Multi - modal approach in the management ofCerebro Vascular accident

Introduction

Stroke is a major global public health problem. It is second leading cause of death and a major cause of disability world wide. According to World health Organization around 15 million people suffer stroke worldwide each year, Of these, 5 million die, and others are left permanently disabled¹ . Major risk factors of stroke include Age, Hypertension, Diabetes Mellitus, Cardiac disease, lifestyle issues, obesity. Stroke is defined as the sudden occurrence of focal, non conclusive neurological deficit. The presentation varies ranging from subtle to severe. The common signs and symptoms of stroke includes abrupt onset of hemiparesis, sensory deficits, dysarthria, facial droop. This signs and symptoms can be corelated to the lakshanas of pakshaghata viz. chesta nivrutti, vak sthamba, ruja. Pakshaghata has been mentioned as one among the vata vyadhi. The line of treatment of pakshaghata as mentioned in classics are, snehana, swedana, shodhana, anuvasana, asthapana, shirobasti, abhyanga.

Vital data :

Age : 52 years

Sex : Female

Religion : Hindu

Education : High School

Occupation : House Wife

Marital status : Married

Socio-economic status : Upper Middle class

Presenting concerns :

i. Loss of strength in left upper and lower limbs since one and half months,

ii. Unable to stand or walk since one and half months

iii. Heaviness in the left upper and lower limbs

Past history :

Known case of hypertension since 5 months

H/o Pneumonia one and half months back

H/o Hysterectomy 18 years back

Clinical findings :

Gait: Unable to walk

NIH Score- 11

CNS:

• GCS: E4V5M6

• Mental Status: conscious, Alert, Co-operative

• Thought- Coherent, Oriented to person, place and time

• Cranial nerve examinations:

Olfactory: Normal

Optic: Visual acuity- Normal near & distant vision, Visual fields- Normal

Occulomotor, Trochlear & abducens: No ptosis or nystagmus, Pupillary light reflex B/L symmetrical, Extraocular movements intact, No diplopia, Accomodation reflex-normal.

Trigeminal nerve: Sensations normal over opthalmic, maxillary , and mandibular divisions, No atrophy of temporalis & masseter.

Facial nerve: Deviated, No involuntary movements. Wrinkling of forehead- Symmetrical. Forcibly opening of eye with fingers-ve Clenching teeth- Angle of mouth deviated to right. Vestibulocochlear :Hearing- normal Glossopharyngeal & Vagus: No deviation of Uvula. Accessory nerve: Shrug shoulders-ve (left) Turn head from side to side- + Hypoglossal: No tongue atrophy, No fasiculations, No deviation

Roga pareeksha :

Nidana : Aharaja: Ati katu, lavana rasa sevana and Excessive intake of fried items

Viharaja: Ati chesta, Prajagara, Chinta, Ati sheeta vata

Poorvaroopa : Avyakta

Roopa : i.Loss of strength in left upper and lower limbs

ii. Unable to stand or walk

iii. Heaviness in the left upper and lower limbs

Samprapti :

Nidana sevana-( Vata and kapha prakopaka nidanas) --> kapha dosha does avarana of vata --> prasara of vata in sarva sharira through dhamani --> sthana samshraya in ardha sharira --> causes sankocha of sira and snayu --> leading to chesta nivrutti, ruja, vaksthamba, gaurava, sthamba--> pakshaghata

Investigations : CT-Brain(28-10-17): Right MCA territory acute infarct with associated frontal subarachnoid hemorrhage

Treatment :

Assessment :

After Treatment:

Discussion

The medicines prescribed above are mainly indicated in vata vyadhis in the classics. Initially, for dipana and amapachana dhanwantaram vati was given, Tab triphala was given for vata anulomana. Udwartana+ Nadi sweda and agnichikitsa lepa was done for kapha shamana in order to reduce the gaurava and sthabdata. Basti was planned with Manjistadi Kashaya as it is rakta prasadana. For anuvasana manjistadi taila +sukumara ghrita was used as it is rakta prasadana, balya, vata kapha shamaka. Abhyanga was done with pariseka taila, it is vata shamaka, balya and shrama hara. It was followed by Nadi sweda with dashamoola kwatha, which is vata kapha shamaka, reduces shoola and sthabdata. Pratimarsha nasya with yastimadhu+ksheera+sharkara was advised as.Yestimadhu has cerebro protective effect.

Conclusion

Dipana, pachana, Vata-kapha shamana, balya, rakta prasadana, are the main treatment modalities in this case. Hence Multi Modal approach in Pakshaghata after proper assessment of the doshas involved can give promising results.