แนวทางการรักษาโรคหลอดเลือดสมองตีบหรืออุดตัน-สำหรับแพทย-2550

·π«∑“ß°“√√—°…“ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ∫’ À√Õ◊ Õ¥ÿ μπ—  ”À√∫— ·æ∑¬å(Clinical Practice Guidelines for Ischemic Stroke) ©∫—∫ª√—∫ª√ÿߧ√—Èß∑’Ë 1 æ.». 2550 ISBN : 978-974-422-400-2

·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√Õ◊ Õ¥ÿ μπ—  ”À√∫— ·æ∑¬åπ’È ‡ªìπ‡§√Ë◊Õß¡◊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·≈–§âÿ¡§à“ ¢âÕ·π–π”μà“ß Ê „π·π«∑“ßπÈ’‰¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—μ‘ ºŸâ„™â “¡“√∂ªØ‘∫—μ‘·μ°μà“߉ª®“°¢âÕ·π–𔉥â„π°√≥’∑Ë’ ∂“π°“√≥å·μ°μà“ßÕÕ°‰ªÀ√◊Õ¡’‡Àμÿº≈∑Ë’ ¡§«√ ‚¥¬„™â«®‘ “√≥≠“≥∑ˇ’ ªìπ∑Ë’¬Õ¡√∫— „π«™‘ “™’æ

§”𬑠¡ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß (cerebrovascular disease, stroke) À√◊Õ‚√§Õ—¡æƒ°…å/Õ—¡æ“μ ‡ªìπ‚√§∑Ë’æ∫∫Õà ¬·≈–‡ªπì ª≠í À“ “∏“√≥ ÿ¢∑Ë’ ”§—≠¢Õߪ√–‡∑»‰∑¬ ®“° ∂‘μ‘ “∏“√≥ ÿ¢ æ.». 2548 (public healthstatistics A.D. 2005) æ∫«à“ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߇ªìπ‚√§∑Ë’‡ªπì  “‡Àμÿ°“√‡ ’¬™’«‘μÕ—π¥∫— ∑’Ë 3 „πª√–™“°√‰∑¬·≈–¡’·π«‚πâ¡«à“®–‡æ‘Ë¡ Ÿß¢÷Èπ  Õ¥§≈âÕß°—∫√“¬ß“π°“√»÷°…“∑Ë’‡ªìπ°“√»÷°…“√à«¡°—π√–À«à“ß°√–∑√«ß “∏“√≥ ÿ¢·≈–Õߧ尓√Õπ“¡—¬‚≈° æ∫«à“ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߇ªìπ‚√§∑’ˇªì𠓇Àμÿ°“√‡ ’¬™’«‘μ∑Ë’ ”§—≠Õ—π¥—∫ 1 „π‡æ»À≠‘ß ·≈–Õ—π¥—∫ 2 „π‡æ»™“¬ πÕ°®“°π’È ¬—ßæ∫«à“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õ߬—߇ªπì ‚√§∑ˇ’ ªì𠓇Àμÿ¢Õß°“√ ≠Ÿ ‡ ’¬ªï ¢ÿ ¿“«– (disability adjusted life year) ∑’Ë ”§≠— Õπ— ¥∫— ∑’Ë 2 ∑—Èß„π™“¬·≈–À≠ß‘  ∂“∫π— ª√– “∑«‘∑¬“ ‡ªπì  ∂“∫—π™—Èππ”∑“ß«™‘ “°“√‡©æ“–∑“ߥâ“π‚√§√–∫∫ª√– “∑ ‰¥âμ√–Àπ—°∂÷ߧ«“¡®”‡ªìπ·≈–‡√àߥà«π¢Õߪí≠À“¥—ß°≈à“« ®÷߉¥â¥”‡π‘π°“√®—¥∑”·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μπ—  ”À√∫— ·æ∑¬å (©∫∫— ∑Ë’ 1) ‡¡◊ËÕªï æ.». 2544 ·≈–„πªï 2549 ‰¥ªâ √–‡¡‘π·π«∑“ß°“√√—°…“¥—ß°≈“à «∑”„Àâ∑√“∫«à“·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μ—π  ”À√—∫·æ∑¬å (©∫—∫∑Ë’ 1) ‡ªìπ∑’ˬա√—∫·≈–‰¥√â ∫— °“√Õâ“ßÕß‘ „π√–¥—∫ÀπßË÷ Õ’°∑—È߬ߗ æ∫«à“°“√π”·π«∑“ß°“√√—°…“œ π’ȉª„™âπ—Èπ¡’∫“ß à«π∑Ëμ’ âÕߪ√—∫ª√ÿߪ√–°Õ∫°—∫¢≥–π’È„π¥“â π°“√√—°…“¡§’ «“¡°â“«Àπ“â ¡“°¢÷πÈ ®÷ß ¡§«√ª√—∫ª√ÿß·°â‰¢‡π◊ÈÕÀ“„π «à πμ“à ß Ê ¥ß— π—Èπ„πªï æ.». 2550 πÈ’  ∂“∫—πª√– “∑«‘∑¬“®÷߉¥â¥”‡π‘π°“√®—¥ª√–™ÿ¡æ—≤π“·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√Õ◊ Õ¥ÿ μπ—  ”À√—∫·æ∑¬å¢π÷È ‚¥¬ ∂“∫—πª√– “∑«‘∑¬“‰¥â¢Õ§«“¡√à«¡¡Õ◊ ®“° ∂“∫—π«‘™“°“√μ“à ß Ê °≈“à «§Õ◊  ¡“§¡ª√– “∑«‘∑¬“·Àßà ª√–‡∑»‰∑¬  ¡“§¡‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õ߉∑¬ √“™«∑‘ ¬“≈¬— ·æ∑¬‡å «™»“ μ√øå πôó ø·Ÿ Àßà ª√–‡∑»‰∑¬  ”π°— ß“π§≥–°√√¡°“√°“√Õ¥ÿ ¡»°÷ …“ °√¡·æ∑¬∑å À“√∫° ‚√ß欓∫“≈·≈– ∂“∫π— „π ß— °¥— °√¡°“√·æ∑¬å °√–∑√«ß°≈“‚À¡°√ÿ߇∑æ¡À“π§√ ‚√ß欓∫“≈ ß— °—¥¿“§‡Õ°™π ‚¥¬¡’°“√¥”‡π‘π°“√¥ß— π’È

1. ª√–™ÿ¡§≥–∑”ß“πºâŸ∑√ߧÿ≥«ÿ≤‘·≈–ºâŸ‡™’ˬ«™“≠ 5 §√—Èß ¥—ßπ’È «—π∑’Ë 23 ¡°√“§¡ 2550 «—π∑Ë’15 °ÿ¡¿“æ—π∏å 2550 «π— ∑’Ë 29 ¡π’ “§¡ 2550 «—π∑’Ë 26 ‡¡…“¬π 2550 ·≈–«—π∑’Ë 11 情¿“§¡ 2550 2. ®—¥ àß·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μ—π  ”À√—∫·æ∑¬å 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«—π∑Ë’ 6 °√°Æ“§¡ 2550 3. ‡™‘≠·æ∑¬∑å Ë—«ª√–‡∑»‡¢“â √«à ¡ª√–™¡ÿ / ¡— ¡π“ ª√∫— ª√ÿß·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ’∫À√Õ◊ Õ¥ÿ μ—π  ”À√∫— ·æ∑¬å (©∫—∫√à“ß) „π«π— ∑’Ë 7  ‘ßÀ“§¡ 2550 Õ¬à“߉√°μÁ “¡ ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ’∫À√Õ◊ Õÿ¥μ—π  ”À√∫— ·æ∑¬πå ’È ‡ªì𧔷π–π”„π Ë‘ß∑Ë’§«√·°à°“√ªØ‘∫—쑇∑à“πÈ—π ∑—Èßπ’È „π°“√ªØ‘∫—μ‘®√‘ߢ÷Èπ°—∫¥ÿ≈¬æ‘π‘®¢Õß·æ∑¬å·≈–∫ÿ§≈“°√∑“ß°“√·æ∑¬å∑Ë’¥Ÿ·≈ºªŸâ «É ¬¢≥–ππ—È ‡ªì𠔧—≠ ∑⓬∑Ë’ ÿ¥π’È  ∂“∫—πª√– “∑«‘∑¬“À«—߇ªìπÕ¬à“߬‘Ëß«à“ ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μ—π  ”À√—∫·æ∑¬å©∫—∫π’È ®—°‡°‘¥ª√–‚¬™πå ”À√—∫·æ∑¬å∑Ë’®–𔉪ª√–¬ÿ°μ儙⠇æË◊Õ§ÿ≥¿“æ™’«‘μ∑’Ë¥’°«à“¢Õߪ√–™“™π „π‚Õ°“ πÈ’ „§√à¢Õ¢Õ∫§ÿ≥ ¡“§¡ª√– “∑«‘∑¬“·Ààߪ√–‡∑»‰∑¬  ¡“§¡‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߉∑¬·≈–√“™«‘∑¬“≈—¬·æ∑¬‡å «™»“ μ√åøπôó øŸ·Àßà ª√–‡∑»‰∑¬ °√¡·æ∑¬∑å À“√∫° §≥–·æ∑¬»“ μ√®å “°¡À“«∑‘ ¬“≈¬—μà“ß Ê ‚√ß欓∫“≈∑—Èß¿“§√—∞·≈–¿“§‡Õ°™π∑Ë—«ª√–‡∑» ∑Ë’‰¥â„À⧫“¡√à«¡¡◊ÕÕ¬à“ߥ’„π°“√®—¥∑” √«¡∑—Èß°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ¢ÿ ∑Ë ’ π∫—  ππÿ °“√¥”‡π‘πß“π§√ß—È π’ÕÈ ¬“à ߥ¬’ ß‘Ë (π“¬¡—¬∏™—  “¡‡ π) ºâŸÕ”𫬰“√ ∂“∫—πª√– “∑«‘∑¬“

§≥–∑”ß“π‚§√ß°“√®—¥∑”·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√Õ◊ Õ¥ÿ μ—π  ”À√∫— ·æ∑¬å 1. πæ. √ÿ «∑‘ ¬å ‡μ™∏ÿ«“π—π∑å ∑’˪√°÷ …“ 2. πæ.¡¬— ∏™—  “¡‡ π ∑Ë’ª√÷°…“ 3. πæ. ¡™“¬ ‚μ«≥–∫ÿμ√ ∑ª’Ë √°÷ …“ 4. πæ. ™ÿ “μ‘ À“≠‰™¬æ∫‘ ≈Ÿ ¬°å ÿ≈ ∑Ë’ª√°÷ …“ 5. æ≠.∑»— π’¬å μπ— 쑃∑∏‘»°— ¥‘Ï ª√–∏“π 6. ». πæ.π‘æπ∏å æ«ß«√‘π∑√å §≥–∑”ß“π 7. √». æ≠.¥‘…¬“ √μ— π“°√ §≥–∑”ß“π 8. æ.Õ. (º».) πæ. “¡“√∂ π∏‘ ‘π—π∑πå §≥–∑”ß“π 9. æ≠.»»‘∏√ »√‘ ¡‘ À“√“™ §≥–∑”ß“π10. √». æ≠.π‘®»√’ ™“≠≥√ß§å §≥–∑”ß“π11. º». æ≠.æ™— √«¡‘ ≈ §ÿªμåπ‘√μ— »‘ —¬°ÿ≈ §≥–∑”ß“π12. πæ.Õ¥ÿ≈¬å ∫—≥±°ÿ ÿ≈ §≥–∑”ß“π13. º». æ≠. «ÿ √√≥“ ‡»√…∞«—™√“«π™‘ §≥–∑”ß“π14. πæ.æ√™—¬  ∂‘√ª≠í ≠“ §≥–∑”ß“π15. πæ.Õ“§¡ Õ“√¬“«™‘ “ππ∑å §≥–∑”ß“π16. πæ. ¡»—°¥‘Ï ‡∑’¬¡‡°“à §≥–∑”ß“π17. æ≠.æ√æ‘¡≈ ¡“» °ÿ≈æ√√≥ §≥–∑”ß“π18. πæ.Õ—§√«ÿ≤‘ «√‘ ‘¬‡«™°ÿ≈ §≥–∑”ß“π19. πæ. ÿ√»—°¥‘Ï ‚°¡≈®—π∑√å §≥–∑”ß“π20. πæ.‡¡∏“ Õ¿«‘ —≤π“°ÿ≈ §≥–∑”ß“π21. π“ß “¬ ¡√ ∫√ ‘ ∑ÿ ∏‘Ï §≥–∑”ß“π22. πæ.∏‡π» ‡μ‘¡°≈‘Ëπ®π— ∑πå §≥–∑”ß“π23. æ≠.¢«≠— √—μπå À«—ߺ≈æ≤— π»√‘ ‘ ‡≈¢“πÿ°“√24. π. .Õ ‘ √’ μ√°’ ¡≈ º™Ÿâ ૬‡≈¢“πÿ°“√·≈–ºâŸª√– “πß“π∫√√≥“∏°‘ “√ : æ≠.∑—»π¬’ å μπ— 샑 ∑∏‘»—°¥Ï‘

ºâ‡Ÿ ¢â“√«à ¡®¥— ∑”·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√◊ÕÕ¥ÿ μ—π  ”À√∫— ·æ∑¬å1. æ≠.æ√¿—∑√ ∏√√¡ ‚√™ §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å2. ». πæ.«√’ ®μ‘ μå ‚™μ¡‘ ߧ≈ §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ3. º». πæ.Õ”π“® °‘®§«√¥’ §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈¬— ¢Õπ·°àπ4. πæ. ÿ√μ— πå ∫ÿ≠≠–°“√°ÿ≈ μ—«·∑π ¡“§¡‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õ߉∑¬

§”π” ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß (cerebrovascular disease, stroke) À√◊Õ‚√§Õ—¡æƒ°…å/Õ—¡æ“μ ‡ªìπ‚√§∑Ë’æ∫∫àÕ¬·≈–‡ªìπªí≠À“ “∏“√≥ ÿ¢∑’Ë ”§—≠¢Õߪ√–‡∑»‰∑¬ ®“° ∂‘μ‘ “∏“√≥ ÿ¢ æ.». 2548 (publichealth statistics A.D. 2005) æ∫«à“ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߇ªìπ‚√§∑’ˇªì𠓇Àμÿ°“√‡ ’¬™’«‘μÕ—π¥—∫∑Ë’ 3„πª√–™“°√‰∑¬ ·≈–¡’·π«‚π¡â «à“®–‡æ¡Ë‘  Ÿß¢÷Èπ*  Õ¥§≈âÕß°∫— √“¬ß“π°“√»°÷ …“∑’‡Ë ªπì °“√»÷°…“√«à ¡°—π√–À«à“ß°√–∑√«ß “∏“√≥ ÿ¢·≈–Õߧ尓√Õπ“¡—¬‚≈° æ∫«à“ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߇ªìπ‚√§∑’ˇªì𠓇Àμÿ°“√‡ ’¬™’«‘μ∑Ë’ ”§—≠Õ—π¥—∫ 1 „π‡æ»À≠‘ß ·≈–Õ—π¥—∫ 2 „π‡æ»™“¬** πÕ°®“°πÈ’ ¬—ßæ∫«à“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߬—߇ªìπ‚√§∑ˇ’ ªì𠓇Àμ¢ÿ Õß°“√ Ÿ≠‡ ¬’ ª ï ¢ÿ ¿“«– (disability adjusted life year) ∑’Ë ”§—≠Õ—π¥∫— ∑’Ë 2 ∑ß—È „𙓬·≈–À≠‘ß***  ∂“∫—πª√– “∑«∑‘ ¬“ ‡ªìπ ∂“∫π— ™—πÈ π”∑“ß«™‘ “°“√‡©æ“–∑“ߥâ“π‚√§√–∫∫ª√– “∑ ‰¥âμ√–Àπ°— ∂ß÷§«“¡®”‡ªìπ·≈–‡√àߥà«π¢Õߪí≠À“¥—ß°≈à“« ®÷߉¥â¥”‡π‘π°“√®—¥∑”·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√Õ◊ Õ¥ÿ μπ—  ”À√—∫·æ∑¬å (©∫∫— ∑’Ë 1) ‡¡◊ËÕªï æ.». 2544 ·≈–„πªï 2549 ‰¥ªâ √–‡¡π‘ ·π«∑“ß°“√√—°…“¥ß— °≈“à «∑”„À∑â √“∫«à“·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√◊ÕÕÿ¥μ—π  ”À√∫— ·æ∑¬å (©∫∫— ∑Ë’ 1) ‡ªìπ∑¬Ë’ Õ¡√—∫·≈–‰¥â√—∫°“√Õâ“ßÕ‘ß„π√–¥—∫Àπ÷Ëß Õ’°∑ȗ߬—ßæ∫«à“°“√π”·π«∑“ß°“√√—°…“œ π’ȉª„™âπ—Èπ ¡’∫“ß à«π∑Ë’μâÕߪ√—∫ª√ÿߪ√–°Õ∫°∫— ¢≥–π’È„π¥“â π°“√√°— …“¡§’ «“¡°â“«Àπâ“¡“°¢π÷È ®ß÷  ¡§«√ª√—∫ª√ÿß·°â‰¢‡π◊ÈÕÀ“„π à«πμ“à ß Ê ¥—ßπÈπ—„πªï æ.». 2550 πÈ’  ∂“∫—πª√– “∑«‘∑¬“®÷ߢէ«“¡√à«¡¡◊Õ°—∫ ∂“∫—π«‘™“°“√μà“ß Ê ®—¥∑”·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μ—π  ”À√—∫·æ∑¬å ‡æË◊Õ‡ªìπ·π«∑“ß„π°“√¥Ÿ·≈√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„Àâ¡’ª√– ‘∑∏‘¿“æ  “¡“√∂𔉪„™â„π°“√√—°…“„Àâ‡À¡“– ¡°—∫·μà≈–æÈ◊π∑’ˉ¥â¡“°∑’Ë ÿ¥ ·μàºâŸ∑’Ëπ”·π«∑“ß„π°“√¥Ÿ·≈√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߉ª„™â ®–μâÕßμ√–Àπ—°«à“·π«∑“ßπÈ’‡ª√’¬∫‡ ¡◊Õ𧔷π–π” ”À√—∫°“√ªØ‘∫—μ‘√—°…“‡∑à“πÈ—π ∑È—ßπÈ’ ¢÷Èπ°—∫¥ÿ≈¬æ‘π‘®¢Õß·æ∑¬åºŸâ¥Ÿ·≈ºŸâªÉ«¬„π°“√π”‡Õ“§”·π–π”‡À≈à“πÈ’‰ªª√–¬ÿ°μå„™â„Àâ‡À¡“– ¡°—∫μπ‡ÕßμÕà ‰ª §≥–ºâŸ®¥— ∑”* Viriyavejakul A. Stroke in Asia : An Epidemiological consideration. Clin Neuropharmacol 1990; 13 Suppl 3 : 526-33.** Ministry of Public Health. Burden of disease and injuries in Thailand Priority setting for policy. 2002; A14 - A16.*** Ministry of Public Health. Burden of disease and injuries in Thailand Priority setting for policy. 2002; 58.

 “√∫≠—·ºπ¿Ÿ¡∑‘ ’Ë 1 Sudden onset of focal neurological deficit with suspicious of stroke Àπ“â·ºπ¿¡Ÿ ‘∑Ë’ 2 Lacunar infarct 3·ºπ¿Ÿ¡‘∑Ë’ 3 Non lacunar infarct with midline shift 4·ºπ¿¡Ÿ ‘∑’Ë 4 Non lacunar infarct without midline shift 5·ºπ¿Ÿ¡‘∑Ë’ 5 Brainstem & cerebellar infarction 6·ºπ¿¡Ÿ ‘∑’Ë 6 Stroke with undetected abnormality of CT brain 7Appendix 1 °“√¥·Ÿ ≈∑«—Ë ‰ª (General management) 8Appendix 2 °“√√°— …“¿“«–§«“¡¥—π„π°–‚À≈°»’√…– Ÿß 9 11 (Treatment of increased intracranial pressure)Appendix 3 °“√μ√«®«π‘ ®‘ ©¬— ‡æËÕ◊ À“ “‡Àμ¢ÿ Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß 12 (Work up for etiology of stroke) 13Appendix 4 °“√√—°…“„π√–¬–‡©¬’ ∫æ≈π— (Acute treatment) „π 48 ™Ë«— ‚¡ßÀ≈—ß¡’Õ“°“√ 14Appendix 5 ¿“«–∑√ÿ¥Àπ°— ¢ÕߺŸâª«É ¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕ¥ÿ μπ— Õ¬à“߇©’¬∫æ≈—π 16 (Deterioration of acute ischemic stroke)Appendix 6 °“√§—¥°√ÕߺŸâª«É ¬‡æË◊Õ°“√øóπô øŸ ¡√√∂¿“æ ”À√—∫‚√ß欓∫“≈∑¡’Ë ’ 17 ·æ∑¬å‡«™°√√¡øóπô øŸ π—°°“¬¿“æ∫”∫—¥ ·≈–/À√Õ◊ π—°°®‘ °√√¡∫”∫¥— 19Appendix 7 °“√ªÑÕß°—π°“√‡°¥‘ ´È”¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ∫’ À√◊ÕÕ¥ÿ μπ— (Secondary prevention)‡Õ° “√Õâ“ßÕß‘

○○○ ∫∑π” ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß (cerebrovascular disease, stroke) À√◊Õ‚√§Õ—¡æ“μ/Õ—¡æƒ°…å ‡ªìπ‚√§∑Ë’æ∫∫àÕ¬·≈–‡ªìπª≠í À“ “∏“√≥ ÿ¢∑Ë’ ”§—≠¢Õߪ√–‡∑»‰∑¬ ®“° ∂μ‘  ‘ “∏“√≥ ÿ¢ æ.». 2548 (public healthstatistics A.D. 2005) æ∫«“à ‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õ߇ªπì ‚√§∑’ˇªì𠓇Àμÿ°“√‡ ’¬™’«‘μÕ—π¥∫— ∑Ë’ 3 „πª√–™“°√‰∑¬·≈–¡’·π«‚πâ¡«à“®–‡æ‘Ë¡ Ÿß¢È÷π  Õ¥§≈âÕß°—∫√“¬ß“π°“√»÷°…“∑’ˇªìπ°“√»÷°…“√à«¡°—π√–À«à“ß°√–∑√«ß “∏“√≥ ÿ¢·≈–Õߧ尓√Õπ“¡—¬‚≈° æ∫«à“ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߇ªìπ‚√§∑Ë’‡ªì𠓇Àμÿ°“√‡ ’¬™’«‘μ∑’Ë ”§—≠Õ—π¥—∫ 1 „π‡æ»À≠‘ß ·≈–Õ—π¥—∫ 2 „π‡æ»™“¬* πÕ°®“°π’È ¬—ßæ∫«à“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߬—߇ªìπ‚√§∑’ˇªì𠓇Àμÿ¢Õß°“√ ≠Ÿ ‡ ’¬ªï ¢ÿ ¿“«– (disability adjusted life year) ∑ Ë’ ”§≠— Õ—π¥∫— ∑’Ë 2 ∑ß—È „𙓬·≈–À≠‘ß** °“√®¥— ∑”·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√Õ◊ Õ¥ÿ μπ—  ”À√—∫·æ∑¬å π’È ¡’®¥ÿ ª√– ß§‡å æË◊Õ„Àâº∑⟠’ˇ°’ˬ«¢Õâ ß𔉪ªØ∫‘ μ— ‘‰¥âÕ¬à“߇À¡“– ¡·≈–‡ªπì ·π«∑“߇¥¬’ «°π— ÕπË÷ß °“√®—¥∑”·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μ—π  ”À√—∫·æ∑¬å π’È ‰¥âÕâ“ßÕ‘ßÀ≈—°∞“π∑“ß«™‘ “°“√∑’ˉ¥âμ’æ‘¡æÀå √◊Õ‡º¬·æ√à·≈«â ‡™πà AHA Guideline, NCEP Guideline ·≈–Õ◊Ëπ Ê ‡π◊ÈÕÀ“¢Õß·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μ—π  ”À√—∫·æ∑¬å ©∫—∫π’Ȫ√–°Õ∫¥â«¬·ºπ¿Ÿ¡‘ Appendix ‡Õ° “√Õâ“ßÕ‘ß* Ministry of Public Health. Burden of disease and injuries in Thailand Priority setting for policy. 2002; A14 - A16.** Ministry of Public Health. Burden of disease and injuries in Thailand Priority setting for policy. 2002; 58. ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μπ—  ”À√—∫·æ∑¬å 1 (Clinical Practice Guidelines for Ischemic Stroke)

Level of evidence and recommendations used for guidelines inmanagement of patients with cerebrovascular diseaseClass I Conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effectiveClass II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatmentClass IIa Weight of evidence or opinion is in favor of the procedureClass IIb Usefulness/efficacy is less well established by evidence or opinionClass III Conditions for which there is evidence and/or general agreement that the procedure or treatment is not useful/effective and is someLevel of evidence A cases may be harmfulLevel of evidence B Data derived from multiple randomized clinical trialsLevel of evidence C Data derived from a single randomized trial or nonrandomized trials Expert opinion or case studiesFrom Sacco RL et al. stroke. 2006; 37: 577 - 617.○○○2 ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√Õ◊ Õ¥ÿ μ—π  ”À√∫— ·æ∑¬å (Clinical Practice Guidelines for Ischemic Stroke)

·ºπ¿Ÿ¡∑‘ ’Ë 1Sudden onset of focal neurological deficit with suspicious of stroke (Base on history and physical examination)< 3 hr. Onset 3 - 72 hr.Thrombolytic guideline Basic life support (airway, breathing, circulation, O2 saturation)Emergency blood sugar and additional lab. (CBC, BUN, Cr. Electrolytes) Emergency CT brain (non contrast)Non stroke (ex. brain tumor, brain abscess) StrokeAppropriate consultation Normal/hypodensity* Hyperdensity and treatment (hemorrhage) Ischemic stroke Appropriate General management** consultation and treatment* Size of infarction by CT (Appendix 1)1. Lacunar infarct (·ºπ¿Ÿ¡‘∑’Ë 2)2. Non lacunar infarct with midline shift (·ºπ¿¡Ÿ ∑‘ ’Ë 3)3. Non lacunar infarct without midline shift (·ºπ¿¡Ÿ ∑‘ ’Ë 4)4. Brainstem/cerebellar infarct (·ºπ¿Ÿ¡‘∑’Ë 5)5. Stroke with undetected abnormality of CT brain (·ºπ¿¡Ÿ ‘∑’Ë 6)** General managementë Avoid antihypertensive drug except SBP > 220 mmHg/DBP > 120 mmHgë Avoid intravenous glucose solutionë Control BS 140 - 180 mg/dL in hyperglycemic patientë Treatment of concomitant conditions ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√◊ÕÕÿ¥μπ—  ”À√∫— ·æ∑¬å 3○○○ (Clinical Practice Guidelines for Ischemic Stroke)

·ºπ¿Ÿ¡∑‘ Ë’ 2 Lacunar infarct* ë Pure motor hemiparesis ë Pure sensory stroke ë Motor sensory stroke ë Ataxic hemiparesis ë Dysarthria clumsy hand syndrome Work up for etiology of stroke (Appendix 3) Acute treatment (Appendix 4) Stable Worse Appendix 5Consider PM & R (Appendix 6) &secondary prevention (Appendix 7)○○○* Common clinical lacunar syndromes (patient must have good consciousness and no cortical signssuch as aphasia, apraxia, etc.) and CT findings compatible with lacunar infarct (normal or infarctdiameter < 1.5 cm. in deep area)4 ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μ—π  ”À√∫— ·æ∑¬å (Clinical Practice Guidelines for Ischemic Stroke)

·ºπ¿Ÿ¡∑‘ ’Ë 3Non lacunar infarct with midline shift (Massive MCA or ICA : Hemiplegia with alteration of consciousness with forced eye deviation, aphasia, hemi-inattention, unequal pupils, bilateral signs) 1. Treatment of increased intracranial pressure (Appendix 2) - Intubation and on respirator - Hyperventilation, keep pCO2 30 - 35 mmHg - Elevate head position up 20 - 30 - Avoid hypervolemia - Osmotherapy and diuretic 2. Consult neurosurgeon 3. Avoid antiplatelet/anticoagulant in first week of onset, then reconsider upon patientûs conditions 4. Work up for etiology of stroke (Appendix 3)Surgery Non surgery Worse ○○○ Stable Stable (Appendix 5) Acute treatment (Appendix 4)Consider PM & R (Appendix 6) & secondary prevention (Appendix 7) ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ’∫À√Õ◊ Õÿ¥μ—π  ”À√∫— ·æ∑¬å 5 (Clinical Practice Guidelines for Ischemic Stroke)

·ºπ¿Ÿ¡∑‘ Ë’ 4Non lacunar infarct without midline shift (MCA or ACA territory : Discrepancy of hemiparesis with good consciousness with/without aphasia, hemi-inattention or visual field defect) Work up for etiology of stroke (Appendix 3) Acute treatment (Appendix 4) Stable Worse (Appendix 5) Consider PM & R (Appendix 6) & secondary prevention (Appendix 7)6 ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√◊ÕÕ¥ÿ μπ—  ”À√—∫·æ∑¬å○○○ (Clinical Practice Guidelines for Ischemic Stroke)

·ºπ¿Ÿ¡‘∑’Ë 5Brainstem & cerebellar infarction Impaired consciousness Ataxia or incoordination Vertigo or dizziness Double vision Nystagmus Dysphagia Slurred speech 1. Notify neurosurgeon if there is evidence of cerebellar infarction 2. Work up for etiology of stroke (Appendix 3) 3. Acute treatment (Appendix 4)Surgery Non surgery Worse ○○○ Stable Stable (Appendix 5)Consider PM & R (Appendix 6) & secondary prevention (Appendix 7) ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μπ—  ”À√—∫·æ∑¬å 7 (Clinical Practice Guidelines for Ischemic Stroke)

○○○ ·ºπ¿Ÿ¡‘∑’Ë 6 Stroke with undetected abnormality of CT brain Sudden onset of focal neurological deficits : ë Hemiparesis/hemianesthesia ë Dysarthria, aphasia ë Visual loss, hemianopia ë Ataxia, inbalance, brainstem/cerebellar singns ë etc. Treat as ischemic stroke (·ºπ¿Ÿ¡∑‘ ’Ë 2 - 5)8 ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ∫’ À√◊ÕÕ¥ÿ μπ—  ”À√∫— ·æ∑¬å (Clinical Practice Guidelines for Ischemic Stroke)

○○○ Appendix 1 °“√¥Ÿ·≈∑—Ë«‰ª (General management)(1, 3, 4, 6, 7, 8, 9) 1. ‡Ω“Ñ √–«ß— ‰¡à„À‡â °¥‘ ¿“«–°“√æ√Õà ßÕÕ°´‡‘ ®π„π‡≈Õ◊ ¥ (O2 satulation > 92%) ·≈–°“√À“¬„®º¥‘ ª°μ‘ 2. °“√„À⬓≈¥§«“¡¥—π‚≈À‘μ À≈—°°“√„À⬓≈¥§«“¡¥—π‚≈À‘μ„πºâŸªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μ—π„π√–¬–‡©’¬∫æ≈—π 1.1 SBP < 220 mmHg À√Õ◊ DBP < 120 mmHg ‰¡àμÕâ ß„À¬â “≈¥§«“¡¥π— ‚≈À‘μ ¬°‡«πâ „π°√≥¥’ —ßμÕà ‰ªπ’È - ¿“«–À«— „®≈¡â ‡À≈« (congestive heart failure) - À≈Õ¥‡≈Õ◊ ¥‡ÕÕÕμ°‘ ·μ°‡´“– (aortic dissection) - °≈â“¡‡π◊ÕÈ À«— „®¢“¥‡≈Õ◊ ¥‡©¬’ ∫æ≈π— (acute myocardial ischemia) - ‰μ«“¬‡©¬’ ∫æ≈π— (acute renal failure) - ¿“«– hypertensive encephalopathy 1.2 SBP > 220 mmHg À√Õ◊ DBP 121 - 140 mmHg À√◊Õ∑—Èß 2 Õ¬à“ß ‚¥¬«¥— Àà“ß°π— Õ¬à“ßπÕâ ¬20 π“∑’ 2 §√È—ß „À°â “√√—°…“‚¥¬ - Captopril 6.25 - 12.5 mg ∑“ߪ“° ÕÕ°ƒ∑∏¿Ï‘ “¬„π 15 - 30 π“∑’ Õ¬Ÿà‰¥âπ“π 4 - 6 ™«Ë— ‚¡ßÀ√Õ◊ - Nicardipine 5 mg/hr ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥” „Àâ„π™«à ß·√°·≈«â ª√∫— ¢π“¥¬“®π‰¥§â «“¡¥π— ‚≈Àμ‘μ“¡‡ª“Ñ À¡“¬ (≈¥≈ß 10 - 15%) ‚¥¬‡æË‘¡¢π“¥¬“§√Èß— ≈– 2.5 mg/hr ∑ÿ° 5 π“∑’ ¢π“¥¬“ Ÿß ¥ÿ §Õ◊ 15 mg/hr * ‰¡à§«√„™â¬“ Nifedipine Õ¡„μâ≈‘ÈπÀ√◊Õ∑“ߪ“° ‡πË◊Õß®“°‰¡à “¡“√∂∑Ë’®–§«∫§ÿ¡¢π“¥À√◊Õ∑”π“¬º≈¢Õ߬“‰¥·â ππà Õπ ·≈–‰¡à “¡“√∂ª√∫— ≈¥¬“‰¥âÀ“°‡°‘¥¿“«–§«“¡¥π— ‚≈À‘μμ”Ë μ“¡¡“ 1.3 DBP > 140 mmHg ¥â«¬°“√«¥— 2 §√È—ß쥑 μàÕ°π— „π 5 π“∑’ „Àâ - Nitroprusside 0.5 μg/kg/min ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„π™à«ßμâπ·≈â«μ‘¥μ“¡°“√«—¥§«“¡¥—π‚≈Àμ‘ Õ¬“à ßμÕà ‡πÕ◊Ë ß ª√—∫¢π“¥¬“∑’≈–πâÕ¬ ®π°√–∑ß—Ë ‰¥â√–¥∫— §«“¡¥π— ‚≈À‘μμ“¡μÕâ ß°“√ (≈¥≈ß 10 -15%) ¬“®–ÕÕ°ƒ∑∏Ï‘¿“¬„π 1 - 5 π“∑’ À√Õ◊ - Nitroglycerine 5 mg ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥” μ“¡¥â«¬ 1 - 4 mg/hr À√Õ◊ - ∂Ⓣ¡à¡’¬“¥ß— °≈à“«¢“â ßμπâ Õ“®æ‘®“√≥“°“√„™â¬“„πÀ—«¢âÕ∑Ë’ 1.2 ·∑π‰¥â À“°ºªâŸ «É ¬¡ª’ √–«μ— §‘ «“¡¥π— ‚≈Àμ‘  ßŸ Õ¬‡àŸ ¥¡‘ ·≈–‰¥√â ∫— ¬“√°— …“¡“°Õà π “¡“√∂À¬¥ÿ ¬“∑ßÈ— À¡¥‰¥â·≈–„™â‡°≥±å°“√√—°…“μ“¡√“¬≈–‡Õ’¬¥¥—ß°≈à“«¢â“ßμâπ ¬°‡«â𬓰≈ÿà¡ β-blocker ∑Ë’„™â√—°…“°≈â“¡‡π◊ÈÕÀ—«„®¢“¥‡≈◊Õ¥ À—«„®‡μâπº¥‘ ®—ßÀ«– ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√Õ◊ Õÿ¥μ—π  ”À√—∫·æ∑¬å 9 (Clinical Practice Guidelines for Ischemic Stroke)

○○○ °“√„À⬓≈¥§«“¡¥—π‚≈À‘μ´Ë÷߇ªìπ°“√√—°…“√–¬–¬“« ®–æ‘®“√≥“‡√Ë‘¡¬“À≈—ß®“°‡°‘¥¿“«– À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√Õ◊ Õ¥ÿ μπ— ª√–¡“≥ 1 - 4  ª— ¥“Àå ‚¥¬°“√„À¬â “≈¥§«“¡¥π— ‚≈Àμ‘ ‡ªπì ‰ªÕ¬“à ߧÕà ¬‡ªπì §Õà ¬‰ª ¢πÈ÷ °—∫ ¿“«–¢ÕߺŸâªÉ«¬ „π°√≥’∑Ë’ºâŸªÉ«¬¡’§«“¡¥—π‚≈À‘μμË” (SBP < 100/DBP < 70 mmH) „Àâ√—°…“μ“¡ “‡Àμÿ ·≈–æ‘®“√≥“„À⬓‡æ‘¡Ë §«“¡¥π— „π°√≥∑’ ’√Ë °— …“·≈«â ‰¡à¥’¢÷Èπ 3. °“√„Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ¢È÷πÕ¬àŸ°—∫¿“«–°“√ ¡¥ÿ≈¢Õßπ”È „π√à“ß°“¬ „π°√≥’∑Ë’¢“¥π”È ·π–π”„Àâ Isotonic solution ‚¥¬‡©æ“– 0.9% NaCl À≈’°‡≈Ë’¬ß°“√„Àâ “√π”È ∑Ë’¡’π”È μ“≈·≈– Free water §«√„Àâ√“à ß°“¬Õ¬àŸ„π¿“«– ¡¥≈ÿ ¢Õßπ”È 4. ߥՓÀ“√·≈–πÈ” (nothing per oral) „π°√≥’ºŸâªÉ«¬ - ´¡÷ ·≈– ß ¬— «à“®–¡’ massive infarction - ¡·’ π«‚πâ¡∑’Ë®–‰¥√â ∫— °“√ºà“μ¥— 5. §«∫§¡ÿ √–¥∫— πÈ”μ“≈„π‡≈◊Õ¥ πâÕ¬°«“à 140 - 180 mg/dL (πÕâ ¬°«“à 7.78 - 10 mmol/L) „πºªŸâ «É ¬ ∑’¡Ë ¿’ “«–π”È μ“≈„π‡≈Õ◊ ¥ ßŸ 6. °“√„À¬â “≈¥‰¢â „π°√≥’∑’Ë¡’‰¢â æ√Õâ ¡∑—ÈßÀ“ “‡Àμ·ÿ ≈–√—°…“μ“¡ “‡Àμÿ 7. „À¬â “ªÑÕß°π— ™—°·≈–√–«ß— ™°— „π°√≥∑’ ºË’ ªŸâ «É ¬¡’Õ“°“√™—° 8. √°— …“‚√§Õπ◊Ë Ê √«à ¡°π— ‰ª ‡™àπ À≈Õ¥‡≈Õ◊ ¥À—«„®μ∫’ ¿“«–‡ ’¬ ¡¥ÿ≈¢Õ߇°≈◊Õ·√à„π√“à ß°“¬10 ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√◊ÕÕ¥ÿ μπ—  ”À√∫— ·æ∑¬å (Clinical Practice Guidelines for Ischemic Stroke)

○○○ Appendix 2 °“√√—°…“¿“«–§«“¡¥π— „π°–‚À≈°»√’ …– Ÿß (Treatment of increased intracranial pressure) ë 殑 “√≥“„ ∑à Õà ™«à ¬À“¬„® ë „Àπâ Õπ¬°»√’ …–·≈– à«π∫π¢Õß√“à ß°“¬ ßŸ 20 - 30 Õß»“ ë ®¥— ∑à“ºâŸªÉ«¬§Õμ√ß À≈’°‡≈Ë’¬ß°“√°¥∑∫— ¢ÕßÀ≈Õ¥‡≈◊Õ¥¥”∑Ë’§Õ (jugular vein) ë Hyperventilation ‚¥¬°“√„À§â «“¡∂’¢Ë Õß°“√À“¬„®ª√–¡“≥ 16 - 20 §√ßÈ— /π“∑’ ‡æ◊ËÕ„Àâ pCO 2 30 - 35 mmHg ¡’ª√–‚¬™πå„π°“√≈¥§«“¡¥—π„π ¡Õ߉¥â‡√Á«¿“¬„π‰¡°à π’Ë “∑’ ·μà‰¥âº≈„π™à«ß Èπ— Ê „π√–¬–·√°‡∑à“πÈ—π (ª√–¡“≥ 1 - 3 ™—Ë«‚¡ß) ‡π◊ËÕß®“°√à“ß°“¬®–¡’°“√ª√—∫ ¡¥ÿ≈°√¥-¥à“ß (correct acid-base mechanism) ë æ‘®“√≥“„Àâ osmotherapy : 20% Mannitol* 1 g/kg ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” μ“¡¥«â ¬ 0.25 - 0.5 g/Kg ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥”„π 20 π“∑’ 4 - 6 §√Èß— μÕà «π— (‰¡‡à °‘π 2 g/kg μÕà «—π) À√◊Õ 10% Glycerol 250 ml ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„π 30 - 60 π“∑’ «π— ≈– 4 §√ßÈ— À√Õ◊ 50% Glycerol 50 ml ∑“ߪ“° «—π≈– 4 §√È—ß ·≈–/À√Õ◊ Furosemide 1 mg/Kg ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥” ë À≈°’ ‡≈¬’Ë ß¿“«–¢“¥ÕÕ°´‘‡®π ë À≈’°‡≈’ˬ߿“«–πÈ”‡°‘π ·≈–°“√„Àâ hypotonic solution, steroid ë ª√°÷ …“ª√– “∑»≈— ¬·æ∑¬å ‡æ◊ËÕ∑” wide craniectomy „π°√≥∑’ ’Ë„À°â “√√—°…“¢È—πμπâ ‰¡à‰¥âº≈À√◊Õ¡’ Õ“°“√∑“ß√–∫∫ª√– “∑‡≈«≈ß * °“√„Àâ Mannitol §«√¡’°“√μ√«®°“√∑”ß“π¢Õß‰μ ‡°≈◊Õ·√à„π‡≈Õ◊ ¥ 쥑 μ“¡ª√‘¡“≥π”È ‡¢â“-ÕÕ° (intake-output) ·≈–§«√ √–«—ߺ≈¢“â ߇§¬’ ß ¥—ßπÈ’ 1. °“√„À⬓πÈ’„πª√‘¡“≥¡“° Õ“®∑”„À⇰¥‘ ¿“«– volume over expansion, congestive heart failure, pulmonary edema À√Õ◊ cerebral dehydration 2. ¿“«–¢“¥πÈ”À√Õ◊ ª í  “«–ÕÕ°πâÕ¬ ·≈–‡≈Õ◊ ¥¢âπ 3. ‡°≈Õ◊ ·√ລ‘ ª°μ‘ ‡™àπ hyperkalemia, hyponatremia 4. Anaphylaxis 5. °“√„Àâ “√π’ÈÕ¬“à ß√«¥‡√Á« Õ“®®–∑”„À⇡¥Á ‡≈Õ◊ ¥·¥ß·μ°‰¥â 6. Extravasation of manitol ®–∑”„À⇰‘¥Õ“°“√∫«¡‡©æ“–∑Ë·’ ≈–º«‘ Àπß— ∫√‡‘ «≥ππÈ— 쓬‰¥â 7. ‰¡à§«√„À‡â °π‘ 2 g/Kg/d¢âÕÀâ“¡„π°“√„™â Mannitol 1. ¿“«– anuria with acute tubular necrosis 2. ¿“«–°“√¢“¥πÈ”√πÿ ·√ß 3. ¿“«–π”È ∑«à ¡ªÕ¥ 4. ¿“«–™ÕÁ °À√Õ◊ §«“¡¥π— ‚≈Àμ‘ μË” ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ∫’ À√Õ◊ Õ¥ÿ μπ—  ”À√∫— ·æ∑¬å 11 (Clinical Practice Guidelines for Ischemic Stroke)

○○○ Appendix 3 °“√μ√«®«‘π‘®©¬— ‡æÕË◊ À“ “‡Àμ¢ÿ Õß‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õß(5, 9) (Work up for etiology of stroke) °“√μ√«®∑“ßÀâÕߪؑ∫μ— °‘ “√æÈπ◊ ∞“π ë Blood test : FBS, CBC, lipid profile (total cholesterol, triglyceride, HDL, LDL) : BUN, Creatinine, electrolyte, liver function test, PT, PTT, VDRL urine exam. ‡æ◊ÕË ª√–‡¡π‘ baseline condition ë Cardiac work up : CXR, EKG „π°√≥∑’ ’ Ë ß —¬«“à ¡ ’ “‡Àμÿ¡“®“°≈¡‘Ë ‡≈◊Õ¥Õÿ¥μπ— ∑Ë¡’ “®“°À«— „® ë Echocardiogram „π°√≥’∑Ë’ºŸâªÉ«¬Õ“¬ÿπâÕ¬°«à“ 45 ªï ·≈–‰¡à¡’À≈—°∞“π«à“¡’≈‘Ë¡‡≈◊Õ¥Õÿ¥μ—π∑’Ë¡“®“°À—«„® ·≈–‰¡à¡’ªí®®—¬‡ ’Ë¬ß ∑’ Ë ”§—≠„π°“√‡°¥‘ atherosclerosis ‡™πà ‡∫“À«“𠧫“¡¥π— ‚≈À‘μ Ÿß °“√ ∫Ÿ ∫ÿÀ√Ë’ ë ESR ë ANA profile ë Coagulogram, protein C, protein S, antithrombin III, anticardiolipin, homocysteine, factor VII leden, prothrombin gene ë Vascular work up ë Anti HIV °“√μ√«®‡æ¡Ë‘ ‡μ‘¡„π°√≥∑’  ’Ë ß ¬— ¿“«–°“√μ’∫μ—π¢ÕßÀ≈Õ¥‡≈◊Õ¥·¥ß§“‚√μ‘¥ ë Vascular work up : Carotid duplex ultrasonography Transcranial doppler ultrasonography Magnetic resonance angiography CT angiography Cerebral angiogram12 ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√Õ◊ Õ¥ÿ μ—π  ”À√—∫·æ∑¬å (Clinical Practice Guidelines for Ischemic Stroke)

○○○ Appendix 4 °“√√°— …“„π√–¬–‡©’¬∫æ≈—π (Acute treatment) „π 48 ™—Ë«‚¡ßÀ≈—ß¡Õ’ “°“√(1, 2, 3, 4, 9)1. ¬“μ“â π‡°≈Á¥‡≈◊Õ¥ (Antiplatelets) „Àâ aspirin 160 - 325 ¡‘≈≈‘°√¡— μàÕ«π— ¿“¬„π 48 ™Ë«— ‚¡ß (Appendix 7) ¬°‡«âπ„π°√≥’ - ·æ⬓ aspirin Õ“®æ®‘ “√≥“„À¬â “μâ“π‡°≈Á¥‡≈◊Õ¥μ—«Õ◊Ëπ - Non lacunar infarct with midline shift2. ¬“μ“â π°“√·¢ßÁ μ«— ¢Õ߇≈◊Õ¥ (Anticoagulants) ‰¡·à π–π”„Àâ„™â„πºâŸªÉ«¬ acute stroke ‡π◊ËÕß®“°À≈°— ∞“π¢Õâ ¡≈Ÿ ¬ß— ‰¡à‡æ¬’ ßæÕ ¬°‡«πâ „π°√≥’μàÕ‰ªπÈ’ §Õ◊extracranial carotid À√◊Õ vertebral dissection ·≈– cerebral venous thrombosis3. Neuroprotective agents ª®í ®∫ÿ π— ‰¡à¡’¬“μ«— „¥∑’¡Ë À’ ≈—°∞“π«à“¡’ª√–‚¬™πå™—¥‡®π4. ¬“Õ◊πË Ê æ‘®“√≥“„Àâμ“¡ “‡Àμÿ ‡™àπ immunosuppressive drug „π vasculitis ‡ªπì μπâ5. √∫— ºªŸâ «É ¬‰«â√—°…“„π stroke unit (¥∑Ÿ Ë’‡Õ° “√·π«∑“ß°“√®—¥μÈ—ß stroke unit) ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√Õ◊ Õÿ¥μπ—  ”À√—∫·æ∑¬å 13 (Clinical Practice Guidelines for Ischemic Stroke)

○○○ Appendix 5 ¿“«–∑√¥ÿ Àπ°— ¢ÕߺªâŸ É«¬‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√◊ÕÕÿ¥μπ— Õ¬à“߇©’¬∫æ≈π— (Deterioration of acute ischemic stroke)(1, 3) Deterioration of acute ischemic stroke À¡“¬∂÷ß ¿“«–∑Ë’¡’Õ“°“√À√◊ÕÕ“°“√· ¥ß∑“ß√–∫∫ ª√– “∑∑‡Ë’ ªìπ¡“°¢Èπ÷ ‡™πà ÕÕà π·√ß¡“°¢πÈ÷ ª«¥»√’ …– À√◊Õ√–¥—∫§«“¡√⟠°÷ μ«— ≈¥≈ß  “‡Àμÿ¢Õß Deterioration of acute ischemic stroke 1. Systemic causes - Dehydration - Hypotension - Extreme degree of hypertension - Fever - Hyper or hypoglycemia - Hypoxia - Infection (pneumonia, urinary tract infection, sepsis) - Myocardial ischemia - Electrolyte imbalance eg. hyponatremia 2. Neurological causes - Recurrent stroke - Progressive of thrombosis - Hemorrhagic transformation - Cerebral edema - Hydrocephalus - Seizure14 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ’∫À√Õ◊ Õ¥ÿ μ—π  ”À√∫— ·æ∑¬å (Clinical Practice Guidelines for Ischemic Stroke)

○○○·π«∑“ß°“√√—°…“„πºâªŸ «É ¬∑¡’Ë ’ deterioration of acute ischemic stroke 1. μ√«®À“ “‡Àμÿμ“¡ ¿“«–¢Õߺ⪟ «É ¬·≈–·°â‰¢ systemic causes ¥ß— °≈à“« 2. ∂“â ‰¡àæ∫§«“¡º‘¥ª°μ∑‘ ’Ë “¡“√∂Õ∏‘∫“¬¿“«–¥ß— °≈“à «‰¥â „Àâ àßμ√«® CT scan ´È” 2.1 „π°√≥’∑¡Ë’ ’ hemorrhagic transformation ∂⓺⟪«É ¬‰¥â¬“ thrombolytic drug „ÀâÀ¬ÿ¥¬“∑π— ∑’·≈«â ªØ‘∫—μμ‘ “¡·π«∑“ß°“√√°— …“°“√„À¬â “≈–≈“¬≈¡‘Ë ‡≈◊Õ¥ „π°√≥∑’ ’ˉ¥â√∫— ¬“ anticoagulant À√◊Õ antiplatelet„ÀâÀ¬ÿ¥¬“∑—π∑’ „Àâ°“√√—°…“·∫∫ª√–§—∫ª√–§Õß ·°â‰¢¿“«–§«“¡º‘¥ª°μ‘°“√·¢Áßμ—«¢Õ߇≈◊Õ¥ ·≈–ª√÷°…“ª√– “∑»—≈¬·æ∑¬μå “¡§«“¡‡À¡“– ¡ 2.2 „π°√≥’∑Ë’¡’ cerebral edema „Àâ°“√√—°…“·∫∫ increased intracranial pressure(Appendix 2) ·≈–∂â“¡’ midline shift „π CT scan „Àâª√°÷ …“ª√– “∑»—≈¬·æ∑¬å殑 “√≥“∑”°“√ºà“μ¥— 2.3 „π°√≥∑’ ¡’Ë ’Õ“°“√™—° „À⬓°π— ™—° 2.4 °“√„Àâ anticoagulant ®“°°“√»÷°…“·≈–¢âÕ¡Ÿ≈„πªí®®ÿ∫—π¬—߉¡à¡’°“√»÷°…“„¥∑Ë’∫àß™’È™—¥‡®π«à“°“√„Àâ unfractionated heparin À√◊Õ low molecular weight heparin ®–™«à ¬¬—∫¬—Èß¿“«– progressing ofthrombosis À√◊Õ reocclusion ¬°‡«âπ„π°√≥’μàÕ‰ªπ’È §◊Õ cardioembolic stroke, extracranial carotid orvertebral dissection ·≈– cerebral venous thrombosis 2.5 „π°√≥’∑’Ë¡’ hydrocephalus À√◊Õ brainstem compression „Àªâ √°÷ …“ª√– “∑»≈— ¬·æ∑¬å ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ∫’ À√◊ÕÕ¥ÿ μ—π  ”À√∫— ·æ∑¬å 15 (Clinical Practice Guidelines for Ischemic Stroke)

Appendix 6 °“√§—¥°√ÕߺªâŸ «É ¬‡æ◊ÕË °“√øôóπøŸ ¡√√∂¿“æ ”À√—∫‚√ß欓∫“≈∑Ë’¡·’ æ∑¬å‡«™°√√¡øôπó øŸ π—°°“¬¿“æ∫”∫¥— ·≈–/À√◊Õπ—°°‘®°√√¡∫”∫¥—  ¿“«–∑“ß°“√·æ∑¬å§ß∑Ë’ (°) ‰¡à „™à ™–≈Õ°“√øπôó øŸ ¡√√∂¿“æ À√◊Õ Õπ‚ÿ ≈¡‡©æ“– passive exercise ·æ∑¬/å π°— °“¬¿“æ∫”∫—¥ª√–‡¡‘π ‰¡à §«“¡ Ÿ≠‡ ’¬ ¡√√∂¿“æ„π°“√‡§≈ÕË◊ π‰À« ‰¡àμâÕß∑”°“√øôóπøŸ ·≈–ª√–°Õ∫°®‘ °√√¡ „™à ‡√¬’ π√⟉¥â (¢) ‰¡à ·π–π”≠“쑇√◊ÕË ß°“√¥Ÿ·≈ ‰¡à (nursing care) „™à ‚ª√·°√¡°“√øôóπøŸ πßË— ‰¥âÕ¬“à ßπâÕ¬ 2 ™«Ë— ‚¡ß  ¡√√∂¿“æÕ¬“à ߇∫“ (§) √à«¡¡◊Õ„π°“√Ωñ°øôπó ø Ÿ ¡√√∂¿“æ „™à μâÕß°“√§«“¡™«à ¬‡À≈Õ◊ ‰¡à ‚ª√·°√¡Ω°ñ °‘®«—μ√ª√–®”«—π „π°“√‡§≈Õ◊Ë π‰À« À√◊Õ ∑’Ë´∫— ´Õâ π (IADL) (ß) ª√–°Õ∫°‘®«μ— √ª√–®”«π— √–¥∫— æÈ◊π∞“π μâÕß°“√°“√°”°∫— ¥·Ÿ ≈ À√Õ◊ ™à«¬‡À≈◊Õ‡≈Á°πâÕ¬ μâÕß°“√§«“¡™à«¬‡À≈◊Õ ª“π°≈“ß∂ß÷ ¡“° ‰¡à ‚ª√·°√¡°“√Ωñ°∑’∫Ë “â π À√◊Õ ·∫∫ºâªŸ É«¬πÕ° 殑 “√≥“√—∫‰«â„π‚√ß欓∫“≈ ‰¥â ‚ª√·°√¡°“√øπôó ø Ÿ ¡√√∂¿“æ ·∫∫ºâªŸ É«¬„π*  “¡“√∂ª√—∫‡ª≈’ˬπ‚ª√·°√¡‰¥μâ “¡§«“¡æ√Õâ ¡¢Õß∫§ÿ ≈“°√(°)  ¿“«–∑“ß°“√·æ∑¬å§ß∑’Ë À¡“¬∂ß÷ ºªŸâ É«¬∑Ë’‰¡¡à ’‰¢â ¡ ’ ≠— ≠“≥™’æ®√§ß∑Ë’ ‰¡¡à ’°“√‡ª≈’ˬπ·ª≈ß∑“ß°“√·æ∑¬å∑ ’Ë ”§—≠ ·≈–‰¡à¡’°“√ ‡ª≈Ë’¬π·ª≈ß°“√√—°…“¿“¬„π 48 ™—Ë«‚¡ß∑Ë’ºà“π¡“ §«“¡∫°æ√àÕß∑“ß√–∫∫ª√– “∑§ß∑Ë’À√◊Õ¥’¢÷Èπ ºâŸªÉ«¬ “¡“√∂√—∫Õ“À“√·≈–πÈ” ∑“ß “¬¬“߉¥âμ“¡∑’Ë°”À𥉫â(¢) ‡√’¬π√Ÿâ‰¥â §◊Õ  “¡“√∂∑”μ“¡§” —ßË ‰¥âÕ¬“à ßπÕâ ¬ 2 ¢—πÈ μÕπ ·≈– “¡“√∂®¥®” Ëß‘ ∑’ˇ√’¬π√⟉¥âπ“π Õ¬“à ßπÕâ ¬ 24 ™«Ë— ‚¡ß(§) ‚ª√·°√¡°“√øóôπøŸ ¡√√∂¿“æÕ¬à“߇∫“ À¡“¬∂÷ß ºâŸªÉ«¬®–μâÕ߉¥â√—∫°“√øóôπøŸ ¡√√∂¿“æÕ¬à“ßπâÕ¬§√—Èß≈– 1 ™Ë—«‚¡ß  —ª¥“Àå≈– 2 - 3 §√—ÈߢÈπ÷ ‰ª ‡™àπ °“√∑” passive, active À√◊Õ active assistive exercise °“√‡§≈◊ËÕπ‰À«∫π‡μ¬’ ß °“√∑√ßμ«— πßË— °“√‡§≈ÕË◊ π¬“â ¬ (transfer)(ß) ‚ª√·°√¡°“√Ωñ°°‘®«μ— √ª√–®”«π— ∑´’Ë —∫´âÕπ (Instrumental Activity of Daily Living, IADL) ‰¥â·°à °“√ª√–°Õ∫Õ“À“√ ‚∑√»æ— ∑å ¢∫— √∂ ‡ªìπμπâ○○○16 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√◊ÕÕ¥ÿ μ—π  ”À√∫— ·æ∑¬å (Clinical Practice Guidelines for Ischemic Stroke)

Appendix 7 °“√ªÕÑ ß°π— °“√‡°‘¥´”È ¢Õß‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√◊ÕÕ¥ÿ μπ— (1, 2, 4, 5, 9) (Secondary prevention)¬“μ“â π‡°≈¥Á ‡≈Õ◊ ¥ (Antiplatelet) 1. „π°√≥’∑Ë’À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μ—π¡‘‰¥â¡’ “‡Àμÿ¡“®“°À—«„® æ‘®“√≥“„Àâ aspirin 60 - 325¡≈‘ ≈°‘ √¡— μàÕ«—𠇪ìπ≈”¥—∫·√° (class I, level of evidence A) „π°√≥’ºâŸªÉ«¬·æ⬓ aspirin ‰¡à “¡“√∂∑πº≈¢â“߇§’¬ß¢Õß aspirin À√◊Õ¡’Õ“°“√‡°‘¥‡ªìπ´”È ¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡ÕßÕÿ¥μ—π„π¢≥–∑’ˉ¥â√—∫ aspirin (‚¥¬∑’˧«∫§ÿ¡ªí®®—¬‡ ’ˬßÕ¬à“ߥ’) „Àâæ‘®“√≥“„ÀâTiclopidine 250 ¡‘≈≈‘°√—¡ «—π≈– 2 §√È—ß (§«√√–«—ߺ≈¢â“߇§’¬ß¢Õ߬“§◊Õ ¿“«–‡¡Á¥‡≈◊Õ¥¢“«μ”Ë §«√®–μâÕ߇®“–‡≈Õ◊ ¥¥Ÿ CBC ‡ªìπ√–¬– „π™à«ß 3 ‡¥◊Õπ·√°) (class IIa, level of evidence A) À√Õ◊ Clopidogrel 75¡≈‘ ≈‘°√—¡μÕà «π— (class IIa, level of evidence A) À√Õ◊ aspirin 25 ¡‘≈≈°‘ √—¡ √à«¡°—∫ Dipyridamole ™π¥‘extended release 200 ¡‘≈≈‘°√—¡ (class IIa, level of evidence A) «—π≈– 2 §√È—ß À√◊Õ Cilostazol 200¡‘≈≈‘°√—¡μÕà «—π (class IIa, level of evidence B) 2. „π°√≥’∑’ËÀ≈Õ¥‡≈◊Õ¥Õÿ¥μ—π¡’ “‡Àμÿ®“°≈‘Ë¡‡≈◊Õ¥À—«„®Õÿ¥μ—π ·μຟâªÉ«¬‰¡à “¡“√∂√—∫ª√–∑“π¬“μâ“π°“√·¢Áßμ—«¢Õ߇≈Õ◊ ¥‰¥â „Àâ殑 “√≥“„À¬â “μâ“π‡°≈¥Á ‡≈◊Õ¥μ“¡„π¢Õâ 1¬“μ“â π°“√·¢ßÁ μ—«¢Õ߇≈◊Õ¥ (Anticoagulant) „π°√≥∑’ À’Ë ≈Õ¥‡≈Õ◊ ¥Õ¥ÿ μπ— ¡ ’ “‡Àμ®ÿ “°≈¡Ë‘ ‡≈Õ◊ ¥À«— „® 殑 “√≥“„À¬â “μ“â π°“√·¢ßÁ μ«— ¢Õ߇≈Õ◊ ¥„π√–¬–¬“«‚¥¬„Àâ Warfarin ·≈–§«∫§¡ÿ „À¡â ’ International normalized ratio (INR) = 2.0 - 3.0 „πºŸâªÉ«¬∑Ë¡’ ¿’ “«–¥—ßμàÕ‰ªπ’È - Persistent or paroxysmal AF (class I, level of evidence A) - Acute MI and LV thrombus (class IIa, level of evidence B) - Cardiomyopathy (class IIb, level of evidence C) - Rheumatic mitral valve disease (class IIa, level of evidence C) - Bioprosthetic heart valve (class IIb, level of evidence C)·≈–§«∫§¡ÿ „Àâ¡’ International normalized ratio (INR) = 2.5 - 3.5 „π°√≥’∑º’Ë âŸªÉ«¬À≈Õ¥‡≈Õ◊ ¥ ¡ÕßÕ¥ÿ μ—π∑¡’Ë ’mechanical prosthetic heart valves (class I, level of evidence B) ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ∫’ À√◊ÕÕÿ¥μπ—  ”À√∫— ·æ∑¬å 17○○○ (Clinical Practice Guidelines for Ischemic Stroke)

○○○°“√º“à μ¥— À≈Õ¥‡≈Õ◊ ¥§“‚√쥑 (Carotid endarterectomy) „π°√≥’∑’ËÀ≈Õ¥‡≈◊Õ¥§“‚√μ‘¥μ’∫ 70 - 99% ·≈–ºâŸªÉ«¬¡’§«“¡æ‘°“√À≈߇À≈◊ÕÕ¬Ÿà‰¡à¡“° æ∫«à“ °“√ºà“μ—¥À≈Õ¥‡≈◊Õ¥§“‚√쥑 (carotid endarterectomy) ¡ª’ √–‚¬™πå °“√„ à “¬ «π¢¬“¬À≈Õ¥‡≈Õ◊ ¥§“‚√μ‘¥ (Carotid angioplasty) °“√„ à “¬ «π¢¬“¬À≈Õ¥‡≈◊Õ¥§“‚√μ‘¥ (carotid angioplasty) Õ“®æ‘®“√≥“„π°√≥’∑Ë’ºâŸªÉ«¬ ¡’§«“¡‡ Ë’¬ß Ÿß ¡’¢Õâ À“â ¡„π°“√º“à μ¥— À≈Õ¥‡≈Õ◊ ¥§“‚√μ‘¥À√Õ◊ μ”·Àπàß∑Ëμ’ ’∫‰¡ à “¡“√∂º“à μ—¥‰¥â °“√§«∫§¡ÿ ª®í ®¬— ‡ ’ˬßÕ◊Ëπ Ê 1. §«“¡¥π— ‚≈Àμ‘  ßŸ §«∫§¡ÿ „À¡â §’ «“¡¥π— ‚≈Àμ‘ πÕâ ¬°«“à 140/90 mmHg ·≈–πÕâ ¬°«“à 130/80 mmHg „πºŸªâ «É ¬‡∫“À«“π 2. ‡∫“À«“𠧫∫§ÿ¡„Àâ√–¥∫— πÈ”μ“≈„π‡≈Õ◊ ¥√–¬–¬“« HbA1C πâÕ¬°«“à 7.0% 3. ‰¢¡π— „π‡≈◊Õ¥ Ÿß §«∫§¡ÿ „Àâ¡’√–¥∫— ‰¢¡π— LDL πâÕ¬°«“à 100 mg/dL ·≈–πâÕ¬°«“à 70 mg/dL „πºªâŸ É«¬‡∫“À«“π √–¥—∫‰¢¡—π TG πÕâ ¬°«“à 150 mg/dL ·≈–§«√„Àâ¡’√–¥—∫‰¢¡π— HDL > 40 mg/dL „πºâ™Ÿ “¬ ·≈– > 50 mg/dL „πºâŸÀ≠ß‘ 4. °“√ ∫Ÿ ∫ÿÀ√Ë’ ·π–π”„À‡â ≈‘° Ÿ∫∫Àÿ √’ËÀ√◊Õ√∫— §«π— ∫ÿÀ√’Ë 5. ÕÕ°°”≈—ß°“¬ ·π–π”„ÀÕâ Õ°°”≈—ß°“¬√–¥∫— ª“π°≈“ß ª√–¡“≥ 30 - 45 π“∑μ’ Õà «—π Õ¬“à ßπâÕ¬ 5 «π— μÕà  ª— ¥“Àå 6. °“√¥¡◊Ë  ÿ√“ §«√À¬¥ÿ À√◊ÕÀ≈’°‡≈¬Ë’ ß°“√¥◊¡Ë  ÿ√“À√Õ◊ ‡§√Ë◊Õߥ¡Ë◊ ∑¡’Ë ’·Õ≈°ÕŒÕ≈å 7. §«“¡Õâ«π ≈¥π”È Àπ—°„Àâ¡’¥—™π’¡«≈°“¬μ”Ë °«à“ 23 kg/m2 À√◊Õ¡’√Õ∫‡Õ« < 36 πÈ‘« (90 ´¡.) „πº™Ÿâ “¬ ·≈– < 32 π‘È« (80 ´¡.) „πºÀ⟠≠ß‘ 8. ªí®®—¬ÕË◊π Ê ∑Ë’¡’º≈μàÕÀ≈Õ¥‡≈◊Õ¥ ¡Õß„Àâ√—°…“μ“¡ “‡Àμÿ ‡™àπ À≈Õ¥‡≈◊Õ¥Õ—°‡ ∫ ¿“«–°“√ ·¢ßÁ μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥º‘¥ª°μ‘ ‡ªìπμπâ ÕπË÷ß „π°“√§«∫§ÿ¡ªí®®—¬‡ ’ˬߥ—ß°≈à“«¢â“ßμâπ ·æ∑¬å§«√·π–π”ºŸâªÉ«¬„Àâª√—∫‡ª≈Ë’¬πæƒμ‘°√√¡ °“√¥”‡ππ‘ ™«’ μ‘ ·≈–°“√∫√‚‘ ¿§„Àâ‡À¡“– ¡ §«∫§à°Ÿ —∫°“√√—°…“∑“߬“18 ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√◊ÕÕ¥ÿ μ—π  ”À√∫— ·æ∑¬å (Clinical Practice Guidelines for Ischemic Stroke)

○○○ ‡Õ° “√Õâ“ßÕß‘1. Adams HP, Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke : a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke 2007; 38: 1655-1711.2. Caplan L. Antiplatelet therapy in stroke prevention : present and future. Cerebrovasc 2006; 21 (suppl 1): 1-6.3. Kaste M, Roine RO. General stroke management and stroke units. In : Mohr JR, Choi DW, Grotta JC, Weir B, Wolf PA, eds. Stroke pathophysiology, diagnosis, and management. 4th edition. Churchill Livingstone, 2004: 975-6.4. Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, et al. Guideline for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke. Stroke 2006; 37: 577-617.5. Executive Summary of the Third Report of The National Cholesterol Education Programe (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001; 285: 2486-97.6. Can beta-blocker therapy be withdrawn from patients with dilated cardiomyopathy ? Am Heart J 1990; 138 (3 Pt 1): 456-9.7. Close clinical observation minimizes the complications of beta-blocker withdrawal. Ann Pharmacother. 1994; 28: 849-51.8. The relative risk of incident coronary heart disease associated with recently stopping the use of beta-blockers. JAMA 1990; 23-30; 263: 1653-7.9. ‚√§À≈Õ¥‡≈◊Õ¥·¥ß·Ààߪ√–‡∑»‰∑¬,  ¡“§¡. ·π«∑“߇«™ªØ‘∫—μ‘ ”À√—∫°“√ªÑÕß°—π‚√§À≈Õ¥‡≈◊Õ¥·¥ß ¢πÈ— ª∞¡¿Ÿ¡.‘ 2550. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ∫’ À√Õ◊ Õ¥ÿ μπ—  ”À√∫— ·æ∑¬å 19 (Clinical Practice Guidelines for Ischemic Stroke)

¢Õ¢Õ∫§ÿ≥ ·æ∑¬å∑‡’Ë ¢“â √«à ¡ª√–™ÿ¡ ª√–™¡ÿ / —¡¡π“°“√ª√—∫ª√ÿß·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ’∫À√Õ◊ Õ¥ÿ μπ—  ”À√∫— ·æ∑¬å ≥ ÀâÕß°‘ßË ∑Õß ‚√ß·√¡‡Õ‡™’¬ °√ßÿ ‡∑æ¡À“π§√ «π— ∑’Ë 7  ‘ßÀ“§¡ 25501. πæ. æÿ ®πå ¿‡Ÿ °“â ≈Õâ π √æ.°√–∫’Ë °√–∫’Ë2. πæ.™“≠æß»å μß— §≥–°≈ÿ √æ.°√ÿ߇∑æ °√ÿ߇∑æ¡À“π§√3. §≥ÿ ªî¬¥“ ¬Õ¥«√’ –æß»å √æ.°√ÿ߇∑æ °√ßÿ ‡∑æ¡À“π§√4. πæ.Õ∑‘ ∏æ‘ ≈ μ–«—π°“≠®π‚™μ‘ √æ.‡®√≠‘ °√ÿߪ√–™“√°— …å °√ßÿ ‡∑æ¡À“π§√5. πæ.«√“«—≤πå Õÿμ¡‡æ∑“¬ √æ.»√’ ¬“¡ °√ßÿ ‡∑æ¡À“π§√6. πæ.™—¬æ√ ‡√Õ◊ ß°‘® √æ. ¡μ‘ ‡‘ «™  ÿ¢ÿ¡«∑‘ °√ÿ߇∑æ¡À“π§√7. πæ.æ‘æ—≤πå ™π‘ –®‘μæπ— ∏åÿ √æ.μ“° π‘ °√ÿ߇∑æ¡À“π§√8. æ≠. ¥ÿ “ æ—π∏å√ÿ π‘ ∑√å √æ.∑Õߺ“¿¡Ÿ ‘ °“≠®π∫ÿ√’9. æ≠.™π‘°“πμå «ß»ªå √–‡ √∞‘  ¢ÿ √æ.§≈Õß≈“π °”·æ߇æ™√10. πæ.«™— √π‘ ∑√å ª√–‡ √‘∞ ÿ¥ √æ.æ“π∑Õß ™≈∫ÿ√’11. πæ.™“μ√’ Õ‰ÿ æ»≈‘ ªá μæ√ √æ.≈–·¡ ™ÿ¡æ√12. æ≠.°‡‘ √Ëπ‘ ‚´πË’ √æ.‡™¬’ ß√“¬ª√–™“πÿ‡§√“–Àå ‡™¬’ ß√“¬13. πæ.»¿ÿ √—»¡å «ß— ∑Õߧ” √æ.ª√– “∑‡™’¬ß„À¡à ‡™¬’ ß„À¡à14. πæ.æß»°√ æ«à ß¿‘≠‚≠ √æ. ¬“¡√“…Æ√‡å ™’¬ß„À¡à ‡™’¬ß„À¡à15. πæ.¡ß§≈ ∏“¥“√μ‘ √æ.·À≈¡ßÕ∫ μ√“¥16. æ≠.°—≈¬“≥’ Õ—§√™‚‘ π‡√» √æ.∑“à  Õ߬“ß μ“°17. πæ.懑 ™…∞ æ«— æ—π°‘®‡®√‘≠ √æ.π§√𓬰 π§√𓬰18. æ≠.®—π∑√宑√“  «— ¥‘ “√ √æ.æ∑ÿ ∏¡≥±≈ π§√ª∞¡19. πæ.®°— √¿æ «—π«—≤π å —πμ°‘ ≈ÿ √æ.‚æπ «√√§å π§√æπ¡20. πæ.®μ‘ μ™‘ —¬ À≈Õà √àÿß‚√®πå √æ.¥à“π¢πÿ ∑¥ π§√√“™ ’¡“21. æ≠.æ√«π—™ · ß √ÿ ’¬å √æ.æ¡‘ “¬ π§√√“™ ’¡“22. πæ.∫≠ÿ ‡°’¬√μ‘ ∏π≈“¿Õπ—πμå √æ.∫“ß°√«¬ ππ∑∫ÿ√’23. πæ.¬ß¬» ª≈È◊¡®‘μμ°‘ ≈ÿ √æ.‡°…¡√“…Æ√å √—μπ“∏‡‘ ∫»√å ππ∑∫ÿ√’24. æ≠. ¥ÿ “∑‘æ¬å ∏π»√«’ π‘™™¬— √æ. ¡‡¥®Á æ√–¬æÿ √“™ “¬∫√ÿ ’ ªíμμ“π’○○○20 ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õßμ∫’ À√Õ◊ Õÿ¥μπ—  ”À√—∫·æ∑¬å (Clinical Practice Guidelines for Ischemic Stroke)

25. πæ. ¡¿æ ‡¡Õ◊ ß™◊πË √æ.‡™’¬ß¡à«π æ–‡¬“26. πæ.¡πμ√’  √–∑ÕßÀ¬Õà ¡ √æ.∫“ß¡Ÿ≈π“° æ‘®μ‘ √27. πæ. ¡æß…å μ—πμ‘∏π«—≤πå √æ.·æ√à ·æ√à28. æ≠.»√’ ¥ÿ “ ∑Õß∫«— ∫“π √æ.¡À“ “√§“¡ ¡À“ “√§“¡29. πæ.Õπÿ«μ— √ ·°«â ‡™’¬ßÀ«“ß √æ.§”™–Õ’ ¡ÿ°¥“À“√30. æ≠.≥Æ— ∞‘¬“ ª√–«—π∏≥“ √æ.∏«—™∫ÿ√’ √âÕ¬‡ÕÁ¥31. πæ.™“≠≥√ß§å ™—¬Õ¥ÿ ¡ ¡ √æ.‚æπ∑Õß √âÕ¬‡ÕÁ¥32. πæ.ª√–°Õ∫°‘® «’√–‰«∑¬– √æ.√–¬Õß √–¬Õß33. πæ.°ƒ…¥“ √Õ¥ª√–‡ √∞‘ √æ.√“™∫√ÿ ’ √“™∫√ÿ ’34. πæ. ‘ªªππ∑å ·°â«∑“ ’ √æ.‡≈¬ ‡≈¬35. πæ.∏”¡√ߧå Õߧ å ƒ∑∏Ï‘ √æ.¿°Ÿ √–¥ß÷ ‡≈¬36. æ≠.‡∫≠®æ√ ‡À≈◊Õߪ√–‡ √∞‘ √æ.‰æ√∫÷ß »√’ –‡°…37. πæ.‡™‘¥™“μ‘ «∑‘ √Ÿ “¿√≥å √æ.À«â ¬∑—∫∑—π »√ ’ –‡°…38. æ≠.æ√‘ ≥ÿ ’  —æ‚  √æ.æ—ß‚§π  °≈π§√39. πæ. √√§æ≈ «≤ÿ ¿‘ ¥“¥√ √æ.∫“ßæ≈’  ¡∑ÿ √ª√“°“√40. πæ.§ß°ƒ™ æ√‘ “π‡°◊ÕÈ °ÿ≈ √æ.∫“ß®“°  ¡∑ÿ √ª√“°“√41. æ≠.¿—∑√æ√ ∫ÿ√æ°»ÿ ≈»√’ √æ.Õ√≠— ª√–‡∑»  √–·°«â42. æ≠.®‘πμπ“ ™Ÿ‡°¬’ √μ‘»‘√‘ √æ.æ√–æÿ∑∏∫“∑  √–∫√ÿ ’43. πæ. ÿ«—≤πå ∏π°√π«ÿ —≤πå √æ.‡ “‰Àâ  √–∫√ÿ ’44. π“ßæ‘¡æåπ¿“ ·´à‚´« √æ.‡ “‰Àâ  √–∫√ÿ ’45. π. .¬ÿ«‡√» „  ’ ∫Ÿ √æ.Õÿμ√¥‘μ∂å Õμÿ √¥μ‘ ∂å46. æ≠.«√‘ ≠— ≠“ √◊Ëπ√¡¬å √æ.≈“π °— Õ∑ÿ —¬∏“π’47. πæ.™¬— ‡«™ ƒμ‘«√“ߧå°√Ÿ √æ.‡¥™Õÿ¥¡ Õ∫ÿ ≈√“™∏“π’ ·π«∑“ß°“√√°— …“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßμ’∫À√◊ÕÕÿ¥μ—π  ”À√—∫·æ∑¬å 21○○○ (Clinical Practice Guidelines for Ischemic Stroke)