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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 22-29

Management of Cerebrovascular Accident (CVA) through Ayurveda


1 Department of Panchakarma, All India Institute Ayurveda, New Delhi, India
2 Department of Kaumarabhritya, All India Institute Ayurveda, New Delhi, India

Date of Web Publication13-Jul-2022

Correspondence Address:
Jitender Kumar Dhiman
Department of Panchakarma, All India Institute Ayurveda, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2667-0593.350867

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  Abstract 


Cerebrovascular Accident (CVA), the third most common cause of death in developing countries, is the term used to describe episodes of focal brain dysfunction due to focal ischemia or hemorrhage. Acute stroke is characterized most commonly by hemiplegia with or without signs of focal higher cerebral dysfunction that has posed a great problem as far as its management is concerned. Ayurveda can help in such conditions. A 54 years old male patient diagnosed with non-hemorrhagic infarct presented with right side hemiplegia and difficulty in speech was admitted in IPD. This manifestation was compared with Kaphavrita dakshina pakshaghata. Panchakarma procedures including Rookshana, Snehana and Virechana were adopted along with other internal medicines. Assessments were made using National Institute of Health Stroke Scale (NIH-SS), Barthel Index (BI) and Modified Rankin Scale (MRS). At the end of the treatment, there was considerable improvement in the subjective and objective clinical features. The observations reveal that, Panchakarma procedures can play a key role in the management of conditions like CVA. The treatment strategies followed in this study can be safely adopted under the supervision of a trained Ayurveda specialist.

Keywords: Cerebrovascular Accident, Pakshaghata, Stroke, Virechana


How to cite this article:
Dhiman JK, Prasanth D, Kumar MA, Bhatted SK. Management of Cerebrovascular Accident (CVA) through Ayurveda. J Ayurveda Case Rep 2018;1:22-9

How to cite this URL:
Dhiman JK, Prasanth D, Kumar MA, Bhatted SK. Management of Cerebrovascular Accident (CVA) through Ayurveda. J Ayurveda Case Rep [serial online] 2018 [cited 2022 Dec 9];1:22-9. Available from: http://www.ayucare.org/text.asp?2018/1/2/22/350867



Introduction: Cerebrovascular Accident (CVA), to the general public means a weakness either permanent or transient on one side, often with loss of speech. It is defined as a focal neurological deficit due to a vascular lesion lasting longer than 24 hours[1]. Hemiplegia following middle cerebral arterial thrombo-embolism is the typical example. The global burden of stroke is high with increasing incidences, mortality and economic impact, particularly in low and middle income countries. Of patients presenting with stroke, 85% will have sustained a cerebral infarction due to inadequate blood flow to some part of the brain[2]. The clinical features will be variable and depends on site and extent of infarct. Pure motor stroke caused by an infarct in the internal capsule is the most common lacunar syndrome that result in weakness of the face, arm, and/or leg. Since both motor and sensory fibers are carried in the internal capsule, a stroke to the posterior limb of the internal capsule can lead to contralateral weakness and sensory loss.[3] The signs and symptoms of CVA can be correlated with Pakshaghata in Ayurveda. The condition affects Sira (vascular structures) and Snayu (tendons and ligaments) of half of the body and face. The cardinal features of Pakshaghata includes Chestahani (decreased motor activity), Ruja (pain) and Vakstambha (slurred speech.[4] Such manifestations can be managed in Ayurveda successfully.

Case report: A 54 years old male patient with complete loss of strength in the right side of the body, difficulty in speech since seven days was brought by his relatives to the OPD on 22.02.2017. Initial history revealed that the patient developed sudden weakness in the right side of the body seven days back and was under conventional medical supervision for a week. MRI brain revealed non-hemorrhagic infarct in the posterior limb of left internal capsule. On examination, patient was afebrile, conscious, well oriented, responding to verbal commands but was unable to walk and had dysarthria. Pulse was 76/min, blood pressure was 130/90 mmHg. Muscle tone was hyper, muscle strength in right upper and lower limbs was zero (as estimated by Medical Research Council Scale for Muscle Strength). Babinski sign was positive.

Ayurveda perspective: The patient showed Kaphaavruta vata lakshana like Shaitya (cold to touch), Guruta (heaviness)[5] along with Chestahani (impaired motor activity in the right side), Ruja (pain), Vakstambha (slurred speech) based on which kaphaavruta vatajanya dakshina pakshaghata was diagnosed. The symptoms resembles with acute CVA. The prognosis of this manifestation is kruchra Sadhya (difficult to cure)[6]. Prakriti of the patient was Vata pitta. He has Pravara satva, complained of Vibandha (constipation) and Agni mandya (poor appetite). As per treatment principles Panchakarma procedures and internal medicines were planned [Table 1],[Table 2],[Table 3],[Table 4],[Table 5].
Table 1: Panchakarma procedures adopted

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Table 2: Rookshana procedure

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Table 3: Kshara basti schedule

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Table 4: Schedule of Snehapana with Kalyanaka Ghritam

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Table 5: Schedule of Virechana adopted

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Previous treatment history: Patient was known hypertensive with history of Myocardial Infarction and underwent percutaneous transluminal coronary angioplasty 9 years back. Since then, he was on Amlodipine 5 mg OD under medical supervision. No other significant medical history was observed.

Besides these procedures; 500mg of Kaishora guggulu[18] thrice a day with 10ml of Guduchayadi kashayam[19] with 30ml of lukewarm water thrice a day before food, 10ml of Amrutottaram Kashayam[20] mixed with 10ml Abhayarishta[21] thrice a day after food added with 5g of Hingwashtaka choorna,[22] 10ml Eranda taila bed time with lukewarm water were administered during the first 7 days of the management.

This was followed by 500 mg Kaishora guggulu and 10ml Ashtavargam kashayam[23] thrice before food, 10ml Punarnavasava[24] added with 10ml Abhayarishta and 5gm Hingawashtaka choorna thrice after food. 10ml of Gandharvahastadi eranda tailam[25] at bed time for next 11 days until Samyak Deepana Pachana lakshanas[26] were observed.

Criteria for selection of procedure / medicine:

The present case was diagnosed as Kaphaavruta vatajanya pakshaghata in which Kaphaghna and Vatanulomana procedures are preferred.[27] Rookshana was adopted first to alleviate Kapha by Jatamayadi Rooksha Choorna Pinda Sveda, Kshara basti and Takra dhara. Mastishka (application of medicated oil over anterior frontanallae) is specially mentioned in the treatment of Pakshaghata.[28] Virechana is indicated in the treatment of Kaphaavruta vata[29] and also in the management of Pakshaghata.[30] Oral medication was selected on the basis of the properties of ingredients in the respective formulations that help in pacifying aggravated Pitta kapha dosha keeping Vata under control.

Assessment criteria: Before and after treatment, assessment was made using National Institute of Health Stroke Scale (NIH-SS)[31], Modified Rankin Scale (MRS[32] and Barthel Index.[33] [Table 6],[Table 7],[Table 8].
Table 6: National Institute of Health Stroke Scale (NIH-SS)

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Table 7: Modified Rankin Scale

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Table 8: Barthel Index

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Observations: After a week of treatment, adduction and abduction movements were observed in the right lower limb. After two weeks, patient was able to lift his leg slightly and walk with support. Appetite was increased and bowel movements were regular. After 2 weeks of Virechana; patient was able to move his right upper limb at elbow joint and was able to walk for some distance without support. On NIH-SS scale maximum improvement was noted in right lower and upper extremity functions. MRS scale was 4 before treatment indicating severe disability was reduced to 2 after treatment indicating slight disability. Barthel Index showed maximum improvement on mobility, toilet use, grooming and bathing domains.

Discussion:

Cerebrovascular accident or stroke is defined by this abrupt onset of a neurological deficit that is attributed to a focal vascular cause[34]. A stroke can be ischemic or hemorrhagic. The present case was a typical example of ischemic stroke caused by occlusion in lenticulostriate arteries (branch of middle cerebral artery) that supplies posterior limb of internal capsule [35]. Since both motor and sensory fibers are carried in the internal capsule, a stroke to the posterior limb of the internal capsule can lead to contralateral weakness and sensory loss. Patient showed similar symptoms like weakness of right side of the body with dysarthria. Patient also had symptoms like Shaitya (cold to touch), Guruta (heaviness), and Shula (pain) which indicates towards the Kapha avarana. Virechana was planned because Virechana is the gold standard treatment of pakshaghata. Virechana is best to remove the avarana of vata by kapha. Before Virechana, rookshana was done with Rooksha Choorna Pinda Sveda, Kshara Basti along with Takra Dhara because rookshana would be the procedure of choice to remove Kapha avarana. Jatamayadi choorna was choosen for Rooksha Choorna Pinda Sveda considering its karmukata as rooksha guna opposite to the snigdhata of kapha and ushna guna opposite to sheeta guna of kapha and vata. Takra Dhara is specially indicated in Hemiplegia[36].

Kaishora guggulu[18] considering its action on Vata and Pitta, Guduchayadi kashayam[19] which is known to have Pitta kapha hara effect. As the patient had Agnimandhya Amrutottaram Kashayam[20] was also given due its Agni deepaka nature. For Vatanulomana; Abhyarishta[21].along with Hingwashtaka choorna[22] followed by Eranda taila[13] at bed time

Later this was followed by 500 mg Kaishora guggulu and 10ml Ashtavargam kashayam[23] thrice before food, 10ml Punarnavasava[11] added with 10ml Abhayarishta and 5gm Hingawashtaka choorna thrice after food. 10ml of Gandharvahastadi eranda tailam[25] at bed time for next 11 days until the appearance of Samyak Deepana Pachana lakshanas[26].

After rookshana, patient was able to lift his leg slightly and walk with support. After observing Samyak Deepana Pachana lakshanas[26], Snehapana with Kalyanaka ghritam was started, as preparatory procedure of Shodhana. Kalyanaka ghritam provides nourishment, bestows strength and also beneficial in persons Swara Vikruti (Slurred speech) the management of Vata vyadhi. After observing samyaka snigdha lakshana[37] Sarvanga Abhyanga (full body oil massage with Kottamchukkadi Taila) was done followed by Sarvanga Nadi Sveda (full body fomentation with Dashamoola Kwatha). This was followed by Snigdha Virechana (Therapeutic purgation along with oil) by administering a blend of Trivrut avaleha, Triphala kwatha and Eranda taila. Trivrut Avaleha has Kaphapittahara properties and it can be easily tolerated by the patient. Eranda is best to remove vata[38]. Triphala kwatha was given as anupana. Triphala is Kaphapittahara and agnideepaka in nature. 14 Virechana vegas were obtained indicating Madhyama Shuddhi (medium level of purification). No complication occurred after virechana and during samsarjana karma. Virechana helps in eliminating Pitta followed by Kapha and Vata was well tolerated by the patient. After 2 weeks of Virechana; patient was able to move his right upper limb at elbow joint and was able to walk for some distance without support. Later on follow up after 36 days with continuation of same internal medicines showed very good remission of clinical symptoms and improved quality of life. Patient was on Tab amlodipine 5mg for hypertension during and after the treatment.

Conclusion:

This case study shows effectiveness of stage wise Panchakarma management in Cerebro Vascular Accident (CVA) comparable to Pakshaghata. Whilst there is enormous scope for further research but still it proves that with proper diagnosis and proper treatment protocol. Ayurveda can be beneficial in such cases of CVA. Recovery in the present case was promising and worth documenting.

Source of Support: None

Conflicts of Interest: Nil



 
  References Top

1.
Nicki R. Colledge, Brian. R. Walker, Stuart H. Ralson editors. Davidson’s principles and practice of medicine, 21st edition. 2010, Churchill Livingstone Elsevier; p.1180.  Back to cited text no. 1
    
2.
Nicki R. Colledge, Brian. R. Walker, Stuart H. Ralson editors. Davidson’s principles and practice of medicine, 21st edition. 2010, Churchill Livingstone Elsevier; p.1181.  Back to cited text no. 2
    
3.
Parveen Kumar, Michael Clark editors. Kumar & Clark Clinical Medicine 5th edition. 2002, W.B. Saunders; p.1163.  Back to cited text no. 3
    
4.
Acharya YT, editor. Charaka samhita of Agnivesha, Chikitsa sthana, Vatavyadhi chikitsitam, chapter 28, verse 53-54, Chaukhambha Sanskrit Sansthan; Varanasi: reprint 2002;619.  Back to cited text no. 4
    
5.
Acharya YT, editor. Charaka samhita of Agnivesha, Chikitsa sthana, Vatavyadhi chikitsitam, chapter 28, verse 62, Chaukhambha Sanskrit Sansthan; Varanasi: reprint 2002;619.  Back to cited text no. 5
    
6.
Harishastri P, editor. Ashtanga Hridayam of Vagbhata, Nidana sthana; Vata vyadhi Nidana, chapter 15, verse 41. Chowkhambha Surbharati Prakashan; Varanasi: reprint 2017; 533.  Back to cited text no. 6
    
7.
Nishteswar K, Vidyanath R, editors. Sahasrayogam, Choorna Prakarana, chapter 4, verse 76, Chaukhamba Sanskrit Series Office; Varanasi; 2014, p. 20.  Back to cited text no. 7
    
8.
Nishteswar K, Vidyanath R, editors. Sahasrayogam, Taila Prakarana, chapter 3, verse 4, Chaukhamba Sanskrit Series Office; Varanasi; 2014, p. 111.  Back to cited text no. 8
    
9.
Harishastri P, editor. Ashtanga Hridayam of Vagbhata, Uttara tantra, Unmada pratishedha adhyaya, chapter 6, verse 31. Chowkhambha Surbharati Prakashan; Varanasi: reprint 2017; p.799.  Back to cited text no. 9
    
10.
Nishteswar K, Vidyanath R, editors. Sahasrayogam, Parishishta Prakarana, chapter 11, verse 2, Chaukhamba Sanskrit Series Office; Varanasi; 2014, p. 405.  Back to cited text no. 10
    
11.
Sharma PV, editor. Commentary Nibandha Sangraha of Dalhana on Sushruta Samhita of Sushruta, Sutra tantra; Dravya sangrahaneeya adhyaya, chapter 38, verse 71. Chaukhambha Visvabharti; Varanasi: 2010, p. 169  Back to cited text no. 11
    
12.
Harishastri P, editor. Ashtanga Hridayam of Vagbhata, Kalpa siddhi sthana; Virechana adhyaya, chapter 2, verse 9. Chowkhambha Surbharati Prakashan; Varanasi: reprint 2017; 743.  Back to cited text no. 12
    
13.
Sharma PV, editor. Commentary Nibandha Sangraha of Dalhana on Sushruta Samhita of Sushruta, Sutra sthana; Dravya dravya vidhi adhyaya, chapter 45, verse 114. Chaukhambha Visvabharti; Varanasi: 2010, p. 205  Back to cited text no. 13
    
14.
Sharma PV, editor. Commentary Nibandha Sangraha of Dalhana on Sushruta Samhita of Sushruta, Sutra sthana; Dravya sangrahaneeya adhyaya, chapter 38, verse 56-57. Chaukhambha Visvabharti; Varanasi: 2010, p. 168  Back to cited text no. 14
    
15.
Nishteswar K, Vidyanath R, editors. Sahasrayogam, Taila Prakarana, chapter 3, verse 11, Chaukhamba Sanskrit Series Office; Varanasi: 2014, p. 116.  Back to cited text no. 15
    
16.
Devraj TL. The Practical Panchakarma Therapy, Keraliya Panchakarma Therapies & Other Special Treatments of Kerala, First edition, 2009, Chaukhamba Orientalia; Delhi: p. 330.  Back to cited text no. 16
    
17.
Dwivedi M, Sharma T, Mishra B editors. Ayurvediya Panchakarma Chikitsa, Basti Prakarana Adhyaya, Chaukhambha Sanskrit Pratishthan; Delhi: 2012, p. 606  Back to cited text no. 17
    
18.
Srivastava S, editor. Sharangadhara Samhita, Madhyama Khanda, Vati kalpana adhyaya, chapter 7, verse 70-81, Chaukhambha Orientalia; Varanasi: 2011  Back to cited text no. 18
    
19.
Harishastri P, editor. Ashtanga Hridayam of Vagbhata, Sutra sthana; Shodhanadigana sangraha adhyaya, chapter 15, verse 16. Chowkhambha Surbharati Prakashan; Varanasi: reprint 2017; 235.  Back to cited text no. 19
    
20.
Nishteswar K, Vidyanath R, editors. Sahasrayogam, Kashaya Prakarana, chapter 1, verse 6, Chaukhamba Sanskrit Series Office; Varanasi: 2014, p. 4.  Back to cited text no. 20
    
21.
Rao GP, editor. Bhaisajya Ratnavali, Volume 1, Arshoroga Chikitsa Prakarana, chapter 9, verse 175-180, First edition, Chaukhambha Orientalia; Varanasi: 2014, p. 406.  Back to cited text no. 21
    
22.
Rao GP, editor. Bhaisajya Ratnavali, Volume 1, Agnimandya Chikitsa Prakarana, chapter 10, verse 59, First edition, Chaukhambha Orientalia; Varanasi: 2014, p. 433.  Back to cited text no. 22
    
23.
Nishteswar K, Vidyanath R, editors. Sahasrayogam, Kashaya Prakarana, chapter 1, verse 54, Chaukhamba Sanskrit Series Office; Varanasi: 2014, p. 4.  Back to cited text no. 23
    
24.
Rao GP, editor. Bhaisajya Ratnavali, Volume 2, Shotharoga Chikitsa Prakarana, chapter 42, verse 193-197, First edition, Chaukhambha Orientalia; Varanasi: 2014, p. 185.  Back to cited text no. 24
    
25.
Sharma S, editor. Ashtanga Samgraha of Vagbhata, Chikita Sthana, Vidradhi vidhi chikitsa adhyaya, chapter 15, verse 25, fourth ed., Chaukhamba Sanskrit Sansthan, Varanasi, 2012, p. 521.  Back to cited text no. 25
    
26.
Acharya YT, editor. Charaka samhita of Agnivesha, Sutra sthana, Langhana brimhaneeya Adhyaya, chapter 22, verse 34-35, Chaukhambha Sanskrit Sansthan; Varanasi: reprint 2002;121.  Back to cited text no. 26
    
27.
Acharya YT, editor. Charaka samhita of Agnivesha, Chikitsa sthana, Vata vyadhi chikitsa adhyaya, chapter 28, verse 245, Chaukhambha Sanskrit Sansthan; Varanasi: reprint 2002;627.  Back to cited text no. 27
    
28.
Sharma PV, editor. Commentary Nibandha Sangraha of Dalhana on Sushruta Samhita of Sushruta, Chikita sthana; Maha vata vyadhi chikitsa adhyaya, chapter 5, verse 19. Chaukhambha Visvabharti; Varanasi: 2010, p. 427  Back to cited text no. 28
    
29.
Acharya YT, editor. Charaka samhita of Agnivesha, Chikitsa sthana, Vata vyadhi chikitsa adhyaya, chapter 28, verse 187, Chaukhambha Sanskrit Sansthan; Varanasi: reprint 2002;624.  Back to cited text no. 29
    
30.
Acharya YT, editor. Charaka samhita of Agnivesha, Chikitsa sthana, Vata vyadhi chikitsa adhyaya, chapter 28, verse 100, Chaukhambha Sanskrit Sansthan; Varanasi: reprint 2002;621.  Back to cited text no. 30
    
31.
National Institute of Health, National Institute of Neurological Disorders and Stroke. Stroke Scale. http://www.ninds.nih.gov/doctors/NIH_Stroke_ Scale. last assessed on 24th March 2018, 11:30 AM.  Back to cited text no. 31
    
32.
Quinn TJ, Dawson J, Walters M. Dr John Rankin; his life, legacy, and the 50th anniversary of the Rankin Stroke Scale. Scott Med J. 2008:53 (1):44-7.  Back to cited text no. 32
    
33.
Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: A reliability study. Int Disability Study. 1988; 10:61-63.  Back to cited text no. 33
    
34.
Anthony S. Fauci et al editors. Harrison’s Principles of Internal Medicine, Cerebrovascular Diseases. Volume-2, 17th edition, McGraw Hill Companies; p.2513.  Back to cited text no. 34
    
35.
Anthony S. Fauci et al editors. Harrison’s Principles of Internal Medicine, Cerebrovascular Diseases. Volume-2, 17th edition, McGraw Hill Companies; p.2523.  Back to cited text no. 35
    
36.
Devraj TL. The Practical Panchakarma Therapy, Keraliya Panchakarma Therapies & Other Special Treatments of Kerala, First edition, 2009, Chaukhamba Orientalia; Delhi: p. 331.  Back to cited text no. 36
    
37.
Acharya YT, editor. Charaka samhita of Agnivesha, Sutra sthana, Sneha adhyaya, chapter 13, verse 58, Chaukhambha Sanskrit Sansthan; Varanasi: reprint 2002;85.  Back to cited text no. 37
    
38.
Acharya YT, editor. Charaka samhita of Agnivesha, Sutra sthana, Yajjapurusheeya adhyaya, chapter 25, verse 40, Chaukhambha Sanskrit Sansthan; Varanasi: reprint 2002;131.  Back to cited text no. 38
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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