STROKE AND HEMIPLEGIA (CEREBRAL APOPLEXY, CEREBROVASCULAR ACCIDENT, CVA)

WESTERN MEDICAL KNOWLEDGE: Cerebral apoplexy, cerebrovascular accident (CVA) is caused by the destruction of brain substance resulting from intracerebral hemorrhage, thrombosis, embolism, or vascular insufficiency. CVAs, the most common brain disease, occurs equally in males and females of any age. Cerebral hemorrhage is most common after 50 and cerebral thrombosis after 60. The incidence of cerebral embolism is more evenly distributed from ages 20 to 70, but is greatest after 40. 

The pathology is that intracerebral hemorrhage destroys the parenchyma; cerebral thrombosis or embolism causes necrosis of the parenchyma (infarction, encephalomalcia) in the area supplied by the occluded vessel. If the embolus is septic and infection spreads beyond the vessel wall, encephalitis, brain abscess, or meningitis may result.

Premonitory symptoms are seldom present, includes dizziness, vertigo, nausea and vomiting, and transient paresthesia or weakness of one side of the body. Immediately after the onset, general symptoms of cerebral dysfunction are headache, nausea and vomiting, convulsions, and coma. 

Specific symptoms are determined by the site of the lesion. Cerebral hemorrhage is most common in the region of the thalamus and internal capsule, and is usually accompanied by severe hemiplegia, hemianesthesia, speech disturbance, and sometimes hemianopsia. Since the middle cerebral artery or its branches are frequently the site of thrombosis or embolism, common symptoms are hemiplegia (affecting the arm more than the leg) and cortical sensory loss in the affected limbs. Various disturbances (e.g., aphasia and apraxia) may follow damage to the dominant hemisphere. 

Signs of cerebrovascular lesions may develop suddenly and reach maximum intensity within a few minutes. Signs progressing for several hours indicate spreading hemorrhage, propagation of thrombosis to another tributary, or edema secondary to hemonilage or brain softening. 

The patient may be in deep coma and hemiplegia can be shown only by the failure to withdraw an arm or leg from vigorous stimulation. In the conscious patient, the extent of the cerebral defect can be ascertained by neurologic examination.

SYMPTOMS AND SIGNS: In TCM, wind stroke has two types according to the degree of severity: 

  1. The severe type or what is called the zang-fu organs being attacked: symptoms are further divided into two syndromes:
    1. Tense type: sudden collapse, coma, staring eyes, fists and jaws clenched, redness of face and ears, gurgling with sputum, coarse breathing, retention of urine and constipation, wiry and rolling forceful pulse.
    2. Flaccid type: Coma, hands relaxed and mouth opened, eyes closed, pale face, profuse drops of sweat over head and face, snoring. There may be incontinence of feces and urine, cold limbs and feeble pulse. 
  2. The mild type, or channels and collaterals being attacked: Symptoms and signs are mostly those of the sequelae of the severe type, which involve the channels and collaterals. There are also primary cases without affliction of zang-fu organs. Symptoms show hemiplegia, or hemianesthesia, speech disturbance, or aphasia, or deviation of mouth due to motor or sensory impairment.

ETIOLOGY AND PATHOLOGY: The fundamental factors are the deficiency of Qi, blood, and the imbalance of Yin-Yang in the major organs, such as heart, liver, and kidneys. Other factors are due to the prolonged strong unstable emotions; or excessive food and alcoholic drinks; excessive sexual activities; or some other exogenous factors, such as wind, cold or cold factors. Those combined factors cause the deficiency or malnourishment of channels and collaterals; or deficient excessive Yang combined with phlegm and fire attacking upward due to the yin deficiency of liver and kidney. All these changes create an excessive state in the upper body and a deficient state in the lower body; furthering the disconnections of Yin and Yang. 

Generally speaking, the pathological factors can be categorized as the following: deficiency (Yin and Qi), fire (liver and heart fire), wind (of liver, and exogenous wind), phlegm (wind-phlegm, damp-phlegm), Qi (rebellious Qi), blood (stagnant blood). The fundamental factor is the deficiency of liver and kidney. 

DIFFERENTIATIONS: 

1. Wind Attacks Channels and Collaterals:

(1). Wind Attacking due to the Deficiency of Channels and Collaterals: 

Indications: Numbnessoffourlimbsorskin, or sudden deviation of mouth and eyes, speech difficulty, loss of control of saliva, or hemiplegia, or accompanied with fever, aversion to cold, or spasm of four extremities, sore and painful joints, white and thin coating, floating and wiry, or thready and wiry pulse. 

Treatment & Formulas: Dispel wind and promote the circulations of channels and collaterals, Tonify the blood and harmonize the tension of channels. 

Products:

    • Xiao Shu Ming Tang (Ma-huang and Paeonia Combination, Item No. 2032):This is a very effective formula to dispel wind, harmonize the Ying Qi (the nutritive Qi) and Wei Qi (the defensive Qi); so it is often used for stroke showing the deviations eyes, mouth, facial paralysis, etc. 
    • Shu Ming Tang ( Ma-huang and Ginseng Combination, Item No. 2273): This treats hemiplegia, aphasia, headache, hypertension, cerebromalacia by dispelling wind, dear heat and tonifying the Qi so as to promote the circulation of Qi and blood. 
    • San Bi Tang (Tuhuo and Gentian Combination, Item No. 2022): This is very good at dispelling wind and eliminating the stagnant Qi and blood. It also has the tonic functions for Qi and blood. 
    • Wu Yao Shun Qi San (Lindera Formula, Item No. 2164): It treats the stroke of cerebral strophy, hemiplegia, paralysis, painful arms and shoulders by dispelling wind, regulating the Qi and blood circulations. 

(2). Wind Attacking due to the Yin Deficiency of Liver and Kidney: 

Indications: Frequent dizziness, headache, blurry vision, tinnitus, sore and weak sensation of lumbar regions and knees; then sudden deviations of mouth and eyes, stiff tongue and difficult speech, hemiplegia, red tongue, yellow coating, wiry and thready or wiry and rolling pulse. 

Treatment & Formulas: Tonify the liver and kidney Yin, harmonize and sedate the excessive liver Qi and dispel wind. The following herbs may be used individually or combined together. 

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2. Wind Attacks the Zang-fu Organs: Both tense and flaccid types belong to the severe and emergency type. Western medicine and modem facilities, or acupuncture and moxibustions are strongly advised and recommended.

3. Sequelae of Wind Stroke:

(1). Hemiplegia due to the Qi Deficiency and Blood Stagnation: 

 

Indications: Hemiplegia, weakness of the four limbs, dull and light yellowish complexion, or numb sensation of four limbs, pale or purple tongue, white coating, thready and uneven or weak pulse. 

Treatment & Formulas: Tonify the Qi and blood, promote the circulations. 

Products:

    • Ba Xian Tang (Tang-kuei and Gentian Combination, Item No. 2009) 

(2). Hemiplegia due to Excessive Liver Yang caused by the deficiency of liver and Kidney Yin:

Use same treatment and formulas like Wind Attacking due to the Yin Deficiency of Liver and Kidney. 

(3). Aphasia due to the Obstruction of Wind-phlegm:

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(4). Aphasia due to Kidney Essence Deficiency: 

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(5). Aphasia due to Excessive Liver Yang: 

Products:

    • Go Teng San (Gambir Formula, Item No. 2238) Yi Gan San (Bupleurum Formula, Item No. 2105) 

(6). Deviation of Eyes and Mouth: 

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