1. Initial management of hemorrhagic stroke focuses on stabilizing the patient, performing a CT scan of the brain, and determining if hemorrhage is present. 2. Subarachnoid hemorrhage requires prompt diagnosis using CT scan to rule out aneurysm. 3. Patients under 45 years old or with unusual bleeding patterns require further evaluation with contrast CT scan to identify underlying causes like tumors or abnormal vessels.

1. ∫∑π”
‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß (stroke, cerebrovascular disease) ‡ªìπ‚√§∑’æ∫∫àÕ¬„πª√–™“°√ ŸßÕ“¬ÿ
Ë
∑—Ë«‚≈° „πª√–‡∑»∑“ßµ–«—πµ° æ∫‡ªì𠓇Àµÿ°“√µ“¬Õ—π¥—∫ “¡1 „πª√–‡∑»®’π ≠’˪ÿÉπ 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 √“¬ ‡¡◊Õªï æ.». 2526 æ∫«à“¡’Õµ√“‡∑à“°—∫ 690 µàÕ 100,000 ¢Õߪ√–™“°√∑’Ë
Ë —
Õ“¬ÿ‡°‘π 20 ªï4 ·≈–≈à“ ÿ¥„πªï æ.». 2541 ‰¥â¡°“√»÷°…“„πª√–™“°√ºŸ¡Õ“¬ÿ‡°‘π 60 ªï„π™π∫∑∑—ß 4 ¿“§
’ â ’ È
®”π«π 3,036 √“¬ æ∫«à“¡’Õµ√“§«“¡™ÿ°√âÕ¬≈– 1.12 ´÷ß„°≈⇧’¬ß°—∫ª√–‡∑»µà“ß Ê ∑—«‚≈°5 ¥—ßπ—π‚√§
— Ë Ë È
À≈Õ¥‡≈◊Õ¥ ¡Õß®÷߇ªìπ‚√§∑’¡§«“¡ ”§—≠¬‘ß‚√§Àπ÷ߢÕߪ√–™“°√‰∑¬
Ë ’ Ë Ë
Õߧ尓√Õπ“¡—¬‚≈°‰¥â„À⧔®”°—¥§«“¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߉«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¡¢Õ߇§√◊ËÕß¡◊Õ∑“ß°“√·æ∑¬å∑’Ë¡’À≈“¬
ª√–‡¿∑ √«¡∑—ß°“√°√–®“¬∑’‰¡à‡À¡“– ¡7 ®÷ß¡’‡«™ªØ‘∫µ‰¡à‡À¡◊Õπ°—π∑—ߥâ“π°“√«‘π®©—¬·≈–√—°…“
È Ë — ‘ È ‘
‚√§π’È ¥—ßπ—π°“√∑”·π«∑“߇«™ªØ‘∫µ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å ®÷߇ªìπ«‘∏°“√∑’‡Ë À¡“– ¡
È —‘ ’
‡æ◊Õ “¡“√∂𔉪ªØ‘∫µ‰¥â∂°µâÕß·≈–‡ªìπ¡“µ√∞“π∑—«ª√–‡∑»
Ë —‘ Ÿ Ë
°“√®—¥∑”·π«∑“߇«™ªØ‘∫µ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°π’È Õ“»—¬À≈—°∞“π∑“ß«‘™“°“√∑’‰¥âµæ¡æå
—‘ Ë ’ ‘
·≈â« ‚¥¬·∫àß√–¥—∫§”·π–π”Ցߧÿ≥¿“æ¢ÕßÀ≈—°∞“π (strength of recommendation) ‡ªìπ 3 √–¥—∫ §◊Õ
A, B, C (µ“√“ß∑’Ë 1)
·π«∑“߇«™ªØ‘∫µ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°π’È ·∫àßÕÕ°‡ªìπ 3 ¢—πµÕπ¥—ßπ’È
—‘ 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«∑“߇«™ªØ‘∫µ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°∑’‡Ë À¡“– ¡ (¥Ÿ·ºπ¿Ÿ¡∑’Ë 2-8)
—‘ ‘
‡π◊ÈÕÀ“¢Õß·π«∑“߇«™ªØ‘∫—µ‘©∫—∫π’Ȫ√–°Õ∫¥â«¬ ·ºπ¿Ÿ¡‘ §”Õ∏‘∫“¬ ‡Õ° “√Õâ“ßÕ‘ß µ“√“ß
·≈–¿“§ºπ«°
1
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

2. 2
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

3. ∫∑∑’Ë 1
·π«∑“ß°“√∫”∫—¥√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°
(Guidelines for the Management of Hemorrhagic Stroke)
‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° (hemorrhagic stroke) ‡ªìπ‚√§∑’æ∫∫àÕ¬„πª√–‡∑»·∂∫‡Õ‡™’¬¡“°°«à“
Ë
ª√–‡∑»∑“ßµ–«—πµ° ‚¥¬¡’Õ∫µ°“√≥å ß∂÷ß√âÕ¬≈– 25-35 ¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß8 ¿“«–π’‡È ªì𠓇Àµÿ
ÿ —‘ Ÿ
°“√µ“¬·≈–§«“¡æ‘°“√Õ—π¥—∫µâπ Ê ‚¥¬‡©æ“–„πºŸ ßÕ“¬ÿ ·¡â«“¡’°“√»÷°…“·∫∫ randomized double-
â Ÿ à
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”Ցߧÿ≥¿“懰’¬«°—∫‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° Õ¬Ÿ„π√–¥—∫ C ®÷ßµâÕß¡’°“√«‘®¬·≈–
Ë à —
æ—≤π“‡æ◊Õ„À≥⧔µÕ∫∑’¥¢πµàÕ‰ª
Ë Ë ’ È÷
3
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

4. ·ºπ¿Ÿ¡∑’Ë 1. °“√∫”∫—¥√—°…“‡∫◊Õßµâπ·≈–°“√«‘π®©—¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß
‘ È ‘
(Initial Management and Diagnosis of Stroke)
À¡“¬‡Àµÿ * µ√«®√à“ß°“¬ºŸª«¬‡æ◊Õ¥Ÿ«“¡’Õ“°“√√ÿπ·√ß (GCS < 8, signs of brain herniation, hypoxia,
â É Ë à
‡ ’¬ßµàÕ°“√ ”≈—°) À√◊Õ‰¡à ‡æ◊Õæ‘®“√≥“„Àâ advanced life support °àÕπ°“√ ◊∫§âπ‚√§
Ë Ë
** ºŸª«¬∑ÿ°√“¬§«√‰¥â√∫°“√µ√«® CT brain ·µà„π ∂“π∑’∑‰¡à “¡“√∂ àßµ√«® CT scan ·≈–ºŸª«¬¡’Õ“°“√
â É — Ë ’Ë â É
∑“ߧ≈‘π°‡¢â“‰¥â°∫ stroke ™—¥‡®π Õπÿ‚≈¡„™â Siriraj Stroke Score ( SSS ) ·∑π (¥Ÿ¿“§ºπ«° 1 Àπâ“ 31)
‘ —
∂⓺≈‡ªìπ hemorrhagic stroke À√◊Õ uncertained ®”‡ªìπµâÕß àßµàÕ (refer) ‡ ¡Õ
*** ∂â“ CT brain ª°µ‘·≈–≈—°…≥–∑“ߧ≈‘π°‡¢â“‰¥â°∫ subarachnoid hemorrhage (SAH) „Àâ殓√≥“µ√«®¬◊π¬—π
‘ — ‘
¥â«¬°“√‡®“–µ√«®πÈ”‰¢ —πÀ≈—ß
**** ∂â“ CT brain æ∫ hemorrhage ·≈–ºŸª«¬¡’Õ“¬ÿ < 45 ªï À√◊Õ¡’√Õ¬‚√§Õ◊𠇙àπ bleeding tumor ‡ªìπµâπ À√◊Õ
â É Ë
‡ªìπ unusual site of hypertensive hemorrhage æ‘®“√≥“©’¥ contrast media ‡æ◊Õ¥Ÿ abnormal vessels „π°√≥’∑’Ë
Ë
‰¡à¡¢ÕÀâ“¡
’â
4
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

5. §”Õ∏‘∫“¬·ºπ¿Ÿ¡∑’Ë 1
‘
ºŸª«¬∑ÿ°§π∑’¡“‚√ß欓∫“≈¥â«¬Õ“°“√ acute neurological deficit µâÕßµ√«® vital signs, neurological
â É Ë
signs ‡æ◊Õª√–‡¡‘π«à“µâÕß„Àâ emergency advanced life support À√◊Õ‰¡à ¥Ÿ airway, ventilation ‡æ’¬ßæÕ
Ë
À√◊Õ‰¡à ‚¥¬‡©æ“–ºŸª«¬∑’¡√–¥—∫§«“¡√Ÿ °µ—«µË” (GCS < 8) À√◊Õ brain stem dysfunction À√◊Õ hypoxia
â É Ë ’ â ÷
(PaO2< 60 mmHg), hypercarbia (PaCO2 > 40 mmHg) À√◊Õ ‡ ’¬ßµàÕ°“√‡°‘¥ aspiration §«√‰¥â√∫°“√
Ë —
„ à∑àՙ૬À“¬„® æ√âÕ¡°—∫ àß emergency laboratory tests (CBC, BS, BUN, Cr, electrolytes)
´—°ª√–«—µ‘·≈–µ√«®√à“ß°“¬∑’ˇ°’ˬ«¢âÕß ‡™àπ °“√∫“¥‡®Á∫∑’Ë»’√…– ¥◊Ë¡ ÿ√“ §«“¡¥—π‚≈À‘µ Ÿß ‚√§À—«„®
‚√§‡∫“À«“π ‚√§‡≈◊Õ¥ ‚√§µ—∫ ‚√§‰µ °“√„™â ¬“ anticoagulants ¬“‡ 浑¥ ‡æ◊Õ·¬°¿“«– Õ◊π∑’‰¡à„™à
Ë Ë Ë
‚√§À≈Õ¥‡≈◊Õ¥ ¡ÕßÕÕ°‰ª
‡¡◊Õ ß —¬«à“‡ªìπ acute stroke §«√‰¥â√∫°“√µ√«® CT brain ∑ÿ°√“¬9 ·µà∂“‰¡à¡’ CT scan
Ë — â
·≈–ºŸª«¬Õ“°“√‰¡à√π·√ßÕπÿ‚≈¡„Àâ„™â Siriraj Stroke Score (SSS) ·∑π ‡æ◊Õ·¬°«à“‡ªìπ hemorrhagic
â É ÿ Ë
stroke À√◊Õ‰¡à
„π°√≥’∑’Ë CT brain ∫àß«à“‡ªìπ ischemic stroke „Àâª√÷°…“ª√– “∑·æ∑¬å ‡æ◊Õ„Àâ°“√√—°…“
Ë
µ“¡·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫À√◊ÕÕÿ¥µ—π ”À√—∫·æ∑¬å17 µàÕ‰ª ·µà∂“‡ªìπ hemorrhagic
â
stroke „ÀâªØ‘∫µµ“¡·ºπ¿Ÿ¡∑’Ë 2
—‘ ‘
5
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

6. ‘
·ºπ¿Ÿ¡∑’Ë 2. °“√·¬°‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°µ“¡µ”·Àπàß
(Classification of Hemorrhagic Stroke by Location)
6
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å
À¡“¬‡Àµÿ ICH = Intracerebral hemorrhage ICH & IVH ‘
¥Ÿ·ºπ¿Ÿ¡∑Ë’ 3-7 (Àπâ“ 10,12,14,16,18)
IVH = Intraventricular hemorrhage SAH & ICH ‘
¥Ÿ·ºπ¿Ÿ¡∑’Ë 8 (Àπâ“ 20)
Lobar = ICH in cortical or subcortical area SAH & IVH ‘
¥Ÿ·ºπ¿Ÿ¡∑’Ë 8 (Àπâ“ 20)
Non-lobar = ICH in basal ganglia, thalamus, brain stem, cerebellum Primary IVH §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å
SAH = Subarachnoid hemorrhage
Primary IVH = IVH only

7. §”Õ∏‘∫“¬·ºπ¿Ÿ¡∑’Ë 2
‘
·æ∑¬åºŸâ√—°…“µâÕß欓¬“¡À“ “‡Àµÿ¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°∑ÿ°√“¬ ‚¥¬¥Ÿ®“°µ”·Àπàß
¢Õ߇≈◊Õ¥„π CT brain √à«¡°—∫ Õ“¬ÿ ª√–«—µ§«“¡¥—π‚≈À‘µ Ÿß·≈–‚√§∑’‡Ë ªìπ√à«¡ ‡¡◊Õæ‘®“√≥“®“° CT
‘ Ë
brain “¡“√∂·∫àß hemorrhagic stroke µ“¡µ”·ÀπàߢÕ߇≈◊Õ¥∑’ÕÕ°‰¥â‡ªìπ 3 °≈ÿ¡ §◊Õ subarachnoid
Ë à
hemorrhage (SAH), intraventricular hemorrhage (IVH), intracerebral hemorrhage (ICH) ·µà∫“ߧ√—ß
È
Õ“®æ∫¡“°°«à“ 1 µ”·Àπàß „Àâ殓√≥“«à“µ”·Àπàß∑’‡Ë ≈◊Õ¥ÕÕ°Õ¬Ÿ∑‰Àπ ·≈–„Àâ∫”∫—¥√—°…“‰ªµ“¡µ”·Àπàß
‘ à ’Ë
π—π Ê
È
7
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

8. 8
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

9. ∫∑∑’Ë 2
°“√∫”∫—¥√—°…“∑“ß»—≈¬°√√¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°
(Surgical Management of Hemorrhagic Stroke)
°“√∫”∫—¥√—°…“∑“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◊Õ≈¥§«“¡¥—π
Ë
„π°–‚À≈°»’√…– ”À√—∫°“√ºà“µ—¥°âÕπ‡≈◊Õ¥∑’ËÕ¬Ÿà≈÷° Õ“®∑”„À⇰‘¥¿“«– ¡Õß∫«¡‡æ‘Ë¡¡“°¢÷Èπ
º≈°“√√—°…“®÷߉¡à¥’ ¥—ßπ—π °“√æ‘®“√≥“ºà“µ—¥®”‡ªìπµâÕß¡’¢Õ∫àß™’∑™¥‡®π
È â È ’Ë —
9
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

10. ·ºπ¿Ÿ¡∑’Ë 3. °“√∫”∫—¥√—°…“ Lobar Hemorrhage
‘
(Management of Lobar Hemorrhage)
À¡“¬‡Àµÿ
°“√§”π«≥ª√‘¡“µ√°âÕπ‡≈◊Õ¥ = 0.524 x X x Y x Z ¡‘≈≈‘≈µ√ ‘
(X,Y,Z = §«“¡¬“«¢Õ߇ âπºà“»Ÿπ¬å°≈“ߢÕß°âÕπ‡≈◊Õ¥„π·π«·°π X,Y,Z Àπ૬‡ªìπ ‡´πµ‘‡¡µ√)27,28
* ∂â“°âÕπ‡≈◊Õ¥Õ¬Ÿ∑’Ë temporal lobe ¡—°¡’ early herniation20 §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å
à
GCS = Glasgow Coma Scale
HC = Hydrocephalus
IVH = Intraventricular hemorrhage
SAH = Subarachnoid hemorrhage
10
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

11. §”Õ∏‘∫“¬·ºπ¿Ÿ¡∑’Ë 3
‘
Lobar hemorrhage À¡“¬∂÷ß intracerebral hemorrhage (ICH) ∑’Õ¬Ÿ„πµ”·Àπàß cortical À√◊Õ
Ë à
subcortical ‰¥â·°à frontal, temporal, parietal, occipital lobes “‡Àµÿ¢Õ߇≈◊Õ¥∑’ÕÕ° ∫√‘‡«≥π’ «π„À≠à
Ë È à
‰¡à„™à‡°‘¥®“°§«“¡¥—π‚≈À‘µ Ÿß ·µà¡ “‡ÀµÿÕ𠇙àπ cerebral amyloid angiopathy, aneurysm, AVM
’ ◊Ë
‡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“°ºŸª«¬Õ“°“√‡≈«≈ß §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å ·µà∂“Õ“°“√¥’¢π·≈–ºŸª«¬Õ“¬ÿ < 45 ªï
â É â ÷È â É
À√◊Õ‰¡à¡ª√–«—µ§«“¡¥—π‚≈À‘µ ŸßÀ√◊Õ CT brain ß —¬«à“¡’ abnormal blood vessels §«√ª√÷°…“ª√– “∑
’ ‘
»—≈¬·æ∑¬å‡æ◊Õ°“√∫”∫—¥√—°…“∑’‡Ë À¡“– ¡ ‡™àπ àßµ√«® cerebral angiography24,25,26 ‡ªìπµâπ
Ë
”À√—∫°âÕπ‡≈◊Õ¥∑’µ”·Àπàß temporal lobe ¡’‚Õ°“ ∑’®–‡°‘¥ early brain herniation20 ¥—ßπ—π
Ë Ë È
§«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å
°“√∫”∫—¥√—°…“ 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 ·µàºª«¬∑’Õ“¬ÿ
Ÿâ É Ë
πâÕ¬°«à“ 45 ªï À√◊ÕºŸª«¬∑’¡§«“¡º‘¥ª°µ‘Õπ Ê „π CT brain §«√∑”°“√µ√«®«‘π®©—¬‚√§‡æ‘¡‡µ‘¡
â É Ë ’ ◊Ë ‘ Ë
11
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

12. ·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√ ‘
(X,Y,Z = §«“¡¬“«¢Õ߇ âπºà“»Ÿπ¬å°≈“ߢÕß°âÕπ‡≈◊Õ¥„π·π«·°π X,Y,Z Àπ૬‡ªìπ ‡´πµ‘‡¡µ√)27,28
*Basal ganglia hemorrhage À¡“¬∂÷ß °âÕπ‡≈◊Õ¥∑’µ”·Àπàß putamen, globus pallidus ·≈–
Ë
caudate nucleus (¥Ÿ¿“§ºπ«°∑’Ë 5 Àπâ“ 35)
GCS = Glasgow Coma Scale
HC = Hydrocephalus
IVH = Intraventricular hemorrhage
SAH = Subarachnoid hemorrhage
12
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

13. §”Õ∏‘∫“¬·ºπ¿Ÿ¡∑’Ë 4
‘
Basal ganglia hemorrhage ·∫àßÕÕ°‡ªìπ Õß°≈ÿ¡ À“°æ∫¢âÕ∫àß™’È > 2 ¢âÕ ‰¥â·°à GCS < 1318,19,
à
volume > 30 ml. 27,28,29,30, midline shift > 0.5 cm. 23 §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å ·µà∂“¢âÕ∫àß™’È < 2 ¢âÕ
â
„Àâ√°…“·∫∫ª√–§—∫ª√–§Õß À“°ºŸª«¬Õ“°“√‡≈«≈ß ®÷ߪ√÷°…“ª√– “∑»—≈¬·æ∑¬å
— â É
13
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

14. ·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 = §«“¡¬“«¢Õ߇ âπºà“»Ÿπ¬å°≈“ߢÕß°âÕπ‡≈◊Õ¥„π·π«·°π X,Y,Z Àπ૬‡ªìπ‡´πµ‘‡¡µ√)27,28
GCS = Glasgow Coma Scale
HC = Hydrocephalus
IVH = Intraventricular hemorrhage
14
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

15. §”Õ∏‘∫“¬·ºπ¿Ÿ¡∑’Ë 5
‘
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∂“¢âÕ∫àß™’È
â
< 2 ¢âÕ ·≈–‰¡à¡’ hydrocephalus „Àâ√°…“·∫∫ª√–§—∫ª√–§Õß „π°√≥’∑ºª«¬¡’Õ“°“√‡≈«≈ß®÷ߪ√÷°…“
— ’Ë Ÿâ É
ª√– “∑»—≈¬·æ∑¬å
15
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

16. ·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√ ‘
(X,Y,Z = §«“¡¬“«¢Õ߇ âπºà“»Ÿπ¬å°≈“ߢÕß°âÕπ‡≈◊Õ¥„π·π«·°π X,Y,Z Àπ૬‡ªìπ ‡´πµ‘‡¡µ√)27,28
* Cerebellar hemorrhage ∑’Ë vermis41 ¡—°®–¡’ early brain stem compression §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å
**°“√ àßµ—«ºŸª«¬ (refer case) ºŸª«¬Õ“®®–À¬ÿ¥À“¬„®„π¢≥–‡¥‘π∑“߉¥â ©–π—π µâÕ߇µ√’¬¡‡§√◊Õß¡◊Õ‡æ◊Õ
â É â É È Ë Ë
™à«¬°“√À“¬„®„Àâæ√âÕ¡
GCS = Glasgow Coma Scale
HC = Hydrocephalus
IVH = Intraventricular hemorrhage
16
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

17. §”Õ∏‘∫“¬·ºπ¿Ÿ¡∑’Ë 6
‘
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∑”„À⧔π«≥ª√‘¡“µ√°âÕπ‡≈◊Õ¥‰¡à‰¥â·µà‡ âπºà“»Ÿπ¬å°≈“ߢÕß°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—«ºŸª«¬ (refer case) ºŸª«¬Õ“®®–À¬ÿ¥À“¬„®„π¢≥–‡¥‘π∑“߉¥â ©–π—π µâÕ߇µ√’¬¡
â É â É È
‡§√◊Õß¡◊Õ‡æ◊ՙ૬°“√À“¬„®„Àâæ√âÕ¡
Ë Ë
17
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

18. ·ºπ¿Ÿ¡∑’Ë 7. °“√∫”∫—¥√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°∑’µ”·Àπàß Pons
‘ Ë
(Management of Pontine Hemorrhage)
À¡“¬‡Àµÿ
GCS = Glasgow Coma Scale
HC = Hydrocephalus
IVH = Intraventricular hemorrhage
*Repeated episodes À¡“¬§«“¡«à“‡°‘¥ pontine hemorrhage ´È”∑’µ”·Àπà߇¥‘¡
Ë
18
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

19. §”Õ∏‘∫“¬·ºπ¿Ÿ¡∑Ë’ 7
‘
Brain stem hemorrhage ¡—°æ∫¡“°∑’µ”·Àπàß pons ‰¡à§«√ºà“µ—¥‡æ√“–¡’§«“¡‡ ’¬ß Ÿß ∂â“
Ë Ë
GCS < 13 À√◊Õ¡’ hydrocephalus À√◊Õ intraventricular hemorrhage À√◊ÕÀ≈Õ¥‡≈◊Õ¥·µ°´È”∑’µ”·Àπà߇¥‘¡
Ë
(repeated episodes) §«√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å ∂â“ GCS > 13 ·≈–‰¡à¡’ hydrocephalus „Àâ√°…“ —
·∫∫ª√–§—∫ª√–§Õß
19
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

20. ·ºπ¿Ÿ¡∑’Ë 8. °“√∫”∫—¥√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°„π Subarachnoid Space
‘
(Management of Subarachnoid Hemorrhage)
À¡“¬‡Àµÿ * ∂Ⓣ¡à¡’ CT brain Õπÿ‚≈¡„À⇮“–µ√«®πÈ”‰¢ —πÀ≈—߇æ◊Õ°“√«‘π®©—¬‚√§ À“°‰¡à¡Õ“°“√
Ë ‘ ’
·≈–/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
IVH = Intraventricular hemorrhage
20
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

21. §”Õ∏‘∫“¬·ºπ¿Ÿ¡∑’Ë 8
‘
Subarachnoid hemorrhage (SAH) À¡“¬∂÷ß ‡≈◊Õ¥ÕÕ°„π subarachnoid space ∑”„Àâ
ºŸª«¬¡’Õ“°“√ª«¥»’√…–Õ¬à“ß√ÿπ·√ߢ÷π∑—π∑’∑π„¥ Õ“®¡’À¡¥ µ‘À√◊Õ‰¡à¡°‰¥â µ√«®√à“ß°“¬æ∫¡’§Õ·¢Áß
â É È — ’Á
´÷ßÕ“®µâÕß·¬°®“°‚√§‡¬◊ÕÀÿ¡ ¡ÕßÕ—°‡ ∫ “‡Àµÿ¢Õß SAH ‰¥â·°à ruptured aneurysm, ruptured AVM,
Ë Ë â
blood dyscrasia, head injury, parasite ‡ªìπµâπ
ºŸª«¬∑’¡Õ“°“√ ß —¬ SAH „Àâ ßµ√«® CT brain (À“°‰¡à “¡“√∂ àßµ√«® CT brain
â É Ë ’ à
‰¥â ·≈–‰¡à¡¢ÕÀâ“¡„π°“√‡®“–À≈—ß Õπÿ‚≈¡„À⇮“–πÈ”‰¢ —πÀ≈—߉¥â‡æ◊Õ°“√«‘π®©—¬‚√§) ∂â“ CT brain
’â Ë ‘
‰¡àæ∫ SAH „À⇮“–µ√«®πÈ”‰¢ —πÀ≈—ß À“°º≈‡¢â“‰¥â°∫ SAH ´÷߉¡à‰¥â‡°‘¥®“° parasite §«√ª√÷°…“
— Ë
ª√– “∑»—≈¬·æ∑¬å
21
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

22. ∫∑∑’Ë 3
°“√∫”∫—¥√—°…“∑“ßÕ“¬ÿ√°√√¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°
(Medical Management for Hemorrhagic Stroke)
°“√∫”∫—¥√—°…“§«“¡¥—π‚≈À‘µ Ÿß (Blood pressure management)
‚¥¬∑—«‰ª®–‰¡à„À⬓≈¥§«“¡¥—π‚≈À‘µ„πºŸª«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°„π√–¬–·√° ¬°‡«âπ„π
Ë â É
√“¬∑’¡§«“¡¥—π‚≈À‘µ Ÿß¡“° ®÷ßæ‘®“√≥“„À⬓¥—ß√“¬≈–‡Õ’¬¥„πµ“√“ß∑’Ë 3 (Àπâ“ 28)
Ë ’
°“√∫”∫—¥√—°…“§«“¡¥—π„π°–‚À≈°»’√…– Ÿß (Management of increased intracranial pressure)
°√≥’∑ ß —¬¡’§«“¡¥—π„π°–‚À≈°»’√…– Ÿß ‡™àπ ºŸª«¬ª«¥»’√…–√ÿπ·√ß ´÷¡≈ß Õ“‡®’¬π ‡ÀÁπ
’Ë â É
¿“æ´âÕπ √Ÿ¡“πµ“¢¬“¬ ™’æ®√™â“ pulse pressure °«â“ß ‡ªìπµâπ „Àâ°“√√—°…“¿“«–§«“¡¥—π„π°–‚À≈°
à
»’√…– Ÿß¥—ß√“¬≈–‡Õ’¬¥„πµ“√“ß∑’Ë 4 (Àπâ“ 29) ·≈–ª√÷°…“ª√– “∑»—≈¬·æ∑¬å
°“√∫”∫—¥√—°…“Õÿ≥À¿Ÿ¡√“ß°“¬ (Management of body temperature)
‘à
„π√–¬–·√°ºŸª«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°¡—°¡’‰¢â ß °√≥’∑Õ≥À¿Ÿ¡√“ß°“¬ Ÿß¡“° ®–¡’º≈µàÕ
â É Ÿ ’Ë ÿ ‘à
brain metabolism ∑”„Àâ°“√欓°√≥å‚√§‡≈«≈ß ¥—ßπ—π ∂⓺Ÿª«¬¡’‰¢â > 38.5 0C §«√„Àâ°“√√—°…“¥—ß
È â É
√“¬≈–‡Õ’¬¥„πµ“√“ß∑’Ë 3 (Àπâ“ 28)
22
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

23. ‡Õ° “√Õâ“ßÕ‘ß
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(stroke) ©∫—∫‡√’¬∫‡√’¬ß§√—ß∑’Ë 2. °√ÿ߇∑æ¡À“π§√: ‡√◊Õπ·°â«°“√æ‘¡æå, 2544: 1-37.
È
2. Zhang LF, Yang J, Hong Z, Yuan GG, Zhou BF, Zhao LC, et al. Proportion of different subtypes
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‡∑§‚π‚≈¬’∑“ß°“√·æ∑¬å ©∫—∫ª√—∫ª√ÿß. °√ÿ߇∑æ¡À“π§√:‚√ßæ‘¡æåÕߧ尓√∑À“√ºà“π»÷°, 2546:5.
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23
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

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°√ÿ߇∑æ¡À“π§√ : ∂“∫—πª√– “∑«‘∑¬“; 2545: 1-28.
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24
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

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25
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

26. 38. Schutz H. Intracerebral hemorrhage. Ther Umsch 1996; 53: 590-6.
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hematomas. Neurology 1998; 51: 1364-9.
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Acta Neurol Belg 1989; 89: 7-11.
26
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

27. µ“√“ß∑’Ë 1.
√–¥—∫§”·π–π”Ցߧÿ≥¿“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◊Õ«‘π®©—¬
Ë ‘
1. ºŸª«¬∑’ ß —¬«à“‡ªìπ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°
â É Ë CT brain (grade A)
2. ∂â“ CT brain ª°µ‘ ≈—°…≥–∑“ߧ≈‘π°‡¢â“‰¥â°∫ SAH
‘ — µ√«®πÈ”‰¢ —πÀ≈—ß
3. ºŸª«¬ ICH „π°√≥’¥ßµàÕ‰ªπ’È
â É — §«√æ‘®“√≥“ àßµ√«® cerebral
- µ”·Àπà߇≈◊Õ¥ÕÕ°∑’‰¡à “¡“√∂À“ “‡Àµÿ‰¥â
Ë angiography (grade C)
- Õ“¬ÿ < 45 ªï
- ‰¡à¡ª√–«—µ§«“¡¥—π‚≈À‘µ Ÿß
’ ‘
4. ºŸª«¬∑’‡Ë ªìπ Primary IVH , SAH
â É §«√æ‘®“√≥“ àßµ√«® cerebral
angiography (grade C)
27
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

28. µ“√“ß∑’Ë 3.
°“√∫”∫—¥√—°…“∑“ßÕ“¬ÿ√°√√¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°
(Medical Management of Hemorrhagic Stroke)
1. Respiration
ºŸª«¬∑’À“¬„®‰¡àæÕ À√◊ÕÀ¡¥ µ‘ À√◊Õ¡’‚Õ°“ ‡°‘¥ ”≈—° §«√„ à∑ՙ૬À“¬„® 欓¬“¡§«∫§ÿ¡
â É Ë à
blood gas „ÀâÕ¬Ÿ„π‡°≥±åª°µ‘
à
2. Blood Pressure* 9,17
• À≈’°‡≈’¬ß¿“«– hypotension
Ë
• §«∫§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 ∑“ߪ“° ÕÕ°ƒ∑∏‘¿“¬„π 15-30 π“∑’ Õ¬Ÿ‰¥âπ“π 4-6 ™.¡.À√◊Õ
Ï à
- Small patch of nitroglycerine ªî¥Àπâ“Õ° À√◊Õ
- Hydralazine 5-10 mg ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ÕÕ°ƒ∑∏‘Ï ¿“¬„π 1-2 π“∑’ Õ¬Ÿ‰¥âπ“π 1-2 ™.¡. À√◊Õ
à
- Nicardepine º ¡¬“„À⡧«“¡‡¢â¡¢âπ 0.1-0.2 mg/ml ·≈â«„Àâ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”™â“ Ê 5 mg/hr.
’
- ‰¡à§«√„™â nifedipine Õ¡„µâ≈π À√◊Õ∑“ߪ“° ‡π◊Õß®“°‰¡à “¡“√∂∑”π“¬º≈¢Õ߬“‰¥â ·πàπÕπ
‘È Ë
·≈–‰¡à “¡“√∂ª√—∫≈¥¬“‰¥âÀ“°‡°‘¥¿“«–§«“¡¥—π‚≈À‘µµË”¡“°
3. Temperature
ºŸª«¬∑’¡‰¢â ß > 38.5 0 C §«√„À⬓ acetaminophen À√◊Õ‡™Á¥µ—« À√◊Õ„™â cooling blanket
â É Ë ’ Ÿ
4. Fluid & Electrolyte*
- 欓¬“¡Õ¬à“„À⇰‘¥ dehydration À√◊Õ overhydration ‚¥¬·µà≈–«—π ¡§«√„Àâ
ª√‘¡“≥ = urine output + 500 ml (insensible loss) + 300 ml/1oC ∑’‡Ë æ‘¡¢÷π
Ë È
®“°Õÿ≥À¿Ÿ¡°“¬ª°µ‘ (37 oC)
‘
- §«∫§ÿ¡§à“√–¥—∫ electrolyte „À⪰µ‘*
* ¢π“¥¬“·≈–ª√‘¡“≥ “√πÈ”∑’„™âπ‡’È À¡“– ”À√—∫ºŸ„À≠à
Ë â
28
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

29. 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“ºŸª«¬‚¥¬„ÀâÀ≈’°‡≈’¬ß°“√°¥∑—∫À≈Õ¥‡≈◊Õ¥¥”∑’§Õ (jugular vein)
â É Ë Ë
3. Clear airway „ à∑ՙ૬À“¬„® ·≈– Foleyûs catheter
à
4. Hyperventilation ‡æ◊Õ„Àâ PaCO2 = 30-35 mmHg ·µà«∏π¡ª√–‚¬™πå„π™à«ß —π Ê
Ë ‘ ’ ’È ’ È
°àÕπºà“µ—¥
5. æ‘®“√≥“„À⬓*
- 20% mannitol : loading dose 1 gm/kg ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”¿“¬„π 20 π“∑’ µ“¡¥â«¬
0.25-0.5 gm/kg ∑ÿ° 6 ™—«‚¡ß ‰¡à§«√„Àâµ¥µàÕ°—π‡°‘π 5 «—π (grade C) À√◊Õ
Ë ‘
- 10% glycerol 250 ml ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ¿“¬„π 30 π“∑’ ∑ÿ° 6 ™—«‚¡ß À√◊Õ Ë
- 50% glycerol 50 ml ∑“ߪ“° «—π≈– 4 §√—ß À√◊ÕÈ
- Furosemide 1 mg/kg ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” (grade C)
6. À≈’°‡≈’¬ß°“√„Àâ hypotonic solution
Ë
7. °“√„™â steroid ¬—߉¡à¡À≈—°∞“π∑“ߧ≈‘π° π—∫ πÿπ«à“‰¥âª√–‚¬™πå42,43 (grade A)
’ ‘
* ¢π“¥¬“∑’„™âπ‡’È À¡“– ”À√—∫ºŸ„À≠à
Ë â
29
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

30. µ“√“ß∑’Ë 5.
·π«∑“ß°“√ª√÷°…“ª√– “∑»—≈¬·æ∑¬å„π‡√◊Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°
Ë
(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
3. Midline shift > 0.5 cm.
Thalamus 1. GCS < 13 Criteria < 2 Criteria > 2 C
2. Volume > 10 ml
3. Midline shift > 0.5 cm.
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
30
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

31. ¿“§ºπ«° 1
Siriraj Stroke Score (SSS)
31
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

32. ¿“§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
32
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

33. 33
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

34. 34
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

35. 35
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

36. 36
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

37. 37
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

38. ¢Õ¢Õ∫§ÿ≥
·æ∑¬å∑‡’Ë ¢â“√à«¡ª√–™ÿ¡
°“√ª√–™ÿ¡/ —¡¡π“ª√—∫ª√ÿß·π«∑“߇«™ªÆ‘∫µ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å
— ‘
≥ ÀâÕßæ“‚π√“¡“ 1 ™—π 14 ‚√ß·√¡¥‘ ‡Õ¡‡¡Õ√—≈¥å
È
«—π∑’Ë 9 › 10 ‘ßÀ“§¡ 2547
1. æµ∑. æ≠.«√√≥’¬å µ√–°“√«π‘™ ‚√ß欓∫“≈µ”√«® °√ÿ߇∑æ¡À“π§√
2. πæ. À— ‡À≈’¬¡ ÿ«√√≥ Ë ∂“∫—π ÿ¢¿“懥Á°·Ààß™“µ‘¡À“√“™‘π’ °√ÿ߇∑æ¡À“π§√
3. πæ. ¡∫—µ‘ ¡ÿß∑«’æß…“à ‚√ß欓∫“≈∏√√¡»“ µ√凩≈‘¡æ√–‡°’¬√µ‘ °√ÿ߇∑æ¡À“π§√
4. πæ. ÿ°® ∑—»π ÿπ∑√«ß»å
‘ ‚√ß欓∫“≈‡≈‘¥ ‘π °√ÿ߇∑æ¡À“π§√
5. √».æ≠.π‘®»√’ ™“≠≥√ß§å §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬ °√ÿ߇∑æ¡À“π§√
6. πæ.™—™«“≈ ÿ√π∑√催∏‘π ‘ ‚√ß欓∫“≈π§√ª∞¡ π§√ª∞¡
7. πæ. ¡™—¬ µ—ß∫”‡æÁ≠ ÿπ∑√
È ‚√ß欓∫“≈π§√ª∞¡ π§√ª∞¡
8. πæ.«‘√™ °≈‘π∫—«·¬â¡
— Ë ‚√ß欓∫“≈ —π°”·æß ‡™’¬ß„À¡à
9. πæ.«’√–«—≤πå ÿ¢ ßà“‡®√‘≠ ‚√ß欓∫“≈ª√– “∑‡™’¬ß„À¡à ‡™’¬ß„À¡à
10. πæ. ¡‡°’¬√µ‘ ≈’≈“æ—π∏å‰æ∫Ÿ≈¬å ‚√ß欓∫“≈∫â“π∫÷ß ™≈∫ÿ√’
11. πæ.æß…åπ‡√» ‚æ∏‘‚¬∏‘π ‚√ß欓∫“≈ ÿ√π∑√å
‘ ÿ√π∑√å
‘
12. πæ.©—µ√™—¬ ∫ÿ≠ª√–™“√—µπå ‚√ß欓∫“≈ÀπÕߧ“¬ ÀπÕߧ“¬
13. πæ.¿“≥ÿ¡“» ¢«—≠‡√◊Õπ ‚√ß欓∫“≈·æ√à ·æ√à
14. πæ.∑√ß«ÿ≤‘ ÿ‡¡∏«“∑“𑬠‚√ß欓∫“≈≈”æŸπ ≈”æŸπ
15. πæ.∫—≥±‘µ À«—ß —𵑫√»“ ‚√ß欓∫“≈欗§¶¿Ÿ¡æ ¬
‘ ‘ — ¡À“ “√§“¡
16. πæ. —πµ‘ Õ—ß§≥“‚ ¿‘µ ‚√ß欓∫“≈Õà“ß∑Õß Õà“ß∑Õß
17. πæ.«‘∫≈¬å ‡µ™–‚°»≈
Ÿ ‚√ß欓∫“≈√âÕ¬‡ÕÁ¥ √âÕ¬‡ÕÁ¥
18. πæ.«ÿ≤ππ∑å æ—π∏–‡ π
‘ — ‚√ß欓∫“≈∫ÿ√√¡¬å
’— ∫ÿ√√¡¬å
’—
19. æ≠.æ“Ωíπ ¡ÿ °«—µ√ ‘ ‚√ß欓∫“≈¡À“√“™π§√»√’∏√√¡√“™ π§√»√’∏√√¡√“™
20. πæ.∏π‘π∑√å Õ—»««‘‡™’¬√®‘𥓠‚√ß欓∫“≈¡À“√“™π§√√“™ ’¡“ π§√√“™ ’¡“
21. πæ.°‘µµ‘°√ ª√– “∑æ√‚√®πå ‚√ß欓∫“≈ª√–®«∫§’√¢π∏å
’— ª√–®«∫§’√¢π∏å
’—
22. πæ.∏«—™ ®—π·¥ß ‚√ß欓∫“≈π§√æπ¡ π§√æπ¡
23. πæ.¡ÿ®≈‘π∑å ‡©≈‘¡æ√æß»å ‚√ß欓∫“≈æ√–ª°‡°≈â“ ®—π∑∫ÿ√’
38
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å

39. 24. πæ.™—¬ ’Àå Õ“ –π–‡ π ‚√ß欓∫“≈»√’ ß«“≈¬å
— ·¡àŒÕß Õπ
à
25. πæ.æß…å«≤πå æ≈æß…å
— ‚√ß欓∫“≈√“…’‰»≈ »√’ –‡°…
26. πæ.∏’√«—≤πå √—°®‘µ√ ‚√ß欓∫“≈æ‘®µ√
‘ æ‘®µ√
‘
27. πæ.°‘µµ‘™¬ ªí°∏߉™¬
— ‚√ß欓∫“≈æ√–π§√»√’Õ¬ÿ∏¬“ æ√–π§√»√’Õ¬ÿ∏¬“
28. πæ. ÿ¢ —πµå ‡µ™–æ‘ ∑∏‘Ï
ÿ ‚√ß欓∫“≈ «√√§åª√–™“√—°…å π§√ «√√§å
29. πæ.‡©≈‘¡æ≈ ™§—µµ√¬“æß…å ‚√ß欓∫“≈‡¡◊Õß©–‡™‘߇∑√“ ©–‡™‘߇∑√“
30. æ≠.∏πæ√ ‡æ™√«‘∫≈ Ÿ ‚√ß欓∫“≈ ¡ÿ∑√ “§√ ¡ÿ∑√ “§√
31. πæ.∏“π’ „∫·°â« ‚√ß欓∫“≈ ÿ√“…Æ√å∏“π’ ÿ√“…Æ√å∏“π’
32. πæ.¿“≥ÿ¡“» ªî¬–√µ‘√µπå — ‚√ß欓∫“≈¢Õπ·°àπ ¢Õπ·°àπ
33. πæ.æ—≈≈¿ ¬Õ¥»‘√®‘𥓠‚√ß欓∫“≈™—¬π“∑ ™—¬π“∑
39
·π«∑“߇«™ªØ‘∫—µ‘‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ”À√—∫·æ∑¬å