PHN IN QUANG THN KINHPhm Minh Thng

I. GII PHU IN QUANG:Mc tiu: Nm c gii phu in quang ca no, mch mu no v h thng no tht1.1 GII PHU NHU M NO

1.1.1. Gii phu thy no: -Thy trn : nm trc rnh trung tm (Rolando) -Thy nh: Nm sau rnh trung tm -Thy thi dng: nm di khe bn (Sylvius) -Thy chm: pha sau -Thy o 1.1.2.Cc hch nn (cc nhn xm trung tm) -Claustrum: phn cht xm mng nm pha bn ca bao ngoi, chc nng cha bit r rng. -Th vn: lin quan n cc vn ng c iu phi .Nhn ui: gm u, thn v ui .Nhn bo: hnh tam gic nh quay vo trong, pha bn l bao trong v pha ngoi l bao ngoi Bo m nm pha trong Bo nht nm pha ngoi

Hnh 1.1. Cc thu no 1.Thu trn; 2.Thu nh 3.Thu chm; 4.Thu thi dng

1.1.3. i th: l trm trung chuyn, bao gm i th: -Nhn bn -Nhn gia -Nhn trc Vng di i

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-Vng nm di i th sau vng hypothalamus v pha trn ca gian no -L cc trm tip ni cho cc ng vn ng ngoi thp cho cc c vn -Cc nhn di i Hypothalamus: -L phn phn chia pha trc ca gian no -Bao gm phn nn ca cc ngch no tht ba, nn phu tuyn tng, thn cc c nm v -Ha nhp cc ng dn truyn thn kinh ni tit v t ng bo m chc nng iu ha ca c th -Gm nhiu cc nhn xm1 2 4 5Hnh 1.2. Cc nhn xm trung tm 1.Bao trong; 2.Nhn bo 3.Bao ngoi; 4.u nhn ui 5.Claustrum; 6.i th

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1.1.4. Mylin ha ca no. Hnh nh CLVT v cng hng t no s sinh v tr nh khc vi ngi ln do -No cha nc nhiu hn: r hn trn T2W -Mylin ha t: thy r hn trn T1W -t ion lng ng -Trng thnh ca no bt u t cung no, n tiu no ri n i no c im hnh nh CHT ca no: -Trc khi sinh: .B mt v no nhn, cc np cun no rt t .Cht xm v no v cc nhn xm c tn hiu tng -Sau khi sinh: c mylin ha cc t chc ca no khc nhau ty tng vng1.2. H THNG NO THT.

1.2.1. Gii phu: -Cc no tht bn bn phi v bn tri ni vi no tht 3 ti thnh hnh ch T, cc no tht bn thng vi nhau qua cc l Monro, no tht bn c cc phn: .Sng trn ( pha trc) .Sng chm ( pha sau) .Sng thi dng ( pha di) -No tht ba ni vi no tht bn qua cng Sylvius, no tht ba gm .Ngch th gic .Ngch phu

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.Ngch tuyn tng .Ngch trn tuyn tng .Vng ni gia hai i th -No tht bn: ni .Pha bn vi dch no ty qua cc l Luschka .Pha sau qua l Magendie .Pha di vi ng trung tm ca ty sng

Hnh 1.3. H thng no tht 1.Sng trn no tht bn; 2.Thn no tht bn;3.Ca no tht bn; 4.Sng thi dng 5.Sng chm; 6.L Monro; 7.Thn no tht ba; 8.Ngch phu th gic no tht ba; 9.Ngch trn tuyn tng no tht ba; 10.Cng Sulvius; 11.Thn no tht 4; 12.ng gia tu; 13,L Magendie 14.ngch bn NT 4v l Luska; 15.Ngch sau trn; 16.Phn chp NT 4

1.2.2. Cc bin th ca vch trong sut: -Nang vch trong sut: .Hnh nang phn chia hai sng trn ca no tht bn (trcl Monro) .80% gp tr em, ch c 15% ngi ln .Nang c th gin to, rt t khi chn p gy nc no tht. -Nang cnh ra no tht: .Nm tip ni pha sau ca vch trong sut, khng bao gi xut hin khi khng c nang vch trong sut .80% tr em, 15% ngi ln -Nang rim gia cc no tht: Nm trong vng b no t c no sinh t ti l Monro 1.2.3. Gii phu vng tuyn tng: -V tr: .Nm sau no tht 3 .Nm gia hai i th -Vi ha bnh thng ca tuyn tng: .10% vi ha trong 10 nm u .50 % vi ha tui 20 .Vi ha c th to gn bng kch thc ca tuyn tng .Kch thc bnh thng ca vi ha < 10mm1.3. GII PHU VNG TUYN YN:

1.3.1. Tuyn yn: -Tuyn yn c chia lm hai thy :

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.Thy trc( vng tuyn ): ngun gc t ti Rathke( trn hc ming nguyn thy), bi tit prolactin, ACTH(adenocorticotropic hormone); c tn hiu trung gian trn CHT .Thy sau: ngun gc t sn no tht 3, bi tit oxytoxin v vasopressin; thng tng tn hiu T2 -Kch thc tuyn o trn CHT ct mt phng trn .Dy 3-8mm ; c th ti 10mm tui dy th, >10mm c thai .Kch thc ngang 2-5mm .Tip ni vi vng di i .Nm sau giao thoa th gic .Tng m nhiu khi tim thuc i t hay thuc cn quang 1.3.2. B trn yn : -V tr : Nm pha trn mn chn h yn .C hnh sao 5 cnh trn lp ct ngang qua cu no .C hnh 6 cnh nu ct ngang gian no -Thnh phn bn trong : .C a gic Wllis .Giao thoa th gic, dy th gic .Cc dy III, IV, V .Thn tuyn yn. -B no c th thot v vo h yn (hi chng h yn rng) 1.3.3. Xoang hang -L xoang tnh mch do mng cng bao bc, bn trong c: .ng mch cnh trong, m ri giao cm .Cc dy thn kinh s: III,IV,V1,V2 v VI -Cc mch mu vo xoang hang .Tnh mch mt .Tnh mch vng mc .Tnh mch mng no gia .Tnh mch chn bm .Cc xoang trn v di .Xoang bm nhHnh 1.4. Gii phu vng h yn, xoang hang 1.Tuyn yn; 2.phu; 3. Dy TK III; 4.Dy IV 5.Dy V1; 6.Dy VI; 7. Xoang bm; 8.ng mch cnh trong; 9.Phn trc bn dc; 10.No tht III; 11.Giao thoa th gic; 12.B trn yn; 13.Cc khoang ca xoang tnh mch 14.Xng thi dng; 15.Vng di i 16.Dy V2; 17. Diapham tuyn yn1.4. H THNG MCH MU

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1.4.1. ng mch cnh ngoi:ng mch cnh ngoi c 8 nhnh chnh -ng mch gip trn -ng mch hu ln -ng mch li -ng mch mt -ng mch chm -ng mch vnh tai -ng mch thi dng nng -ng mch hm trong +ng mch hm trong c cc nhnh chnh -ng mch mng no gia -ng mch mng no gia ph chui qua l van -ng mch hu xung -Cc nhnh mt, xoang, mi v mt -ng mch bm khu ci, ng mch trong hc mt + Cc ng mch cp mu cho Hnh 1.5. S ng mch cnh ngoi mng no bao gm 1.M gip trn; 2.M hu ln; 3.ng mch -T ng mch cnh trong: li; 4.ng mch mt; 5.M chm; 6. M .Thn di bn tai sau; 7.M thi dng nng; 8. ng .Thn mng no vng h yn mch hm trong 9.M cnh trong .Cc nhnh ng mch mt -T ng mch cnh ngoi: .ng mch mng no gia .ng mch mng no ph .ng mch bm vm .Cc nhnh ca ng mch chm -T ng mch sng: .ng mch mng no sau 1.4.2. ng mch cnh trong: c 4 on -on c: khng c nhnh bn, bt u t hnh cnh, n c th gin trn on 2-4cm - on trong xng .C cc nhnh hu nh rt t thy trn Hnh 1.6. S ng mch chp mch cnh trong .ng mch hm nh trc v sau cho tai gia 1.M cnh trong on c; .ng mch cnh hm nh 2.Thn mng cng tuyn yn; ( carotidotympanic artery) cho tai gia v tai trong 4.M mt; 5.M thng sau; -on trong xoang hang: 6.M no sau .Thn mng no tuyn yn( thn sau) .Thn di bn -on trong xoang hang v on trn yn to ln xiphng c hnh ch S, c 5 on .C5 hay l on ln ca cnh trong nm trong xoang hang: hng i ng thng t nh xng ti gi sau .C4 hay gi sau: ni gia on ng v on ngang .C3 hay on ngang trong xoang hang: on ni gia gi gi sau v gi trc

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.C2 hay gi trc: phn trc trn trong xoang hang .C1: phn cui ca ng mch cnh trong xoang hang -on trn h yn hay on trong mng cng : .ng mch mt .ng mch yn trn (thng khng thy) .ng mch thng sau .ng mch mng mch trc.

Hnh 1.7. H ng mch sng thn nn nhn nghing 1.M sng; 2.M mng no sau; 3.M tiu no sau di; 4.M tiu no trc di; 5.Thn nn; 6.M xin cu no; 7.M tiu no trn; 8.M giun trn; 9.M giun di

1.4.3. H thng ng mch thn nn. ng mch sng l nhnh u tin ca ng mch di n (95%), Trong 5% cc trng hp thy ng mch di n tri xut pht trc tip t quai ng mch ch gia ng mch di n v ng mch cnh tri. Trong 25% ng mch sng hai bn c u th ging nhau, 25% ng mch sng tri u th hn bn phi. ng mch sng thng chy trong l ca cc gai ngang t C6 n C1, nhng cng c th bt u chui vo l gai ngang t C4. Chia on v cc nhnh ca ng mch sng. -on vng c( ngoi mng cng) .Cc nhnh cho c .Cc nhnh cho ty sng .ng mch mng no sau -on trong s .ng mch ty trc .ng mch tiu no sau di (PICA) ng mch thn nn. .Nhnh tiu no trc di .ng mch tiu no trn .Cc ng mch xin .ng mch no sau. Hnh 1.8. S gii phu h thng 1.4.4.a gic Willis: a gic c cc cnh M thn nn trong 25%, khng y trong 25% 1. M sng; 2.ng mch tu sng -ng mch cnh on trn h yn trc; 3.ng mch tiu no sau di; 4.M thn nn; 5.M tiu -on A1 ca ng mch no trc hai bn no trc di; 6.Cc nhnh xin -ng mch thng trccu no; 7.ng mch no sau.

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-Cc ng mch thng sau -on P1 ca cc ng mch no sau 1.4.5. Cc ng mch no ng mch no trc: l mt trong hai nhnh tn ca ng mch cnh trong -on nm ngang hay on A1: .T nguyn y n ch ng mch thng trc .Cho cc nhnh bo th vn gia, cp mu cho u nhn ui v phn trc bao trong .ng mch thng trc: ni hai on A1 .ng mch qut ngc ca Heubner: xut pht t A2( 50%), A1(45%), cp mu cho u nhn ui, nhn bo, pha trc bao trong -on A2: .T ng mch thng trc n ch chia nhnh tn .ng mch qut ngc ca Heubner .Cc nhnh trn cc .Nhnh trn mt -Nhnh tn: .ng mch vin th trai .ng mch trai vinHnh 1.9. ng mch cnh trong t th thng 1.B trn xng ; 2.B trn hc mt; 3.M cnh trong on trong xng ; 4.Xiphng; 5..on trong trong b no ca M mc mch trc; 6. on trong no tht chy vng quanh cc trn i th; 7.on A1 M no trc; 8.on A2; 9.on ngang( M1) trc khe sylvius ca M no gia; 11.Cc ng mch bo vn cp mu cho cc nhn xm; 12.Ch quay li cui cng ca M no gia13.Cc nhnh v no ca M no gia st bn trong xng s.

ng mch no gia: l nhnh tn ln nht ca ng mch cnh trong, n gm cc on -on M1 hay an nm ngang: .T nguyn y n ch chia nhnh ca ng mch no gia .Nhnh bn c cc ng mch bo vn bn, cp mu nhn bo, mt phn nhn ui, cnh tay trc bao trong -an M2: t ch chia, cho 2 nhnh ( 78%) , 3 nhnh ( 12%) chy vo khe Sylvius .Cho cc nhnh thy o -on M3: cho cc nhnh i theo khe Sylvius cho cc nhnh ra b mt bn cu i no,c hai nhm .Nhm trn: cp mu cho vng trn v thy nh .Nhm di cp mu cho thy thi dng

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.Cho cc nhnh xin vo i th sau -on P2: .T thng sau n chia nhnh .Cho cc nhnh i th .ng mch mc mch sau -Cc nhnh tn v no Cc bin th ca ng mch no. -ng mch cnh trong: .Cn tn ti cc phi thai ca ng mch cnh trong vng c ni vi ng mch sng nn -ng mch cnh ngoi: .ng mch mng no gia i t ng mch mt .Thay i trt t ca cc nhnh -a gic Willis .Thiu sn ng mch thng sau .Thiu sn hay khng c A1 .ng mch no sau phi thai : bt ngun t ng mch cnh trong, khng thy ng mch sng khi chp mch, phi hp thiu sn hay khng c P1 .Gim sn ng mch thng sau 1.4.6. Cc vng ni ca ng mch no. -Ni gia cnh trong v cnh ngoi: .Cc nhnh ca hm trong vi ng mch mt .Nhnh mt vi ng mch mt .Cc nhnh ni mng no ( ng mch chm, hu ln, mng no gia) .Cnh ngoi ni vi cnh ngoi i din v ni vi ng mch cnh trong -Ni gia cnh ngai v ng mch no: .Cnh ngoi ni vi ng mch mng no gia, qua mng cng ni vi cc nhnh mng nui ni vi ng mch no trc v gia .Cnh ngoi ni vi cc nhnh mng no-> ng mch thn nn. -Ni gia cc ng mch no: .Ni gia no trc hai bn qua ng mch thng trc .ng mch cnh trong ni vi ng mch no sau qua thng sau .ng mch cnh trong -> ng mch mc mch trc sau-> ng mch thn nn.

Hnh 1.10. M cnh trong trn t th nghing 1.Xiphng M cnh; 2.M mng no trc xuyn v sng thi dng T ri chy quanh i th trong no tht; 3..M no trc; 4.M quanh th trai; 5..M vin th trai; 6.Nhnh v no ln ca M no gia ; 7..Ch gp pha trn ca nhnh ny; 8.ng ni cc ch gp pha trn song song ng mch no sau: vi ng OC (b ngoi hc mt-on P1: l tai); 9.Cc nhnh v no xung .T nguyn y n ng mch thng sau ( on trc thng gia; 10.M mt. ca M no sau)

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.Cc ng mch no ni vi nhau qua mng nui.

Hnh 1.11. Gii phu a gic Willis 1.M cnh trong; 2.on A1 ca M no trc; 3.M thng trc; 4.M thng sau; 5.on P1 ca M no sau; 6. M thn nn; 7.M no gia; 8.M sng; 9. Giao thoa th gic

1.5.MNG NO V H THNG TNH MCH.

1.5.1. Mng no: +Mng cng: -Mng dy, bc mt trong hp s, dnh vo bn trong xng s Mng cng c nhiu ch li vo trong s to thnh cc vch: lim no, lu tiu no, lim tiu no, diaphram h yn. -Mng cng lan rng vo bn trong to ln cc vch: +Lim no: .Hnh lim nm ng gia phn chia hai bn cu . pha sau rng hn pha trc .Pha trc bm vo mm mo g, pha sau vo chm trong v lu tiu no .C mt s xoang nm bn trong: xoang dc trn, dc di, xoang thng +Lu tiu no: .C lnh lim, nm ngang, phn chia no thnh vng trn lu v di lu .Pha trc dnh vo cc mm sng, xng , pha sau dnh vo xng chm .Cha xoang thmg v xoang bn .B trc gia t do + Diaphram ca h yn . Vng np gp nh nm ngang to thnh mi ca h yn . gia c l thng cho phu tuyn yn nm - Mng cng trn CLVT v cng hng t u tng t trng hay tng tn hiu + Mng mm -Mng nhn: mng trong sut bao ph no -Mng nui: .L mng mng nhiu mch mu bao ph trong cng dnh vo b mt no c trong cc rnh cun no cc khe no .Bao quanh mch mu ging nh ng tay o v chui vo trong nhu m no v to nn cc khoang (khoang Wirchow-Robin) v khoang ny c th thng vi khoang di nhn... -Mng mm tng tn hiu trn chp cng hng t .C chiu dy < 1mm .ng mm mi .Thy khng lin tc 1.5.2. Cc khoang mng no. + Khoang ngoi mng cng:

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-V tr: nm ngoi mng cng, gia mt trong hp s v mt ngoi mng cng -L khoang o, khoang tht khi c mu t y bc tch mng cng khi mt trong hp s -C lin quan cht ch vi mch mu, nguy c khi phu thut hay khi b chn thng: cc ng mch v tnh mch mng no, cc xoang tnh mch + Khoang di mng cng: -V tr: nm gia mng cng v mng nhn -L khoang o, ch c t dch bn trong -Lin quan mch mu cht ch nn cng c nguy c khi chn thng: tnh mch ni gia tnh mch v no v cc xoang tnh mch. + Khoang di nhn: -V tr: nm gia mng nhn v mng nui -Cha dch no ty, thng vi h thng no tht v dch trong khoang di nhn ty -Lin quan mt thit vi mch mu: Cc ng mch no phn ln chy qua cc b no nn cng c nguy c khi chn thng. 1.5.3. H thng no tht. + No tht bn: -C hai no tht bn, hnh ch C -Bao gm : cc sng trn, thi dng, chm, thn no tht -Ni vi no tht 3 pha di qua l Monro -Cha m ri mch mc ln nht v ni lin tc vi mch mc no tht 3 -Bin th bnh thng: .Kch thc hai bn khng bng nhau .Teo mt bn hay mt phn .Nang vch trong sut (Pellucidum): c bo thai , mt i khi sinh, c th tn ti tr nh; mt s trng hp nang thng vi NT bn .Nang b: nm pha sau vch trong sut dc theo th trai, lun km vi nang vch trong sut + L Monro: L hng hnh ch Y ni cc NT bn vi NT 3 + No tht 3. -Nm ng gia pha di cc thn NT bn -Cu to: ngch th gic, phu v ngch trn yn pha sau -Ni vi NT bn qua l Monro, NT 4 qua cng Sylvius -m ri mng mch nm trn NT, ni vi mc mch NT bn qua l Monro

Hnh 1.12. S lu thng dch no tu 1.Hnh thnh dch no tu t m ri mch mc no tht bn. 2.L Monro; 3. Hnh thnh dch no tu t m ri mch mc trong no tht ba; 4. Hnh thnh dch no tu t m ri mch mc no tht 4; 5. Dch no tu i ra ngoi no tht qua cc l Magendie l Luska; 6. Hp thu qua cc ht mng nhn vo xoang dc trn; 7.Lu thng dch no tu trong khoang di nhn quanh tu; 8. Mt phn dch no tu vo ng trung tm tu.

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1.5.4. Cc b no. B no Cc b no h sau B ty sng B ty sau B cu no B gc cu tiu no B trn tiu no V tr Nm pha trc ty Nm pha sau ty Nm quanh cu no Nm gia trai xng thi dng v tiu no, cu no v lu tiu no Gia lu tiu no v thy nhng, bn cu tiu no v ni vi b c no sinh t pha trn Nm gia cc cung no Nm pha trn h yn Cc thnh phn bn trong Cc ng mch sng, ng mch ty sau v trc, TK XII Cc M tiu no sau di, TM tiu no di, dy TK IX, X, XI M sng nn , nguyn y ca cc M tiu no sau di v trn bn, dy TK VI M tiu no trc di, c th c TM trn, dy TK V, VII, VIII TM tiu no trn, cc TM nhng trn

B y ( hay b trn yn) B quanh cung B giao thoa th gic( b trn yn)

M thn nn, nguyn y cc M xin vo i th v M mc mch sau, dy TK III on cui M cnh trong, xut pht cc M no trc v gia, M mng mch trc, TM Rosenthal, TK th gic, Cc th nm v, ngch trc NT 3. ng mch no sau, thn nn, ng mch tiu no trn, dy thn kinh IV, cc tnh mch gian no. Tuyn tng, phn sau NT ba, ng mch mc mch sau, TM Galien v TM nn Rosenthal

Cc b gian no B bao quanh gian no

B c no sinh t

Nm quanh gian no, ni vi b trn yn, quanh cu no v b c no sinh t Nm sau tuyn tng v c no sinh t, ni vi b quanh gian no v b tiu no trn.

Cc b trn bn B Sylvien

Nm gia thu o v ng mch no gia v cc xng s, ni vi b trn nhnh ca n, cc tnh ,mch

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Cc khoang di nhn vm s

yn Hai bn bn cu

nng ca M no gia ng tnh mch v no

1.5.5. Nc no ty. + C th c khong 150ml + Nc no ty c sinh ra khong 500ml/ngy -85% do m ri mch mc, quan trng nht trong NT3 -15% do mng no hay thm qua mao mch + Lu thng ca dch no ty khong 3 ln /ngy nh sc p ca mch mu -Nc no ty i t NT bn sang NT 3 qua l Monro , sang NT 4 qua cng Sylvius -T NT4 nc no ty qua cc l bn v sau vo cc b no h sau, thng chng ch lu thng mt lng rt nh vo ng gia ty. -Sau phn ln NNT lu thng ln tng trn lu vo cc b trn yn, b quanh cung, khoang di nhn bn cu i no -Mt phn NNT i xung di trong khoang mng nhn ty + Phn b nc no ty: -20% trong cc NT -50% trong khoang di nhn -30% trong khoang di nhn ty + Hp th NNT -Phn ln NNT c hp th qua cc nh ca mng nhn trong cc xoang TM nht l xoang dc trn v xoang bn -Mt phn qua mng no tht -Mt phn qua thnh mao mch -Mt phn qua h thng bch mch cnh cc dy thn kinh s no v ty sng.

II. BNH L MCH MU.Mc tiu: Nm c mt s bnh l mch mu no: chy mu, nhi mu v bnh l cht trng 2.1.CHY MU TRONG NO: (intracranial hemorhage) L mt trong cc ch nh hay gp nht trong cp cu v in quang thn kinh. Chp ct lp vi tnh v cng hng t c nhy rt cao trong chn on, l khm xt u tay chn on phn bit vi nhi mu no v chn thng s no. 2.1.1.Biu hin trn CLVT: + Giai on cp tnh (Chy mu trong nhu m, no tht, mng no hay phi hp >T l t vong t 10-17% >Mc bnh vi cc biu hin thiu ht thn kinh 10% .Khong 25% biu hin bng cn ng kinh .Khong 25% biu hin phi hp, v cc du hiu khc -Nguy c chy mu: .Nguy c chy mu hng nm t 3-4%, c tnh tch ly . Chia mc tn thng theo Spetzler-Martin 1) Chia thnh 5 t 1-6, da vo cc im i vi: kch thc (1= 6cm). nh hng n nhu m no xung quanh (0= khng nh hng; 1= c nh hng) .Tnh mch dn lu ( 0= ch dn lu ra tnh mch nng; 1= dn lu vo tnh mch su). Vng chc nng (nm vng nhiu chc nng=1; vng t chc nng =0). 2) Bnh nhn 1 l tt nht 3) 6 thng khng cn ch nh phu thut .Tng nguy c chy mu khi 1) Tn thng nm trong no tht hay cnh no tht 2) C phi hp vi phnh mch (cung nui, trong , u xa) 3) C dn lu vo tnh mch trung tm hay tnh mch su 4) Hp hay tc tnh mch dn lu .Gim nguy c chy mu khi: 1) Khi d dng c nhiu mch nui ln t cc nhnh v no v nhiu mch ni t v no hay mng no 2) C nhiu tnh mch dn lu phi hp -c im hnh nh: .Cng hng t l tt nht pht hin tn thng, chp mch c tin hnh bc tip theo nh gi tnh cht tn thng v c k hoch iu tr thch hp. .Tng hay gim tn hiu trong lng mch nui hay tnh mch dn lu ty thuc vo lu lng dng chy, thy r trn chp mch cng hng t. .Khi d dng chim ch nhng khng gy hiu ng khi tr trng hp c chy mu v ph no. .Ph no ch xut hin khi c chy mu mi hay c tc tnh mch do nhi mu

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.C kt hp vi phnh mch trong 10% .Nhu m no bn cnh thng c teo no do hin tng cp mu v thiu mu .Vi ha gp trong 25% .C th c nhiu nh trn cng hng t i vi cc chy mu c -Bin chng. .Chy mu .ng kinh .Nguy c chy mu khong >3% /nm 2.3.1.2. Thng ng tnh mch mng cng -Gii phu bnh v nguyn nhn. .Coi l bnh d dng mch mc phi .Cc mch nui t mng cng hay mng nhn ch khng phi mng mm .H thng dn lu vo cc xoang mng cng, tnh mch v no hay c hai .Hay phi hp hc gy tc, ti thng xoang tnh mch -V tr: .Hay vng di lu (xoang bn v xoang sigma hay gp nht) .Cc v tr khc: Xoang hang, nn s, lu tiu no -T l, tui gii: .Chim khong 10-15% d dng mch mu no .Chim 6% d dng thng ng tnh mch trn lu v 35% di lu .Gii khng phn bit nam-n; biu hin lm sng tui 40-60 -Lm sng: Thay i ty thuc v tr tn thng .Nghe c thi, au u khng c hiu (thng vng xoang ngang, sigma) .Li mt, gim th lc (thng vng xoang hang) .Lit cc dy thn kinh: .Tnh mch dn lu vo v no hay tnh mch su: c th gy chy mu no, co git, thiu ht thn kinh. -c im hnh nh: 1) Chp mch: .Mt hay nhiu ng mch mng cng trc tip vo xoang tnh mch .Cc ng mch hay gp: ng mch chm, ng mch mng no gia, thn mng no tuyn yn .Hp hay tc xoang tnh mch c th gp .Xp loi da vo chp mch, i chiu lm sng: Loi 1: Thng ng tnh mch mng cng dn lu vo xoang tnh mch, c dng chy xui chiu (biu hin lm sng lnh tnh) Loi 2:Thng ng tnh mch mng cng dn lu vo xoang tnh mch nhng c cc tnh mch dn lu ngc chiu, chy vo TM v no gy chy mu no (10%), tng p lc ni s (20%) Loi 3: Thng ng tnh mch mng cng c dn lu trc tip vo tmh mch v no nhng khng gin, chy mu no gp trong 40% Loi 4: Thng ng tnh mch mng cng c dn lu trc tip vo tnh mch v no vi gin tnh mch >5mm, chy mu trong 65% cc trng hp Loi 5: Thng ng tnhmch mng cng vi dn lu vo tnh mch quanh ty, bnh l ty gp trong 50% cc trng hp

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2) Chp ct lp vi tnh: .Thng bnh thng .C th thy gin xoang tnhmch, tnh mch( xoang hang, TM mt) 3) Chp cng hng t: .Thng khng thy bt thng, c th thy gin tnh mch dn lu .Cng hng t mch mu khng pht hin c nhnh nui

Hnh 2.4. Thng ng tnh mch mng cng 1. d dng vi cc TM dn lu vo xoang bn v xoang sigma; 2. Xoang tnh mch; 3. Cc ng mch chm v vnh ti sau xuyn qua cng vo nui khi.

2.3.1.3.Tn thng phi hp thng ng tnh mch mng cng v mng nui -Gii phu bnh: .Tn thng ln trong nhu m no c c cc mch nui t mng cng .Mch nui t c mng cng v mng nui gp trong 10% cc AVMs -Hnh nh: .Thy mch nui t mng nui (ng mch v no) .Mch nui t mng cng (thng t ng mch mng no) 2.3.2. D dng tnh mch: 2.3.2.1. U mu tnh mch (venous angioma) -Gii phu bnh: .Gin cc tnh mch trong no hay ty sng nh hnh u bch tuc .Gin cc tnh mch dn lu mu v no .Nhu m no nm gia cc tnh mch gin bnh thng -Nguyn nhn: .Do sai st trong pht trin phi gy tc hay khng pht trin tnh mch dn lu .Thng l biu hin ca cc bin th bnh thng, t khi c d dng thc s .Hay km vi bt thng ca h thn kinh. -Tui gii, t l: .Gp trong khong 3% m xc cc nc pht trin .Thng n c khng biu hin lm sng. . bt k tui no, nam hi nhiu hn n. .Gp vng trn lu 65% hay gn sng trn,vng di lu 35%. -Biu hin lm sng: .Khng triu chng 60%

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.C triu chng (40%):trong au u (15-30%), co git (50%), chy mu (5-15%) -c im hnh nh: .Chp mch th ng mch bnh thng; th tnh mch thy gin tnh mch v no hay ty hnh u bch tuc (TM nng 70%, gin TM su 30%), c th c hp ca tnh mch dn lu v y l nguyn nhn gy chy mu. .Chp ct lp vi tnh: sau tim thuc cn quang c th pht hin gin tnh mch .Chp cng hng t: T1 v T2W c th thy cc ng dng chy cao, sau tim thuc c th pht hin tnh mch gin, c th thy hnh chy mu

Hnh 2.4. U mu tnh mch Gin cc tnh mch tu trong cht trng (mi tn nh) dn lu v tnh mch v no (mi tn to) vo xoang dc trn, to thnh hnh Bch tuc

2.3.3. D dng mao mch( capillary malformation) 2.3.3.1. Gin mao mch( Capillary talangiectasia) -Bnh hc: .Tp hp ca hay chm cc mao mch gin c thnh bt thng( thiu cc c trn v si chun) .Nhu m no bnh thng .C th c cc cht ca mu thoi ha ca cc ln chy mu trc -V tr: .C th bt k ni no trong no v ty .Hay gp hn cu no v ty -Dch t: .Hay gp vo hng th hai trong cc d dng mch no khi m xc (d dng tnh mch hay gp nht) .Thng hay gp c nhiu tn thng -Lm sng: .Thng im lng trn lm sng .C th chy mu nht l khi phi hp vi u mu th hang -Hnh nh: .Chp mch thng khng pht hin tn thng, c th thy m mao mch gin.

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.Chp CLVT khng tim thuc thng bnh thng, c tim thuc c th thy vng tng t trng nh khng r .Chp CHT: Thy nhiu vng gim tn hiu trn T2W v gradient C th thy m cc vch tng tn hiu sau khi tim thuc

Hnh 2.5. Gin mao mch vng cu no ( mi tn)

2.3.3.2. Gin mao mch chy mu di truyn (Bnh Rendu Osler Weber) +Di truyn: di truyn nhim sc th thng, ch yu l hi chng thn kinh da +Tn thng mch mu: -Tn thng gin mao mch da v nim mc -D dng mch mu trong no (pht hin 23% s bnh nhn) .Khong 4%: d dng thng ng tnh mch .6% d dng tnh mch .12,5% biu hin u mu th hang hay d dng thng M-TM siu nh .D dng thng ng tnh mch nhiu ni c th pht hin chp mch s ha xa nn .D dng mch trong tng, r mch AVM trong gan khong 30% M phi 15-20% +Biu hin lm sng: -Chy mu mi trong 85% -Bin chng thn kinh : .50% do d dng M phi (nhi mu phi) .Biu hin khc do d dng mch no, gan, rut... 2.3.3.D dng u mu th hang (Cavernous angioma) 2.3.3.1.U mu th hang trong no Bnh hc: -i th: tn thng tm nhiu thy c gianh gii r vi xung quanh

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-M bnh hc: .Hnh t ong gm nhiu hc c lt lp ni m khng c si chun .C cc vch x phn chia cc hc mch .C dng chy bn trong rt chm, c huyt khi bn trong .Khng c nhu m no lnh bn trong tn thng .T chc no xung quanh thng lng ng hmsiderin +Di truyn: -Th n l: tn thng n c, ch 10-15% a tn thng -Th Gia nh: .Di truyn nhim sc th thng .C nhiu tn thng trong 75% cc trng hp .Tn bin i theo thi gian: CHT thy thay i kch thc, s lng, tnh cht tn thng

Hnh 2.6. U mu th hang cu no: Nhiu hc cha mu thoi ho cc giai on khc nhau; c vin hemosiderin v ferritin

Dch t: .Chim khong 15% d dng mch no khi m xc .Chim khong 0.5-0,7% dn s M V tr: .80% trn lu .Khong 1/3 cc trng hp c nhiu thng tn .i khi mng cng, xoang tnh mch Tui gii: .Thng biu hin tui 20-40 .Khng u tin gii Lm sng: .Thng khng c du hiu lm sng .Chy mu( hay ngi tr xoang sigma>xoang >xoang hang Du hiu sm: .Hnh huyt khi tng t trng trn CT, gim t trng trn CT c tim thuc .CHT: tng tn hiu xoang tnh mch trn T1-T2 (tu giai on) Khng c dng chy trong xoang tnh mch Mun: (hu qu ca nhi mu tnh mch) .Nhi mu vng di v .Chy mu gianh gii tu v thng gp

III. CHN THNG S NO.Mc tiu: nm c mt s loi tn thng s no do chn thng v cc tn thng th pht sau chn thng3.1. I CNG

Xp loi chn thng s no 1)Cc tn thng u tin -Chy mu ngoi trc .Chy mu khoang di nhn .T mu di mng cng .T mu ngoi mng cng -Cc tn thng trong trc .Thng tn si trc lan to .ng dp nhu m .Tn thng cht xm trong su .Tn htng thn no .Chy mu trong no tht -V xng 2) Cc thng tn th pht -Thot v no -Thiu mu do chn thng -Ph no lan to

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-Thiu oxy no3.2. CC TN THNG :

3.2.1 T mu ngoi mng cng: Cc th: .T mu ngoi mng cng do ng mch: 90% (M mng no gia) .T mu ngoi mng cng tnh mch; 10% (rch cc xoang, TM mch mng no) H sau: Rch xoang bn, xoang sigma (thng gp) Cnh gia: Rch xoang dc gia T mu ngoi mng cng ln l cp cu ngoi thn kinh, t mu nh (dy CT nht l i vi: Cc trng hp t mu hai bn T mu dc lu no T mu gia hai bn cu T mu di mng cng mn tnh -Cc hnh nh khc: .Hnh mc ngang ca hematcrit ca t mu bn cp v mn sm .Hiu ng khi rng trong t mu di mng cng -T mu di mng cng cp: .Tng t trng hay t trng hn hp -T mu di mng cng bn cp (sau 1 tun) .C th ng t trng nn kh pht hin trn CLVT .Ngm thuc ca mng no v y cc mch mu v no sau tim thuc cn quang -T mu di mng cng mn tnh (sau vi tun) .Gim t trng .T trng hn hp khi c chy mu li .Vi ho 1% Bng so snh chy mu di v ngoi mng cng Chy mu ngoi mng cng Chy mu di mng cng T l M cnh trong ( on trong xng ) > M sng > cc mch khc. Nguyn nhn: -T pht hay sau chn thng nh -Chn thng -Tng huyt p -Bnh l mch mu( bnh Marfan, bnh lon sn x c) -au na u -Lm dng thuc Hnh nh: Cng hng t: -Thm khm c la chn hng u, khi khng r nguyn nhn th c th chp mch chn on xc nh -T1: tng tn hiu ca t mu trong thnh mch. -Hp trn on di hnh thoi vng mch tn thng -Cng hng t mch mu: du hiu si dy do mch rt nh Bin chng: -Huyt khi -Nhi mu no -Chy mu trong thnh mch -Gi phnhHnh 3.5. Hnh bc tch ng mch cnh; phnh bc tch v gi phnh: A. Hnh in hnh bc tch ni mc vi khi mu t di ni mc B. Bc tch di thanh mc t gp, khi mu t li ra ngoi v thng lng mch khng hp C. Phnh bc tch khi khi t mu bc tch thng trc tip vi lng mch, chp mch thy r khi phnh. D. Tn thng v thnh mch to khi mu t v c th to thnh gi phnh

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3.3.4. Thng ng mch cnh xoang hang Thng ng mch cnh xoang hang l thng bt thng gia ng mch cnh v xoang tnh mch hang Lm sng: -Nghe ting thi lin tc -Li mt -Cng t kt mc Nguyn nhn: -Nguyn nhn hay gp nht l chn thng s no ( tai nn giao thng tc thp) gy thng ng mch cnh xoang hang lu lng cao -Thng t pht: .V ti phnh ng mch cnh trong xoang hang cng gy thng c lu lng cao (him gp) .D mng cng (dural fistula): thng ng mch tnh mch mng cng vng xoang hang, thng ngi gi, ph n nhiu hn nam gii, thng c lu lng thp thng t cc nhnh mng cng ca ng mch cnh ngoi vo xoang hang. Hnh nh: -Xoang tnh mch hang gin rng -Tnh mch trn ca mt gin trn CLVT v chp mch -Siu m Doppler: ng mch cnh trong c tc tng, RI gim, TM mt ng mch ho -iu tr bng nt mch (th bng hay coil)

IV U NO.Mc tiu: 1)Nm c phn loi u no 2) Nu c cc du hiu chn on v chn on phn bit mt s loi u no hay gp4.1. I CNG

4.1.1. Xp lo theo gii phu bnh A.Cc u ca nron thn kinh -U nguyn bo thn kinh khu gic, xc gic B. Cc u t bo thn kinh m (gliomas) -U t bo hnh sao( astrocytoma) -U t bo hnh sao t nhnh (oligodendroglioma) -U mng no tht (ependymoma) -U m ri mch mc (choroid plexus tumors) -U t bo thn kinh m hn hp

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C. Cc U t bo thn kinh v thn kinh m hn hp (Mixed neuronal-glial tumors) -Ganglioglioma, gangliogliocytoma -Central neurocytoma -Dysembryoplastic neuroepithelial tumors -Desmoplastic infantile ganglioglioma D. Cc u thn kinh ngoi b nguyn pht (Primitive neuroectodermal tumors PNET) -U nguyn bo thn kinh (neuroblastoma) -U nguyn bo tu (medulloblastome) -U nguyn bo tuyn tng (pineoblastoma) -U nguyn bo mng no tht (ependymoblastoma)... E. Cc u do di tch ca phi thai -U dng biu b, u biu b (epidermoid, dermoid) -U s hu (craniopharingioma) -Nang cht keo (colloid cyst) -U m (lipoma) -Hamartoma F. U t bo mm -Germinoma -Teratoma -Choriocarcinoma -Ung th biu m phi (embryonal carcinoma) G. U ca nhu m tuyn tng -Pineoblastoma -Pineocytoma H. U tuyn yn -Adenoma -Adenocarcinoma I. Cc u bao thn kinh -Schwannoma -Neurofibroma J. Cc u mng no -Meningioma K. U t chc li ni m -Lymphoma -Leukemia -Plasmocytoma, myeloma L. Cc U trung m -Hemangiopericytoma -Hemangioblastoma -Sarcoma M. Di cn 4.1.2. Xp loi theo tnh ph bin ca bnh (theo Osborn 1996) A. Cc U nguyn pht: chim 2/3 cc u no 1. U thn kinh m (glioma) thng gp nht, chim 45-50% -U t bo hnh sao (astrocytoma) 35-40%

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-U TB TK m t nhnh (oligodendroglioma) 2% -U mng no (ependymoma): 3% -U m ri mch mc< 1% (3% u tr em) 2. U mng no (meningioma) 15% 3. Adenome tuyn yn 10% 4.U nguyn bo tu (medulloblastoma) 6% 5. U bao r thn kinh (Schwannoma)6% 6.U s hu (Craniopharingioma)6% 7.U tuyn tng :1% 8.U lymphm: 1% 9.U nguyn bo mu (hemangioblastoma) 1% 10. Cc U khc : 5-10% B.Cc U th pht chim 1/3 cc trng hp 1.V tr: -Trong nhu m: Thng thy, hay nm ranh gii cht trng-xm -Mng no: hay gp di cn t cc u h thn kinh trung ng -Mng cng: t gp, thng phi hp vi di cn vo vm s 2. Nguyn nhn: -Ung th phi: 45% -Ung th v: 15% -U hc t: 10-15% -ng tiu ho: 10-15% 4.1.3. Xp loi theo tui v v tr. A. Ngi ln: 1.c im chung: -80-85% cc u no ngi ln -U nguyn pht chim 2/3, u th pht 1/3 -Di cn ngi ln nhiu hn tr em -Tui cng cao th t l c tnh cng cao 2. V tr: a. Cc u trn lu (chim 3/4) -Cc u thng gp: .U t bo hnh sao (astrocytoma) .U mng no (meningioma) .Adenoma tuyn yn .U thn kinh m t nhnh (oligodendroglioma) .U cn -U t gp: .Lymphoma -U him gp: .U mng no (ependymoma) b. U di lu tiu no: -U thng gp: .U bao r thn kinh (Schwannoma) .U mng no (meningioma) .U dng biu b (epidermoid) .Di cn

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-U t gp: .U nguyn bo mu (hemangioblastoma) .Glioma ca thn no -U him gp: .U nh m ri mch mc (choroid plexus papilloma) B.Tr em: 1. c im chung: -Chim 15-20 % cc u no -15% cc u tr em xut hin no -U ng th hai tr em sau lxmi -Thng l u nguyn pht 2. Tr nh < 2 tui -Thng l bm sinh -M bnh hc .U t bo hnh sao (astrocytoma) .U thn kinh ngoi b (primitive neuroectodermal tumors PNET) 15% .U qui (teratoma) .U m ri mch mc -V tr: 2/3 trn lu, 1/3 di lu 2. Tr trn 2 tui: -M bnh hc: .U t bo hnh sao 50% .U thn kinh ngoi b 15% .U mng no 10% .U s hu 10% .U vng tuyn tng 3% -V tr: .Trn lu: 50-70% U t bo hnh sao bc thp hay nang lng: 45-50% U s hu 12% Glioma ca giao thoa th gic, TK th, di i;12% U nh m ri mch mc 12% U mng no tht 10% U vng tuyn tng 5% U khc : him . Di lu : 30-50% U t bo hnh sao 25-30% U nguyn bo tu 25-30% Glioma thn no 15-25% U mng no tht 12-15% 4.1.4. Chn on u trong trc v ngoi trc. Chn on u trong trc hay ngoi trc l giai on u tin quan trng trong chn on phn bit. Chn on da vo mt s cc du hiu sau Du hiu Nm lin vi xng, mng cng Thay i xng U trong trc Thng khng Thng khng U ngoi trc C C

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Cc khoang dch mng no v b B xo no Gianh gii tu v B ph Mch nui Cnh trong

Thng rng Cn Cnh ngoi

4.1.5 nh gi lan to ca u Khi pht hin c u th cn phi chn on v nh gi lan to ca u : .Xc nh r v tr lm sinh thit ni khi c th .C k hoch phu thut ct b chnh xc .C k hoch x tr Trong phn ln cc khi u no th khng c phng php chn on hnh nh no c th chn on chnh xc lan to ca u. Cc u loi thn kinh m (glioma) thng thm nhim ra t chc no xung quanh, cc nt tn thng nh vi th khng th pht hin c trn chn on hnh nh thm ch trn cng hng t c tim thuc i t. nh gi lan to u thng hay dng: chp ct lp vi tnh c tim thuc cn quang v sau l chp cng hng t vi cc chui xung khc nhau v nht l c tim thuc i t. 4.2. MT S LOI U . 4.2.1. U thn kinh m. 4.2.1. 1. U t bo hnh sao (astrocytoma) Astrocytoma chim ti 80% cc u thn kinh m, l u hay gp nht bn cu i no ngi ln. tr em n hay vng h sau, giao thoa th gic, di i. Cc loi u t bo hnh sao c xp theo gii phu bnh theo t chc Y t th gii: U t bo hnh sao si( fibrillary astrocytoma) .U t bo hnh sao bc I (AI) . U t bo hnh sao bc II (AII) .U t bo hnh sao t bit ho, bc III ( AAIII) (Anaplastic astrocytoma) .U nguyn bo thn kinh m nhiu dng (Glioblastoma multiforme); bc IV Cc u t bo hnh sao khc: .Glioma nhiu ni .U t bo hnh sao nang lng thiu nin (astrocytoma pilocytic) .U t bo hnh sao khng l .Xanthoastrocytoma .Gliosarcoma U t bo hnh sao bc thp (Astrocytoma AI, AII) -Chim 20 % cc u t bo hnh sao, tui thng gp 20-40, v tr hay bn cu i no -Hnh nh: Chp ct lp vi tnh .Tn thng gim t trng cht trng vi hiu ng khi t .Tn thng khi khu tr hay lan to .Vi ho trong 20% cc trng hp .Chy mu v ph no lan rng t gp .Ngm t thuc cn quang Cng hng t .Gim hay ng tn hiu trn T1W, tng tn hiu T2W. Vi ho nh tng tn

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hiu T1W .B khng r lm TIW, r hn trn T2W .U thn no c th khu tr hay lan to .C th chy mu Chn on phn bit: .U thn kinh m t nhnh (oligodendroglioma): thng v no, hay vi ho .Gangliocytoma: Him gp , hay vng thi dng . Thoi ho myelin trong bnh x ho ri rc .Nhi mu .Vim no U t bo hnh sao t bit ho (anaplastic astrocytoma- AAIII) -Chim 30% cc u t bo hnh sao, tui 40-60, v tr bn cu tr ln (thn no) -Hnh nh: Chp mch: Hiu ng khi vi mc cp mu khc nhau Ct lp vi tnh: .Khi khng ng u .t khi c vi ho .Thng c ph n .Thng c ngm thuc cn quang mt phn, hnh th khc nhau .C th c chy mu trong u .U thn no lan to, kh chn on trn CLVT Cng hng t: .Khi khng ng u trn TIW v T2W, c vin tng tn hiu T2W do ph no hay thm nhim .C xu hng lan rng ra trong cht trng .U lan to cu no c th bao quanh c ng mch thn nn v y NT 4 pha sau gy nc -Chn on phn bit:( cc tn thng khc thn no) .U t bo hnh sao nang lng .Nhi mu .Thoi ho Mylin U nguyn bo thn kinh m nhiu dng( glioblastoma multiforme GBM) bc IV -L u hay gp nht no v cng l bc hay gp nht trong u thn kinh m -C th nguyn pht hay t u bc thp hn chuyn ln -Tui: Thng >50 tui, t khi < 30 tui -Gii: nam hi nhiu hn n -V tr: .Thng cht trng( nht l trn, thi dng) .Hay nhiu thu v ni vi nhau qua th trai .Di mng no tht cnh no tht .Cc ht trong khoang di nhn .Lan to trong cht trng -Hnh nh: Chp mch: .Khi y, tng sinh mch

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.C th c thng ng tnh mch v dn lu tnh mch sm Chp ct lp vi tnh: .Khi khng ng u khng r gianh gii , gim t trng trung tm, hiu ng khi nhiu , ph n lan rng trong cht trng .Lan rng qua th trai cho hnh nh con bm .Vim dy ngm nhiu thuc cn quang, t khi khng ngm thuc, hoi t ngm t thuc .Chy mu thng gp( bc thp) .Vi ho him (15%) tr khi pht trin t astrocytoma bc thp .C th c nhiu tn thng Cng hng t .Tn hiu hn hp , khi thm nhim vi trung tm hoi t, vin tng tn hiu T2 .C th c chy mu bn trong vi cc thi k khc nhau .C th c trng tn hiu ca dng chy .C th lan ra mng no, mng tu, di nhn Chn on phn bit -Vin tng tn hiu: .Lymphm: khng u, c vin tng tn hiu, lm sng .Di cn: Thng nh, nhiu khi, khi to kh phn bit .Nhi mu bn cp: c cht trng v xm, vng ti mu,m ngm thuc. .T mu tiu: ph n t .Tia x .Cc mng x ho tin trin (MS): nhiu, nh, v tr, ph t -Cc tn thng chy mu trong nhu m .Cc u nguyn pht hay th pht khc chy mu (kh) . D dng ng tnh mch no .U mu th hang .Chy mu do cao huyt p .Thoi ho mch tinh bt: vng gianh gii tu v, nhiu ni .Chy mu nhi mu -Tn thng hnh bm vng th trai: .U t bo hnh sao t ghp : kh phn bit .Lymphm .U mng no (meningioma) U t bo hnh sao nang lng (pilocytic astrocytoma) c im chung: .U thn kinh m hay gp nht tr em .U no hay gp ng hng th hai tr em .Im lng v tin trin t t .V tr hay gp: giao thoa, di i, tiu no, thn no .Tin lng tt: 85% sng trn 5 nm Hnh nh: -Chp mch: hiu ng khi, c th ngm thuc phn c -Ct lp vi tnh: .Khi trn na c na rng, ph n rt t. Khi vng thn no v giao thoa th gic thng l khic

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.Nang vng tiu no thng ln, vng bn cu thng nh .t vi ho (10%) .Phn c c th c ngm thuc vi cc mc khc nhau, v nang in hnh khng ngm thuc cn quang .U thn no c th kh pht hin trn CLVT . nc no tht hay gp vi u NT 4, thu nhng, thn no -Cng hng t: .Phn c gim hay ng tn hiu vi cht xm trn T1W. Phn nang ging hay tng tn hiu hn nc no tu T2W .Tn thng ca giao thoa v di i c th do lan vo t u vng dy th gic v hu nhn cu. .U vng thn no thng li ra sau, chn p NT4 gy nc. Chn on phn bit -Tn thng tiu no: .U nguyn bo tu (medulloblastoma) ng gia, tng t trng u, khng in hnh kh chn on .U mng no( ependymoma): u c khng u, hay c vi ho, gin no tht, lan vo b no... .U nguyn bo mu (hemangioblastoma) Him gp, tr em, nt tng t trng ngm nhiu thuc cn quang thnh .U dng biu b ( epidermoid) trong no tht: him gp, khng c nt thnh, cu trc khng u, thng ging nc no tu -Tn thng vng giao thoa th gic v di i: .U t bo mm trn yn( germinoma) ngm thuc u, thng lan ra khoang dch no tu .U qui( teratoma) Khng u, vi ho, m .U tuyn yn .U s hu .Hamartoma di i: khi khng ngm thuc vng phu nm v 4.2.1.2. U thn kinh m lan to ( gliomatosis cerebri) M bnh hc : Thm nhim lan to no do cc t bo thn kinh m (thng l t bo hnh sao si) vi ph hu bao mylin. Khng phn bit c gia u v lan to ca t chc thn kinh m. Tui: bt k tui no, thng 20-40 tui, khng phn bit gii V tr: -Cht trng: giao thoa th gic, th trai, cung no, cung tiu no > hch nn, i th -Thm nhim quanh mch mu, thnkinh, di mng nui Lm sng: .Tin trin chm khng t l thun gia du hiu lm sng v hnh nh .Tin lng xu, khng th ly ht, x tr v ho tr liu. Hnh nh. -Ct lp vi tnh: .Khng tim thuc: Khi gim t trng, mt phn bit cht -xm trng, ranh gii khng r .Tim thuc: thng khng ngm thuc

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.i khi CT bnh thng do u lan to rng -Cng hng t: .ng hay gim tn hiu T1W .Tng tn hiu T2W, FLAIR .C th c ngm thuc cc nt nh .CHT tt hn CLVT trong chn on, nh gi lan to Chn on phn bit: -Bnh l cht trng (bnh tui gi, bnh cc mch nh) .Khng hiu ng khi .i khi kh phn bit -Astrocytoma v cc u thn kinh m khc .Glioblastoma thng ngm thuc .Gliomatosis khng ngm thuc -Nhim trng, vim nhim .Biu hin cp tnh hn .C th thm nhim mng no 4.2.1.3. U thn kinh m thn no (Brainstem glioma) c im chung: -U h sau hay gp tr em -Tui trung bnh 10 tui, 80% bc cao, ch 20% bc thp -V tr: cu no> cung no> tu -Lm sng: Tn thng cc dy thn kinh, nc no tht, tng p lc ni s Hnh nh: -Thn no to ra -No tht 4 b y ra sau -Hnh nang him gp -Hnh nc no tht -Tn thng gim t trng trn CLVT v tng tn hiu T2W, gim tn hiu T1W -Tim thuc cn quang: ngm thuc trong 50% trng hp, ngm lm m. -Lan to ra ngoi vo cc b no 4.2.1.4. U t bo thn kinh m t nhnh (oligodendroglioma) c im chung: .U bit ho, pht trin chm nhng thm nhim. .U thun nht cc t bo hnh sao t nhnh him gp, hay phi hp t bo hnh sao .Chim 5-10% cc u nguyn pht no .Tui 30-50 .V tr : v no v di v bn cu i no, hay gp vng trn > nh > thi dng Hnh nh: -c im chung: .Du hiu chn on tt nht: khi u c vi ho mt phn ngi trung nin .C th lan to v bo mn vm s -Chp ct lp vi tnh: .Khng tim thuc Khi gim t trng, ng t trng

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C nhiu vi ho C th c chy mu v hoi t u (t gp) Nang thng gp Gm mn xng vm s .C tim thuc: Ngm thuc cn quang tu thuc mc bit ho -Chp cng hng t .Thng khi khng u ng hay gim tn hiu trn T1W Tng tn hiu T2W Chy mu v hoi t khi lon sn .C th biu hin bng khi gianh gii r, vin ph n nh .50% ngm thuc Chn on phn bit: -U t bo hnh sao (astocytoma) .Khng c vi ho .Tn thng thng cht trng -Ganglioma: .U tr em hay ngi tr .Thng vng thi dng v cht trng trong su .Gianh gii r, hay c nang .Vi ho t gp hn 4.2.1.5. U mng no tht( ependymal tumors) c im chung: .U tr em v ngi tr .L u hay gp ng th ba h sau tr em .U pht trin t t bo mng no tht hay t pha sau mng no tht .T chc hc c cc loi Ependymoma ( tr em) Subependymoma (ngi gi) Anapplastic ependymoma Myxopapillairy ependymoma Ependymoblastoma (PNET) Ependymoma Hnh nh -Du hiu in hnh : nh cht nha n ra khi NT4 qua cc l, lan vo b no -Ct lp vi tnh: +Khng tim thuc .Tn thng vng di lu( tr em < 3 tui) T sn NT4 lan vo ng tu, qua cc l Luska vo gc cu tiu no v b ln Thng ng t trng vi nhu m no Vi ho thng gp( 50%), nang, chy mu c th gp .Vng trn lu: tr ln > 3 tui, ngi tr Khi t chc khng u>khi trong hay cnh no tht (u ngoi no tht ging astrocytoma) Vi ho hay gp (50%)

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+ Tim thuc cn quang: Ngm thuc khng u vi nhiu mc khc nhau -Chp cng hng t: +Khi khng u .Hi gim tn hiu hn nhu m no trn T1W .ng hay gim tn hiu trn T2W .Thng vi ho, nang, hoi t, chy mu + nc no tht ( >90%) +Ngm thuc nh khng ng u

Hnh 4.1. U mng no tht (ependymoma) U mng no tht trong no tht 4 lan ra pha sau qua l magendie (mi tn cong) vo b ln nh hnh cht keo

Chn on phn bit -U nguyn bo tu (medulloblastoma) .Tng t trng .ng u -U t bo hnh sao tiu no (astrocytoma) .Nang hay c .Thng khng ng gia -U thn kinh m thn no .Gim t trng, thn no to ra .C th lan vo NT 4 ch khng phi t trong NT4 U di mng no tht (subependymoma) Tnh cht chung -U him gp ( < 1%) -Tui trung nin hay ngi gi -T chc hc: a s l cc t bo si -V tr; dc theo thnh no tht, sn NT 4, vch trong sut gia cc NT bn Hnh nh: -Chp mch: hiu ng khi, khng c tng sinh mch -Ct lp vi tnh: .Khi gim hay ng t trng gianh gii r, nm di mng no tht hay trong no tht. U NT 4 c th lan qua cc l Magendie hay Luschka .Vi ho t gp

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.Ngm thuc thay i: t khng ngm ti ngm nhiu .t khi c chy mu -Cng hng t: .Thng gim hay ng tn hiu vi cht xm trn T1W hi tng tn hiu T2W, c th c cung .C th c khng ng tn hiudo c cc nang nh, vi ha nh hay chy mu nh khng biu hin lm sng -Chn on phn bit: .Tn thng trong NT4: U mng no : khng u, ngm thuc, hay vi ho U nh m ri mch mc: ngm nhiu thuc Di cn .Vng vch trong sut: U di mng no t bo khng l( subependymal giant cell astrocytoma): Khng u, ngm nhiu thuc, vi ho Ependymoma(u mng no tht) Nang keo(Colloid cyst) ng gia trc NT3, tng t trng, khng ngm thuc. 4.2.1.7. U m ri mch mc (papilloma/carcinoma) c im chung: -U him gp, pht trin t biu m m ri mch mc -Tui < 5 tui, l u no hay gp nht tr < 1 tui -C hai loi : u nh (papilloma) chim 90% v carcinoma (10%) -Chn on hnh nh khng phn bit hai loi u ny -V tr : .Vng tam gic ca no tht bn (tr em) .No tht bn .Di cn vo ng tu Hnh nh: Chp ct lp vi tnh: -Khng tim thuc .Khi ng hay tng t trng (75%) .Nm trong no tht .Gin h thng no tht do tng bi tit hay tc .C th c vi ho (25%) .i khi c chy mu vi mc ngang -C tim thuc: .Ngm nhiu thuc cn quang ng u Cng hng t: -Khi ng hay gim tn hiu T1W c vn lm m -Cc nh thy khi c dch xen k gia cc nh u -Ngm nhiu thuc i t -Thm nhim nhu m c gianh gii r vi u nh, khi thm nhim nhiu th nghi ng ung th Chp mch s ho -Gin cc ng mch mc mch -U ngm nhiu thuc v gi thuc lu

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-C th c thng ng tnh mch Chn on phn bit -Ph i cc nh lng( villous hypertrophy) .m ri mch mc hai bn NT bn to ra lan to .C th phi hp vi tng tit nc no tu -Cc loi u khc trong no tht .Di cn, u mng no (meningioma) .U mng no tht (ependymoma) .U ht vng (xanthogranuloma) ngi gi , khng c mch -Cc u cnh no tht: .U di mng no tht .U nguyn bo tu, u nguyn bo mch... 4.2.2. Cc U mng no v u trung m( meningeal and mesenchymal Tumors) 4.2.2.1 U mng no (meningioma) c im chung: -L no nguyn pht khng phi thn kinh m hay gp nht -L u no trong trc v ngoi trc hay gp nht ngi ln -Tui thng 40-60 tui -Gii : n nhiu hn nam (2/1 c khi ti 4/1) -V tr: vng trn lu> vng di lu .Vm s dc theo lim no v hai bn ; 45% .Vng cnh h yn:10% .Vng rnh khu gic 10% .Dc h sau 10% .Lu tiu no .Xng bm .V tr t gp: no tht bn, v TK th gic -Phn loi theo t chc y t th gii .U mng no in hnh: lnh tnh 90-95% .U mng no khng in hnh: tng sn v phn bo trung gian ( 5%) .U mng no khng bit ho (u c tnh) 1-2%

Hnh 4.2. U mng no 1.Khi u ln dnh vo thnh vm s 2.Gin ng mch mng no gia 3.Nhiu nhnh nui gin t M mng no 4 v 5.Cc nhnh nui gin t M v no 6.Nhu m no b y vo trong (u ngoi trc)

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Du hiu hnh nh: Du hiu chung -Khi ngoi trc: .Khi c chn rng st mng cng .V no b y .C khe gianh gii mch mu-nc no tu vi u -Du hiu tt nht chn on: du hiu ui mng cng Chp ct lp vi tnh: -Du hiu khi tng t trng trn CLVT: .Tng t trng (75%), hay ng t trng (25%) khng tim thuc .Ngm thuc cn quang nhiu v ng u .m ging nh lim no khi khng tim v c tim thuc .Vi ho hay gp (20%) .Vng nang (15%) -Cu trc khi .Khi trn, mt thu c b r (thng gp) .Khi dt nm dc theo mng cng (him gp) .Du hiu ui mng cng : lan vo mng cng hay phn ng mng cng .Ph no t, khng ph no trong 40% cc trng hp do u pht trin chm -Bt thng xng (20%) .Khng thay i (hay gp) .Bn xng dy (hay gp) .Xng b gm mn (him) thng hay trong ung th Chp cng hng t -U thng ng t trng vi cht xm trn tt c cc chui xung -25% khng in hnh ( hoi t, nang, chy mu) -Ph no trong 50-60% -Ngm rt nhiu thuc i t, thng khng u -Du hiu ui mng cng trong 35-80% nhng khng c hiu -Tng sinh mch (hnh trng tn hiu do dng chy) Chp mch s ho: -Hnh tng sinh mch nh nan hoa xe p -Cc mch mng mm cp mu cho chu vi khi -Mch mng cng nui khi tng sinh mch -Khi gi thuc lu -Tnh mch dn lu dn Chn on phn bit -Di cn mng cng: .V xng thng b tn thng .Di cn ung th v c th khng phn bit c -Cc bnh khc: .Sarcoit .Dy mng cng t pht .D dng mch mu mng cng( hemangioma) 4.2.2.2. U mng no c tnh ( malignant meningioma)

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-Khng c cc du hiu c hiu trn chn on hnh nh chn on xc nh u mng no c tnh, c mt s du hiu gi : . U pht trin nhanh .Lan to xm ln ra xng hay t chc no .Trn T2 tng tn hiu (do c cc thnh phn mng no, nguyn bo mu, t bo trung m quanh mao mch...) ngc li gim tn hiu ca u mng no n thun (thnh phn x, vi ho) -V m bnh hc, u mng no c tnh gm cc th t bo .Hemangiopericytoma .M bo x c tnh (malignant fibrous histiocytoma) .U mng no nh (papillary meningioma) .U mng no chuyn thnh c tnh 4.2.2.3. U nguyn bo mu (hemangioblastoma) c im chung: -L u trong trc h sau hay gp nht tui trung nin, ngi tr, t khi tr em v ngi gi (tui 30-65) -Chim 10% cc U h sau -10-20% c phi hp vi bnh von Hippel-Lindau ( u x thn kinh VHL), 45% cc bnh nhn VHL c pht trin u nguyn bo mu -Gii: nam hi nhiu hn n, trong khi VHL th n nhiu hn nam. -U thng biu hin nang c nt v( 75), 10 % dng c, 15% nhiu nang Hnh nh -CLVT .Khng tim thuc: nang gim t trng vi nt ng t trng bn trong .C tim thuc: phn nt ngm nhiu thuc, nang khng ngm;him thy th c, th ngm thuc vin -Cng hng t: .Nang gim tn hiu T1 nhiu tn hiu T2 .Phn c ng tn hiu T1 .Tim thuc: ngm nhiu thuc phn c, tng tn hiu -Chp mch: .Hiu ng khi khi u ln, ngm v gi thuc lu phn c, c th c thng ng tnh mch trong u Chn on phn bit: -Di cn no: thng ngi gi, ti mu khc u nguyn bo mu -Glioma: rt him tui trung nin, trong h sau. -U mng no tht -U thn kinh m nang lng: thng tr em, phn c khng dnh vo thnh chu vi 4.2.3. Cc u thn kinh ngoi mc nguyn pht ( Primitive Neuroectodermal Tumors- PNET) Gm cc u khng bit ho c ngun gc t cc t bo biu m phi thn kinh, thng tr em Cc loi u bao gm: -U nguyn bo tu (medulloplastoma) di lu -U nguyn bo thn kinh ( primery cerebral neuroblasstoma)

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-Reticuloblastoma -Pineoblastoma -Ependymoblastoma 4.2.3.1. U nguyn bo tu (medulloblastoma) c im chung: -L u thn kinh ngoi mc h sau( PNET-MB) -U c tnh, thm nhim, u t bo phi ca tiu no (thu nhng) -L u h sau hay gp nht tr em (theo mt s tc gi) -Hnh nh c trng l khi c nm ng gia, tng t trng -Di cn Hnh nh: -Ct lp vi tnh: .Khi tng t trng, thng khi c, trong h sau ng gia .t gp hn l hnh ng t trng khng u (nang) .10-20% c vi ho .No tht bn b y ra trc bao ly u . nc no tht thng gp (95%) .Tim thuc: u thng ngm thuc t t n trung bnh, ngm t lm m n ngm u -Cng hng t: .Thng l khi ng u ng gia h sau .Gim hay ng tn hiu vi cht xm trn T1 .ng tn hiu T2, c th hn hp tng/gim tn hiu (nang) .C th c chy mu, nang, hoi t .90% c ngm thuc vi mc khc nhau Chn on phn bit. -U t bo hnh sao nang lng (pilocytic astrocytoma) .Gim t trng trn CLVT khng tim thuc .Thng khng nm ng gia .Hnh nang vi t chc c bm thnh (nang nhiu hn c) -U mng no tht (ependymoma) .U nm trong no tht bn , lan ra ngoi qua cc l .Vi ho ++, chy mu , nang .Ngm thuc khng u -U thn kinh m thn no (brainstem glioma) .Khi gim t trng thn no .NT 4 b y ra sau .Khng ngm thuc hay ngm rt t thuc cn quang 4.2.3.2. U nguyn bo thn kinh (neuroblastoma) -c im chung: .U him gp, 2mm .Mn v leo rng ng tai trong .ng tai trong > 8mm .Lan vo trong vng gc cu tiu no( nh hnh kem c qu ) + Chp ct lp vi tnh v cng hng t: .Khi ng t trng trn CLVT, ngm ng u v nhiu thuc cn quang .CHT nhy cao hn CLVT , thng ng i khi hn hp ng/tng tn hiu T1 .15% c nang trong khi, i khi thm ch c th thy hnh mc dch dch. Rt t khi c chy mu .90% c tng tn hiu T2 .Tim thuc i t: ngm nhiu, 2/3 l khi c, 1/3 khng u hay c hnh vng

Chn on phn bit U mng no V tr m trn CLVT Vi ho ng tai trong Tng tn hiu T2 so cht xm Dnh mng no Tng hay ng Thng gp Bnh thng 50% ng Schwannoma ng tai trong ng t trng Khng Rng Tng tn hiu U dng b(Epidermoid) Gc cu tiu no Gim t trng i khi Bnh thng Tng

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Ngm thuc

Nhiu

Nhiu

Khng

4.2.4.2. U x thn kinh (neurofibroma -NF) c im: -U x thn kinh c th cc r thn kinh, t khi cc dy thn kinh -C th lc c, phi hp vi NF1 -Th m ri l dng duy nht ca NF1 -H mt l vng hay gp tn thng nht vng u c Hnh nh: -C th c gianh gii r (th khi c) hay thm nhim lan to (th m ri) -Du hiu chn on : l khi hnh con giun thm nhim t chc lin kt trn bnh nhn u x thn kinh da -CLVT: .Th nt c: khi ng t trng ngm nhiu thuc cn quang .Th m ri: khi thm nhim hc mt , c th lan vo vng xoang hang .V tr khc: da u, nn s -CHT: (th m ri) .Khi xm ln nhiu thy ng tn hiu T1, tng tn hiu T2 .Ngm thuc khng nhiu Chn on phn bit: Chn on phn bit gia Schwannoma v Neurofibroma Schwannoma Neurofibroma Ngun gc T bo Schwann T bo Schwann v nguyn bo x V tr Dy VIII > ni khc Thn kinh da v r tu Thng gp hay gp t gp Khng 5-10% Thoi ho c tnh Pht trin Khu tr Thm nhim Ngm thuc Nhiu Khng nhiu T1W 70% gim, 30% ng tn ng tn hiu vi c hiu T2W Tng tn hiu Tng tn hiu

4.2.5. Di cn no. c im: -Chim 30% cc u ni s, v tr thng gp theo th t: ranh gii cht xm trng> t chc no trong su> thn no. U c th mng no v hp s - Cc u di cn no hay gp theo th t: ung th ph qun phi> ung th v> ung th i trc trng> ung th thn> u hc t bo -80% cc di cn no thng nhiu khi. Hnh nh: +Ct lp vi tnh:

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-Nhu m no: .Khi ng hay gim t trng trong vng gia cht xm v trng .Ph n quanh khi, c th c chy mu .Ngm thuc cn quang dng lm m, nt, hay hnh vng. -Mng cng: .Khi ng t trng> tn thng lan to mng cng .Ca s xng pht hin tn thng xng +Cng hng t: .Tn thng ng hay gim tn hiu T1, tng tn hiu T2, FLAIR (u hc t bo hay chy mu c th thy tng tn hiu T1) .Ngm nhiu thuc lm m, hay u, hnh vng .Ph no thng gp. .Cng hng t tim thuc nhy hn CT tim thuc, liu thuc CHT tng gp 2 ln bnh thng tng nhy. Chn on phn bit: -Khi c ngm thuc vin n c hay nhiu khi: .Apxe: thng tng tn hiu trn DWI v gim trn ADC .U nguyn pht (thng cht xm) .Bnh khc: Thoi ho mylin, mu t ang tiu -Tn thng nhiu cht trng: .Nu khng ngm thuc thng khng phi di cn. 4.2.6. Cc tn thng nang: C nhiu loi tn thng nang khng phi do nhim trng hay u trong no: -Nang mng nhn -Nang keo -Nang khe Rathke -Nang biu m thn kinh: nang mng no tht trong no tht ca, nang m ri mch mc. -Nang trong nhu m Nang mng nhn: c im: -Khng thc s l u, do gp i hay trt ca mng nhn -Hay gp tr em ( chim 75%) -V tr: h gia, h sau, trn yn, b c no sinh t, b Magna -Du hiu in hnh: hnh nang dch no tu trn, bu dc gianh gii r Du hiu: -Khi ngoi trc t trng nc no tu (trn CLVT), tng tn hiu T2 gim T1 -Khng ngm thuc -Tin trin chm vi chn p nhu m no -Khng thng vi dch no tu ( CLVT b no cn quang) -p lc ca khi c th gy mn vm s. Chn on phn bit vi nang dng b epidermoid cyst) T trng Cng hng t CHT khuch tn Nang mng nhn Nh nc no tu Ging nc no tu Ging nc Nang dng b C th tng hay ng t trng Hi tng tn hiu PDW Gim hn nhu m no

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Vi ho Ngm thuc Hnh thi

Khng Khng y

C th gp C th c Lun lch, bao quanh cc mch mu v dy thn kinh

Nang keo: (colloid cyst) c im: -Nang pht trin trong vng l Monro, ngi ln -Lm sng au u nh, mt iu ho nh do nc no tht -V tr c trng: phn trc no tht ba, l Monro Hnh nh: -Nang keo trn hay bu dc kch thc trung bnh 15mm -Tng t trng trn CLVT (2/3), ng hay gim t trng (1/3 cc trng hp) -Vi ho him gp -C th c nc no tht -Khng ngm thuc cn quang -Cng hng t c tn hiu thay i tu bn cht dch: ng /tng tn hiu T1, tn hiu t gim n tng tn hiu T2, c th c mc ngang dch/dch. C th c ngm thuc vin . Chn on phn bit: -Nang sn (neurocysticercosis) -Gi nang do dng chy dch no tu -Phnh mch, M thn nn to v di -U : u di mng no tht (subependymoma); u nh m ri mch mc (choroid plexus papilloma) Nang khe Rathke c im: -Nang pht trin t di tch phi ca ti Rathke (thy tun th 4 ca phi, l tin thn ca thu trc v phn gia tuyn yn) -Nang nm trong h yn v trn yn trong 70% cc trng hp, 20% ch trong tuyn yn -Du hiu c trng: hnh nang khng ngm thuc, khng vi ho, tng tn hiu T2 nmg trong tuyn yn Hnh nh: -Ct lp vi tnh: .Khi trn, hay c thu, nm trong h yn hay trn yn .Kch thc < 10mm (trong h yn 40%), pht trin ln trn yn (60%) .70% gim t trng, 25% hn hp gim v ng t trng .Ch c 10-15% c vi ha .Rt t khi c vim xoang bm .Khng ngm thuc cn quang -Cng hng t: .Nu trong h yn: thy nhu m tuyn yn lnh xung quanh .Tn hiu thay i tu theo dch trong nang (thanh dch hay dch nhy) 30-40% nh dch no tu (gim tn hin T1, tng tn hiu T2) 50-60%: tng tn hiu T1, gim/ng tn hiu T2 5-10% hn hp

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.Khng ngm thuc i t trong nang( vin ngm thuc ca tuyn bnh thng b p c th thy) .75% c nt trong nang khng ngm thuc .Kch thc thng nh, i khi to Chn on phn bit: -U s hu: .Hay c vi ho .90% c ngm thuc (nt, vin) -Nang tuyn yn ( Cystic pitutary adenoma) .Vi ho him .C vin tng m -Cc nang khc khng phi u: .Nang mng nhn .Nang hn hp trong tuyn yn: ( dermoid, epidermoid...)

V. BNH L THOI HO V BNH L CHT TRNG.Mc tiu: Nm c cc du hnh nh ca mt s bnh l thoi ho v bnh l cht trng5.1. I CNG

5.1.1.Xp loi cc bnh thoi ho: Cht trng: -Bnh thoi ho Mylin: bnh mc phi do mylin ho b ri lon -Bnh ri lon to mylin: sai st bm sinh di truyn to mylin, bo v v thoi ho mylin Cht xm: -Sa st tr tu tui gi, th Alzheimer -Bnh Pick -Sa st tr tu do mch mu v no( sa st tr tu do nhi mu nhiu ) -Bnh Parkinson -Lyosomal storage disease Cc hch nn: -Bnh Hungtington (di truyn, bin d cnh ngn NST 4, tng tng hp Nucleotit CAG, ) -Bnh Wilson ( ri lon chuyn ho ng) -Bnh Fahr -Bnh Leigh (bnh no tu sng hoi t bn cp, di truyn NST thng ln, thoi ho mt mylin , t chc m lan to, hoi t ) 5.1.2. Thoi ho v gi ho. Nhiu thay i xut hin trong h thn kinh trung ng cng vi s gi ho -Teo no lan to: .Gin cc no tht , rnh cun no, cc khe v cc b no .Mt nhu m no -Bt thng cht trng: .Bt thng cht trng trung tm hay vng di v .Bt thng cht trng quanh no tht (gp trong 30% ngi gi) do: Cc bnh l vi mch (thoi ho mylin thiu mu), lan to t chc m, lng ng protin, nhi

52

mu khuyt; biu hin bng tng tn hiu thng T2 quanh no tht khng ngm thuc v khng c hiu ng khi. .Khoang Virchow-Robin (VR) gin ( gin khoang quanh mch mu): mt mylin quanh cc mch mu lm cho gin khoang di nhn quanh mch mu cha nc no tu. Khoang VR lun c tn hiu tng ging nh dch no tu. .ng st hch nn: T2 gim tn hiu.5.2. BNH L CHT TRNG.

5.2.1. Phn loi: -Mt mylin ho .Bnh x ho ri rc( Multiple Sclerosis- MS) .Bnh vim no v tu sng (encephalomyelitis) .Bnh lin quan n nhim c: Thoi ho mylin ca cu no nhn xm Hi chng cn u iu tr tia x, ho cht Nghin ru -Bnh ri lon mylin ho tn thng cht trng su (leukodystrophies) .Ri lon cc enzym tiu th .Cc ri lon to v tiu hu peroxyt t bo (oxy gi) .Bnh ri lon chuyn ho axit amin .Bnh t pht ... 5.2.2. Bnh x ho a ( MS) *i cng: -Bnh mt mylin t pht c trng bng tn thng vim ph n quanh cc mch mu (cc mng cp tnh) v tin trin gy pht trin m m v mt mylin (cc mng mn tnh) -Bnh c pht sinh c th do phn ng vim t min hay do cc yu t bn ngoi -Hay gp ngi da trng tr, n hi nhiu hn nam. L nguyn nhn hay gp nht ca bnh l cht trng. -Lm sng: ph thuc vo v tr tn thng; gim th lc mt bn, dng i kh khn, ri lon cm gic hay gp. *Chn on hnh nh: -CLVT: cc tn thng ng hay gim t trng c ngm thuc t (kh chn on) -Cng hng t: Cc x ho: .Thng nhiu , s lng trn 3 , kch thc trn 5mm gip chn on .Kch thc trung bnh: 0,5-3cm .Ngm thuc: ng u, hnh vin, hay loang l( cc khng hot ng khng ngm thuc) .Tng tn hiu trn T2 v FLAIR .Hnh c trng: tng tn T2 hiu hnh van, hnh thun di th trai (ct theo mt phng ng dc) .Hnh cc ngn tay cu Dawson:Cc cu trc hnh elip lan n trong cht trng su quanh no tht bn. V tr cc : .Vng trn lu: Hai bn quanh no tht :85%

53

Thn th trai: 70% Ri rc trong cht trng Trong cht xm (him gp) .Thn no .Tiu no .Tu sng: 50% .Thn kinh th gic, giao thoa th gic. Cc tn thng khc: .Teo v no: 20-80% .Teo th trai: 40% .Gim tn hiu trn T2W ca i th v nhn bo ( tng lng ng st) .Hiu ng khi vi cc ln( >3cm) c th nhm vi u( him) *Chn on phn bit: -Vim no tu ri rc cp : .Nhng t cp x ho ri rc n c kh chn on vi vim no .Vim no thng tn thng v v di v -U no: . x ho c nhiu vng ngm thuc c th nhm vi di cn . x ho ln, c, hiu ng khi c th nhm vi u thn kinh m 5.2.3. Vim no tu ri rc cp ( Acute Disseminated Encephalomyelitis ADEM) -Phn ng min dch vi viurut hay sau tim chng -Bnh tn cng t ngt, thng tr em -Khng phn bit c v hnh nh vi x ho a trn hnh nh nhng n tin trin mt giai on khc hn vi x ho tin trin nhiu t 5.3.1. Bnh mt tr nh ngi gi th Alzheimer. c im chung: -L bnh l mt tr nh hay gp nht do teo v no ngi gi -T l thng tng ln cng vi tui:t l ti 50% ngi trn 85 tui -Du hiu hnh nh khng c hiu nhng gip chn on phn bit vi cc bnh khc c biu hin lm sng tng t (t mu ngoi mng cng, nhi mu thiu mu nhiu , bnh Binswarger, nc no tht khng tng p lc...) Hnh nh: -Khng c cc du hiu hnh nh thc s c hiu trn CLVT v cng hng t -Gin rng lan to ca cc rnh cun no v no tht (thng gp) -Teo no nhiu hn vng thi dng, thu hi m,v vng khe Sylvius. -Tng tn hiu trong cht trng c th gp nhng khng phi l du hiu c trng thng gp -Thng c phi hp vi bnh tn thng vi mch -PET v SPECT : .Vng gim chuyn ho trong no( gim tiu th glucose v xy) .Ti mu no b gim Chn on phn bit: -Bnh th Lewy lan to .Bnh mt tr nh ng hng th hai .7% -30% bnh Alzheimer c tn thng th Lewy( nm trong nron thn kinh) .Gim chuyn ho ca c no:c v no, tiu no -Bnh Pick: teo no vng trn v thi dng trc khng cn i

54

-Thoi ho nn v no( corticobasal degeneration) .Hi chng ngoi thp v v no .Teo no nng vng trn nh - nc no tht p lc bnh thng: .Thiu ht nng v vn ng v dng i .Gin nng ton b h thng no tht khng tng xng vi teo hi hi m 5.3.2.Bnh Pick. c im chung: -Bnh mt tr nh t gp, la tui trc 65 -Ni bt bng du hiu teo thu no -Thng thu trn, thi dng trc Hnh nh in quang: -Teo no vng trn v thi dng trc -C th c teo nhn ui -Sng trn no tht bn, phn trc rnh lin bn cu gin -PET v SPECT:gim ti mu v gim chuyn ho vng tn thng 5.3.3.Mt tr nh do thiu mu no (ischemic vascular dementia) c im chung: -L bnh mt tr hay gp ng th hai sau Alzheimer -Nhiu thiu mu nh v no v di v -H thng no tht, rnh cun no ch gin nh Hnh nh in quang: -Nhi mu nhiu mt tr nh: .Cc nhi mu trong v no .Gin cc rnh cun no v no tht .Tng tn hiu T2 -Mt tr nh do tn thng vng di v (bnh Binswanger) .Tng tn hiu quanh no tht (thiu mu ca cc mch xin) . Thng c tng huyt p -Cc khuyt trong cht xm trong su v cht trng .Cc nhi mu trong i th, nhn ui bao trong v thn no 5.3.4. Bnh Parkinson c im chung: -L bnh thoi ho thn kinh, tui thng trn 50 t pht -Hnh i th l teo no ton th -Tn thng h thng dopamine ca ca ng lim en th vn (substania nigra) Hnh nh in quang -Cng hng t thng bnh thng -Gim chiu rng trn T2 ca phn c lim en -Gim tn hiu ca hch nn trn T2W v Spin echo v gradient echo (hch nn en) -Teo no trong trng hp bnh mn tnh5.4. BNH L RI LON CHC NNG HCH NN

5.4.1. Vi ha hch nn. c im chung -Vi ho hch nn gp trong 1% dn s v khng c lin quan n biu hin lm sng -a s cc bnh nhn vi ho hch nn khng c biu hin lm sng. -Khng c cc du hi xc nh vi ho hch nn no l bnh l

55

Nguyn nhn -T pht, hin tng ho gi bnh thng -Chuyn ho: .Thiu nng tuyn gip (hay gp) .Gi thiu nng cn gip .Cng nng cn gip -Nhim trng .Toxoplasmosis .HIV -Lin quan n nhim c .CO .Nhim c ch .Tia x, ho tr niu -Chn thng thiu mu, thiu oxy -Bnh thoi ho no (him gp) .Bnh Fahr .Ri lon phn bo sn .Bnh Cockayne 5.4.2.Bnh ma git Huntington c im chung -Bnh di truyn nhim sc th thng -Lm sng: ma git v mt tr nh Hnh nh in quang -Teo nhn ui -Gin rng sng trn no tht bn 5.4.3.Bnh Wilson c im chung -Bnh di truyn gen nn -Ri lon chuyn ho ng -Biu hin x gan, thoi ho hch nn Hnh nh in quang -Cng hng t c th bnh thng -Tng tn hiu ca nhn bo v i th trn T2 -Thoi ho chung ca no -Gim t trng ca cc hch nn trn CLVT -X gan 5.4.4. Bnh Fahr c im: -Trc kia bnh Fhar c gi cho nhm nhiu bnh l ri lon c biu hin bng vi ho cc hch nn -Nay n c dng cho nhm bnh nhn c vi ho cc hch nn v c biu hin mun hi chng mt tr nh v ri lon vn ng ngoi thp, di truyn nhim sc th thng -Vi ho cc hch nn t pht Hnh nh in quang -Hnh nh in hnh l hnh vi ho i xng hai bn cc hch nn trn CLVT -Cng hng t:

56

. T1 tng tn hiu tu theo mc v giai on ca bnh .T2 c vng tng tn hiu trong trung tm bu dc c th do qu trnh vim

VI. NC NO THTMc tiu: Nm c cc loi nc no tht v chn on phn bit6.1. I CNG

Xp loi: - nc no tht khng lu thng: tc bn trong no tht, cc l , cng Sylvius, bm sinh - nc no tht lu thng: .Tc cc ht Pacchioni (do chy mu mng no, vim mng no) .Tng bi tit dch no tu (him): u m ri mch mc . nc no tht p lc bnh thng Bin chng ca Shunt -Vim mng no, vim no tht -Tc shunt: tng nc no tht -T mu di mng cng hay d vo khoang di mng cng -X ho mng no6.2. NC NO THT KHNG LU THNG

c im chung -Gin cc no tht khng c thng tn ca nhu m no -Do tc bn trong hay ngoi h thng no tht trc cc l Luska v Magendie -C th cp tnh hay mn tnh Nguyn nhn: -Tc l Monro: .U trong no tht 3: Nang nhy no tht (colloid cyst) Oligodendroglioma Central neurocytoma U t bo hnh sao vi t bo khng l U mng no tht( ependymoma) U mng no (meningioma) .Cc u vng trn h yn -Tc cng Sylvius .Hp bm sinh .Vim no tht .Chy mu trong no tht .Cc u: U cung no U tuyn tng, vng sau no tht 3 -Tc vng no tht 4: .Bnh bm sinh: Dandy Walker .Chy mu trong no tht .Nhim trng (cysticercosis) .U di mng no tht .U thn kinh m thn no .Cc u h sau: ependymoma, medulloblastoma, hemangioblastoma, di cn,

57

astrocytoma Hnh nh in quang: -Gin h thng no tht pha trn ch tc: .T l ng knh ngang 2 sng trn/ng knh no > 0.33 .Sng thi dng rng > 3mm cho du hiu tai chut Mickey kh in hnh -Thy nguyn nhn pha di gy tc -Xo cc rnh cun no do hiu ng khi -Ph n t chc k quanh no tht do tng p lc trong no tht v dng chy qua mng no tht( tng tn hiu T2) -Mt hnh rng ca dng chy bnh thng trong cng Sylvius -i khi o p lc trong no tht bng chc trc tip chn on -Thm khm chn on hnh nh nn lm thm: cng hng t nghin cu dng chy nc no tu6.3. NC NO THT LU THNG

c im chung -Thng l hu qu ca tc lu thng dch no tu ngoi no tht: ht Pacchioni, b y hay vm no. -Nguyn nhn: .Vim mng no: nhim khun hay ung th mng no .Chn thng, chy mu mng no .Sau phu thut .Tc tnh mch Du hiu in quang -Cc du hiu ging nc no tu khng lu thng: .Gin sng thi dng .Xo cc rnh cun no .Ph n t chc lin kt quanh no tht (tng tn hiu T2) -Gin cn i ton b h thng no tht -No tht 4 thng khng gin nhiu trong nc no tht do tc vm no.6.4. NC NO THT VI P LC BNH THNG

c im chung -L loi nc no tht lu thng nhng khng c tng p lc ni s -Tam chng trn lm sng: l ln, i khng t ch, dng i khng phi hp ng tc. Du hiu chn on hnh nh -Du hiu chn on tt nht : phi hp gin cc no tht, khe sylvius gin v thu o v cc rnh cun no bnh thng. -Tng tn hiu trn T2 quanh no tht t gp hn. -Th trai cong li ln trn v c th chm ti lim no -Du hiu trng tn hiu ca dng chy trong cng sylvius -Nghin cu lu lng nc no tu : thy tng lu lng qua cng sylvius Chn on phn bit -Gi ho bnh thng -Bnh suy gim tr nh Alzheimer -Bnh suy gim tr nh nhi mu nhiu -Bnh no do x ho tiu ng mch di v (bnh Binswanger) gy cc thiu mu nh v thoi ho no.

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VII. CC BNH VIM NHIM:Mc tiu:Nm c mt s bnh vim nhim hay gp no do cc nguyn nhn khc nhau7.1.C IM CHUNG

-Xp loi cc nguyn nhn gy vim nhim .Nhim trng do vi trng .Nhim trng do nm .Do k sinh trng .Do siu vi trng -Xp loi theo v tr tn thng .Vim mng no: mng mm, khoang di nhn, khoang di mng cng, mng nhn .Vim m: khoang ngoi mng cng, khoang di mng cng .Vim no: trong nhu m, giai on sm ca apxe no .Ap xe trong nhu m no .Vim no tht.7.2. VIM MNG NO DO VI KHUN

c im chung -Nguyn nhn chung: .Tr s sinh: nhm B Streptococcus, Escherichia Coli, Listeria .Tr em: Hemophilius, N.meningitidis .Ngi ln: Streptococcus pneumonia, N.meningitidis -Gii phu bnh chia thnh hai th .Vim mng no (leptomeningitis) thng gp, mng nui v mng nhn b tn thng .Vim mng cng: mng cng v lp ngoi ca mng nhn b tn thng -Cc yu t thun li cho tn thng: .Vim xoang .Vim phi mn tnh .T chng Fallot .o v tr cc mch mu ln .Cc bnh tim c tm khc Hnh nh in quang -Vim mng no l chn on ca xt nghim dch no tu -Hnh nh in quang khng c hiu -Hnh nh in quang ch yu chn on cc bin chng -Giai on sm hnh CLVT bnh thng -Hnh mng nui v mng nhn ngm thuc, mng nui v khoang mng nhn vm no ngm thuc (trn T1) l du hiu c trng. -Hnh mng no vng nn s ngm thuc n c gp trong vim mng no u ht -C th c nc no tu ( bin chng sm)

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-Siu m qua thp tr em: .Cc du hiu tinh t: bt thng v mt m ca nhu m no .Cc rnh cun no tng m .T dch ngoi nhu m no .Gin h thng no tht .Vim no tht thy trong 70-90% cc trng hp: Thnh no tht tng m, c m lng ng trong no tht. -Bin chng: . nc no tht do tc ngoi no tht .Vim no tht, vim m ri mch mc .Tn thng mch mu: vim ng mch, tc tnh mch 7.3. VIM M KHOANG MNG NO (empyema) c im chung -L khi m khu tr trong khoang di mng cng (thng gp) hay trong khoang ngoi mng cng (t gp) -Bnh c th tin trin nhanh, coi nh cp cu ngoi khoa -Nguyn nhn : vim tai, chn thng, sau phu thut s no Hnh nh in quang -Hnh nh chung: .Khi dch ngoi no, c vin ngm thuc .Ti 2/3 cc trng hp c phi hp vim xoang .15% cc trng hp c c khi m khoang di v ngoi mng cng -Ct lp vi tnh: .Khoang di mng cng: Khi dch hnh lim ngoi no ng hay tng t trng C vin ngm nhiu thuc Hay phi hp vi vim xoang, vim tai xng chm .Khoang ngoi mng cng: Khi t trng thp li hai mt Thng lin vi xoang trn -Cng hng t: .Vim m di mng cng: Tn hiu > dch no tu tt c cc xung B khi c v ngm nhiu thuc, c th c vch bn trong khi T chc no di khi tng tn hiu trn T2, FLAIR .Vim m ngoi mng cng: Khi dch li hai mt y mng cng( tng tn hiu) Khi c th vt qua ng gia nu nm vng trn Chn on phn bit -T mu di mng cng mn tnh -T dch di mng cng -Trn dch di mng cng: dch nh dch no tu khng nhim trng, khng ngm thuc, hay gp tr em vim mng no m7.4. VIM MNG NO DO LAO

c im chung -Vim mng no do lao l biu hin hay gp nht ca lao h thn kinh trung ng, sau mi n lao trong nhu m no

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-Vi khun lao thm nhp ch yu theo ng mu t lao phi -Tn thng mn tnh to cc u ht vng nn no c th gy lit cc dy thn kinh -Bnh ph bin tr li do AIDS, tnh trng khng thuc ca lao Hnh nh in quang -Lao mng no vng nn s .Ngm nhiu thuc ca mng no vng nn s trn CLVT v CHT .Vng h yn v quanh yn cng b tn thng .Mng no gim tn hiu trn T2 .Vi ho mng no c th thy trong cc trng hp mun -U lao ( ap xe do lao) .t gp tr trng hp b suy gim min dch hay trong vng dch .Khi c vin xung quanh tng hay gim tn hiu , c th c ph n .Thng biu hin bng khi c hoc khi c vin ngm thuc trn CLVT .U lao cha b u ho: tng tn hiu T1, gim tn hiu T2 v ngm thuc u .U lao b u: C vin tng tn hiu nh T1, gim tn hiu T2 .Vin ngm thuc u hay nhiu thu, nhiu khi tp trung -Du hiu phi hp . nc no tht (70%), nhi mu no (40%) .Lao ct sng .Vim hch... Chn on phn bit: -Vi cc vim mng no nguyn nhn khc, u mng no -Vim mng no khng c hiu (sarcoid...) -U lao vi : cc p xe no, sn no, di cn no7.5. AP XE NO

c im chung -Cc loi vi khun: .Tr em hay do Staphylococcus, Streptococcus, Pneumococcus .Ngi ln: phi hp vi khun ym kh v hiu kh .Suy gim min dch: toxoplasmosis, cryptococcosis, nm -C ch gy bnh: .Theo ng mu .Theo ng trc tip: vim xoang, vim tai, sau phu thut .T pht Du hiu in quang -V tr: .Lan theo ng mu: nhiu tn thng cht xm v gianh gii cht trng-xm .Lan trc tip sau chn thng hay vim xoang: Tn thng quanh vng ng vo -Hnh thi: .Hiu ng khi (do khi p xe v ph n xung quanh) .Vin hay vch ngm thuc nhiu (90%) .V ap xe (t ngy 7-14) V p xe mng hn trong cht trng do t mch nui dng hn (p xe c th v vo no tht hay to p xe mi khi nm v tr ng gia) V gim tn hiu trn T2 v thng nhn V c th xut hin mun do dng khng vim steroid

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.C th lan vo no tht gy vim no tht Tng t trng dch no tu Ngm thuc ca mng no tht C th c vch no tht v nc no tht .Tn thng p xe th pht Chn on phn bit -U nguyn pht hay th pht -Cc tn thng khc c ngm thuc vin: t mu ang tiu, x ho ri rc... 7.6. NHIM K SINH TRNG NO( bnh sn no- cysticercosis) c im chung: -Nguyn nhn: do Taenia solium ( sn dy ca ln). -Dch t: Bnh nhiu nc trn th gii, nht l trung v nam M, n hay ung nc b nhim trng sn, trng qua rut non theo ng mu to cc nang sn trong c, da, no. Nang sn lc u cha u trng cn sng, sau cht gy vim v vi ho. 75% bnh nhn mc bnh sn c biu hin sn no -Lm sng : thng biu hin ng kinh -iu tr: praziquantel, salbendezol. Lm shunt no tht trong trng hp tc no tht -Tin trin: .u tin l nang khng ngm thuc (u trng sn sng) .Vin ngm thuc: do u trng cht gy vim .Vi ho: tn thng c Hnh nh in quang: -Biu hin c trng bng hnh cc nang .Nhiu nang ri rc t trng dch .Kch thc cc nang t 5-15mm .u trng sn biu hin bng nt trong nang c mc tng tn hiu khc nhau trn T2. .Vin ngm thuc -V tr cc nang: .Thng nm ri rc trong nhu m no .Nm trong no tht c th gy nc( tng tn hiu trn xung FLAIR) .Nm trong khoang di nhn -Tm cc tn thng khc: . nc no tht .Vim mng no mn tn .Cc vi ho trong c Chn on phn bit: -Cc nang k sinh trng khc -Tn thng do lao -U ht k sinh trng: u no7.7.VIM NO

c im chung -L tn thng vim lan to khng khu tr ca no -Nguyn nhn thng do siu vi trng -Thng gp nht l do Herpes -C th vim cp hay mn tnh

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-Cc vng tn thng c gianh gii r hay khng r do .Ph n nhim c lan to .C th c chy mu lm m hay khng .Vim mng no .Ngm thuc t th sm hoc khng ngm thuc -Cc v tr c trng ca mt s loi vim no: .Vim no do Herpes ( HSV-1) cun no vng thi dng v trn di hai bn, thu o. .HIV: tn thng cht trng v thn no, hch nn v i th .Vim no nht bn: Tn thng vng i th hai bn, thn no, tiu no. .Vim no do Varicella-Zoster Virus (mt loi siu vi trng thu u-zona): t tn thng no (1%), tn thng tiu ng mch gy cc nhi mu nh v chy mu .Virut Estein-Barr (EBV) tn thng i xng hch nn hai bn.... Hnh nh in quang -Ct lp vi tnh: .CLVT m tnh trong 75% tr em b vim no cp .Vim no do Herpes Chp CLVT sm thng m tnh Gim t trng, vng thi dng v trn su hai bn, vng cun no gianh gii vng trn vi vng thi dng, hiu ng khi Chy mu v ngm thuc c trng giai on mun -Cng hng t: .Vim no Herpes Nhy hn CLVT, gim tn hiu T1, tng tn hiu T2 v FLAIR Tng tn hiu trn DWI C th c ngm thuc sm lm m sm Chy mu, nhuyn no xut hin mun hn Tn thng cc cun no vng trn gianh gii vng thi dng v vng thi dng i din cng gi chn on. .Nhim siu vi trng mn tnh HIV: Nhiu tng tn hiu khng ngm thuc trong cht trng quanh no tht, vng chm, trn (thm nhim t chc m, thoi ho mylin) Teo no lan to Cc nhim trng c hi: toxoplasmoisis, cryptoccocosis, CMV PLM ( Tn thng no cht trng nhiu tin trin Progressive Multifocal Leukoencephalopathy) Bnh thoi ho mylin do phn ng vi vi virt Jakob Creutzfeldt, gy tn thng cc t bo thn kinh m t nhnh. Tn thng phn sau trung tm bu dc Tn thng cn i hai bn Bt u t cht trng gn v v lan vo cht trng trong su T2 tng tn hiu Khng ngm thuc (khc cc vim nhim khc v u) C th vt qua c th trai Khng c hiu ng khi

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VIII. CC BNH BM SINHMc tiu: Nm c mt s bnh bm sinh hay gp ca no8.1. TNG QUAN

Xp loi -Thiu ht ng kn ng thn kinh: .V s (thng gp) .Chiari II,III .Thot v nhu m no (encephalocele) -Ri lon to nn cc ti tha, cc phn cch .Mt na trc ca no (holoprosencephaly) .Lon sn vch- th gic (septo-optic dysplasia) .Bt thng th trai -Bt thng pht trin ca v no .V no nhn (lissencephaly) .Cc np cun no dy (pachygyria) .Cc np cun no nh (polymicrogyria) . Tt nt i no (schizencephaly) .No lc ch (heterotopia ) .Ph i mt na no (hemimegalencephaly) -Cc d dng h sau .Chiari I,II,III .Dandy-Walker .Cc bin th ca Dandy-Walker .Phnh to b y -Hi chng thn kinh da (pharcomatoses) .X cng c (tuberous sclerosis) .U x thn kinh (neurofibromatosis) .Hi chng Sturge-Weber (encephalotrigerminal angiomatosis ) .Bnh Von Hippel-Lindau8.2. THIU HT NG NG THN KINH

8.2.1.D dng Chiari II. im chung v d dng Chiari -Chiari I: Hnh nhn tiu no nm xung di l chm > 5mm, khng lin quan n Chiari II -Chiari II: bt thng h thn kinh vi h sau nh, thn no ra sau, thot v hch nhn tiu no qua l chm, hay km thot v no mng no vng tht lng -Chiari III: Chiari II v thot v no (him gp) -Chiari IV: Thiu sn nng ca tiu no (him) c im chung ca Chiari II. -L d dng hay gp nht tr s sinh, hay km cc bt thng khc -Km vi thot v no mng no tu trong 90% - nc no tht do tc (90%) -Khng c th trai -Rng tu (50%)

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-Bt thng cc cun no -Khng km Chiari I Hnh nh in quang -Bt thng h sau: .H sau nh .Thu giun tiu no thot v qua l chm ( hnh ming g chn ca) .Thot v tiu no ln trn .Tiu no bc quanh cu no ( hnh tim) .Lu tiu no hp .Xo b gc cu tiu no v b y .Khng thy no tht 4 hay no tht bn rt nh ko di -Bt thng trn lu: .Thiu sn lim no hay lim no c cc khong trng nn cc cun no hai bn bn cu nh an vo nhau .Cc cun no nh v nhiu . nc no tht .Sng trn no tht bn b thun nh do nhn ui n vo. .No tht 3 nh v cong lm hai bn .Pht trin khng hon chnh ca th trai -Bt thng xng: .Khuyt xng s bn trong v ngoi (xut hin s sinh v mt dn) do thiu ht trung m .Hi lu tnh mch v lu tiu no bm thp st l chm .L chm rng hnh phu .Thp xng n lm, bn dc kha lm( do p lc tng) -Tu sng: .Thot v no mng no tu (myelomeningocele) trong 90% cc trng hp .Tu c b xon vng l chm (do p lc) .Bnh rng tu v bnh tu tch i vng ngc cng d dng ct sng (diastematomyelia)Hnh 8.1. Chiari II 1. No tht bn ko di hnh ng 2. Thu nhng b y xung di to cc nt 3. Tu sng c hnh ca g 4. Tu sng b xon 5.Bn cu tiu no b bao quanh pha trc thn no. 6. Hi lu Herophil v xoang bn xung tht 7.Bn trt cong lm 8.Tectum c m 9.Khi gian no to 10. Thiu sn mt phn th trai

8.2.2.Thot v no mng no (cephalocele) -Khuyt xng s lm cho no , mng no, dch no tu thot v ra ngoi s

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-Thng nm ng gia v phi hp vi cc bnh bme sinh khc nh: Chiari, thiu sn th trai -Cc v tr: .Vng chm 80% .Trn hay mi sng .Vng nh 10% .Xoang bm8.3.CC KHUYT TT VNG BN CU I NO

8.3.1.Thiu sn th trai (agenesis of corpus callosum) Cc im chung: -L d tt hay gp nht trong cc d tt ca no -Th trai gm cc si ni hai cht trng hai bn (trung tm bu dc) qua th trai. Cc si chy bt thng thnh cc b dc (bundles of Probst) dc thnh trong ca no tht bn hai bn, y cc no tht bn ra hai bn v dng vng thu chm v nh -No tht 3 bt thng ln cao v rng -C th thiu sn ton b hay mt phn th trai. -C th km cc d tt khc (tim mch, tiu ho, sinh dc tit niu) v di tt no: .Dandy-Walker .U m .Chiari II .Thot v no .Cc di ch bt thng no Hnh nh in quang -Khng thy th trai mt phn hay ton b -Bt thng b Probst cnh pha trong no tht bn -Cht trng km pht trin quanh sng chm hai bn -Cc bt thng i theo: .No tht 3 ln cao gia cc no tht bn .Cc sng trn no tht bn nh, nhn .Cc sng chm gin .Cc no tht bn song song khng ni vi nhau .Ct mt phng trn: cc sng trc nhn hnh inh ba thn bin .Sng thi dng gin hnh l cha kho -Cc bt thng khc ca no .

Hnh 8.2. Thiu sn th trai Cc hnh A.B.C cho thy khng c th trai; Hai b si nm hai ben phi trong no tht bn (A v B); Hnh lan hoa to ra xung quanh ca cc cun no (C), no thtt III ni lin vi rnh lin bn cu (B).

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8.3.2. Di tt khng pht trin phn trc ca no (holoprosencephaly) i cng -L bt thng trong thi k chia i ca no nguyn thu thnh hai bn cu i no. Thng phi hp vi cc bt thng mt : d dng mt mt gia (cyclopia), hai mt gn nhau u nh d dng mt (hypotelorism) -50% bnh nhn c 3 nhim sc th 13 -C ba th Holoprosencephaly Khng c thu (Alobar) Khng c Mt no tht hnh ch U Khng Mt bn cu St nhp nhau Nng khng c Bn thu (Semilobar) Ch c pha sau Thng lin nhau phn trc S khai Chia i mt phn st nhp tu ca t nng hn khng c C thu (Lobar) c Gn bnh thng Gn bnh thng Gn bnh thng Gn bnh thng Bnh thng hay nh khng c

Rnh lin bn cu v lim no Cc no tht bn No tht ba Bn cu i no i th Bt thng mt Vch trong sut

Hnh nh in quang Th khng c thu no (alobar): .No khng phn chia thnh hai bn cu: no hnh ci tch dng ngc .Ch c mt no tht .i th nhp lm mt .Khng c lim no, th trai, ng th gic, hnh khu .Thng c nang vng pha sau .Trung no, thn no v tiu no bnh thng Th c thu mt phn (semilobar) .C phn chia mt phn thnh hai bn cu .C mt phn sng thi dng v sng chm .Khng c vch trong sut .C mt phn rnh lin bn cu v lim no (thng pha sau) .Cc hch nn v i th chia i mt phn Th c thu (lobar) .No gn nh phn chia thnh hai bn cu hon ton .Cc no tht bn bnh thng hay hi gin, c th hnh vung (sng trn) .Khng c vch trong sut .Khng c lim no, khng c rnh lin bn cu Chn on phn bit -Khng c bn cu i no (hydranencephaly) thay bng dch no tu, cc nhn xm bnh thng

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-Thiu sn th trai cng nang ln pha sau - nc no tht nng Cc d dng mt km theo .Cc bt thng mt thng tng ng vi mc nng ca bt thng no nhng khng ngc li .Hai mt qu gn nhau (hypotelorism) .H hm ch .Ch c mt mt gia (cyclopia) .Mi vi voi hai mt lin nhau (ethmocephaly), hnh mt kh mt l mi hai mt gn nhau (cebocephaly)Hnh 8.3. D tt khng pht trin phn trc ca no (holoprosencephaly) Ch c mt no tht (V); i th nhp vi nhau ( T), khng c lim no v lu tiu no

8.3.3.Teo na no (Dyke-Davidoff) -i cng: nhi mu no trong thi k trong t cung hay gn gy teo no -Hnh nh in quang: .Teo na no lm ng gia thay i v tr .Xng s cng bn dy ra b tr .Cc xoang chm v hm rng cng bn 8.3.4. Bt thng cc rnh cun no v di ch bt thng no i cng -T chc mm di mng no xut hin vo tun th 7 ca phi. Cc t bo thn kinh c to thnh t cc vng t chc mm sau di chuyn theo si t chc m ra ngoi to nn v no. -Bt thng trong qu trnh di chuyn cc nron v bt thng trong qu trnh to ra v no gy ra cc bt thng bm sinh v tu thuc vo thi gian xy ra ri lon. -Cc loi bt thng .Bt thng to rnh cun no: bnh lissencephaly (no nhn) .Bt thng di ch : Heterotopias (di ch bt thng no) Schizencephaly (bnh no phn chia) Hemimegalencephaly (no ph i mt bn) .Bt thng xp t cc nron: bnh lon sn v no khng phi no nhn (nonlissencephalic cortical dysplasias- polymicrogyria).

Hnh 8.6. Hnh no phn chia (Schizencephaly) Bn phi: khe nt ng vi ng sng mng mm v cht xm di ch bt thng ( mi tn). 68 Bn tri: Khe nt m (mi tn cong)vi t chc no di ch bt thng quanh khe nt ( mi tn nh)

Bnh no nhn (lissencephaly) -Bnh no nhn c th ton b( agyria) hoc no nhn khng ton b( pachygyria) -Hnh nh: .Phi 22-23 tun tui no gn nh bnh thng .Khe Sylvius nng, cc rnh cun no nng nhn .V no dy vi cht trng bao bc nhn. Bnh no b phn chia ra (split brain-schizencephaly) -c im: .Khe nt no bao bc bng cht xm, thng l lon sn .Nc no tu thng t no tht ra khoang di nhn .C th mt hay hai bn, khng c hay c triu chng lm sng .Khe nt c th ng hay m -Hnh nh: .C khe nt cha dch no tu .Hnh nh nm v t no tht ra ngoi .Cht xm ng khe nt khng u,lon sn .Trong cc trng hp nt ln thng xng s bao bc kn vng h -Tn thng phi hp: .Khng c vch trong sut trong 80% .Dy th gic thiu sn trong 1/3 cc trng hp .C nhiu ni cht xm khng u v lon sn Di ch bt thng no (heterotopias) -o cht xm bnh thng nm v tr bt thng do dng bt thng ca di chuyn n ron thn kinh. -Thng to cc nt hay bng nm cnh no tht hay trung tm bu dc -Lm sng tng ng vi mc nng ca di ch bt thng, biu hin bng co git; tr pht trin v tr thng minh ph thuc vo mc gin no tht. -Hnh nh: .Cht trng v cht xm c tn hiu bnh thng .Xut hin lp cht xm trong cht trng (hai lp cht xm)v no ph ln bn ngoi thng mng v c th b lon sn .Cc nt nm di mng no tht (ng tn hiu cht xm, khng ngm thuc) -Tn thng phi hp: hay phi hp vi no nhn -Chn on phn bit: .Cc nt di mng no tht vi lao .Cc nt di v no vi u no

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8.4. Bt thng h sau 8.4.1. D dng Dandy-Walker

Hnh 8.7. D dng Dandy-Walker Nang ln h sau (mi tn to); Thiu sn thu giun v b y ln trn (hai mi tn nh song song) ; hai bn cu tiu no rt nh (hai u mi tn) l lng trong nang

-im chung: .D dng h sau khng r nguyn nhn .Tn thng pht trin tiu no v no tht 4 .Hp, tc cc l Magendie v Luska .T vong 25-50% -Lm sng: .Thng pht hin khi 1 tui .Biu hin ch yu l nc no tht .Tr ln hn c th biu hin hi chng u vng h sau -Chn on hnh nh: .Du hiu c bn: Nang nc ln vng h sau nc no tht (75%) Thiu sn vi cc mc khc nhau ca bn cu tiu no v thu nhng .Hnh nh: H sau gin rng, y xoang tnh mch bn, hi lu tnh mch ln trn Nang ln vng h sau thng vi no tht 4 Khng thy hay thiu sn cc mc khc nhau ca thu nhng Thu nhng cn li b y ln trn Thiu sn tiu no nc no tht .Tn thng km theo Khng c th trai trong 1/3 cc trng hp Ri lon di ch no (5-10%) Thot v no C th c thiu sn thn no 8.4.2. D dng Chiari I c im chung -Hch nhn tiu no di chuyn xung di l chm trn 5mm -No tht 4 c th b ko di nhng vn v tr bnh thng -Khng lin quan m Chiari II-III, khng c thot v no mng no -Lm sng: chn p tng t thn no

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Hnh nh -Thot v hch nhn tiu no -Bnh rng tu sng -Khng c bt thng trong no Tn thng phi hp -Rng tu trong 50% (yu tay, mt phn x gn...) - nc no tht trong 25% -D dng Klippel-Feil 10% (dnh lin 2 hoc 3 t sng c) -Dnh t i vi t trc 5% 8.4.4. Chiari IV c im chung -Khng r nguyn nhn Hnh 8.8.Chiari I: Hnh nhn tiu no -Khng lin quan n Chiari II b ko di xung di l chm > 5mm -C thiu sn tiu no Hnh nh -Kch thc h sau bnh thng -Thn no nh -Tiu no v thu nhng thiu sn rt nng hay bin mt -Cc b no to

IX. H YN V VNG CNH H YNMc tiu: nm c mt s bnh l h yn v vng cnh h yn9.1. U TUYN CA TUYN YN (adenoma)

i cng: -U tuyn t phn trc ca tuyn yn chim 10-15% cc u nguyn pht no -U tuyn yn c chia thnh hai loi: .U nh tuyn yn (microadenoma 10mm) thng khng bi tit 9.1.1.U nh tuyn yn (microadenoma) Cc typ: -Prolactinoma: thng gp nht, chy sa, mt kinh, gim hot ng tnh dc -Hooc mn tng trng (GH): u to, ngi khng l -Hooc mn ACTH : hi chng Cushing -Hooc mn hng sinh dc (v sinh, ri lon kinh nguyt, hooc mn kch thch trng) -Phi hp cc loi (bi tit sa, tng trng, kch thch tuyn gip) t gp Hnh nh in quang: -Cng hng t: nhy nht trong chn on u tuyn yn -K thut chp cng hng t: .Chp cc lp ct theo mt phng trn v dc gia khng v c tim thuc i t .Chp vi phn gii cao, cc lp mng

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-Trn cc xung T1 khng tim thuc: .Nt gim hay ng tn hiu vi tuyn yn .Tuyn khng cn i .Li ln trn (bnh thng lm hay phng) .Lm y tuyn yn -Tim thuc i t: .Chp cc hnh nh chc nng .Tim liu thp (0,05mmol Gd/kg) nh gi cc u nh .Dng liu bnh thng (0,1mmol/kg) nh gi cc u ln .Adenoma ngm thuc chm hn nhu m tuyn -Chn on phn bit cc typ qua ngm thuc .U bi ACTH: ngm nhiu thuc, kh chn on .70% cc u tuyn ca tuyn yn gim tn hiu so vi tuyn bnh thng trong cc pha chc nng .Th chp mun khng pht hin c u .Cng hng t tht bi c th ly mu mu trong xoang chn on 9.1.2. U to tuyn yn khng bi tit (macroadenoma) i cng: -U gy cc biu hin lm sng ca hiu ng khi (gim chc nng tuyn yn, th gic b nh hng...) -C th u pht trin rt to trc khi c cc du hiu thn kinh -U khng bi tit nn t du hiu lm sng Hnh nh in quang -U ln vt ra ngoi gii hn ca h yn .U ln trong h yn pht trin ra ngoi .Pht trin ra ngoi vo b trn yn to thnh Khi c hnh s 8 Xoang hang dy Bao bc v lm hp dng chy ng mch cnh trong xoang hang Chn p giao thoa th gic No tht ba b y ln trn Tc l Monro gy nc no tht (him) y sng trn no tht bn y lm loe rng cung no -Cu trc khi .t c vi ho trong khi .Hoi t, chy mu trong khi( tng tn hiu T1) .Khng th chn on phn bit u tuyn ( adenoma) lnh tnh vi u c tnh (carcinoma) nhng u c rt him gp -Ngm thuc: ngm nhiu khng u -Cng hng t hn CLVT: thy hnh nh trn nhiu mt phng, nh gi tt hn lin quan vi xung quanh.

72Hnh 9.1. U ln tuyn yn (macroadenoma)

9.2. U s hu( craniopharyngioma) i cng: -L u lnh tnh pht trin t di tch cn li ca biu m vy ti Rathke. -L u hay gp nht ca vng trn yn -Tui thng gp: 5-15 tui -Tui trn 50: thng th mao mch (th ny ch yu ngi ln) -Tn thng c th c trong v ngoi h yn, u ch trong h yn him gp. -Lm sng: .Chm pht trin: u chn p vng di i .i nht do u chn h yn .Bn manh vng thi dng hai bn .au u .Lit cc dy thn kinh (u chn vo xoang hang) Hnh nh: -Hnh nang (90%) c nt c thnh, nm vng trn h yn -Vi ho trong 90% (tr em), vi thnh khi ; t vi ho hn ngi ln -Ngm thuc nt dnh thnh nang, nang khng ngm thuc -Tn hiu trn cng hng t tu thuc vo bn cht dch trong nang: mu, nhiu protein, cholesterol. Thng T1 gim tn hiu, T2 tng tn hiu; nang khng mt trn FLAIR -Tc l Monro gy nc no tht (60%) -Thng khng ngm thuc khi chp mch. Chn on phn bit vi: -Adenoma tuyn yn hoi t -Glioma dng nang ca giao thoa th gic -Phnh mch huyt khi -Nang khe Rathke (khng c vi ho, khng ngm thuc)

X. CT SNGMc tiu:Nm c mt s bnh l bm sinh, bnh l thoi ho, bnh l vim nhim v u ct sng v tu10.1. CC BNH BM SINH CT SNG:

10.1.1.Xp loi:

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D tt khng ng kn ca ng tu sng (spinal dysraphism) l nhm cc d tt do khng ng kn ng gia xng, thn kinh, phn mm ct sng - Khuyt tt h ng tu sng m (open spinal dysraphism- spinal bifida aperta) c ti 85% c li ra sau ca cc thnh phn tu sng qua l khuyt ct sng ng khng kn; c cc thiu ht thn kinh hay gp: .Thot v tu v mng no (myelomeningocele) thng phi hp vi Chiari II (100%) .Thot v tu mng no v m (lipomyelomeningocele): khi thot v ra sau cng vi m .Thot v tu(myelocele): Khi thot v thn kinh khng c da bao bc -H ng sng pha sau nhng c bt kn (occult spinal dysraphism) 15% khng c thot v t chc thn kinh, thng khng c thiu ht thn kinh: . Thot v tu mng no v m (lipomyelomeningocele) .Meningocele .Hm da vng lng (dorsal dermal sinus) .U m ct sng (spinal lipoma) .Tu sng b tht (tethered cord) .Hi chng tu sng chia i( split notochord syndromes) Cc d tt h ng sng thng c chn on trc sinh bng siu m, ct lp vi tnh hay cng hng t v gip cho phu thut. 10.1.2.Ngch da vng lng (dorsal dermal sinus) -L ng d c biu m ho ni da vi ng tu sng, tu sng. -ng ny c th kt thc t chc di da, mng no hay dy sng. -50% to u b hay dng b -V tr: Vng tht lng cng n chm -Lm sng: nhim trng, mc lng da, bt thng da bn ngoi. 10.1.3.Thot v tu mng no v m (lipomyelomeningocele) -i cng: .L tn thng hay gp nht trong cc d dng h ng sng kn .Biu hin tr em c th thiu nin .Lm sng: bng quang thn kinh, bin dng v hnh th, ri lon cm gic. -Hnh nh in quang: .Phim Xquang thng quy: Cung sau ct sng khng ni lin nhau (spina bifida) ng tu rng Bt thng mt on ca ct sng .Cng hng t: Tu sng tht (tethered cord) Syringohydromyelia (25%) U m ngoi mng cng ni vi m di da Cc r tu sng nm trong khi thot v. 10.1.4.Tu sng b tht (tethred spinal cord) -i cng: .Cc bt thng v ct sng v thn kinh vi dy tu dy v ct ct .Chp tu xung thp di L2( phi 16 tun chp tu nm L4/5; s sinh ngang L2/3; sau ny ngang L1/2).

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.Cc d tt khc thng gp: u m, lipomyelomeningocele, diastematomyelia ( tt tu sng chia i di D5); khe da... .Lm sng: bnh tr em hay thiu nin, biu hin lit, au, bng quang thn kinh, i a khng t ch... -Hnh nh: .Du hiu chn on c trng: ct tu sng dy hn 2mm ngang L5-S1 trn cng hng t ct ngang v khi u m phi hp dnh vo ct tu .Xquang thng ct sng: d dng ct sng khng dnh lin cung sau (dysraphism) .Ct lp vi tnh bm thuc khoang di nhn( Myelo-CT) v cng hng t ct ngang cho php chn on .Ti cng tu xung thp di L2 v dy >2mm ngang L5-S1 .Ti cng mng cng gin rng .U m thng gp( trong khoang mng cng, dnh v chp cng tu...) .C th c rng tu chp tu hay pha trn. -Chn on phn bit: .Chp tu xung thp sau phu thut .Bin th bnh thng: chp xung thp nhng khng dy v khng c cc d tt khc, khng c u m.10.2. CC BNH VIM NHIM.

10.2.1. Vim t sng, a m: -i cng: .Nhim trng ct sng c th tin trin t thn t n a m to thnh p xe ngoi mng cng ri p xe tu. .Cc nguyn nhn: Do vi khun: t cu vng, cu khun rut, E coli, Salmonella. Do nm Do trc khun lao K sinh trng -Hnh nh in quang: .Xquang thng qui thng m tnh ti 8-10 ngy sau khi b nhim trng .Thn t tip gip a m: gim tn hiu T1W, ngm thuc, ng hay tng tn hiu T2W. Tng tn hiu trn T2 xo m hay STIR .a m hp , gim tn hiu T1 v tng tn hiu T2, ngm thuc .Tn thng phn mm xung quanh thn t sng -Chn on phn bit vi: .Tn thng t sng do thoi ho .Di cn ct sng .Tn thng ct sng v khp do chy thn ko di 10.2.2. Lao ct sng (bnh Pott) -i cng: .Tn thng u tin thn t sng pha trcri lan n thn ln cn dc theo dy chng dc .a b tn thng, xp .Tn thng c th la theo ng mu, quanh ct sng, hay vo khoang di nhn -Du hiu hnh nh: .Du hiu gi nht: p xe c i chu hai bn vi vi ho .Xquang khng chun b:

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>Tn thng thy mun sau vi tun >Ph hu lan to thn t sng v x ho >Nhiu t sng b tn thng( thng hai thn) >Khe khp hp, b khp khng u >p xe lnh hai bn ct sng >Bin dng ct sng( g, vo) .Ct lp vi tnh: > Ph hu thn t sng ban u pha pha trc >Xng ph hu c cc mnh xng cht >Vi ho v p xe cnh ct sng .Cng hng t: >Vim thn t sng gim tn hiu T1W, tng tn hiu T2W v STIR > a m ct sng b tn thng , hp v tng tn hiu T2W >Ap xe trong thn t v quanh ct sng thy r sau tim thuc >Cng hng t ct cc lp dc vi xung STIR v T2 xo m cho php thy r ph n tu xng v tn thng lan ra mng cng -Chn on phn bit: .Vim t sng do nm: Tn thng khu tr hn thn t, cu trc xng cn Nhiu v tr b tn thng Lan vo mng cng nhng khng c tn thng quanh ct sng a m hp v hay c kh .Di cn ct sng: .a m khng b tn thng .Khng c apxe cnh ct sng, mng cng. 10.2.3.Vim tu ct ngang cp (acute transverse myelitits) i cng: -Biu hin lm sng thay i tu theo nguyn nhn -Nguyn nhn: .Nhim trng cp .Sau nhim trng: Sau tim phng Bnh t min .Bnh ton thn .Sau chn thng -Hnh nh: .Cng hng t bnh thng trong 50% trong t cp .T2 tng tn hiu .Ty gin rng khu tr .C th c ngm thuc10.3.TN THNG THOI HO CT SNG.

10.3.1. Thot v a m. i cng: cc loi thot v -Thot v a m ra sau >Li a m: Thot v cn dnh vo a m, kch thc thot v lun nh hn khong cch hai im ca chn thot v trn cng mt phng >Thot v b y ra (extrusion): phn thot v c chn hp hay khng c chn.

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Kch thc thot v lun ln hn hai im chn thot v; thot v di ch (migration) khi thot v tch khi a m -Thot v a m ra trc: y dy chng dc trc, c th ging m xng -Ht Schmorl: nhn a dm thot v vo thn t, thng ngi tr, b 1-2 khe khp, nu tn thng > 3 thn gi bnh Scheuerman. Hnh nh thot v ra sau: -Xquang khng chun b: khng chn on c, pht hin thoi ho ct sng, khe khp hp. -Ct lp vi tnh: > Khi t trng t chc mm li vo ng tu >Ct lp vi tnh myelo: thy r cc r thn kinh v du hiu chn p r -Cng hng t: >K thut: Dc T1W v T2W Ct ngang T1 v c th c T2, ct ngang c th theo mt phng a m >Khi thot v ng tn hiu T1, tng hay ng tn hiu T2 (so vi a c thotv) >Thot v li ra nh hnh "thuc nh rng", n c th dnh vo a m hay di chuyn khng dnh vo a m >Du hiu chn on phn bit thot v y v li a m l khi thot v hnh nm( chn hp) -V tr khi thot v: >Thot v gn tm (thng gp) >Thot v sau bn >Thot v trung tm( t gp v dy chng chc vng ny) >Thot v ngoi l tip hp, trong l tip hp -Tim thuc: >Chn on phn bit x sau m v thot v ti pht >Gip chn on mnh thot v > Chn on vim r thn kinh th pht sau thot v. -Thoi ho a m th pht: >Thoi ho a m T2 gim tn hiu >Cc m xng, ph i cc mt khp mu sng gy hp l tip hp >Ph i dy chng vng 10.3.2. Hp ng sng: Hnh 10.1. Thot v a m i cng: sau bn tri chn p ng tu -L hp ng tu sng c th c hay khng c chn p sng tu sng hay tc lu thng dch no tu. -Nguyn nhn ch yu mc phi: >Li a m hay thot v a m y >Ph i dy chng vng >Ph i cc mt khp ca mu sng >Cc m xng do thoi ho >Trt thn t sng -Nguyn nhn bm sinh: >Cung sng ngn, l sng dy, cc mt khp mu sng rng >Hi chng Morquio: thn t sng xp, d dng mt, trt khp hng, chn cong..

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>Achondroplasia: ngng pht trin chiu cao, vi ho sn u xng, vi ho mng xng. Hnh nh: -Du hiu chn on tt nht: ct nc no tu b dng li ni hp; ng knh trc sau ca ng sng < 12mm cho vng tht lng -Chp ct lp c bm thuc cn quang di nhn (CT Myelo): >ng sng v cc l tip hp b hp >Phi hp ngch bn ng sng hp( tht lng) >Cc mc chn p khc nhau ca tu v r thn kinh. - Chp cng hng t: >Ct sng tht lng: .Hnh ng h ct trn T2 ct dc .Mt lp m quanh cc r thn kinh trn cc lp dc cnh bn .Tn thng thoi ho vi cc mc thot v a m khc nhau .Cc m xng ct sng .Hnh chun nhp ca ng tu trn lp ct ngang .Hp ngch bn trn cc lp ct ngang T2 .Ph i cc khp bn, cung sng ngn, dy chng vng dy 10.3.3. Hp l tip hp. i cng: -Hp l tip hp gia cc thn t sng gy chn p cc r thn kinh -Nguyn nhn: .Nguyn nhn hay gp l thot v a m sang bn .Thoi ho ph i cc mt khp mu sng .Trt thn t sng (spondylolisthesis) .Chn thng .So sau m .Khi ngoi mng cng vng ngch bn. -Hnh nh in quang: .Xquang thng quy: pht hin cc trt thn t sng, thoi ho ct sng... . Ct lp vi tnh: Thot v a m sang bn vo l tip hp Thoi ho khp ca cc mm khp, ph i mt khp Trt thn t sng .Cng hng t: Ct dc bn T2W: mt lp m quanh cc r thn kinh trong l tip hp Pht hin cc thot v a m sang bn: ng hay tng tn hiu trn T2, ng tn hiu vi a m T1, khng ngm thuc Tn thng khi u ngoi mng cng chn p r. 10.3.4. Teo eo v trt thn t sng( spnodylolisis v spondylolisthesis) i cng: - Spnodylolisis l tn thng mt eo (ni gia cc khp mu sng) -Hay km trt thn t sng (spondylolisthesis): trt thn t pha trn so vi thn t di c nh. -Cn nguyn: .Do co cc c mnh cng mt lc nhc i nhc li, xoay qu mnh

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.C tham gia ca chi th thao, nng nng, vt, chi bng khi nh tui. .Cc vi gy vng gia cc khp mu sng nhc li nhiu ln -Tui: c th c tr em v ngi ln -Di truyn: .C yu t gia nh .Ngi bnh xng ho .C c tnh di truyn...