Stroke is the leading cause of disability and more than half of the stroke survivors will end up severely impaired. The prevalence of stroke in India ranges from 40 to 270 per 100 000 population. Like any other surgical procedure, decompressive craniectomy is not without risk and cranioplasty also carries its own risks. Some of the complications arising out of these surgeries may require additional surgery which further increases the risk to the patient for neurological deterioration or death. The present article deals with a diagnosed case of post hemi craniectomy squeal clinically presented as left sided hemiplegia, focal seizures/myoclonic jerks and irritable mood. The Ayurvedic diagnosis of pakshaghata was made and various panchakarma procedures were implemented along with internal Ayurvedic medicines. Two assessments were taken before and after treatment on NIH-SS (National Institute of Health Stroke Scale) and SS-QOL (Stroke Specific Quality of Life Scale). There is 57.1% relief on NIH-SS and 83.5% improvement found on SS-QOL in present case. Ayurvedic panchakarma procedures and medicines were found effective in the management of post hemi craniectomy squeal. The recovery was promising and worth documenting.

Keywords:hemi craniectom, decompressive craniectomy, stroke, ayurveda, pakshaghata, focal seizures

According to WHO (world health organization) publication, ‘Gloabal health risks: Mortality and burden of disease attributable to selected major risks’, cardio-vascular disease accounts for 30% of deaths globally. Out of these, 5.7million deaths (i.e. 9.7% of all deaths) are caused by stroke. Stroke is the leading cause of disability and more than half of the stroke survivors will end up severely impaired.¹ The prevalence of stroke in India ranges from 40 to 270 per 100000 populations.² Decompressive craniectomy (DC) has been used in the management of raised intra cranial pressure (ICP) or herniation syndrome. A large portion of the skull is removed to allow swollen brain to herniate outwards in DC. Cranioplsaty is another surgical procedure follows DC in which the autologous skull or synthetic material or bio-ceramics are used to repair the skull defect caused by DC. DC is not without risk like any other surgical procedure and cranioplasty also carries its own risks. Some of the complications arising out of these surgeries may require additional surgery which further increases the risk to the patient for neurological deterioration or death.³

Here we are reporting a case of ischemic stroke, has undergone DC followed by cranioplasty and has been suffering with focal seizures, non-functioning left upper limb with irritable mood. The patient came to our care for an Ayurvedic management for his condition. Written and informed consent was obtained from the patient for the publication of the present case report.

A 57year aged old gentleman came to our care (11.07.2016), with the complaints of left sided weakness, pedal edema (left leg), myoclonic jerks / focal seizures (involving left upper and lower limb), irritability / aggressive mood, drowsiness, frequent urinary tract infections, gaze preference to the right, hypertension and dyslipidemia. This gentleman has suffered with an ischemic stroke (May 2014) and undergone right decompressive craniectomy for right middle cerebral artery (MCA) infarction (May 2014) followed by right side titanium cranioplasty (December 2014). He has made progress since then. He is left with a non functioning upper limb but able to manage this well. He mainly resides in a wheel chair, however does mobilize with a tripod / quad stick (Figure 1). He has reported recurrent urinary tract infections and experiences poor flow, terminal dribbling, penile pain and dysuria. He has developed seizures followed by surgery which comes without warning, four times a week and causes his left sided limbs to shake. He is fully awake during the seizure episodes and is confused afterwards. He also had abdominal pain, bloating / discomfort. He has been taking anti-epileptics, anti-hypertensive, thrombolytics, NSAID’s and laxatives. He has not satisfied with the western medicines and management for his condition and came to our care for Ayurvedic treatment with the hope of getting functional recovery of left upper and lower limb. Hematological, biochemical investigation reports were within normal limits (26 & 30.08.2016) (Table 1). No past history of head injury, diabetes, cardiac pathology and any major medical illness found. No positive family history of stroke, diabetes, hypertension, dyslipidemia and cardio-vascular pathology found. Patient has undergone surgery for varicose veins of right lower limb. At the time of examination patient’s vital functions were normal and patient was drowsy and responded to vocal commands. Tendon reflexes were exaggerated; muscle tone was increased in left upper and lower limb with positive babinski. Clinical examination revealed a soft, non tender abdomen with no palpable bladder. DRE (digital rectal examination) revealed a 30gm benign feeling prostate. Pitting edema was found in left lower limb. Patient used to smoke, takes alcohol and not having allergy to any drug or food item.

Figure 1 Left sided hemipegia with pitting edema at left foot.

Patient got right MCA infarction (ischemic stroke) and undergone right decompressive craniectomy followed by elective cranioplasty. CT brain (18.05.2014) revealed evidence of extensive thrombus involving right MCA and right internal carotid artery (ICA) (Table 1). Total two assessments were carried out. Baseline / initial assessment was taken on the first day of starting Ayurvedic treatment (11.07.2016) and second assessment was carried out at the time of discharge (21.03.2017). A criterion of assessment was based on the scorings of NIH-SS (National Institute of Health - Stroke Scale)⁴ and SS-QOL (Stroke Specific Quality of Life Scale).⁵ Ayurvedic diagnosis of ‘Pakshaghata (vama parshwa)’ is made and treated accordingly.

Initially line of treatment was planned to control focal seizures, myoclonic jerks, to improve mood, to reduce urinary tract infection, to reduce pedal edema and to bring stability in general condition of the patient (from 11.07.2016 to 14.09.2016). Later allopathic medicines which the patient has been consuming like, anti-epileptics, anti-hypertensive’s, thrombolytics, NSAID’s and laxatives were withdrawn and replaced by Ayurvedic internal medicines (from 24.01.2017 to 21.03.2017) (Table 2).

DC is an effective means of controlling elevated ICP and it is also life saving; while the procedure is technically straight forward, it places the patient at risk for many non-trivial complications, which can negatively impact outcome. Complications of DC are mainly of three types, hemorrhagic, infectious/inflammatory and disturbances of the cerebrospinal fluid (CSF) compartment. Complications which are associated with cranioplasty also fell under similar major types with additional complications relating to the bone flap.³

Pakshaghata is a vata vyadhi (disease caused by vata dosha) and can be correlated with  hemiplegia/stroke. Panchakarma (five major cleansing procedures) procedures like Udwartana (herbal powder massage), Vasti (medicated enema), Nasya (nasal medication)and virechana (therapeutic purgation) were found to be beneficial in the management of pakshaghata. Previous study has reported significant relief on NIH-SS and on SS-QOL in stroke patients with integrated approach (conventional modern medicine with Ayurveda and physiotherapy).^6,7 The present case report deals with the efficacy of an Ayurvedic treatment in the management of post hemi craniectomy complications.

Udwartana procedure was selected initially to reduce the pedal edema and to achieve ‘niraamavastha’. Abhayarishta was used to relieve constipation and laxatives were stopped. Neeri tablets, sheetaprabha tablets were prescribed to tackle urinary tract infection whenever required. Palnsineuron capsules were prescribed for left shoulder pain and pain at left thigh (NSAID’s were stopped). Cardocalm tablets were used to control hypertension (after stopping anti-hypertensives). Maha yogaraja guggulu, Rasa rajeshwara ras, prasaranyadi kwatha and Dhanwantaram101 avarti sofgels were prescribed for vata shamana (to pacify vata dosha) (Table 2).

Panchakarma procedures like vasti (yoga vasti and kaala vasti schedules), nasya, patra pottali pinda sweda (massage with the bolus prepared by medicinal leaves and herbal powders), sarvanga abhyanaga (full body oil massage), bashpa sweda (steam in steam chamber) and udwartana were implemented according to the requirement and condition of the patient. Takra dhara (pouring medicated butter milk over forehead) and shiro pichu (keeping cotton over the head which is dipped in medicated oil) (Figure 2) were implemented to tackle aggressiveness, sleeplessness and irritability. Patient has also received physiotherapy treatment along with panchakarma wherever feasible (Table 2).

Figure 2 Shiro pichu.

On NIH SS, good relief was noticed in left upper and lower extremity function. Baseline score (11.07.2016) on NIH-SS was 7 which was improved to 3 at the time of second assessment (21.03.2017). There was 57.1% of improvement was found on NIH-SS. On SS-QOL, maximum relief was noticed in items like, energy levels, mobility, personality, mood and upper extremity function. The baseline score on SS-QOL during initial assessment was ‘91’ (11.07.2016) which is improved to ‘167’ during second assessment (21.03.2017) (which denotes 83.5% relief). Patient was able to climb the stairs without support at the time of discharge and able to do his routine works with ease. Pedal edema got reduced and constipation relieved. Left shoulder pain and left thigh pain were diminished, range of movement were improved in left upper and lower limb with reduced stiffness. Myoclonic jerks, focal seizures got reduced (frequency of once a week) with improved mood and quality of life. The recovery was promising and worth documenting.

Udwartana is effective in reducing the pedal edema in present case. Various panchakarma procedures like vasti, nasya, patra pottali pinda sweda, bashpa sweda are seems to be beneficial in improving the functioning / mobility in present case. Shiro pichu and takra dhara are effective in the management of aggressiveness / irritable mood and sleeplessness in present case. There is 57.1% relief on NIH-SS and 83.5% improvement found on SS-QOL in present case. Ayurvedic treatment seems to be promising in the management of post hemi craniectomy squeal.

None.

Author declares there are no conflicts of interest.

None.

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