E-ISSN:2456-3110

Review Article

Hypertensive Bleed

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 6 JUNE
Publisherwww.maharshicharaka.in

Ayurvedic management of Acute Cerebro Vascular Accident due to Hypertensive Bleed (Pakshaghata): A Case Report

Amarnath BR1*, Muttappa T2, Vasantha B3, Merlyn TJ4
DOI:10.21760/jaims.9.6.49

1* Amarnath BR, Post Graduate Scholar, Department of Kayachikitsa, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

2 Muttappa Totad , Associate Professor, Department of Kayachikitsa, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

3Vasantha B , Associate Professor, Department of Kayachikitsa, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

4Merlyn TJ , Postgraduate Scholar, Department of Kayachikitsa, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

Stroke is defined as the fast onset of focal neurological deficit within which poor blood flow to the brain ends up in necrobiosis. It is the second most common reason for worldwide mortality. Hemorrhagic strokes are classified based on their underlying pathology. Some common causes of bleeding are hypertensive trauma, ruptured aneurism, arteriovenous fistula, transformation of previous ischemic pathology and drug-elicited hemorrhage. They result in tissue injury by inflicting compression of tissue from an expanding hematoma. Pakshaghata described in Ayurveda can be correlated with Stroke. All Acharyas have emphasized that in the manifestation of Pakshaghata, Vata is predominant with the association of Pitta and Kapha Dosha. Here is the case of 46 years old male diagnosed as an acute case of hypertensive bleed in the right centrum semiovale and putamen (Magnetic Resonance Image-MRI of Brain) resulting in left-sided hemiparesis. Assessments were done on the basis of National Institute of Health (NIH) Stroke Scale, Medical Research Council (MRC) Scale for Muscle Strength, Barthel Index and Scandinavian Stroke Scale. He was given Yastimdhu Ksheera Nasya, Takra Shirodhara, Kalyanaka Ghrita as Anuvasana Basti and oral medications. After 12 days of treatment there was marked improvement in these scales.

Keywords: Pakshaghata, CVA, Stroke, hemorrhage, Ayurveda, Nasya, Shirodhara

Corresponding Author How to Cite this Article To Browse
BR Amarnath, Post Graduate Scholar, Department of Kayachikitsa, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.
Email: 		Amarnath B, Muttappa T, Vasantha B, Merlyn TJ, Ayurvedic management of Acute Cerebro Vascular Accident due to Hypertensive Bleed (Pakshaghata): A Case Report. J Ayu Int Med Sci. 2024;9(6):302-307.
Available From
https://jaims.in/jaims/article/view/3266

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-04-12 2024-04-22 2024-04-02 2024-05-13 2024-05-24
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Authors state no conflict of interest. Non Funded. The conducted research is not related to either human or animals use. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

© 2024by Amarnath B, Muttappa T, Vasantha B, Merlyn TJand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Stroke is the most common cause of neurological disability in the adult population[1] and it is the third leading cause of death worldwide. It is responsible for 4.4 million deaths worldwide. The incidence of stroke increases with age and it is higher in men than women.[2]

Stroke is a clinical term for acute loss of blood circulation to the brain tissue. Spontaneous intracerebral hemorrhage occurs mostly in patients experiencing hypertension. The common sites of hypertensive intracerebral hemorrhage are the region of basal ganglia, Pons, and the cerebellar cortex. Clinically, the onset is typically fulminant with headache and loss of consciousness. Depending on the location of the lesion, hemispheric brain stem or cerebellar signs will be present. The explosive entry of blood into the brain parenchyma during primary intracerebral hemorrhage causes immediate cessation of function in that area, as neurons are structurally disrupted and the white matter fibre tract is split apart. A rim of cerebral edema forms around, resulting in a blood clot, which with the hematoma acts like a mass lesion. If big enough, this can cause a shift of intracranial contents, producing trans tentoria coning and 15% people die shortly after stroke.[3]

The description of the clinical signs and symptoms of stroke can be interpreted with Pakashaghata in Ayurveda science. Pakshaghata has been enlisted among the eighty forms of Vataja Nanatmaja Vyadhi and explained in the Madhyama Rogamarga.[4] Acharya Charaka, in Chikitsa Sthana describes Pakshaghata by saying that morbid Vata beholds either side of the body, dries up Sira and Snayu of that part and producing loss of motor activity with pain dysarthria/aphasia.[5] This case report of Pakshaghata shows the successful outcome of the Ayurvedic intervention such as Nasya, Takradhara, Basti and Shamanaushadhis.

Case Report

Patient Information

A male patient aged 46 years, who was conscious and oriented to time, place and person brought in a wheelchair to Kayachikitsa OPD of Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital,

Hassan on 19 October 2022 at 11 AM with the chief complaints of giddiness, reduced strength in the left upper and lower limb, headache, difficulty in getting up from lying position and walking, slurred speech, heaviness, pain and complete loss of sensation in the left upper and lower limb since 6 AM, got admitted on the same day under IPD No:061888.

History of Present Illness

The patient was apparently healthy in the morning, suddenly around 6 AM he developed giddiness followed by reduced strength in the left upper and lower limb, difficulty in sitting and walking without support, slurred speech and complete loss of sensation in the left upper and lower limb.

Clinical Findings

General Examination

Built, nutritional status, hair and nail of the patient are normal, pallor, clubbing, cyanosis, icterus, lymphadenopathy and edema were absent. Blood pressure was 140/80 mm of Hg and pulse rate was 80 beats /minute.

Systemic Examination

Respiratory system - on auscultation, normal bronchio vasicular sounds heard and no abnormality detected. Cardiovascular system - S1 S2 heard and no abnormality detected. Per abdomen was soft, nontender, no organomegaly detected. Central nervous system - Higher mental functions found to be normal. Glasgow coma scale - Eye opening response was - 4, verbal response - 5 and motor response - 6 total score - 15/15 Motor functions: · Power Left Upper and Lower limb - 2/5 Right Upper and Lower limb - 4/5 · Deep tendon reflexes such as biceps, triceps, supinator, knee jerk and ankle jerk on affected side (left) were found to be 3+ and on normal side (right) found to be 2+. Babinski’s sign was present on left side. · Tone: Left upper and lower limb was hypotonic · Sensory functions: Left Upper and Lower limb fine touch - absent, crude touch - present, Left Upper and Lower limb fine and crude touch - present · Gait - hemiplegic with support.

Investigation

Magnetic Resonance imaging (MRI) of Brain done on 19/10/2022 showed acute hypertensive bleed in the right centrum semiovale and putamen without any intraventricular extension.


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Diagnosis
Pittakaphavruta Vamaparshwa Pakshaghata (Acute Left sided Hemiparesis – ICH)

Treatment

DateMedication/ProcedureDose and Time
19/10/2022Dhanwantara Vati Rasaushadi Yoga - Ekangaveera Rasa, Mahavata Vidvamsana Rasa, Vatakulantaka Rasa, Vata Ganajankusha Rasa, Bala, Shuddha Shilajitu - Each 160mg Nadi Kashaya Tab. Anuloma DS2 TID B/F (S/L) TID A/F 100 ml OD Morning A/F 1 HS A/F
Shiropichu with Ksheerabala Taila Nasya with Ksheera Saditha YastimadhuOD 8 Drops in Each Nostril TID A/F
20/10/2022Dhanwantara Vati Rasaushadi Yoga Nadi Kashaya Tab. Anuloma DS2 TID B/F (S/L) TID A/F 100 ml OD Morning A/F 1 HS A/F
Shiropichu with Ksheerabala Taila Nasya with Ksheera Saditha YastimadhuOD 8 Drops in Each Nostril TID A/F
21/10/2022Dhanwantara Vati Sukumara Ghrita Rasaushadi Yoga Nadi Kashaya Tab. Anuloma DS2 TID B/F 10 ml OD B/F (Morning) (S/L) TID A/F 100 ml OD Morning A/F 1 HS A/F
Shiropichu with Ksheerabala Taila Nasya with Ksheera saditha Yastimadhu Takradhara Sarvanga Parisheka with Dashamoola Kwatha and DhanyamlaOD 8 Drops in Each Nostril TID A/F OD
OD
22/10/2022Dhanwantara Vati Sukumara GhritaPunarnavashtaka Kashaya Rasaushadi Yoga Tab. Anuloma DS Takradhara Sarvanga Abhyanga with Ksheerbala Taila Followed by Parisheka with Dashamoola Kwatha and Dhanyamla2 TID B/F 10 ml OD B/F (Morning) 15 ml + 1 tsp jaggery TID A/F (S/L) TID A/F1 HS A/F OD OD
23/10/2022Dhanwantara Vati Sukumara Ghrita Punarnavashtaka Kashaya Rasaushadi Yoga Tab. Anuloma DS Takradhara Sarvanga Abhyanga with Ksheerbala Taila Followed by Parisheka with Dashamoola Kwatha and Dhanyamla2 TID B/F 10 ml OD B/F (Morning) 15 ml + 1 tsp jaggery TID A/F (S/L) TID A/F 1 HS A/F OD OD
24/10/2022Dhanwantara Vati Punarnavashtaka Kashaya Rasaushadi Yoga Tab Anuloma DS Takradhara Sarvanga Abhyanga with Ksheerbala Taila followed by Parisheka with Dashamoola Kwatha and Dhanyamla Anuvasana Basti with Kalyanaka Ghrita2 TID B/F 15 ml + 1 tsp jaggery TID A/F (S/L) TID A/F 1 HS A/F OD OD 40 ml OD A/F
25/10/2022Dhanwantara Vati Punarnavashtaka Kashaya Rasaushadi Yoga Tab Anuloma DS Takradhara Sarvanga Abhyanga with Ksheerbala Taila followed by Parisheka with Dashamoola Kwatha and Dhanyamla Anuvasana Basti with Kalyanaka Ghrita2 TID B/F 15 ml + 1 tsp jaggery TID A/F (S/L) TID A/F 1 HS A/F OD OD 60 ml OD A/F
26/10/2022Dhanwantara Vati Punarnavashtaka Kashaya Rasaushadi Yoga Tab Anuloma DS Takradhara Sarvanga Abhyanga with Ksheerbala Taila followed by Parisheka with Dashamoola Kwatha and Dhanyamla Anuvasana Basti with Kalyanaka Ghrita2 TID B/F15 ml + 1 tsp jaggery TID A/F
(S/L) TID A/F1 HS A/FODOD80 ml OD A/F
27/10/2022Dhanwantara Vati Punarnavashtaka KashayaRasaushadi YogaTab Anuloma DSTakradharaSarvanga Abhyanga with Ksheerbala Taila followed by Parisheka with Dashamoola Kwatha and DhanyamlaAnuvasana Basti with Kalyanaka Ghrita2 TID B/F15 ml + 1 tsp jaggery TID A/F
(S/L) TID A/F1 HS A/FODOD80 ml OD A/F
28/10/2022Dhanwantara Vati Punarnavashtaka KashayaRasaushadi YogaTab Anuloma DSTakradharaSarvanga Abhyanga with Ksheerbala Taila followed by Parisheka with Dashamoola Kwatha and DhanyamlaAnuvasana Basti with Kalyanaka Ghrita2 TID B/F15 ml + 1 tsp jaggery TID A/F
(S/L) TID A/F1 HS A/FODOD90 ml OD A/F
29/10/2022Dhanwantara Vati Punarnavashtaka KashayaRasaushadi YogaTab Anuloma DSSarvanga Abhyanga with Ksheerbala Taila followed by Bhaspa SwedaAnuvasana Basti with Kalyanaka Ghrita2 TID B/F15 ml + 1 tsp jaggery TID A/F
(S/L) TID A/F1 HS A/FOD100 ml OD A/F
30/10/2022Dhanwantara Vati Punarnavashtaka KashayaRasaushadi YogaTab Anuloma DSSarvanga abhyanga with Ksheerbala Taila followed by Bhaspa SwedaAnuvasana Basti with Kalyanaka Ghrita2 TID B/F15 ml + 1 tsp jaggery TID A/F
(S/L) TID A/F1 HS A/FOD100 ml OD A/F
31/10/2022Discharged with following medicationsDhanwantara VatiRasaushadi YogaTab. Anuloma2 TID B/F1 TID A/F1 HS A/F

Observations and Results

The condition of the patient was improved gradually along with the course of the treatment. The strength and power of both left upper and lower limb was increased to 4+/5,

also tone of the muscle were improved and deep tendon reflex were normal after the course of treatment. Gait before treatment was hemiplegic and at the time of discharge it was reduced and was able to walk without support.


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Assessment Scales

NIH Stroke Scale

AssessmentScore
BT AT
1.a. Level of consciousness00
1.b. LOC questions00
1.c. LOC commands00
2. Best gaze00
3. Visual00
4. Facial palsy10
5. Motor arm20
6. Motor leg20
7. Limb ataxia00
8. Sensory21
9. Best language00
10. Dysarthria10
11. Extinction and Inattention (formerly Neglect)00
Total:81

Muscle Power (MRC Scale for Muscle Strength)

AssessmentBTAT
RightULProx55
Dist55
LLProx55
Dist55
LeftULProx24
Dist24
LLProx45
Dist45

Deep Tendon Reflexes

AssessmentBTAT
RightleftRightleft
Biceps reflexNormal = 2+Exaggerated = 3+Normal = 2+Normal = 2+
Triceps reflexNormal = 2+Exaggerated = 3+Normal = 2+Normal = 2+
Knee reflexNormal = 2+Exaggerated = 3+Normal = 2+Normal = 2+
Ankle reflexNormal = 2+Exaggerated = 3+Normal = 2+Normal = 2+

Barthel Index

AssessmentBTAT
1.  Feeding510
2.  Bathing05
3.  Grooming05
4.  Dressing510
5.  Bowel1010
6.  Bladder1010
7.  Toilet use510
8.  Transfers1015
9.  Mobility1015
10. Stairs510
Total score (100)60100

Muscle Tone

AssessmentBTAT
Right upper limbNormotonicNormotonic
Right lower limbNormotonicNormotonic
Left upper limbHypotonicNormotonic
Left lower limbHypotonicNormotonic

Scandinavian Stroke Scale

AssessmentBTAT
Consciousness66
Eye movement44
Arm motor power46
Hand motor power46
Leg motor power46
Orientation66
Speech610
Facial palsy02
Gait612
Total score (58)4058

Discussion

Pakshaghata is described as one of the Vatavyadhi. Vata is the main Dosha in the pathology of Pakshaghata. Vitiation of Vata is caused by Dhatukshaya (depletion of Rakta-ICH). Hence, in this case Pithahara and Rakta Prasadaka treatment was first initiated with Shiropichu with Ksheerabala Taila and Nasya with Yastimadhu Ksheera.

Shiropichu: Ksheerabala Taila Shiropichu helps in pacifying the Pitha and Vata Dosha and nourishing the Indriya (motor and sensory activity). Pichu was advised for 7-8 hrs. It works through action on Tarpaka Kapha, Sadhaka Pitta and Prana Vayu. Shiropichu may be helpful in regularizing the blood supply of brain and reducing the neurological symptoms.[6]

Nasya: Yastimadhu being Pithashamaka and Medhya, Ksheera being Pithashamaka in combination which is of Sheeta Guna administered as Nasya helps in pacifying Pitha Dosha and nourishing the Indriya (motor and sensory activity). Yastimadhu has pharmacological actions like cerebroprotective, anticonvulsant and memory enhancing effects.[7]

Takradhara: Takradhara with the combination of Amalaki and Dhanyaka Choorna, with its Pithahara properties does Indriya Prasadana, produces relaxing effect, enhance the alertness and concentration abilities, improves cerebral function and anxiolytic action.[8]


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Abhyanga: Ksheerbala Taila is used for Abhyanga followed by Sarvang Parisheka with Dashamoola Kwatha and Dhanyamla. Ksheerbala Taila nourishes Dhatu and provides strength. It constitutes of Bala, cow milk, and sesame oil, which pacify the Vata and Pitta Dosha.[9]

Anuvasana Basti: Vata is seen as the main aggravating factor and Basti Chikitsa is regarded as the prime line of treatment for it. Medicated enema helps to eliminate vitiated Dosha from the body, increases the strength and spreads the potency of the drug due to its Prabhava (specific action). The potency of Basti drug acting on Dosha brings them into normalcy and provides them with nourishment. Just as the farm gets its nourishment from water supplied through channels, the whole body gets nourishment from Virya (potency) of the enema drug carried by five types of Vata through Srotas.[10] Anuvasana Basthi was given with Kalyanaka Ghrita clears Majja Dhatugata Vikara and also has nootropic[11] and neuroprotective property.[12]

Shamana Aushadhi

Dhanvantara Vati: The major ingredients are Ela, Shunti, Haritaki, Jiraka helps in Deepana, Vatanulomana.[13]

Tab. Anuloma DS: It is a combination of Swarnapatri (Senna), Ajamoda, Jiraka, Haritaki, Yastimadhu, Shunti and Saindhava Lavana helps in Anulomana Karma.[14]

Rasaushadi Yoga

Ekanga Veera Rasa explained in Rasayoga Sagara possesses Deepana, Pachana, Atiteekshana, Brimhana and Rasayana property.[15]

Maha Vata Vidvamsana Rasa explained in Rasa Tantra Sara possesses Vatahara, Balya and Rasayana properties.[16]

Vatakulantaka Rasa explained in Bhaishajya Ratnavali Possesses Deepana, Vatahara, Brimhana and Rasayana properties.[17]

Vata Gajankusha Rasa explained in Bhaishajya Ratnavali Possesses Deepana, Vatanulomaka, Balya, Rasayana, Vata Pradhana Tridosha Shamaka.[18]

Nadi Kashaya: It is a Kashaya prepared out of Atasi, Rasna, Ajamoda, Shunti, Jeeraka, Bakuchi, Musta, Triphala, Bala and Dashamoola proved to have Vatahara and Balya properties.[19]

Conclusion

This case study demonstrates the successful management of Acute CVA (hypertensive bleed in the right centrum semiovale and putamen) by Ayurveda principles. The significant improvement was assessed by National Institute of Health (NIH) Stroke Scale, Medical Research Council (MRC) Scale for Muscle Strength, Barthel Index, Scandinavian Stroke Scale. Significant recovery and improvement were seen in deep tendon reflexes, walking without support, speech, fine touch and in the quality of life within 15 Days. So, this case was believed to be value documenting.

References

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10. Sharma S, Commentator. Sidha Basti kalpa Adhyaya, chapter 5, verse 24. In: Kalpasthana. Ashtanga Samgraha of Vriddha Vagbhatta. 4th ed. Varanasi: Chaukhamba Sanskrit Series Office; 2016. p. 605.

11. Subhan F, Karim N, Gilani AH, Sewell RD. Terpenoid content of Valeriana wallichii extracts and antidepressant - like response profiles. Phytother Res. [Internet] 2010 [Cited 2019 March 26]; 24(5):686 – 91.

12. Padmaja Kalshetti, Ramesh Alluri, Prasad Thakurdesai. Antidepressant and Anti – Anxiety Effect of Ellagic Acid from Punica granatum L. Rind in Olfactory Bulbectomy Model in Rats. Int. J. Pharm. Sci. Rev. Res., 34(1), September-October 2015; Article No. 32, Pages: 197-204.

13. Nishteswar K and Vaidyanath R. Sahasrayogam; Sanskrit text with English Translation, Gutika Prakarana chapter 9, verse 54, Reprint; Varanasi; Chaukambha Sanskrit series office, 2020; p. 346.

14. Varuni B G, An Open-labeled Clinical Study to Evaluate the Safety and Efficacy of Anuloma DS in Improving Constipation, Indian Journal of Clinical Practice, Vol.34, No.2, July 2023.

15. Hariprannaji V P. Rasayogasagara; vol-1, verse 1813-5; Chaukambha Krishnadas Academy, Varanasi (India); p. 192.

16. Rasa Tantra Sara-Sidha Yoga Sangraha kharaliya Rasayana 37.

17. Das G, Mishra B, Shastri A D. Apasmara Rogadhikara verse 40-43 In:Shastri RD(editor).Bhaishajya Ratnavali Vidhyotini Hindi Vyakhya-Vimarsha-Parishista Sahita. Reprint,131-2 edition 2005. Varanasi: Chaukhambha Sanskrit Prakashan. 2005:p.

18. Das G, Mishra B, Shastri A D. Raktapitta Rogadhikara verse 102-6 In:Shastri RD(editor).Bhaishajya Ratnavali Vidhyotini Hindi Vyakhya-Vimarsha-Parishista Sahita. Reprint,131-2 edition 2005. Varanasi: Chaukhambha Sanskrit Prakashan. 2005:p.701.

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