โรคหลอดเลือดสมองแตกสำหรับแพทย์ : p1 39

1

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß (stroke, cerebrovascular disease) ‡ªìπ‚√§∑’Ëæ∫∫àÕ¬„πª√–™“°√ ŸßÕ“¬ÿ

∑—Ë«‚≈° „πª√–‡∑»∑“ßµ–«—πµ° æ∫‡ªìπ “‡Àµÿ°“√µ“¬Õ—π¥—∫ “¡1 „πª√–‡∑»®’π ≠’ËªÿÉπ æ∫‡ªìπ

“‡Àµÿ°“√µ“¬Õ—π¥—∫Àπ÷Ëß2,3 ”À√—∫ª√–‡∑»‰∑¬‰¥â¡’°“√»÷°…“§«“¡™ÿ°¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„π

™ÿ¡™π‡¡◊Õß ®”π«π 1,361 √“¬ ‡¡◊ËÕªï æ.». 2526 æ∫«à“¡’Õ—µ√“‡∑à“°—∫ 690 µàÕ 100,000 ¢Õßª√–™“°√∑’Ë

Õ“¬ÿ‡°‘π 20 ªï4 ·≈–≈à“ ÿ¥„πªï æ.». 2541 ‰¥â¡’°“√»÷°…“„πª√–™“°√ºŸâ¡’Õ“¬ÿ‡°‘π 60 ªï„π™π∫∑∑—Èß 4 ¿“§

®”π«π 3,036 √“¬ æ∫«à“¡’Õ—µ√“§«“¡™ÿ°√âÕ¬≈– 1.12 ´÷Ëß„°≈â‡§’¬ß°—∫ª√–‡∑»µà“ß Ê ∑—Ë«‚≈°5 ¥—ßπ—Èπ‚√§

À≈Õ¥‡≈◊Õ¥ ¡Õß®÷ß‡ªìπ‚√§∑’Ë¡’§«“¡ ”§—≠¬‘Ëß‚√§Àπ÷Ëß¢Õßª√–™“°√‰∑¬

Õß§å°“√Õπ“¡—¬‚≈°‰¥â„Àâ§”®”°—¥§«“¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß‰«â¥—ßπ’È

Stroke means çrapidly developed clinical signs of focal (global) disturbance of cerebral

function lasting more than 24 hours or leading to death, with no apparent cause other than a

vascular origin.é 6

‡π◊ËÕß®“°§«“¡·µ°µà“ß„π¥â“π∫ÿ§≈“°√·≈–§«“¡æ√âÕ¡¢Õß‡§√◊ËÕß¡◊Õ∑“ß°“√·æ∑¬å∑’Ë¡’À≈“¬

ª√–‡¿∑ √«¡∑—Èß°“√°√–®“¬∑’Ë‰¡à‡À¡“– ¡7 ®÷ß¡’‡«™ªØ‘∫—µ‘‰¡à‡À¡◊Õπ°—π∑—Èß¥â“π°“√«‘π‘®©—¬·≈–√—°…“

‚√§π’È ¥—ßπ—Èπ°“√∑”·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å ®÷ß‡ªìπ«‘∏’°“√∑’Ë‡À¡“– ¡

‡æ◊ËÕ “¡“√∂π”‰ªªØ‘∫—µ‘‰¥â∂Ÿ°µâÕß·≈–‡ªìπ¡“µ√∞“π∑—Ë«ª√–‡∑»

°“√®—¥∑”·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°π’È Õ“»—¬À≈—°∞“π∑“ß«‘™“°“√∑’Ë‰¥âµ’æ‘¡æå

·≈â« ‚¥¬·∫àß√–¥—∫§”·π–π”Õ‘ß§ÿ≥¿“æ¢ÕßÀ≈—°∞“π (strength of recommendation) ‡ªìπ 3 √–¥—∫ §◊Õ

A, B, C (µ“√“ß∑’Ë 1)

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°π’È ·∫àßÕÕ°‡ªìπ 3 ¢—ÈπµÕπ¥—ßπ’È

1. ·π«∑“ß°“√«‘π‘®©—¬«à“‡ªìπ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß (¥Ÿ·ºπ¿Ÿ¡‘∑’Ë 1)

2. ·π«∑“ß°“√«‘π‘®©—¬™π‘¥·≈– “‡Àµÿ¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° (¥Ÿ·ºπ¿Ÿ¡‘∑’Ë 2-8)

3. ·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°∑’Ë‡À¡“– ¡ (¥Ÿ·ºπ¿Ÿ¡‘∑’Ë 2-8)

‡π◊ÈÕÀ“¢Õß·π«∑“ß‡«™ªØ‘∫—µ‘©∫—∫π’Èª√–°Õ∫¥â«¬ ·ºπ¿Ÿ¡‘ §”Õ∏‘∫“¬ ‡Õ° “√Õâ“ßÕ‘ß µ“√“ß

·≈–¿“§ºπ«°

∫∑π”

2

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

3

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° (hemorrhagic stroke) ‡ªìπ‚√§∑’Ëæ∫∫àÕ¬„πª√–‡∑»·∂∫‡Õ‡™’¬¡“°°«à“

ª√–‡∑»∑“ßµ–«—πµ° ‚¥¬¡’Õÿ∫—µ‘°“√≥å Ÿß∂÷ß√âÕ¬≈– 25-35 ¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß8 ¿“«–π’È‡ªìπ “‡Àµÿ

°“√µ“¬·≈–§«“¡æ‘°“√Õ—π¥—∫µâπ Ê ‚¥¬‡©æ“–„πºŸâ ŸßÕ“¬ÿ ·¡â«à“¡’°“√»÷°…“·∫∫ randomized double-

blinded controlled trials ”À√—∫ ischemic stroke ‡ªìπ®”π«π¡“°°«à“ 300 √“¬ß“π9 ·µà„π hemorrhagic

stroke ¡’‡æ’¬ß 7 √“¬ß“π‡∑à“π—Èπ10,11,12,13,14,15,16 ¥â«¬¢âÕ®”°—¥„πÀ≈—°∞“π∑“ß«‘∑¬“»“ µ√å ∑”„Àâ°“√

°”Àπ¥√–¥—∫§”·π–π”Õ‘ß§ÿ≥¿“æ‡°’Ë¬«°—∫‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° Õ¬Ÿà„π√–¥—∫ C ®÷ßµâÕß¡’°“√«‘®—¬·≈–

æ—≤π“‡æ◊ËÕ„Àâ‰¥â§”µÕ∫∑’Ë¥’¢÷ÈπµàÕ‰ª

∫∑∑’Ë 1

·π«∑“ß°“√∫”∫—¥√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°

(Guidelines for the Management of Hemorrhagic Stroke)

4

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

·ºπ¿Ÿ¡‘∑’Ë 1. °“√∫”∫—¥√—°…“‡∫◊ÈÕßµâπ·≈–°“√«‘π‘®©—¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß

(Initial Management and Diagnosis of Stroke)

À¡“¬‡Àµÿ * µ√«®√à“ß°“¬ºŸâªÉ«¬‡æ◊ËÕ¥Ÿ«à“¡’Õ“°“√√ÿπ·√ß (GCS < 8, signs of brain herniation, hypoxia,

‡ ’Ë¬ßµàÕ°“√ ”≈—°) À√◊Õ‰¡à ‡æ◊ËÕæ‘®“√≥“„Àâ advanced life support °àÕπ°“√ ◊∫§âπ‚√§

** ºŸâªÉ«¬∑ÿ°√“¬§«√‰¥â√—∫°“√µ√«® CT brain ·µà„π ∂“π∑’Ë∑’Ë‰¡à “¡“√∂ àßµ√«® CT scan ·≈–ºŸâªÉ«¬¡’Õ“°“√

∑“ß§≈‘π‘°‡¢â“‰¥â°—∫ stroke ™—¥‡®π Õπÿ‚≈¡„™â Siriraj Stroke Score ( SSS ) ·∑π (¥Ÿ¿“§ºπ«° 1 Àπâ“ 31)

∂â“º≈‡ªìπ hemorrhagic stroke À√◊Õ uncertained ®”‡ªìπµâÕß àßµàÕ (refer) ‡ ¡Õ

*** ∂â“ CT brain ª°µ‘·≈–≈—°…≥–∑“ß§≈‘π‘°‡¢â“‰¥â°—∫ subarachnoid hemorrhage (SAH) „Àâæ‘®“√≥“µ√«®¬◊π¬—π

¥â«¬°“√‡®“–µ√«®πÈ”‰¢ —πÀ≈—ß

**** ∂â“ CT brain æ∫ hemorrhage ·≈–ºŸâªÉ«¬¡’Õ“¬ÿ < 45 ªï À√◊Õ¡’√Õ¬‚√§Õ◊Ëπ ‡™àπ bleeding tumor ‡ªìπµâπ À√◊Õ

‡ªìπ unusual site of hypertensive hemorrhage æ‘®“√≥“©’¥ contrast media ‡æ◊ËÕ¥Ÿ abnormal vessels „π°√≥’∑’Ë

‰¡à¡’¢âÕÀâ“¡

5

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

ºŸâªÉ«¬∑ÿ°§π∑’Ë¡“‚√ßæ¬“∫“≈¥â«¬Õ“°“√ acute neurological deficit µâÕßµ√«® vital signs, neurological

signs ‡æ◊ËÕª√–‡¡‘π«à“µâÕß„Àâ emergency advanced life support À√◊Õ‰¡à ¥Ÿ airway, ventilation ‡æ’¬ßæÕ

À√◊Õ‰¡à ‚¥¬‡©æ“–ºŸâªÉ«¬∑’Ë¡’√–¥—∫§«“¡√Ÿâ ÷°µ—«µË” (GCS < 8) À√◊Õ brain stem dysfunction À√◊Õ hypoxia

(PaO2< 60 mmHg), hypercarbia (PaCO

2 > 40 mmHg) À√◊Õ ‡ ’Ë¬ßµàÕ°“√‡°‘¥ aspiration §«√‰¥â√—∫°“√

„ à∑àÕ™à«¬À“¬„® æ√âÕ¡°—∫ àß emergency laboratory tests (CBC, BS, BUN, Cr, electrolytes)

´—°ª√–«—µ‘·≈–µ√«®√à“ß°“¬∑’Ë‡°’Ë¬«¢âÕß ‡™àπ °“√∫“¥‡®Á∫∑’Ë»’√…– ¥◊Ë¡ ÿ√“ §«“¡¥—π‚≈À‘µ Ÿß ‚√§À—«„®

‚√§‡∫“À«“π ‚√§‡≈◊Õ¥ ‚√§µ—∫ ‚√§‰µ °“√„™â ¬“ anticoagulants ¬“‡ æµ‘¥ ‡æ◊ËÕ·¬°¿“«– Õ◊Ëπ∑’Ë‰¡à„™à

‚√§À≈Õ¥‡≈◊Õ¥ ¡ÕßÕÕ°‰ª

‡¡◊ËÕ ß —¬«à“‡ªìπ acute stroke §«√‰¥â√—∫°“√µ√«® CT brain ∑ÿ°√“¬9 ·µà∂â“‰¡à¡’ CT scan

·≈–ºŸâªÉ«¬Õ“°“√‰¡à√ÿπ·√ßÕπÿ‚≈¡„Àâ„™â Siriraj Stroke Score (SSS) ·∑π ‡æ◊ËÕ·¬°«à“‡ªìπ hemorrhagic

stroke À√◊Õ‰¡à

„π°√≥’∑’Ë CT brain ∫àß«à“‡ªìπ ischemic stroke „Àâª√÷°…“ª√– “∑·æ∑¬å ‡æ◊ËÕ„Àâ°“√√—°…“

µ“¡·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫À√◊ÕÕÿ¥µ—π ”À√—∫·æ∑¬å17 µàÕ‰ª ·µà∂â“‡ªìπ hemorrhagic

stroke „ÀâªØ‘∫—µ‘µ“¡·ºπ¿Ÿ¡‘∑’Ë 2

§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 1

6

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

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7

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

·æ∑¬åºŸâ√—°…“µâÕßæ¬“¬“¡À“ “‡Àµÿ¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°∑ÿ°√“¬ ‚¥¬¥Ÿ®“°µ”·Àπàß

¢Õß‡≈◊Õ¥„π CT brain √à«¡°—∫ Õ“¬ÿ ª√–«—µ‘§«“¡¥—π‚≈À‘µ Ÿß·≈–‚√§∑’Ë‡ªìπ√à«¡ ‡¡◊ËÕæ‘®“√≥“®“° CT

brain “¡“√∂·∫àß hemorrhagic stroke µ“¡µ”·Àπàß¢Õß‡≈◊Õ¥∑’ËÕÕ°‰¥â‡ªìπ 3 °≈ÿà¡ §◊Õ subarachnoid

hemorrhage (SAH), intraventricular hemorrhage (IVH), intracerebral hemorrhage (ICH) ·µà∫“ß§√—Èß

Õ“®æ∫¡“°°«à“ 1 µ”·Àπàß „Àâæ‘®“√≥“«à“µ”·Àπàß∑’Ë‡≈◊Õ¥ÕÕ°Õ¬Ÿà∑’Ë‰Àπ ·≈–„Àâ∫”∫—¥√—°…“‰ªµ“¡µ”·Àπàß

π—Èπ Ê

§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 2

8

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

9

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

°“√∫”∫—¥√—°…“∑“ß»—≈¬°√√¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°∑’Ë ”§—≠ §◊Õ °“√ºà“µ—¥‡æ◊ËÕ‡Õ“

°âÕπ‡≈◊Õ¥ÕÕ° ·≈–/À√◊Õ ºà“µ—¥ arteriovenous malformation (AVM), aneurysm ‡æ◊ËÕ≈¥§«“¡¥—π

„π°–‚À≈°»’√…– ”À√—∫°“√ºà“µ—¥°âÕπ‡≈◊Õ¥∑’ËÕ¬Ÿà≈÷° Õ“®∑”„Àâ‡°‘¥¿“«– ¡Õß∫«¡‡æ‘Ë¡¡“°¢÷Èπ

º≈°“√√—°…“®÷ß‰¡à¥’ ¥—ßπ—Èπ °“√æ‘®“√≥“ºà“µ—¥®”‡ªìπµâÕß¡’¢âÕ∫àß™’È∑’Ë™—¥‡®π

∫∑∑’Ë 2

°“√∫”∫—¥√—°…“∑“ß»—≈¬°√√¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°

(Surgical Management of Hemorrhagic Stroke)

10

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

À¡“¬‡Àµÿ

°“√§”π«≥ª√‘¡“µ√°âÕπ‡≈◊Õ¥ = 0.524 x X x Y x Z ¡‘≈≈‘≈‘µ√

(X,Y,Z = §«“¡¬“«¢Õß‡ âπºà“»Ÿπ¬å°≈“ß¢Õß°âÕπ‡≈◊Õ¥„π·π«·°π X,Y,Z Àπà«¬‡ªìπ ‡´πµ‘‡¡µ√)27,28

* ∂â“°âÕπ‡≈◊Õ¥Õ¬Ÿà∑’Ë temporal lobe ¡—°¡’ early herniation20 §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å

GCS = Glasgow Coma Scale

HC = Hydrocephalus

IVH = Intraventricular hemorrhage

SAH = Subarachnoid hemorrhage

·ºπ¿Ÿ¡‘∑’Ë 3. °“√∫”∫—¥√—°…“ Lobar Hemorrhage

(Management of Lobar Hemorrhage)

11

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

Lobar hemorrhage À¡“¬∂÷ß intracerebral hemorrhage (ICH) ∑’ËÕ¬Ÿà„πµ”·Àπàß cortical À√◊Õ

subcortical ‰¥â·°à frontal, temporal, parietal, occipital lobes “‡Àµÿ¢Õß‡≈◊Õ¥∑’ËÕÕ° ∫√‘‡«≥π’È à«π„À≠à

‰¡à„™à‡°‘¥®“°§«“¡¥—π‚≈À‘µ Ÿß ·µà¡’ “‡ÀµÿÕ◊Ëπ ‡™àπ cerebral amyloid angiopathy, aneurysm, AVM

‡ªìπµâπ À“°æ∫¢âÕ∫àß™’È > 2 ¢âÕ ‰¥â·°à GCS < 1318,19, volume > 30 ml.18,20,21,22, midline shift > 0.5 cm.23

§«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å ∂â“æ∫¢âÕ∫àß™’È‡æ’¬ß 1 ¢âÕ „Àâ√—°…“·∫∫ª√–§—∫ª√–§Õß (conservative

treatment) À“°ºŸâªÉ«¬Õ“°“√‡≈«≈ß §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å ·µà∂â“Õ“°“√¥’¢÷Èπ·≈–ºŸâªÉ«¬Õ“¬ÿ < 45 ªï

À√◊Õ‰¡à¡’ª√–«—µ‘§«“¡¥—π‚≈À‘µ ŸßÀ√◊Õ CT brain ß —¬«à“¡’ abnormal blood vessels §«√ª√÷°…“ª√– “∑

»—≈¬·æ∑¬å‡æ◊ËÕ°“√∫”∫—¥√—°…“∑’Ë‡À¡“– ¡ ‡™àπ àßµ√«® cerebral angiography24,25,26 ‡ªìπµâπ

”À√—∫°âÕπ‡≈◊Õ¥∑’Ëµ”·Àπàß temporal lobe ¡’‚Õ°“ ∑’Ë®–‡°‘¥ early brain herniation20 ¥—ßπ—Èπ

§«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å

§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 3

°“√∫”∫—¥√—°…“ Non-Lobar Hemorrhage

(Management of Non-Lobar Hemorrhage)

Non-lobar hemorrhage À¡“¬∂÷ß intracerebral hemorrhage ∑’Ë basal ganglia ( à«π„À≠à‡ªìπ∑’Ë

putamen), thalamus, cerebellum, brain stem ( à«π„À≠à‡ªìπ∑’Ë pons) ∂â“¡’ª√–«—µ‘§«“¡¥—π‚≈À‘µ Ÿß À√◊Õ

‡§¬‡ªìπ stroke ¡“°àÕπ ·≈–Õ“¬ÿ¡“°°«à“ 45 ªï ¡—°®–‡ªìπ hypertensive hemorrhage24,25 ·µàºŸâªÉ«¬∑’ËÕ“¬ÿ

πâÕ¬°«à“ 45 ªï À√◊ÕºŸâªÉ«¬∑’Ë¡’§«“¡º‘¥ª°µ‘Õ◊Ëπ Ê „π CT brain §«√∑”°“√µ√«®«‘π‘®©—¬‚√§‡æ‘Ë¡‡µ‘¡

12

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

·ºπ¿Ÿ¡‘∑’Ë 4. °“√∫”∫—¥√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°„πµ”·Àπàß Basal Ganglia

(Management of Basal Ganglia Hemorrhage)

À¡“¬‡Àµÿ

°“√§”π«≥ª√‘¡“µ√°âÕπ‡≈◊Õ¥ = 0.524 x X x Y x Z ¡‘≈≈‘≈‘µ√


*Basal ganglia hemorrhage À¡“¬∂÷ß °âÕπ‡≈◊Õ¥∑’Ëµ”·Àπàß putamen, globus pallidus ·≈–

caudate nucleus (¥Ÿ¿“§ºπ«°∑’Ë 5 Àπâ“ 35)


HC = Hydrocephalus


SAH = Subarachnoid hemorrhage

13

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

Basal ganglia hemorrhage ·∫àßÕÕ°‡ªìπ Õß°≈ÿà¡ À“°æ∫¢âÕ∫àß™’È > 2 ¢âÕ ‰¥â·°à GCS < 1318,19,

volume > 30 ml. 27,28,29,30, midline shift > 0.5 cm. 23 §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å ·µà∂â“¢âÕ∫àß™’È < 2 ¢âÕ

„Àâ√—°…“·∫∫ª√–§—∫ª√–§Õß À“°ºŸâªÉ«¬Õ“°“√‡≈«≈ß ®÷ßª√÷°…“ª√– “∑»—≈¬·æ∑¬å

§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 4

14

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

·ºπ¿Ÿ¡‘∑’Ë 5. °“√∫”∫—¥√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°„πµ”·Àπàß Thalamus

(Management of Thalamic Hemorrhage)

À¡“¬‡Àµÿ

°“√§”π«≥ª√‘¡“µ√°âÕπ‡≈◊Õ¥ = 0.524 x X x Y x Z ¡‘≈≈‘≈‘µ√

(X,Y,Z = §«“¡¬“«¢Õß‡ âπºà“»Ÿπ¬å°≈“ß¢Õß°âÕπ‡≈◊Õ¥„π·π«·°π X,Y,Z Àπà«¬‡ªìπ‡´πµ‘‡¡µ√)27,28


HC = Hydrocephalus


15

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

Thalamic hemorrhage À“°æ∫¢âÕ∫àß™’È > 2 ¢âÕ ‰¥â·°à GCS < 13, volume > 10 ml.16,31,32,33,

midline shift > 0.5 cm. ·≈–/À√◊Õ¡’ hydrocephalus (HC) §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å ·µà∂â“¢âÕ∫àß™’È

< 2 ¢âÕ ·≈–‰¡à¡’ hydrocephalus „Àâ√—°…“·∫∫ª√–§—∫ª√–§Õß „π°√≥’∑’ËºŸâªÉ«¬¡’Õ“°“√‡≈«≈ß®÷ßª√÷°…“

ª√– “∑»—≈¬·æ∑¬å

§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 5

16

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

·ºπ¿Ÿ¡‘∑’Ë 6. °“√∫”∫—¥√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°„πµ”·Àπàß ¡ÕßπâÕ¬

(Management of Cerebellar Hemorrhage)

À¡“¬‡Àµÿ

°“√§”π«≥ª√‘¡“µ√°âÕπ‡≈◊Õ¥ = 0.524 x X x Y x Z ¡‘≈≈‘≈‘µ√


*Cerebellar hemorrhage ∑’Ë vermis41 ¡—°®–¡’ early brain stem compression §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å

**°“√ àßµ—«ºŸâªÉ«¬ (refer case) ºŸâªÉ«¬Õ“®®–À¬ÿ¥À“¬„®„π¢≥–‡¥‘π∑“ß‰¥â ©–π—Èπ µâÕß‡µ√’¬¡‡§√◊ËÕß¡◊Õ‡æ◊ËÕ

™à«¬°“√À“¬„®„Àâæ√âÕ¡


HC = Hydrocephalus


17

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

Cerebellar hemorrhage æ∫‰¥â∑’Ë cerebellar hemisphere ·≈– vermis À“°æ∫¢âÕ∫àß™’È >

1 ¢âÕ ‰¥â·°à GCS< 1334, volume > 15 ml.35,36,37,38 À√◊Õ¡’ hydrocephalus (with or without IVH)

§«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å

„π°√≥’∑’Ë CT ‰¡à™—¥‡®π∑”„Àâ§”π«≥ª√‘¡“µ√°âÕπ‡≈◊Õ¥‰¡à‰¥â·µà‡ âπºà“»Ÿπ¬å°≈“ß¢Õß°âÕπ

‡≈◊Õ¥¡“°°«à“ 3 ‡´πµ‘‡¡µ√39,40 §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å

Cerebellar hemorrhage ∑’Ë vermis41 ¡—°®–¡’ early brain stem compression §«√ª√÷°…“ª√– “∑-

»—≈¬·æ∑¬å

°“√ àßµ—«ºŸâªÉ«¬ (refer case) ºŸâªÉ«¬Õ“®®–À¬ÿ¥À“¬„®„π¢≥–‡¥‘π∑“ß‰¥â ©–π—Èπ µâÕß‡µ√’¬¡

‡§√◊ËÕß¡◊Õ‡æ◊ËÕ™à«¬°“√À“¬„®„Àâæ√âÕ¡

§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 6

18

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

·ºπ¿Ÿ¡‘∑’Ë 7. °“√∫”∫—¥√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°∑’Ëµ”·Àπàß Pons

(Management of Pontine Hemorrhage)

À¡“¬‡Àµÿ


HC = Hydrocephalus


*Repeated episodes À¡“¬§«“¡«à“‡°‘¥ pontine hemorrhage È”∑’Ëµ”·Àπàß‡¥‘¡

19

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

Brain stem hemorrhage ¡—°æ∫¡“°∑’Ëµ”·Àπàß pons ‰¡à§«√ºà“µ—¥‡æ√“–¡’§«“¡‡ ’Ë¬ß Ÿß ∂â“

GCS < 13 À√◊Õ¡’ hydrocephalus À√◊Õ intraventricular hemorrhage À√◊ÕÀ≈Õ¥‡≈◊Õ¥·µ° È”∑’Ëµ”·Àπàß‡¥‘¡

(repeated episodes) §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å ∂â“ GCS > 13 ·≈–‰¡à¡’ hydrocephalus „Àâ√—°…“

·∫∫ª√–§—∫ª√–§Õß

§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 7

20

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

·ºπ¿Ÿ¡‘∑’Ë 8. °“√∫”∫—¥√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°„π Subarachnoid Space

(Management of Subarachnoid Hemorrhage)

À¡“¬‡Àµÿ * ∂â“‰¡à¡’ CT brain Õπÿ‚≈¡„Àâ‡®“–µ√«®πÈ”‰¢ —πÀ≈—ß‡æ◊ËÕ°“√«‘π‘®©—¬‚√§ À“°‰¡à¡’Õ“°“√

·≈–/À√◊Õ°“√· ¥ß¥—ßµàÕ‰ªπ’È

1. Focal neurological deficit

2. Disturbance of consciousness

3. Signs of increased intracranial pressure

CSF = Cerebro spinal fluid LP = Lumbar puncture

CT brain = Computer tomography brain RBC = Red blood cell

ICH = Intracerebral hemorrhage SAH = Subarachnoid hemorrhage


21

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

Subarachnoid hemorrhage (SAH) À¡“¬∂÷ß ‡≈◊Õ¥ÕÕ°„π subarachnoid space ∑”„Àâ

ºŸâªÉ«¬¡’Õ“°“√ª«¥»’√…–Õ¬à“ß√ÿπ·√ß¢÷Èπ∑—π∑’∑—π„¥ Õ“®¡’À¡¥ µ‘À√◊Õ‰¡à¡’°Á‰¥â µ√«®√à“ß°“¬æ∫¡’§Õ·¢Áß

´÷ËßÕ“®µâÕß·¬°®“°‚√§‡¬◊ËÕÀÿâ¡ ¡ÕßÕ—°‡ ∫ “‡Àµÿ¢Õß SAH ‰¥â·°à ruptured aneurysm, ruptured AVM,

blood dyscrasia, head injury, parasite ‡ªìπµâπ

ºŸâªÉ«¬∑’Ë¡’Õ“°“√ ß —¬ SAH „Àâ àßµ√«® CT brain (À“°‰¡à “¡“√∂ àßµ√«® CT brain

‰¥â ·≈–‰¡à¡’¢âÕÀâ“¡„π°“√‡®“–À≈—ß Õπÿ‚≈¡„Àâ‡®“–πÈ”‰¢ —πÀ≈—ß‰¥â‡æ◊ËÕ°“√«‘π‘®©—¬‚√§) ∂â“ CT brain

‰¡àæ∫ SAH „Àâ‡®“–µ√«®πÈ”‰¢ —πÀ≈—ß À“°º≈‡¢â“‰¥â°—∫ SAH ´÷Ëß‰¡à‰¥â‡°‘¥®“° parasite §«√ª√÷°…“

ª√– “∑»—≈¬·æ∑¬å

§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 8

22

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

°“√∫”∫—¥√—°…“§«“¡¥—π‚≈À‘µ Ÿß (Blood pressure management)

‚¥¬∑—Ë«‰ª®–‰¡à„Àâ¬“≈¥§«“¡¥—π‚≈À‘µ„πºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°„π√–¬–·√° ¬°‡«âπ„π

√“¬∑’Ë¡’§«“¡¥—π‚≈À‘µ Ÿß¡“° ®÷ßæ‘®“√≥“„Àâ¬“¥—ß√“¬≈–‡Õ’¬¥„πµ“√“ß∑’Ë 3 (Àπâ“ 28)

°“√∫”∫—¥√—°…“§«“¡¥—π„π°–‚À≈°»’√…– Ÿß (Management of increased intracranial pressure)

°√≥’∑’Ë ß —¬¡’§«“¡¥—π„π°–‚À≈°»’√…– Ÿß ‡™àπ ºŸâªÉ«¬ª«¥»’√…–√ÿπ·√ß ÷¡≈ß Õ“‡®’¬π ‡ÀÁπ

¿“æ´âÕπ √Ÿ¡à“πµ“¢¬“¬ ™’æ®√™â“ pulse pressure °«â“ß ‡ªìπµâπ „Àâ°“√√—°…“¿“«–§«“¡¥—π„π°–‚À≈°

»’√…– Ÿß¥—ß√“¬≈–‡Õ’¬¥„πµ“√“ß∑’Ë 4 (Àπâ“ 29) ·≈–ª√÷°…“ª√– “∑»—≈¬·æ∑¬å

°“√∫”∫—¥√—°…“Õÿ≥À¿Ÿ¡‘√à“ß°“¬ (Management of body temperature)

„π√–¬–·√°ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°¡—°¡’‰¢â Ÿß °√≥’∑’ËÕÿ≥À¿Ÿ¡‘√à“ß°“¬ Ÿß¡“° ®–¡’º≈µàÕ

brain metabolism ∑”„Àâ°“√æ¬“°√≥å‚√§‡≈«≈ß ¥—ßπ—Èπ ∂â“ºŸâªÉ«¬¡’‰¢â > 38.5 0C §«√„Àâ°“√√—°…“¥—ß

√“¬≈–‡Õ’¬¥„πµ“√“ß∑’Ë 3 (Àπâ“ 28)

∫∑∑’Ë 3

°“√∫”∫—¥√—°…“∑“ßÕ“¬ÿ√°√√¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°

(Medical Management for Hemorrhagic Stroke)

23

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

1. π‘æπ∏å æ«ß«√‘π∑√å. Epidemiology of stroke. „π: π‘æπ∏å æ«ß«√‘π∑√å, ∫°.‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß

(stroke) ©∫—∫‡√’¬∫‡√’¬ß§√—Èß∑’Ë 2. °√ÿß‡∑æ¡À“π§√: ‡√◊Õπ·°â«°“√æ‘¡æå, 2544: 1-37.

2. Zhang LF, Yang J, Hong Z, Yuan GG, Zhou BF, Zhao LC, et al. Proportion of different subtypes

of stroke in China. Stroke 2003; 34: 2091-6.

3. Shimamoto T, Iso H, Iida M, Komachi Y. Epidemiology of cerebrovascular disease : stroke

epidemic in Japan. J Epidemiol 1996; 6(Suppl III): S43-47.

4. Viriyavejakul A, Poungvarin N, Vannasaeng S. The prevalence of stroke in urban community

of Thailand. J Neurology 1985; 232(suppl):93.

5. Viriyavejakul A, Senanarong V, Prayoonwiwat N, Praditsuwan R, Chaisevikul R, Poungvarin N.

Epidemiology of stroke in the elderly in Thailand. J Med Assoc Thai 1998; 81:487-505.

6. World Health Organization Meeting on Community Control of Stroke and Hypertension. Control

of stroke in the community: methodological considerations and protocol of WHO stroke register.

CVD/s/73.6 Geneva: WHO,1973.

7. ¡‡°’¬√µ‘ ‚æ∏‘ —µ¬å. Technology assessment. „π: ¡‡°’¬√µ‘ ‚æ∏‘ —µ¬å, ∫°. °“√ª√–‡¡‘π

‡∑§‚π‚≈¬’∑“ß°“√·æ∑¬å ©∫—∫ª√—∫ª√ÿß. °√ÿß‡∑æ¡À“π§√:‚√ßæ‘¡æåÕß§å°“√∑À“√ºà“π»÷°, 2546:5.

8. Poungvarin N. Stroke in the developing world. Lancet 1998; 50(Suppl III): 19-22.

9. Broderick JP, Adams HP, Barsan W, Feinberg W, Feldmann E, Grotta J, et al.Guidelines for the

management of spontaneous intracerebral hemorrhage. Stroke 1999 ;30:905-15.

10. McKissock W, Richardson A, Taylor J. Primary intracerebral hemorrhage: a controlled trial of

surgical and conservative treatment in 180 unselected cases.Lancet 1961; 2:221-6.

11. Zuccarello M, Brott T, Derex L, Kothari R, Tew J, Loveren HV, et al. Early surgical treatment for

supratentorial intracerebral hemorrhage: a randomized feasibility study. Stroke 1999; 30: 1833-9.

12. Juvela S, Heiskanen O, Poranen A, Valtonen S, Kuurne T, Kaste M, Troupp H. The treatment of

spontaneous intracerebral hemorrhage: a prospective randomized trial of surgical and conservative

treatment. J Neurosurg 1989; 70: 755-8.

13. Batjer HH, Reisch JS, Allen BC, Plaizier LJ, Su CJ. Failure of surgery to improve outcome in

hypertensive putaminal hemorrhage: a prospective randomized trial. Arch Neurol 1990; 47:

1103-6.

‡Õ° “√Õâ“ßÕ‘ß

24

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

14. Chen X, Yang H, Czherig Z. A prospective randomized trial of surgical and conservative treatment

of hypertensive intracranial hemorrhage. Acta Acad Med Shanghai 1992; 19: 237-40.

15. Morgenstern LB, Frankowski RF, Shedden P, et al. Surgical treatment of intracerebral hemorrhage

(STICH) : a single-center, randomized clinical trial. Neurology 1998; 51: 1359-63.

16. Tan SH, Ng PY, Yeo TT, et al. Hypertensive basal ganglia hemorrhage: a prospective study

comparing surgical and nonsurgical management. Surg Neurol 2001; 56: 287-93.

17. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫À√◊ÕÕÿ¥µ—π ”À√—∫·æ∑¬å ©∫—∫∑’Ë 1 (æ‘¡æå§√—Èß∑’Ë 2).

°√ÿß‡∑æ¡À“π§√ : ∂“∫—πª√– “∑«‘∑¬“; 2545: 1-28.

18. Flemming KD, Wijdicks EF, Li H. Can we predict poor outcome at presentation in patients with

lobar hemorrhage? Cerebrovasc Dis 2001; 11: 183-9.

19. Flemming KD, Wijdicks EF, St Louis EK, Li H. Predicting deterioration in patients with lobar

haemorrhages. J Neurol Neurosurg Psychiatry 1999; 66: 600-5.

20. Andrews BT, Chiles BW 3rd, Olsen WL, Pitts LH. The effect of intracerebral hematoma location

on the risk of brain-stem compression and on clinical outcome. J Neurosurg 1988; 69: 518-22.

21. Auer L,Deinsberger W, Niederkorn K, Gell G, Kleinert R, Schneider G, et al. Endoscopic surgery

versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg

1989; 70: 530-5.

22. Yoshimoto H, Fujita H, Ohta K, Yoshikawa M, Shibata K, Takahashi M, et al. Clinical study of

hypertensive subcortical hemorrhage: surgical indication and long-term functional prognosis.

No Shinkei Geka 1988; 16: 1465-70.

23. Sakas DE, Singounas EG, Karvounis PC. Spontaneous intracerebral haematomas: surgical versus

conservative treatment based on Glascow Coma Scale score and computer tomography data.J

Neurosurg Sci 1989; 33: 165-72.

24. Zhu XL, Chan MS, Poon WS. Spontaneous intracranial hemorrhage: which patients need

diagnostic cerebral angiography? A prospective study of 206 cases and review of the literature.

Stroke 1997; 28: 1406-9.

25. Loes DJ, Smoker WR, Biller J, Cornell SH. Nontraumatic lobar intracerebral hemorrhage:

CT/angiographic correlation. Am J Neuroradiol 1987; 8: 1027-30.

25

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

26. Halpin SF, Britton JA, Clifton A, Hart G, Moore A. Prospective evaluation of cerebral angiography

and computered tomography in cerebral hematoma. J Neurol Neurosurg Psychiatry 1994; 57:

1180-6.

27. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage,

a powerful and easy-to-use predictor of 30-day mortality. Stroke 1993; 24: 987-93.

28. Lin CL, Howng SL. Surgical outcome of hypertensive putaminal hemorrhage in patients older than

65 years. Kaohsiung J Med Sci 1998; 14: 280-5.

29. Kaya RA, Turkmenoglu O, Ziyal IM, Dalkilic T, Sahin Y, Aydin Y. The effects on prognosis

of surgical treatment of hypertensive putaminal hematomas through transsylvian transinsular

approach. Surg Neurol 2003; 59: 176-83.

30. Maira G, Anile C, Colosimo C, Rossi GF. Surgical treatment of primary supratentorial intracerebral

hemorrhage in stuporous and comatose patients. Neurol Res 2002; 24: 54-60.

31. Sasaki K, Matsumoto K. Clinical appraisal of stereotactic hematoma aspiration surgery for

hypertensive thalamic hemorrhage--with respect to volume of the hematoma. Tokushima J Exp

Med 1992; 39: 35-44.

32. Kwak R, Kadoya S, Suzuki T. Factors affecting the prognosis in thalamic hemorrhage.

Stroke 1983; 14: 493-500.

33. Schutz HJ. Clinical aspects and long-term prognosis of spontaneous thalamus hematomas.

Fortschr Neurol Psychiatr 1985; 53: 355-62.

34. Kobayashi S, Sato A, Kageyama Y, Nakamura H, Watanabe Y, Yamaura A. Treatment of

hypertensive cerebellar hemorrhage--surgical or conservative management? Neurosurgery 1994 ;

34: 246-51.

35. Yoshimoto H, Fujita H, Ohta K, Yoshikawa M, Shibata K, Ohba S, et al. Clinical study of

hypertensive cerebellar hemorrhage: surgical indication and measurement of volume of hematoma.

No Shinkei Geka 1989; 17: 1105-10.

36. Zieger A, Vonofakos D, Steudel WI, Dusterbehn G. Nontraumatic intracerebellar hematomas:

prognostic value of volumetric evaluation by computed tomography. Surg Neurol 1984; 22:

491-4.

37. Wang CQ, Xu HQ, Luo ZP. The indication of surgical treatment of cerebellar hemorrhage.

Chung Hua Nei Ko Tsa Chih 1992; 30: 643-5.

26

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

38. Schutz H. Intracerebral hemorrhage. Ther Umsch 1996; 53: 590-6.

39. Lui TN, Fairholm DJ, Shu TF, Chang CN, Lee ST, Chen HR. Surgical treatment of spontaneous

cerebellar hemorrhage. Surg Neurol 1985; 23: 555-8.

40. Cohen ZR, Ram Z, Knoller N, Peles E, Hadani M. Management and outcome of non-traumatic

cerebellar haemorrhage. Cerebrovasc Dis 2002; 14: 207-13.

41. St Louis EK, Wijdicks EF, Li H. Predicting neurologic deterioration in patients with cerebellar

hematomas. Neurology 1998; 51: 1364-9.

42. Poungvarin N, Bhoopat W, Viriyavejakul A, Rodprasert P, Buranasiri P, Sukondhabhant S, et al.

Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 1987;

316: 1229-33.

43. De Reuck J, De Bleecker J, Reyntjens K. Steroid treatment in primary intracerebral haemorrhage.

Acta Neurol Belg 1989; 89: 7-11.

27

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

µ“√“ß∑’Ë 1.

√–¥—∫§”·π–π”Õ‘ß§ÿ≥¿“æ¢ÕßÀ≈—°∞“π ( Strength of Recommendation)

Grade Recommendation

A supported by data from randomized controlled trials with low false-positive and

low false-negative errors

B supported by data from randomized controlled trials with high false-positive and

high false-negative errors

C supported by data from non-randomized cohort studies, case series, case report,

expert opinion or consensus

µ“√“ß∑’Ë 2.

√ÿª°“√µ√«®«‘π‘®©—¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° (Diagnosis of Hemorrhagic Stroke)

¢âÕ∫àß™’È °“√µ√«®‡æ◊ËÕ«‘π‘®©—¬

1. ºŸâªÉ«¬∑’Ë ß —¬«à“‡ªìπ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° CT brain (grade A)

2. ∂â“ CT brain ª°µ‘ ≈—°…≥–∑“ß§≈‘π‘°‡¢â“‰¥â°—∫ SAH µ√«®πÈ”‰¢ —πÀ≈—ß

3. ºŸâªÉ«¬ ICH „π°√≥’¥—ßµàÕ‰ªπ’È §«√æ‘®“√≥“ àßµ√«® cerebral

- µ”·Àπàß‡≈◊Õ¥ÕÕ°∑’Ë‰¡à “¡“√∂À“ “‡Àµÿ‰¥â angiography (grade C)

- Õ“¬ÿ < 45 ªï

- ‰¡à¡’ª√–«—µ‘§«“¡¥—π‚≈À‘µ Ÿß

4. ºŸâªÉ«¬∑’Ë‡ªìπ Primary IVH , SAH §«√æ‘®“√≥“ àßµ√«® cerebral

angiography (grade C)

28

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

µ“√“ß∑’Ë 3.

°“√∫”∫—¥√—°…“∑“ßÕ“¬ÿ√°√√¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°

(Medical Management of Hemorrhagic Stroke)

1. Respiration

ºŸâªÉ«¬∑’ËÀ“¬„®‰¡àæÕ À√◊ÕÀ¡¥ µ‘ À√◊Õ¡’‚Õ°“ ‡°‘¥ ”≈—° §«√„ à∑àÕ™à«¬À“¬„® æ¬“¬“¡§«∫§ÿ¡

blood gas „ÀâÕ¬Ÿà„π‡°≥±åª°µ‘

2. Blood Pressure* 9,17

À≈’°‡≈’Ë¬ß¿“«– hypotension

§«∫§ÿ¡ mean arterial pressure (MAP) < 130 mmHg (grade C)

MAP = Diastolic BP + 1/3 (Systolic BP − Diastolic BP)

2.1 ∂â“ systolic BP > 230 mmHg À√◊Õ diastolic BP > 140 mmHg „Àâ

- Nitroprusside 0.25 - 10 µg/kg/min ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ‰¡à§«√„Àâµ‘¥µàÕ°—π‡°‘π 3 «—π À√◊Õ

- Nitroglycerine 5 mg ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” µ“¡¥â«¬ 1 - 4 mg/hr

- À“°‰¡à¡’¬“¥—ß°≈à“«¢â“ßµâπ Õ“®æ‘®“√≥“„™â¬“„πÀ—«¢âÕ∑’Ë 2.2 ·∑π

2.2 ∂â“ systolic BP = 180-230 mmHg À√◊Õ diastolic BP = 105-140 mmHg „Àâ

- Captopril 6.25-12.5 mg ∑“ßª“° ÕÕ°ƒ∑∏‘Ï¿“¬„π 15-30 π“∑’ Õ¬Ÿà‰¥âπ“π 4-6 ™.¡.À√◊Õ

- Small patch of nitroglycerine ªî¥Àπâ“Õ° À√◊Õ

- Hydralazine 5-10 mg ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ÕÕ°ƒ∑∏‘Ï ¿“¬„π 1-2 π“∑’ Õ¬Ÿà‰¥âπ“π 1-2 ™.¡. À√◊Õ

- Nicardepine º ¡¬“„Àâ¡’§«“¡‡¢â¡¢âπ 0.1-0.2 mg/ml ·≈â«„Àâ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”™â“ Ê 5 mg/hr.

- ‰¡à§«√„™â nifedipine Õ¡„µâ≈‘Èπ À√◊Õ∑“ßª“° ‡π◊ËÕß®“°‰¡à “¡“√∂∑”π“¬º≈¢Õß¬“‰¥â ·πàπÕπ

·≈–‰¡à “¡“√∂ª√—∫≈¥¬“‰¥âÀ“°‡°‘¥¿“«–§«“¡¥—π‚≈À‘µµË”¡“°

3. Temperature

ºŸâªÉ«¬∑’Ë¡’‰¢â Ÿß > 38.5 0 C §«√„Àâ¬“ acetaminophen À√◊Õ‡™Á¥µ—« À√◊Õ„™â cooling blanket

4. Fluid & Electrolyte*

- æ¬“¬“¡Õ¬à“„Àâ‡°‘¥ dehydration À√◊Õ overhydration ‚¥¬·µà≈–«—π ¡§«√„Àâ

ª√‘¡“≥ = urine output + 500 ml (insensible loss) + 300 ml/1oC ∑’Ë‡æ‘Ë¡¢÷Èπ

®“°Õÿ≥À¿Ÿ¡‘°“¬ª°µ‘ (37 oC)

- §«∫§ÿ¡§à“√–¥—∫ electrolyte „Àâª°µ‘*

* ¢π“¥¬“·≈–ª√‘¡“≥ “√πÈ”∑’Ë„™âπ’È‡À¡“– ”À√—∫ºŸâ„À≠à

29

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

µ“√“ß∑’Ë 4.

°“√√—°…“¿“«–§«“¡¥—π„π°–‚À≈°»’√…– Ÿß (Treatment of Increased Intracranial Pressure)

°“√√—°…“¿“«–§«“¡¥—π„π°–‚À≈°»’√…– Ÿß

1. „ÀâπÕπ¬°»’√…–·≈– à«π∫π¢Õß√à“ß°“¬ Ÿß 20-30 Õß»“

2. ®—¥∑à“ºŸâªÉ«¬‚¥¬„ÀâÀ≈’°‡≈’Ë¬ß°“√°¥∑—∫À≈Õ¥‡≈◊Õ¥¥”∑’Ë§Õ (jugular vein)

3. Clear airway „ à∑àÕ™à«¬À“¬„® ·≈– Foleyûs catheter

4. Hyperventilation ‡æ◊ËÕ„Àâ PaCO2 = 30-35 mmHg ·µà«‘∏’π’È¡’ª√–‚¬™πå„π™à«ß —Èπ Ê

°àÕπºà“µ—¥

5. æ‘®“√≥“„Àâ¬“*

- 20% mannitol : loading dose 1 gm/kg ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”¿“¬„π 20 π“∑’ µ“¡¥â«¬

0.25-0.5 gm/kg ∑ÿ° 6 ™—Ë«‚¡ß ‰¡à§«√„Àâµ‘¥µàÕ°—π‡°‘π 5 «—π (grade C) À√◊Õ

- 10% glycerol 250 ml ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ¿“¬„π 30 π“∑’ ∑ÿ° 6 ™—Ë«‚¡ß À√◊Õ

- 50% glycerol 50 ml ∑“ßª“° «—π≈– 4 §√—Èß À√◊Õ

- Furosemide 1 mg/kg ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” (grade C)

6. À≈’°‡≈’Ë¬ß°“√„Àâ hypotonic solution

7. °“√„™â steroid ¬—ß‰¡à¡’À≈—°∞“π∑“ß§≈‘π‘° π—∫ πÿπ«à“‰¥âª√–‚¬™πå42,43 (grade A)

* ¢π“¥¬“∑’Ë„™âπ’È‡À¡“– ”À√—∫ºŸâ„À≠à

30

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

µ“√“ß∑’Ë 5.

·π«∑“ß°“√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å„π‡√◊ËÕß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°

(Guidelines for Neurosurgical Consultation in Hemorrhagic Stroke)

µ”·Àπàß ‡°≥±å (criteria) √—°…“·∫∫ ª√÷°…“√–¥—∫ §”·π–π”

°âÕπ‡≈◊Õ¥ ª√–§—∫ª√–§Õß ª√– “∑»—≈¬·æ∑¬å (recommendation

grading)

Lobar 1. GCS < 13 Criteria < 2 Criteria > 2 C

2 Volume > 30 ml

3. Midline shift > 0.5 cm.

Temporal lobe - ª√÷°…“∑ÿ°√“¬ C

Basal ganglia 1. GCS < 13 Criteria < 2 Criteria > 2 C

2. Volume > 30 ml


Thalamus 1. GCS < 13 Criteria < 2 Criteria > 2 C

2. Volume > 10 ml


Cerebellum 1. GCS < 13 Criteria = 0 Criteria > 1 C

2. Volume > 15 ml

3. HC or IVH with HC

Cerebellar vermis - - ª√÷°…“∑ÿ°√“¬ C

Pons 1. GCS < 13 Criteria = 0 Criteria > 1 C

2. HC

3. IVH

4. Repeated episodes

Subarachnoid - - ª√÷°…“∑ÿ°√“¬ C

hemorrhage (SAH)

Primary - - ª√÷°…“∑ÿ°√“¬ C

intraventicular

hemorrhage (IVH)

Hydrocephalus (HC) - - ª√÷°…“∑ÿ°√“¬ C

31

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

¿“§ºπ«° 1

Siriraj Stroke Score (SSS)

32

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

¿“§ºπ«° 2

Glasgow Coma Scale (GCS)

Level of response Scale value

1. Eye opening

Spontaneously 4

To speech 3

To pain 2

None 1

2. Motor response

Obeys commands 6

Localizes to pain 5

Withdraws to pain 4

Abnormal flexion 3

Abnormal extension 2

None 1

3. Verbal response

Oriented 5

Confused 4

Inappropriate words 3

Incomprehensible 2

None 1

33

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

34

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

35

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

36

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

37

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

38

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

¢Õ¢Õ∫§ÿ≥

·æ∑¬å∑’Ë‡¢â“√à«¡ª√–™ÿ¡

°“√ª√–™ÿ¡/ —¡¡π“ª√—∫ª√ÿß·π«∑“ß‡«™ªÆ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

≥ ÀâÕßæ“‚π√“¡“ 1 ™—Èπ 14 ‚√ß·√¡¥‘ ‡Õ¡‡¡Õ√—≈¥å

«—π∑’Ë 9 › 10 ‘ßÀ“§¡ 2547

1. æµ∑. æ≠.«√√≥’¬å µ√–°“√«π‘™ ‚√ßæ¬“∫“≈µ”√«® °√ÿß‡∑æ¡À“π§√

2. πæ. À— ‡À≈’Ë¬¡ ÿ«√√≥ ∂“∫—π ÿ¢¿“æ‡¥Á°·Ààß™“µ‘¡À“√“™‘π’ °√ÿß‡∑æ¡À“π§√

3. πæ. ¡∫—µ‘ ¡ÿàß∑«’æß…“ ‚√ßæ¬“∫“≈∏√√¡»“ µ√å‡©≈‘¡æ√–‡°’¬√µ‘ °√ÿß‡∑æ¡À“π§√

4. πæ. ÿ°‘® ∑—»π ÿπ∑√«ß»å ‚√ßæ¬“∫“≈‡≈‘¥ ‘π °√ÿß‡∑æ¡À“π§√

5. √».æ≠.π‘®»√’ ™“≠≥√ß§å §≥–·æ∑¬»“ µ√å ®ÿÃ“≈ß°√≥å¡À“«‘∑¬“≈—¬ °√ÿß‡∑æ¡À“π§√

6. πæ.™—™«“≈ ÿ√‘π∑√å‚¬∏‘π ‚√ßæ¬“∫“≈π§√ª∞¡ π§√ª∞¡

7. πæ. ¡™—¬ µ—Èß∫”‡æÁ≠ ÿπ∑√ ‚√ßæ¬“∫“≈π§√ª∞¡ π§√ª∞¡

8. πæ.«‘√—™ °≈‘Ëπ∫—«·¬â¡ ‚√ßæ¬“∫“≈ —π°”·æß ‡™’¬ß„À¡à

9. πæ.«’√–«—≤πå ÿ¢ ßà“‡®√‘≠ ‚√ßæ¬“∫“≈ª√– “∑‡™’¬ß„À¡à ‡™’¬ß„À¡à

10. πæ. ¡‡°’¬√µ‘ ≈’≈“æ—π∏å‰æ∫Ÿ≈¬å ‚√ßæ¬“∫“≈∫â“π∫÷ß ™≈∫ÿ√’

11. πæ.æß…åπ‡√» ‚æ∏‘‚¬∏‘π ‚√ßæ¬“∫“≈ ÿ√‘π∑√å ÿ√‘π∑√å

12. πæ.©—µ√™—¬ ∫ÿ≠ª√–™“√—µπå ‚√ßæ¬“∫“≈ÀπÕß§“¬ ÀπÕß§“¬

13. πæ.¿“≥ÿ¡“» ¢«—≠‡√◊Õπ ‚√ßæ¬“∫“≈·æ√à ·æ√à

14. πæ.∑√ß«ÿ≤‘ ÿ‡¡∏«“∑“π‘¬ ‚√ßæ¬“∫“≈≈”æŸπ ≈”æŸπ

15. πæ.∫—≥±‘µ À«—ß —πµ‘«√»“ ‚√ßæ¬“∫“≈æ¬—§¶¿Ÿ¡‘æ‘ —¬ ¡À“ “√§“¡

16. πæ. —πµ‘ Õ—ß§≥“‚ ¿‘µ ‚√ßæ¬“∫“≈Õà“ß∑Õß Õà“ß∑Õß

17. πæ.«‘∫Ÿ≈¬å ‡µ™–‚°»≈ ‚√ßæ¬“∫“≈√âÕ¬‡ÕÁ¥ √âÕ¬‡ÕÁ¥

18. πæ.«ÿ≤‘π—π∑å æ—π∏–‡ π ‚√ßæ¬“∫“≈∫ÿ√’√—¡¬å ∫ÿ√’√—¡¬å

19. æ≠.æ“Ωíπ ¡ÿ ‘°«—µ√ ‚√ßæ¬“∫“≈¡À“√“™π§√»√’∏√√¡√“™ π§√»√’∏√√¡√“™

20. πæ.∏π‘π∑√å Õ—»««‘‡™’¬√®‘π¥“ ‚√ßæ¬“∫“≈¡À“√“™π§√√“™ ’¡“ π§√√“™ ’¡“

21. πæ.°‘µµ‘°√ ª√– “∑æ√‚√®πå ‚√ßæ¬“∫“≈ª√–®«∫§’√’¢—π∏å ª√–®«∫§’√’¢—π∏å

22. πæ.∏«—™ ®—π·¥ß ‚√ßæ¬“∫“≈π§√æπ¡ π§√æπ¡

23. πæ.¡ÿ®≈‘π∑å ‡©≈‘¡æ√æß»å ‚√ßæ¬“∫“≈æ√–ª°‡°≈â“ ®—π∑∫ÿ√’

39

·π«∑“ß‡«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

24. πæ.™—¬ ’Àå Õ“ –π–‡ π ‚√ßæ¬“∫“≈»√’ —ß«“≈¬å ·¡àŒàÕß Õπ

25. πæ.æß…å«—≤πå æ≈æß…å ‚√ßæ¬“∫“≈√“…’‰»≈ »√’ –‡°…

26. πæ.∏’√«—≤πå √—°®‘µ√ ‚√ßæ¬“∫“≈æ‘®‘µ√ æ‘®‘µ√

27. πæ.°‘µµ‘™—¬ ªí°∏ß‰™¬ ‚√ßæ¬“∫“≈æ√–π§√»√’Õ¬ÿ∏¬“ æ√–π§√»√’Õ¬ÿ∏¬“

28. πæ. ÿ¢ —πµå ‡µ™–æ‘ ÿ∑∏‘Ï ‚√ßæ¬“∫“≈ «√√§åª√–™“√—°…å π§√ «√√§å

29. πæ.‡©≈‘¡æ≈ ™§—µµ√¬“æß…å ‚√ßæ¬“∫“≈‡¡◊Õß©–‡™‘ß‡∑√“ ©–‡™‘ß‡∑√“

30. æ≠.∏πæ√ ‡æ™√«‘∫Ÿ≈ ‚√ßæ¬“∫“≈ ¡ÿ∑√ “§√ ¡ÿ∑√ “§√

31. πæ.∏“π’ „∫·°â« ‚√ßæ¬“∫“≈ ÿ√“…Æ√å∏“π’ ÿ√“…Æ√å∏“π’

32. πæ.¿“≥ÿ¡“» ªî¬–√µ‘√—µπå ‚√ßæ¬“∫“≈¢Õπ·°àπ ¢Õπ·°àπ

33. πæ.æ—≈≈¿ ¬Õ¥»‘√®‘π¥“ ‚√ßæ¬“∫“≈™—¬π“∑ ™—¬π“∑

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