Paralysis (Stroke)

PARALYSIS DEFINITION:
The complete loss of muscle function - this can be in a small area (localized) or widespread (generalized).

CEREBROVASCULAR ACCIDENT, OR CEREBROVASCULAR DISEASE (CVA, or STROKE)
DEFINITION:
A group of brain disorders involving loss of brain functions that occur when the blood supply to any part of the brain is interrupted.
CAUSES, INCIDENCE AND RISK FACTORS
The brain requires about 20% of the circulation of blood in the body. The primary blood supply to the brain is through 2 arteries in the neck (the carotid arteries), which then branch off within the brain to multiple arteries. Each artery supplies a specific area of the brain. Even a brief interruption to the blood flow can cause a decrease in brain function (neurologic deficit). The symptoms vary with the area of the brain affected and commonly include such problems as changes in vision, changes in speech, decreased movement or sensation in a part of the body, or changes in the level of consciousness. If the blood flow is decreased for longer than a few seconds, brain cells in the area are destroyed (infarcted), causing permanent damage to that area of the brain, or even death.
Stroke affects about 4 out of 1,000 people. It is the 3rd leading cause of death in most developed countries, including the U.S. The incidence of stroke rises dramatically with age. The risk doubles with each decade after age 35. 5% of people over the age of 65 have had at least one stroke. The disorder occurs in men more often than women.
A stroke involves the loss of the brain’s functions (neurologic deficits) caused by a loss of blood circulation to certain areas of the brain. The specific neurologic deficits may vary depending on the location, extent of damage, and cause of the disorder. A stroke may be caused by reduced blood flow (ischemia) that results in a deficient blood supply and the death of tissues in that area (infarction). Causes of ischemic strokes are blood clots that form in the brain (thrombus) and blood clots or pieces of atherosclerotic plaque or other material that travel to the brain from another location (emboli). Bleeding (hemorrhage) within the brain can also occasienally cause symptoms that mimic stroke.
The most common cause of a stroke is secondary to atherosclerosis (cerebral thrombosis). Atherosclerosis ("hardening of the arteries") is a condition in which fatty deposits occur on the inner lining of the arteries, and atherosclerotic plaque (a mass consisting of fatty deposits and blood platelets) develops. The occlusion of the artery develops slowly. Atherosclerotic plaque does not necessarily cause a stroke. There are many small connections between the various brain arteries. If the blood flow gradually decreases, these small connections will increase in size and "by-pass" the obstructed area (collateral circulation). If there is enough collateral circulation, even a totally blocked artery may not cause neurologic deficits. A second safety mechanism within the brain is that the arteries are so large that 75% of the blood vessel can be occluded and there will still be adequate blood flow to that area of the brain.
A thrombotic stroke (stroke caused by thrombosis) is most common in older people. Often there is underlying atherosclerotic heart disease or diabetes mellitus. This type of stroke may occur at any time, including when the person is at rest. The person may or may not lose consciousness.
Strokes caused by embolism (a moving blood clot) are most commonly strokes secondary to a cardiogenic embolism (clots that develop because of heart disorders that then travel to the brain). An embolism may also originate in other areas, especially where there is atherosclerotic plaque. The embolus travels through the bloodstream and becomes stuck in a small artery in the brain. This type of stroke occurs suddenly with immediate maximum neurologic deficit. It is not associated with activity levels and can occur at any time. Arrhythmias of the heart are commonly seen with this disorder and often are the cause of the embolus. Damage to the brain is often more severe than with a stroke caused by cerebral thrombosis. Consciousness may or may not be lost.
The probable outcome is worsened if blood vessels damaged by a stroke rupture and bleed (hemorrhagic stroke).

HIGH RISKS
The risks for a stroke include:
1) A history of high blood pressure (hypertension is present in about 70% of all victims of stroke)
2) Heart disease (especially with atrial fibrillation/flutter)
3) Smoking
4) Transient ischemic attack (TIA)
5) Atherosclerosis or high blood lipids
6) Diabetes
7) Migraine headaches
8) Other disorders.
9) Gout and high red blood cell count have been associated with a stroke.
Although young women generally have a fairly low risk for a stroke, use of birth control pills will increase their risk, and smoking combined with use of birth control pills makes the risk even highter.

SYMPTOMS
1) Loss of movement (paralysis) of any body area
2) Weakness
3) Decreased sensation
4) Numbness
5) Tingling or other sensation changes
6) Decreased vision
7) Language difficulties (aphasia): slurred, thick or difficult speech, inability to speak, inability to understand speech
8) Difficulty with reading or writing
9) Inability to recognize or identify sensory stimuli (agnosia) resulting in "neglect" of one side of the body
10) Loss of memory
11) Vertigo (abnormal sensation of movement)
12) Loss of coordination
13) Swallowing difficulties
14) Personality changes
15) Mood/emotion changes (such as depression or apathy)
16) Consciousness changes: sleepy, stuporous/somnolent/lethargic, comatose/unconscious
17) Urinary incontinence (lack of control over bladder)
18) Lack of control over the bowels
19) Cognitive decline: dementia, easily distracted, impaired judgment, limited attention

ADDITIONAL SYMPTOMS THAT MAY BE ASSOCIATED WITH THIS DISEASE:
1. Tongue problems
2. Seizures
3. Movement unpredictable: jerky movement, uncontrollable movement
4. Dysfunctional incontinence
5. Fatigue
6. Fainting
7. Facial paralysis: eye movements uncontrollable, drooping eye lid, drooling
8. Breathing temporarily absent
9. Behavior unusual or strange
10. Abnormal lack of sweating
NOTE: Specific changes in brain functions (neurologic deficits) depend on the location and amount of injury to the brain. The symptoms are typically on one side of the body but may be isolated to specific functions, may involve one side of the body and the opposite side of the face, or may involve the face only.

SIGNS AND TESTS
A history of the pattern of symptom development is important in the diagnosis of a stroke. Maximum neurologic deficits may be present at the beginning (onset) of the stroke. Or symptoms may progress or fluctuate for the first day or two (stroke in evolution). Once there is no further deterioration, the stroke is considered a complete stroke.
Examination may include:
1. Neurologic, motor, and sensory examination to determine the specific neurologic deficits present, because they often correspond closely to the location of the injury to the brain. An examination may show changes in vision or visual fields, changes in reflexes including abnormal reflexes or abnormal extent of "normal" reflexes, abnormal eye movements, muscle weakness, decreased sensation, and other changes.
2. A bruit (an abnormal sound heard with the stethoscope) may be heard over the carotid arteries of the neck.
3. There may be signs of atrial fibrillation.
4. Tests may be used to determine underlying disorders, the location and cause of the stroke, and to rule out other disorders that may cause the symptoms.
5. A head CT or MRI of the head may be used to rule out bleeding (hemorrhage) or other lesions and to define the location and extent of the stroke.
6. An ECG (electrocardiogram) may be used to determine the underlying heart disorders
7. An echocardiogram may be used if the cause is suspected to be cardiac embolus
8. A carotid duplex (ultrasound) may be used if the cause is suspected to be carotid artery stenosis
9. A cerebral (head) arteriography may be used if a disorder involving the blood vessels is suspected

This disease may also alter the results of the following tests:
1. Platelet aggregation test
2. Osmolality
3. LDH isoenzymes
4. LDH
5. Cytometric study
6. CSF collection
7. CPK isoenzymes
8. BERA (Brainstem Evoked Response Audiometry)

TREATMENT
A stroke is an acute and serious condition. Immediate treatment is required. Treatment varies depending on the severity of the symptoms. For virtually all strokes, there is a need for hospitalization, possibly including intensive care and life support.
There is no known cure for a stroke. The treatment is essentially rehabilitation, based on the symptoms presented. The treatment is also aimed at secondary prevention of future strokes. The recovery may occur as other areas of the brain take over functioning for the damaged areas. The goal of treatment is to prevent the spread of the stroke and to maximize the ability of the person to function.
IMMEDIATE TREATMENT
Life support and treatment of a coma are performed as appropriate to the condition of the person.
Medications are variable. Those that help one kind of stroke may increase damage in another. For example, anticoagulants may be beneficial in a stroke caused by emboli, but they may increase damage if the stroke is due to hemorrhage.
Analgesics may be needed to control severe headache.
Antihypertensive medication may be needed to control high blood pressure.
Nutrients and fluids may need to be supplemented, especially if swallowing difficulties are present. This may include intravenous nutrients and fluids, or feeding through a tube in the stomach (feeding tube or gastrostomy tube). Swallowing difficulties may be temporary or permanent.
Surgery may be appropriate in some cases. This may include surgical removal of blood or blood clots from the brain cavity, repair of the source of the bleeding, or other surgeries.
Carotid endarterectomy (removal of plaque from the carotid arteries) may be indicated for some people to prevent new strokes from occurring.
Positioning, range of motion exercises, speech therapy, occupational therapy, physical therapy, and other interventions may be advised to prevent complications and promote maximum recovery of function.
LONG-TERM TREATMENT
Recovery time and the need for long-term treatment vary depending on each case. Depression and other symptoms should be treated.
Physical therapy may benefit some persons. Activity should be encouraged within physical limitations. Speech therapy, occupational therapy, or other interventions may benefit some people.
Urinary catheterization or bladder or bowel control programs may be required to control incontinence.
Environmental safety must be considered. Some people with a stroke appear to have no awareness of their surroundings on the affected side. Others show a marked indifference or lack of judgment, which increases the need for safety precautions. Reality orientation, with repeated reinforcement of environmental and other cues, may help reduce disorientation.
Communication may require alternative forms, such as pictures, verbal cues, demonstration, or other techniques, depending on the type and extent of language deficit.
In-home care, boarding homes, adult day care, or convalescent homes may be required to; provide a safe environment, control aggressive or agitated behavior, and meet physiological needs.
Behavior modification may be helpful for some people in controlling unacceptable or dangerous behaviors. This consists of rewarding appropriate or positive behaviors and ignoring inappropriate behaviors (within the bounds of safety).
Family counseling may help in coping with the changes required for home care. Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful.
Legal advice may be appropriate. Advance directives, power of attorney, and other legal actions may make it easier to make ethical decisions regarding the care of the person with organic brain syndromes such as stroke.

EXPECTATIONS (PROGNOSIS)
Stroke is the third leading cause of death in developed countries. One-fourth of the sufferers die as a result of the stroke or its complications. One half of the victims have long-term disabilities, and one-fourth recover most or all functions.
COMPLICATIONS:
Pressure sores, permanent loss of movement or sensations of a part of the body, bone fractures, joint contractures, muscle spasticity, permanent loss of cognitive or other brain functions that are disruptive to communication, decreased social interaction, decreased ability to function or care for oneself, decreased life span, multi-infarct dementia, side effects of medications, aspiration, malnutrition and pain syndromes (reflex sympathetic dystrophy).

PREVENTION
The prevention of a stroke involves the control of risk factors. Hypertension, diabetes, heart disease, and other associated disorders should be treated appropriately. Smoking should be minimized or, preferably, stopped. A low-cholesterol and low-salt diet may be appropriate if the risk factors include atherosclerosis or hypertension.

Acupoint Injection Therapy (AIT) for Stroke:

Traditional Chinese Medicine (TCM) holds that the pathogenesis of stroke is stagnation of wind, qi and blood, which obstructs the channels and collaterals, giving rise to unsmooth circulation of qi in the Channels. Acupuncture points combined with Chinese herb and Vitamin B (injected directly into "acupoints") eliminate the obstruction to improve local circulation of qi and blood. This reducing maneuver will instantly eliminate stagnation of blood. Because certain acupuncture points located at important positions (including head, back, belly, arms and legs), a reinforcing maneuver should be adopted and performed for supplementing qi, nourishing yin, resolving the block, restoring consciousness and promoting the action of all bodily functions.

CASE DETAILS:
Case 1:
Mr. A, 65 years old, paid his first visit to AIT on Oct. 27, , with the complaint of sudden partial paralysis on the right side. He could not speak clearly, choked while he was drinking, and was unable to swallow food. These symptoms were accompanied by dizziness and dry mouth. Multiple cerebral infarction was evidenced by a CT examination. His body temperature was 36.7 C, pulse rate 76 beats/min, blood pressure 180/101mmHg, respiratory rhythm 18 /min. He was conscious, with an expression of acute disease, impaired phonation, no abnormality in the heart, lung, liver, spleen and kidney functions. Other symptoms were:
1. His mouth was deviated to the left, and the tongue to the right when extended.
2. His neck was soft
3. His bilateral soft palate was paralyzed
4. The pharyngeal reflex disappeared
5. No atrophy of the lingual muscles
6. Muscle strength of the right limb IV grade
7. Muscular tension normal
8. Tendon reflex active
9. Babinski sign positive on both sides
10. CT examination revealed multiple cerebral infarction

The diagnosis was cerebral infarction with pseudobulbar palsy due to accumulation of wind-phlegm in the channels and collaterals.
On admission, he was fed with a nasal tube, through which oral cerebral vascular dilators were given. He failed in swallowing despite the fact that the above drugs were also intravenously administered. AIT was then administered. After 5 treatments, nasal feeding was withdrawn and he could take liquid food himself. After 10 treatments, he could eat food normally with occasional choking. His speaking basically returned to normal. After 2 AIT courses ( 30 treatments / course ), his blood pressure dropped to normal (145 / 87 mmHg). In addition, his speech, mouth angle, swallowing, right limb muscular strength and brain stem reflex became normal with no recurrence during the one-year follow-up.

Case 2:
Mr. B, 50 years old. He first visited AIT with a complaint about a second recurrence of paralysis on his right side which had gone for one month. He was not able to walk so two people carried him. His other symptoms were:
1. Right arm and hand had no power
2. Blood pressure 178/ 99 mmHg
3. Could not talk clearly
AIT was administered. After 4 treatments, the patient could walk better, his BP dropped to 159 / 88 mmHg and the patient began doing exercises. One month later, the patient was able to walk by himself slowly, raise his right arm and pick up things with his right fingers. In addition, his blood pressure steadily came down until it became normal. After that, he started doing more exercise and reduced treatments to a maintenance level. 3 months later, he was able to run and go back to work normally. After this, the patient kept up once a week treatments for two months to stablize his situation. There has been no recurrence during the five-year follow-up.