Post-surgical management of pontine hemorrhage with Ayurvedic treatment.

A female aged 30 years, consulted the Govt. Ayurveda Hospital, Perinthalmanna with complaints of left side of the body totally paralysed along with severe shivering of the right hand and head and the patient was bedridden for 1½ years. She was diagnosed earlier with spontaneous pontine hematoma (on 10(th) Nov 2007) and had undergone midline sub occipital craniectomy (on 13(th) Nov 2007) as an emergency treatment. She developed neurotrophic ulcer in the right eye with lagophthalmos post-surgery. The patient showed no improvement to treatment but further developed stromal abscess and hence paramedian tarsorraphy (4(th) Jan 2008) was done. The deficits in the right eye led to diminution of vision of that eye after Allopathy treatment. The patient sought Ayurvedic treatment for a better prognosis. The patient was under Ayurvedic treatment from 5(th) Mar 2009 to 24(th) Nov 2009. During that period Ayurvedic treatment such as abhyaṅga (oil massage), patra poṭṭalī sveda (use of poultices) and mṛdu virecana (purgation) was also done. After a period of 8 months of internal medication and treatment, the shivering of the right hand and head resolved. She could move the left leg and left hand and started walking without support. There was gradual loss of vision during the course of Ayurvedic treatment. At present, the patient is able to move around and do household works on her own.

INTRODUCTION

Pontine hemorrhage is an ischemia involving the brain stem and infarcts are restricted to the pons. The clinical features vary from cranial nerve dysfunctions to eye movement disorders, motor sensory and cerebellar manifestations.[1] Surgical evacuation is the treatment done for patients involving younger age group with a better prognosis.[2] A study showed good recovery in a patient who was conscious on admission and had smaller unilateral hemorrhages.[3]

The female was young and conscious on admission, this showed a chance of better prognosis. However in this patient for a period of nearly 1½ years, there was no significant change in the functional abilities during the entire course of Allopathic treatment. It was observed that the functional deficits improved during the course of Ayurveda treatment.

CASE REPORT

The patient was admitted in an Allopathic hospital with the complaints of numbness over left half of the body for 2½ months, involving right half of the face for 3 days with weakness of left half of the body for 1½ months, blurring of vision, impaired hearing of left ear and slurring of speech for 20 days, difficulty in swallowing was present for 3 days along with breathlessness. The patient did not have any history of hypertension. She was diagnosed with spontaneous pontine hematoma and underwent midline sub occipital craniectomy and evacuation of clot and evacuation hematoma by trans vermian approach under general anesthesia and was discharged after a month on 11th Dec 2007. She later developed right eye neurotrophic ulcer with lagophthalmos and sustained paramedian tarsorraphy. Anti-glaucoma medications were started after admitting her to hospital again on 11th Jan 2008. Dental consultation was sought for the inability of the patient to open her mouth and then on the patient was under tracheostomy. The patient was discharged from the allopathic hospital on request on 9th Feb 2008. At the time of discharge, patient was oriented and conscious with Bilateral VI nerve palsy and right side mild lower cranial palsy. The patient complained of paralysis of left side of the body along with weakness and severe shivering of the right hand and head. She was bedridden and was unable to sit upright without support when she was brought for Ayurvedic treatment. The timeline depicting the treatment has been presented in Figure 1.

Figure 1

Timeline depicting history of diagnosis and treatment

INVESTIGATIONS AT BASELINE

Magnetic resonance imaging (MRI) taken prior to treatment showed acute parenchymal hemorrhage in the pons (dt. 13th Nov 2007). MRI dt. 11th Feb 2009 showed an old hemorrhagic lesion measuring 1.4 × 1.2 cm in the right dorsal pons and impression mentions no increase in the size of the lesion.

INVESTIGATIONS AT ENDPOINT

MRI showed no active lesions in the brain. Minimal gliotic changes in right pontine region. No complaints of hydrocephalus (dt. 24th Nov 2009).

TREATMENT

The patient was under Ayurvedic medication for a continuous period of 8 months from 5th Mar 2009 to 24th Nov 2009. She was on internal and external medication during this period. At present, she is not under any medication.

Internal medication – Sahadevi root kalka (Vernonia cinerea [Linn.] Less.) 5 g twice daily, Nimbāmṛtādi pañcatiktakam kaśāyam[4] 60 ml (freshly prepared), Varaṇādi kaśāyam[5] 60 ml (freshly prepared) twice daily, Rasa sindūram[6] capsules twice daily, Daśamūlaharītakī lehyam[7] 10 g. After 2 months Brāhma rasāyanam 10 g was started. The internal medication was continued for a period of 8 months.

External – Abhyaṅga (oil massage) was done for 7 consecutive days in the first and second visit with Dhānvantaram tailam,[9] patra poṭṭali sveda (use of poultices) and mṛdu virecana (purgation) was done in the third visit. The medication details are furnished in Table 1.

Table 1

Medication chart

OUTCOME AND FOLLOW-UP

After 41 days of treatment, the shivering on right hand and head reduced slightly. Mild pain and numbness was felt in the body. The sensation of pain was felt by the patient only after the treatment. Gradually with 2 months of treatment she could walk with the support of two people. The shivering also reduced moderately. By the end of 8 months of treatment, she had the functional abilities of the hand and leg restored. She could walk without support. The shivering of right hand and head stopped.

DIAGNOSIS AND TREATMENT DECISION MAKING

The patient was diagnosed with spontaneous pontine hematoma based on MRI and had surgery done as per the treatment protocols of modern medicine. From the Ayurvedic point of view, the condition was treated as granthi (cyst) associated with śopha (swelling) in the brain. Due to the involvement of rakta (blood) and śopha, Sahadevi root, Daśamūlaharītakī lehyam and Nimbāmrtādi pancatiktakam kasāyam was used. Varaṇādi kaśāyam was used as it is indicated in antarvidradhi (internal abscess and growth). Rasa sindūram was used to accelerate the effect and Brāhma rasāyanam was indicated for the purpose of rejuvenation. Dhānvantaram tailam was used for its general effect in pacifying Vāta and improving motor functions.

DISCUSSION

In Allopathy, surgery is the treatment of choice in which evacuation of the clot is performed and this has been found to help the patient get back to normalcy in some cases. In this particular case, the patient developed right VIth and VIIth nerve palsy along with clinical symptoms. It was 1½ years after the onset of the disease that she started Ayurveda medicines, during which period the patient did not respond well to Allopathic treatment. There was significant change in the functional parameters such as grip, flexion and extension of the limbs and improvement in walking during the period of Ayurvedic treatment. MRI showed that the patient had an active lesion before the start of the Ayurvedic medication and that there are no active lesions in brain after the course of the Ayurvedic treatment. The patient improved clinically after the Ayurvedic treatment.

LEARNING POINTS/TAKE HOME MESSAGES

This case is a pointer to the potential benefits of Ayurvedic treatment in patients with pontine hematoma who do not recover satisfactorily after surgery.

Observations of more cases and rigorous well-designed studies are warranted to arrive at conclusive evidence regarding the benefits of post-surgical management of pontine hematoma with Ayurvedic interventions.