ishcemic and hemorrhagic stroke, a light on integrated approach
DESCRIPTION
Management of stroke in Ayurveda gives very good results. In severe cases with the help of some emergency management from modern medicine gives tremendous result with Ayurveda management. We have treated more than 2500 patients as in patients with nearly half of them being acute strokes. Other than that we have also treated many stroke patients on out patient basis. This slide show is for all Ayurveda practitioners to which may help them in the management of stroke with better understanding. Now days many modern physicians criticize Ayurveda for treating stroke stating that Ayurveda people don't know the pathology involved in it, they treat with massage, how come a massage can help stroke patient and so on. I wonder why can't the modern physicians appreciate the tremendous result which we get in stroke patients with Ayurveda. Here I have tried my best to explain the mode of action of these Ayurveda measures both from Ayurveda point of view and also as per the contemporary medical science. Also welcome comments from Ayurveda scholars.TRANSCRIPT
Ishcemic and Ishcemic and Hemorrhagic stroke - A Hemorrhagic stroke - A
light on Integrated light on Integrated approachapproach
ByBy
Dr Jayagovinda UkkinadkaDr Jayagovinda Ukkinadka
““Ukkinadkas Ayurveda”Ukkinadkas Ayurveda”
Stroke
Stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurological function.
Stroke is a nonspecific term encompassing a heterogeneous group of pathophysiologic causes.
In Ayurveda, in Simple words Samanavritha Vyanavayu
Stroke can be explained as Samanavritha Vyanavayu.
Here The brain centers responsible for body movement (regulated by vyanavayu) is affected by obstructed peripheral blood circulation (regulated by Smanavayu)
Various etiological factors which in turn produces Srothorodha or Srothobheda (in Murdhni) causes this condition.
Consider Avarana of other vatha factors also
Samana vayu Avarana of Prana vayu, Udana vayu and Apana vayu should also be considered depending upon the signs and symptoms involved.
Samanavritha Vyanavayu Lakshana And Chikitsa
• Murcha, Tandra, Pralapa, Angasada, Agni, Oja and Bala kshaya.
• Treatment is Vyayama and Laghu bhojana along with other Vathavyadhi chikitsa.
• Also consider chikitsa of Avaraka followed by Avritha depending upon the pathophysiology.
Ishchemic & Hemorhagic stroke
Broadly stroke is classified into two. Ischemic & Hemorhagic
Ischemic stroke- 3 major types
Large artery infarction Small-vessel, or lacunar infarction Cardioembolic infarction
Others are Thrombotic stroke Water shed infarcts
Non modifiable Risk factors
Age Race Sex History of migraine headaches Sickle cell disease Fibromuscular dysplasia Heredity
Modifiable risk factors Hypertension (the most important) Diabetes mellitus Cardiac disease Hypercholesterolemia Transient ischemic attacks (TIAs) Carotid stenosis Hyper homocystinemia Lifestyle issues - Excessive alcohol intake, tobacco use,
illicit drug use, obesity, physical inactivity Oral contraceptive use
ACA-MCA-PCA territory
Large artery infarct-MCA left side
Middle cerebral artery stroke
Contralateral hemiparesis & hypesthesia, Ipsilateral hemianopia, & gaze preference
toward the side of the lesion. Agnosia is common (sensory damage) Aphasia - if the lesion occurs in the dominant
hemisphere. Since the MCA supplies the upper extremity
motor strip, weakness of the arm and face is usually worse than that of the lower limb.
Anterior cerebral artery stroke
ACA occlusions primarily affect frontal lobe function
can result in disinhibition and speech perseveration, producing primitive reflexes (eg, grasping, sucking reflexes)
altered mental status, impaired judgment contralateral weakness (greater in legs
than arms), contralateral cortical sensory deficits gait apraxia, and urinary incontinence.
Posterior cerebral artery stroke
Affect vision and thought producing contralateral homonymous
hemianopia, cortical blindness, visual agnosia, altered mental status, and impaired memory.
Other features include
Posterior cerebral artery stroke Vertigo Nystagmus Diplopia Visual field deficits Dysphagia Dysarthria Facial hypesthesia Syncope Ataxia
MCA and ACA infarct with petechial hemorhage
Internal Carotid artery occlusion
Lacunar infarct – in CT and MRI
Infarct diameter less than 1.5 cm Due to occlusion in circle of willis either in MCA
or ACA territory
Internal capsule - thalamus
1, Insula. 2, Internal capsule. 3, Caudate nucleus. 4, Putamen. 5, Posterior limb, internal capsule. 6, Splenium, corpus callosum.7, Thalamus.
Investigation modalities
CBC Blood Chemical analysis CT scan MRI MRA ECG, Echo cardiography etc as
necessary
ISCHEMIC CORE
An acute vascular occlusion produces heterogeneous regions of ischemia in the affected vascular territory. The quantity of local blood flow is made up of any residual flow in the major arterial source and the collateral supply, if any.
Regions of the brain with CBF lower than 10 mL/100g of tissue/min are referred to collectively as the core, and these cells are presumed to die within minutes of stroke onset.
PENUMBRA
Zones of decreased or marginal perfusion (CBF < 25 mL/100g of tissue/min) are collectively called the ischemic penumbra. Tissue in the penumbra can remain viable for several hours because of marginal tissue perfusion.
Saving Penumbra
In Acute ischemic stroke the current modern approach is to save and to convert penumbra to normal tissues as much as possible
Thrombolytic therapy is the recent addition, others are use of antiplatelet and anti coagulant drugs to prevent the recurrence of stroke.
The main aim of the medication in modern medicine are
Thrombolytic-alteplase (rt-PA) Reperfusion-recanalisation Antiplatelet- Clopidogrel, aspirin Anticoagulants-warfarin etc- usually in
thromboembolic stroke Neuroprotective- citicoline, vitamins etc Symptomatic management
Major drugs used in modern medicine
Thrombolytic Antiplatelet and anti coagulants Antipyretic drugs Anti hypertensives Diuretics to reduce cerebral edema Anti epileptics in case of seizure And all symptomatic approach to handle the
different situation
Management of Hypertension in Ischemic stroke
Sudden bringing down of blood pressure is not recommended in ischemic stroke
BP <200/120 should not be managed aggressively and should wait for spontaneous recovery. But BP above this should be treated but care should be taken so that sudden fall in BP should be avoided to prevent fall in blood perfusion
Main aim of Treatment in UA Reperfusion- Theekshna Nasya (TN) Antiplatelet- Cholestonorm Capsule Neuroprotective- Herbal preparations Protecting vitals-symptomatic management Encouraging Neuroplasticity- by1. TN, Irritant Lepas, Pindasweda,
Physiotherapy & Accupunture 2. Internal medicines to encourage possible
regeneration
Theekshna Nasya (TN)
TN is the 1st treatment to be considered in Management of Acute CVA. But should be very cautious before administration.
This simultaneously treats Avaraka and Avritha.
TN Indication in Acute CVA
Ischemic CVA Ischemic CVA with BP <190/110 Ischemic CVA with hypotension- an ideal
treatment
TN can be used with Caution in
All Acute Hemorhagic CVA without headache, vomitting and siezure
Acute Hemorhagic CVA with BP <190/110 CVA with Bulbar Palsy Acute Ischemic or Hemorhagic CVA who is
comatose/stupor with Bulbar Palsy CVA ischemic with BP >190/110 and <220/120
TN is Contra indicated in Acute CVA in the following condns.
Hemorrhagic stroke with seizure, neck stiffness, headache and vomiting till stabilisation.
Hemorrhagic stroke with BP> 190/110 Massive hemorhagic stroke- 1st 2-4 days Large artery infarct with BP >220/120 CVA in a patient with h/o epilepsy. In Huge ischemic stroke, who is already under
anti coagulants with INR >3 IU or high doses of anti platelets.
TN Ingredients
Mode of Action of TN in Acute CVA- A hypothesis
Perfusion Immediately after administration of TN BP
raises to its peak up to 220-280/130-170 mm of Hg in most of the patients and gradually comes down to mid phase in 20-30 minutes and previous level in 1-6 hours depending upon the persistance of irritation, in some patients constantly maintained in high mid level for some hours.
Mode of Action of TN in Acute CVA- a hypothesis
Perfusion
This sudden hike in blood pressure helps in flushing of blood to the Penumbra area and also encourages fast collateral circulation to reach penumbra and can save the dying brain tissue.
Mode of Action of TN in Acute & Chronic CVA - A hypothesis
Neuroplasticity
Neuroplasticity is activation of the spared adjacent latent neurons which are capable of doing the functions of damaged cells. If such cells are viable action of TN is excellent.
Complications of TN
Hemorrhagic conversion of Ischemic stroke worsening of hemorrhagic stroke Increase in the Intracranial pressure which
may ultimately result in reduced perfusion. (Repeated intermittent administration must be avoided)
Possibility of development of aspiration pneumonia in comatose pts especially with Bulbar palsy.
Mode of Action of Irritant Lepas
Neuroplasticity by stimulating the CNS through nerve endings
Possibility of absorption of active lipid soluble molecules through skin having specific neuroprotective activity
Lepas
Saindhavadi Lepa- Saindhava, Grihadhooma and Gingelly Oil
Agni chikitsa Lepa
Pinda sweda
Oil massage with specific herbal oil which may also contain some specific neuroprotective molecules.
Massage and phomentation once again stimulates CNS through Nerve endings which encourages neuroplasticity.
Pindasweda Usually practiced
Shastikashali Pindasweda Masha Pindasweda
Others Pizichil Annalepana
Main oils used are
Mahamasha taila and Agni taila (prop)
Shirodhara
Which helps to subside anxiety, depression, and psychological symptoms which is very common in CVA
Also helps in gradual reduction of hypertension
Commonly practiced are Taila and Takra dhara
Basti
We also treat some patients with medicated enema if found essential
Accupuncture & Physiotherapy
Stimulates Nerve endings and helps in neuroplasticity
Rehabilitation through Physiotherapy. We use a special technique of inducing
pressure over pain points a variety of Marma therapy – Ayurveda physiotherapy.
Herbal medicines
Cholestonorm Capsule in ischemic stroke Main ingredients are garlic, Ajwain, Krishna
jeeraka, Saindhava lavana, Shunti, and Chandraprabha vati with additional shilajithu.
Main action as antiplatlet drug. Confirmed the action by observing the bleeding and clotting time. Also helpful in reducing Cholesterol and Triglyceride level.
Kwatha preparations
Mashathmagupthadi kwatha Balakulathadi kwatha Dhanadanayanadi kwatha Bala godhumadi kwatha Rasna sapthaka kwatha Bala jeerakadi kwatha etc
Considering the associated symptoms
Kapikachu and Ashwagandha churna
5g three times daily as a neuroprotective and to improve healing power.
Kapikachu alone - specially we use in cerebellar stroke with gait ataxia gives tremendous result. Dosage must be 15-25g per day in 3-5 divided doses.
Projeny M tablet
Improved version of Pusphadhanva Ras where we reduced the Naga bhasma to 1/10th and added with Jasada bhasma and trace of Swarna bhasma.
Improves healing ability of the tissues, and used as neuroprotective
Kshirabala Avarthitha
As a rejuvenative drug, and as anupana with Mashathmaguptha kwatha
Nasika Taila (prop)
TN can not be used for long time. Hence in chronic management, Nasya
which is not a Marsha nor Prathimarsha but with mid potency which can be used for long time without any complicaton, we use Nasika taila to encourage neuroplasticity.
Main ingredients are Kokilaksha beeja, Hingu and Gomuthra
Thank You