Journal of Acuherb in Medicine


Stroke

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By Dr. Kenneth Wang

Stroke, sometimes called “brain attack” or in earlier times “apoplexy,” is medically known as a cerebrovascular accident (CVA). It occurs when a blood vessel is so severely blocked or damaged that part of the brain is deprived of oxygen long enough for brain tissue to die. It is one of the most common causes of death and disability worldwide. 

While some people die from their first stroke about 25 percent of people who suffer a stroke die within one month. Many people recover but are left with brain damage of different degrees, depending on what part of the brain has been affected. If it occurs in the speech area the victim may be left with no speech, or may forget a second language learned in childhood. If it affects the “motor area” controlling movement, the person may be left paralyzed on one side of his body. Stroke is more common in “first world” countries where people survive childhood infections that still kill many people in “third world” countries. Because vaccination, cleaner water systems and antibiotic use have effectively reduced deaths from infectious diseases, death from stroke occurs in older people and is often caused by lifestyle habits. 

How a stroke happens:
Strokes are commonly caused in three ways. 

1.Hemorrhage
This occurs when an artery bursts and bleeds into brain tissue. The part of the brain that should have been supplied with oxygen by that artery is deprived of oxygen and begins to die off. 

2.Thrombosis
A thrombus is a clot. If it forms in an artery supplying a part of the brain, the blood supply will be blocked and damage occurs because that part of the brain is deprived of oxygen. 

3.Embolus
This is the most common cause of stroke. It occurs when a clump of tissue, usually a blood clot, forms deposits blocking arteries somewhere else in the body (often the carotid arteries in the neck), and then breaks off and gets stuck in a small artery in the brain.(See above picture) Again, this prevents a part of the brain from getting oxygen so the cells in that part of the brain die.

Chinese people in ancient times classified the type of stroke according to where it originated. Mostly they thought stroke was caused by an invasion of exogenous pathogens (factors from outside the body that invade it and cause illness), and called this a true stroke or exogenous stroke. Stroke induced by endogenous pathogens (factors originating from inside the body causing disease) were labeled as stroke-like or called an internal stroke. Now, according to modern day Traditional Chinese Medicine (TCM) understanding and clinical practice, stroke is thought to be mostly due to internal factors.

These factors whether originating from inside or outside the body are generally attributed to “wind evils.” Wind evils are negative influences that upset the healthy balance of the body. The Chinese likened these influences to being knocked down by a natural wind because of their sudden onset and lingering, changeable nature. In ancient China, the disease was referred to as “zhongfeng,” which literally translated means “wind stroke.” According to Chinese medicine theory, stroke is not thought of as a disease affecting the brain only. It can affect either the meridians or a whole range of organs (viscera).

An early definition of a stroke can be found in the classic medical book named “Huang Di Nei Jing” (The Yellow Emperor’s Classic of Internal Medicine), written during the Han Dynasty (approx. 200 B.C). Under this book’sSuwen (The Book of Plain Questions) section, stroke is described in the following manner. “The organ’s acupoints are the doors for evil winds to flow into the body. When wind flows inside the body, it will turn into internal wind-evils. If allowed to stay inside, the internal wind evils cause stroke.” This book also described stroke related symptoms such as hemiplegia (paralysis on one side of the body), difficulty in speech, and facial distortion. (See diagrams above) Another TCM medical classic named “Synopsis of the Golden Chamber” (300A.D.), stated that stroke was mainly caused by a lack of blood in small vessels, a lack of qi flow, and the invasion of outside evil winds into the body. The symptoms of a stroke were described according to what part of the body the evil winds invaded. It stated “if a evil wind invades the collaterals (these are part of the meridian system and they run more on the surface of the body), the skin and muscles feel numb. When it invades the channels (these are also part of the meridian system and they run deep and vertical in the body), the body will become seriously ill. When it invades the hollow organs or Fu-organs which consists of the stomachsmall intestinelarge intestinegall bladderand bladder, the body will become unconscious; and when it invades the solid organs or Zang-organs, which consists of the liverheartlungsspleen and kidneys, speech difficulties and drooling can occur.” This book also divides stroke into two categories, strokes involving the meridians and strokes involving the viscera or organs. Stroke in the later medical classics like ” A Thousand Golden Prescriptions“, “Medical Secrets of an Official” and ” Prescriptions for Saving Lives“, have similar classifications. Much progress was made understanding stroke in the Jin and Yuan Dynasties, and consequently many more TCM prescriptions were developed or improved for treatment of this disease. 

Stroke is characterized by a combination of symptoms such as a sudden fall, unconsciousness accompanied by hemiplegia (paralysis on one side of the body), an appearance of facial distortion or the presence of a speech disorder. In minor cases, individuals may not suddenly collapse or lose consciousness. Instead, they may just suffer from hemiplegia (paralysis on one side of the body) and facial distortion.

 Causes

High blood pressure is a leading cause of stroke.

Other factors that make people more likely to suffer stroke are:

Smoking
Atherosclerosisa condition where fatty deposits build up in and weaken arteries. If those deposits build up in the carotid arteries, the large arteries in the neck, the chances of stroke are very much increased because the risk of embolus is so great.
Having heart disease, especially atrial fibrillation (a condition where the upper chamber of the heart, the atrium, develops an irregular beat). This irregular beat makes the blood flow more slowly so that clots form on the walls of the atrium. Pieces of these clots break off and travel to the brain where they block blood vessels, causing strokes.
Obesity
Being male
Taking oral contraceptive pills, which make the blood more likely to form clots.
Having blood disorders interfering with normal clotting.
Having high blood fat and/or blood cholesterol levels.
Diabetes

 In TCM theory, stroke is not just considered an illness of the brain. It affects the meridians, other organs and blood vessels as well. It is thought to be caused by internal and external influences that induce a build up of qi and blood and create a high pressure state, which ultimately leads to a stroke. This is similar to western medicine’s understanding of high blood pressure being a risk factor for developing a stroke.

The mechanisms by which a stroke occurs and causes bodily damage are complicated. At least four external factors and six internal factors have been identified that contribute to this process. The external risk factors that contribute to the development of a stroke include the hypo- functioning or under functioning of the liver and kidney, improper diet and body overstrain, emotional disturbance, and aging and weak body constitution. These lead to further problems inside the body that upset its natural healthy balance. The six internal influences that contribute to a stroke are deficiency states such as yin deficiency and qi; deficiency an excess of fire (sometimes referred to as excessive heat) such as liver-fire and heart-fire; wind evils such as endogenous wind originating from inside the body and exogenous wind originating from outside the body; an accumulation of phlegm; stagnant qi flow and blood stasis. These six factors will interact with each other under certain conditions to bring forth diseases such as a stroke. The TCM mechanisms by which a stroke occurs are further detailed below.

How the under- functioning or hypo- function of the liver and kidney cause a stroke 

A yin deficiency occurring from old age, hypo-function (under-function) of both the liver and kidney, or an excess of sexual activities can all lead to a gradual exhaustion of germ cells and blood. Germ cells are the sperm and egg cells. Germ cells and blood come from the same source in TCM. When germ cells decrease with age, production of blood declines. This leads to relative yang excess in the body, and causes wind evil to build up inside. Stroke will finally develop if the wind evils are not removed from the body. 

When the kidney, which belongs to water of the five elements, fails to nourish the liver- a wood element – a liver-yang excess is produced that transforms into an internal wind evil. The wind evil is responsible for causing the stroke. Alternatively, stroke may be also caused by an insufficiency of liver-yin. This occurs when heat is produced due to the dryness of the blood. The heat makes the wind evil flow upwards in the body which affects the meridians and obstructs orifices (openings of the body). This in turn causes qi and blood flow to become stagnant which can cause a stroke. 

How excess fire or heat causes a strokeThe kidney belongs to the water of the five elements. When kidney yin is exhausted, it cannot restrict a build up of fire or heat in the body caused by mental stress, emotional disturbances or an extreme excess of heart-fire. Excess heat causes depression and confusion, and induces too much qi and blood to ascend to the brain, which leads to a stroke. 

Accumulation of phlegm and dampness 
Over consumption of food and drink leads to spleen malfunction. In TCM, the spleen is responsible for transforming food and drink into qi, and transporting it to the lungs where it can be distributed throughout the body to nourish it. When it malfunctions, an accumulation of dampness develops which leads to a build up of phlegm. When this phlegm cannot be removed, it transforms into heat and then an evil wind; all of which exert negative influences on the body and cause illness. The build up of phlegm, heat and wind all disturb the meridians and brain, which can lead to a stroke.

Alternatively, phlegm can accumulate when there is a liver-yang excess. It is produced when wind evils builds up in the liver and a person overworks or is unable to sleep at night. One of the liver’s main functions is to support the flow of qi throughout the body, so a build up of wind evils accompanied by phlegm disturbs the meridians and causes the circulation of qi to stop. This results in unconsciousness, which is a serious symptom of a stroke. 

How old age, body weakness and qi deficiency allow evil influences to invade the body and cause stroke 

When a person experiences old age, a qi deficiency or has excessive thinking and fatigue, qi flow and blood circulation are damaged especially in the small collaterals of the meridians. Pathogens (any substance that causes an illness) take this opportunity to invade the body, which leads to further stagnation of qi and blood flow. This lack of normal qi and blood movement within the body causes a loss of nourishment to the tendons and muscles, which ultimately can lead to numbness of skin and muscles often seen with stroke. 

A weak body constitution can cause a chronic accumulation of phlegm-dampness and allow exogenous pathogens (any substance originating from outside the body that causes an illness) like wind to invade the body. These wind and phlegm evils block the meridians and orifices (any body opening like the mouth) and lead to stroke symptoms such as hemiplegia (paralysis on one side of the body). 

Symptoms

The symptoms experienced by someone having a stroke depend on which part of the brain is being deprived of oxygen. Sometimes people get early warning signals that they may soon suffer a stroke when they suffer “mini-strokes” otherwise known as “transient ischemic attacks (TIA’s).” People who suffer from mini-strokes have all the symptoms of stroke, but recover completely within a few hours or days. If a clot is slowly forming or a small hemorrhage has developed, early signs may give enough warning for effective medical treatment to be started. These signs should be taken seriously and qualified medical help should be immediately sought. 

The most common warning signs of a stroke are:

Weakness down one side of the body. Depending on how much of the brain is affected, this can range from “clumsiness,” where weakness makes it hard to lift the arm or leg and to hold or carry things, to complete paralysis down one side of the body. If this weakness occurs as part of a transient ischemic attack (TIA) or “mini stroke”, the sufferer often thinks they are just getting old, are a bit tired or perhaps slept in the wrong position.
A numbness/ loss of feeling in a part of the body.
Sudden inability to tell hot from cold.
A sudden problem with vision-blurred vision, double vision or loss of part of the visual field (part of the picture just disappears).
Dizziness, nausea, or feeling unsteady when standing or walking.
Difficulty walking and sudden `clumsiness’: leaning to one side or falling to one side and bumping into objects when walking.
Sudden problems remembering words or actually speaking. Speech may (understood from last sentence) become slurred.
Sudden problems understanding what people are saying.
Dribbling
Confusion
Episodes of loss of consciousness.
Difficulty swallowing


Less common symptoms include sudden, very severe headaches, described by neurologists as an intensely painful headache, which comes on ‘like a thunderclap’. This symptom, when it occurs, is most often felt when the stroke is being caused by hemorrhage.

 

Because a stroke often sees a sudden onset and rapid change in clinical symptoms, the symptoms’ degree of seriousness can differ greatly. In TCM, stroke symptoms are differentiated according to what area the stroke affects. Strokes affecting themeridians mainly impair superficial parts of the body. Individuals, who suffer from this kind of stroke, usually have symptoms that are not too serious and their prognosis is favorable. On the other hand, strokes involving the internal organs (viscera) deeply impair normal body functioning. These individuals usually experience serious and severe symptoms and have a less favorable outcome.

Strokes Involving the Meridians


Meridian System

Meridians are pathways in which the qi and blood circulate and through which the organs and limbs are connected, allowing the upper-lower and interior-exterior portions of the body to communicate.

Channels run in straight fixed courses

Collaterals run crisscross in the body

Stroke involving the meridians is considered to be minor. Symptoms include numbness of the muscles, skin and limbs, difficulty in walking, an appearance of a crooked mouth, difficulty speaking and hemiplegia (paralysis on one side of the body).

If the individuals suffering from this type of stroke have a lack or stagnation of qi andblood flow in the small collaterals of the meridian system, other symptoms may be present such as an aversion to cold temperatures, fever, muscular stiffness, and joint soreness. On physical exam, there may be a thin white film covering the tongue and the presence of a floating and rapid pulse.

If this type of stroke is caused by either a liver-yin or kidney-yin deficiency, wind and phlegm evils that result from these conditions will flow upwards in the body and cause symptoms of dizziness, blurred vision, headache, tinnitus (ringing in the ears), irritable sleeping, and deep yellow-colored urine. On physical exam there may be the appearance of a red tongue with a stringy, thready and rapid pulse. 

Strokes Involving the Viscera (Organs)

 

A serious stroke is usually associated with symptoms of a sudden collapse or loss of consciousness and usually involves the muscles, limbs or joints. It can be differentiated into stroke bi-syndrome and collapse syndrome. 

1. Stroke of Bi-syndrome
This is due to an accumulation of wind-phlegm evils inside the body, leading to an obstruction of the orifices (openings to the body such as the mouth). The general clinical manifestations are sudden coma, unconsciousness, trismus (persistent contraction of the masseter muscle which helps close the jaw and chew food), clenching of fists, constipation and no urination. 

Additional symptoms such as fever, flushed face, irritability, rough breathing sounds, and halitosis (bad breath) belong to the yang bi-syndrome of stroke. On physical examination, these individuals may have a red tongue with a yellowish and greasy covering, and a stringy and rapid pulse. 

Symptoms like sleepiness, snoring, pale facial appearance, purple lips, and cold limbs belong to the yin bi-syndrome of stroke. On physical examination, there may be a white and greasy tongue covering and a deep, moderate and rolling pulse.

2. Stroke Collapse-syndrome
This condition occurs when there is a dissociation of yin and yang in the body, meaning these two forces are unable to work together and create balance to maintain a healthy state. It is a life threatening condition that can be caused by a severe and prolonged deficiency of vital qi. The main symptoms are a sudden collapse, unconsciousness, weak and superficial breathing, cold limbs, and a loss of control of urination and defecation (ability to stool). The eyes appear shut and the mouth is open. 

When symptoms such as the appearance of a red face, profuse greasy sweating, cold limbs, faintness and the presence of a thready pulse start to diminish, it indicates the exhaustion of true-yang and that a person is dying.

Stroke Sequelae
After obtaining emergency treatment for a stroke, many individuals regain consciousness, resume eating and drinking, and regain control of normal urination and defecation (stooling). However, some symptoms may not return to normal and remain as stroke sequelae. Symptoms such as hemiplegia (paralysis on one side of the body), difficulty in speech, an appearance of a crooked mouth, puffy and weak limbs, stiffness, limb contraction and spasm, or muscle wasting (atrophy) can be present long after the stroke occurs and may not be able to be reversed back to normal functioning. For these individuals, rehabilitation such as physical, speech and occupational therapy are used by western doctors to help regain some amount if not all of the lost body functions. TCM practitioners can also assist in this process by using techniques such as Chinese medicine, acupuncture, acupressure, massage, moxibustion and tai chi exercises to help strengthen the muscles, relieve lingering pain and restore the normal flow of qi throughout the body. 

Differentiating a Stroke from Epilepsy and Syncope (Fainting)
When there is a loss of consciousness or the presence of a coma, it is important to differentiate whether the cause is from a stroke, syncope (fainting), or epilepsy since the treatment for each of these conditions will be different. 

Stroke: 
When a person experiences a major stroke, there are usually other accompanying symptoms such as facial distortion, the presence of a crooked mouth or paralysis down one side of the body. After the stroke has occurred and a person regains consciousness, these symptoms usually remain and may not get better over time without other medical interventions. 

Syncope: 
This condition is a temporary sudden loss of consciousness caused by a lack of blood flow to the brain. This condition usually lasts for a short amount of time, and the person may have a pale complexion and cold limbs while unconscious. Stroke symptoms such as paralysis on one side of the body and facial distortion are not present. Individuals generally return to normal functioning once consciousness is regained. 

Epilepsy: 
Epilepsy is a chronic disease where the brain cells do not function properly this causing seizures. Typically, an epileptic seizure is characterized by an altered state of consciousness and may involve convulsions of one part or the entire body. Other symptoms that can occur with a seizure include drooling, foaming at the mouth, making abnormal sounds and having abnormal eye movements. An epileptic seizure generally lasts only for a short period. When individuals regain their normal conscious state, the symptoms experienced during the seizure are gone. They may have a headache and feel extremely tired, but otherwise have normal functioning. 

Diagnosis

Diagnosis in TCM is based on four examination techniques. The first is “questioning.” The TCM practitioner will want to know what the individual’s current complaints are, and will need their medical history and family health history. The second technique is “observation.” Physical features of the body such as the face, tongue, hair, nails, sputum (mucus that is coughed up), and examining the area of pain all offer clues as to what the problem may be. Observation of the tongue is particularly useful as a gage to assess illness. The third technique is “hearing and smelling.” Smelling the sputum and breath and listening to the sounds coming from the chest offer additional clues. The last technique used in examination is “touching.” Feeling the pulse is a cornerstone of TCM diagnosis and gives the TCM practitioner a lot of information about the body’s imbalance. 

With stroke, the TCM practitioner will want to diagnose whether it involves the meridians or the viscera (organs) in order to make appropriate treatment decisions. 

During the acute stage of a stroke involving the meridians, the TCM practitioner will assess the individual for symptoms of:

Distortion of mouth and tongue
Numbness
Difficulty in speech
Hemiplegia
(paralysis on one side of the body)

During an acute stage of a stroke involving the viscera, the TCM practitioner will assess the individual for symptoms of:

Hemiplegia
(paralysis on one side of the body)
Distortion of mouth and tongue
Paraesthesia of one side of body
Difficulty in speech
Unconsciousness
Problems excreting urine or stool

Note: If a TCM practitioner suspects there might be a serious problem that Chinese medicine alone cannot treat, he or she will normally recommend the individual see a western doctor for further follow up. In the case of a stroke where an individual is experiencing any of the above symptoms, it should be taken very seriously and the appropriate medical care should be sought out preferably in an emergency setting. 

If the stroke symptoms are stable and have remained longer than half a year, they are considered to be sequelae symptoms.Damage has already been done to the body that usually cannot be reversed back to its original state of functioning. TCM practitioners in these cases will try to help these individuals gain back as much functioning as they can. 

Treatment

Generally, for the acute phases of stroke affecting the meridians or organs, herbal decoctions or remedies are mainly be used for treatment. The use of acupuncture and moxibustion may also be used as additional therapy. During the recovery phase, stroke sequelae symptoms will be principally treated with acupuncture,(click here to see moxibustion techniques) and accompanied by some Chinese medicine. It is always best to seek the advice of a qualified Chinese medicine practitioner before undergoing such treatment, so they can form a correct diagnosis and monitor an individual’s response to therapy. The following are some examples of prescriptions and acupuncture points that can be useful for treating stroke. 

Strokes Involving the Meridians

Therapeutic aim: Expel wind evils, eliminate phlegm, enrich the blood and remove obstruction in the meridian channels.

Prescriptions for strokes involving the meridians 

Acupuncture and Moxibustion: 
Mainly acupuncture or moxibustion is applied along the Arm-Yangming and Leg-Yangming meridians. Acupuncture with purgation techniques are used. 

Acupoints for hemiplegia(paralysis on one side of the body):
Jian Yu, Qu Chi, Shou San Li, Wai Guan, He Gu, Huan Tiao, Zu San Li, Yang Ling Quan, Feng Long, Jie Xi, Kun Lun, Tai Chong. 

Additional acupoints for facial distortion such as a crooked mouth: 
Di Cang, Jia Che, Qian Zheng, Feng Chi 

Additional acupoints for dizziness and blurred vision: 
Bai Hui, Feng Chi, Feng Fu, He Gu 

Additional acupoints for difficulty with speech:
Lian Quan, Ya Men, Jin Jin, Yu Ye, Tong Li 

Additional acupoints for contracted fingers: 
Ba Xie, Hou Xi, San Jian, Da Ling.

Additional acupoints for numbness foot toes:
Tai Chong, Tai Xi, San Yin Jiao, Ba Feng 

Additional acupoints for tinnitus (ringing of the ears) and irritable sleeping: 
Shen Yu, Guan Yuan, Tai Xi, San Yin Jiao

 
Strokes Involving the Viscera (Organs)
   
1. Stroke of Bi-syndrome
Therapeutic aim: Restore consciousness, eliminate phlegm, suppress the hyperactive liver and dispel the wind evils. 

(a). Treatment for yang Bi-syndrome of strokes

Therapeutic principle: clear liver-yang excess by eliminating wind-evils, extinguish the fire (or expel the evil heat influence), expel phlegm and restore consciousness. 

Prescriptions for yang Bi-syndrome of strokes 

Acupuncture and moxibustion: 
Mainly the acupuncturist can apply acupressure, acupuncture or moxibustion to the twelve Well-points. (On each of the twelve meridians, there is one special point known as the well point, which makes up the twelve well points.) When using acupuncture it is best to prick with a three-edged needle to cause bleeding. 

For unconscious persons: 
Shi Xuan, Ren Zhong, twelve Well-point, He Gu, Lao Gong, Feng Long, Tai Chong, Xing Jian. 

Additional acupoints for facial clenching:
Jia Che, xia Guan, He Gu 

Additional acupoints for abundant expectoration: 
Tian Tu, Feng Long, Yin Ling Quan, San Yin Jiao 

(b). Treatment for yin Bi-syndrome of stroke

Therapeutic principle: restore consciousness by warming up the body, remove phlegm and arrest wind-evils. 

Prescriptions for yin Bi-syndrome of strokes 

Acupuncture and moxibustion: 
It is best to use a filiform needle with mild reinforcing and attenuating acupuncture techniques.Use the same acupoints as for the yang Bi-syndrome of stroke, plus Zu San Li and San Yin Jiao. 

2. Collapse Syndrome of Stroke

Therapeutic principle: Restore vital energy (qi) from collapsing and replenish the depleted yang. 

Prescriptions for Collapse Syndrome of Stroke 

Acupuncture and moxibustion: 
Acupuncture is applied to the large collaterals of the Ren meridian, also known as the “Conception Vessel Meridian“. A big moxa roll should be used with moxibustion along these collaterals. 

Acupoints: Guan Yuan (monkshood moxibustion), Shen Que (Salt interposed moxibustion). 

Stroke Sequelae
   
1. Hemiplegia

Therapeutic principle: Benefit qi by activating blood circulation and promote the flow of qi and blood in the meridians.

Prescriptions for Stroke Sequelae

Acupuncture and moxibustion: 
The same acupoints along the Yangmingmeridians that used for Stroke Involving the Meridians are suggested for hemiplegia (paralysis on one side of the body). 

Additional acupoints for individuals with qi deficiency: Dan Zhong, Zu San Li.

Additional acupoints for individuals with yang hyperactivity: Fen Chi, He Gu and Tai Chong.

Additional acupoints for individuals with yin deficiency: San Yin Jiao, Zhao Hai and Tai Xi. 

2. Difficulty with speech

Therapeutic principle: Eliminate phlegm for resuscitation.

Prescription: Jieyu Decoction (See the treatment of Stroke Involving the Meridians) 

Acupuncture and moxibustion: Use Lian Quan (triple puncture technique), Tong Li and Feng Long acupoints. 

3. Facial Distortion such as Crooked Mouth

Therapeutic principle: Break up the evil wind and make the crooked mouth return normal.

Prescription: Qianzheng Powder (See the treatment of Stroke Involving the Meridians) 

Acupuncture and moxibustion: Use Di Cang, Xia Guan, Jia Che, Feng Chi and He Gu acupoints. 

4. Other Therapies

Scalp acupuncture: Select the part of the scalp that is opposite of the paralyzed part of the body. Use the acupuncture zones that correspond to the type of stroke injury i.e motion zone, zone for motion sensation of feet, and speech zone for the patients unable to speak.

Hydro-acupuncture therapy: Danshen injection, Chinese angelica (dang gui) injection, Safflower (hong hua) injection, Cerebrolysin injection, Citicoline (cytidine diphoshate Choline) injection and other injections of traditional Chinese medicines or Western medicines can be injected into the acupoints of Shou San Li and Zu San Li on the paralyzed part of the body.

Massage therapy: Relevant parts of the body are selected to have massage therapy in accordance with clinical symptoms.

 

 

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