Stroke is a condition characterized by sudden loss of unconsciousness, hemiplegia, numbness, wry mouth and tongue, and dysphasia or aphasia. Depending on the extent of injury to the brain, or meridians, it may be classified into two kinds: that involving the meridians and that involving the viscera.
Etiology and Pathology
Stroke develops in a patient when chronic dysfunction of the visceral organs leads to Qi deficiency and blood insufficiency. In this state, a number of processes can result in disordered movement of Qi and blood and give rise to endogenous Wind, Fire, Phlegm and blood stasis, thereby causing blockage of or extravasation of blood from the cerebral vessels. These processes include the following: excessive fatigue injuring the interior; melancholic brooding or excessive rage; dietary overindulgence or overtaxing physical activity leading to blood stasis and blockage; internal accumulation of Phlegm and Heat; and Yang transforming into Wind. In all these cases, cerebral vessel blockage or extravasation of blood can lead to coma and partial or total paralysis.
Cumulative Deficiency of Genuine Qi. Senescence may reduce Yang-Qi to as low as half of its normal level. Chronic illness with a weak constitution also results in deficiency of both Qi and blood. Regardless of its cause, deficient Qi loses its motive force for blood circulation, so that blood becomes static and forms clots that block the cerebral vessels. In Yin deficiency Yang become hyperactive so that endogenous Wind stirs. This in turn causes Qi and blood to move abnormally, carrying Phlegm and blood clots to attack the orifices and cause a stroke.
Intemperate Diet. Overindulgence in alcohol or fatty and sweet foods or obesity with impairment of Qi actions may impair spleen functions. Spleen dysfunction allows endogenous Dampness and Phlegm to form and accumulate. Gelling of Phlegm transforms into Heat and induces the stirring of liver-Wind. Erratic Wind in turn attacks upward and disturbs the channels and meridians, causing blockage of the orifices and inducing a stroke.
Injury by Passions. Unregulated passions can lead to stagnation of liver-Qi and blood stasis in the cerebral vessels. Strong rage can injure the liver and cause sudden hyperactivity of liver-Yang and blazing of Heart-Fire. Wind and Fire interact and readily cause Qi and blood to move erratically. If this erratic movement of Qi and blood disturbs the brain, a stroke may result.
Physical Exhaustion. This leads to impaired regulation of Yang-Qi, which may then rise upward and cause Wind to stir. Phlegm and static blood move upward, carried by ascending Qi and Fire, and disturb the upper orifices. This may also cause a stroke.
Exogenous Pathogen. Deficiency of genuine Qi makes the patient highly susceptible to attack by exogenous pathogenic evils. In this state, the exogenous pathogen may induce the stirring of Phlegm and Dampness or stagnation of Qi and blood by direct attack on the meridians. In either case, blockage of cerebral vessels may ensue and lead to a stroke.
The location of a stroke is principally the brain, but the heart, liver, spleen and kidney are also affected. Broadly speaking, the pathological mechanism of stroke falls within the following six categories: deficiency (Yin or Qi), Fire (liver or heart), Wind (liver or exogenous), Phlegm (with Wind or Fire), Qi (abnormal movement) and blood (stasis). Any of them can interact and influence any other.
Clinical Manifestation
The principal and characteristic features of stroke are loss of consciousness, hemiplegia, numbness, dysphasia or aphasia, and wry mouth and tongue. In addition, there may be dizziness, headache, vomiting, agitation, convulsion, much sputum, hiccup and incontinence of both urine and feces. The pupils may be dilated or constricted. The tongue may be stiff, wry or curled. It may be cyanotic, red or crimson, and may be speckled with petechiae. The tongue coating may be thin and white, white and greasy, yellow or yellow and greasy. The pulse is mostly taut, but may be slippery and threadlike, hesitant or intermittent. The stroke may be preceded by an aura, usually dizziness, headache, tinnitus, speech difficulty or numbness in the limbs.
Loss of Consciousness. In mild cases, there may be mental confusion or somnolence. In severe cases, there is loss of consciousness or coma. The patient may fall into coma from the outset, or may be mentally clear at first but gradually fall into coma, with delirium and agitation along the way.
Paralysis. This may be hemiplegia or paralysis in only one limb. In mild cases, the affected part is merely weak or poorly controlled. In severe cases, it is complete paralysis, often with anesthesia. During the acutes phase, the affected limbs are usually flaccid but a small portion of patients may have clonic or tonic tetany. In later stages, the affected limbs may have stiffness or contracture, especially in the joints of the fingers.
Mouth and Tongue. These may be wry, with deviation toward the side of hemiplegia. This is often accompanied by excessive salivation.
Speech. In mild cases, speech may be slow or slurred, with a sensation of stiffness in the tongue. In severe cases, there is aphasia.
Key Points of Analysis and Differential Diagnosis
Diagnosis. Stroke may be diagnosed if there are two or more of the following groups of findings. (1) Principal symptoms: mental confusion, loss of consciousness or coma; hemiplegia, with wry mouth and tongue; dysphasia or aphasia; or numbness in the affected parts. (2) Abrupt onset often associated with sudden changes in weather; excessive physical fatigue or exhaustion; or over-stimulation by passions or other emotional stress. (3) Preceding symptoms of dizziness, headache, numbness or weakness in the limbs. (4) Patient’s age is over 40.
Deficiency versus Strength. Stroke is a condition wherein the root is deficiency and the appearance is the strength of symptoms.
The acute phase is mainly a condition of strong symptoms. In a patient with chronic dizziness and headache, sudden appearance of hemiplegia, especially if accompanied by loss of consciousness, tetany or convulsion, the condition is due to the stirring of endogenous Wind. If the prominent symptoms are expectoration of much sputum, respiration with gurgling in the throat, a disturbed mental state and a white and greasy tongue coating, it is due to large accumulation of turbid Phlegm. If the prominent symptoms are a dry mouth with bitter taste, restless agitation, scant dark urine, constipation and feverishness in the neck and back, it is due to exogenous Heat. If the limbs are flaccid and the tongue cyanotic, it is due to deficiency of Yang-Qi and much stasis of blood.
The convalescent phase is mainly a condition of deficiency. If paralysis of the limbs is accompanied by edema of the hands and feet, shortness of breath, spontaneous sweating and copious salivation, the condition is mostly due to Qi deficiency. If there is cold-aversion and the limbs are cold, it is mostly due to Yang deficiency. If the prominent symptoms are restlessness with insomnia, dry mouth, hotness in the palms and soles, a red tongue with scant coating, it is due to Yin deficiency with internal Heat.
Meridian versus Viscera. Stroke may be classified as that primarily involving the meridians and that primarily involving the viscera. In stroke involving the meridians only, the mental state is unaffected and the prominent symptoms are hemiplegia or numbness, stiff tongue with dysphasia or aphasia, and wry mouth and tongue. The pathogenic evil is relatively shallow and the condition relatively mild. In stroke involving the visceral organs, there is mental confusion or loss of consciousness. The pathogenic evil is relatively deeper and the condition relatively more serious.
Stroke involving the visceral organs may be further classified as the blockage type and the prostration type. The blockage type of stroke manifests disturbances of the mental state, trismus and spasticity of the limbs. It is due to pathogenic evil Qi blocking the upper orifices, and is a condition of symptom (pathogen) strength. If in addition there are facial flushing, body feverishness, coarse respiration, halitosis, restlessness, a yellow and greasy tongue coating and a slippery and rapid pulse, the blockage is caused by Phlegm-Heat. This is stroke due to Yang-blockage. If instead the additional symptoms are pallid lips and complexion, calm resting, copious saliva and sputum, cold limbs, a white and greasy tongue coating and a deep and slippery or even pulse, the blockage is caused by Dampness-Phlegm. This is stroke due to Yin-blockage. In contrast to the blockage type, the prostration type of stroke manifests coma, closed eyes and open mouth, flaccidity of all limbs with open and relaxed hands, cold limbs, incontinence of urine and feces, and shallow and weak respiration. Prostration-stroke is caused by the escape to the outside of genuine Yang of the zang viscera.
Course and Prognosis. Progression from the meridian-type to the viscera-type reflects waning of genuine Qi and waxing of evil Qi. It indicates worsening of the condition and a poor prognosis. This progression can be recognized from the development of coma, and spasticity and impairment of pupillary reaction to light. Conversely, progression from the viscera-type to the meridian-type, with improvement in the mental state, indicates improvement and a better prognosis.
Herbal Treatment
Meridian-Type Stroke
Hyperactivity of Liver-Yang with Upward Attack by Wind-Fire
Main Symptoms. Hemiplegia and numbness, dysphasia or aphasia; or, wry mouth and tongue, headache, dizziness, flushed face with red eyes, restlessness, irascibility, dark urine, dry feces, bitter taste in the mouth, a deep red tongue body with thin yellow coating, and a taut and forceful pulse.
Therapeutic Principle. Calm the liver, extinguish Wind, purge Fire and unblock channels.
Treatment. Tianma Gouteng Tang (Gastrodia-Uncaria Decoction). Its composition is as follows: tianma (Gastrodia) 10 g, gouteng (Uncaria) 10 g, shijueming (Haliotis) 30 g, huangqin (Scutellaria) 12 g, zhizi (Gardenia jasminoides) 10 g, chuanniuxi (Cyathula officinalis) 10 g, duzhong (Eucommia) 12 g, sangjisheng (Loranthus) 15 g, yimucao (Leonurus) 10 g, fushen (Poria cocos) 10 g, and yejiaoteng (Polygonum multiflorum) 10 g. Note: shijueming is decocted first.
If headache and dizziness are severe, add jili (Tribulus terrestris), juhua (Chrysanthemum) and muli (Ostrea) to enhance the formula’s ability to suppress Yang and extinguish Wind.
If restlessness and irascibility are severe, add mudanpi (Paeonia suffruticosa) and baishaoyao (Paeonia lactiflora).
Wind-Phlegm-Induced Blood Stasis and Meridian Blockage
Main Symptoms. Hemiplegia with numbness; wry mouth and tongue; stiff tongue with dysphasia; dizziness with blurred vision; gray tongue with white and greasy coating; and a taut and slippery pulse.
Therapeutic Principle. Extinguish Wind, dissipate Phlegm, mobilize blood and unblock channels.
Treatment. Hua Tan Tong Luo Tang (Phlegm-Dissipating Channel-Unblocking Decoction). It has the following composition: tianma (Gastrodia) 10 g, bile-treated nanxing (Arisaema erubescens) 10 g, tianzhuhuang (Bambusa textilis) 5g, danshen (Salvia) 10 g, banxia (Pinellia) 10 g, baizhu (Atractylodes) 12 g, fuling (Poria) 10g, raw dahuang (Rheum palmatum) 6g, and xiangfu (Cyperus) 10 g.
If blood stasis is marked, with cyanotic tongue speckled with ecchymosis, add taoren (Prunus persica), honghua (Carthamus) and chishaoyao (Paeonia).
For agitation, with a yellow and greasy tongue coating, add huangqin (Scutellaria) and zhizi (Gardenia jasminoides) to cool Heat and purge Fire.
For dizziness and headache, add juhua (Chrysanthemum) and xiakucao (Prunella) to extinguish liver-Wind.
Phlegm-Heat in FH-Viscera Inducing Upward Attack by Wind-Phlegm
Main Symptoms. Hemiplegia with numbness, dysphasia, wry mouth and tongue; abdominal distention, constipation; dizziness, blurred vision; copious sputum and saliva; or fever. The tongue coating is yellow and greasy. The pulse is either taut and slippery or taut, slippery and large on the side with hemiplegia.
Therapeutic Principle. Dissipate Phlegm and unblock the fu-viscera.
Treatment. Xing Lou Cheng Qi Tang (Arisaema-Trichosanthes Qi-Soothing Decoction). It has the following composition: bile-treated nanxing (Arisaema erubescens) 10 g, gualou (Trichosanthes) 10 g, raw dahuang (Rheum palmatum) 6 g, and mangxiao (Mirabilite) 6 g.
For constipation and marked abdominal distention lasting many days, add zhishi (Citrus aurantium), houpo (Magnolia) and herbs with similar actions to regulate Qi.
For an elderly patient with weak constitution and insufficient fluids, add shengdi-huang (Rehmannia), xuanshen (Scrophularia) and maimendong (Ophiopogon).
Qi Deficiency and Blood Stasis
Main Symptoms. Hemiplegia with numbness, dysphasia, wry mouth and tongue; pallid complexion; shortness of breath, lassitude; drooling of saliva; spontaneous sweating; edema of the hands and feet; and palpitation of the heart. The tongue is pale gray, with a thin coating. The pulse is deep and threadlike or threadlike and impeded.
Therapeutic Principle. Augment Qi, mobilize blood and unblock channels.
Treatment. Modified Bu Yang Huan Wu Tang (Yang-Tonifying Balance-Restoring Decoction), with the following composition: huangqi (Astragalus) 15 g, danggui (Angelica) 10 g, chishaoyao (Paeonia) 10 g, chuanxiong (Ligusticum) 10 g, taoren (Prunus persica) 10 g, honghua (Carthamus) 10 g, and dilong (Pheretima) 10 g.
For dysphasia, add yuanzhi (Polygala), shichangpu (Acorus) and yujin (Curcuma) to dissipate Phlegm and open orifices.
For wry mouth and tongue, add baifuzi (Typhonium giganteum), jiangcan (Bombyx mori) and quanxie (Buthus) to expel Wind and dissipate Phlegm.
For numbness in the limbs, add mugua (Chaenomeles), shenjincao (Lycopodium japonicum) and fangji (Stephania) to loosen the sinews and unblock channels.
Wind Stirring due to Yin Deficiency
Main Symptoms. Hemiplegia with numbness, dysphasia, wry mouth and tongue; dizziness, tinnitus; hotness in the palms and soles; and restlessness, insomnia. The tongue is red, with scant coating. The pulse is threadlike and taut, either even or rapid.
Therapeutic Principle. Nourish the liver and the kidney, suppress Yang and extinguish Wind
Treatment. Zhen Gan Xi Feng Tang (Liver-Sedating and Wind-Extinguishing Decoction).
If restlessness and insomnia are prominent, add huangqin (Scutellaria) and zhizi (Gardenia) to remove restlessness and cool Heat and yejiaoteng (Polygonum multi-florum) and zhenzhumu (Pteria magaritifera) to sedate and calm.
Stroke Involving Viscera
Yang-Blockage Stroke
Main Symptoms. Sudden onset mental confusion or loss of consciousness, spasticity in the limbs, trismus; flushed face, fever; snoring; gurgling of sputum; restlessness; anuria and constipation; or, convulsion and hematemesis. The tongue is crimson red, with yellow and greasy coating. The pulse is taut, slippery and rapid.
Therapeutic Principle. Open orifices with acrid-cool herbs, cool the liver and extinguish Wind.
Treatment. An Gong Niuhuang Wan, initially administered by naso-gastric or oral feeding tube, followed by Lingyangjiao Tang (Goat-Horn Decoction). Lingyangjiao Tang has the following basic composition: lingyangjiao (Saiga tatarica) 0.5 g, juhua (Chrysanthemum) 10 g, xiakucao (Prunella) 10 g, baishaoyao (Paeonia) 10 g, guiban (Chinemys) 20 g, shijueming (Haliotis) 20 g, shengdihuang (Rehmannia) 10 g, and mudanpi (Paeonia suffruticosa) 10 g. Note: shijueming is decocted first, and lingyangjiao is decocted separately. (In its original composition, Lingyangjiao Tang includes chaihu, bohe and chanyi. These have an ascending and dispersing nature and should be removed for treating Yang-blockage stroke.)
If sputum is copious, add zhuli (Phyllostachys nigra), bile-treated nanxing (Arisaema consanguineum) and tianzhuhuang (Bambusa textilis) to cool Heat, dissipate Phlegm and open orifices.
For constipation, add raw dahuang (Rheum palmatum) and mangxiao (Mirabilite). If there is convulsion, add herbs that extinguish Wind and relieve spasm, such as quanxie (Buthus), wugong (Scolopendra) and baijiangcan (Bombyx).
If there is hematemesis and hematochezia, add huangqin (Scutellaria), digupi (Lycium) and baiji (Bletilla).
Yin-Blockage Stroke
Main Symptoms. Sudden coma, hemiplegia, flaccidity; cold limbs; pallid complexion, cyanotic lips; copious sputum and saliva. The tongue is dark or pale, with white and greasy coating. The pulse is deep and slippery, or even.
Therapeutic Principle. Open orifices with acrid-warm herbs, eliminate Phlegm and extinguish Wind.
Treatment. Suhexiang Wan by naso-gastric or oral feeding tube, followed by Di Tan Tang (Phlegm-Cleansing Decoction). Di Tan Tang has the following basic composition: processed banxia (Pinellia) 10 g, processed nanxing (Arisaema consanguineum) 10 g, chenpi (Citrus tangerina), zhishi (Citrus aurantium) 10 g, fuling (Poria) 10 g, renshen (Panax), shichangpu (Acorus) 6 g, zhuru (Phyllostachys nigra) 10 g, gancao (Glycyrrhiza) 6 g, and raw ganjiang (Zingiber) 6 g.
If symptoms of Cold are prominent, add guizhi (Cinnamomum).
Prostration Stroke
Main Symptoms. Sudden loss of consciousness or coma, flaccidity of the limbs; incontinence of urine; sweating with cold limbs; eyes shut; spastic tongue; retracted testes; and shallow and weak respiration. The tongue is cyanotic, with white and greasy coating. The pulse is either deep and even or indistinct, threadlike and on the verge of collapse.
Therapeutic Principle. Augment Qi, rescue Yang and arrest collapse.
Treatment. Shen Fu Tang (Ginseng-Aconitum Decoction). The composition is very simple: renshen (Panax) 10 g and processed fuzi (Aconitum) 10 g.
For persistent sweating, add shanzhuyu (Cornus), longgu (fossil bone) and muli (Ostrea).
Acupuncture Treatment
Meridian-Type Stroke
Hemiplegia
Use filiform needles and apply the reducing method on the affected side and the reinforcing method on the unaffected side.
Upper limbs: select Jianjing (GB-21), Quchi(LI-11), Shousanli(LI-10), Waiguan (SJ-5) and Hegu (LI-4).
Lower limbs: select Huantiao (GB-30), Yanglingquan (GB-34), Zusanli (ST-36), Jiexi (ST-41) and Kunlun (BL-60).
Wry Mouth and Tongue
Use filiform needles and apply the even method (neither reducing nor reinforcing).
Select the acupoints Dicang (ST-4), Jiache (ST-6), Hegu (LI-4), Neiting (ST-44) and Taichong (LR-3).
Viscera-Type Stroke
Blockage-Stroke
Select the twelve Jing (Well) acupoints, Shuigou (GV-26), Taichong (LR-3) and Fenglong (ST-40). Use filiform needles and apply the reducing method. The Jing (Well) acupoints are pricked with a three-edged needle to cause bleeding.
Prostration-Stroke
Select the acupoints Guanyuan (CV-4) and Shenque (CV-8). Apply ignited moxa cones at these acupoints.
Case Study
The patient was a 65-year old female with a 10-year history of high blood pressure and frequent headaches. She was admitted to hospital because of sudden coma, right-sided hemiplegia and aphasia for 3 days. There was no vomiting.
On examination the patient was comatose. Her temperature was 38.5°C (101.3°F) and blood pressure 150/90mmHg. She had trismus and dry lips. The tongue was flaccid, with thin, yellow and greasy coating. The pulse was slippery, rapid and forceful.
Auscultation of the lung revealed medium and fine moist rales over the lower lobes. Percussion of the heart showed the cardiac border at the left mid-clavicular line in the fifth intercostal space. The heart rhythm was normal. Neurological examination revealed a stiff neck. On the right (affected side) the muscle tone was reduced, deep tendon reflexes were 1+ , and the Babinski sign was positive. Lumbar puncture yielded blood in the cerebrospinal fluid and a cerebrospinal fluid pressure of 270 mmH2O.
Diagnosis. Stroke of the viscera-type and Yang-blockage.
Therapeutic Principle. Dissipate Phlegm, unblock the viscera, cool heart-Heat and open orifices (resuscitate).
Treatment and Course. Upon admission, the patient was given the following treatment. An infusion of 40 ml of Qing Kai Ling (Wonder Solution to Clear and Open) in 500 ml of 10% glucose solution and antibiotics was given intravenously, and the decoction from the following herbal formula by naso-gastric catheter. The formula had the following composition: gualou (Trichosanthes kirilowii) 30 g, bile-treated tiannanxing (Arisaema consanguineum, erubescens) 10 g, tianzhuhuang (Bambusa textilis) 10 g, raw dahuang (Rheum palmatum) 10 g, mangxiao (Mirabilite) 6g, shichangpu (Acorus gramineus) 10 g, and yujin (Curcuma wenyujin, aromatica) 10 g. Mangxiao was infused separately.
The patient remained comatose with stiff neck and trismus, but fever subsided and feces evacuated. The tongue was now red, with thin yellow and dry but greasy coating. The pulse was now threadlike, taut, slippery and rapid.
The therapeutic approach was changed to augmenting Yin, extinguishing Wind and dissipating Phlegm. The formula used had the following composition: shengdi-huang (Rehmannia) 10 g, xuanshen (Scrophularia) 12 g, raw muli (Ostrea) 30 g, xiakucao (Prunella) 15 g, gouteng (Uncaria) 30 g, juhua (Chrysanthemum) 10 g, tianzhuhuang (Bambusa textilis) 6 g, and bile-treated nanxing (Arisaema consan-guineum). Note: muli was decocted first.
While this decoction was administered for three daily doses the patient was also given Niuhuang Qing Xin Wan (Gallstone Mind-Clearing Pill), one pill twice daily. After 12 days the patient regained consciousness. She was further treated by the method of nourishing Yin, augmenting Qi and mobilizing blood for a month. At that point, she was able to walk with a walking staff. She was discharged from the hospital with residual paresis on the right side and dysphasia.
