Dr Samir Parikh and Gayathri Prabhu in conversation with Dr Ennapadam S Krishnamoorthy
Category: Stroke & Cardiovascular Diseases
It was the harvest festival of South India, Pongal – the day of Thanksgiving to the Sun God – the beginning of the new Tamil month, Thai, and as the popular saying goes, “Thai brings in its wake, new hope and cheer”. The house had to be decorated with flowers and the pot of rice with all its special ingredients had to be allowed to boil over, symbolic of plenty, peace and prosperity. Families would gather to celebrate the joyous occasion together. The festivities would continue over 4 days – cattle pampered with special food, decked with bells, cowrie shells and flower garlands and rejoicing covered every aspect of agricultural life. Urbanisation had not taken away from marking this day of festivity every year, when man, beast, the sun and rain gods and the earth, all came together to celebrate the yield of man’s toil, in the form of nature’s harvest bounty. It was a celebration of life and all living things in an environment of harmony, peace and goodwill to all.
January 14th, 2015, 6 am on Pongal day and the 80 year old lady Mrs. Devi was already up, bathed and dressed in the exquisite new Kanchipuram sari gifted to her by her family for the festive occasion. The gift was also to mark a warm home-coming, after three months of grappling with the acute phase and serious sequelae of a cerebrovascular event she had miraculously conquered. The spirit of Pongal which signifies the unity of all living things on the face of the earth and the five elements, seemed to echo the principles of Yoga, acupuncture, Ayurvedic massage and other forms of traditional Medicine of the East, which follow the tenet that the body heals itself. Mrs. Devi had undergone these alternative therapies in the subacute and rehabilitation phase of the stroke.
Was Devi slowly reclaiming her original, premorbid personality, which many could have envied? She had been active and on her toes from dawn to dusk, warm in her relationship with the members of her family and friends alike, a good wife, a loving mother, a doting grandmother and a charming and gracious host. As a homemaker, home and hearth were always her priority, but it was the joy of giving of her best that made her unique! The grandchildren swore that only grandma could make such exotic ‘meen kozhumbu’ (fish curry). The daughters’- in – law sharpened their culinary skills, with Devi overseeing the making of the new recipe, or produced the most intricate rangoli designs on the floor in their courtyard, with her active participation, or just tucked the children in bed before going out for a function with their respective husbands, with the assurance that Devi was there to keep a watchful eye on them, even through their deep slumber.
Exploring the Condition
Mrs Devi, a known hypertensive on regular antihypertensive medication for 6 years, (Tab Telma 40 mg. 1-0-0 and Tab. Tazloc 20mg.-0-0-1), had an episode of seizure followed by difficulty in speaking and weakness of the right upper and lower limbs in mid October 2014, when she was admitted to a leading hospital in Chennai.
Frisium (Clobazam) and Dicorate (Divalproex Sodium) tablets were added to her drug regimen as anticonvulsant therapy. A diagnosis of left middle cerebral artery (MCA) infarct was made, confirmed by CT scan and routine stroke management initiated. All seemed well till 3rd November, when she developed acute breathlessness and emergency tracheostomy was performed, following which she was on ventilator support for a period of ten days. On inpatient treatment, she recovered, was able to talk normally, walk, and attend to her activities of daily living with partial support.
A second episode of seizure and loss of consciousness occurred, The repeat MR imaging revealed bilateral subarachnoid haemorrhage, with oedema and mass effect. There was a 50-60% block of the right internal carotid artery and a small berry aneurysm of the left middle cerebral artery. After a stormy period in ICU, she slipped into deep coma. The hospital indicated to the family that continued intensive care while required, did not guarantee a good prognosis.
At this point, she was transferred at the family’s initiative to Trimed-Neurokrish care in our partner hospital. At the time of take over, Devi was barely conscious, had the tracheostomy tube, feeding tube and catheter in place, was severely paralysed on the left side, with not even a flicker of muscle contraction and had excessive throat secretions and severe chest congestion.
The first stroke was an infarct, due to lack of blood supply to a well – defined vascular territory of the brain, the first indicator of a cerebrovascular deficit. The second stroke was the result of a bleed from the berry aneurysm into the subarachnoid space. Was there a minor re-bleed resulting in the first respiratory distress event, or was it caused purely by aspiration, and secondary chest congestion and infection? Initially, the tracheostomy tube was blocked requiring constant attention and had to be replaced by a metal tube, and this was electively removed after a few months of stabilization of the patient’s condition by the ENT surgeon.
Saccular Cerebral Aneurysms, also known as Berry Aneurysms, are intracranial aneurysms with a rounded appearance and account for the majority of intracranial aneurysms. They are also the most common cause of non-traumatic Subarachnoid Haemorrhage (SAH). SAH accounts for 3% of all strokes, and 50% are fatalSudlow and Warlow, 19971
Of those who survive, “All in all, only a small minority of all patients with SAH have a truly good outcome.”Johnston 19982
Aneurysmal Subarachnoid Haemorrhage (aSAH): The prevalence of intracranial aneurysms from various parts of India varies from 0.75 to 10.3%, with higher numbers of cases being diagnosed due to increasing age of the population and improvements in imaging techniques. Surgical clipping of aneurysm is not much resorted to in IndiaKoshy 20103
Un-ruptured aneurysms are asymptomatic making it difficult to identify the patients with un-ruptured aneurysms and prevent subarachnoid haemorrhageShingare 20114
There is familial predisposition to SAH, with 5-20% having a positive family history. Hypertension, excessive alcohol consumption and smoking are the other risk factors. Though a very severe headache of sudden onset is the typical history, as in the case of Devi, seizure may mark the onset, with loss of consciousness initially and in an obtunded state over several days. The risk of rebleeding gradually decrease between 1-6 months. MRA is a feasible tool for detecting aneurysms.
1 Sudlow CL, Warlow CP. Comparable studies of the incidence of stroke and its pathological types: results from an international collaboration. Stroke 1997; 28: 491–9.
Our Healing Approach
After the TriMed-Neurokrish comprehensive assessment, overseen by our neurologist and rehabilitation physician, supported by our chest and ENT physician, we optimised all Devi’s medication including broad spectrum antibiotics, bronchodilators and nebulisation, and the patient’s condition stabilized. We introduced moderate dose intravenous steroids to kick start brain function. We also started to deliver to her, on the bedside, an integrative therapy program. She was discharged after an ENT opinion was obtained on the tracheostomy status and the cardiologist opinion. She continued therapy at home.
The patient was readmitted 3 weeks later into the ICU with acute symptoms following a probable aspiration. Endotracheal secretion culture and sensitivity was positive for Klebsiella pneumoniae and Pseudomonas aeroginosa, and treated with the antibiotic of choice. Suction of the lung secretions and chest physiotherapy was part of the intensive treatment of this second episode of acute respiratory distress. This was followed by stepping up the alternative therapies and the patient’s recovery has been on a remarkable upward curve.
Devi had undergone Yoga, Ayurvedic massage, acupuncture, acupressure, reflexology and other forms of traditional Medicine of the East over the subacute and rehabilitation phase of the stroke. All these forms of what is globally termed Complementary and Alternative Medicine (CAM) sets its strong belief in the body healing itself, empowered by the energy centres in the body and the flow of this energy through specific channels. Any block in the energy flow causes ill health. Traditional knowledge-based interventions released these blocks, to pave the way to recovery. The TriMed-Neurokrish technique is to encourage the CAM procedures of the trained team, to complement the astute Allopathic diagnosis and management, cognitive therapies and counseling. It allows patient participation in his/her own healthcare, along with family members, who witness the palpable improvement in the patient’s health condition.
A little detail of the yoga breathing patterns and exercises that benefitted Devi and its rationale in yogic terms, will not be out of place in its elaboration here.
Yoga asanas involve movements (bending, stretching, rotating), that stimulate ‘injured’ parts of the body by increasing the blood supply, followed by phases of total relaxation, Savasana, between movement phases. In the case of Devi, our Naturopathy & Yoga doctor believed that the group of asanas that stretch and strengthen the thoracic cage muscles, to encourage full excursion of the chest wall in efficacious breathing would benefit her most as therapy and eliminate her acute respiratory episodes. Considering her age and health state, the therapist chose to put her on a simple but an intensive asana regimen which he stepped up in a graded manner. Padahasthasana involves a set of asanas with stretching and touching toes standing and in a seated position, with outstretched lower limbs. Thadasana is standing upright ‘like a mountain’, stretching backward and bending forward to touch toes on the same side. Trikonasana: standing and bending diagonally to touch toes on the opposite side; repeating stretches in the seated position – Paschimottanasanas – seated and bending forward to touch toes; also bending diagonally to touch toes on opposite feet, alternately. Rhythmic abdominal breathing accompanies these movements, with the inhalation phase accompanying the stretch and exhalation phase, the bending.
Breath is the essence of Prana – the ‘life force’. Pranayama, alternative nostril breathing in Padmasana meditative seated posture, seeks to harness this prana. By focusing the mind totally on the rhythmic breathing, the body channels are opened, allowing energy to flow freely and connect with the life force. In modern scientific terms, the role of the autonomic nervous system in this breathing pattern has been recognized, with increase in sympathetic inputs. As a result, concentration and clarity of thought develops. Prana provides the strength, power and vitality required to carry out higher level activity. Attentive awareness of the breath can gently lead the aspirant to the art of meditation.
Chinmudra is hand gesture with opposition of the thumb and index finger bilaterally and the other fingers are outstretched and facing upwards. Chinmudra in yogic meditative posture enhances Ekagrhachittam – one-pointed concentration of the mind during meditation. When the finger touches the thumb a circuit is established, which allows the energy that would normally dissipate into the environment, to travel back into the body. When the fingers and hands are placed on the knees, in the meditative seated posture, the knees are sensitized, creating another pranic circuit that maintains and redirects prana within the body. As the palms face upwards in Chinmudra, the chest and heart area are opened up as well.
Why this thumb and index finger alignment in yoga gesture, towards deep concentration? It makes us look for a link with theories regarding the evolution and attributes of thumb opposition in the early homo sapien, employment of toys which encourage a pincer grip for toddlers in the Montessori system of child education, the Neuroscience concept in modern Medicine of the homunculus, where the cortical motor (and sensory) representation of the thumb is enormous, with the index finger next in line, the maximum use of the index finger for serious Braille reading.
“It is specifically the opposition between the thumb and index finger that has made it possible to execute the extremely refined movements that have produced the whole of human culture — from architecture to writing, from music to painting, and all the technology that enriches our lives.”
With the last admission for the aspiration pneumonia, Devi had left behind the roller coaster ride through various catastrophic health events. She was alert and poised to instruct her daughters-in-law on making the rice dish to perfection and all the other delicacies for lunch, when the whole family would feast together. Till the previous year, she had led the women of her household by nonchalantly tossing in hand-measured quantities of ingredients with the flourish of the seasoned cook that she was. This year she had to be content with gesturing the instructions with her hands, with the occasional word thrown in. She knew that the cashew-nut jar was on the topmost shelf, out of reach of the children, the jaggery in the jar could not be adequate and more had to be purchased from the corner store. All these minor details of the kitchen front, her culinary skills her motivation and leadership quality returned and she was to participate in yet another family Pongal festivity.
The family members felt that the level of recovery was well beyond all expectations and recollected their shocked state and hopelessness when they saw their dear one being wheeled into the hospital in an obtunded state for the second time in a month. The TriMed-Neurokrish team gave of their best, with total co-operation from the family. But it was the Iron Lady, the patient herself, with her ekagrhachittam or single –pointed intent, focus and willpower that saw her in this recovered state, with some residual visual deficit, a more subdued, rasping voice due to left laryngeal nerve palsy, mild gait disability, but with a mind to overcome even these residual problems or accept the discomfort they posed, with cheer, to lead from the front once again, as was her nature.