2 / khong co s u xam lan va o xoang hang
. C hufii sau ti&m ch o it th d n g tin h o n : khdng cho p h 6 p phan biet g iu a s u tang tin hieu do dong tTnh m ach
va s u tang tin hieu d o lan rong cua kh6i u
N ghifin ci>u tin hi£u cua xoang hang b in h th u d n g &r ben p h a i:
D6ng khdng c6 h o$c rat ch ^m ; xo a n g hang la mOt « ho m au » th o n g noi v o i toan the tTnh m ach nen so
xem giai phau tra n g 17
- T r§n T1 : dong hoac tang tin hi$u t y phat lien quan den hien tu y n g di va o lat c a t : dong tTnh m ach rat cham
- Trfen T 2 : tang tin h ieu ca c tTnh m ach; ca c ddng tTnh m ach khdng du nhanh de tg o nen h inh anh giam tin hieu cua
d d n g chay
- T r6n T1 gado : tang tin hieu ro, dong nhat, th y c ra lien quan d en hien tu y n g cac ddng rat cham
- T rong t i t ca cac chuoi ddng d o n g m ach lu c n ao cung g ia m tin hieu

- 3 / U tuyen lan ; su lan rong len tren, ra ngoai, xuong d u o i ra truoc, ra sau

T1 gadolinium vdi ky thugt bao hoa dd n g : th a y d u o ’C he dong m ach cd tin hieu cao

- U tu y e n « u-a m a u » k h o n g b a i tie t : p h a t h ie n n h o h o i c h u n g u v o i n h u ’n g b ie u h ie n k h a c n h a u
- H in h a n h Io n ro n g c u a h o y e n : to n th u o n g c o tru n g ta m b e n tro n g y e n
- S y la n ro n g . le n tre n : g ia o th o a th j g ia c k h o n g th a y ro , h in h a n h c l t c u t n g a c h t r u o c c u a n a o th a t III
. ra t r u o c : m o t p h a n c o tin h c h a t n a n g , m y c n u o c n g a n g
. x a m la n v a o x o a n g h a n g tra i v a x o a n g b u o m , la n ro n g d e n h 6 th a i d u o n g
- U tu y e n c o x u a t h u y e t it tre n T 2 *

- U tuyen : (Jieu trj / kiem tra lam sang + sinh hoa + hinh anh

U tuyin nho bai tiet : . D ie u trj npi khoa : 9 5 /1 0 0 : ket q ua tot

. Neu th a t bai lam sang va sin h hoa : dieu trj ngoai khoa qua nga xuyen xoang b u d m
. Neu d ieu trj ngoai khoa th a t b a i : xa trj da chum
d ac bie t tro n g tru d n g h o p co n ve t tich cua u trong xoang hang

P h l u th u g t X a tri d a c h u m

U tuy4n cua tuyen yen da m o phau th u a t q ua n ga xu ye n xo a n g b u o m D o m uc tie u trong 3 rra*.

Di vao nga m i£ng. phia sau m oi tren. di vao tro n g ho c m ui D in h vi cac day than k i - 1' th -■*■+
toe tach niem m ac hoc mui an toan 5 mm giO a m uc tieu va than kinh thi
va la th in g g o c v d i xo an g sang N guy c o hoai tu TK thi cc t a
xuyen qua T hanh tr u d c cua xoang b u o m d ac biet la gan r o .a c i ~ g tn
Phan vd x u o n g cua hd yen

277
 H in h a n h hQc u tu y e n h i/ a n g v 6 t h ir g n g th $ n

- B e n h C u s h in g d o t u y in ydn
- U t u y in n h d b ai t i i t , k ic h th u d c nhd, th g m c h i tin h b ln g m ilim at

- C h an doein c d t l m q u a n trpng vi dieu trj n0i khoa khdng phai luc ndo cung h i$u q ua
... cd c h i d jnh c l t b o u t u y in q ua nga xu yd n xoa n g b u d m : c l t n ira t u y in ydn, ban n do ?
- H in h a nh h p c p ha i c h in doan u tuyen nhd d i tranh phai do lu y n g horm on tro n g m au l l y q u a d u d n g th d n g ca th e te c £ c xo a n g da d u d i

- N eu khd n g c h in d o a n d u a c tren ca c c h u 6 i m $t p h ln g tran T 2 v a /h o a c c h u 6 i d d n g sa u ti6 m g a dolinium .

c l n t h y c hi§n c a c ch udi th $ t m udn, 3 0 phut sau tiem : b i t g a d o lin iu m khdng d i in h in h / b i t g a d o lin iu m m u $ n

r
m i
▼V

v* ^ S -
\ JBU !
•
t r' \
T1 tin hi$ u h a i t h i p T2 tin h i§u cao T 1 g a d o 3 phut B$nh nhdn khac :
T 1 gado 45 phut sau tidm :
b it tu o n g phdn dang vdnh,
khdng d iln hinh.

H in h anh h o c cac u tuyen tie t GH : b£nh to dau chi

- 1 / Di h in h : cac d l u hieu sp-mat

. phi dai Id p da, m o te b a o d u d i da, c a , s q : ban ngoai, tu y m a , ban trong
. phi dai cac xo a n g tra n, ca c xo a n g sang, xo a n g b u d m , niem m ac day

U tu y e n cu a tu y e n .
. H o y en " q u a c u n g " : p h i dai vd x u a n g . xoang b u d m . hoa n h yen
. u tu yen cd tin hieu dong tre n T1 va tin hieu thap tren T2. khdng bat g a d o lin iu m , n g a y ca thi t r i
ket q ua tu d n g trin h phau th u a t tin hieu th a p T 2 do h oai ti> va nong do p ro te in cao; kh d n g cd dich t^a'. - j y e t
. lan len tren ye n : chen ep g ia o thoa thj gia c
lan d en p ha n ben yen : xam l l n xo a n g hang ben phai tren m at p h ln g tra n va m at p h ln g c l t ngang
. P h lu th u a t c a t b o m pt p h ln : th u d n g co hien tu a n g tai phat c l n xa tn da chum b o sung

278
 - C a c to n t h i r o n g t r o n g y e n : c a c t r ir o n g h a p d a c b ie t

A/ U tuyen xuat h u y e t: nhoi m au xuat huyet." dot quy tuyen yen "
- B/ C £c ton th u o n g djch trong yen
- C / Viem nhiem tuyen yen
- D/ P hinh dong m ach trong yen

- A / U tuyen xuat huyet, nhoi mau xuat huyet, «dot quy tuyen yen»

Mu d ot n go t d m o t phy nO tre
U tuyen cua tuye n yen khong bai tiet: can thiep khan qua nga xuyen xoang b u o m

M u c ngang dien hinh do lang dpng cac ch at tho a i bien ti> mau

279
 - B / Chan doan ceic t6n thi/ang djch trong y§n

- B 1/ U tuyen nhd dang nang nong dQ protein cao

T 1 gado s6m T 1 gado trfi

D ii n b in c u a mQt
u t u y in x u it h u y it:
mi>c n g ang d iln h inh

- B2/ U sg h lu dang nang trong yen

- Nang ton trong y§n, lan rpng,

c6 tin hi#u cao: nong do protein cao
Nang dupe d in lu-u b ln g cathete de hut h it va de dung
lieu ph£p Curie m6 ke: hoat c h it phong xa rhenium
K ilm tra vj tri cua cathete

- U & th£inh nang bai t iit

a p h in tren cua nang

XQCLDT cho nhieu thong tin han CHT trong viec chan doan u so hau : dong voi dang " vo trung "
... d lu hieu nay khong th iy d u o c tren CHT

T1 T2 Spin Echo T1 Gado T2 Echo Gradient T 1 Gado

- Phat hien tinh c o " ho yen lo-n " o mot ngucri Ion . ton thuong duong thj giac d ud i mire lam sang
- CHT : ton thuong co . tin hieu cao tu phat tren T1 nang chua protein
. tin hieu cao T2 SE khong dong n h it, tin hieu th ip T2 * voi hoa
tuyen yen bat thuoc binh thuong: khong bien doi tin hieu cua u so hau. giai han ben trong mong. tin hieu thae
. ha th ip san ho yen, day nhe giao thoa thj giac

280
. B 3 / Nang cua tui Rathke

- B 5 / Thoat vj mang nhen trong yen : "ho yen trong"

Bien the cua binh thuong, co the b| nhuc sa_ "c c mat
Thay ro cuong tuyen yen ben trong ho ye r *rer 3 mat p -a rg
Ket hp-p (hiem gap) voi u tuyen nho
 - B 6 / Gian nao tha t III "gia u"

CHT T1 : - Gi3n nao t h lt III gia u do hep kenh Sylvius

- M£nh vuong rut ngSn lai. nao that IV binh thudng
chan do£n kho tren XQCL0 ... lQ-i ich cua XQCLDT da hang d6 c i t I3t mong vd tai tao d i/n g dgc

Chup n§o th^t vdi iot :

tiem vdo trong nao th£t qua 16 khoang xu’ong
Hep cu kenh sylvius

Gian n3o th£t III gi£ u

Co the c6 chi djnh m d c£c b& qua da

- B 7 / Ap xe tuyen yen: rat hiem gap

C / Viem nhidm tuyen yen

- C han doan b ln g sinh hoa; C H T it ich lg i neu khong co dau h ieu ch en ep, n ha t la d au hieu thj g iac
- "T uyen yen Ion " deu dan, dong nhat, T1 dong tin hieu, T 2 tin h ieu cao, b i t g ad olin ium
ca c ton th u o n g vie m lan rong den . cuong tuye n yen va san n ao th a t III
. m ang nao lan can : d o c yen (clivus), xoang hang

282
 Benh ly TREN YEN

Cac ton th u o n g

- u tuyen Ion cua tuyen yen lan ve p hia tren

- u m ang nao cua hoanh yen

- u te bao dem c iia g iao thoa thj giac
- u so hau. nang dang bi (kyste derm oide). u quai, u syn (chondrom e)

- u san nao that III, di can khoang d u o i nhpn

- ham arto m cua cu vu

- benh saccoit, viem m ang nhpn thj-g iao thoa thj giac. benh m 6 bao X

- tui p h in h dpng mach gia u

. Lam sang :

- N hin m o m pt hoa c hai ben, ban m anh thai d u o n g hai bSn

- Hoi ch u n g gian nao-tuyen yen
. su y tuyen yen
. dai tha o nhat
. ch am phat trien
- Hoi ch u n g th u y tran
- Hoi ch u n g hang : lipt ca c than kinh sp
dau than kinh V 6 m$t
 U mang nao cua hoanh yen
La vj tri hiem khi c6 u mang nao dcrn d$c ; thudng la u mang nao cua xoang hang lan I6n hoanh yftn
Ch£n doan phan bi£t vd'i u tu y in cua tu y in y&n lan I6n tr&n ySn v i :
I - Chi djnh p h lu thu£t qua nga duett tran n lu la u mang nao
| - Chi djnh p h iu thuat qua nga xuy§n xoang b ud m n lu la u tu y in tu y in y6n

X? trj da chum se kho khan vi g in giao thoa thj giac va cac th&n kinh thj giac

D lu hi$u - Trung tam cua u mang nao ngay trfin y£n

- Tdn trQng hinh the cua h6 y&n, khdng lam r$ng ra
- Lan rQng cua u mang nao dQC theo mang cung I3n can : "dudi" cua u mang nao
- T h ly mang ci>ng day ISn trong ban than k h li u, u mang nao phat triln 6r hai ia cua mang cung
- T u y in ydn bj dd dep xu6ng day h6 ydn, c6 tin hieu th ip hon tin hi$u u mang nao sau khi ti£m gadolinium
- Khdng t h ly cu6ng tu y in ydn

N /

A t J
S M r
iN b

Hinh anh "ch u th a p ": hoanh ydn co tin hi£u cao

sau tiem, d u d i cu a s6 hep, u mang nao cd tin hi$u cao
thay m0t p h ln hoanh ydn vd i tin hieu th ip
Phi dai cac m lu giudng sau

T1 T2 SE T 1 gado

- U m ang n ao cu a h oa nh yen :

Cac dau hieu true tiep :

. Mat tren cua hoanh yen, tuyen yen con nguyen ven
. Llan vao trong xoang hang : la trong cua xoang hang ben trai
. Llan dQC theo mat tren than xu on g b uo m va mat doc (clivus) : "duoi u mang nao"

Cac dau hieu gian tiep :

. T h in kinh thj ben trai bj day len. khong tach khoi voi u mang nao
Than kinh thj ben phai binh thuo’ng

. Cac dQng mach nao tru d c c6 the thay d u o c

%
. Ddng mgeh bdn trai bj nang cao. tao thanh dau an lorn vao u tr£n mat p h ln g dUng doc
. DQng mgeh ben phai tiep giap vd’i u mang nao
... djnh vj tien p h lu , can bo sung vd'i chuoi dong dong mach bang TOF 3D
Day thuy tran ben trai ma khong gay tang tin hieu nhu mo nao tren T2
cd the cd dau hieu ton th u o n g nhu mo nao khai mem u mang nao "dang hoat dQng"
. Khdng thay cuong tuyen yen

284
 U te bao dem cua giao thoa thj giac

. fiAn can b$nh Recklinghausen

- Gap 6 em va thiAu niSn
’ T^ , thcrcrng c6 thA dnh hi/dng todn bO du-dng thj gidc :
. Giao thoa thj gidc, vj tri thudng gdp
. Lan <56n m$t hay cd hai th£n kinh thj cho d in t$n cdc nhan c&u? Phi dai u d than kinh th| va giao thoa thi gidc
. Lan dAn cdc ddi thj chu yeu d ben phai
. Tham nhiAm u trong cdc thuy thdi duong, doi thj Bat manh gadolinium d
. ThA da A : giao thoa thj gidc, than nao, cdc bdn c&u tieu ndo - Be lien cuong. cuong nao ben phai
. u tA bdo hinh sao phan d$> thAp khong b it chAt tua n g phan - Doi thj ben phdi cho den cac lo lien nao thdt
hiAm khi diAn tiAn sang u tA bdo dem phan dp cao - Cdc nhan dau
.Theo d6i sau diAu trj : tdi phdt? thu’dng chuyen sang u phan dp cao han - Thuy dao ben phai
U te bao dem phan dp cao

T1 gado

XQCLOT sau tiem : phi dai deu dan 2 than kinh thj va giao thoa thj giac
lan rong u te bao dem den cac nhan xam trung tam

B?nh u s y i than kinh Von Recklinghausen : u te bao dem than kinh thi ben phai
Ghi chu: t6n thi/a n g tin hieu cao tren T2 d thuy tran trong ben phai, o te bao dem hen quan den b en* da-tk (phacomatose)

285
 U sp hau

- G£p 61t r i em va th iiu nidn, nhung cung c6 khi c h in dodn t r i ngudi Idn va n gu di cao tuAt

- Vj t r i : . T i n thuong san nao t h lt III

. Tdn thuong khu tru d cuong tu y in y6n "cu6ng tu y in y&n m$p"
. H iim khi gap u sp h iu trong ydn : lam XQCLOT d i tim hi$n tu’p'ng vPi h6a
. U sp h iu d u d i y§n la ngogi 10 : bp y6n-thi$t (tractus hypophyso - glosse)

- C iu tru e :
Ph6i hpp cac t6n thuong , 0 $ c : bat c h it tuong phan?
d ilu trj n iu cd t h i d up e bang ngogi khoa
Dang nang . c h it chua ben trong cd thanh p h in protein hoac m d cdc tinh t h i cholesterin
m$t nang duy n h it, c6 vach ngdn? n h iiu nang9
c6 t h i d ilu trj bang d in luu va tru y ln nho gipt hogt c h it phdng xa rhenium
. V6i h6a thanh kh6i hay thanh nhung v£t th in g CHT khfing c h in doan d i/o c

- Li6n quan vdi . Giao thoa thj giac? th in kinh thj? cu6ng tu y in y&n? tu y in y6n
. San nao t h it III? cac 16 Monro : nghen d ud ng luu thdng djch?
. B i li£n cuong? b i tru d c c iu ? da giac Willis
...quyet djnh d ilu trj? d ud ng vao p h iu thuat qua nga nao?

- K iim tra hinh anh tuy theo dien t iin iam sang va kiem tra moi 2 nam n iu khPng c6 d iu hi$u tiln th in trfen 15m sang,
sau d6 m6i 10 nam vi nhu’ng tru dn g hpp tai phat co the khdng tri^u chung

U sp h iu v6i h6a Tang tin hipu t y phat d T1 :m 6 m& ho$c djch cd n&ng d$ protein cao

T2 T 1 gado U sp hau d an g da nang

T h e d a c : ca c n ang n ho tro ng u . Nang nho 6 phan sau tren c6 nong do protein cao, tang tin hi$u T1
Nang Ion tien th in rat chgm : lan den tru d c c£u va tru d c hanh tuy
. B it gadolinium tren thanh nang

U sp hau vdi mot phan dang dec va chu yeu la dang nang.
Do kich th u d c cac nang tuy vao kich th u d c co the dieu tn dan li/u ngoai va dieu tri cune me *e
tiem hoat chat phong xa rhenium neu chi mpt nang duy nh£t

286
 U s o h a u d a n g d a c va n a n g
B enh nhan 14 tuoi. ch a m phat tnen roi loan th i lu c

- Ton th u a n g ddc, tro n g va tren yen khong dong nhat

b i t g a d o lin iu m

- P h a t tnen ca c n a n g tro n g nao th a t va doi thi

D ie u trj n g o a i kh o a q ua n ga d u d i tran

K ie m tra 4 th d n g sau khi can thiep

- G iam kich th u d c ro re t c a c p h a n u dd c va cd c nang

co n v e t tic h cu a u tro n g ho yen. kho n g l£y d u p e
q ua n ga d u d i tran

- X a tri b o sung

K ie m tra 4 th a n g sau khi ch a m d ir t xa tri

- H ieu q u a c u a vie c dieu tri tren p h a n u dd c

G ia m k ic h th u d c u
T in hieu kh o n g d o n g n h a t : h oai tir m pt phan
- N h u n g p h a n n a n g banh tru d n g trd lai d o tie t djch
N ang "kh o n g co n d p lu c n u a " p h d t tnen tro n g k h o a n g tro n g dd
dup'C p h iu th u a t
B at g a d o lin iu m d th a n h nang
C o th e dieu trj nang b a n g lieu p h a p c u rie m o ke:
tiem h o a t ch a t p h o n g xa rh e n iu m v d o tro n g nang

Nang dang bi (kyste dermoide)

. X quang quy u d c : c6 th e p h a t h ien d o n g v o i Id n tre n vd tro n g ho yen

. CHT
• Tdn thuang khdng d o n g n h a t d a n g nan g . c h u a m d , voi hoa
tin hieu g a n n h u g io n g nhau tren T 1, T 2 SE . T 2 F LA IR , T1 G ado
- N^m d d u d n g g iu a tren yen, lan d en cd c th u n g lung S ylviu s,
- Khfing dnh h u d n g sa n n a o th a t III : d a u hieu p h d n bie t v d i u sp hau
- Ti6n tri&n r£t c h am , k h d i p h d t tr u d c k h i c h d o d d i h o a c chu sinh ; d au h ieu ia m s a n g tre. co the d u a c phat h ien tin h c d
- Khfing c6 dciu hieu g id n tie p

Rdt c6 th6 la u quai

B$nh nh§n khong phau thuat

287
 Cac ton th u o n g cua san nao th a t III
c h in d oa n ca n n g u yen kho. co the d u g c ? tre n h in h anh hpc

- U te bao dem cua giao thoa thi giac?

- U te bao dem cua san nao that III?

U te b^o mam (u tuyen tung "lac cho")?
Lymphom?
Di can qua khoang d u d i nhen
(u nguyen bao tuy, u mang ong npi tuy)

- Ton thuo’ng viem : Bpnh saccoit?

Benh mo bao X
Viem mang nhpn do lao?

... Huong xu t r i:
. Khao sat DNT : sinh hoa, te bao lympho?
. Khong sinh thiet
. Co the dieu trj th u : dieu tri bang corticoid
Giai p h lu benh : U t l bao d$m san ndo t h lt III

T in thucmg thdm n hilm

- Vao cac ngach tru trc cua nao th lt III

r nhung khong bj dang r$ng,

c6 t h i la d lu hi$u u t l bao d$m cua
giao thoa thj giac
- Vao manh cung
- Vao cac tru tru d c
va t h i tam giac
... d iln tiln : benh saccoit

T1 g a d o lin iu m ... Ton th u o n g hai ben g iao tho a thi g ia c va doi thj: co the la u te b ao d e m g ia o th o a thj g iac
. C han d oa n cu oi cu ng sau khi lam ton g ke: u te b ao m a m
. H inh th e ca c ton th u a n g khong phai la d a c hieu

. T on th u o n g u cua sa n n ao th a t III, d o i xung

kh on g b ien d an g ca c nga ch g iao tho a thj g ia c va n g a ch p he u cu a nSo m i l in
. K ho n g co ca c u d ien h in h k h a c cua lym p h o m nao
ch a n d oa n co the la kh o khan
. K ha o s a t D N T : xe t n g h ie m tu c thi : co c a c te b ao lym ph o

288
 - Hamartom cua c£c CU VU tang sinh cua mfl binh thudrng ; cd th& day thi s6m

T1

Hinh the dien h inh ia h in h a nh "d a p va o c a i ch uo ng ", tin hieu gion g n h u tin hieu cua c h it xam : dong tin hi£u 6 T1 va 12

-Truong hap dac b ie t:

bat san (hay di>t) cuong tuyen yen

Tin hi0u cao 6/ p h ln h0u y£n

khdng lan di, g in chat vao san nao t h lt III

Viem mang nhpn c£c be nen sq

Lao
B0nh saccoit

Tui phinh dpng mach gia u o’ vung tren yen

. Cd th£ g a p 6 m pi li>a tu oi, n h a t ia p hu n u gia
. Can nguydn : loan san ca spi dpng mach, phoi hpp vPi dpng mach phinh lan va dai n g o ln ngoeo
. C h in doan c6 thd khp tren XQCLOT, ngay ca sau khi tiem
c h in doan ro tr§n CHT : dPng co tin hipu thap
. Kha nang tui phinh mach bj huyet kh6i mpt phan : tin hipu phuc tap : cue mau dong, tin hi£u cao cua gadolinium trong dpng mach
tuy theo t6c dp ddng

CHT : dong dong mach TOF 3D

T2 Spin Echo Khdng cd tin hipu do ddng dpng mach sau do chyp mach mau : co chi dinh dieu tn noi mach9

289
 B$nh ly B£ n YeN

- U t u y in Idn cu a tu y£ n y6 n lan sa ng xo a n g h an g
- U m dng n 3o cua xo an g hang
- U d 3 y t h i n kinh sin h ba
- U te b ao try (cylin d ro m e )
- Di can
- P h in h m gch d $n g m ach, d d d m ca n h - xo a n g hang
- H$i c h u n g T o lo sa H unt

L am sa ng : . Li$t ca c d a y III, IV, V I, d au t h i n kin h V 6 m^t,

. L6i mQt m a t

U mang nao xoang hang

- P hi dgi deu d an ca c tha n h xo an g hang

- T h a y d irg e tha n h xo a n g hang tro n g kh oi u m ang n ao de x a c d jn h dO lan rong cua u
. Phat trie n cu a u m ang nao va o ben tro ng xo a n g h an g, ngogi kh o a kh 6 n g can th i£ p d irg e
. Phat trien cu a u m ang nao ben ngoai xo a n g hang, tro n g h6 th a i d u o n g , n g o a i kh oa can th i$ p d irg e
- C o the lan d en : . Hoanh yen va cu o n g tuye n yen, th e hai ben : u m a n g n 3o " b lc c iu "
. Lan tro ng yen : lam di I0ch tu ye n ye n b in h th irg n g
. Lan den b d t g d o cua leu tieu nao, h in h anh ”d u 6 i 6n"
- D ie u t r j : tu y th e o d au h i$u lam sang cu a d ien t iln benh;
neu dau hieu lam sa ng rat i t : dieu trj tu y th e o d ien tie n tren x q ua ng
. P hau thu a t phan u m a n g nao c6 the can th i^ p d u g c
. X a tri da ch u m neu th e tich n ho ho$ c xa trj to a n the

U mang nao xoang hang

Lan den . Cu6ng tu y in yfin

. Bdr t y do cua llu tieu nao
. Mang cipng cua m$t doc (clivus)
Xam lln vao h6 y§n
tu y in ySn, khfing bj t in th ira n g gi ca. bj d ly qua trii

D ilu trj bang xa trj da chum

hoac xa trj theo kich th ird c hinh dang

U mang nao mat ngoai xoang hang

Phat trien phia ngoai trong h6 thai d ira ng

the kha quan : d ilu trj p h lu thuat cb t h i d irg e

Lan den hoanh yen va xoang hang

doi ben
d irg e dira vao trong chi djnh xa tn b6 sung
(u mang nao phan d fi cao)

Ghi chu : chuoi T2 Spin Echo mat p h ln g tran ia c ln th ilt

/ lat cat 4 mm sat nhau :
mang lgi n h ilu thfing tin han chu& T1 Gado:
n h lm lln giOa u mang nao va dong binh thirfrng
cua xoang hang

290
 >
f1

B$nh u sqm thdn kinh tip 2 : u mdng ndo cua xoang hang, u mdng nao cua loi c iu xuang cham; xac dinh hinh anh cua mdng cirng :
phdn ngodi xoang hang cua u mdng ndo c 6 th& p h lu thudt dug c, phdn trong xoang hang khong can thi£p dup'c

Xi> ly hinh dnh ban d iu

chuSn bj cho x? trj da chum :

nrPngcuau XSc djnh du-d-ng bdr vd kich th u d ’c

. 0 6 xdc djnh s6 luo’ng va kich th u d c cdc ti§u di&m
. Djnh vj thdn kinh thj
W V k it . oanh gia vi$c theo d5i dien tien

in '

xquang

/ mang nao xoang hang

Cuong tuyen yen - Khong phai tat ca u cua mang nao deu la u mang nao

Mang am g cua mat doc (dws)

ho yen
yen, khdng bi ton thirong gi ci, tjdfv

<atridachiim
a trj theo k/ch thirdc hinh d^ng

ngoai xoang hang

oai trong ho thai diwng

: dieu trj phau thu?t c d t h w

n va xoang hang

) rong chi djnh x a & i M

phan d6 cao)

SpinEctwroll

Tong ke dau hau n ha n cau ben trai

- Phi d ai xo an g h an g ben trai, lan den ca c ho ch an bipom

G hi chu ; th a y hai tha n kinh va n n han ch un g, 6 g o c tre n -n g o a i xo an g hang hai ben

- T o n th u o n g m a n g nao nhie u n o i d a c b ie t la m ang nao a p ha n vo m n ao ben phai

- G id th u y e t ch an d oa n? U m dng n ao ? Di ca n ? L ym p h o m ? U te b ao tru (cylin d ro m e )? Ton th u o n g vie m ?

- K ha o sa t D N T kh on g g iup ich ch o ch an dodn

- Q u y e t d jnh th e o doi d ien tien khong dieu trj; neu lan rong : sin h th ie t q ua n ga tai m ui hong

291
 U day than kinh sinh ba
- P hi d ai deu dan m o t p ha n hoa c to3 n bo d a y th lm kinh sinh ba

- Vj t r i: . H ach G a s s e r : lan ra tr u a c v a o tro n g ho M eckel

. N h anh m l t W illis cua tha n kinh sin h ba ch o den khe b i/6 m
. T h an kinh h3m tren : g ia n rong lo trbn
. T h an kinh h 3m d u c r i: g ian ro n g lo bciu due v3 lan d en c3 c h6 ch §n b ir^ m

- C h an d oa n kho d oi v a i ca c ton th i/a n g u c h i gi6-i h an tro ng xo a n g hang

- R a t co the la u d a y tha n kin h sin h ba, kh on g the sin h th ie t

T 2 SE

292
 u te b4o hinh try (cylindrome)

. U Sc tin h tai c h i, phdt t r ii n cham , khdng nhay v » i X9 tri. kh6 hoSc kh dn g the ca n thi$p ngoai khoa
. Tdn th u cm g p hd t t h in the o du-crng (Ji cua t h in kinh hdm du”a i

Di cSn khu tru tro ng xo an g hang h o a c lan d en xo an g hang t u m o t di can cua tha n x u o n g b u o m ?
P h6i hp-p nh& ng di c3n ra t n ho 6 c iu n3o

- Tui phinh dpng mach g

B$nh nhSn tr§, r6i logn thj lye
Lo?n s in <J0ng mgeh :
dOng mgeh cdnh dogn c6 phinh lan
hii phinh mgeh gia u tren y£n
Ton thirang ben yen co tin heu khong dong nhat tren T1 va T2
. Tren ly thuyet co the la voi hoa, co the la
hemosiderine hay dong dong mach
. Hinh anh dong TOF 3D : phinh dong mach gia u
kha nang huyet khoi mot phan ben trong tui phinh

Do dpng m ^ch canh - xoang hang : xem phan chan thu a ng sp-nao

• C hin th u a n g da b ie t : x u i t h ipn thu- p h£ t a m thoi, loi m l t

D6 t y phdt tr§n nen loan san d on g m ach :
. C h in doan m o t "xo a n g h ang Ion " kern v o i g ian n o
m $t hay hai tTnh m ach m l t tre n, cd c xo a n g da sau
Ip i ich cu a ch uo i d on g d on g m ach va d on g tTnh m a ch va chuoi thu tha p the tich
sau tiem / tai ta o da m a t p h ln g
. C h in d oa n kho n h u n g tru a n g h o p do d on g m ach ca nh - xo a n g hang d an g h in h thanh
h u ye t khoi t y p h a t h o a c huye t kh6i m o t phan

- H^i c h u n g T o lo s a H u n t t6 n th u o n g vie m cua xo an g hang

293
 Benh ly DUOI YEN

- U tuye n Idn c iia tuye n yen : lan va o tro ng x u a n g b u a m

- U ngu yen so ng , di can
- V ie m x u a n g b u a m , u n h a y xo an g b u a m
- Lan den th§ n x u a n g b u a m cua u vu ng m ui h au : lan toa cua u b ilu bi vu n g m u i-h lu
- U x a m G i-h lu / u cua tu 6 i thieu nien
- C 3 c dj dang hiem g ap : th o a t vj m&ng n ao xu yen xo an g b u 6 m

- Lam s&ng it g g i y ... Nhi>c d au sau h o c m lt , liQt c d c d a y tha n kin h sq

U nguyen song

T on th u a n g cu a tha n x u a n g buQ-m v&/hoSc m lu rang

T in hieu dien h inh : tan g ro tin hi£u tre n T2, nhieu v£ ch ngSn
B i t g a d o lin iu m kh on g dong n h lt
T re n X Q C L D T c6 the t h l y c£ c m anh vo x u a n g

- Viem xoang I polyp

Nang nhay xoang b ird m

X Q C L D T sau tie m : c a c la t c l t m a t p h ln g tra n, dau n g u a

. M at d o th a y doi tu y the o nong d o pro te in
. P hat trie n r l t cham , it d lu h ieu lam sang
ch an d oa n m uon doi v a i n h u n g tru a n g h g p nhipc d au sau hoc m l t
. D ie m kh a i p h a t : m o t te bao cua xo a n g b u a m

. Lan va o tro n g so : ho yen

. d a y d pn g m ach canh tro ng doan tro n g hang
. nang g ia o tho a thj g ia c len
. Lam b ien d an g th u y thai d u a n g
. Lan n go ai sq :
d l y vu ng miQng-hau va ca c ho ch an x u o n g b u a m

294
 - DI cin n&n sp

- H pi c h u n g G arcin : lipt ca c d a y tha n kinh sq cu oi cung

- T h a n x u a n g b u a m d on g tin hieu , d u t doan ca c vo x u a n g
- L on ich d a c b ie t cua ch uo i T 2 S T IR , tu y it d ung tro n g C H T so-nao,
m a co tin hieu tha p , tu a n g phan v a i tin hieu ca o cua c a c ton th u a n g phu ne
- B i t g a d o lin iu m khong d on g nhat

Di cSn cua than x u a n g buO’m :

- Hinh 3nh X Q C LO T sau tiem

- T6n th u a n g huy x u a n g , khong co

hi$u iFng ch oa n ch6
- Khdng 3nh h u a n g tu ye n yen

- C 6 th e ch an d o a n s o t tren CH T

T 1 GADO
 DLffifNG GlO'A PHIA TRU’O'C / D U O N G G lt/A PHlA SAU

2 vj tri noi lien doi thi 16 m 6p tr§ng sau

4 c$ t th e tam g i^c 17 t u y in tung
5 m 6p tr in g trucrc 18 cu nao sinh tu tr§n
6 16 lien nao that 19 cu nao sinh tir d u d i

D u’O’ng giO a p h ia t r ir a c

H inh anh h o c : I . Vj tri ... trung tam cua ton th u a n g ? h inh thai?
m at do hay tin hieu. tru a c hay sau tiem
j Cac lap luan h u a n g d in can nguyen

I - U mang nao cua Mem dai nao

tru a n g h a p dgc b i$ t : liem dai nao voi hoa ch u a m o thuQc loai tuy x u a n g sq

i - Nang the keo cua nao tha t III

! - U te bao dem vung tran-vach-nhan duoi- the chai phat trien hai ben. cac u nhu hiem gap cua dam roi m ach m ac
di can, lym phom

- Benh x a cirn g rai rac, b?nh saccoit

- Tien can nghiQn ru'Q u nang : benh M achiafava Bignam i

- Cac tui phin h mach hiem gap cua dong mach nao tru a c doan quanh the chai
- Nhoi m au hoi vien

- Dj dang Nang cua vach trong suot nang cua ho Verga

Bat san the chai, u m o cua the chai

296
 U m dng n d o & bdr t y d o c u a lie m d ai n a o

Tdn th u a n g d6ng n h lt, ngodi ndo, phi dgi liem dgi nao

V d i h 6 a m & n g n a o b in h t h u o n g : & lie m d a i n ao , le u tie u n a o

. Mdng cu ng d u a c c iu tgo b ai hai Id d inh vdo nhau

. Vdi h6a c6 t h i chi dnh h u 6 n g m pt Id vd c6 tin hieu thap ro
. N lu v6i h6a cd hai Id c6 the do dj sdn xu a n g
vd phdt t r iln m $t top tu y trung gian, tin hi$u n h u rrto
... c6 t h i c6 sai s6 t tr§n T1 : c h in dodn nham Id xuat huyet m ang nao

X u a n g h6a liem dai nao : m o x u a n g + m o m a thuQc loai tuy xu o n g so

T in higu cao T1 : mau m ao ga, liem dgi nao

U nguyen bdo dgm vung tran-vach-nhan duoi-the chai

U te bdo dgm
cua vdch trong suot

T1

U khdng d in g n h it : vung hoat d$ng a ngoai bifen, c6 tinh c h it n h iiu t l bao : T1 dong tin hieu, T2 tang, khuech tdn han che
tdng tin hieu b 1000 I ADC d6ng tin hi#u
b it mgnh gadolinium
vung trung tSm hoai t i r : tin hifeu d6ng a T1 vd T2 do n6ng do protein cao. giam tin hieu tren khuech tan
kh6ng bi han c h i khuech tdn
Di c3n theo lan t6a cua dirdT>g cJltcti nhfen : bdt gadolinium lan tda trfen mang nuoi cua than nao

297
 Nang the keo cua nSo thlt III

N6 ng do protein ca o N6 ng dO protein cao

X Q C LD T : nang c6 m $t dO ca o C H T : nang c6 tin hi$u c a o 6 T1

N ong dO protein cao : d iin t iin d$ c bie t cua tin hieu N ang t h i ke o Icrn cu a nao t h l t III :
tS n g T I, g i£ m T 2 S E , gi£m T2 FLAIR N h irc d lu theo tir the sau d o nht>c d l u lidn tyc :
nghen cdc 16 liSn n ao t h lt

Ou’d’ng giOa phia sau

... D au la trung tam ?

- U mang nao a goc liem dai nao - l&u tieu nao. u m ang nao cua m ai mach m ac cua nao t h l t III. u nhu dam roi
mach m ac hiem hon
- Goi the chai : u te bao dem tham nhiem , u nguyen bao dem , lym phom , x o ci>ng rai r£c, benh saccoit
- Ton th u o n g tuyen tung : chan doan nhd sinh thiet : u te bao m lm , u quai, u tuyen tung, di can, u h lc to
- Ton th i/a n g cua m anh tip giac: vj tri th ira n g gap cua u te bao sao it nhanh

- Dj dang : . B at san cua the chai, u m o cua the chai

. Nang cua vdch interpositum , nang m ang nhen cua bau G alien
. P hinh mach cua bau G alien
(xem ch ira n g Dj dang)

- Tien can nghien riro ’u nang : benh M achiafava Bignam i

298
 U mang n§o cua g6c liem dai nao - leu tieu nao

X Q C LO T khong tiem X Q C LO T sau tiem

T in th u o n g c6 dac tin h nhieu te bao v o i hang rdo m du nao bj phd v o : m at dp cao, b i t chat tiro n g phan

T 1 Gado
C H T hau phau : tong ke ch inh xac mipc dp lan rpng cua u m ang nao trong 3 m at phdng
xam lan xoang th in g

N a n g m a n g n h e n c u a b e la n

- Ton th u o n g cu, doi xu ng

- Kenh Sylvius bj keo dai, khong co hien tu o n g chen ep

Xem phan di dang, trang 328

299
 U tuyen tung : u t l bdo mdm, u qudi, u tuyin tung, di cdn. u hdc tl, u tl bdo d$m ...

- U t l bdo m&m : u d$c, c6 tin h chdt n h ilu t l bdo n£n cb m at d0 cao hodc d in g m dt d$. n h ilu nang nh6 . khdng 6 & *ur»g gn‘r han r6
c6 t h i bao quanh tu y in tung v6 i h6a
b i t chdt tu a n g phdn,
t i n th u a n g u k i t h g p : sdn ndo thdt III ( " u tu y in tung Igc c h i ")
lan theo dudrng d u 6 i nh$n :
cdc b i n in so, cd c khodng tro n g m ang cirn g cua c$t s in g
- U t u y in tung, u ngu yfin bdo tu y in tung: . V6 i h6 a trong u
. G id i han khdng rd, xdm idn d 6i thj
... nhu n g h inh th d i tu a n g tu n h u cdc u khdc cua t u y in tung cdn sinh th»lt
- U h l c t6 : t i n th u a n g c6 tin hi§u cao d T 1

K t ''
*■

U tu yin tung

- C h in d o d n g id i p h lu b$nh :
u t u y in tung
- N ghen kdnh S ytvius

- G hi c h ii : dj d a n g C h ia ri I

Ton th u a n g co tin h i^u cao tu phdt 6 T1

di cdn cua u hdc to :
- 0 vj tri tu y in tung
- 0 thuy giun p h ia tren

Chan dodn phan b ie t : nang tuyen tung

. C h ira djch, Id b iin t h i cua dang b inh th u a n g , ngoai le m d i co tnfeu ch u n g

Ton th u a n g tu a n g tu
. D jch c6 nong d $ pro tein trung binh, h iim khi voi hoa a ngoai bien
n h u n g cd ch6 n 6 p k firtfi S ytvius
N ang co tin h d oi x irn g tr§n m dt phdng cdt ngang va m at p h ln g tran
. D 6 i khi c 6 t h i bdt tu a n g phan d ngogi bi§n, rat deu ddn
C dn sinh thiet u t l bao m dm
. G iu nguye n h in h thai cua m anh tir giac va kenh Sylvius
. K hong c6 t i c nghen D N T ngay ca khi nang rat lan
T h e o doi Idm sdng . tr ir khi khong d iin h inh ve h inh thdi hay v i tin hieu
. tr ir khi xuat hien dau hieu lam sdng

300
 H6 SAU : CAC TdN THl/PNG NGOAI NAO

ong ban khuyen

bo than kinh thinh giac-

TK mat VII. VIII, VII bis
tien dinh
oc tai

tai giua
mang nhT
tai ngoai

voi Eustache

LAM SANG TAI G ll/ A TAI TRONG THAN NAO

Oinh x u a n g da G oc cau tieu nao t i£ u nAo

Tien can, lam sang,

Diec mpt ben ngng dan
Chong mgt = XQCLOT = CHT
U tai
Li£t mat ngogi bien
- Viem tai - U day than kinh VIII, VII - U than nao
- Xop x u a n g tai U mang nao tieu nao
- U cholesteatom di can
Ceic nghigm phap ch uc nang d§n khoang d u a i nhen - Nhoi mau
than kinh - U can hach / cuon mau tu
tru’P’C khi Icim hinh anh mang nhT - Viem day than kinh do virut
- U cua tui noi djch - X a cu n g rai rac
- U cholesteatom
- U hat viem (u hat ngoc) - Liet tren nhan
• XQCLOT hay CHT ? - U quai, u m a
- Di can den xu a n g da - U can hach / Teo da he thong
- T6n thu a ng tai giua? cuon canh (glomus jugulaire)
= XQCLOT - Dj dang - U nguyen s6ng - Di dang
Chiari
- T6n thu a ng tai trong ? - Nang mang nhen Dandy W alker
- T6n thuang than nao Co the th u c hien CH T bo sung
= CHT ... viem me dao - Tui phinh mach. dong mach
phinh Ion gay chen ep cau true
than kinh

3 01
 IRM T2 chuoi CISS: 50 iat, dp ctey : 0,7 mm, tai tgo
ChuSi nay mang lai n h iiu thdng tin han chuoi T1 gadolinium
D lu sao chu6i T1 gadolinium v ln cOn d u p e th i/c hien de c h in doan u day th in kinh cua bd t h in kinh thinh giac- thin kinh m$t
nhu’ng mi>c dp it han so v d i dung de c h in doan phan bi$t : t in th u a n g vi&m cua b6 thinh giac- th in kinh m$t ? cua m6 dgo?

Cach th u ’C tien hanh khao sat CHT :

- Thu’C hi$n tong ke mot tru d n g h ap D i£ C mpt b§n n$ng d in , mpt tru d n g h pp L l£ T MAT NGOAI B l£ N
- T 1 TSE c l t ngang toan bo hpp so va T1 c l t ngang 3mm d 6ng tai trong
c6 ti§m gado
- T2 FLAIR c l t ngang toan bo hpp sp; hinh anh khuech tan
- T2 CISS c l t ngang hoac t6t han iam tren m$t p h ln g tran. t£p trung tgi x u a n g da : xem p h ln tai trong. tai giO-a,
tai tgo d m$t p h ln g khac
phim : 5 lat t$p trung tai ong tai trong va 1 MIP toan dien d i khao s&t 6c tai va cac 6ng ban khuyftn).
- T1 c l t ngang gado 3 mm (phim : 6 lat tap trung tai 6ng tai trong)

n iu li§t m$t ngoai bien

- T2 d ung ngang 4 mm tap trung vung mi-it, tu rang cu a cho den xu a n g da ; n iu ia u : T1 gado d irn g dpc va ngang

- Tong ke mpt tru d n g h pp benh Meniere. CHO NG MAT, U TAI, mpt tru d n g h pp diec dpt ngpt mpt ban
... Binh th u d n g ? nhoi mau than nao ? x a c irn g rai rac ? viem naron do virut ? u ? xem p h ln m6 dao.
Them chuoi T2 d irng dpc dp phan giai cao 3 mm. khao sat than nao. c6 the iam T2 FLAIR d irn g dpc 4 mm

- Tong k§ mQt trudng hpp DAU THAN KINH V d MAT, CO THAT NLfA MAT trfen th in kinh m$t, co that nira mat d udi th in kinh sinh ba

- T1 TSE c l t ngang roi tiem gadolinium

- T2 FLAIR c l t ngang
- T2 TSE c l t ngang 2 echo 3 mm / vung c u o n g -c lu nao
- T1 TSE gado toan bp hpp sp ; neu ia u them T1 gado dirng ngang va d irn g dpc
- T2 CISS dirng ngang qua goc c iu tieu nao : chen ep dpng mach vao th in kinh ? u ?
- Neu binh thu d ng : them chuPi T2 phan giai cao, theo mat p h ln g tran, tir diem mui den h6 y£n
ton th u a n g vung mat ?

- Di dgng A RNO LD CHIARI . nghi n gd d ua tren iam sang hoac do ket qua XQC LO T cu

- T 1 TSE c l t ngang toan bo hop sp - xem dot doi-dot true

- T2 TSE c l t ngang toan bo hop so - xem dot doi-dot true (chen ep hanh tuy ?)
- T2 FLAIR c l t ngang toan bo hop so - xem dot doi-dot true
- T2 TSE d un g doc phan giai cao 3 mm qua ban le cham -cpt song
- T2 TSE d un g ngang phan giai cao 3 mm
- T2 TSE d irn g dpc, cot song co va nguc, sau do (7) cot song t h l t lung : tuy dai ?

- Hpi chirng CLAUDE BERNARD HORNER

Khao sat dinh khoang mang phoi. cpt song co. ho sau va xoang hang
- T1 TSE c l t ngang toan bo hpp sp
- T2 TSE d irn g ngang, do phan giai cao
tru d n g rong nguc-co
- T2 TSE d un g ngang 3 mm tap trung tai vung yen
- T2 d irn g dQC tru d n g rpng nguc-co
- Neu 13 u. tiem gadolinium va th u c hien cac chuoi trong 3 mat p h ln g

302
 U th£ n kin h kic h th u d c n h o cu a b o th a n k in h th in h g i^ c - th£n kinh m £ t

M d binh th u d n g
cua dinh x u a n g d£

U dSy TK kich
th u d c nhd

T1 gado

T2 CISS x£c djnh vj tri cua u day than kinh so v a i mao tien dinh
giup ich cho d u d n g v^o phau thuat than kinh qua nga xuyen me dao

U d a y th a n k in h kich th u d c la n cu a bo th a n k in h th in h g ia c - than kinh mSt

T1 gado

- U day than kinh kich th u d c Idn th u d n g hoai tu mpt phan

- Thoat vi cua u vao trong lo bau due :
- Chen ep cuong nao
- Tac nghen mot phan cac d u d n g lu u thong d!ch

303
 U dSy th£n kinh kich th u d c Idn cua bd th&n kinh thinh gi£c- thAn lunh m #

U day than kinh kich thuac lan : dien tien den hoai ti> dang nang
- U day than kinh luc dau n lm trong ong tai trong phat trien dan den be g6c cau tieu n3o
- Phan bi#t v d i u cholesteatom hay u hat ngQC khong phat trien trong ong tai trong

U day than kinh hoai ti> : giam tin hieu d T1 va tang tin hieu d T2 : nguy c o b| bo sot neu khong
 U m dng nao 6 go c cau tieu nao

- X u it d$ It horn 15 l i n so v& i u dSy th in kinh b6 th in kinh thinh gidc- t h in kinh mdt

- O m$t sau xiro-ng dd vd liu t iiu ndo, phi dgi mdng ctrng
- Khdng c6 trung tdm Id Ang tai trong
- Cd thA cd vdi hda
- Cdc xoang bAn cd thdng thodng khdng ? Hinh dnh ddng tTnh mach vd hinh anh T1 gadolinium , thu thdp MPR
lgi ich tiAn phlu : xoang bj tic , khd ndng cd thA c lt bd, xoang thdng thodng : khdng lam gi

U mdng ndo mdt sau xu a n g dd

XQCLDT : U xu a n g phdn ung

T in thuang vdi hda mdt phln
Ang tai binh thudng

U mdng ndo Idn d gdc c !u tieu nao

. Ldm tie Ang tai trong nhung khdng xuyen vdo trong
. Lan dAn cdc tA bdo cua dinh xu a n g dd
. Xoang bAn cdn t h ly d u p e , thdng thodng
. Phu bdn c !u ti&u ndo rd ret
... u mdng ndo " xdm lln ‘ /
. Cdc vj tri u mdng nao ket hap :
m$t ddc (clivus), xoang hang

T2 FLAIR, T1 gado

Benh u sp-i than kinh tip II : diec hai ben

- U day th in kinh cua 2 bd thinh giac-m at hai ben va cua cac day than kinh so hon h ap ben phai va trai
- U m ang nao : benh da u mang nao lan toa
. Liem dai nao, phan vdm cua nao trai
. Xoang hang ben phai va trai
• Mdt d dc (c liv u s ): chen ep hanh tuy, m ang cu ng trong ong sdng cho den dot tryc

305
 L un n en sp

1-2 : Lun nen sp do nen sp mem

- A / Benh Paget co s u phan ly giCra d u d n g Cham berlain d u d n g noi khau cai cu n g - b d sau lo cham Idn
va d u d n g Mac G regor d u d n g noi khau cai cu ng - diem trung ciia trai xu a n g c h a ~ ecaiile o ccip ita l),
d u d n g nay cat ngang qua mau rang, do la bat th u d n g

310
 - B / Tgo xuang b£t toan

Bi6n dgng c a hpc cua n&n sq Nen so det p h ln g , cac xu a n g da doc len

3- G ii lun n&n sp
. n&n sp binh thu d ng
. b$nh ly cua d6t dpi-dot true

-1 / B$nh ly viSm

. Vi§m da khdp dang thap

y6u tu chi kieu co cung, di§n tien cham

. C6 hi^n tu p n g trat ra tru a c cua dau va dot dpi

. So vdi d6t trgc do t6n th u a n g cua day c h ln g Mac Rae
. M lu rSng chui vao lo cham Idn
khPng tang tin hieu hanh tuy

Phi dgi day c h ln g song sau

tSng tin hi£u cua tuy song ngang m u c C3-C4

311
 CHAN TH U ’O'NG SQ - NAO Hinh anh hoc

- Ccic c h in th u a n g sq nSo m d i :

- A / Cac t6n thuang :

. T in thuang ngoai n3o

. So : 16m so ? Gian (phan ly) cac dudng khdp sq ?
day cac m6 d ud i da
tran djch trong cac xoang khi
gay xuang da, gay n ln sq

. Mau tg ngoai mang cung

. Mau ty d udi mdng cung, tg djch d ud i mang cirng
. X u it h u y it mang nao sau c h in thuang
. Khi : tg khi d khoang d u d i nh$n

. T6n thuang trong nao

Giap : phu nao khu tru
. Mau tg trong nao. mau tg trong nao t h lt
. Gi^P n a t: phu va x u it h u yit
. T6n thuang li ti theo trgc, x u it huyet li ti do hi£n tuang tru a t d u t doan
. Phu nao lan t6a . Do r6i loan lifin lac cac sai trgc th in kinh
. Do ngung tu ln hoan nao

- B / Cac h£ qua ciia t in thuang len cac c iu true binh thudng

. X6a cac ranh v6 nao
. D ly l£ch cac c iu true dudng giua : the chai. nao t h lt III. tu y in tung
. Thoat vj - Cua t h i chai d ud i lilm dai ndo
- Cua m6c thuy thdi duang
- Cua hgnh nhan tiiu nao
. Gian ndo t h lt do t ic nghen cac dudng luu thong djch trong hoac ngoai nao

- B ien c h u n g : . Tg mu d u d i mang cirng, ap xe nao, h u y lt khoi tTnh mach nao

. D6 d0ng mach canh-xoang hang, tui phinh dpng mach sau c h in thuang
- Di c h u n g : . Mdu tg d udi mang cirng man tinh teo nao, hoc khuyet nao

- X QUANG HQP SQ QUY U’O’C ? ... Khao sat "khong c6n dung nua", ngoai trir nhu nhi va trd em b| n gu oc ddi.

. Ngudi ta nh$n th ly X quang quy u d c khdng cung c ip thong tin q u y lt djnh nao giuo c6 hudng xir tri
Kh6ng c6n huu ich de thuc hien X quang quy u d c
X quang quy u d c chi cho t h ly cac t in thuang cua hop sq
Chgp X quang quy u d c tham chi co the . iam ch$m tre vide chi djnh XQCLDT
. tao su an toan gia tao khi ma ket qua binh thudng
Ngoai ra, khdng chgp X quang quy u d c cung tiet kiem duo c ve mat tai chinh
va Idm giam nhiem birc xa trong dan s i
X quang quy u d c hi$n nay khong dii gia tri phap y.
cac l$p lugn ve phap y khong the tien triien them dua vao x quang quy u d c
ViQC bo iam tin g ke x quang quy u d c chi lien quan den hinh anh chup hop sq ma thdi
c6n tin g kd vd cac c h in thuang vung mat : h ie m lt. ham tren, xuang that s u ciia mOi v in phai co X quang quy u d c

Neu x quang quy u d c d u a c thuc hign thi ket qua ia .

- Dudng gay : luu y "dudng gay x l u " : X uang dinh : vung mang cirng cd the bong Idn
B ud n g gay b it ngang qua d ud ng giua
Dudng gay trai dai den nen so
- Lom so, gian do c h in thuang cac khdp sp : gay li ti d cac rang ciia dudng khdp sq
- Di lech tuyen tung bj vdi hoa
- Tran djch trong cac xoang khi

dudng gay chup tu y d n

312
XQCLDT

Chi djnh
■Chi djnh rit rQng: ■ XQCLOT dugc chi djnh ngay ca khi c6 chut nghi ngd tren 13m sang
Trudng hgp d$c bi$t: . Thiiu m3u khdng giai thich dirge x£y ra sau chin thirang s q n§o a nhu nhi va tr£ em
. Cd thi thyc hi$n XQCLDT s q nao de dam bao an toan trudc mQt trudng hgp gay m6 toan than
k6o dai khdng cho phep theo ddi iam sang duac nua.

K? thu^t XQCLOT dugc thyc hi$n khin, ddi khi t6i khin
It nhit 20 lat cit ngang ; XQCLOT da hang dd : 20 - 40 lat
hay 100 lat cit ngang b i sung giiip tai tao hinh anh mat phing dirng dQC va dirng ngang cd chit li/gng cao
Khao sat hinh scout view : dudng g3y ? gay kit hgp d c0t song co : cac iat c it va tai tao 9
Khdo sat toan bd cac iat cit qua hai cua so hep va cua so rdng :
. Dudng gay, Idm s q . tg khi trong s q , dj vat ?
Ngoai ra cOng khao s£t cac iat c it d cua s6 trung binh d i chin doan cac mau tg k i can vdm s q ;
nh&ng loai mau tu nay se bj lin vdi vdm s q d cua s6 hep. va bi x6a mit hin d cua s i xuang

XQCLOT cd ti§m chit can quang tTnh mach ? Chi djnh ngoai IQ
. Nghi ngd mau tg dudi mang cung cd dong mat dQ. rnQt hoac hai ben : tang dO tuang phan cua nao
. Ldm s q d vdm s q : phai khao sat trudc m6 tinh thdng thoang ciia xoang tTnh mach doc tren .
ddi khi cd the sir dgng XQCLDT-MM
. Nghi ngd dd dQng mach canh - xoang hang : lot mit cd tinh chit d£p theo nhip, cd 3m thii (XQCLDT-MM hay CHT)
O giai dQan sau, khi benh nhan tram tTnh, tuy vdo diu hieu 13m sang, cd the khao sat
. Xuang da vdi iat cit be d£y tinh bing milimet / tren benh nhan cd chay nude tai. chay nude mui
. Ting trudc ciia nin s q / tren benh nhan cd chay nude mui
. Vung mat : tren benh nhan cd chin thuang SQ-mat

. D qc vd ly giai

. a / ... X em h inh s co u t vie w

iik \ V v *
- "kiem tra”
-dudng gay ? cdtsong c i 9

. b / K ha o sa t ci>a so rong, ci>a so x u o n g , m o t cach co he thong :d u d n g gay? Lorn so?

Ldm s q phai dugc phiu thuat de nang len ... va tinh huong nay khong duac tim thiy d cua so hep

. c / X Q C L D T nhieu hang do : chat lu’Q’ng hinh anh tai tao ti> 120 lat c it co dQ day 1 mm +++

313
- CHT : . C h at lu’Q’ng hinh anh to t nhat n h u n g :
. gia th ^ n h ca o va co s in m ay d e th u c hign khong
. b i t d on g tro ng 20 p h iit, kho the o doi lam sa ng khi d ang nam trong m ay

. C h i d jnh :
- c6 s y kh on g dong bo giO a lam sa ng nang ne va X Q C LO T b in h th u d n g : . T6n th u a n g li tj s<n try c d o tru Q l d irt dogr
. D $p nSo d 6n g m £ t dQ tr6 n X Q C LD T?
- kh6 ly giai h inh anh X Q C L D T . T on th u o ’ng tro ng nao ? T6n th u a n g ngoai n ao ?
. Vj tri cua ton th u a n g so vd’i ranh tru ng tam ?
- c h in d oa n va lam tong ke m o t tru d n g h a p do dong m a ch ca nh - xo an g hang

. P ha c do kh ao sat :
- M ^ t p h ln g c l t ngang: - T 1S E - T2 F L A IR - T 2 *: h em o sid e rin e ? - K h u e ch tan b 1000 va ban d6 A D C
- M gt p h ln g tra n: -T2 F LAIR , phan giai tu a n g phan (re so lu tio n en co ntra ste)
- H o # c T2* m at p h ln g tran, xu a t huye t li ti, tuy the o ke t qua cua n h u n g ch u6 i xu n g tru d c d6
- D o i khi co the : -T 2 F LA IR d u n g d oc: . T 6n th u a n g the chai
. K hao sa t ban le SQ -C Q t song, t u y so ng d u a c kh a o sa t ch o d in C5
- dong dQng m a ch T O F 3 D, thu tha p c l t ngang, tai tao tro ng 3 m $ t p h ln g
... V d dong m a ch ? N g u n g tuan hoan ?
- nghi n g d d o d on g m a ch ca nh - xo an g hang :
T1 g a d o M P R , thu tha p d u n g dQC, tai tao

- Kh&ng d6ng bd giua b^nh canh ldm sang

va k it qua cua XQCLDT

M lt ng6n ngd Broca khdng giai thich dugc

b ln g kh6i ty mau nhd ngoai mang cung d vbm nflc

CHT ... mau ty trong nao d chan h6i n3o tr£n

thu 3 b&n trai.

- C h in doan x u it h u y lt li ti do "trug t c lt" giua chat xam c6 ty trqng cao han va c h it trin g cd ty trong th ip han

- CHT c6 the bo sung XQCLDT trong trudng hap kho ly giai

Cau hoi dgt ra tren XQCLDT

mau ty trong hay ngoai Tra Idi cua CHT tr&n mat p h ln g tran:
tilu nao ? mau ty ngoai tieu nao

Chu thich thuc hȣn mQt hinh In h bA

sung XQCLDT lat mong va tai tao trong
mat p h ln g tran cung cd t h i cung d p
thdng tin tu a n g tu

- Lai ich cua CHUP MACH M Au ?

. Lgi ich trong c h in doan chet nao tru dc khi lay tang, bo sung cho phuang phap dien nao :
c h in doan ngung tuan hoan nao
. Chyp mach mau se d u g c thay the b ln g XQCLDT-MM hoac CHT-MM khi nhung ky thuat nay d u g c hgp thuc hoa
. Trudng hgp khong co may XQCLDT. neu toi khan, chyp mach mau nao cd the d u g c thgc hien: cd mau ty ngoai m a rc
. Lgi ich trong dieu trj: iam thuyen t ic mach cac dd dong mach canh - xoang hang

314
 Mau tu ngoai mang ci>ng

Tin th i/a n g tan g d dm d $ d6 ng nhdt

161 vd 16m, (r mOt b6 n
HiAm khi m du ty hai bdn n h i/n g c6 t h i c6
t i n th i/a n g n d o d 6 i b 6 n d o cu d$i

Mdu ty bj gidri han, c6 tru n g td m Id d u O ng gdy

Vj t r i : - vung d in h b b c tdch d u a c G erard M archand
- mdu ty dfnh v6m sq : xoang tTnh mach dQC tren ?
- b6ch tdch mQt xoang ngang
C6 thA : . c6 nhung b6ng khi trong mdu ty
. C6 ty mu thu phdt

OiAu trj ngoai khoa tuc thi

nhi/ng c6 the h ip thu ty nhien Mdu ty ngoai mdng cung dien hinh Mdu ty dang hap thu
cdc mdu ty ngo^i m ang cipng
... phdi theo doi lam sa ng ch g t che va theo doi tren XQCLDT

C h in thi/ang sq :
v lt thi/a n g da thdi duang-cham trdi
. Mdu ty ngodi mdng cung
. B6ng khi trong kh6i mdu ty
. Dap ndt tran phai do cu dpi
. Thoat vj the chai d u a i liem dgi nao

Nguy ccy sai s o t :

- Mdu ty trong vd ngodi nao thi/ p h d t: mdu ty cQ the chi x u it hien mQt cdch tu tu. trong vong vdi gia hay vai ngay

NAu XQCLDT d i/ac thyc hien khong lau sau c h in thi/ang, no co the binh thuang
• Vi vdy ro rq2ng mQt XQCLDT binh thi/ang ro rang khong the bo di viec theo doi lam sang deu dan
- Ldm lgi XQCLOT neu benh nhan nang han hodc khong cai thien

■ Mdu ty g in nen sq hodc dinh vom sq : co the bo sot tren XQCLOT do nham lln giua mdu ty vai tinh trang tang dam do cua vom sq hodc nen sq
Lpi Ich cua XQCLOT lat mong tinh b ln g milimet va tai tao; co the thyc hien CHT bo sung
■ Mdu ty ngodi mdng cung vung dinh vom so . iQi ich cho phau thuat vien biet d u a c tinh trang cua xoang tTnh mach doc tren :
. co the th yc hien XQCLOT-MM hoac CHT co gadolinium
. co vet thuang xoang khong?

M §3 A *

CHT T1 gado T 2 FLAIR

CHT : mdu ty ngodi mdng cung vung dinh vdm sq , mdu ty trong nao vung day thuy tran ben trai di kem
XQCLDT : XQCLDT lat c lt ngang 5 mm c6 t h i bo s6t c h in dodn ... nham lan giua mau tu va vom so
. Cdt bo sung tren XQCLDT 120 lat day 1mm vd tdi tao theo mat phang tran co the cung cap cac thong tin nhu CHT

315
 Mau tu duc^i mang ctrng

. Mau ty m$t (JO cao, kh6ng d in g n h lt a vung vdm n5o b£n phai
Gi6i han trong 16m
C/ mOt ho$c hai b§n
L6p mdng DNT gi&a n io va mau ty
khoang d udi nh$n

. Bj gidi hgn b6i cac xoang tTnh mach, khdng bong Idn du’Q'c ,
. Lan d in lilm dai nao, llu tilu nao

. H ip thu kh6ng d lu
C6 t h i c6 mau ty d tu6i khac nhau
D iln tiln c6 t h i thanh
- Mau ty d ud i mang ci>ng mat dO ddng
- Ty djch m$t dO th ip
. T6n tgi mQt Idp DNT m gt dO dong giua nao va kh6i mau ty.
trong khoang d u d i nh$n XQCLOT kh6ng tidm

. B$nh nhan gia, nghi^n ru yu

Teo nao c6 t h i di kdm
am gi6’i hgn d lu hi$u ch6n 6 p tren ISm sang va tren X Q C L D T

. Cl trd em "bj va d$p" n h ilu m yc nudc-mau

Mau ty d u d i mang cung

kh6ng d in g nhat

Chay mau n h ilu thi

S inh ly b?nh

"Ban c iu nao I6n" di kdm mau ty d uo i mang cung :

Cac t in thu-ong thudng la phuc tap, k it hyp n h ilu y lu to can nguyen
- Phil nao, c6 t h i r l t Idn
- Gian tTnh mgch do Net mgch dpng mach (vasoplegie arteriellei: "tu d i mau xa xi" (perfusion de luxe)
- C6 t h i x u it h u y lt mang nao va / hoac ton th ro n g viem cua mang nao bat iot hay gadolinium
- Kdo dai, tham chi bj dirt, cac tTnh mgch bj cang ra giua vo nao va cac xoang mang cung.

T2 FLAIR T1 gadolinium

. Phu chu y lu d chat xam

. T u d i mau xa xi do liet mach

Chup mach mau keo cang cac tTnh mgch tree o_>6c cua nao bO
Co the co d irt mgch mau mau tu nn <eu tn i

316
 Mau ty dti’O'i mang ci>ng dong dam dp
-M&u ty di/6'i mdng ci>ng c6 thA c6 mdt dQ ddng . Tuy nhidn c6 the c h in doan d u a c khi dung cua so hep
"ddy qud m uc cua c h it xdm"
• B0i khi chu6i sau tidm tuang phdn cd thA ldm tang ddm d$ nhu mo nao.
.Ityttru’d'ng hap d$c bifet: cdc ndo th it cQ dang "tai th6” : cdc ndo that ben hep. co the doi xung hodc khong
bj khdi ty djch d u 6 i mdng ci>ng hai bdn chdn 6p : hinh dnh cua "chat xam qua lan"

XQCLDT kh6ng ti£m XQCLDT c6 tiem XQCLDT khong tiem XQCLDT co tiem
ku ty du’d'i mdng cung kh6ng dong n h it, mat do dong hogc hai cao Hinh anh "c h it xam qua I6n"
chu6i c6 tiem giup cung cap thong tin nao mat dp thap do phu Chuoi giup cung cap thong tin

_____ khdng tifem: mdu ty d u a i mang cung dong mgt dQ v(y\ chat xdm XQCLOT sau tiem: mdu ty d ua i mdng cung
... Phu bdn c iu nao co mat dQ thap

Mau tu duxyi m a n g ci> n g v u n g le u tie u n a o

- Hinh the rat gai y

- Mdu ty dan dQc hodc ket hap voi cdc ton thuang khac

I I
T a i ta o tro n g m a t p h l n g tr a n d u a c th u c h ie n t h u a n g q u i

3<7
 Bong tu khi

- Cdc bong tg khi trong so sau chan thi/ang la hau qua cua mot vet rdch mang cung va thodt D N T
cdc b6 ng khi Ipt vdo khoang d uai nhen roi co the vdo cac ndo that ben do khi di qua cdc 16 Magendi

- C h in dodn phai d i/a c nghi den vi chi hien dien mQt bong khi rat nho cung phai d iiu tq khdng sinh phOng ngua vi^fn mdng ndo

- Ngodi ra, cung c in tim vi tri cua vet rdch mdng nao de co the dieu tri ngoai khoa

- Gdy xi/ang tin g tru ac co the lam rdch bao mang nao ciia cac sa> th in kinh nho khi/u gidc :
trdn ldm sdng benh nhan bieu hien chay n i/a c mui
tren XQCLDT : Idt r i t mong. tai tao mdt phdng tran
. Co mdt do djch trong cdc te bdo xoang sdng
hay dan gian chi Id day cdc niem mac ke cdn manh sang.
. Cdc b6 ng khi a trong cdc be cua tin g tru a c hodc dQC theo thdnh sau cua xoang trdn
d iiu trj c6 t h i Id tai tgo tin g tn/ac.

- Gdy xuang dd :
. Benh nhdn co the bieu hien chay nufrc lo tai hoac chay n i/a c mui qua v 6 i Eustache
tim cac bong khi phia sau manh tu gidc
. Sau d 6 , khdo sdt xuang dd a tung Idt mong tinh bdng milimet vd tdi tao
. C 6 the dieu trj bdng phau thuat

M iu giai p h iu B 6 ng tg khi n$i so

Gay thdnh sau xoang trdn Be tru a c c iu
rngt tren than xuang buam . mdt doc (clivus) vd Be lidn cuong
loi c iu xuang c h im C 6 the gay xu an g da

Gay canh lan xuang b ua m trai

XQCLDT thu th^p tren mat p h ln g tran

- Gdy mdt tren than xu an g b ua m
- Bong tg khi du<5ri thuy thai d uo ng

Cac bong tu khi co the r i t nho can phai c h in doan ra nguy co viem mang nao dieu tn khang sinh du ohonc

318
 Mau tu trong nao
M£u tg trong ndo

V
'/

Chin thi/ang tran phdi N h iiu o

Nhieu 6 tg m£u,
mau, b6ng khi thuy tran Mau tg trong nao
mdu tg dinh trai do cu d$i c6 the n h im v6i khi trong xoang tran c h in thi/ang ia nguyfen nhan hay hau qua 7

- Trong tn/dng hap c h in thi/ang, mau tg trong nao c6 t h i li£n quan tGi ban than chan thi/ang
- Mau tg cGng c6 t h i xay ra tg phat hay ia h$u qua ciia v& phinh mgch .
Khi d6, c h in thi/ang Id h$u qua cua tinh trgng mat y thuc do tai b iin mgch mau nao .
Chin doan ia quan trpng vi n iu chay mau mang nao, chi djnh tin g ke chgp mach mau se d upe d$t ra
- Lpi Ich cua vi$c nghifen cuu lgi tinh h u in g xay ra c h in thi/ang; Ipi ich v i mat phap y la r6 rang

C h in thuang sp nao ... mau tg sau c h in thi/ang ? hay v a tui phinh dpng mgch nao giua ben trai, m it y thuc va c h in thuang ?

- D$p n ^ t nao

K it hpp t in thi/ang phu va ton thi/ang xuat h u yit

T o n th u ’o n g th u d c loai "tru ,<yt c a t"

Vdi d$c tru n g la n h ilu ch 6 x u a t h u ye t li ti. C h un g lien quan ta i s y kh ac biet ve ty tro n g giOa ch at xam va ch a t t r in g von co
thanh p h in m o h a i nhe h a n . Khi co s y g ia m toe d o t ngpt, s y kh ac biet ty trp n g g a y ra n h u n g chuye n dong e y e nho lam ton
thuang cac dpng m gch nho. H ipn ty p n g n a y d a c b ie t n g h ie m trp ng vi d y p c g h i nhan a the chai, c a c nhan xam tru ng ta m va
than n§o.

- Nhung t6n th u a n g n a y kh o h o g c kh on g the th a y d y p c tren X Q C LD T . L a i ich cua C H T, d a c biet la cac ch uo i E cho G ra dien t
khi c6 s y m a t d ong bp g iu a tin h tra n g lam sa ng nang va X Q C L D T "b in h th u a n g ” .

XQCLDT
M$t dO cao trong nhu m6 T2 *
L6p mau tg m6ng d u a i X u it huyet li ti do hieu ung ’ tru a t cat’ a loi the chai
mdng cirng liSn ban c iu

319
 Phu nao lan toa, ton thu’O'ng nao do gidm tram trpng lisu lif ^ n g tuan ho£n

B$nh cdnh v& mdt gidi p h lu -X quang gdp sau mQt c h in thuang sq ndo ndng
nhu’ng cQng c6 the gdp trong b it c u trudrng hap nao th ilu oxy ndo keo ddi: c h it du6i, trgng thdi dQng kinh. nh& mdu co tim

• Mdt dO th ip d hai bdn c iu dai ndo, chu yeu d c h it xdm v6 ndo vd c h it trdng cua trung tdm bdn b lu due
■ Cdc nhdn xdm trung tdm vd tilu ndo co ve nhu tdng dam dQ tuang d6i
■ Todn bO hd thong ndo that nho lai hodc bj x6a hdn

• Bdnh sinh phuc tap : . Phu do t6n thuong li ti lan toa: roi loan su tiep noi cdc sai tryc lidn quan tdi cdc t&n thuong do tinh trang tro ly ciia ndo
. Phu vdn mach do giarm luu luong tu ln hoan :
chdm hdn tu ln hoan ndo hoac ngung tu ln hodn
. Tao mQt vong lu ln q u in giua phu vd nh6i mdu

• N iu cdc tidu c h u ln ldm sdng vd dien ndo d6 goi y c h it ndo, c6 the thuc hign XQCLOT-MM d l khdng djnh tinh trang ngung tu ln hodn

. Ngung c h it tuong phan trong dQng mach canh trong d cho di vdo khoang d u d i nh§n d vj tri trdn hang
. Hodc cdc tieu c h u ln c h it ndo it chdt che hon tren XQCLOT-MM: co c h it tuang phdn trong d$ng mach ndo giua doan g in
nhung khong d6 d ly d cdc doan xa
khdng th ly c h it tuang phdn d cd tTnh mach sdu lln tTnh mgch ndng
XQCLOT-MM co the thay dien nao do vd chgp mgch ndo quy u d c trong vigc c h in dodn c h it ndo tru dc khi c h u ln bi lly tang. •

O
XQCLDT sau tifem
Gidm d|im d$ cua todn bO c h it trin g
x6a hfe th6ng n io t h lt vd ranh vo ndo
XQCLDT sau tiSm
NhSn xdm trung tdm c6 mdt d$ binh thud’ng
C h it trin g co mdt do r it th ip do phu th ilu oxy
D lu hifeu "tieu ndo trin g " so vdi ndo bO
Chup mach mdu
Ngirng tu ln hodn nflo

. Vi tri d a c biet cua cac ton th u o n g : vung tu d i cua dong m ach nao g iu a va tru d c
vung tu d i cua d ong m ach so ng -th an nen b inh th u d n g : ho sau, dpng m ach nao sau, d$ng m gch m a ch m ac sau
. T in hieu ca o T1 : hoai ti> Idp vo nao; tang tin hieu lan toa tren T2 F LA IR : ch a t xam va ch at tr in g
. K h in g d jnh phu ngu on g o c dong m ach d u a vao khuech tan blOOO va ban do A D C
. B i t g a d o lin iu m d v o n ao va ca c cau true d u d i nhen lan can
. K ho n g cd huye t khoi tTnh m a ch nao

320
 H# qua cua todn bO cdc t6n thirang len cac c£u true binh thirong

. T h od t v j nao
- T h o a t vj thA ch ai d i/ 6 i lil m dgi nao: . kha nang c6 t6n th u a n g x u it h u y lt lien quan c h in h th o a t vj i y
. kha nang c6 nhoi m au tro ng vu ng tu’d’i cua mQt hoa c hai dOng m g ch nao trud-c
- T h oa t vj m 6c thai d u a n g : g ian ddng tip, syp mi
- T h oa t vj hgnh nhan t ilu nao : ch6n 6p hanh nao, ch $m n h jp tim , n g u n g h6 h ip - t u in hoan
. Trdn djch n ao thAt c i p tin h

T on thu ’O'ng x u it h u y lt 6" t h i chai.

L ien quan td i tho a t vi the ch ai du’d i l i l n
M du tg du’d'i m dng ci>ng,
Ban cau ben phai ldm do phu

L u u y "vbng lu in q u in "
hOp sq khong g ian ra d u a c , d in td i "vo n g lu in q u in " can p hai phan tich c h in h xa c truQ’c mQi tha o tac p h iu thuat

T in thi/ang phirc tap

Ton thipang do-n gidn :
- mdu ty d i/d i da dinh-chim
- mdu ty ngodi mdng ci>ng
- mdu ty nho d udi mdng cirng
- I#ch cdc c iu true du’b’ng giOa
. vung dinh vdm so
- gidn nao t h lt d6i bdn
. vung lilm dai ndo
- xuat h u y lt mdng ndo
- phu ndo
- ddp hai thuy trdn do cii d$i
- lech cdc c iu true d i/irn g giua
- gian nao th it hai ben

Chin thirang sp n d o --------► x u it h u y lt vd phu ndo ----------► thoat vj nao, gian nao th it
--------► “t in thu-ang ndo" ----------► phu ndo lan tda ------► thodt vj n a o ------► ngung tu in hodn .
Muc tifiu : D ilu trj nguydn nhdn neu c6 t h i : mdu ty ngodi mdng cirng
Vd / hodc d ilu trj hdu qud : chong phu nao, c6 t h i m a hop so giai dp (trong tn/drng hap ngoai le)

321
 Bien chu ng nhiem trung a p xe nao, ty m u d u o i h a y ngoai m ang c irn g , vi6 m m ang nao

000
XQCLDT khong tiem
C h in thu’O'ng tu 10 ng&y trub’c ; nhi>c dau, s6t
Ton thuong ngo£i n§o khong dien hinh, thuQc logi ngo^i m&ng cung,
Gi3m d#m do
Phu n§o, hi$u ung cho£n cho

Bien c h im g m ach mau

-1 / Tu i p h in h d ong mach

XQCLDT khong ti&m : XQCLDT sau ti&m

tang dam do cua be tru a c cuong tui phinh dQng mach sau c h in thuang

-2 / Do dQng mach canh - xoang hang

C h in do^n lam Scing : loi m lt co nhjp dap a ben ph^i x u it hi§n thu phat sau c h in thuang
§m th6i noi sp, gian tTnh mach ket mac

- Chyp mach mau: tiem tuc thi

- Dieu tri b ln g dud’ng noi mach : dung aong hay coil
. tu xoang hang trai va phai qua xoang vanh trong yen
cac tTnh mach m lt, cac dam roi chan buam

322
 Di c h u n g cua chan th ip o n g sp nao

. Di£n tidn mdu ty dw&i mdng cirng thdnh mdu ty d u6i mdng cirng dong dam do va sau do thdnh tg dich d uai mdng cirng man tinh

- Ddp ndt cdc "d in h ": 2 eye trdn, 2 eye thdi duong, 2 eye cham
. di&n tiln cdc ton thirang den teo nao vd tao hoc nao, Di chung ciia dap ndo
. gidn cdc sirng ndo that vd cdc ranh v6 nao ke can hai eye trdn
. hinh thdnh mo dem seo vd dong kinh hai eye thdi dirang

Di c h irn g cua d ap nao c u c tran va e y e thai d u o n g

"L o kh uye t b lu due" c iia so :

Dien tien d a c biet. va rat hiem . t u m o t d u o n g gay th y p ha t sau
m o t ve t rach m a n g cu ng

- thoat D N T va n h u c dau do "ri D N T " : C H T co tie m I P hi dai m ang cu ng d ieu tri b ang blood patch
- v6i h6a cu a m a u tu cu d u o i m ang c u n g : h in h anh "m ai m u c "

323
 Dj DANG NAO, Dj DANG MANG NAO

Phan loai theo vj tri :

1 / Dj dang b in c iu n io : Di dang chi c6n n io tnr6c (holoprosenc6phalie), loan s in vich-thi De Morsier,

trin djch nio, n io ni>t
Nao ling, hoi nao to, da h6i nao nh6
Lac cho c h it xim , dang not ho^c dang l&p, loan s in v6 n io
Nao nho, nao to mQt ben

2 / Dj dang du-dyng giOa
Bat san mQt p h ln hay to in bp th£ chai, u mo the chai
Nang cua v ich trong suot, cua mang mach mac n io th lt III, cua cavum vergae
Hep kenh Sylvius blm sinh
B it san cuong tuyen yen
Di dang Dandy Walker, bien the cua Dandy Walker

3 / Di dang m ing nao : Nang mang nhen : - Be Ion, be Galien

- Nang thung lung Sylvius, nang phan v6m n io
- Nang tren yen, nang cua tui Rathke
Thoat vj mang nao : - Vung cham, sang, bu’crm, dinh vdm sp
- Lo ro bi mui (fistule dermique nasale)

. 4 / Di dang Chiari: loai I, loai II, loai III

- Sa noi noi hinh tuy-tuy song v i hanh nhan tieu nao v i :
. Dj dang du’b’ng giOa nao, dtFoi v i tren leu
. Dj dang m ing cipng
. O’ djch ong tuy, gai doi dot song, thoat vj tuy-ming tuy, tuy song dinh, t it che dpc giOa tuy s6ng

- Khdng k£ : - Dj dgng dOng-tTnh mgch, tui phinh mgch cua b lu Galien, xoang quanh sp
- Cdc u qudi khac ngPai u m a : nang dang bi, nang dgng bieu bi, u sp h£u
- DNET : dysem bryoplasic neuroepithelial tum or = u bieu mo th&n kinh loan sdn ph6i, nang tui Rathke
- Dj dgng nao : - Dinh kho-p sp : - Lun nen sp

- Dj dgng vd gian nao t h lt : Can nguyen cua s y gidn no

. Gian nao th£t "hogt dong", co dp lye, do tdc nghen cac duPng luu thong djch trong ndo hogc ngodi ndo
b nguP i I6n, neu cP the, can phan biet v6i trdn djch nao that dp lye binh thu’P'ng do khi&m khuyAt h ip thu DNT,
... chpc thao djch nao tuy co ket qua trong tri/P ng hpp nay?
. Teo nao, hau qua cua cdc roi loan luu thong DNT

. Gian nao that "co khoang khong", do nao khong phat trien

- Ket hpp : . Dj dgng nen sp, nhat la xu a n g da

. Dj dang mdt, di dgng nhan cau
. Dj dgng tim, byng, tgt dinh ngon

- Khuyen cao di truyen : hinh anh hpc co the cung cap mot so thong tin

- Ky thugt hinh anh :

XQCLOT : XQCLDT khong tiem chat tu a n g phan. th i/a n g sir dung thuoc an than cho bgnh nhdn.
hiem khi phai cho gay me toan than
XQCLOT nhieu hang do 130 lat co dp day 1 mm, tai tao dirng dpc vd dirng ngang

CHT : - La khao sat cung cap nhieu thong tin han

hinh anh Spin Echo T1 va T2
Ipi ich dgc bigt ciia hinh anh Inversion Recuperation, trong 3 mdt phdng
- Hinh anh hpc trong tir cung: chi dinh tuy theo ket qua ciia sieu dm
khi d6 vigc tong ke ton th u a n g la rat quan trpng vi co the d i/a tai quyAt dinh ngang tha> ■

Sieu am thai, sieu am xuyen thop

324
 1 - DI DANG BAN CAU

- Dj dgng chi c6n nap tri/frc (holoprosenc6phalie)

Dj d gng n do trud-c thA vd th u y :

Ndo thAt ddc nhAt, khdng cd vdch trong suAt
Hai dAi thj dinh nhau
Gidm s^n cdc dud ng thj gidc
. Hai hA m lt cdch xa, dj dgng x u an g mdt dud ng gi&a

Dj dgng chi cdn n do trud-c thA b dn th u y : dinh hai thuy trdn

. Dj dgng c h i cdn ndo trud'C the thuy

ndo thAt ddc nhAt nhung cdc thuy ndo tdch bi$t nhau

. KAt hQ-p :
- Nang mdng nhgn cua be
m
cua bdu Galien
- Thodt vj mdng nh$n trong yen

. Logn sdn vdch-thi De M o rs ie r: . Bat sdn cuAng tuyAn ydn, suy phdn tien yen
. Teo thj
. Khdng cd vdch lidn th lt

- Chi>ng nao ni>t

. Cd khe ndo d bdn cau

- MOt phAn
- Todn bd : thdng th u a n g g iua cdc khoang d ud i nh$n vdi cdc nao thAt
dj dgng m0t b§n hodc hai b6n, doi xung hodc khdng dAi xung

. PhAi hgrp : Da hAi ndo nhd

Lgc chA chAt xdm dgng nAt

Nao n irt vd da hAi nao nhd

- Nao Idng, hoi n ao to, da hoi n ao n ho :

Nao Idng logi I : khdng cd ranh vd nao

vd nao day ro r£t
it chdt trdng

HAi nao ddy : it ranh vo nao. tAn thu a ng doi xung

ndo Idng vd hAi nao ddy Id nhung b£nh di truyAn

Da hAi ndo nhd : khdng dAi xung, vd nSo cd dQ ddy binh thu d ng
benh khdng di truyAn

325
 . D p n g k in h & ngudri tre : th& n he cu a d a h6i n § o nh6, g ia m san h3i m 3

L g c ch o c h a t xam

T o n t h u a n g g a y d Q n g k in h
C a c n o ro n n g u n g ch uye n d jch ti> m ang n$i m a c nao th a t ra vo n ao : h ign d ign c h it x£ m lg c ch o
C h an d oa n b ln g X Q C L D T va C H T : . M g t do va tin h igu y h gt n h u cu a n ao b<?
. K ho n g b i t tu a n g phan
K ho n g co h igu u n g ch oa n cho, nguQ’c lgi c6n g ian ca c k h o a n g m a n g n ao l£n c$n

3 lo g i: - L gc ch 6 c h it xa m d gn g n o t : gia u n §o
kha n an g p ha t trie n c a c tin h m g ch kh o n g d ien h in h
- C a c h gt c h it xam d u o i m a n g nQi m g c nao t h l t iam b ien d gn g th a n h cu a nao t h l t
- L gc ch o c h it xa m d gn g I6 p : h in h the cua "v o n ao k6 p"

L a c c h o dgng not

C d c n o t c h a t xa m duo-i m a n g npi m a c n a o th a t V o n a o k6 p

- Loan san vo nao :

X Q C LD T T1
K h o c h in d o a n p ha n b ig t v o i D N E T
L a c ch 6 c h it xam d an g n ot Lo-i ich c iia p he p d o p h o : p h o b in h th u a n g
D o n g d g m d o va d on g tin h ieu so v o i c h a t xam tro n g tru crn g hQ-p lo g n sa n vo n a o

326
 2 - Dj DANG 0U&NG GlCPA
B^t s£n t h i chai

T h i ch ai p ha t t r ii n t u tr u fic ra sau : t i t ca ca c bat san m o t p ha n luon luon th u fic p h ia sau

. D iu hi$u : . P hat t r iin m fit p h in cua t h i chai
. C 6 hi$n tu’p'ng bu tn> bang cach gian ca c kh oa ng m a n g nhgn, c o the co n ang lien nao tha t
. K ho a ng li§n nao t h i t rfin g ra, m $t tro ng nao t h i t ben so n g so ng , :
trfin m at p h in g tra n c6 h in h d gng "s u n g trSu"
. K h fin g g ian c i c s u n g tran
. K h fin g v fii hfia
. Hfii ch u n g A ica rd i : d fin g kinh, lg c ch o c h it xa m , dj d gn g nhan cau, g ap a th ie u n u

B i t san th e ch ai p ha t hi$n tin h co- / nhoi m au doi thi trai

- U ma the chai :

. Dj s^n m fi va v fii h fia lie m dgi nao

. T h i ch ai k h fin g dj d g n g n h u n g s y p ha t t r ii n cua n fi bj can

tr f i do s y p h a t trie n cu a u m o va ca c vfii hfia

U m fi t h i chai :
phat t r iin sau - tr u d c

Dj dgng n lm k i c$n t h i ch ai

U m fi d u d i t iiu nao b fin tra i

U m d t h i chai:
t h i phipc tgp

B it san t h i ch ai do p h a t t r iin
u m d quanh t h i ch a i va g iu a
hai thuy tran

U m d bpc q u a n h ca c d on g
mgch n ao tru d c

327
 3 - Dj DANG MANG NAO

- N ang m ang nhen

- P ha t h ign tin h c a h o a c b en h nhan bi nhi>c dau kinh nien,

h o a c n ha n m o t lan bj ch an t h i/a n g d iu du nhe, co the c o xu a t h u y it

- N a ng thu n g lung S ylviu s

. Kha nang lam x i/a n g bj kh um vom
. K ho n g co h o a c co it h ieu i>ng ch oa n cho, d u d n g g iu a b in h th u d n g
N ang cu a be g o c lie m d ai n a o -le u tieu nao
N ang g o c ca u tieu n ao :
la m lo m m a t sau x u a n g da
p ha n b ie t v d i nang d an g bieu bi hay ”u h at ng<?c"
n h d ch uo i kh ue ch tan : nang m a n g nhen = k h u e ch tan tang
N a ng m ang n hen cu a be Id n :
K et h a p tu d jch d u d i m a n g c u n g

N e u n an g g a y trig u c h u n g : co the d in lu u n a n g -p h u c m ac
C a n p hai b ao d am kh on g c o th o n g th u a n g g iu a n an g v a i c a c kh oa ng d u d i nhgn
. D ong D N T kh a o sa t tren T 2 S pin E cho va T 2 F LA IR
. T a n g tin h ieu tren T 2 do tan g nong d o p ro te in th a m chi ta n g r i t it

Nang thung lung Sylvius

XQCLDT T1

Nang mang nhen d p h in loi so nao co the co chen ep dang 'kin h dong h o ' cua ban trong hQp so

328
. Nang vd ch tro n g su6t
T d ch d di vd ch lid n n do t h it , g ifii han b p hia sau Id 16 lidn tha t
H in h th d i b in h th u fin g tru P c sa nh vd nhO nhi; c6 t h i ton tai a n g u o i Io n : b ien the b in h th u a n g

- Cavum ve rg ae
. P hdt t r ii n ra sa u m fit nang cu a vdch, ra p hia sau c d c lo lidn t h i t , ch o den loi the chai
. T h fin g th u a n g vd'i djch tro n g ndo t h i t :

• Nang cua m^ng mach mac nao that III (velum interpositum) t^ fla ir ^ d6n9 ^
. Nang phdt triin d y a trdn cdc c iu true mdng ndo cua khe Bichat
gib’i han trdn la t h i tam gidc, c6 hinh dang tam gidc
. Nang khfing phdi nguydn nh3n sinh b£nh nhung Id trieu chUng cua tinh trang h o tiep d uo ng giOa
V 6i tinh trang n3y nang c6 the di kdm v&i b$nh canh tdm than do mat lien ket g iua ban c iu phai vd tr3i

Dj dang Dandy W alker :

. Vi tri ndm ca o cua leu tie u nao, cu a h o p lu u xo an g sau, c iia ca c xo an g ngang

trai x u o n g ch a m bi kh u m tro n : h in h a nh "b u i toe"
. G iam sa n tieu nao
. Bat sdn th u y n ho ng d u f i i : lo M a g en die r i t rong, th o n g v o i m o t n an g Io n p h a t trie n tro n g ho sau
th u y n h p n g tre n bj n an g d i y len
. N h u n g kh on g co s y th o n g th u o n g g iu a he tho n g nao t h i t va c a c kh oa ng m a n g n ao q ua nh nao :
trd n d jch n a o th a t khong th o n g th u o n g tro ng 80 / 100 c d c tru a n g h g p
. Higu u n g ch o a n ch 6 la m tha n n ao dp s a t va o m a t d o c (clivus)
. Phoi h p p : loan sa n t i i u nao, b at san t h i chai, la c ch o c h a t xam

- B iin t h i D a n d y W a lk e r : . B ien t h i nhe

. Lo M a g en di th o n g th o a n g , hign d ign leu tie u nao
. K ho n g co tra n djch n a o t h i t

- Tieu nao nho Leu t i i u n ao b am b in h th u o n g

H in h th e cu a b i Io n giO n g u yen
T h a y d u p e th u y nho ng tre n va d u o i
T h a n n ao cu n g g ia m san
D N T lu u th o n g b in h th u o n g

- B i Ion kh on g id : Leu tie u nao b am b in h th u o n g

H in h the cu a b i Ion giu1n g u yen
T t iiu n a o b in h th u o n g
Tra i x u o n g c h im kh u m tro n v u a phai
D N T lu u th o n g b in h th u o n g

N ang m a n g n hg n be Ion : c h in d oa n p ha n b ie t n h o
. H oc djch tro n do D N T bai t i i t ben tro ng
. K ho n g tdc ngh en d u o n g lu u th o n g dich
Di dang Dandy Walker

329
 jlj V V
■ **
, t » r ■ - ^
_ - >•

T 2 Spin Echo B iin t h i c iia D a n d y W a lk e r

Thoat vi mang nao

T h o £ t vj m ^ n g n ao o vu n g sa ng - b u o m

. T h o a t vj m ang nao vu n g d in h vo m sp

330
 4 - D| DANG ARNOLD CHIARI

- Di dgng C h ari : loai I : d j d an g nhe, & mi>c g id i h an cu a bien th e b in h th u d n g

p h d t hien tin h c d , kh dn g c6 dau h ieu tha n kin h lien quan td i di dang

. Hanh nhdn t iiu n do ddi, nhQn, ndm d u d i m u c cua lo c h im

Ndo t h i t IV vd n o i n6i h dnh ndo -tu y so n g c6 vj tri b in h th u d n g +++
B i Idn bj x6a m it , khdng cd ch d n ep hdnh tuy, lo M a g e n d ie th o n g tho d ng
C6 t h i p h6i h p p phi>c tap v d i cd c di d an g q ua n trp n g k h a c cua d i d an g C hiari:
. T rdn djch n do t h i t chu y iu d v iin g cham ,
. Dj dgng cd c m dng d u d i nhpn gan lo M a g en di, trd n djch n ao th a t ca 4 nao t h i t
. L f djch 6ng tuy

- Dj dang C hiari : loai II : dj d ang p h u c tap ; dj d an g nay co the la n g u yen nhan sin h benh va g a y ra cd c dau hieu lam sang
- Dj dang C hiari : loai III : dj d an g n an g : th o a t vj n ao -m a n g nao vu n g ch am co

. Ldm sdng : - S o sin h v d n hu n hi : co trdn djch nao tha t

- X d y ra d m pi tuoi vd n h it Id th ie u n ien hoa c thanh n ien tre :
. C h dn g m a t khi x o a y dau, yeu tu chi, dj cam tip chi
. C o n td nga d p t ngot, h p i c h u n g hdnh tuy, ton th u o n g cac tha n kinh sp hon h p p
... G idi dp cd c c i u true tha n kin h bdng ca ch c d t bd cu ng sau cu a d ot dpi, m d ro n g lo c h im
d in lu u D N T b dn g va n d an lu u n ao th it- p h u c m ac

Hinh dnh h p c :
. Dj dang dau tie n 1a "m p t ho sau n hd " :
M d t d o c (c liv u s ) n gd n, xo an g tTnh m ach thd n g b am t h ip , leu tie u nao bam t h ip
H$u q ua 1a p hd t t r ii n b i t th u d n g cua than n ao vd c a c ban c iu t iiu nao
- T g t n o i g ia o tie p h anh tu y -tu y so n g vd c d c hanh nhdn tie u nao
v d o tro ng o ng so ng den tan d o t dpi vd d o t trg c
- T h o d t vj t u d u d i len tren cua th u y n ho ng q ua lo b iu d g c rpng
- P hd t trie n th u y n h u n g t iiu nao xu n g qua nh va tha m c h i d p hia tru d c hdnh tuy
- B ie n d a n g th d n h h in h tam g id c cua m anh t u g idc
- K en h S ylviu s h o a c d j d an g, h o a c bj ch e n ep tu sau ra tru d c : cd the cd t i c n gh en D N T

Dj dang khdng chi han ch e d c d c c iu tru e cua ho sa u :

Dj d ang cd th e ket h p p v d i trie u c h u n g lam sa n g ro ret

- T ren leu : . G ia n t r im trp ng n ga t u n ao t h i t va cd c s u n g cham

. do n ao khdng p ha t trie n c h u kh dn g phai do tan g ap lu c cu a DN T
. cd c s u n g trdn kh dn g bien doi ... d in lu u n ao th a t ?
. T a n g sa n m e p xd m (h o ac d in h lien n ha u) lien d oi thj
. B at san lie m dai n ao va m a t tro n g hai ban cau d an va o nhau
. Dj d an g v d n ao lien ban cau

- O ng so n g : . O’ djch tro n g o ng tu y d o td c n gh en lo M a g en die

. T u y so ng d in h , n u t d p c g iu a tuy, th o a t vj tu y-m a n g tuy

Chu y: . Khi t h i y dj d a n g ho sau, p hai tim dj d an g co t so n g -tu y so ng

. Khi th a y dj d a n g c o t so n g -tu y so ng , p hai tim dj d an g tre n va d u d i leu

C h ia ri I C h ia n II C h ia n III

331
 C h ia r i I : Hinh anh hpc : mo xe m p h ia trfin

binh thi/drng

C h ia ri I va tra n djch n ao th a t "h o a t d o n g " ... dj d an g phi>c ta p cu a c £ c m ^ n g d u 6 i n hpn

cu a be Ion v3 c ^ c d j d g n g di ke m ... diiu trj ?

XQCLOT : c£c dau hieu cua dj dgng C h a ri: c3c hanh nhSn "bao quanh" h3nh nSo
. Lo c h im gian ra. hanh nh3n tiiu n3o th ip .
. Gian nao t h it khong dien hinh : t£p trung chu yeu a sung c h im
. X6a Ccie ranh vo nao v3 thung lung Sylvius

CHT : . Xoang tinh mach th in g b£m th ip

. Gian ca bon nao t h it khong thong thu o ng :
Gi3n ngach pheu nao t h it III "do chju cip lye"
Gian ro ret nao t h it IV do t i c nghen 16 Magendie
... giam ro tin hieu dong DNT o kenh Sylvius
va khong co tin hieu d6ng 6 lo Magendi

Chiari II : 2 loai

Nao th a t IV bj keo ca n g ra va ha tha p N a o th a t IV co vj tr i b in h th u o n g ,

hanh n ha n b inh th u o n g
C a c hanh n han tie u n ao keo dai ra
va nhon G hi chu : b ien d an g d ien h inh c a c cu nao
sin h tu , h in h tam gi&c
Ha th a p c h o tie p noi h an h tu y -tu y so ng
B at sa n m o t p han th e ch ai

chgp nao that v& i i6t

332
 C h ia ri II : khdng rd ti&n cdn; d $ t van d an lu u ; Nhi>c dau g an d ay, oi mi>a CHT

Chiari II ■ H? nh nhap tieu nao bao quanh hanh tuy

- N3o that IV co kich th u d c nho
- Bien dang hinh tam giac d$c hieu cua cuong nao do dj dang cac cu nao sinh tu
- Nao that gian v a i hinh thai dac b ie t: sung tr£n binh thuang
gian lan nga tu va cac sung cham
- Giam san liem dai nao
- Dj dgng vo nao lan cgn / mat trong nao bo
da hoi nao a ben trai, bat san vo nao a ben p h a i... co the co hoi chung lam sang
a nga tu d uo ng lien ket: co ton thuang su phoi hap?
 - C h ia ri va dj d gn g o n g so ng va tiiy so ng :
. O’ djch 6ng tuy do t i c nghen 16 Magendie
. Tuy s6ng bi d in h , nirt dpc giOa tuy, thoat vj tuy-mang tiiy

C h ia ri II
O’ djch o n g tu y ro
tu y so n g bj d in h
p h iu th u a t d ie u trj g a i d6i
C h ia ri I hoa c C h ia ri II
C h o tie p noi h an h n io - tu y
C h o tie p noi h anh tuy
so ng ha t h i p
-tu y so ng ha th a p ?
D in h khoi C 2 -3 b am sinh
if d jch o n g tu y ro
Dj d an g d o t so ng
va Cp djch o n g tu y dj dang
ti> C 6 d en D3
C h ia ri I
. Dj d an g n hp
h an h nh3n ti&u n ao
v a ch o ti&p n6i h a n h n a o -tu y s6ng
. O' djch 6 n g tu y m p t d o a n 6 vu n g cA
. M a t d 6 c (c liv u s ) n ga n d o b i t san cac d6t
s6 n g v u n g c h im
H au q ua : g a p g o c nhi&u
giCra m a t d 6 c va m iu rang

- Dj d an g ke t h p p g iu a nen sp va ban le s p -c o t so ng :

- M a t d o c (clivu s) ngan
- T a n g g o c g a p giO a m a t d o c (c liv u s ) va d o t tru e : ch en ep h an h tu y
- P hi d ai (bu tru ? ) cu ng trip o c c iia d o t dpi
- Lo ch a m Ion g ia n rong
- B at san cu n g sa u d o t dpi

A rn o ld C h ia ri d a p h lu th u a t

- R ong 16 ch a m Ion
- C a t bo cu ng sau cu a d o t d pi va d ot try c
- T ru o n g h p p n go ai le, di n ga t r u a c xu yen q ua m ien g d e giai ep m a t
tr u a c hanh tu y

334
 BENH THAN KINH - DA

BENH U SQf\ THAN KINH VON RECKLINGHAUSEN

• N F1 : b im sinh hay Id td / 1 trdn 3.000 / u spi th in kinh d u d i da, dom ca phe sOa / tuAi thQ trung binh 67 tu6i

A / T in th i/a n g tang sinh . U t i bdo dem giao thoa thj gidc : d tre em, u te bdo dem dien tien r i t chdm. 3 /1 0 0 tru dn g h ap cd tinh
c h it xdm lin
lan ra phia tru d c den mot hodc hai day th in kinh thi gidc
lan ra phia sau den cdc ddi thj, den doi thj
h iim khi thodi h6a thdnh saccom s a ' th in kinh (neurofibrosarcome)/ b it manh gadolinium
. cdc mo tdng sinh te bdo dem nao : lanh tinh, khong tien triin , khdng thodi h6a, d ud ng kinh d u d i 15 mm
c h in dodn kho neu n h i/ khong nghT den benh u sgi th in kinh / xem p h in cdc lo k h u y it ndo
. U ddy t h in kinh dang ddm r6i (ndvromes p le xifo rm e s): di/6'i da, h6c mdt, m i m d t.
. U cufin : u cu0n ddng mach cdnh, cupn canh, cuon mdng nhT
. U nfii tuy

B / Logn sdn : . Loan sdn cdnh Idn x i/a n g b ud m , loi mdt do khuyet t r in h6c mdt
gidn Idn . Cdc ong tai trong md khdng tim t h iy u ddy th in kinh
. Cdc 6ng thj gidc md khdng t h iy u te bdo dem
c6 the gidi thich Id do nhjp dap binh th i/d n g cua DNT tdc dpng Idn cdc c iu true x i/a n g dd b iin dAi
thodt vi mdng nhen trong yen
. K h u y it cdc d u d n g khdp sp
. H0p sp to khdng kdm trdn djch ndo th it
. Tui phinh dQng mach, hep ddng mach
. C0t sdng : veo cdt song, lom cdc thdn dot song, thodt vj mdng tuy n gi/c
. Cdc c h i: kh dp gid

• NF 2 : b im sinh, di truyen nhiem sdc the trpi / 1 tren 30.000 / d iu hieu than kinh / tuAi thp trung binh 35 tuAi

. K it hap giOa u th in kinh "dang chuoi" vd i u mdng nao ; nhieu u mang ndo (meningiomes multiples) hay bdnh u mdng ndo lan
tda (mdningiomatose diffuse) n h it Id u than kinh hai ben ciia bo th in kinh thinh g id c-th in kinh m$t, u th in kinh ciia ddy sinh ba
. U t i bdo ddm v d i nhieu phdn dp khde nhau
. U mdng Ang npi tuy trong tuy
. C i/d m mdt, ham artom vong mac

- Benh u s&\ th a n k in h lo a i I

B$nh V on R e cklin g h a u se n

- Cdc A t i bao d dm h oa n h ie u n o i:

- U t i b do d em th a n kin h thj ben p ha i g g i y ch a n d o a n b£nh

- Cdc A t i b ao d e m h oa n h ie u n o i tro n g nao
. T o n t h i/a n g kh o n g h o g c it tie n trie n
. K ho n g c o h ie n tir a n g hoa th a n h u te b ao d em
- TAn thuang co tinh chat nhieu te bao
. C 6 th e ta n g d $ m d o h o a c ta n g tin h ie u tre n T 1,
. K h o n g b d t c h a t tu a n g phan

335
 - Benh u spi than kinh loai I loan san xirong, logn san I6p trung bi

. H in h k h u y e t dr tra i c h im (ecaille
o c c ip ita l)
. N a n g m6r>g n h $ n dr b fin d u d i

XQ quy u d c XQCLOT. tai tao T 1 gado

. K h u ye t a ca n h Io n x u a n g b u a m
. T h o a t vj va o tro n g h o c m l t c a c hoi tro n g cu a th u y th £ i d u o n g , loi m l t
. P h i dai b an ca u ben phai

- Benh u so’i than kin h loai II

x x T1 Gado
- U s a i th a n kin h hai b en cu a bo th a n kin h th in h g ia c -th a n kin h m a t va cu a c a c d a y th a n kin h sp hon h o p
- P h i d ai lan to a c a c x o a n g hang

- B en h u m a n g n a o la n to a 6 h £ rr d ai n a o
- U m a n g n a o c u a m a t d o c ( d iv u s i

336
 b $nh x a n Ao c u b o u r n e v il l e

. C£c d lu hi$u 6 da : u tu y in cua tu y in b§ quanh m6ng, quanh mieng

Da d3y Idn nhu- g ily

- Ch$m phat triln tam th in , d$ng kinh

. V6i h6a trong nao
. Ct d udi mang nQi mgc nao t h l t : " cac c i i "
u t l bao sao loai te bao khong lo, mQt ho$c hai ben
g in lA liSn nao th lt
. Cl chA t ilp n6i c h it trin g , c h it xam
. V6i h6a va kha nang xu an g h6a 6- nhQ-ng t6n th u a n g sau :
Ang Havers, m d thufic logi tuy x u a n g so

- PhAi hap
- T in thuang mgch mau : gian mgch, t i c mgch
- Da u mang nao
- U than, u n h ly tim ...

- Tho£i h6a : u te b a o g a i it n h a n h
ho$c u te b ao s a o lo ai te b a o la n
 Bgnh STURGE WEBER KRABBE
. B$nh u mgch nao - th4n kinh sinh ba mdt bdn
. U mgch da trong vung chi ph6i cua th£n kinh sinh ba
. Vdi h6a vo n3o phat triAn tu sau ra tru d c, giong n h u v6i hoa dfing mgch,
d6ng th d i co thA cd u mgch vung mj-it cung bdn
nguy c a bd sdt vdi hoa tren CHT : tin higu thap trdn t£t c6 c3c chudi
. Teo s<?-n3o mpt ben rd rgt
. 0 6 m rdi mgch mgc Idn

Chan doan lam sang : u mgch da d toan bp hoac mpt phan vung chi phdi cua th^n kinh sinh ba, ddng kinh

Benh Sturge W eber Krabbe. the dien hinh

. Teo nira sp nao ben trai
. Vdi hda va bat gadolinium d u mgch mang nuoi

338
 B $ n h V O N H IP P E L L IN D A U : u lu o i m g ch

. N h ie u u / u lu a i m g ch ; to n th u o n g r i t gteu m g ch n u o i, c o th e l& g ia u m g ch
to n th u o n g d $ c, d o n g n h lt h o $ c d $ c v a n an g : u bai tie t t u th& nh, c o th e n h o du6n 1 cm .
. V j t r i : tie u n ao , th a n nao, v o n g m g c, tu y co, n g y c : p hoi h o p v 6 i u d jch o n g tu y
p h 6 i h o p u tu y th u p ’ng th g n mQt h o g c h ai b en , v a i u ng th u th§ n

- Tieu nao
Vong mgc
Tuy song: u djch trong ong tuy

Benh RENDU O SLER

- Logn s3 n m g ch co tin h g ia d in h : g ia n m a o m g c h , u m a ch h a n g , di d a n g d p n g -tln h m a ch v o n ao n h ie u n o i.

h ie m khi x u a t h u y e t
- ChSy m £ u m u i ta i d i ta i lgi / th u y e n t i c , h o ra m a u , x u a t h u y e t tie u hoa
- G ian m a o m g c h . k h o n g ch a n d o a n ra h o g c ch a n d o a n kh o b ln g C H T
- N h6i m £ u n a o lie n q u a n t o i b gn h d a h o n g ca u, a p xe n ao d o th u ye n ta c n g h ic h (e m b o lie p a ra d o x a le )
339
 | M O T SO T H U A T NGLT T H U O N G D U NG T R O N G C Q N G H U O N G TL SQ N A O . |

- T1W
o T hoi gian T l: con goi la thcri gian hoi gian doc (longitudinal relaxation). Then gian T l co gia trj
tir khoang 100ms -> 3000m s. T rong m ot tir tnrcmg nhat dinh thcri gian T l cua cac m o co gia tri
khac nhau. M o m a co th ai gian T l ngan nhat (20 0 -^2 5 0 m s), n u a c tir do cang nhieu thcri gian Tl
cang dai (>2000m s). C hat trin g co thoi gian T l ngan hem chat xam vi chat trang chira nhieu md
hem. Tren hinh cong huang tir cac m o co thoi gian T l khac nhau se tao m uc do trin g den tucmg
phan.
o Tren hinh trong T l (T l-W ) sir khac biet giua cac m o dircrc tao nen khi chung ta chon thai gian
TR va thai gian TE sao cho cac m o co thcri gian T l khac nhau cang nhieu de tin hieu co cuong
do khac nhau cang 1cm. Do do ta chon TR ngan (600m s)va TE ngan (20m s). M o nao co T l ngin
se co tin hieu m anh (trang) va m o nao co T l dai se co tin hieu yeu (den). C u the m a se co mau
trang nhat, cac m o m em co m au xam h a n va cac loai djch co m au den.

- T2W
o T hoi gian T2: con goi la thai gian hoi gian ngang (transverse relaxation). Thcri gian T2 ngin
ha n nhieu so vdi T 1, thirang thay doi tir khoang 40m s -> 200m s, sir khac biet cac m o cung tuang
tu T l nhung nguac lai; tren hinh trpng T2 ta chon thcri gian T R dai va TE dai. M o co T2 dai s6
cho tin hieu m anh (trang) va m o co T2 ngan se co tin hieu yeu (den). D ay la yeu to phan biet
giua hinh trpng T l va hinh trpng T2.
o Tren hinh trong T2 (T2-YV). T rong c a the, gan co thai gian T2 ngan nhat (40m s). m a (80m s) va
djch nao tuy co thai gian T2 dai nhat (160m s). T ren hinh T2W djch nao tuy a nao that va khoang
d u a i nhen co m au trang. cac m o m em co m au xam va vo xucmg hau n h u khong co tin hieu nen
co m au den.

- PDW
o D am do proton: So lupng proton co trong te bao va m o, khong lien quan vcri thcri gian T l va
th ai gian T2. M o nao co dam do proton cang cao thi tin hieu cong hucmg tir cang m anh.
o Tren hinh trong dam do (Proton density w eighted , PD -W ) ta chon TR dai va TE ngan de co
tin hieu tot nhat. H ien nay hinh anh PD W d u p e sir dung trong chuyen khoa than kinh va ca
x u a n g khap, tren thuc te lam sang PD W co gia tri khi can danh gia cau true co tin hieu th ip nhu
m o spi.

- Thin gian TR (R epetition tim e): La khoang thai gian giura hai lan phat xung kich thich. Thcri
gian TR co lien quan m at thiet v a i thcri gian T l ciia cac m o khac nhau. D e co tin hieu cong
h u a n g tir m anh nhat TR > thai gian T l, n gupc lai tin hieu se yeu. T R < 1000m s d u p e xem la
ngan.
- T hoi gian TE (echo tim e): La khoang thcri gian nhat djnh ke tir liic t i t xung kich thich d§n liic
do tin hieu. T h ai gian TE co m oi lien he chat che v ai thcri gian T2 ciia cac m o. D e co tin hieu
cong hucmg tir m anh nhat TE phai kha nho so v a i th ai gian T2. TE < 30m s dirpc xem la ngin,
> 80m s la dai.
- T rong ky thuat cong h u a n g tir. cucmg do tin hieu cua m o cang m anh thi hinh anh cang tring.
T rong thirc hanh lam sang, tin hieu cao (high signal) de m o ta viing trin g va tin hieu th ip (low
signal) de m o ta viing den. Sir khac biet tin hieu giua cac m o. n g u a i ta dung thuat n g u tang tir
hieu (hypersignal), dong tin hieu (isosignal) va giam tin hieu (hyposignal).

- V O X E L hay con goi la diem vat. la khoi the tich nho cua la p cat co chiSu cao b i n e do day lof
cat va dien tich day la kich thudc no chiem trong m ot tnrcmg nhin. T he tich cua m oi voxel canj
nho thi so lupng voxel cang 1cm.

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. PIXEL hay con goi la difim anh, la phan dien tich cua voxel tuong ung khi no bieu lo tren be
mSt cua lop cat.
. Ma tran anh la tdng s6 pixel co d u a c trong m ot tru an g nhin. Khi so pixel cang Ion thi kich thudc
moi pixel cang nho va the tich voxel tuong img cang nho. do phan giai khong gian cang cao, luc
do chi tiet cua c iu true tren trucmg nhin cang ro.
. Ty If tin hi$u / n h ilu hay ty If SN R (signal to noise ratio) la do Idn cua tin hieu thuc so vdi do
nhieu, ty le SN R cang Idn thi do trung thuc cua anh cang cao nghta la hinh anh chi tiet va sac
net. Muon d u a c nhu the ta can phai giam kich thudc cua voxel cang nho cang tot dong thdi phai
co tir trudng m anh va ty le SN R cung phu thuoc vao thdi gian do tin hieu (acquisition time).

- Chuoi xung spin echo (SE) la chuoi xung d a n gian va dugc su dung nhieu nhat. Cac anh trong
ky thuat T1W , T 2W va PDW deu dung ky thuat nay. T rong chudi xung SE thudng cd thdi gian
TR kha dai do do thdi gian chup thudng dai hern cac chudi xung khac. Chuoi xung nay thudng
khdi dau bang m ot xung kich thich vdi goc lat 90 do, tai thdi diem TE/2 m ot xung tai lap 180 do
ducrc phat ra va ghi nhan hinh d thdi diem TE.
- Chuoi xung G radient echo(G R E): chudi xung nay cd 2 dac diem khac vdi chudi xung SE la:
o Chudi xung GRE khdng dung xung tai lap 180 do ma su dung them 1 thuy hoi pha de dieu chinh
tinh trang lech pha do tac dung cua thuy khir pha gay ra.
o Xung kich thich dung goc lat a < 90 do.
- Hinh thu dugc trong chudi xung GRE c a ban la hinh trong T2W . Vdi chudi xung nay ta co the
phat hien dugc cac ton thuong vdi hda chira canxi hoac xuat huyet chira sat ma chudi xung SE
khdng thay dugc.

- Ky thuat hoi phuc dao nguwc (Inversion recovery, IR) la dang m d rong cua chudi xung SE.
Chudi xung IR khac chudi xung SE la tai thdi diem nhat dinh trudc khi phat xung kich thich 90
do ngudi ta phat m ot xung dao 180 do. K hoang thdi gian tir luc phat xung dao nay den luc phat
xung kich thich 90 do dugc goi la thdi gian dao ngugc TI (inversion tim e). T rong thuc te ngudi
ta thudng dung 2 loai chudi xung hoi phuc dao ngugc la:
o Chuoi STIR (sh ort tim e inversion recovery) la chudi xung lam m at tin hieu cua m d m d, do
vay thdi gian dao ngugc TI dugc chon kha ngan gan vdi thdi gian T l cua m d m a va khi phat
xung kich thich, cac m d cd T l dai se cho tin hieu m anh hern cac m d cd T l ngan. Chudi xung
STIR thudng cd T R dai va TE ngan va hinh thu dugc bang chudi xung STIR la hinh dao ngugc
am ban cua hinh T l W.
o Chuoi F L A IR (fluid attenuated inversion recovery) la chudi xung xoa tin hieu cac dich, nhu
dich nao tuy. Ta chon thdi gian TI that dai > 2000m s phu hop vdi cac thdi gian T l dai cua dich.
Chuoi xung FL A IR cd TR that dai va TE dai. Hinh thu dugc tir chudi xung FLAIR thuoc loai
hinh T2W nhung cac thanh phan thuan nude khdng cd tin hieu (den).
Ky thuat bao hoa tuong tu nhu ky thuat hoi phuc dao ngugc. nghta la ngudi ta chuyen xung tir
hda doc thanh tir hda ngang de lam tra m ot m d nao dd. khdng cd tin hieu khi phat xung kich
thich. Phuong phap bao hda m d (fat saturation, FS) la m ot trong cac ky thuat nay.
- Ky thuat khir mo' hay xoa mo' (fat suppression) la phuong phap xoa m d bang ky thuat cong tin
hieu cua 2 anh nghjch pha va ddng pha cua nude va m d. 2 chat nay quay vdi toe do khac nhau va
dugc do bdi ky thuat SE kep. D ay la ky thuat Dixon.
- Ky thuat EPI (echo planar im aging): ky thuat nay dugc su dung gan day vdi diem noi bat la
thdi gian chup toan bo rat ngan. thudng < 100m s va cd the dat a mire 20m s nen loai bo dugc cac
xao anh (artefact) va cd the ghi nhan dugc nhieu qua trinh sinh ly xay ra nhanh nen no cd the
danh gia dugc chuc nang m ot so co quan. Ky thuat nay cd the dung xung kich thich duy nhat
(mot phat, single shot) hoac nhieu xung kich thich (nhieu phat. multi shot I. Mot bien the cua ky
thuat nay la SE + EPI. Do thdi gian chup rat ngan nen trong benh ly than kinh ky thuat nay dung
de danh gia kha nang tudi m au (perfusion) cho nhu m d nao. kha nang khuech tan (diffusion) cua

34 1
 nude qua cac m o nao. Hien nay EPI la c a s a nen tang cho linh vuc cong h u a n g tu chirc nSng
(funtional M RI).
K y thu at spin echo nhanh (fast spin echo) la phien ban nhanh cua SE cung giong n h u EPI la
phien ban nhanh cua GRE.

H IE U ifN G D O N G C H A Y (flow effect): dong m au chay trong long m ach tuan theo dinh lu |t
huyet dpng hpc. D uai anh h u a n g cua tir trucrng dong m au dang chay co nhung tin hi?u khac han
v a i m o tTnh xung quanh, sinh ra cac hieu img dong chay. Tiiy theo dong chay deu (lam inar flow),
dong chay don (plug flow), dong chay xoay (turbulent flow ) se co cac tin hieu khac nhau tren
cong hucmg tir ve dong chay:
o H ifu irng trong dong (flow void) la tinh trang m ach m au trong, khong co tin hieu (den) tren
chuoi xung SE nhat la khi TE kha dai trong hinh T2W .
o H ieu u n g nQi dong (inflow effect): phan m au d trung tam long m ach chay nhanh hem dong mau
or sat thanh m ach cho ra tin hieu cao (trang) han. D ay d u a c goi la hieu ung noi dong,
o H ieu ung can thanh: phan m au a sat thanh m ach chay cham h a n va co toe do khac nhau khien
cho tin hieu chung cua toan voxel bj m at, gay ra tinh trang m at tin hieu (den) cr viing sat thanh
m ach.

C on g hirffng tir m ach mau (M RA): khac vcri CT va DSA can phai dung thudc can quang de tao
tu a n g phan m ach m au, ky thuat M RA cd the cd hoac khdng su dung chat tu a n g phan tir. Kha
nang khdng sir dung chat tu a n g phan tir la m ot uu diem cua cong hucmg tir so vdi cac ky thuat
khac. M RA cd thudc tu a n g phan thudng giup danh gia m uc do va pham vi cua ton th u a n g nhieu
h a n , ro h a n va thdi gian chup cung ngan han nhieu.
M R A khdng dung thudc tu a n g phan d u a c chia lam 2 nhom : ky thuat m au toi (dark blood), ky
thuat m au den (black blood), hay ky thuat m au sang (bright blood) hay ky thuat m au trang (white
blood). T rong ky thuat m au toi, ngudi ta dua vao hieu ling trdng ddng (flow void) va su dung
chudi xung nhanh FSE ; trong ky thuat m au sang ngudi ta su dung hieu im g noi ddng (ky thuat
T O F) hay ky thuat tu an g phan pha.
K y thu at m au sang T O F (tim e o f flight) dua vao hieu im g noi ddng va sir dung chudi xung
GRE. Cd 2 ky thuat TO F 2 chieu (2D TO F) va T O F 3 chieu (3D T O F) trong dd de danh gia viing
m au chay nhanh n h u viing dong m ach canh va viing da giac W illis n gudi ta th u d n g dung ky
thuat 3D TO F va vdi viing cd ddng m au chay cham ngudi ta thudng dung ky thuat 2D TOF.
K y thu at tu’ffng phan pha (phase contrast, PC) sir dung su lech pha cua ddng m au dang chay
cua giua 2 lan chup de tinh ra toe do ddng chay. No cd the loai bo tin hieu cao cua cac m d dung
yen n h u m a va cac san pham ciia m au tot h a n ky thuat TO F nhung ton thdi gian chup nhieu han.

K Y T H U A T D l/N G H iN H la quy trinh tai tao hinh thuc hien bdi cong nghe m ay tinh.
o K y thuat M PR (m ultiplanar reform ation) la ky thuat tai tao nhieu m at phang theo nhiiu
hucmg khac nhau tir dur lieu cua m ot m at cat nao dd. H ien nay ky thuat nay d u p e su dung rit
nhieu trong CT va M RI giup lam giam thdi gian rat nhieu n hung v in cd day du nhidu m at cit
khac nhau de chan doan.
o K y thu at M IP (m axim um intensity projection) la ky thuat giiip chiing ta nhin he thong mach
m au hay m ot to chirc khac tir m ot goc do nao do m a hinh anh m ach m au hien ro han tren m ot n£n
toi h a n d xung quanh. T rong ky thuat M IP hinh anh se giu lai cac voxel cd tin hieu cao n h it tren
m ot h udng nhin den vat (trong CT la cac viing cd thudc can quang, trong M RI la cac voxel cd tin
hieu cao nhat). T rong M RA . ky thuat M IP cd the dung dupe trong ca n hung tnrcm g hop khdng
dung thudc tu a n g phan va d u lieu tao hinh bang ky thuat m au sang,
o K y thu at d u n g be m at (surface ren dering) la kv thuat lam hien thi cac voxel nam a b d cua mot
cau true, cac voxel khac cdn lai dupe cho an di tao ra m ot hinh be m at cua cau true. Ky thuat nay

342
thudng dugc su dung dS quan sat be m at cua ong tieu hda, khi quan, m ach m au goi la noi soi ao
hoSc ngoai soi ao (virtual endoscopy, exoscopy).
Ky thuat dirng khoi (volum e rendering): day la ky thuat ket hgp 2 ky thuat M IP va ky thuat
dung b6 mat; ky thuat su dung toan bo d u lieu 3 chieu va voxel dugc hien thi hay khong hien thi
dua vao mot ngudng chgn trudc. Ky thuat nay cho phep dung lai toan bo khoi c o the can khao
sat va cd the boc khoi nay thanh tung ldp.

Nguyen ly khuech tan (DW ): C huyen dong a goc do sinh hoc la bieu thi hoat dong chirc nang
cua c a the ma qua trinh sinh ly xay ra tir mire do dai the den mire do vi the deu dugc bieu hien cu
the bang hinh anh. Gan day MRI da m d ra m ot llnh vuc m di la cong hucmg tir chirc nang trong
dd 2 ky thuat c a ban la ky thuat khuech tan va ky thuat tudi mau.
Hi?n tirong khuech tan: N gudi ta dua vao chuyen dong cua phan tir nude khi dat trong mot tir
trudng, ggi la chuyen dong Brown theo moi hudng. He so khuech tan (diffusion coefficient, mm
vuong/giay) dugc bieu hien bdi he so khuech tan bieu kien AD C (apparent diffusion coefficient).
He so ADC ciia m di m d cang Idn thi kha nang khuech tan trong m d dd cang manh. He so khuech
tan bieu thj theo 3 chieu khdng gian x, y, z va dugc sir dung de tao ra hinh cong huong tir cd ten
la ban dd ADC. He so nhay khuech tan b dugc tinh bang dcrn vj giay / m vuong. Gia trj nhay
khuech tan thudng dugc su dung trong lam sang thay ddi tir 500 1500 giay m vuong. De tao
hinh khuech tan ngudi ta thudng dung xung EPI vi kha nang chup nhanh ciia no. Mot bo hinh
anh de danh gia hien tug n g khuech tan gom cd T2W , DW va ban dd ADC. Trong dd hinh T2W
chup bang xung EPI cd gia tri b = 0, hinh khuech tan DW theo 3 true khdng gian va hinh ban dd
ADC cd gia trj b= 500-> 1500. T rong hinh DW viing m d cd hien tuong khuech tan kern se cd tin
hieu cao (trang) va tren hinh ban dd AD C viing m d kem khuech tan se cd tin hieu thap (den).

Nguyen ly tiroi mau: Hoat dong chirc nang cang nhieu thi lugng m au den nuoi cang Idn nhu vay
danh gia tinh trang tudi m au m ot vung thdng qua cac chi so huyet dong giup ta danh gia mire do
hoat dong chirc nang dang xay ra tai cho trong m ot don vj thdi gian. Cac chi so thudng dung la
the tich mau trong m d (tissue blood volum e, TBV ), lugng m au chay qua m d (tissue blood flow,
TBF) hay thdi gian qua canh (transit tim e , TT). De thuc hien danh gia viec tudi m au ta cd 2
phucrng phap dung chat noi sinh hay ngoai sinh. Chat ngoai sinh thudng dung la chat tuong phan
tir ngoai bao lam giam thdi gian T l va T2. Viing giam tin hieu dugc xem nhu viing cd tudi mau
kem. Ta cd the dirng phuo n g phap bom nhanh (bolus) va dung chudi xung EPI de nhan xet thay
ddi tin hieu khac nhau trong vung. C hat noi sinh la cac proton trong ddng m au dugc danh dau tir
tinh trudc khi chay vao vung m d can khao sat va su dung phuo n g phap bao hda hoac phuong
phap dao ngugc.

343
 H IN H A N H H O C SO N A O
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