prasatwitthaya · §”π‘¬¡ ¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus)...
TRANSCRIPT
![Page 1: Prasatwitthaya · §”π‘¬¡ ¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus) ‡ªìπ‚√§¢Õß√–∫∫ª√– “∑ à«π°≈“ß (central nervous](https://reader033.vdocuments.mx/reader033/viewer/2022053113/608bbce52a94383b983b5284/html5/thumbnails/1.jpg)
![Page 2: Prasatwitthaya · §”π‘¬¡ ¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus) ‡ªìπ‚√§¢Õß√–∫∫ª√– “∑ à«π°≈“ß (central nervous](https://reader033.vdocuments.mx/reader033/viewer/2022053113/608bbce52a94383b983b5284/html5/thumbnails/2.jpg)
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
(Clinical Practice Guidelines for Hydrocephalus)
©∫—∫∑’Ë 1 æ.». 2549 (æ‘¡æå§√—Èß∑’Ë 1)
ISBN : 974-422-313-8
![Page 3: Prasatwitthaya · §”π‘¬¡ ¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus) ‡ªìπ‚√§¢Õß√–∫∫ª√– “∑ à«π°≈“ß (central nervous](https://reader033.vdocuments.mx/reader033/viewer/2022053113/608bbce52a94383b983b5284/html5/thumbnails/3.jpg)
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”π’È ‡ªìπ‡§√◊ËÕß¡◊Õ à߇ √‘¡
§ÿ≥¿“æ¢Õß°“√∫√‘°“√¥â“π ÿ¢¿“æ∑’ˇÀ¡“– ¡°—∫∑√—欓°√·≈–
‡ß◊ËÕπ‰¢ —ߧ¡‰∑¬ ‚¥¬À«—ߺ≈„π°“√ √â“߇ √‘¡·≈–·°â‰¢ªí≠À“
ÿ¢¿“æ¢Õߧπ‰∑¬Õ¬à“ß¡’ª√– ‘∑∏‘¿“æ·≈–§ÿâ¡§à“ ¢âÕ·π–π”µà“ß Ê
„π·π«∑“ß°“√√—°…“π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—µ‘ ºŸâ„™â “¡“√∂
ªØ‘∫—µ‘·µ°µà“߉ª®“°¢âÕ·π–π”‰¥â „π°√≥’∑’Ë ∂“π°“√≥å·µ°µà“ß
ÕÕ°‰ªÀ√◊Õ¡’‡Àµÿº≈∑’Ë ¡§«√ ‚¥¬„™â«‘®“√≥≠“≥∑’ˇªìπ∑’ˬա√—∫
„π —ߧ¡
![Page 4: Prasatwitthaya · §”π‘¬¡ ¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus) ‡ªìπ‚√§¢Õß√–∫∫ª√– “∑ à«π°≈“ß (central nervous](https://reader033.vdocuments.mx/reader033/viewer/2022053113/608bbce52a94383b983b5284/html5/thumbnails/4.jpg)
§”π‘¬¡
¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus) ‡ªìπ‚√§¢Õß√–∫∫ª√– “∑ à«π°≈“ß (central nervous
system) ∑’Ëæ∫∫àÕ¬„πºŸâªÉ«¬∑ÿ°°≈ÿà¡Õ“¬ÿ ‚¥¬¡’Õÿ∫—µ‘°“√≥å¡“°„π‡¥Á° ¿“«–π’ȇ°‘¥®“°°“√ √â“ßπÈ”‰¢ —πÀ≈—ß
¡“°º‘¥ª°µ‘ À√◊ժ—Èπ∑“߇¥‘ππÈ”‰¢ —πÀ≈—ß™—Ë«§√“«À√◊Õ∂“«√ À√◊Õ°“√¥Ÿ¥´÷¡°≈—∫¢ÕßπÈ”‰¢ —πÀ≈—ß
∑“ßÀ≈Õ¥‡≈◊Õ¥¥”º‘¥ª°µ‘ à«π„À≠à “¡“√∂µ√«®æ∫ “‡Àµÿ‰¥â (secondary hydrocephalus) ‡™àπ ‡π◊ÈÕßÕ°
„π ¡Õß ‡≈◊Õ¥ÕÕ°„π ¡Õß °“√µ‘¥‡™◊ÈÕ„π ¡Õß venous sinus thrombosis ‡ªìπµâπ ¡’‡æ’¬ß à«ππâÕ¬∑’Ë
°“√µ√«®«‘π‘®©—¬∑“ßÀâÕߪؑ∫—µ‘°“√„πªí®®ÿ∫—π‰¡à “¡“√∂µ√«®æ∫ “‡Àµÿ‰¥â (idiopathic À√◊Õ primary
hydrocephalus) ‡π◊ËÕß®“°„π·µà≈– ∂“π欓∫“≈¡’§«“¡·µ°µà“ß„π¥â“π∫ÿ§≈“°√·≈–‡§√◊ËÕß¡◊Õ∑’Ë„™â«‘π‘®©—¬
∑“ß°“√·æ∑¬å √«¡∑—Èß°“√°√–®“¬∑’ˉ¡à‡À¡“– ¡ ®÷ß¡’‡«™ªØ‘∫—µ‘∑’Ë·µ°µà“ß°—π∑—Èߥâ“π°“√«‘π‘®©—¬·≈–°“√∫”∫—¥
√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
∂“∫—πª√– “∑«‘∑¬“ „π∞“𖇪ìπ ∂“∫—π«‘™“°“√‡©æ“–∑“ߥâ“π√–∫∫ª√– “∑„π√–¥—∫ Ÿß°«à“µµ‘¬¿Ÿ¡‘
‰¥âµ√–Àπ—°∂÷ߪí≠À“¥—ß°≈à“« ®÷߉¥â®—¥∑”·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”„π√–¥—∫ª√–‡∑» ‚¥¬√à«¡°—∫
ºŸâ∑√ߧÿ≥«ÿ≤‘·≈–ºŸâ‡™’ˬ«™“≠¥â“π°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”∑—Ë«ª√–‡∑» ‡æ◊ËÕÀ«—ß„À⇰‘¥ª√–‚¬™πå
·°à·æ∑¬å·≈–∫ÿ§≈“°√ºŸâ‡°’ˬ«¢âÕßÕ¬à“ß·∑â®√‘ß „π°“√∑’Ë®–𔧫“¡√Ÿâ∑’ˉ¥â√—∫‰ªªØ‘∫—µ‘‰¥â∂Ÿ°µâÕß·≈–‡ªìπ
¡“µ√∞“π‡¥’¬«°—π∑—Ë«ª√–‡∑» ‚¥¬¡’°“√¥”‡π‘π°“√¥—ßπ’È
1. ª√–™ÿ¡§≥–∑”ß“πºŸâ∑√ߧÿ≥«ÿ≤‘·≈–ºŸâ‡™’ˬ«™“≠ „π«—π∑’Ë 17 ¡°√“§¡ - 9 ¡’π“§¡ 2549
2. ®—¥ àß·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (©∫—∫√à“ß) æ√âÕ¡·∫∫ª√–‡¡‘π„Àâ·æ∑¬å∑—Ë«ª√–‡∑»
‚¥¬ºà“π∑“ߧ≥–·æ∑¬»“ µ√å¢Õß¡À“«‘∑¬“≈—¬µà“ß Ê ‚√ß欓∫“≈»Ÿπ¬å ‚√ß欓∫“≈∑—Ë«‰ª ·≈– ”π—°ß“π
“∏“√≥ ÿ¢®—ßÀ«—¥ „π«—π∑’Ë 5 ‡¡…“¬π 2549
3. ‡™‘≠·æ∑¬å∑—Ë«ª√–‡∑»‡¢â“√à«¡ª√–™ÿ¡/ —¡¡π“ ª√—∫ª√ÿß·π«∑“ßœ (©∫—∫√à“ß) „π«—π∑’Ë 20 - 21
°√°Æ“§¡ 2549
Õ¬à“߉√°Áµ“¡ ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”©∫—∫π’È ‡ªì𧔷π–π”„π ‘Ëß∑’˧«√·°à°“√
ªØ‘∫—µ‘‡∑à“π—Èπ ∑—Èßπ’È „π°“√ªØ‘∫—µ‘®√‘ߢ÷Èπ°—∫¥ÿ≈¬æ‘π‘®¢Õß·æ∑¬åºŸâ¥Ÿ·≈ºŸâªÉ«¬¢≥–π—Èπ‡ªì𠔧—≠
„π∑⓬∑’Ë ÿ¥π’È ∂“∫—πª√– “∑«‘∑¬“À«—߇ªìπÕ¬à“߬‘Ëß«à“ ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
©∫—∫π’È ®—°‡°‘¥ª√–‚¬™πå ”À√—∫·æ∑¬å∑’Ë®–𔉪ª√–¬ÿ°µå„™â ‡æ◊ËÕ„Àâª√–™“™π¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥’ „π‚Õ°“ π’È
„§√à¢Õ¢Õ∫§ÿ≥ √“™«‘∑¬“≈—¬°ÿ¡“√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ¡“§¡ª√– “∑»—≈¬»“ µ√å ·Ààߪ√–‡∑»‰∑¬
¡“§¡°ÿ¡“√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ °√¡·æ∑¬å∑À“√∫° §≥–·æ∑¬»“ µ√宓°¡À“«‘∑¬“≈—¬µà“ß Ê ∑’ˉ¥â
„À⧫“¡√à«¡¡◊ÕÕ¬à“ߥ’„π°“√®—¥∑” √«¡∑—Èß°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢ ∑’Ë π—∫ πÿπ°“√¥”‡π‘πß“π§√—Èßπ’È
Õ¬à“ߥ’¬‘Ëß
(π“¬¡—¬∏—™ “¡‡ π)
ºŸâÕ”π«¬°“√ ∂“∫—πª√– “∑«‘∑¬“
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![Page 5: Prasatwitthaya · §”π‘¬¡ ¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus) ‡ªìπ‚√§¢Õß√–∫∫ª√– “∑ à«π°≈“ß (central nervous](https://reader033.vdocuments.mx/reader033/viewer/2022053113/608bbce52a94383b983b5284/html5/thumbnails/5.jpg)
§≥–ºŸâ®—¥∑”
1. πæ. ¡“π µ—ÈßÕ√ÿ≥»‘≈ªá ª√–∏“π ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
2. √». πæ.Õπ—πµåπ‘µ¬å «‘ ÿ∑∏‘æ—π∏åÿ √“™«‘∑¬“≈—¬°ÿ¡“√·æ∑¬å·Ààߪ√–‡∑»‰∑¬
3. πæ.™àՇ撬« ‡µ‚™Ã“√ ¡“§¡ª√– “∑»—≈¬»“ µ√å·Ààߪ√–‡∑»‰∑¬
4. º». πæ.‡Õ° À—ß Ÿµ §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏‘∫¥’
5. æ.Õ. πæ. ‘√√ÿ®πå °ÿ≈≥–¡√√§“ ¡“§¡ª√– “∑»—≈¬»“ µ√å·Ààߪ√–‡∑»‰∑¬
6. πæ. ¡®‘µ »√’Õÿ¥¡¢®√ ∂“∫—π ÿ¢¿“懥Á°·Ààß™“µ‘¡À“√“™‘π’ °√¡°“√·æ∑¬å
7. πæ.«‘∫Ÿ≈¬å °“≠®πæ—≤π°ÿ≈ ∂“∫—π ÿ¢¿“懥Á°·Ààß™“µ‘¡À“√“™‘π’ °√¡°“√·æ∑¬å
8. πæ.¿“≥ÿ π“®√ÿß ∂“∫—π ÿ¢¿“懥Á°·Ààß™“µ‘¡À“√“™‘π’ °√¡°“√·æ∑¬å
9. πæ.æ‘™‘µ Õπÿ«ÿ≤‘π“«‘π ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
10. æ≠.°—≈¬“≥å ∏’√–«‘∫Ÿ≈¬å ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
11. πæ.摇™…∞ ‡¡∏“√—°…å™’æ ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
12. æ≠.Õ“¿“»√’ ≈ÿ «— ¥‘Ï ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
13. πæ.°ÿ≈æ—≤πå «’√ “√ ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
14. πæ.∏’√™—¬ º“≥‘µæß»å ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
15. πæ. ÿ√»—°¥‘Ï ‚°¡≈®—π∑√å ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
16. π. .Õ‘ √’ µ√’°¡≈ ‡≈¢“πÿ°“√ ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
∫√√≥“∏‘°“√ : πæ. ¡“π µ—ÈßÕ√ÿ≥»‘≈ªá
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![Page 6: Prasatwitthaya · §”π‘¬¡ ¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus) ‡ªìπ‚√§¢Õß√–∫∫ª√– “∑ à«π°≈“ß (central nervous](https://reader033.vdocuments.mx/reader033/viewer/2022053113/608bbce52a94383b983b5284/html5/thumbnails/6.jpg)
§≥–∑”ß“π‚§√ß°“√®—¥∑”·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
1. πæ. ÿ√«‘∑¬å ‡µ™∏ÿ«“ππ∑å ∑’˪√÷°…“
2. πæ.¡—¬∏—™ “¡‡ π ∑’˪√÷°…“
3. æ≈.Õ.µ. πæ.§”æ√ ™“≠«‘‡»… ∑’˪√÷°…“
4. πæ.æ‘™‘µ Õπÿ«ÿ≤‘π“«‘π ∑’˪√÷°…“
5. æ≠.°—≈¬“≥å ∏’√–«‘∫Ÿ≈¬å ∑’˪√÷°…“
6. πæ.Õ—¡æ√ ®ß‡ √’®‘µµå ∑’˪√÷°…“
7. πæ. ¡“π µ—ÈßÕ√ÿ≥»‘≈ªá ª√–∏“π
8. √». æ≠.®‘√æ√ ‡À≈à“∏√√¡∑—»πå §≥–∑”ß“π
9. πæ.™àՇ撬« ‡µ‚™Ã“√ §≥–∑”ß“π
10. πæ.Õπ—πµåπ‘µ¬å «‘ ÿ∑∏‘æ—π∏ÿå §≥–∑”ß“π
11. º». πæ.‡Õ° À—ß Ÿµ §≥–∑”ß“π
12. æ.Õ. πæ. ‘√√ÿ®πå °ÿ≈≥–¡√√§“ §≥–∑”ß“π
13. πæ.™“§√‘π∑√å ≥ ∫“ß™â“ß §≥–∑”ß“π
14. πæ. ¡®‘µ »√’Õÿ¥¡¢®√ §≥–∑”ß“π
15. πæ.¿“≥ÿ π“®√ÿß §≥–∑”ß“π
16. πæ.摇™…∞ ‡¡∏“√—°…å™’æ §≥–∑”ß“π
17. æ≠.Õ“¿“»√’ ≈ÿ «— ¥‘Ï §≥–∑”ß“π
18. πæ.°ÿ≈æ—≤πå «’√ “√ §≥–∑”ß“π
19. πæ.∏’√™—¬ º“≥‘µæß»å ‡≈¢“πÿ°“√
20. π. .Õ‘ √’ µ√’°¡≈ ºŸâ™à«¬‡≈¢“πÿ°“√
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§”π”
¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (Hydrocephalus) æ∫‰¥â°—∫ºŸâªÉ«¬∑ÿ°°≈ÿà¡Õ“¬ÿ à«π„À≠à¡’ “‡Àµÿ´÷Ëßµ√«®
æ∫‰¥â ¡’‡æ’¬ß à«ππâÕ¬∑’Ë°“√µ√«®«‘π‘®©—¬∑“ßÀâÕߪؑ∫—µ‘°“√„πªí®®ÿ∫—π‰¡à “¡“√∂µ√«®æ∫ “‡Àµÿ‰¥â ¿“«–π’È
¬—ß¡’ªí≠À“„π¥â“π°“√µ√«®«‘π‘®©—¬ ·≈–°“√¥Ÿ·≈√—°…“ ¥—ßπ—Èπ ∂“∫—πª√– “∑«‘∑¬“ „π∞“π–∑’ˇªìπ ∂“∫—π
‡©æ“–∑“ß‚√§√–∫∫ª√– “∑ ®÷߉¥â√à«¡°—∫§≥–·æ∑¬åºŸâ‡™’ˬ«™“≠®“°√“™«‘∑¬“≈—¬»—≈¬·æ∑¬å·Ààߪ√–‡∑»‰∑¬
√“™«‘∑¬“≈—¬°ÿ¡“√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ¡“§¡ª√– “∑»—≈¬»“ µ√å·Ààߪ√–‡∑»‰∑¬ ¡“§¡°ÿ¡“√·æ∑¬å
·Ààߪ√–‡∑»‰∑¬ °√¡·æ∑¬å∑À“√∫° ·≈–§≥–·æ∑¬»“ µ√宓°¡À“«‘∑¬“≈—¬µà“ß Ê ®—¥∑”·π«∑“ß°“√√—°…“
¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å ‡æ◊ËÕ𔉪ªØ‘∫—µ‘‡ªìπ·π«∑“߇¥’¬«°—π ™à«¬„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬Õ¬à“ß¡’
ª√– ‘∑∏‘¿“æ ·≈– “¡“√∂𔉪ª√—∫„™â„Àâ‡À¡“– ¡°—∫·µà≈–‚√ß欓∫“≈
§≥–ºŸâ®—¥∑”
°√°Æ“§¡ 2549
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“√∫—≠
Àπâ“
§”π‘¬¡
√“¬π“¡§≥–ºŸâ®—¥∑”
√“¬π“¡§≥–∑”ß“π
§”π”
∫∑π” 1
∫∑∑’Ë 1 ·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë ß —¬¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ” 3
(Management of patients suspected of hydrocephalus)
∫∑∑’Ë 2 ·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë ß —¬«à“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”√à«¡°—∫ 5
§«“¡¥—π„π°–‚À≈°»’√…– Ÿß
(Management of patients suspected of HCP with increased intracranial pressure)
∫∑∑’Ë 3 ·π«∑“ß°“√∫”∫—¥√—°…“‡¥Á°‡°‘¥°àÕπ°”Àπ¥∑’Ë¡’‡≈◊Õ¥ÕÕ°„π‚æ√ß ¡Õß 12
·≈– ß —¬«à“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
(Management of preterm babies suspected of hydrocephalus)
∫∑∑’Ë 4 ·π«∑“ß°“√∫”∫—¥√—°…“‡¥Á°·√°§≈Õ¥∑’Ë¡’ myelomeningocele/encephalomeningocele 14
(Management of newborn infants with myelomeningocele/encephalomeningocele)
∫∑∑’Ë 5 ·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬ ŸßÕ“¬ÿ∑’Ë ß —¬‡ªìπ normal pressure hydrocephalus 17
(Management of elderly patients suspected of normal pressure hydrocephalus)
‡Õ° “√Õâ“ßÕ‘ß 20
¿“§ºπ«°
1. Õ“°“√· ¥ß¢Õß¿“«–§«“¡¥—π„π°–‚À≈°»’√…– Ÿß„π‡¥Á°‡≈Á° 22
(Signs of increased intracranial pressure in infants)
2. ¿“æ∂à“¬∑“ß√—ß ’„πºŸâªÉ«¬ normal pressure hydrocephalus 28
(MR Imaging of normal pressure hydrocephalus)
3. CSF diversion 32
4. ·∫∫∑¥ Õ∫æ—≤π“°“√ (Denver II) ©∫—∫¿“…“‰∑¬ 34
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“√∫—≠·ºπ¿Ÿ¡‘
Àπâ“
·ºπ¿Ÿ¡‘∑’Ë 1 3
°“√®”·π°ºŸâªÉ«¬∑’Ë ß —¬«à“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
(Categorization of patients suspected of hydrocephalus)
·ºπ¿Ÿ¡‘∑’Ë 2 6
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë ß —¬«à“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”√à«¡°—∫§«“¡¥—π„π°–‚À≈°
»’√…– Ÿß
(Management of patients suspected of HCP with increased intracranial pressure)
·ºπ¿Ÿ¡‘∑’Ë 2.1 7
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”®“°°“√Õÿ¥µ—π¢Õß√–∫∫‚æ√ß ¡Õß
(Management of patients with hydrocephalus from ventricular obstruction)
·ºπ¿Ÿ¡‘∑’Ë 2.2 8
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”®“°°“√Õÿ¥µ—ππÈ”‰¢ —πÀ≈—ß
∑’˵”·Àπàß foramen of Monro
(Management of patients with hydrocephalus from obstruction at foramen of Monro)
·ºπ¿Ÿ¡‘∑’Ë 2.3 10
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”®“°°“√Õÿ¥µ—ππÈ”‰¢ —πÀ≈—ß
∑’˵”·Àπàߵ˔°«à“ third ventricle
(Management of patients with hydrocephalus from obstruction distal to third ventricle)
·ºπ¿Ÿ¡‘∑’Ë 3 13
·π«∑“ß°“√∫”∫—¥√—°…“‡¥Á°§≈Õ¥°àÕπ°”Àπ¥∑’Ë¡’‡≈◊Õ¥ÕÕ°„π‚æ√ß ¡Õß ·≈– ß —¬
¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
(Management of preterm baby with intraventricular hemorrhage suspected of hydrocephalus)
·ºπ¿Ÿ¡‘∑’Ë 4 16
·π«∑“ß°“√∫”∫—¥√—°…“‡¥Á°·√°§≈Õ¥∑’Ë¡’ myelomeningocele À√◊Õ encephalomeningocele
(Management of newborn with myelomeningocele or encephalomeningocele)
·ºπ¿Ÿ¡‘∑’Ë 5 19
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬ ŸßÕ“¬ÿ∑’Ë ß —¬‡ªìπ normal pressure hydrocephalus
(Management of elderly patient suspected of normal pressure hydrocephalus)
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“√∫—≠√Ÿª¿“æ
Àπâ“
√Ÿª∑’Ë 1 Tensed and bulged anterior fontanelle 22
√Ÿª∑’Ë 2 Dilated scalp vein 22
√Ÿª∑’Ë 3 °“√µ√«®¥â«¬«‘∏’ transillumination ‚¥¬„™â‰ø©“¬ àÕß∑’Ë anterior fontanel 23
√Ÿª∑’Ë 4 Transillumination test 23
√Ÿª∑’Ë 5 Fronto-ethmoidal encephalomeningocele 24
√Ÿª∑’Ë 6 Myelomeningocele 24
√Ÿª∑’Ë 7 Ultrasound of hydrocephalus 25
√Ÿª∑’Ë 8 MRI of intraventricular tumor 25
√Ÿª∑’Ë 9 MRI of Chiari malformation 25
√Ÿª∑’Ë 10 ·ºπ¿Ÿ¡‘· ¥ß§à“ª°µ‘¢Õß°“√‡®√‘≠‡µ‘∫‚µ¢Õß∑“√°∑’˧≈Õ¥°àÕπ°”Àπ¥®π∂÷ßÕ“¬ÿ 1 ªï 26
√Ÿª∑’Ë 11 ·ºπ¿Ÿ¡‘· ¥ß§à“‡ âπ√Õ∫«ß»’√…– (occipito-frontal circumference; OFC) 27
„π‡¥Á°Õ“¬ÿµ—Èß·µà·√°‡°‘¥∂÷ß 3 ªï
√Ÿª∑’Ë 12 Axial T2W MR shows ventriculomegaly. 28
√Ÿª∑’Ë 13 Sagittal T1W MR shows aqueductal flow void sign. 28
√Ÿª∑’Ë 14 T2W MR shows enlarged ventricles with rounded frontal horns. 28
√Ÿª∑’Ë 15 Axial FLAIR MR shows ventriculomegaly out of proportion to sulcal enlargement. 28
√Ÿª∑’Ë 16 Axial CT scan with contrast media shows symmetrical dilatation of ventricles 28
out of proportion to sulcal enlargement.
√Ÿª∑’Ë 17 Axial CT scan with contrast media shows frontal and occipital periventricular 28
hypodensities suggest transependymal CSF flow.
√Ÿª∑’Ë 18 Proton MR spectra (TR/TE, 2000/135) in the patient with NPH. 29
√Ÿª∑’Ë 19 Proton MR spectra (TR/TE, 2000/135) in two patients with NPH. 30
√Ÿª∑’Ë 20 Proton MR spectra (TR/TE, 2000/135) before and after continuous spinal drainage 31
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µ—«¬àÕ
CNS = Central nervous system
CSF = Cerebrospinal fluid
CT = Computerized tomography
DDST = Denver developmental screening test
EVD = External ventricular drainage
HCP = Hydrocephalus
ICP = Increased intracranial pressure
IVH = Intraventricular hemorrhage
LP = Lumbar puncture
MRI = Magnetic resonance imaging
MRS = Magnetic resonance spectroscopy
MRV = Magnetic resonance venography
NPH = Normal pressure hydrocephalus
PHH = Post hemorrhagic hydrocephalus
US = Ultrasound
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∫∑π”
¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus) ‡ªìπ‚√§¢Õß√–∫∫ª√– “∑ à«π°≈“ß (central nervous
system) ‡ªìπ¿“«–∑’Ëæ∫∫àÕ¬„πºŸâªÉ«¬∑ÿ°°≈ÿà¡Õ“¬ÿ1 ‚¥¬¡’Õÿ∫—µ‘°“√≥å¡“°„π‡¥Á°2, 3 ¿“«–π’ȇ°‘¥®“°°“√ √â“ß
πÈ”‰¢ —πÀ≈—ß¡“°º‘¥ª°µ‘À√◊ժ—Èπ∑“߇¥‘ππÈ”‰¢ —πÀ≈—ß™—Ë«§√“«À√◊Õ∂“«√ À√◊Õ°“√¥Ÿ¥´÷¡°≈—∫¢ÕßπÈ”‰¢ —πÀ≈—ß
∑“ßÀ≈Õ¥‡≈◊Õ¥¥”º‘¥ª°µ‘ à«π„À≠à “¡“√∂µ√«®æ∫ “‡Àµÿ‰¥â (secondary hydrocephalus) ‡™àπ ‡π◊ÈÕßÕ°
„π ¡Õß ‡≈◊Õ¥ÕÕ°„π ¡Õß °“√µ‘¥‡™◊ÈÕ„π ¡Õß venous sinus thrombosis ‡ªìπµâπ ¡’‡æ’¬ß à«ππâÕ¬∑’Ë°“√µ√«®
«‘π‘®©—¬∑“ßÀâÕߪؑ∫—µ‘°“√„πªí®®ÿ∫—π‰¡à “¡“√∂µ√«®æ∫ “‡Àµÿ‰¥â (idiopathic À√◊Õ primary hydrocephalus)
‡π◊ËÕß®“°„π·µà≈– ∂“π欓∫“≈¡’§«“¡·µ°µà“ß„π¥â“π∫ÿ§≈“°√·≈–‡§√◊ËÕß¡◊Õ∑’Ë„™â«‘π‘®©—¬∑“ß°“√·æ∑¬å
√«¡∑—Èß°“√°√–®“¬∑’ˉ¡à‡À¡“– ¡ ®÷ß¡’‡«™ªØ‘∫—µ‘‰¡à‡À¡◊Õπ°—π∑—Èߥâ“π°“√«‘π‘®©—¬·≈–°“√∫”∫—¥√—°…“¿“«–
‚æ√ß ¡Õߧ—ËßπÈ” ‚¥¬‡©æ“–„π‡¥Á°§≈Õ¥°àÕπ°”Àπ¥ (preterm baby) ‡¥Á°∑’ˇªìπ myelomeningocele À√◊Õ
„πºŸâªÉ«¬ ŸßÕ“¬ÿ∑’ˇªìπ normal pressure hydrocephalus ¥—ßπ—Èπ°“√®—¥∑”·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
®÷߇ªìπ·π«∑“ߙ૬„Àâ·æ∑¬å “¡“√∂𔉪ªØ‘∫—µ‘À√◊Õæ‘®“√≥“ àßµàÕºŸâªÉ«¬‰¥âÕ¬à“߇À¡“– ¡ µ“¡»—°¬¿“æ
¢Õß·µà≈– ∂“π欓∫“≈ ∑—Ë«ª√–‡∑»
Õπ÷Ëß·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”©∫—∫π’È ¡‘‰¥â¡’‡®µπ“„Àâ·æ∑¬åºŸâªØ‘∫—µ‘𔉪‡ªìπ
·π«∑“ß„π°“√√—°…“¿“«–§«“¡¥—π„π°–‚À≈°»’√…– Ÿß®“° “‡ÀµÿÕ◊Ëπ Ê ‡™àπ ¿“«–µ‘¥‡™◊ÈÕ„π ¡Õß
‚√§À≈Õ¥‡≈◊Õ¥ ¡ÕßÀ√◊Õ∫“¥‡®Á∫∑’Ë»’√…– ‡ªìπµâπ ·¡â«à“„π¿“«–‡À≈à“π’ȺŸâªÉ«¬Õ“®®–¡’Õ“°“√·≈–Õ“°“√· ¥ß
¢Õߧ«“¡¥—π„π°–‚À≈°»’√…– Ÿß√à«¡¥â«¬
°“√®—¥∑”·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” Õ“»—¬À≈—°∞“π∑“ß«‘™“°“√∑’ˉ¥âµ’æ‘¡æå·≈â«
‚¥¬·∫àß√–¥—∫§”·π–π”Ցߧÿ≥¿“æ¢ÕßÀ≈—°∞“π (strength of recommendation) ‡ªìπ 3 √–¥—∫ §◊Õ A, B, C
(µ“√“ß∑’Ë 1) ‡π◊ÈÕÀ“¢Õß·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”©∫—∫π’Ȫ√–°Õ∫¥â«¬ ·ºπ¿Ÿ¡‘ §”Õ∏‘∫“¬ ‡Õ° “√
Õâ“ßÕ‘ß µ“√“ß ·≈–¿“§ºπ«°
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 1
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µ“√“ß∑’Ë 1
√–¥—∫§”·π–π”Ցߧÿ≥¿“æ (Strength of Recommendation) µ“¡À≈—°∞“π∑“ß«‘™“°“√
À¡“¬‡Àµ ÿ recommendation A π‘¬¡„™â‡ªìπ¡“µ√∞“π„π°“√ªØ‘∫—µ‘„π ∂“π∑’Ë∑’Ë¡’§«“¡æ√âÕ¡
recommendation B ·π–π”„Àℙ⇪ìπ·π«∑“ß„π°“√ªØ‘∫—µ‘·µà‰¡à„™à¡“µ√∞“π
recommendation C ·π–π”„Àℙ⇪ìπ∑“߇≈◊Õ°„π°“√ªØ‘∫—µ‘ ¢÷ÈπÕ¬Ÿà°—∫¥ÿ≈¬æ‘π‘®¢ÕߺŸâ√—°…“
Grade Recommendation
A supported by data from randomized control trials with low false-positive and low
false-negative errors
B supported by data from randomized control 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
2 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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∫∑∑’Ë 1
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë ß —¬¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
(Management of patients suspected of hydrocephalus)
¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus) ‡ªìπ¿“«–∑’Ëæ∫‰¥â„πºŸâªÉ«¬∑ÿ°°≈ÿà¡Õ“¬ÿ1 ‚¥¬¡’Õÿ∫—µ‘°“√≥å Ÿß
„π‡¥Á°2, 3 ¿“«–π’ȇ°‘¥®“°°“√ √â“ßπÈ”‰¢ —πÀ≈—ß¡“°º‘¥ª°µ‘ À√◊Õ °“√Õÿ¥µ—π¢Õß∑“߇¥‘ππÈ”‰¢ —πÀ≈—ß À√◊Õ
§«“¡º‘¥ª°µ‘¢Õß°“√¥Ÿ¥´÷¡°≈—∫¢ÕßπÈ”‰¢ —πÀ≈—ß∑“ßÀ≈Õ¥‡≈◊Õ¥¥” à«π„À≠à “¡“√∂µ√«®æ∫ “‡Àµÿ‰¥â
(secondary hydrocephalus) ‡™àπ ‡π◊ÈÕßÕ°„π ¡Õß ‡≈◊Õ¥ÕÕ°„π ¡Õß °“√µ‘¥‡™◊ÈÕ„π ¡Õß venous sinus thrombosis
‡ªìπµâπ ¡’‡æ’¬ß à«ππâÕ¬∑’Ë°“√µ√«®«‘π‘®©—¬∑“ßÀâÕߪؑ∫—µ‘°“√„πªí®®ÿ∫—π‰¡à “¡“√∂µ√«®æ∫ “‡Àµÿ‰¥â (idiopathic
À√◊Õ primary hydrocephalus) ¥—ßπ—Èπ‡æ◊ËÕ„Àâ°“√«‘π‘®©—¬·≈–°“√∫”∫—¥√—°…“ºŸâªÉ«¬‰¥â –¥«°¢÷Èπ ®÷ß®”·π°
ºŸâªÉ«¬∑’Ë ß —¬«à“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ÕÕ°‡ªìπ 4 ª√–‡¿∑ ¥—ß·ºπ¿Ÿ¡‘∑’Ë 1
·ºπ¿Ÿ¡‘∑’Ë 1
°“√®”·π°ºŸâªÉ«¬∑’Ë ß —¬«à“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
(Categorization of patients suspected of hydrocephalus)
NB : ICP = Intracranial pressure
NPH = Normal pressure hydrocephalus
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 3
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§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 1
ºŸâªÉ«¬∑’Ë ß —¬¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ” “¡“√∂·∫àßÕÕ°‰¥â‡ªìπ 4 °≈ÿà¡ ¥—ßπ’È
1. ºŸâªÉ«¬∑’Ë¡’Õ“°“√·≈–Õ“°“√· ¥ß¢Õߧ«“¡¥—π„π°–‚À≈°»’√…– Ÿß (symptoms & signs of
increased intracranial pressure) ´÷Ëß¡’§«“¡·µ°µà“ß°—π„π·µà≈–°≈ÿà¡Õ“¬ÿ §◊Õ
1.1 ºŸâªÉ«¬‡¥Á°‡≈Á°∑’Ë anterior fontanel ¬—߉¡àªî¥ Õ“®¡’Õ“°“√ tensed and bulged anterior fontanel,
separation of skull suture, cracked pot sound of skull (Macewenûs sign), sunset eyes,
positive transillumination test, accelerated head growth (¿“§ºπ«°∑’Ë 1)
1.2 ºŸâªÉ«¬‡¥Á°‚µ·≈–ºŸâ„À≠à Õ“®¡’Õ“°“√ progressive headache & vomiting, dilated scalp veins,
acquired lateral rectus palsy, hyper-reflexia, papilledema, alteration of consciousness
1.3 ºŸâªÉ«¬‡¥Á°∑’ˇªìπ macrocephaly (head circumference ¡“°°«à“ 98 percentile4) æ∫«à“¡’¿“«–
‚æ√ß ¡Õߧ—ËßπÈ”√à«¡¥â«¬√âÕ¬≈– 32 - 854, 5 ©–π—Èπ ∂â“¡’Õ“°“√·≈–Õ“°“√· ¥ß§«“¡¥—π
„π°–‚À≈°»’√…– ŸßµâÕß ß —¬«à“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
ºŸâªÉ«¬∑’Ë¡’Õ“°“√·≈–Õ“°“√· ¥ß¥—ß°≈à“«¢â“ßµâπ„Àâæ‘®“√≥“·π«∑“ß°“√√—°…“µ“¡·ºπ¿Ÿ¡‘∑’Ë 2
2. ºŸâªÉ«¬‡¥Á°∑’˧≈Õ¥°àÕπ°”Àπ¥ (Õ“¬ÿ§√√¿åπâÕ¬°«à“ 37 —ª¥“Àå) „Àâæ‘®“√≥“·π«∑“ß°“√√—°…“
µ“¡·ºπ¿Ÿ¡‘∑’Ë 3
3. ºŸâªÉ«¬‡¥Á°·√°‡°‘¥∑’ˇªìπ myelomeningocele & encephalomeningocele „Àâæ‘®“√≥“·π«∑“ß°“√
√—°…“µ“¡·ºπ¿Ÿ¡‘∑’Ë 4
4. ºŸâªÉ«¬ ŸßÕ“¬ÿ∑’Ë ß —¬«à“‡ªìπ normal pressure hydrocephalus (NPH) ´÷Ëß¡’Õ“°“√ ”§—≠ ‰¥â·°à
gait disturbance, dementia and urinary incontinence „Àâæ‘®“√≥“·π«∑“ß°“√√—°…“µ“¡·ºπ¿Ÿ¡‘∑’Ë 5
4 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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∫∑∑’Ë 2
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë ß —¬«à“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”√à«¡°—∫§«“¡¥—π„π°–‚À≈°»’√…– Ÿß
(Management of patients suspected of HCP with increased intracranial pressure)
ºŸâªÉ«¬∑’Ë¡’¿“«–§«“¡¥—π„π°–‚À≈°»’√…– Ÿßæ∫‰¥â∑—Èß„π‡¥Á°·≈–ºŸâ„À≠à ´÷Ë߇°‘¥®“° “‡Àµÿµà“ß Ê °—π
‡™àπ ‡π◊ÈÕßÕ°„π ¡Õß (brain tumors) °“√µ‘¥‡™◊ÈÕ„π ¡Õß (CNS infection) ¡Õß∫«¡ (brain edema) ¿“«–
‚æ√ß ¡Õߧ—ËßπÈ” (hydrocephalus) ‡ªìπµâπ ¥—ßπ—Èπ ºŸâªÉ«¬∑’Ë¡’Õ“°“√·≈–Õ“°“√· ¥ß¢Õß¿“«–§«“¡¥—π„π
°–‚À≈°»’√…– Ÿß¥—߉¥â°≈à“«‰«â„π∫∑∑’Ë 1 ®÷ߧ«√µ√«®À“ “‡Àµÿ‡æ◊ËÕ„Àâ°“√«‘π‘®©—¬·≈–√—°…“∑’Ë∂Ÿ°µâÕß
§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 2
ºŸâªÉ«¬∑’Ë¡’¿“«–§«“¡¥—π„π°–‚À≈°»’√…– Ÿß (increased ICP) §«√ àßµ√«® CT À√◊Õ MRI brain without
or with contrast media („π°√≥’ ß —¬ secondary HCP) „πºŸâªÉ«¬‡¥Á°∑’Ë anterior fontanel ¬—߉¡àªî¥ “¡“√∂
æ‘®“√≥“∑” cranial ultrasound ‰¥âµ“¡§«“¡‡À¡“– ¡ (·æ∑¬åºŸâ∑”°“√µ√«®§«√¡’§«“¡™”π“≠) ∂⓺≈°“√µ√«®
‰¡àæ∫¢π“¥¢Õß‚æ√ß ¡Õß‚µº‘¥ª°µ‘ · ¥ß«à“ ¿“«–§«“¡¥—π„π°–‚À≈°»’√…– ŸßÕ“®‡°‘¥®“° “‡Àµÿ
Õ◊Ëπ Ê ‡™àπ space occupying lesion, pseudotumor cerebri, cryptococcal meningitis ‡ªìπµâπ „Àâ√—°…“µ“¡
“‡Àµÿπ—Èπ Ê
∂â“æ∫¢π“¥¢Õß‚æ√ß ¡Õß‚µº‘¥ª°µ‘ „Àâ·¬°«à“‡ªìπ°“√Õÿ¥µ—π¢Õß√–∫∫‚æ√ß ¡Õß (ventri-
cular obstruction) À√◊Õ¿“¬πÕ°√–∫∫‚æ√ß ¡Õß (extraventricular obstruction)* °√≥’‡ªìπ°“√
Õÿ¥µ—π¢Õß√–∫∫‚æ√ß ¡Õß„Àâæ‘®“√≥“·π«∑“ß°“√√—°…“µ“¡·ºπ¿Ÿ¡‘∑’Ë 2.1, 2.2, 2.3
°√≥’‡ªìπ°“√Õÿ¥µ—π¿“¬πÕ°√–∫∫‚æ√ß ¡Õß (extraventricular obstruction) ∂â“æ∫ “‡ÀµÿÀ≈—ß®“°
°“√µ√«®∑“ß√—ß ’ ‡™àπ venous sinus occlusion À√◊Õ leptomeningeal enhancement „Àâ√—°…“µ“¡ “‡Àµÿ
π—Èπ Ê √à«¡°—∫æ‘®“√≥“∑” CSF diversion
∂Ⓣ¡àæ∫ “‡ÀµÿÀ≈—ß®“°°“√µ√«®∑“ß√—ß ’ „Àâ∑”°“√µ√«® CSF ‡æ◊ËÕæ‘ Ÿ®πå«à“¡’°“√µ‘¥‡™◊ÈÕ„π
CSF À√◊Õ‡´≈≈å¡–‡√Áß„π CSF ´÷Ë߇ªì𠓇Àµÿ¢Õß HCP „Àâ∑”°“√√—°…“µ“¡ “‡Àµÿπ—Èπ Ê ·≈–∂â“®”‡ªìπÕ“®
æ‘®“√≥“∑” CSF diversion √à«¡¥â«¬
À“°º≈µ√«®πÈ”‰¢ —πÀ≈—ߪ°µ‘ „Àâ∑” CSF diversion ·µà∂⓬—ß ß —¬«à“ “‡Àµÿ¢Õß HCP
‡°‘¥®“°‚√§À≈Õ¥‡≈◊Õ¥¥”Õÿ¥µ—πÕ“®æ‘®“√≥“∑”°“√µ√«®‡æ‘Ë¡‡µ‘¡ ‡™àπ MRV ‡ªìπµâπ À“°‰¡àæ∫ “‡Àµÿ®÷ßæ‘®“√≥“
∑” CSF diversion
À¡“¬‡Àµÿ *°“√Õÿ¥µ—π¿“¬πÕ°√–∫∫‚æ√ß ¡Õß (extraventricular obstruction) À¡“¬∂÷ß °“√Õÿ¥µ—π¢Õß∑“߇¥‘π
CSF ∑’Ë√–¥—∫ leptomeninges, arachnoid granulation, venous system ‚¥¬ª√“»®“° mass lesion
∑’Ë°¥‡∫’¬¥√–∫∫‚æ√ß ¡Õß
2
1
3
6
4
5
7
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 5
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·ºπ¿Ÿ¡‘∑’Ë 2
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë ß —¬«à“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”√à«¡°—∫§«“¡¥—π„π°–‚À≈°»’√…– Ÿß
(Management of patients suspected of HCP with increased intracranial pressure)
* „π ∂“π∑’Ë∑’Ë “¡“√∂µ√«®‰¥â
** „π°√≥’∑’Ë ventricle ¢π“¥ª°µ‘ · ¥ß«à“ ¿“«– increased ICP Õ“®‡°‘¥®“° “‡ÀµÿÕ◊Ë𠇙àπ space
occupying lesion, pseudotumor cerebri, cryptococcal meningitis ‡ªìπµâπ
*** „π°√≥’∑’Ë ß —¬ venous sinus obstruction Õ“®æ‘®“√≥“µ√«®‡æ‘Ë¡‡µ‘¡ ‡™àπ MRV ‡ªìπµâπ
a ¥Ÿ„π§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘
6 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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·ºπ¿Ÿ¡‘∑’Ë 2.1
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”®“°°“√Õÿ¥µ—π¢Õß√–∫∫‚æ√ß ¡Õß
(Management of patients with hydrocephalus from ventricular obstruction)
§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 2.1
‡¡◊ËÕµ√«®æ∫ ventricular obstruction „Àâ·¬°«à“
1. ¡’ dilatation ¢Õß lateral ventricle ¢â“߇¥’¬« (monoventricular HCP) ¥Ÿ·ºπ¿Ÿ¡‘∑’Ë 2.2
2. ¡’ dilatation ¢Õß lateral ventricle ∑—Èß 2 ¢â“ß (biventricular HCP) ¥Ÿ·ºπ¿Ÿ¡‘∑’Ë 2.2
3. ¡’ dilatation ¢Õß∑—Èß 3 ventricles (triventricular HCP) ¥Ÿ·ºπ¿Ÿ¡‘∑’Ë 2.3
4. ¡’ dilatation ¢Õß∑—Èß 4 ventricles (panventricular HCP) ¥Ÿ·ºπ¿Ÿ¡‘∑’Ë 2.3
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 7
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·ºπ¿Ÿ¡‘∑’Ë 2.2
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”®“°°“√Õÿ¥µ—ππÈ”‰¢ —πÀ≈—ß
∑’˵”·Àπàß foramen of Monro
(Management of patients with hydrocephalus from obstruction at foramen of Monro)
* „π°√≥’∑’Ë ß —¬«à“¬—ß¡’ active purulent meningitis/ventriculitis µâÕßµ√«® CSF ·≈–√—°…“ infection
„ÀâÀ“¬°àÕπ®÷ßæ‘®“√≥“∑” permanent CSF diversion
8 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 2.2
‡¡◊ËÕµ√«®æ∫ dilatation of lateral ventricle ·µà third ·≈– fourth ventricle ¡’¢π“¥ª°µ‘· ¥ß«à“
¡’ obstruction at foramen of Monro „Àâæ‘®“√≥“«à“¡’°“√Õÿ¥µ—π¢Õß foramen of Monro ¢â“߇¥’¬«À√◊Õ 2 ¢â“ß
1. ∂â“¡’°“√Õÿ¥µ—π¢â“߇¥’¬«∑”„À⇰‘¥ monoventricular HCP „Àâæ‘®“√≥“«à“¡’ mass lesion ∑’Ë lateral
ventricle À√◊Õ‰¡à
1.1 ∂â“¡’ mass lesion ‡™àπ subependymal giant cell astrocytoma ∑’Ëæ∫„π‚√§ tuberous
sclerosis6 ‡ªìπµâπ „Àâ√—°…“µ“¡ “‡Àµÿ √à«¡°—∫æ‘®“√≥“∑” CSF diversion µ“¡§«“¡‡À¡“– ¡
1.2 ∂Ⓣ¡à¡’ mass lesion „Àâæ‘®“√≥“∑” CSF diversion ¬°‡«âπ°√≥’ ß —¬«à“¡’ active purulent
meningitis/ventriculitis µâÕßµ√«® CSF ·≈–√—°…“ infection „ÀâÀ“¬°àÕπ®÷ßæ‘®“√≥“∑” permanent CSF
diversion
2. ∂â“¡’°“√Õÿ¥µ—π∑—Èß 2 ¢â“ß ∑”„À⇰‘¥ biventricular HCP „Àâæ‘®“√≥“«à“¡’ mass lesion ∑’Ë√–¥—∫ third
ventricle À√◊Õ‰¡à
2.1 ∂â“¡’ mass lesion ‡™àπ craniopharyngioma, ependymoma ‡ªìπµâπ „Àâ√—°…“µ“¡ “‡Àµÿ
√à«¡°—∫æ‘®“√≥“∑” CSF diversion µ“¡§«“¡‡À¡“– ¡
2.2 „π°√≥’∑’ˉ¡à¡’ mass à«π„À≠à‡°‘¥®“° atresia of both foramen of Monro „Àâæ‘®“√≥“∑”
CSF diversion ¬°‡«âπ°√≥’ ß —¬«à“¡’ active purulent meningitis/ventriculitis µâÕßµ√«® CSF ·≈–√—°…“
infection „ÀâÀ“¬°àÕπ®÷ßæ‘®“√≥“∑” permanent CSF diversion
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 9
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·ºπ¿Ÿ¡‘∑’Ë 2.3
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬∑’Ë¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”®“°°“√Õÿ¥µ—ππÈ”‰¢ ——πÀ≈—ß
∑’˵”·Àπàߵ˔°«à“ third ventricle
(Management of patients with hydrocephalus from obstruction distal to third ventricle)
* „π°√≥’∑’Ë ß —¬«à“¬—ß¡’ active purulent meningitis/ventriculitis µâÕßµ√«® CSF ·≈–√—°…“ infection
„ÀâÀ“¬°àÕπ®÷ßæ‘®“√≥“∑” permanent CSF diversion
10 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 2.3
‡¡◊ËÕµ√«®æ∫ dilatation of lateral ventricles ·≈– third ventricle „Àâæ‘®“√≥“¥Ÿ«à“ ¡’ dilatation ¢Õß
fourth ventricle À√◊Õ‰¡à
1. ∂â“ fourth ventricle ‰¡à‚µ «‘π‘®©—¬«à“‡ªìπ aqueductal obstruction
1.1 ∂â“¡’ mass lesion ∑’ˇªì𠓇Àµÿ¢Õß HCP ‡™àπ tectal astrocytoma, pineal region tumor,
posterior fossa tumor, cysticercosis ‡ªìπµâπ „Àâ√—°…“µ“¡ “‡Àµÿπ—Èπ Ê √à«¡°—∫æ‘®“√≥“∑” CSF diversion
1.2 ∂Ⓣ¡à¡’ mass «‘π‘®©—¬«à“‡ªìπ aqueductal stenosis ÷́ËßÕ“®‡ªì𧫓¡º‘¥ª°µ‘¡“·µà°”‡π‘¥
(congenital) À√◊Õ‡°‘¥¢÷Èπ¿“¬À≈—ß (acquired) „Àâ°“√√—°…“‚¥¬°“√∑” CSF diversion „π°√≥’∑’Ë ß —¬«à“¡’ active
purulent meningitis/ventriculitis µâÕßµ√«® CSF ·≈–√—°…“ infection „ÀâÀ“¬°àÕπ®÷ßæ‘®“√≥“∑” permanent
CSF diversion
2. ∂â“ fourth ventricle ‚µ „Àâ·¬°«à“‡ªì𧫓¡º‘¥ª°µ‘¡“·µà°”‡π‘¥ (congenital) ‡™àπ Dandy Walker
syndrome, Chiari malformation ‡ªìπµâπ „Àâ√—°…“µ“¡ “‡Àµÿπ—Èπ Ê À√◊Õ∂Ⓡªì𠓇Àµÿ∑’ˇ°‘¥¢÷Èπ¿“¬À≈—ß
(acquired) „Àâæ‘®“√≥“«à“¡’ mass lesion À√◊Õ‰¡à
2.1 ∂â“¡’ mass lesion ∑’ˇªì𠓇Àµÿ¢Õß HCP ‡™àπ meningioma ∫√‘‡«≥ foramen magnum
‡ªìπµâπ „Àâ√—°…“µ“¡ “‡Àµÿπ—Èπ Ê √à«¡°—∫æ‘®“√≥“∑” CSF diversion µ“¡§«“¡‡À¡“– ¡
2.2 ∂Ⓣ¡à¡’ mass lesion „Àâæ‘®“√≥“∑” CSF diversion „π°√≥’∑’Ë ß —¬«à“¬—ß¡’ active purulent
meningitis/ventriculitis µâÕßµ√«® CSF ·≈–√—°…“ infection „ÀâÀ“¬°àÕπ®÷ßæ‘®“√≥“∑” permanent CSF
diversion
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 11
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∫∑∑’Ë 3
·π«∑“ß°“√∫”∫—¥√—°…“‡¥Á°‡°‘¥°àÕπ°”Àπ¥∑’Ë¡’‡≈◊Õ¥ÕÕ°„π‚æ√ß ¡Õß
·≈– ß —¬«à“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
(Management of preterm babies with IVH suspected of HCP)
®“°°“√»÷°…“¢Õß Ment ·≈–§≥–7 „π‡¥Á°‡°‘¥°àÕπ°”Àπ¥ ∑’Ë¡’Õ“¬ÿ§√√¿åπâÕ¬°«à“ 34 —ª¥“Àå À√◊Õ
πÈ”Àπ—°πâÕ¬°«à“ 1,500 °√—¡ æ∫«à“ ¡’Õÿ∫—µ‘°“√≥å¢Õ߇≈◊Õ¥ÕÕ°„π‚æ√ß ¡Õß (intraventricular hemorrhage :
IVH) √âÕ¬≈– 15 - 357, 8 ·≈– √âÕ¬≈– 20 - 50 ¢Õß IVH ®–‡°‘¥¿“«–‚æ√ß ¡Õߧ—ËßπÈ”7, 8, 9, 10 (post
hemorrhagic hydrocephalus : PHH) ¥—ßπ—Èπ „π‡¥Á°‡°‘¥°àÕπ°”Àπ¥∑’Ë¡’ IVH §«√µ√«®À“«à“¡’ PHH À√◊Õ‰¡à
§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 3
‡¥Á°‡°‘¥°àÕπ°”Àπ¥∑’Ë¡’‡≈◊Õ¥ÕÕ°„π‚æ√ß ¡Õß·≈– ß —¬«à“¡’ HCP ·æ∑¬å§«√æ‘®“√≥“µ√«® ¡Õߥ⫬
ultrasound À√◊Õ CT scan ∑ÿ°√“¬ (recommendation C) ∂Ⓣ¡àæ∫¿“«–‚æ√ß ¡Õߧ—ËßπÈ”„Àⵑ¥µ“¡¥Ÿ·≈
Õ¬à“ß„°≈♑¥µàÕ‰ª
∂â“æ∫¿“«–‚æ√ß ¡Õߧ—ËßπÈ”·≈–¡’Õ“°“√Õ¬à“ß„¥Õ¬à“ßÀπ÷Ëߥ—ßµàÕ‰ªπ’È
1. Change in clinical condition ‡™àπ alteration of consciousness, irritable, lethargy vomiting
‡ªìπµâπ
2. Bulging of anterior fontanel
3. Accelerated head growth > 2 cm./wk. ¥Ÿ°√“ø„π‡¥Á°‡°‘¥°àÕπ°”Àπ¥ ¿“§ºπ«°∑’Ë 1
„Àâ∑”°“√√—°…“‡∫◊ÈÕßµâπ (temporizing measures) ‡™àπ LP11, EVD12, ventricular access device13, 14, early
shunting, medical treatment ‡™àπ acetazolamide, furosemide ‡ªìπµâπ (recommendation C) ·¡â«à“°“√√—°…“
¿“«–‚æ√ß ¡Õߧ—ËßπÈ”¥â«¬¬“ acetazolamide, furosemide „πºŸâªÉ«¬∫“ß√“¬®–‰¥âº≈¥’1 ·µà¡’∫“ß√“¬ß“πæ∫«à“
‰¡à‰¥âº≈·≈–§«√√–¡—¥√–«—ß„π°“√„™â¬“¢π“¥ Ÿß°—∫‡¥Á°‡°‘¥°àÕπ°”Àπ¥∑’Ë¡’‡≈◊Õ¥ÕÕ°„π‚æ√ß ¡Õß15, 16
(recommendation B) ∂â“„Àâ°“√√—°…“‡∫◊ÈÕßµâπ·≈⫺ŸâªÉ«¬¡’Õ“°“√§ß∑’Ë„Àⵑ¥µ“¡¥ŸÕ“°“√µàÕ‰ª
À“°ºŸâªÉ«¬¡’Õ“°“√¡“°¢÷Èπ (worsening of clinical conditions) À√◊Õ‰¡à¥’‡∑à“∑’˧«√ À√◊Õ¡’ progressive
ventricular dilatation „Àâª√÷°…“ª√– “∑»—≈¬·æ∑¬å ‡æ◊ËÕæ‘®“√≥“∑” permanent CSF diversion ´÷Ëß·π–π”„Àâ
∑”‡¡◊ËÕ‡¥Á°¡’πÈ”Àπ—°¡“°°«à“ 1,500 °√—¡ ·≈– CSF protein πâÕ¬°«à“ 500 mg%17 (recommendation C)
À“°¬—߉¡à‰¥â‡°≥±å¥—ß°≈à“« ·π–π”„Àâ§ß°“√√—°…“‡∫◊ÈÕßµâπµàÕ‰ª ‡π◊ËÕß®“°‡¥Á°¡’‚Õ°“ ∑’Ë®–‡°‘¥ shunt obstruction
À√◊Õ skin break down
∂⓺ŸâªÉ«¬¡’¿“«–‚æ√ß ¡Õß‚µ·µà‰¡à¡’Õ“°“√º‘¥ª°µ‘¥—ß°≈à“«¢â“ßµâπ „Àⵑ¥µ“¡Õ“°“√·≈–µ√«®
cranial ultrasound À√◊Õ CT scan ‡ªìπ§√—Èߧ√“«µ“¡§«“¡‡À¡“– ¡
12 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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·ºπ¿Ÿ¡‘∑’Ë 3
·π«∑“ß°“√∫”∫—¥√—°…“‡¥Á°§≈Õ¥°àÕπ°”Àπ¥∑’Ë¡’‡≈◊Õ¥ÕÕ°„π‚æ√ß ¡Õß
·≈– ß —¬¿“«–‚æ√ß ¡Õߧ—ËßπÈ”
(Management of preterm baby with intraventricular hemorrhage suspected of hydrocephalus)
* Change in clinical condition means : alteration of consciousness, irritable, lethargy, vomiting
** 1. Lumbar puncture 2. External ventricular drainage
3. Ventricular access device 4. Medical treatment
*** Progressive
1. Worsening of clinical conditions 2. Progressive ventricular dilatation
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 13
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∫∑∑’Ë 4
·π«∑“ß°“√∫”∫—¥√—°…“‡¥Á°·√°§≈Õ¥∑’Ë¡’ myelomeningocele/encephalomeningocele
(Management of newborn infants with myelomeningocele/encephalomeningocele)
°“√»÷°…“¢Õß Lorber18 æ∫«à“√âÕ¬≈– 70 ¢Õ߇¥Á°·√°§≈Õ¥∑’Ë¡’ myelomeningocele ®–¡’¿“«–
‚æ√ß ¡Õߧ—ËßπÈ” ®÷ߧ«√µ‘¥µ“¡ºŸâªÉ«¬„π°≈ÿà¡π’È ‡æ◊ËÕ¥Ÿ¿“«–‚æ√ß ¡Õߧ—ËßπȔլà“ß„°≈♑¥ µ“¡·ºπ¿Ÿ¡‘∑’Ë 4
§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 4
ºŸâªÉ«¬ myelomeningocele À√◊Õ encephalomeningocele ·æ∑¬å§«√„À⧫“¡ ”§—≠„π°“√ºà“µ—¥ repair
myelomeningocele ‚¥¬‡√Á« ‡æ◊ËÕªÑÕß°—π°“√µ‘¥‡™◊ÈÕ∑“ß√–∫∫ª√– “∑ ∂â“ ∂“π欓∫“≈„¥¡’§«“¡æ√âÕ¡·π–π”„Àâ
cranial ultrasound/CT (recommendation C) °àÕπºà“µ—¥ ‡æ◊ËÕª√–‡¡‘π¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ‚¥¬‰¡à∑”„Àâ
°“√ºà“µ—¥≈à“™â“ ∂â“æ∫ severe hydrocephalus Õ“®∑” CSF diversion ¥â«¬
„π ∂“π欓∫“≈∑’ˉ¡à¡’ª√– “∑»—≈¬·æ∑¬å §«√„À⺟âªÉ«¬πÕπ§«Ë”µ≈Õ¥‡«≈“·≈–∑” wet dressing
‰«â∫π myelomeningocele ®“°π—Èπ àߺŸâªÉ«¬‰ªæ∫ª√– “∑»—≈¬·æ∑¬å ‡æ◊ËÕ∑”ºà“µ—¥‚¥¬‡√Á«
À≈—ßºà“µ—¥ repair myelomeningocele µâÕßµ‘¥µ“¡¥ŸÕ“°“√ºŸâªÉ«¬«à“ ¡’Õ“°“√‡≈«≈ßÀ√◊Õ‰¡à ‡™àπ Õ“°“√
∑’Ë· ¥ß¿“«–§«“¡¥—π„π°–‚À≈°»’√…– ŸßÀ√◊ÕÕ“°“√∑’Ë∫àß«à“®–¡’ Chiari crisis ‰¥â·°à laryngeal stridor,
drooling, increased tone in arms and legs, retropulsion of head (opisthotonic posturing), apneic spells
‡ªìπµâπ à«π encephalomeningocele ‰¡àæ∫√à«¡°—∫ Chiari malformation
°√≥’¡’ Chiari crisis µâÕß√’∫ àßµ√«® CT À√◊Õ MRI brain ‡æ◊ËÕª√–‡¡‘𧫓¡º‘¥ª°µ‘¢Õß ¡Õß
à«πÀ≈—ß (posterior fossa) ·≈–¿“«–‚æ√ß ¡Õߧ—ËßπÈ”‚¥¬‡√Á« æ√âÕ¡„Àâ°“√√—°…“©ÿ°‡©‘π∑’ˇÀ¡“– ¡ ‡™àπ posterior
fossa decompression19 À√◊Õ immediate ventriculostomy ‡ªìπµâπ
°√≥’À≈—ßºà“µ—¥ repair ·≈â«Õ“°“√‡≈«≈ß·µà‰¡à¡’ Chiari crisis „Àâ àß ultrasound À√◊Õ CT brain
‚¥¬‡√Á« ‡æ◊ËÕª√–‡¡‘𧫓¡√ÿπ·√ߢÕß¿“«–‚æ√ß ¡Õߧ—ËßπÈ”®“°¢π“¥¢Õß ventricle ·≈– periventricular edema
·≈–„Àâ°“√∫”∫—¥√—°…“¥—ßπ’È
1. ∂â“¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”ª“π°≈“ß∂÷ß¡“°„Àâ∑” CSF diversion ‚¥¬‡√Á«
2. ∂Ⓣ¡à¡’¿“«–‚æ√ß ¡Õߧ—ËßπÈ”À√◊Õ¡’‡≈Á°πâÕ¬ „Àⵑ¥µ“¡Õ“°“√Õ¬à“ß„°≈♑¥ ‰¥â·°à «—¥ head
circumference ·≈–/À√◊Õµ√«® ultrasound À√◊Õ CT brain ‡ªìπ§√—Èߧ√“« ‡¡◊ËÕ‡¥Á°¡’Õ“¬ÿµ—Èß·µà 6 —ª¥“Àå¢÷Èπ‰ª
·π–π”„Àâª√–‡¡‘πæ—≤π“°“√¢Õ߇¥Á° (psychomotor developmental assessment) Õ“∑‘‡™àπ Denver Develop-
mental Screening Test (DDST)20 ‡ªìπµâπ (recommendation C)
2.1 À“°ºŸâªÉ«¬¡’Õ“°“√√ÿπ·√ß¡“°¢÷Èπ ‰¥â·°à progressive HCP À√◊Õ lower cranial nerve
dysfunction À√◊Õ delayed psychomotor development „Àâæ‘®“√≥“∑” CSF diversion
14 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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2.2 ‡¡◊ËÕµ‘¥µ“¡ºŸâªÉ«¬Õ¬à“ß„°≈♑¥ À“°ºŸâªÉ«¬¡’Õ“°“√§ß‡¥‘¡·≈–¡’ psychomotor development ª°µ‘
·≈–‰¡à¡’Õ“°“√· ¥ß¢Õß Chiari crisis ·≈– ‡¡◊ËÕ∑” CT À√◊Õ US æ∫«à“¡’ cerebral cortex Àπ“ (¡’ cortical
mantle > 3.5 cm ‡¡◊ËÕºŸâªÉ«¬Õ“¬ÿ 5 ‡¥◊Õπ)21, 22 (recommendation C) ºŸâªÉ«¬ à«π„À≠à®–¡’°“√欓°√≥å‚√§¥’
‡π◊ËÕß®“°¿“«–‚æ√ß ¡Õߧ—ËßπÈ” à«π¡“°®–‡°‘¥À≈—ßºà“µ—¥ repair myelomeningocele encephalo-
meningocele ª√–¡“≥Àπ÷Ëß —ª¥“Àå ¥—ßπ—Èπ ∂Ⓡ¥Á°¡’Õ“°“√§ß∑’Ë„Àâæ‘®“√≥“µ√«® ultrasound À√◊Õ CT brain
À≈—ßºà“µ—¥ª√–¡“≥Àπ÷Ëß —ª¥“Àå ‡æ◊ËÕª√–‡¡‘π¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (¥Ÿµ“¡¢âÕ 1 ·≈– 2 ¥—ß°≈à“«¢â“ßµâπ)
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 15
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·ºπ¿Ÿ¡‘∑’Ë 4
·π«∑“ß°“√∫”∫—¥√—°…“‡¥Á°·√°§≈Õ¥∑’Ë¡’ myelomeningocele À√◊Õ encephalomeningocele
(Management of newborn with myelomeningocele or encephalomeningocele)
* „π ∂“π欓∫“≈∑’Ë¡’§«“¡æ√âÕ¡§«√∑” cranial US À√◊Õ CT °àÕπºà“µ—¥ repair myelomeningocele
or encephalomeningocele ∂Ⓣ¡à∑”„Àâ°“√ºà“µ—¥µâÕß≈à“™â“
** Chiari crisis (æ∫√à«¡°—∫ myelomeningocele ª√–¡“≥ 5% ·µà‰¡àæ∫√à«¡°—∫ encephalomeningocele)
ºŸâªÉ«¬®–¡’ symptomatic brainstem compression ´÷Ëß¡’Õ“°“√ retropulsion of head (opisthotonic
posturing), laryngeal stridor, drooling, increased tone in arms and legs, apnea
*** Emergency management ‡™àπ posterior fossa decompression, immediate ventriculostomy ‡ªìπµâπ
16 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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∫∑∑’Ë 5
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬ ŸßÕ“¬ÿ∑’Ë ß —¬‡ªìπ normal pressure hydrocephalus
(Management of elderly patient suspected of normal pressure hydrocephalus)
„πºŸâªÉ«¬ ŸßÕ“¬ÿ∑’Ë¡’Õ“°“√ gait disturbance, dementia, urinary incontinence „Àâ ß —¬«à“Õ“®®–‡ªìπ
¿“«– ¡Õߧ—ËßπÈ”™π‘¥§«“¡¥—π„π ¡Õ߉¡à Ÿß (normal pressure hydrocephalus, NPH) À“°ºŸâªÉ«¬¡’Õ“°“√
§√∫∑—Èß “¡Õ¬à“ß„Àâ ß —¬«à“®–‡ªìπ classical NPH ·µàºŸâªÉ«¬ à«π„À≠à¡’Õ“°“√‡æ’¬ß gait disturbance Õß„π
“¡¡’ dementia ·≈–Õ’°§√÷ËßÀπ÷Ëß¡’ urinary incontinence23
∂⓺ŸâªÉ«¬¡’Õ“°“√‡æ’¬ßÕ¬à“ß„¥Õ¬à“ßÀπ÷Ëß®–µâÕß·¬°®“°‚√§Õ◊Ëπ Ê ‡™àπ Alzheimerûs disease,
vascular dementia, chronic subdural hematoma ‡ªìπµâπ Õ“°“√ gait disturbance „π NPH ¡’≈—°…≥– short
stepped gait ´÷ËßµâÕß·¬°®“° myelopathy À√◊Õ Parkinsonism à«πÕ“°“√ urinary incontinence ¡’≈—°…≥–
°≈—Èπªí “«–‰¡à‰¥â (uninhibited urinary incontinence) µâÕß·¬°®“°‚√§Õ◊Ëπ Ê ¢Õß√–∫∫∑“߇¥‘πªí “«–
§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 5
ºŸâªÉ«¬∑’Ë ß —¬ NPH „Àâ àßµ√«® CT À√◊Õ MRI brain ‡æ◊ËÕ¥Ÿ«à“¡’‚æ√ß ¡Õß‚µ°«à“ª°µ‘À√◊Õ‰¡à
∂â“¢π“¥ª°µ‘„ÀâÀ“ “‡ÀµÿÕ◊Ëπ Ê ·≈–√—°…“µ“¡ “‡Àµÿπ—Èπ Ê À“°¢π“¥„À≠à°«à“ª°µ‘„Àâ®”·π°«à“‡ªìπ¿“«– ¡Õß
§—ËßπÈ”·∫∫„¥
1. ∂â“‚æ√ß ¡Õß‚µ°«à“ª°µ‘·≈–æ∫ ventricular obstruction æ‘®“√≥“„Àâ°“√∫”∫—¥√—°…“µ“¡·ºπ¿Ÿ¡‘∑’Ë
2.1, 2.2, 2.3
2. ∂â“‚æ√ß ¡Õß‚µ°«à“ª°µ‘·µà‰¡àæ∫ ventricular obstruction „Àâæ‘®“√≥“Õ“°“√ Õ“°“√· ¥ß ·≈–
º≈°“√µ√«® CT/MRI brain
2.1 „Àâ«‘π‘®©—¬«à“‡ªìπ NPH ‡¡◊ËÕ¡’ clinical criteria Õ¬à“ßπâÕ¬ 2 „π 3 ¢âÕ √à«¡°—∫ suggestive
radiographic imaging
Criteria for diagnosis of NPH (modified from reference 23 - 25)
1) Clinical : ºŸâªÉ«¬ ŸßÕ“¬ÿ∑’Ë¡’Õ“°“√
● gait disturbance
● dementia
● urinary incontinence23
‚¥¬Õ“°“√‡À≈à“π’ȵâÕß·¬°®“° “‡ÀµÿÕ◊Ëπ Ê
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 17
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2) Radiographic imaging
● CT scan
- Rounding of frontal horn of lateral ventricles with periventicular edema
- Symmetrical dilatation of lateral ventricles out of proportion to sulcal enlargement24
● MRI
- Rounding of frontal horn of lateral ventricles with periventicular edema
- Symmetrical dilatation of lateral ventricles out of proportion to sulcal enlargement24
- Normal hippocampus
- Aqueductal çflow voidé sign25
2.2 ∂â“ criteria ‰¡à§√∫·µà¬—ß ß —¬„π°“√«‘π‘®©—¬ „Àâæ‘®“√≥“µ√«®‡æ‘Ë¡‡µ‘¡µ“¡§«“¡‡À¡“– ¡
(Optional) ¥—ßπ’È
2.2.1 Invasive investigation
- serial lumbar puncture À√◊Õ lumbar drainage26 ‡æ◊ËÕ¬◊π¬—π°“√«‘π‘®©—¬·≈–
ª√–‡¡‘π°“√µÕ∫ πÕßµàÕ°“√√—°…“ (therapeutic diagnosis)
- ICP monitoring
2.2.2 Non invasive investigation
- MRI ‡æ◊ËÕ‡æ‘Ë¡§«“¡™—¥‡®π„π°“√«‘π‘®©—¬ („π°√≥’∑’ˬ—߉¡à‰¥âµ√«®)
- CSF flow studies in MRI : increased velocity CSF flow27, 28
- MRS (magnetic resonance spectroscopy) : lactate peak in lateral ventricles29
∂⓺≈°“√µ√«®‡æ‘Ë¡‡µ‘¡‡¢â“‰¥â°—∫ NPH „Àâæ‘®“√≥“∑” CSF diversion À“°‡¢â“‰¥â°—∫ “‡ÀµÿÕ◊Ëπ
„Àâ√—°…“µ“¡ “‡Àµÿπ—Èπ Ê
18 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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·ºπ¿Ÿ¡‘∑’Ë 5
·π«∑“ß°“√∫”∫—¥√—°…“ºŸâªÉ«¬ ŸßÕ“¬ÿ∑’Ë ß —¬‡ªìπ normal pressure hydrocephalus
(Management of elderly patient suspected of normal pressure hydrocephalus)
* „π ∂“π∑’Ë∑’Ë¡’§«“¡æ√âÕ¡∑’Ë®–µ√«® MRI ‰¥â
** Normal pressure hydrocephalus µâÕß¡’≈—°…≥–µ“¡ Criteria for diagnosis of NPH (§”Õ∏‘∫“¬
·ºπ¿Ÿ¡‘∑’Ë 5)
*** Further investigation Õ“®æ‘®“√≥“∑”µ“¡§«“¡‡À¡“– ¡·≈–»—°¬¿“æ¢Õß ∂“π欓∫“≈
(§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 5)
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 19
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20 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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hydrocephalus. (Am J Neuroradiol). 2001 Oct; 22(9): 1659-64.
·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å 21
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¿“§ºπ«° 1
Õ“°“√· ¥ß¢Õß¿“«–§«“¡¥—π„π°–‚À≈°»’√…– Ÿß„π‡¥Á°‡≈Á°
(Signs of increased intracranial pressure in infants)
√Ÿª∑’Ë 1 Tensed and bulged anterior fontanelle
√Ÿª∑’Ë 2 Dilated scalp vein
22 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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√Ÿª∑’Ë 3 °“√µ√«®¥â«¬«‘∏’ transillumination ‚¥¬„™â‰ø©“¬ àÕß∑’Ë anterior fontanel
√Ÿª∑’Ë 4 Transillumination test
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√Ÿª∑’Ë 5 Fronto-ethmoidal encephalomeningocele
√Ÿª∑’Ë 6 Myelomeningocele
24 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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√Ÿª∑’Ë 9 MRI of Chiari malformation
√Ÿª∑’Ë 7 Ultrasound of hydrocephalus √Ÿª∑’Ë 8 MRI of intraventricular tumor
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GROWTH RECORD FOR PREMATURE INFANTS
In relation to
GESTATIONAL AGE AND FETAL AND INFANT NORMS
(combined sexes)
√Ÿª∑’Ë 10 ·ºπ¿Ÿ¡‘· ¥ß§à“ª°µ‘¢Õß°“√‡®√‘≠‡µ‘∫‚µ¢Õß∑“√°∑’˧≈Õ¥°àÕπ°”Àπ¥®π∂÷ßÕ“¬ÿ 1 ªï
·°πµ—Èß· ¥ßπÈ”Àπ—° à«π Ÿß ‡ âπ√Õ∫«ß¢Õß»’√…–
·°ππÕπ· ¥ßÕ“¬ÿ„π§√√¿åµ—Èß·µà 26 —ª¥“Àå ®π∂÷ßÕ“¬ÿÀ≈—ߧ≈Õ¥ 1 ªï
(From Babson SB, Benda GI. Growth record for premature infants in relation to
gestational age and fetal and infant norms (combined sexes). J Pediatr 1989;
89: 814-820.)
26 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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√Ÿª∑’Ë 11 ·ºπ¿Ÿ¡‘· ¥ß§à“‡ âπ√Õ∫«ß»’√…– (occipito-frontal circumference; OFC)
„π‡¥Á°Õ“¬ÿµ—Èß·µà·√°‡°‘¥∂÷ß 3 ªï
·°πµ—Èß· ¥ß§à“‡ âπ√Õ∫«ß»’√…–
·°ππÕπ· ¥ßÕ“¬ÿµ—Èß·µà·√°‡°‘¥∂÷ß 3 ªï
(From DeMyer W. Technique of the neurologic examination.
A programmed text. 4th ed. New York: McGraw-Hill, 1994.)
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¿“§ºπ«° 2
¿“æ∂à“¬∑“ß√—ß ’„πºŸâªÉ«¬ normal pressure hydrocephalus
(MR imaging of normal pressure hydrocephalus)
√Ÿª∑’Ë 12 Axial T2W MR
shows ventriculomegaly.
√Ÿª∑’Ë 13 Sagittal T1W MR
shows aqueductal flow void sign (arrow).
√Ÿª∑’Ë 14 T2W MR
shows enlarged ventricles with
rounded frontal horns.
√Ÿª∑’Ë 15 Axial FLAIR MR
shows ventriculomegaly out of
proportion to sulcal enlargement.
√Ÿª∑’Ë 16 Axial CT scan with contrast
media shows symmetrical dilatation of
ventricles out of proportion to sulcal
enlargement.
√Ÿª∑’Ë 17 Axial CT scan with contrast
media shows frontal and occipital
periventricular hypodensities suggest
transependymal CSF flow.
√Ÿª∑’Ë 12 √Ÿª∑’Ë 13
√Ÿª∑’Ë 14 √Ÿª∑’Ë 15
√Ÿª∑’Ë 16 √Ÿª∑’Ë 17
28 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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¿“æ∂à“¬ MRS ‡æ◊ËÕµ√«®¥Ÿ lactate peak
√Ÿª∑’Ë 18 Proton MR spectra (TR/TE, 2000/135) in the patient with NPH.
Proton MR spectra (TR/TE, 2000/135) in the patient with NPH.
(Upper left) axial T1W MR image. A box outlines volume of interest, which includes the bodies of lateral
ventricles in the hemisphere. Lower left corner shows spectra from the body of the left lateral ventricle and
surrounding parenchyma. The spectrum from the voxel of the parenchyma (white arrow) shows normal
spectral pattern (upper right). The spectrum from the voxel in the body of left lateral ventricle (black
arrow) shows the lactate peak (lower right). NAA, Cho, and Cr peaks also are observed, suggesting that
this intraventricular voxel contains periventricular brain tissue
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√Ÿª∑’Ë 19 Proton MR spectra (TR/TE, 2000/135) in two patients with NPH.
Proton MR spectra (TR/TE, 2000/135) in two patients with NPH. The spectra obtained from
periventricular regions (upper row) with the intraventricular spectra (lower row) are shown. Apparent
inverted doublet peaks at 1.3 ppm are observed in the intraventricular spectrum of one case (left side) and
can be recognized as lactate peaks. In the other case (right side), good qualities of lactate peaks are seen
compared with the peaks from the periventricular region in the upper row
30 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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√Ÿª∑’Ë 20 Proton MR spectra (TR/TE, 2000/135) before and after continuous spinal drainage
Proton MR spectra (TR/TE, 2000/135) before and after continuous spinal drainage in the lateral
ventrical of a patient with NPH. The spectra were obtained from a intraventricular voxel (black arrow in
upper left). Before treatment, lactate peaks are observed as inverted double peaks at 1.3 ppm from the
intraventricular voxel of NPH (lower left). Cho, Cr, and NAA peaks suggest partial volume artifact from
periventricular brain tissue. A metabolic image of lactate (upper right) before treatment shows that lactate
is confined to the lateral ventricles and surroundings. After treatment, lactate is not observed clearly (lower
right).
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¿“§ºπ«° 3
CSF diversion
¿“«–‚æ√ß ¡Õߧ—ËßπÈ” (Hydrocephalus) ¡’º≈„Àâ°“√∑”ß“π¢Õß ¡Õ߉¡à “¡“√∂¥”‡π‘π‰ª‰¥âÕ¬à“ߪ°µ‘
·≈–¡’·π«‚πâ¡®–∑”„À⧫“¡¥—π„π°–‚À≈°»’√…– Ÿß¢÷Èπ À“°‰¡à‰¥â√—∫°“√∫”∫—¥√—°…“Õ¬à“ß∂Ÿ°µâÕßÕ“®∑”„Àâ
‡°‘¥§«“¡æ‘°“√Õ¬à“ß∂“«√ À√◊Õ‡ ’¬™’«‘µ‰¥â
°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ”¡’À≈—°°“√√—°…“¥—ßπ’È
1) °“√„™â¬“≈¥Õ—µ√“°“√ √â“ß CSF «‘∏’π’È®–„™â√—°…“°√≥’∑’Ë¿“«–‚æ√ß ¡Õߧ—ËßπÈ”‰¡à√ÿπ·√ß º≈°“√
√—°…“‰¡à·πàπÕπ ¥—ßπ—Èπ „π¿“«–‚æ√ß ¡Õߧ—ËßπȔլà“ß√ÿπ·√ß ®÷߉¡à·π–π”„Àâ√—°…“¥â«¬«‘∏’π’ȇ撬߫‘∏’‡¥’¬«
2) °“√√—°…“¥â«¬°“√√–∫“¬ CSF ÕÕ°®“°‚æ√ß ¡Õß À√◊Õ subarachnoid space (CSF diversion)
¡’À≈“¬«‘∏’ °“√√—°…“π’È®–™à«¬≈¥§«“¡¥—π„π°–‚À≈°»’√…–‰¥âÕ¬à“ß√«¥‡√Á« ¡’ª√– ‘∑∏‘¿“æ·≈–‰¥âº≈·πàπÕπ
°«à“°“√√—°…“¥â«¬¬“ ¥—ßπ—Èπ °“√∑” CSF diversion ®÷߇ªìπ«‘∏’∑’ˇÀ¡“– ¡„π°“√√—°…“ºŸâªÉ«¬∑’Ë¡’¿“«–‚æ√ß ¡Õß
§—ËßπÈ”∑’Ë√ÿπ·√ß
CSF diversion ‡ªìπ«‘∏’°“√√—°…“‚¥¬°“√√–∫“¬ CSF ÕÕ°®“°‚æ√ß ¡Õß À√◊Õ subarachnoid space
´÷Ëß®”·π°‡ªìπ 3 «‘∏’ ¥—ßπ’È
1) «‘∏’√–∫“¬ CSF ÕÕ°™—Ë«§√“« (Temporary diversion or drainage) „™â ”À√—∫°√≥’∑’Ë¡’ CSF §—Ëß
∑’ˇ°‘¥®“° “‡Àµÿ°“√Õÿ¥µ—π™—Ë«§√“« (∑’˧“¥«à“®– “¡“√∂°≈—∫¡“ Ÿà¿“«–ª°µ‘¿“¬„π‰¡à‡°‘π 2 - 3 —ª¥“Àå ‡™àπ
intraventricular hemorrhage ‡ªìπµâπ À√◊Õ°√≥’ acute hydrocephalus ́ ÷Ëß®”‡ªìπµâÕß√–∫“¬ CSF ÕÕ°Õ¬à“ß√«¥‡√Á«
·µà ¿“«–„π¢≥–π—Èπ‰¡àæ√âÕ¡ ”À√—∫°“√ºà“µ—¥ ́ ÷Ëß°“√∑” Temporary diversion or drainage π’È “¡“√∂∑”‰¥â∑—Èß
bed side À√◊Õ„πÀâÕßºà“µ—¥ “¡“√∂®”·π°‰¥â‡ªìπ 2 «‘∏’ §◊Õ
1.1) Ventricular tapping or drainage À√◊Õ ventriculostomy Õ“®µâÕß∑”„π¿“«– acute
hydrocephalus ∑’ˉ¡à “¡“√∂„Àâ°“√√—°…“∑’Ë “‡Àµÿ‰¥â‚¥¬µ√ß„π¢≥–π—Èπ
1.2) Lumbar puncture À√◊Õ lumbar drainage „™â‰¥â‡©æ“–„π extraventricular obstructive
hydrocephalus À√◊Õ communicating hydrocephalus ‡∑à“π—Èπ ÷́Ëß à«π„À≠à‡°‘¥®“°°“√Õÿ¥µ—π∫√‘‡«≥ basal
cisterns ·µà‰¡àÕÿ¥µ—π„π spinal subarachnoid space ‡™àπ Postmeningitic hydrocephalus, TB meningitis ‡ªìπµâπ
32 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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2) Permanent CSF diversion ®–∑”„π°√≥’∑’Ë¿“«–‚æ√ß ¡Õߧ—ËßπÈ”∑’ˇ°‘¥®“° “‡Àµÿ∑’ˉ¡à “¡“√∂
À“¬‡Õ߉¥â ‡™àπ congenital hydrocephalus À√◊Õ ‰¥â∑” temporary CSF diversion ‡ªìπ√–¬–‡«≈“π“π·≈–
§“¥«à“®–µâÕß¡’ªí≠À“‚æ√ß ¡Õߧ—ËßπÈ”µàÕ‰ª„π√–¬–¬“« ∑”„Àâ¡’§«“¡‡ ’ˬߵàÕ°“√µ‘¥‡™◊ÈÕ ́ ÷Ëß«‘∏’°“√∑’Ëπ‘¬¡„™â ‰¥â·°à
2.1) Ventricular CSF shunt insertion ¡’À≈“¬«‘∏’ ‰¥â·°à
2.1.1) Ventriculoperitoneal shunt (VP shunt)
2.1.2) Ventriculoatrial shunt (VA shunt)
2.1.3) Ventriculopleural shunt
2.1.4) Ventriculocisternal shunt
2.1.5) Ventriculosubgaleal shunt
«‘∏’∑’Ëπ‘¬¡∑”°—π¡“°®π‡ªìπ«‘∏’¡“µ√∞“π„πªí®®ÿ∫—π ·≈–¡—°®–‡≈◊Õ°∑”°àÕπ«‘∏’Õ◊Ëπ Ê ‰¥â·°à
ventriculoperitoneal shunt (VP shunt) ·≈– ventriculoatrial shunt (VA shunt)
°àÕπºà“µ—¥ ventricular shunting »—≈¬·æ∑¬åµâÕß·πà„®«à“ºŸâªÉ«¬‰¡à¡’ªí≠À“‡√◊ËÕß active purulent
infection ‰¡à¡’≈‘Ë¡‡≈◊Õ¥∑’ËÕ“®∑”„Àâ∑àÕ¢Õß shunt Õÿ¥µ—π ·≈–§“¥«à“¿“«–π’È®–‡ªìπÕ¬à“ßµàÕ‡π◊ËÕßµàÕ‰ªÕ’°π“π
2.2) Lumbar subarachnoid-peritoneal shunt (LP shunt) «‘∏’π’È„™â‰¥â‡©æ“– communicating
hydrocephalus ‡∑à“π—Èπ
2.3) Third ventriculostomy „™â„π°√≥’ obstructive hydrocephalus ∑’Ë¡’°“√Õÿ¥µ—πÕ¬ŸàµË”°«à“ third
ventricle ·µà‰¡à·π–π”„Àℙ⫑∏’π’È„π°“√√—°…“ºŸâªÉ«¬∑’Ë¡’ hydrocephalus ∑’ˇ°‘¥√à«¡°—∫ myelomeningocele
„π°√≥’∑’Ë∑√“∫«à“¡’ HCP ®“° Ventricular obstruction Àâ“¡∑” LP shunt ‚¥¬‡¥Á¥¢“¥ ‡æ√“–¡’
§«“¡‡ ’ˬß∑’Ë®–‡°‘¥ acute tonsillar herniation ´÷ËßÕ“®®–∑”„À⺟âªÉ«¬À¬ÿ¥À“¬„®·≈–‡ ’¬™’«‘µ‰¥â„π∑—π∑’
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¿“§ºπ«° 4
34 ·π«∑“ß°“√√—°…“¿“«–‚æ√ß ¡Õߧ—ËßπÈ” ”À√—∫·æ∑¬å
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§”·π–π”°“√∑¥ Õ∫æ—≤π“°“√ ¥â«¬ DENVER II (©∫—∫¿“…“‰∑¬)
1. 欓¬“¡∑”„À⇥Á°¬‘È¡‚¥¬¬‘È¡°—∫‡¥Á° 查§ÿ¬À√◊Õ‚∫°¡◊Õ‡≈àπ°—∫‡¥Á° ·µàÀâ“¡ —¡º— µ—«‡¥Á°
2. ‡¥Á°µâÕß®âÕß¡Õß∑’Ë¡◊Õ —°§√ŸàÀπ÷Ëß ª√–¡“≥ 3 - 4 «‘π“∑’
3. æàÕ·¡àºŸâ‡≈’ȬߥŸÕ“®™à«¬·π–π”«‘∏’·ª√ßøíπ ·≈–„ ଓ ’øíπ„Àâ∫π·ª√ß
4. ‡¥Á°‰¡à®”‡ªìπµâÕߺŸ°‡™◊Õ°√Õ߇∑â“ µ‘¥´‘ªÀ√◊Õ°√–¥ÿ¡‡ ◊ÈÕ¥â“πÀ≈—߉¥â¥â«¬µπ‡Õß
5. ‡§≈◊ËÕπ°≈ÿࡉÀ¡æ√¡Õ¬à“ß™â“ Ê ®“°¥â“πÀπ÷Ë߉ªÕ’°¥â“πÀπ÷Ëß ‡ªìπ‡ âπ‚§âß√–¬–Àà“ß®“°ÀπⓇ¥Á°ª√–¡“≥ 8 π‘È«
6. ºà“π ∂Ⓡ¥Á°®—∫°√ÿâß°√‘È߇¡◊ËÕπ”°√ÿâß°√‘È߉ª —¡º— À≈—ß¡◊ÕÀ√◊Õπ‘È«¢Õ߇¥Á°
7. ºà“π ∂Ⓡ¥Á°æ¬“¬“¡¡ÕßÀ“°≈ÿࡉÀ¡æ√¡∑’˵°≈ß∫πæ◊Èπ ºŸâ∑¥ Õ∫§«√ª≈àÕ¬°≈ÿࡉÀ¡æ√¡Õ¬à“ß√«¥‡√Á«‚¥¬‰¡à¢¬—∫·¢π„π¢≥–∑’ˇ¥Á°¡Õß
8. ‡¥Á°µâÕ߇ª≈’ˬπ¡◊Õ∂◊Õ°âÕπ‰¡â®“°¡◊Õ¢â“ßÀπ÷Ëß‚¥¬‰¡àµâÕß„™â√à“ß°“¬ ª“° À√◊Õ‚µä–™à«¬
9. ºà“π ∂Ⓡ¥Á° “¡“√∂„™âπ‘È«À—«·¡à¡◊Õ à«π„¥°Á‰¥â·≈–π‘È«Õ◊ËπÀ¬‘∫≈Ÿ°‡°¥
10. ‡ âπµ√ß∑’Ë«“¥µâÕß∑”¡ÿ¡‰¡à‡°‘π 30 Õß»“ ®“°‡ âπµ—«Õ¬à“ß
11. °”¡◊Õ ™Ÿπ‘È«À—«·¡à¡◊Õ¢÷Èπæ√âÕ¡°—∫°√–¥‘°π‘È«À—«·¡à¡◊Õ ºà“π ∂Ⓡ¥Á°‡≈’¬π·∫∫·≈–‰¡à¢¬—∫π‘È«Õ◊Ëπ
12. ºà“π ∂â“«“¥‡ âπ«ß°≈¡™π°—π ‰¡àºà“π ∂â“«“¥‡ âπ«π‰ª‡√◊ËÕ¬ Ê 13. ∂“¡‡¥Á°«à“ ‡ âπ‰À𬓫°«à“°—π (‰¡à„™à„À≠à°«à“) À¡ÿπ°√–¥“…
°≈—∫À—«·≈â«∂“¡´È” (ºà“π ∂â“∑”∂Ÿ° 3 „π 3 §√—Èß À√◊Õ 5 „π 6 §√—Èß)
14. ºà“π ∂Ⓡ âπµ√ß 2 ‡ âπ µ—¥°—π∫√‘‡«≥µ√ß°≈“ßÀ√◊Õ„°≈⇧’¬ß 15. „À⇥Á°ÕÕ°·∫∫°àÕπ ∂Ⓡ¥Á°∑”‰¡à‰¥â «“¥√Ÿª„À⇥Á°‡≈’¬π·∫∫«“¥µ“¡
¢âÕ∑¥ Õ∫¬àÕ¬∑’Ë 12, 14 ·≈– 15 ‰¡àµâÕß∫Õ°™◊ËÕ√Ÿª∑√ß ·≈–‰¡àµâÕß∑”„À⥟„π¢âÕ 12 ·≈– 14
16. °“√„À⧖·ππ Õ«—¬«–∑’ˇªìπ§Ÿà„Àâπ—∫‡ªìπ 1 à«π ‡™àπ ·¢π ¢“ ‡ªìπµâπ
17. „ à°âÕπ‰¡â 1 ™‘Èπ„π∂⫬ ‡¢¬à“‡∫“ Ê „°≈âÀŸ‡¥Á°‚¥¬‰¡à„À⇥Á°‡ÀÁπ ∑”‡™àπ‡¥’¬«°—ππ’È°—∫ÀŸÕ’°¢â“ßÀπ÷Ëß
18. ™’È√Ÿª¿“æ·≈â«„À⇥Á°∫Õ°™◊ËÕ (‰¡à„À⧖·ππ∂Ⓡ¥Á°∑”·µà‡ ’¬ß) ∂Ⓡ¥Á°µÕ∫∂Ÿ°πâÕ¬°«à“ 4 ¿“æ „À⇥Á°™’È√Ÿª¿“浓¡§” —ËߢÕߺŸâ∑¥ Õ∫
19. „™âµÿä°µ“‡ªìπÕÿª°√≥å ·≈â«∫Õ°„À⇥Á°™’È ®¡Ÿ° µ“ ÀŸ ª“° ¡◊Õ ‡∑â“ ∑âÕß º¡ ºà“π ∂⓵Õ∫∂Ÿ° 6 „π 8 Õ¬à“ß
20. „À⇥Á°¥Ÿ¿“æ ·≈â«∂“¡«à“ √Ÿª‰Àπ∫‘π‰¥â √Ÿª‰Àπ√âÕ߇À¡’¬« √Ÿª‰Àπ查§ÿ¬‰¥â √Ÿª‰Àπ‡Àà“ √Ÿª‰Àπ«‘Ëß°äÕ∫ Ê ºà“π ∂⓵Õ∫∂Ÿ° 2 „π 5 À√◊Õ 4 „π 5 √Ÿª
21. ∂“¡‡¥Á°«à“ ®–∑”Õ¬à“߉√∂â“ÀπŸÀπ“« ®–∑”Õ¬à“߉√∂â“ÀπŸ‡Àπ◊ËÕ¬ ®–∑”Õ¬à“߉√∂â“ÀπŸÀ‘« ºà“π ∂⓵Õ∫∂Ÿ° 2 „π 3 Õ¬à“ß À√◊Õ 3 „π 3 Õ¬à“ß
22. ∂“¡‡¥Á°«à“ ∂⫬‡Õ“‰«â∑”Õ–‰√ ‡°â“ՒȇՓ‰«â∑”Õ–‰√ ¥‘π Õ‡Õ“‰«â∑”Õ–‰√
23. ºà“π ∂Ⓡ¥Á°«“ß®”π«π∂Ÿ°µâÕß·≈–∫Õ°‰¥â«à“¡’°âÕπ‰¡â°’Ë°âÕπ∫π°√–¥“… (1, 5)
24. ∫Õ°„À⇥Á°«“ß°âÕπ‰¡â∫π‚µä–; „µâ‚µä–; ¢â“ßÀπâ“©—π; ¢â“ßÀ≈—ß©—π ºà“π ∂â“∑”∂Ÿ° 4 „π 4 Õ¬à“ß
25. ∂“¡‡¥Á°«à“ ≈Ÿ°∫Õ≈§◊ÕÕ–‰√ ? ...∑–‡≈ ...‚µä– ...∫â“π ...°≈⫬ ...¡à“π ...√—È« ...‡æ¥“π ºà“π ∂Ⓡ¥Á°„À⧫“¡À¡“¬„π≈—°…≥–°“√„™âß“π √Ÿª√à“ß ∑”¡“®“°
Õ–‰√À√◊Õ∫Õ°ª√–‡¿∑ (‡™àπ °≈⫬‡ªìπº≈‰¡â ‰¡à„™à ’‡À≈◊Õß) ºà“π ∂⓵Õ∫∂Ÿ° 5 „π 8 Õ¬à“ß À√◊Õ 7 „π 8 Õ¬à“ß
26. ∂“¡‡¥Á°«à“∂ⓡ⓵—«„À≠à ÀπŸµ—«... ∂Ⓣø√âÕπ πÈ”·¢Áß... ∂â“¥«ßÕ“∑‘µ¬å¢÷Èπ‡«≈“°≈“ß«—π ¥«ß®—π∑√å¢÷Èπ‡«≈“... ºà“π ∂⓵Õ∫∂Ÿ° 2 „π 3
27. ‡¥Á°Õ“®®–‡°“–√“«À√◊Õ‡°“–°”·æ߇æ◊Ëՙ૬‡¥‘π¢÷Èπ∫—π‰¥ ‰¡à„™à§π®Ÿß ·≈–‰¡à§≈“π¢÷Èπ
28. ‡¥Á°µâÕߢ«â“ß∫Õ≈ÕÕ°‰ª‰°≈ 3 øÿµ „Àâ≈Ÿ°∫Õ≈Õ¬Ÿà„π√–¥—∫·¢π‡Õ◊ÈÕ¡∂÷ß (¡ÕߺŸâ∑¥ Õ∫)
29. ‡¥Á°µâÕß°√–‚¥¥ 2 ‡∑â“ ¢â“¡°√–¥“…∑’Ë¡’¢π“¥§«“¡°«â“ß 8 1/2 π‘È«
30. ∫Õ°„À⇥Á°‡¥‘πµàÕ‡∑Ⓣª¢â“ßÀπâ“ ‚¥¬„Àâπ‘È«‡∑â“·≈– âπ‡∑â“Àà“ß°—πª√–¡“≥ 1 π‘È« ºŸâ∑¥ Õ∫Õ“® “∏‘µ„À⇥Á°¥Ÿ°àÕπ (‡¥Á°µâÕ߇¥‘𵑥µàÕ°—π 4 °â“«)
31. „π¢«∫ªï∑’Ë 2 ‡¥Á°ª°µ‘ª√–¡“≥§√÷ËßÀπ÷ËßÕ“®¡’≈—°…≥–‰¡à§àÕ¬√à«¡¡◊Õ
º≈°“√ —߇°µæƒµ‘°√√¡¢Õ߇¥Á°
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1. πæ.Õ¿‘™“µ‘ ‡®√‘≠∏√√¡ ÿ¢„® √æ.°√–∑ÿà¡·∫π ¡ÿ∑√ “§√
2. πæ.«√“«ÿ∏ °‘µµ‘«—≤π“°ÿ≈ √æ.¢Õπ·°àπ ¢Õπ·°àπ
3. πæ.‡∑’¬π™—¬ ∏“√‡°…¡ √æ.∑Õߺ“¿Ÿ¡‘ °“≠®π∫ÿ√’
4. πæ.æ√™—¬ À™—¬√ÿà߇√◊Õß √æ.πæ√—µπ√“™∏“π’ °√ÿ߇∑æ¡À“π§√
5. πæ.«‘√«‘™¬å ®‘πµ«√ √æ.π«¡‘π∑√å °√ÿ߇∑æ¡À“π§√
6. πæ.™—¬ ‘∑∏‘Ï §”· π √æ.‚ππ —ß ÀπÕß∫—«≈”¿Ÿ
7. æ≠.¡“√‘ “ »‘≈“∫ÿµ√ √æ.∫—«„À≠à π§√√“™ ’¡“
8. πæ.¡ÿ®≈‘π∑å ‡©≈‘¡æ√æß»å √æ.æ√–ª°‡°≈â“ ®—π∑∫ÿ√’
9. πæ.¿“≥ÿ¡“» ¢«—≠‡√◊Õπ √æ.·æ√à ·æ√à
10. πæ.«ÿ≤‘»—°¥‘Ï Õ“√’¬å«—≤π“ππ∑å √æ.≈–À“π∑√“¬ ∫ÿ√’√—¡¬å
11. πæ.«’√–¬ÿ∑∏ ‡ «‘«—≤πå √æ.»√’ ߧ√“¡ π§√æπ¡
12. πæ.®—°√°ƒ…≥å ª√‘‚µ √æ. °≈π§√ °≈π§√
13. πæ. À— ‡À≈’ˬ¡ ÿ«√√≥ ∂“∫—π ÿ¢¿“懥Á°·Ààß™“µ‘¡À“√“™‘π’ °√ÿ߇∑æ¡À“π§√
14. πæ.‰æ‚√®πå ∫ÿ≠≈—°…≥廑√‘ √æ.À“¥„À≠à ߢ≈“
15. πæ. —πµ‘ Õ—ß§≥“‚ ¿‘µ √æ.Õà“ß∑Õß Õà“ß∑Õß
16. πæ.‡Õ°√“™ Õ‘π∑√åÕÿ¥¡ √æ.Õÿ¥√∏“π’ Õÿ¥√∏“π’
17. πæ.«π√—°…å «—™√–»—°¥‘Ï»‘≈ªá §≥–·æ∑¬»“ µ√å ¡.‡™’¬ß„À¡à ‡™’¬ß„À¡à
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·π«∑“ß°“√√—°…“‚√§§«“¡¥ —π‚≈À ‘μ Ÿß „π ... Guideline in the Treatment...1 ·π«∑“ß “√√— …“‚√ «“¡¥ —π‚≈À
Rem tene verba sequentur. (®—∫·°àπ¢Õ߇√ …À—«„®º Ÿâπ” 23 æ√’«“ —∫º¡¡“‡¢’¬πÀπ—ß Õπ’È√à«¡ —π ‡¡ ËÕ®ÕÀåπ