1. MT S D TT BM SINH S NOCc bt thng s no c nh ngha l s thay i qu trnh pht trin bnh thng: -Cc ri lon trong qu trnh khp kn ng thn kinh(bt thng Chiari loi II v loi III).-Cc ri lon to ra cc ti tha Holoprosencphalies.-Bt thng ca mng mi no tht IV.-Bt thng ca vch trong sut(teo th trai).-Cc ri lon v pht trin t chc no.-Cc bt thng do s di tr t bo, v do s hnh nh v no.-Cc tn thng do bin i s thi k bo thai.-Cc bt thng pht trin mng no.Phn loi cc d dng no bm sinh. + Bt thng trong qu trnh ng ng thn kinh. -D dng Chiari.-Cc thot v no.-Cc bt thng th trai: Bt sn, bu m.+ Cc bt thng trong qu trnh to cc ti. -Bt thng hnh thnh bn cu(Holoprosencephaly).-Lon sn vch trong sut- th gic(Septooptic Dysplasia).-Khng c hnh khu(Arrhinencephaly).+ Cc bt thng trong s hnh thnh cc rnh v trong qu trnh di tr t bo(Disorders of Sulcation and Cellular Migration). -Tt khng c hi no( No trn).-Cc lon sn v no, khng phi no trn.-Tt cc t bo thn kinh v tr bt thng.-Tt c khe rng ct ngang qua bn cu no.-No khng l mt bn.-Cc bt thng v kch thc.-Tt u nh.-Chng no to.-Cc thng tn do ph hu. 93

2. -Hydranencephaly( ton b no c thay bng mt ti cha dch no-tu.-Teo mt bn bn cu.-Bnh l no, bnh no nhiu nang.-Thiu xy no.-Cc thng tn do cc cht c.-Cc thng tn nhim trng.-Ri lon trong qu trnh to m.-Cc hi chng thn kinh da.-Bnh x cng no c.-Bnh u si thn kinh.-Hi chng Sturge- Weber.-Hi chng Von-Hippel-Lindau.-Cc hi chng thn kinh da khc.-Cc khi u.-Cc d dng mch mu.I. Ri lon hnh thnh t chc no. 1.Ri lon qu trnh ng ng thn kinh: Thng gy ra cc thot v mng no. Loi bnh l ny thng phi hp vi nhng bt thng pht trin no: Bt thng Chiari loi II( cn gi l Arnold Chiari).Bt thng ny bao gm:-Lc ch thu nhng v thu Amydan tiu no vo ng sng c.-Xo cc b no vng pha sau.- p mng no( bin dng vng c no sinh t do c thot v tiu no qua lu).-No ng thu trn lu xut hin tun u sau sinh.-Gin ng mng no tht.-C nhng bt thng khuyt no, gai i ct sng, thot v mng no tu. Bt thng Chiari loi III t gp: C thot v no di lu. Bt thng Chiari loi I c trng bi s lc ch ca Amydan tiu no qua l chm. No tht IV v thu nhng v tr bnh thng. Thng km theo bnh l vim tu.94 3. Chiari I tt Amydane tiu no 10mm di l chm. Khng c triu chng lm sng.Chiari II, h s sau nh, no tht IV ko di vo lng tht, thiu sn th trai.2.Ri lon cc ti tha ca ng thn kinh. Cc khim khuyt trong qu trnh pht trin no loi Holoprosencphalies c th c ba loi:-Holoprosencphalies alobaire-Holoprosencphalies lobaire-Holoprosencphalies intermdiaires3.Bt thng kn h sau.-Dandy- walker : Teo thu nhng gin dng kn ca no tht IV, no ng thu.-Bt thng dng Dandy- walker teo tiu no lin tip vi vi ti khoang nhn pha sau tiu no thng vi khoang mng no v khng c no ng thu.-Ti khoang nhn b ln.-Kn ca b ln. 95 4. Dandy- walker: Kn dch ln pht trin h sau thng vi no tht IV, n vo vng hi lu Herophili. Teo tiu no.4.Teo th trai: Mt phn hoc ton b c th phi hp vi cc thnh phn khc nh kn h sau, gin no tht, di tr bt thng ca t bo noU m bm sinh th trai. Teo th trai, ng mch no gia b khi bao bc, khi m pht trin, khi m lan xung m ri mch mc v no tht bn.96 5. BNH L VIM V NHIM TRNG S NO Bnh thng h thn kinh c bo v bi mng no xng v hng ro mu no. Khi b nhim trng no khng c s chng hu hiu do trong dch no tu khng c cht min dch, khng c h thng lymplo, cng khng c mng mao mch trong khoang di nhn. Nhim trng s no c chia lm 4 nhm: nhim trng, k sinh trng, nm v nhim virut. Da trn cc c im khu tr c th biu hin: vim mng no, nhim trng no tht, vim m mng no hay p xe no. C 3 ng gy nhim: - Qua ng mu, qua vng khng c hng ro mu no hoc t cc vim ln cn vi mt huyt khi tnh mch hay vim ng mch. - Qua vt thng s no h - Nhim trng ngc dng t cc thn kinh ngoi vi (Herpes) c im chung trn nh CLVT l khng c du hiu trng cho mt loi tc nhn gy vim. Cc du hiu lm sng v xt nghim gip hng ti mt s bnh l nhim trng. Tuy vy, khng phi lc no cng y . A. Nhim trng cc bnh nhn khng c bnh l suy gim min dch 1. Cc vim m ngoi no. 1.1. Vim m di mng cng (Empyem sous dural) L bin chng nng ca cc nhim trng ln cn (vim xoang, vim tai) i khi do chn thng. Nhng cng c th do VMN. T l t vong cao (8-15%), cn c chn on v iu tr sm. Tn thng trn nh CLVT l cc t chc bt thng ngoi no. Vi mt s bt thng nhu m nh ph no, nhi mu nh, huyt khi tnh mch v no, thot v no. Quan trng nht l th tch khi m di mng cng. Cn tm mt cch c h thng cc nhim trng nguyn pht tai, mi, hng. 1.2. Vim m ngoi mng cng: (Empyme pidural). Him hn, tin lng tt hn. Trn nh CLVT l khi ngoi no, hai mt li. Thng khng c tn thng nhu m no phi hp, c th do bin chng ca vim xng chm, vim xoang trn hay sau can thip phu thut. 1.3. Apxe no (Abcs crbral). Do cc tn thng thoi ho m hay gp do cc vi khun nh: Steptocoque, Staphylocoque... Tm thy ng vo trong 80% cc trng hp (tai mi hng, nhim trng mu, chn thng). C 3 dng lan trn: - Qua mt nhim trng ln cn. thu trn: Vim xoang trn sng. thu thi dng, tiu no: vim tai xng chm. - Qua ng mu -> tn thng c th l nhiu . 97 6. - Qua vt thng s no hay sau phu thut TK. a. Giai on trc ho m (G vim no): Hnh nh c du hiu chon ch nhng khng xc nh c gii hn ca tn thng, c th ch thy qung ph no, nht l trung tm ph no nm ti vng cht trng. Cu trc ng gia b y lch sang pha i din vi bn c tn thng. No tht thng b p nhiu mc khc nhau ph thuc vo hin tng ph no nhiu hay t. Giai on ny phi nh tim thuc cn quang tnh mch mi c th pht hin c im ngm thuc mnh nht. y l giai on rt d nhm ln gia p xe no vi thiu mu cc b trong giai on u hay vi nhng di cn nh. Tim thuc i khi thy cu trc tn thng khng thay i do hin tng ph no mnh lm cc tiu mao mch b p m tn thng khng ngm thuc. C th thy huyt khi mch mu hay chy mu xut huyt. b. Giai on p xe: Vng t trng hn hp, ch yu l gim trung tm v vin tng nh t trng thuc cn quang ngm theo kiu dng vng, xung quanh c ph no rng v chon ch bn cu. Cn chn on phn bit vi di cn. Thng thng di cn thng c ph no rng. Nu thy c hai, ba th vic chn on t khi sai lm, nht l tm c tn thng c tnh c ngun gc t ni khc nh u phi, u v, ung th d dy... c. Tin trin tt sau iu tr (sau chc p xe, c p ng vi khng sinh, loi b yu t ng vo)... Trn nh CLVT: Gim hiu ng chon ch, tn thng thu hp. Kiu ngm thuc t dng vng chuyn sang dng nt, tn ti hng thng sau iu tr. giai on mun hn: p xe c th tr thnh mt gim t trng di chng. Trong trng hp ny c th nhm ln vi u t bo hnh sao (Astrocytoma) dng kn. Do lc ny s ph no gim bt, hnh lng ca tn thng khng cn nhn nh ban u. Tuy nhin, t trng trong lng p xe khng tng sau tim thuc, thng th tng ng vi dch no tu hoc cao hn khng ng k. d. p xe no sau m: Chn on kh do bnh thng sau m hnh nh t chc no khng ng nht ch m, c th thy du hiu tng thuc hnh vng bnh thng ngoi cc qu trnh nhim trng. 1.4. Vim mng no (Mningites). Cc VMN do virus hay vi khun m khng c bin chng vim no trc khng thy trn nh CLVT. Du hiu tng thuc cn quang khoang di nhn i khi c th thy trong cc VMN m. Cn tm: - Cc tn thng nhim trng: p xe hay hnh nh tng thuc cn quang thnh no tht. - Tn thng mch mu: Nhi mu tnh mch th pht sau nghn xoang tnh mch mng cng hoc vim ng mch. - Gin no tht: Do dnh cc b nn s, lm nh hng n s lu thng dch no tu hoc do ri lon hp thu dch no tu, do tn thng ht Pacchioni. * C hai trng hp c bit: 98 7. - VMN ti pht sau chn thng s no, thng kh nh gi c th l mt tn thng xng mng cng trn sng hay xoang thng. Cn chp coronal phi hp bm thuc cn quang vo cc b. - VMN tr s sinh (thng do Hemophilus influenzae hay Pneumo coques) hay to thnh cc dch di mng cng. 1.5. Vim no (Encephalites) Thng do virus. Tn thng ch yu m trng. 30% do nhim nguyn pht. 1.5.1. Vim no virus cp (Encephalites virales aigues). a. Vim no Herpes: Tin trin nhanh, c xu hng hoi t nhu m. Cc du hiu X quang thng mun so vi cc du hiu lm sng. Trn nh CLVT: Tn thng 2 bn, ch yu vng trn v thi dng, gim t trng, tng thuc cn quang khng u, ph r, mt s trng hp c th thy hoi t chy mu. giai on sm hnh nh thng khng r: Gim t trng m no nh, chon ch kn o, khng tng thuc cn quang, tn thng mt bn. b. Cc vim no khc: Do arbovirus v entrovirus; vim no tu cp sau nhim trng. 1.5.2. Vim no virus mn tnh (Encephalites virales chroniques). Bnh creutzfeld-Jacob l in hnh nht. c trng v lm sng l tin trin nhanh cc du hiu nh sa st tr tu, thiu st thn kinh... T vong trong vi tun. Trn nh CLVT ch thy hnh nh teo no. 2. Bnh l k sinh trng. 2.1. Bnh u trng sn ln thn kinh (Neuro cysticercose) l cc tn thng h TKTW do u trng Toenia Solium ln. Bnh thng c Chu Phi, Nam M. Vit Nam thng gp mt s vng trung du Bc b. Du hiu lm sng tu theo v tr tn thng v tin trin, c th thy cn t qu, thiu st thn kinh, tng p ni s. Trn nh CLVT c 2 loi tn thng c bn: - Cc nt vi ho nh, thng ranh gii vng m no trng v xm, n c. l hnh nh ca KST cht. Trc hnh nh ny khng cn thit phi iu tr bng thuc. - Cc tn thng dng ti hay kn: l nhng hnh gim m, kch thc nh, thng c nhiu , hu nh khng thay i sau tim thuc cn quang. C th phi hp vi nhng tn thng gim t trng ph no quanh kn. V mt gii phu ngi ta phn ra:- Nhu m - No tht -> gy no ng thu.CLVT ch cho thy hnh nh gin no tht phi hp cc tn thng nhu m vi ho hoc cc ti kn. Cc tn thng trong no tht thng t khi c vi ho. 99 8. 2.2. Bnh sn no (Hydatidose crbrale) Hay gp Bc Phi, Afghanistant, Nam M, Australia. Thng tr em. Tn thng no phi hp tn thng cc tng (ch tm c 62%). Trn nh CLVT: Hnh trn, n c, gim m (dng dch) c khi c th tch rt ln. Sau khi tim cn quang thy thnh ngm nh. Khng c ph no xung quanh. Du hiu chon ch. C th thy vch ngn, him khi a . 3. Lao no (Tuberculose crbrale) Cc lao mng no thng th pht sau lao phi (qua ng mu). C 2 loi tn thng c bn hay phi hp vi nhau: - VMN nn s: Thy sau tim thuc vi du hiu tng cn quang cc b nn s, rnh Sylvius vi dng vng hay dng nt. Gia cc tn thng ny cc cu trc mch mu nh ng mch Sylvien kh nhn thy. - Tn thng nhu m: L cc u lao, v no, ng hoc tng t trng, him khi c vi (hoc vi trung tm). Tng cn quang dng nt hoc dng vng, c ph no xung quanh. Nu tn thng lu ngy th c th tm thy nt vi ho, thng ln hn trong nhim u trng sn ln hoc nhim Toxoplasmosis. Chn on phn bit vi u nguyn pht, di cn, nhim nm hay p xe no. p xe lao c hnh ging u lao. Tng thuc cn quang dng vng, c trung tm gim t trng do hoi t. Nh vy, khi thy du hiu VMN nn s phi hp vi tn thng nhu m no cn phi ngh trc tin l cc tn thng lao. 4. Giang mai thn kinh Do xon khun giang mai. Trn nh CLVT: + Mch mu mng no: c th thy nhi mu c tu v v. Hoc mt hi no ngm thuc mnh hn bnh thng, cng c th thy mt s ht ngm thuc khoang mng cng gi l pachymeningitis. + C giang mai (gumma): rt him. L nt hnh cu khu tr xung quanh c qung ph no nh. + Vim tu: rt him v c lin quan ti mch trong tu. II. Bnh l nhim trng thn kinh do suy gim min dch (Pathologie infectieuse de limmuno dprim) 1. Toxoplasmose. Tn thng thng cc nhn xm trung ng, vng ranh gii m trng m xm hay c khi ch cht trng. Trn nh CLVT thy nhiu gim t trng, tng thuc cn quang dng vng, dng nt c khi ch thy vng gim t trng ngoi vi m khng thy du hiu tng thuc cn quang, hoc ch thy tng nh thuc quanh cc NT (do tn thng di mng no tht).100 9. Sau iu tr (Sulfadazine, pyvimthamine): Gim ph, gim tng thuc cn quang. Du hiu tng thuc cn quang rt quan trng hng n chn on, cn tng liu Iode v c thm nhng nh ct mun (30 pht sau tim) chn on phn bit vi lymphome). 2. Listsiose L loi trc khun Gr+, thng c tn thng thn no, l nguyn nhn gy lit cc si dn truyn thn kinh. 3. Aspergillose v Mucormycose ng vo thng t tn thng xoang gy cc tn thng ko di t nh h mt ti xoang hang v mnh thng xoang sng. N c th theo ng mu (Sau aspergillose phi). 4. Cytomgalovirus. Hay gp tr s sinh, tr nh.CLVT thy hnh vi ho quanh no tht, no ng thu, u nh, teo no, gim t trng cht trng. Du hiu chy mu tn thng v tng thuc cn quang quanh no tht l cc triu chng c gi tr. 5. Bnh tn thng cht trng a (Leuco encphalopathie multifocale progressive: LEMP) Thng gp cc BN Hodgkin, Leucemie mn, gim min dch hoc iu tr gim min dch (ho tr liu, corticoide) v chim 2-7% cc bnh BN SIDA. Nguyn nhn do Papovavirus lm mt myelin vi cc bt thng ca t chc TK m v hoi t t bo. Tn thng thng lan ti trung tm bu dc v vng di v, khng i xng. Tin trin nhanh, khng bao gi c vi ho nhu m, khng thay i sau tim thuc cn quang. T vong nhanh trong vng 4-6 thng. 6. SIDA Tn thng no do 3 nguyn nhn: - Do virus HIV hoc cc tc nhn ngu nhin (Toxoplasmose) - Cc u lympho nguyn pht. - Cc tn thng mch mu (chy mu: Lymphome, cytomgalovirus; nhi mu: Vim ni tm mc, vim mch mu). Trn nh CLVT thng c cc du hiu: Teo no, chon ch, tn thng cht trng, VMN mn tnh. a. Teo no: Km cc du hiu lm sng nh ri lon tm thn, vn ng, hnh vi, do vim no lan to, virus xm ln ph hu cc t bo TK i khi l cytomgalovirus. b. Chon ch: 20% cc trng hp. Do cc Toxoplasmose bi nhim (10%), do lymphome (6%), c tin lng xu.101 10. Trn nh CLVT l khi ng hoc tng m, tng cn quang thnh m hay c dng vng, nm quanh cc no tht. 50% c tn thng nhiu . c. Tn thng cht trng: 30% cc trng hp (do LEMP hay vim no virus cp hay bn cp) virus herpes v cytomgalovirus (CMV) 15%. Tn thng thng lan to ban u trung tm bu dc sau ti bao trong, thn no. d. VMN mn tnh: 5-15%, thng do nm Cryptococus. 13% th hin l VMN v khun do VIH. CLVT cho thy du hiu tng thuc cn quang ca mng no nn s v quanh no tht, no ng thu do vim dnh mng nhn, tai bin mch no do vim mch mu. Tm li: vim nhim ni s xut hin trn hnh nh CLVT rt a dng v kh chn on phn bit. Vic nm r bnh s v din bin lm sng cng cc xt nghim chc nng l vic ht sc cn thit chn on ng tn thng. Hnh nh CLVT ch cho ta nhn nh c hnh thi tn thng vi cc c im ca n hng ti chn on. Mt s nh minh ho Hnh nh vim mng no tht v vim m di mng cng.Hnh nh vim mng no tht.Vim m di mng cng.Hnh nh lao no trn CLVT Ct lp vi tnh trc v sau tim thuc cn quang: Vng gim t trng ngoi vi thi dng phi, ngm thuc cn quang thnh di, vin khng u. Vim no giai on sm. 102 11. Hnh nh a kn ngm thuc cn quang vin. Mt s kn c km theo hnh ngm thuc thnh bn trong. Xung quanh cc kn c ph no. Amip no.103 12. U NO TS.BS Chuyn khoa II Nguyn Quc Dng I. Phn loi u no 1. T chc y t th gii(OMS) (Zulch 1979): Bng : Phn loi TCH u no ca OMS - 1979 A.Cc u ca t chc TK m (Neuro pithlial) 1. U t bo sao (Astrocytome ) 2. U t boTK m t nhnh ( Oligodendrogliome ) 3. U mng no tht v m ri mch mc (Ependymome ) 4. U t bo tuyn tng (Pinalome ) 5 .U t bo TK 6. Cc u km bit ho v c ngun gc bo thai ( Glioblastome , Medulloblastome, Medulloepiliome ) B. Cc u nron TK ( Gangliocytome, Neuroblastome) C.U ngun gc mng no 1.Mningiome 2.Mningo Sarcome 3.Fibro Sarcome 4.Fibroxanthome 5.Melanome D.U hch bch huyt c tnh nguyn pht (Lymphom) E.Cc u c ngun gc mch mu (Hemangioblastome) F.U c ngun gc t bo mm (Germinome, Choriocarcinome) G. Cc d dng bm sinh v gi u 1.Craniopharyngiome 2.Kyste dermoide 3.Lipome 4.Hamartome H.Cc d dng mch mu (Angiome) I.Cc u vng yn (Adenome, Adenocarcinome) K.Cc u bao dyTK (Schwannome,Neurinome,Neurofibrome) L.Cc u di cn M.Cc u khng phn loi104 13. 2. Gn y hn (1993) Osborn p dng mt phn loi mi ca OMS (phn loi ny da trn phn loi ca OMS nm 1979 v phn loi ca Russell Rubinstein). Cc u c chia thnh 2 nhm ln l u nguyn pht v u th pht. 3. Nm 1993, Nguyn Nh Bng, Dng Chm Uyn da vo phn loi ca OMS 1993 kt hp vi thc t Vit Nam phn cc u no thnh 8 nhm ln. Bng phn loi u no p dng Vit Nam a, U t bo TK m (Gliome) -Astrocytome-Spongioblastome-Glioblastome-Ependymome-Medulloblastome-Papillome-Oligodendrogliome-Carcinome plexus choroideb,U mng no v m hc t -Mningiome -Psammome -Melanome c,U dy TK: Neurinome d,U tuyn -Adenome (tuyn yn) -Pinalome (tuyn tng) e, U mch -Hmangiome (Angiome) -Hemangioblastome g, U bm sinh v gi u -Craniopharyngiome -Kyste pidermoide h, U do k sinh trng: Cysticercose i, Cc u di cn 4. Phn loi nh khu (Escourolle v Poirier-1977): 4.1.Cc u trn lu: -Cc u ca thu no (trn, thi dng, nh chm).-Cc u su ca bn cu: Cc nhn xm, trung tm bu dc.-Cc u vng yn.-Cc u vng NT 3.-Cc u vng tuyn tng4.2. Cc u di lu: 105 14. -Cc u ng gia (vermis, NT 4).-Cc u thu tiu no.-Cc u ca thn no.-Cc u ngoi trc trc hay bn.-Cc u l bu dc.-Cc u l chm5. Phn loi giai on U bc IU bc II v IIIU bc IV*Tn thng ng nht, ng hay *Tn tng khng u, gim m, gii tng chm hn khng r nt. *Khng ngm thuc cn quang *Ph t *Vi ho u hoc khng u*Ngm thuc: do v HRMN, do tn thng ni m, do mch tn tnh *Ph rng, du hiu chon ch, thot v no.*U kn n c, thnh khng ngm *Khng c vi (do pht trin nhanh) thuc *a kn, thnh ngm thuc,6. Mt s loi u thng gp Gliome (Astrocytome v U ca thu no Glioblastome) vng su ca bn cu MeningiomeU no trn luDi cn U vng ynU tuyn yn U s huU no di luNgi lnU gc cu tiu U dy VIII no Gliome ca thn no U v tr khcDi cn Hemangioblasto-me Mningiome 106 15. Medulloblastome U ng gia Ependymome Tr em U thu tiu noAstrocytomeII. Du hiu chung trn nh CLVT ca cc u no 1.Du hiu trc tip: CLVT cho thy v nh khu, th tch, ng, b v t trng u. Cc yu t gy gim t trng thng l cc t chc dch (ph, to kn, hoi t v t chc m). Ngc li , cc yu t tng t trng c th do t nhin, khng dng thuc cn quang thy (do tng cc t bo u, t chc vi trong u, do chy mu). C th tng t trng c nhn thy sau khi tim cn quang tnh mch ( do tng ti mu vng u, do v HRMN, hay cc huyt qun c mu lu thng).2.Cc du hiu gin tip: Gim t trng xung quanh u do ph no, thy r cht trng to nn du hiu hnh ngn. C th thy s thay i hnh dng, cu trc cc NT, s dch chuyn ca ng gia hay ca cc hnh vi ho sinh l cn gi chung l du hiu chon ch.3.nh gi v t trng ca u c 5 loi: Loi 1: c t trng thp, c th thy 3 mc I: Thp, nhng trn t trng ca dch (t 15-30HU) II: Thp, ngang t trng dch (0- 14 HU) III: Thp, di t trng dch ( di 0 HU) Loi 2: ng t trng (ngang t trng m no tng ng) Loi3: T trng cao (cao hn t trng m no tng ng) Loi 4: T trng ng nht Loi 5:T trng hn hp4.Mc ph no c th nh gi theo 3 mc I: Ra ph ti 2cm ng knh quanh u II: Ph hn 2cm, c th chim ti na bn cu no III: Vng ph ln hn mt bn cu5.Mc dch chuyn ng gia i: Di 5mm II: 5 10mm III: ln hn 15mm. Cn phi hp LS xt s tr cp cu107 16. 6. Mt s hnh thc th hin thuc cn quang Cc thng tn khc nhau thng ngm thuc mnh hn m no lnh. Kiu ngm thuc trong cc u no c th cho php phn bit vi nhng tn thng trong vim hay trong bt thng mch mu. Tuy vy mu ngm thuc cng nh cng ngm thuc khong th c coi l tiu chun ng tin c 6.1 Cng ngm : S thay i thuc cn quang hp th phn u t 24HU c coi l m tnh, tc l c th coi gi tr phn bit u v t chc no trong nhng trng hp thc t l nh nhau. ngm thuc cn quang c th c phn bit lm 3 mc : i: < 5 HU II: 5 10 HU III: > 10 HU 6.2 Kiu ngm; -Ngm thuc hnh vng -Ngm thuc tng m -Ngm thuc ng nht -Khng ngm thuc III. c im ring ca mt s loi u 1. Cc loi u no trn lu: 1.1. U c cc thnh phn TK m: 1.1.1. Astrocytome(u t bo sao): a) Astrocytome loi si, th nguyn sinh v loi t bo phnh to. (S phn loi nh trn tu theo loi t bo no chim u th). Cc loi u ny c tnh thm nhim, xm ln vi b kh xc nh, c khuynh hng tin trin dn ti s thay i v cht nhy v to thnh kn. t gp chy mu, hoi t hay vi ho. U chim 6,6% trong s 9.000 u no (Zulch - 1986) hay gp la tui 35-45. U thng thu no, i khi c c v v cht trng, u th trn nh v thi dng. Tn thng tin trin chm, c th xm ln th trai v vch trong sut. Trn nh CLVT c th thy tn thng lan to khng c ranh gii hu nh khng ngm thuc cn quang. Cn chn on phn bit: Astrocytome km bit hoOligodendrogliome khng c viU di cn khng ngm thuc 108 17. Nhi mu miPh no khu trb) Astrocytome nang lng. Loi ny c tin lng tt hn (bc I - OMS). U c gii hn r, c mt hay nhiu vng kn. U c th l khi c, i khi c vi hay chy mu. Chim 6% cc u ni s. Hay gp tr em v ngi tr tui (30% cc Gliome ca tr em). vng di lu : u thng pht trin t thu nhng ra bn cu tiu no. vng trn lu : u thng vng di i, giao thoa th gic, thnh bn ca NTB, bn cu. Trn nh CLVT u c dng kn, ph t, khng c vi, khng c chy mu, tng t thuc c khi khng tng thuc cn quang. Chn on phn bit: Astrocytome km bit hoGlioblastomeOligodendrogliomeGangliocytomeU di cnU s huU tuyn ync) Astrocytome di mng no tht t bo ln (u no tht trong bnh hoi t c Bourneville): l loi u lnh (bc I - OMS), c dng nt, c cc t bo TK m pht trin trong NTB. U hay gp tr em v ngi tr tui, khng c u th v gii chim 0,32% cc u ni s. Lm sng: C biu hin ng kinh, tng p lc ni s, trn da c cc tuyn b nhy mt. Trn nh CLVT c hnh nh dng nt, c nhng chm vi, thng quanh thnh no tht bn, ngm thuc cn quang. Chn on phn bit: pendymome bnh thng v loi di mng no tht.Papillome m ri mch mc.109 18. BN nam 18 tui: U kn thi dng tri thun nht. nh trc v sau tim thuc cn quang. Kt qu phu thut: Astrocytome pilocytique.BN n, 2,5 tui. Hi chng TALNS. nh CLVT: tn thng dng nt m vi thnh no tht, khng ngm thuc cn quang.d) Astrocytome km bit ho hay Glioblastome (bc III - OMS). Thng pht trin t u lnh sang dng km bit ho theo thi gian. S phn bit mt Astrocytome km bit ho v Glioblastome da trn mc km bit ho. Do vy, trong mt u thng c tn ti nhiu giai on. Trong u thy phi hp t chc u vi cc t chc hoi t, t chc thoi ho m. Phn ln c km theo du hiu ph rng, ph v HRMN, tng mch. Ging nh Glioblastome, cc u chim 12-17% u ni s, u th ngi trung nin v ngi gi, nam nhiu hn n. U thng khu tr thu trn, thu thi dng, c th c dng a . V lm sng, tu theo v tr c th thy du hiu ng kinh cc b, thiu st TK, TALNS, tin trin nhanh. 110 19. Trn nh CLVT, u thng khng ng nht, bn trong c nhng hoi t, ph, chy mu, du hiu thm nhim xung quanh rng, c cc vng bc c tnh khc nhau. U ngm thuc cn quang vi cc dng khc nhau. Chn on phn bit: Oliodendrogliome km bit ho, khng c viAstrocytomeDi cnAp-xependymomeLymphomeBN Nam 21 tui: U nh phi. nh trc v sau tim thuc. M: Astrocytome km bit ho( bc III- OMS). 1.1.2 Oligodendrogliome C 3 dng: - in hnh l Oligodendrogliome (bc II- OMS) - Oligodendrogliome hn hp (bc II - OMS) - Oligodendrogliome km bit ho (bc III- OMS) a- Oligodendrogliome: C cu trc ng nht to bi nhng t bo dng t ong xut pht t cht trng, c khuynh hng t nhiu thoi ho cht nhy to kn, c cc hoi t nhng t khi thoi ho m. U pht trin chm. b- Oligodendrogliome hn hp: C s phi hp t bo sao v t bo thn kinh m t nhnh. c- Oligodendrogliome km bit ho: C s phi hp t bo km bit ho v t chc hoi t, tng sinh mch v mt s t chc ging nh Glioblastome (bc III OMS).111 20. Cc Oligodendrogliome chim 4% cc U ni s, 18% cc Gliome. Thng gp nam nhiu hn n. Khu tr thu trn, thu nh. tr em c th gp i th. V lm sng thng c biu hin ng kinh cc b, tng ln trong nhiu nm. Trn nh CLVT: U hn hp, 60% c du hiu vi theo kiu khi thuc l hay "cc t" ph t. Tng t thuc cn quang. Chn on phn bit: Astrocytome pilocytiqueGangliocytomeMeningiome vi hoEpendymomeAngiome vi hoBnh Sturge- WeberU lao.1.1.3. U ca mng no tht v m ri mch mc a) Ependymome C 3 dng: Ependymome u c nh, nh, di mng no tht. l cc u lnh (bc I- OMS) nhng c th chuyn thnh u km bit ho (bc II, III - OMS). U pht trin t mng no tht vo trong no tht hay ra nhu m t khi c t chc hoi t hay thoi ho m, c th to kn. Ependymome km bit ho c th thy di cn theo dch no tu. y l loi u chim 4-9% cc u ni s, nam gp nhiu hn n. tr em v ngi tr thng l loi km bit ho. Loi lnh tnh hay tui 20-40. Trn nh CLVT dng in hnh l u nm trong no tht c cu trc khng ng nht, c nhng kn xen k v mt s nt vi ho. Chn on phn bit. - U ca no tht bn: + Papillome ca m ri mch mc. + Astrocytome t bo ln di mng no tht. - U ca no tht 3: U tuyn tng, Astrocytome pilocytique, Papillome ca m ri mch mc, kn keo. - U bn cu. d) Papilome xut pht t t bo biu m ca m ri mch mc chim 0,6% cc u ni s v 3,9% v u ni so tr em di 12 tui, hay gp n. U thng nm th tam gic ca NTB, NT3, 4, gc cu tiu no. Trn nh CLVT: U nm trong no tht, thng ng 3 NT, thng khng ng nht nhng c gii hn r, 20% c vi, tng thuc cn quang mnh. 112 21. Chn on phn bit: U ca NTB: -Papillome ca m ri mch mc.-Astrocytome t bo ln di mng no tht.U ca NT III: -U tuyn tng.-Astrocytome pilocytique-Papillome ca m ri mch mc-Kn keo.U ca bn cu: -Astrocytome pilocytique.-Astrocytome km bit ho.-Glioblastome.1.1.4. U t bo tuyn tng. V t chc hc c hai loi l: Pineocytome v Pineobastome. -Pinealome: C s phi hp t bo sng v t bo bch huyt nh. L loi u ng nht, c mt s t chc hoi t xen k.- Germinome: U xm ln, thm nhim m no ln cn, c vi, c t bo a nhn ln, t bo bch huyt nh c th phn tn theo dch no tu (bc II, III OMS). - Carcinome phi xut pht t t bo nhu m ca thn tuyn tng. l nhng u rt c tnh (bc IV OMS). Cc u tuyn tng chim 0,5% u ni s. Hay gp tr em v thiu nin, u th nam. V nh khu: U nm phn sau ca NT3. V lm sng: C du hiu TALNS v thng gy ra bnh l i nht, ri lon th gic. Trn nh CLVT: U c ranh gii r, c vi, tng t trng, tng mnh thuc cn quang. Chn on phn bit vi cc kn lnh ca tuyn tng (gp t 20-40% cc trng hp m t thi khng c du hiu lm sng). 1.1.5. U si thn kinh. Bao gm cc Gangliocytomes, Gangliogliome, Gangliocytome v Gangliogliome km bit ho.Ganglioneuroblastome,U him gp (0,4%), nh khu thng bn cu, thng c vi, c dng kn ln, c xm ln vo mng mm. 1.1.6. U km bit ho v u phi. a) Glioblastome c hai dng: - Glioblastome (c c sarcome.) 113 22. - Glioblastome t bo ln. l cc loi u c tnh cao (bc IV OMS). C th l chuyn dng c tnh ca Astrocytome hay Oligodendrogliome. L loi u khng c bao vi nhng vng hoi t hoc chy mu tng mch. Hay gp tui 40-65, nam/n = 2/1. U khu tr cc thu no. Tn thng th trai c th xm ln c hai bn cu to hnh nh " cch bm". C th a . LS c biu hin TK khu tr, ng kinh cc b hay ton th. Trn nh CLVT: U hn hp, c vng hoi t khng u, c ph no rng tng thuc cn quang dng vng khng u th hin tnh trng ph v HRMN, tng sinh mch, tn thng t bo biu m. Chn on phn bit -Astrocytome km bit ho-Oligodendrogliome-Ependymome-p- xe-Di cn.b) Medulloblastome: L u khu tr h s sau, c th di cn ln trn lu qua DNT. c) Thoi ho t bo thn kinh m ca no (Gliomatose no): L tn thng him gp c dng vim lan to bi cc t bo TK m, c khi lan ti m trng v m xm. 1.2.U bao dy thn kinh.Hay gp l cc u pht trin h s sau, nn s v h mt. C hai nhm. - Nhm I: Neurinome hay Schwannome lnh tnh Neurinome c tnh. Loi lnh tnh (bc I - OMS) c bao ngn cch vi khoang nhn, tng mch, u pht trin t t bo Schwann bao gm cc loi si (A) v loi li (B) c Antoni m t t lu. - Nhm II: Neurofibrome (lnh v c) L tn thng a u, hay gp trong bnh Recklinghausen. Khc vi loi trn chng pht trin bn trong dy thn kinh nn c s phn bit vi cc thnh phn bnh thng. Bnh l Neurofibrome (Recklinghausen) c chia ra: Loi I (NF1) : Do bt thng nhim st th 17 Loi II (NF2): Do bt thng nhim st th 22 Tiu chun chn on: NF1: C t 2 tiu chun tr ln:114 23. + 6 hay nhiu hn cc ht cafe sa c ng knh ln hn 5mm bnh nhn trc tui dy th > hn 15mm bnh nhn sau tui dy th. + 2 hay nhiu hn cc Neurofibrome hay mt u TK m ri v hm nch hay bn.+ Cc ht pigment+ Gliome ca dy th gic. + 2 hay nhiu hn nt Lischi (Hamartome ca mng mt). + Tn thng xng: Lon sn xng bm, dy v xng di. + Bnh ca cha m gn ging NF1.NF2 (c 1 trong cc tiu chun sau) + Neurinome dy thnh gic 2 bn. + Cha m c 1 u TK thnh gic hay c 2 tn thng sau: Neurofibrome, Meningiome, Gliome, Schwannome.Phn bit NF1, NF2 NF1NF2Tn thng genenhim st th 17Nhim st th 22Tn sut1/2500 - 40001/50000Tn thng daNhiutTn thng ni sGliome ca dy TK th gic, hamartome, AstrocytomeU dy TK VIII hai bn, Meningiome, Neurinome1.3. U ca mng no v m ph. 1.3.1 Meningiome l loi u ni s hay gp nht sau Glioblastome. U pht trin chm, ph thuc t bo mng nhn, thng gn cc xoang hay mng cng. C 1-2% l a u. Thng c dng hnh trn, gii hn r, lin quan n mng cng. V i th l cc tn thng ngoi no p no dn dn. U vng h thi dng thng th hin hnh nh dy mng no (u mng) (Meningiome en plaque). mt s vng c th thy s xm ln xoang mng cng, xm ln vo xng v xuyn qua nn c hnh tng m xng. Meningiome chim 18,5% cc u ni s (theo thng k ca Kasner). Hay gp tui 3570, u th n (70%). nh khu: 115 24. - Meningiome vm s: 30% - Meningiome ca lim no v cnh dc gia: 31% - Meningiome nn s : 26% - Meningiome h sau: 7% - Meningiome trong no tht : 2% - Meningiome a : 4% Trn nh CLVT thy hnh nh u tng m, gii hn r, thng c vi ho thnh m, nm st mng cng, tng mnh thuc cn quang. Nhng trng hp kh chn on thng l u dng kn, dng mng ging u xng n thun. Chn on phn bit theo nh khu. - Meningiome ca vm s v lim no: di cn, Lymphome c tnh, Astrocytome km bit ho hay Glioblastome. - Meningiome nn s: Neurinome, Adenome, Chordome... - Meningiome trong no tht: Papillome ca m ri mch mc, kn keo. - Meningiome ca h s sau: Neurinome, Hemangioblastome th khng c kn, u cun cnh...BN Nam 40 tui: U trn nn trung tm, tng t trng, c vi, tng thuc mnh, ng nht. M: Meningiome.1.3.2 Cc loi u khc: Sarcome meninge, u hc t nguyn pht... 1.4 U t bo mu - Lymphome c tnh nguyn pht: chim 1-1,7% cc u ni s. Hay gp ngi 55-65 tui. Bnh nhn SIDA. - Histiocytose X chim 0,06%, khng r ngun gc, hay gp vng giao thoa th gic. 1.5 U c ngun gc mch mu. 1.5.1 Hemangioblastome: l loi u lnh (bc I- OMS), c 1 hay nhiu , c lp hay km bnh l thn kinh da (Von Hippel- Lindau).116 25. L loi u dng kn (75% trng hp) c gii hn r, c nt thnh, trong kn c dch mu vng. Phn u tht l h mch dng hang. C th gp th c. U hay h sau. vng trn lu c t l thp (0,01%). Trong bnh cnh thn kinh da Von Hippel - Lindau, v tr thng l hc mt, nhn cu, tu, tu, thn, thng thn. 1.6 Cc u t bo mm. Thng gp l: Germinomes, Carcinomes phi, Teratomes. Teratome c coi l lnh tnh thng dng kn, c thnh phn sn, vi, xng phi hp. Chim 0,3% u ni s (theo Zulch - 1986). thng nam. Hay gp nht vng tuyn tng. Trn nh CLVT thng l u khng ng nht, bn trong c t chc m, vi, kn v t chc u c tng thuc cn quang. Cn chn on phn bit vi kn Dermoid.U tuyn ca tuyn tng.U hn hp c vi, m. M: Teratoma.1.7 Di cn no. - Thng gp t cc loi u nguyn pht sau: Ung th ph qun, ung th v, ung th thn, cc u hc t, cc u ng tiu ho... C th gp bt k vng no ca no, k c khoang di nhn, mng no. Chim 1325% cc u ni s ngi ln trn 40 tui. Trn nh CLVT : Hnh nh a dng (dng nt, dng vng, dng hn hp, 1 hay nhiu ) c ph no rng, chon ch mnh, tng thuc cn quang. nhng trng hp n c, c dng chy mu hay p xe th chn on phi c nhng ch dn LS. Chn on phn bit Nu di cn 1 : Glioblastome, lymphome, Meningiome, apxe. Nu di cn a : apxe a , Meningiome a , Glioblastome a , lymphome, bnh l k sinh trng Di cn mng mm: Vim mng no nhim khun.117 26. U phi tri, di cn nhiu no. 2. U vng yn 2.1 U tuyn yn: C 3 loi Adenome tuyn yn: - K mu (Chromophobic): Hay gp nht, pht trin v xm ln rng. - Bt eosin - Bt kim (basophilic): Cn gi l qu sn tuyn, t gy chon ch. V nh ngha:U < 10mm gi l micro - adenome U > 10mm gi l macro - adenomeBN nam, 31 tui. U tuyn yn, c chy BN nam, 15 tui. au u. U trn yn mu trong u. dng kn c vi: u s hu. Kch thc u t l v hot ng hormon trong trng hp Adenome bi tit (75% cc adenome hot ng) 25% cc adenome khng hot ng (thng l cc macro - adenome). V nh khu bn ca u hay gp c mi lin quan vi hormon PRL, GH. 118 27. V nh khu u trung tm hay gp mi lin quan vi cc hormon ACTH, TSCH, FSH v LH. Trn nh CLVT: U c ranh gii vi t chc ln cn, ng hay tng nh t trng, mt s trng hp c dng kn vi trung tm hoi t. U ngm mnh thuc cn quang, t khi c vi ho, i khi c chy mu (trng hp ny thng thy tng t trng mu t vi bnh cnh LS l t qu km mt th lc). 2.2 U s hu (Craniopharyngiome) L u lnh tnh pht sinh t t bo biu m ca ng s hu bo thai (ti Rathke). Hay gp 2 la tui (5-10 v 50-60) l loi u hay gp nht tr em ti vng h yn. L loi u c v bc, trong c nhng vi ho, cc khng kn cha dch nhiu Cholesterol. Phn t chc c ca u gm t chc biu m ngoi b nhiu tng. Trn nh CLVT thy khi trn yn c m hn hp cc vi ho v kh ho. Phn t chc c ca u ngm kh mnh thuc cn quang. 2.3 Mt s u khc t gp. 3.1. Kn ca ti Rathke 3.2. Hamartome 3.3. Gliome ca giao thoa th gic. 3. Cc u no h sau: Trn nh CLVT, nh gi cc u no h sau c hn ch, thng c nhiu nh do xng, do chuyn ng, cc u thng pht trin t cc thnh phn h sau: - T thn no, tiu no: trong nhu m no - T mng no, t dy TK, xng sn: Ngoi nhu m no - T NT4. Tn sut: Theo Escourole, tr em 70% u no nm h sau, thng l u t m no nguyn pht. Hai loi hay gp l Astrocytome v Medulloblastome. ngi ln ngc li ch c 30%. ngi trn 50 tui hay gp l u di cn. Lm sng:Hi chng tiu no Cc du hiu tn thng thn no Cc du hiu tn thng cc dy TK Hi chng tng p ni s...Bng TCH cc u no thng gp di lu 1. Cc u trong nhu no nguyn pht 1.1. tr em: Astrocytome Medulloblastome 1.2. ngi ln: 2. U trong no tht:HemangioblastomeEpendymome Papillome Meningiome 119 28. 3. Cc u ngoi nhu m nguyn pht Hay gp ngi ln: Neurinome Meningiome Kn epidermoid 4. Cc u vng ln cn: Chemodectomes Chordome 5. Cc u di cn: - U di cn trong nhu m - U di cn mng no.3.1 Cc u trong nhu m no nguyn pht3.1.1. Astrocytome L u hay gp h sau. tr em loi u ny v Medulloblastome l hay gp nht. C 3 nhm. Nhm 1: Cc Astrocytome, fibrillaire, protoplmique, gemisto u bc II OMS 55% sng ti 3 nm. Nhm 2: Astrocytome km bit ho, hay cu no, u bc III tin lng xu (khong 20% sng ti 1 nm). Nhm 3: Astrocytome pilocytque l u lnh, (bc I-OMS) hay gp tr em, thng m no c th l u c hay u kn. Hnh nh CLVT: Nhm 1: Thng pht trin t c no sinh 4, ln vo NT4, mt s nm cng hnh tu, cung no. U c t trng khng ng nht, ngm t thuc hoc khng ngm. Nhm 2: Xm ln v lan to rng, c ph. Ngm thuc khng u, a dng, thnh vng, thnh mng. Nhm 3: Nm thy nhng, thy no. U c dng kn, c nt c thnh, ngm mnh thuc sau tim. Ph quanh u. i khi c u c. Chn on phn bit: Trong trng hp cc u c: - tr em: Phn bit vi Medulloblastome, Ependymome - ngi ln: Phn bit Glioblastome, di cn Trng hp u kn: Hemangioblastome, Astrocytome pilocytique.3.1.2. Medulloblastome 120 29. L loi u di lu c tnh nht tr em. Theo cc thng k n chim 3-4% cc u no mi la tui. Chim 20% cc u no tr em. Chim 30-40% cc u h sau tr em (cng nh Astrocytome). Tui: Quanh 6 tui, 56% 10 nm u, u th r nam. Tuy nhin, theo Choux (1982) , 13% BN tui 20-50. nh khu: u th thu nhng tiu no, pht trin nhanh vo NT4, thm nhim vo thn no trc, vo gc cu tiu no qua l Luska bn. V tr thu no hay gp ngi ln. U c xu hng di cn theo tu sng. Lm sng: c du hiu tiu no, hi chng TALNS . Hnh nh CLVT: u thy nhng ng hoc tng t trng, c vi (>20%), c hoi t, kn phi hp, ph no. Chn on phn bit: -Ependymome -Papillome ngi ln cn phn bit: Di cn, Glioblastome, Lymphome. Tin lng xu, t vong sau m 6-13 thng. S phi hp phu thut/ tia x, ho cht: 50-60% sng trn 5 nm. Ti pht hay gp t nm th 2-3. (75% theo Castro - 1987 ti pht ti ch, 8% vo tu) 6% trn lu, trong NT hay khoang nhn.3.1.3. Hemangioblastome Loi u lnh, ngun gc mch mu. Chim 1-2% cc u ni s, 7,3% cc u nguyn pht h sau ngi ln. U c th n thun hay trong bnh l c tnh gia nh Von Hippel Lindau. Tui t 3545. Phn ln cc u c dng kn vi nt c thnh, 1/3 trng hp l u c. nh khu: tiu no: Bn cu: 78%Thng nhng: 14% Tu Dng a u gp trong Von Hippel- Lindau. Hnh nh CLVT c th thy : Dng kn vi nt c thnh.Dng c vi kn trung tm.Dng c n thun.Sau tim thy nt c thnh tng mnh thuc cn quang. Ph quanh u nh, khong 22% c chy mu trong u. U tiu no thng nm b mt ca nhu m. U thnh no thng phi hp vi Syringomyelie. 121 30. Chn on phn bit: Dng kn:- Astrocytome pilocytique (tr em) - Gangliogliome -U ngoi m no, dng kn (kn Epidermoide, kn dermoide).Dng c: U di cn, Lymphome, Meningiome..BN N, 32 tui: U tiu no tri M: Hemangioblastome.BN N 4 tui: U trung tm h sau M: Ependymome.3.1.4 Cc u khc trong nhu m no nguyn pht Thng gp l Glioblastome (chim 12-20% cc u ni s) Tui 40-65 Hnh nh CLVT ging u trn lu. Lymphome, Gangliocytome... c th gp.3.2.U trong no tht 3.2.1. Ependymome L u hay gp tr em, chim 8-9% cc u no v khong 15% cc u h sau. mi la tui, n c t l 1,9-7,8%. Ngi ta thy tui hay gp l nhng nm u v nhng nm 30. V gii: u th nh nam. nh khu: NT 4, NTB, NT3 Cc u NT4 c khuynh hng xm ln vo l Lushka v Magendie, vo b gc cu tiu no. Theo Leibel 1989, u di cn tu khong 4% (loi bc I) v 26% (loi bc cao). 122 31. Hnh nh CLVT: in hnh l u nm trong NT4, c t trng hn hp vi hoi t c ch c vi, 10%, c ch chy mu, 15% c kn nh. Gin NT3, NTB.Sau tim: thuc ngm khng u. Hnh nh xm ln: Thn no, cc b v gc cu tiu no phn tn vo no tht trn lu, hay vo khoang di nhn. Chn on phn bit vi Papillome, Medulloblastome hay Meningiome trong NT.3.2.2. Papillome ca m ri mch mc t gp (t l < 1%). L U lnh (bc I OMS) thng c vi ho t khi c loi km bit ho (bc III, IV OMS) nh khu trong NT, hng u l NT4. Lm sng biu hin hi chng TALNS do no ng thu. Hnh nh CLVT: Thng thy u trong NT4, c vi, hn hp, ngm thuc mnh sau tim, no ng thu. Chn on phn bit: Trc mt khi u c NT4 c th - Ependynome : tr em, c vi (50% trng hp). - Medulloblastome:Tr nh, u thng nhng lan ra NT4. - Meningiome trong NT : gp ngi ln, c th c vi.3.3.Cc u ngoi nhu m 3.3.1. Neurinome L u lnh, pht trin t t bo Schwann. Cn phn bit trong bnh l Neurofibrome (c tng cc thnh phn cho dy TK nh t bo Schwann v fibroblaste trong bnh Reckinghausen), chim 6,8% cc u no (Zulch - 1986), hay gp tui 35-40. N nhiu hn nam. C hai dng Antoni A v Antoni B. Phn ln l loi u dy TK VIII pht trin t TK tin nh y ca l ng tay trong ra gc cu tiu no. Chim 70-80% cc u gc cu. Phn loi ca Koos (1976). Loi 1: K U < 1cm nm hon ton trong ng.Loi 2: K U 1-2cm: u gc cu tiu noLoi 3: K U 2-3cm: u gc cu tiu noLoi 4: K U > 3cm: U h sau, no ng thu. Phn loi ca P.Sarrat- J.M Bouchet (1988).Stade I: Trong ng, khng lm dn CAI.Stade II: Pht trin gc cu v thn no, k: 2-2,5cm.Hai giai on ny ch c triu chng ca Cochleo- vestibular, khng c triu chng thn kinh. 123 32. Stade III: Pht trin ti thn no nhng khng y thn no, trung tm TK.Stade IV: u ln, tn thng nhiu dy TK, c TK vn ng nhn cu, p thn no.Cc u t loi II ti IV thng km rng l ng tai trong. Bn trong thng c kn, ph t, ngm thuc cn quang mnh, qua thy c mi lin quan vi l ng tay trong. Trng hp u loi I, CHT c li th hn so vi CLCT. Dng u hai bn thng gp trng bnh cnh ca u x thn kinh (Neurofibrome). Cc loi u thn kinh ca dy V,VII, hn hp c chn on nh vo tnh nh khu v s xm ln. Chn on phn bit: Meningiome, u thn kinh hn hp, kn Epidermoid.3.3.2. Meningiome L u mng no lnh tnh pht trin t cc t bo khoang nhn, thng gp ngi ln tui 20-60, u th n, chim 13-18% cc u no nguyn pht. vng di lu u hay gp gc cu tiu no, ng th hai sau Neurinome. i khi c th gp u pht trin theo lng yn, theo mt dc xng yn, lu tiu no. Trn nh CLVT: ng, tng nh t trng, tng thuc cn quang mnh ng nht, c vi, c bin i xng st u (tng sinh xng). Nhng u gc cu tiu no thng biu hin dng lch trc so vi l ng tai trong. Cn lu l 5% u dng kn. Chn on phn bit: Neurinome v Chordom (vng Clivus). U vng gc cu tiu no phi, t trng hn hp, b r nt, c nhng mng vi v vt vi, hu xng (Hnh nh u dy III). M: 2 u- Meningiome v Neurinome lnh tnh.124 33. 3.3.3. Kn Epidermoide U lnh, t gp (0,6-1,5% cc u ni s). Thng ngi ln 20-50 tui. U c dng kn, thnh l m lin kt c ph bi mng m biu m c Keratin. Trong kn c cha cc tinh th Cholesterol. U thng gp vng di mng cng (80%), ngoi mng cng ch c 20%. vng di lu thng l loi di mng cng, gp gc cu tiu no, NT4. Loi ngoi mng cng thng c tnh nh khu nh xng , vm s vng chn. LS thng ngho nn v chm v l loi u mm, ln vo cc v tr t do trc khi p cc cu trc TK. Trn nh CLVT: u dng kn, c tnh nh khu, c dng ht trai (Perlees), t trng ln hn DNT, khng ngm thuc cn quang. Nhng u ngoi mng cng c th lm tiu xng vm s. Chn on phn bit: Kn khoang nhn n thun. 3.3.4. Cc u ngoi no khc: Kn khoang nhn, kn Dermoide. 3.4U ca cc t chc ln cn.3.4.1 Chemodectome Cn gi l u cn hch, u cun cnh. L u him gp, thng n (75%) tui khong 50. 2/3 cc trng hp vng xng ch yu t nh cnh (55%), mm li hm nh (25%)... c tnh xm ln xung quanh. Trn nh CLVT: U nm ngang mc l rch sau, l rch sau rng, khng u c hnh nh "ht tiu v mui" (Poivre et sel). U ngm thuc mnh xm ln vo xng gy tiu xng, xm ln vo tai gia v gc cu tiu no, trc cnh trong xng , vi tnh mch cnh, xoang tnh mch bn (nhng lun tn trng thnh mch), hu nh khng thy vi. CLVT c li ch trong nh gi cu trc xng. Chn on phn bit: Ch yu vi cc u TK hn hp vng l rch sau. 3.4.2 Chordome L loi u him gp, chim 1% cc u ni s. C hai dng: Chordome in hnh (c ln gelatin) v Chordome Chondroid (c sn) C tnh nh khu hai vng: xng yn v xng cng ct. Hnh nh CLVT: Vng Clivus c b thay i, tng thuc cn quang khng u. Tn thng u c th xm ln ra sau v pha thn no, ln trn v pha giao thoa th gic, sang bn v pha xoang hang. Chn on phn bit: Vi Chordome, Craniopharyngiome, Meningiome. 3.5. U di cn U di cn trong no. Chim 15-25%, tui 40-70. Cc u nguyn pht: K ph qun, K v, K thn, K i trng. K hc t.125 34. Nhiu nh h sau i khi lm kh khn cho chn on. CHT l phng php nh gi y hn. Tn thng a , ph rng, tng thuc cn quang dng nt hay vng c th thy u hoi t hay chy mu.U di cn ngoi no.Khoang nhn, dng u hay cn gi meningite carcinomateuse t chc ngm thuc r. IV. m tnh gi v dng tnh gi trong chn on u no C 3 loi u no d gy chn on nhm trn nh CLVT l Glioblastome, Astrocytome, di cn. Ngc li cc khi chon ch dng u nh p-xe, bnh l mch mu ( nhi mu, t mu), vim khu tr d nhm trn nh CLVT vi Astrocytome, Glioblastome. Nhng yu t gy chn on nhm thng l: Cc khi chon ch u hay gi u u gy hi chng chon ch vi cc du hiu p h thng NT v dch chuyn ng gia.Tn thng c hnh trn hay bu dc km ph n, b tng thuc cn quang.Tn thng lan to khng thnh khi, kh xc nh kch thc, ranh gii, khng thay i hoc c th thay i sau khi tim thuc cn quang.Chy mu chon ton b u. ci thin chn on cn da trn cc c im sinh bnh hc hay hnh nh thay i theo thi gian trn CLVT cng nh vic phi hp cc yu t chn on: +Trong p-xe no: giai on vim khu tr ng bao ca t chc no,vng nhim khun trung tm c bao bc bi lp t chc ht cn gi l v p-xe. Lp v ny rt giu t bo non v li mao mch. Theo thi gian bao ny cng c nhiu lp dy ln giu tun hon v t chc lin kt. Sau khi tim thuc cn quang s xut hin mt hay nhiu vng m. Hnh nh ngm thuc hnh vng d ln vi Astrocytome, Glioblastome hay u di cn chn on phn bit nhiu khi l khng th c nu khng c cc ch dn v LS v theo di iu tr. Trn cc nh CLVT, du hiu chon ch v ph gim dn theo tui p-xe. V p-xe ngm thuc thng mng. +Nhi mu c th nhm vi Astrocytome bc thp do loi u ny cng c du hiu chon ch kn o, u loi ny thng t hoc khng ngm thuc cm quang (ging nhi mu). C th da vo tnh cht nh u ca mch mu trong nhi mu hay s thay i hnh nh khc bit nhau trong nhng ln chp sau phn bit (Stephen 1990). +Trong t mu, sau tun th 2, phn ln cc mu t nh s tiu hon ton. Cc mu t s tiu dn t ngoi vi vo trung tm bao hnh thnh c v mng v thng tng thuc cn quang mc va.126 35. BN N, 30 tui: au u, yu nh na ngi tri, nhn m CLVT: Khi chon ch chm phi dng u. M: Mu t c bao x.Bnh l thoi ho no Chn on ct lp vi tnh cc bnh l thoi ho no thng kh khn hn so vi cng hng t do phn gii ca nh cng nh phn gii ca t trng trn ct lp vi tnh km hn phn gii tn hiu trn cng hng t. Mt khc cc bnh l v thoi ho mt Myeline no v cc bnh l v lon sn Myeline thng c biu hin chung l gim t trng lan to cht trng hoc l tnh trng teo no. Cn phi c s phi hp gia hnh nh vi tui v tin s lm sng ca bnh nhn: -Khong 1-2 tui gim t trng nhiu cht trng c tnh i xng hai bn bn cu, u th vng quanh no tht: Du hiu ca bnh lon sn cht trng mt mu do thiu arylsulfatase.-Khong t 02-05 tui: Gim t trng cht trng vng trn hai bn lan ti nhn ui: Bnh Alexander.-Khong 5-10 tui: Gim t trng vng nh chm sau, vng th trai, lan vo vng trn. Cc du hiu ny thng thy b trai c phi hp vi teo thng thn hai bn. Gp trong bnh lon sn cht trng thng thn.-Khong 10-30 tui: Gim t trng i xng hai bn nhn bo: Bnh Leigh do thiu ht enzym khi dng thiamin.-Ngi ln teo thu trn hai bn hay gp trong bnh Pick. Teo no lan to u th vng thi dng hay hi hi m hay gp trong bnh Alzheimer. y l bnh thng gp.-Ngi trung nin v ngi gi: Hnh nh phi ho i xng hai bn ca nhn ui hoc km theo ca nhn u, th, nhn rng ca vng h sau thng c tnh cht c trng trong bnh Fahr. Bnh ny nguyn nhn khng r rng, i khi c lin quan ti cc ri lon chuyn ho st. Hi chng Fahr thng lin quan n ri lon chuyn ho Canxi, gi suy cn gip.-No ngi gi: C lin quan n teo no cng nh gim t trng lan to ca cht trng. Hnh nh ny cn phn bit vi nhng bnh l tn thng no cht trng do cn 127 36. nguyn mch mu( do cao huyt p, tc mch no dn n a khuyt vng trung tm bu dc, gin cc rnh ca no). -o cc no tht: + t l hai sng trn khong 30% ngi bnh thng. + t l hai nhn ui khong 12-18% tu theo tui. + t l Evans gia sng trn v ng knh ti a qua no thng 20 n 50 %. + kch thc ca no tht III phi nh hn 7mm( trc tui 60).-Chn on bn cht teo no. + Sa st tr tu: i chiu hnh nh ct lp vi tnh vi cc loi sa st tr tu, c th thy mt s du hiu c ngha(bnh Pick, Alzheimer) + Teo no do cc nguyn nhn khc: Hi chng Parkinson( teo no lan to i khi c km theo vi ho nhn xm trung ng. Teo tiu no ngi nghin ru, rng cc qun no, b no vng thu nhng v vng tiu no trn, c th km theo teo no trn lu).Bnh nhn Nam 40 tui: C hnh nh vi ho vng nhn bo, vng nhn rng.128