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· Loss of activity (akarmanyata), and loss of sensation (achetana) of the affected side. [Su.Sa. Nidana Sthana 1/60-62]<ref name=":1">Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005.</ref>
· Loss of activity (akarmanyata), and loss of sensation (achetana) of the affected side. [Su.Sa. Nidana Sthana 1/60-62]<ref name=":1">Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005.</ref>
===Dosha specific clinical features===
{| class="wikitable"
{| class="wikitable"
|'''Dosha associated'''
|'''Dosha associated'''
· Based on clinical features of disease in Ayurveda as mentioned earlier
· Based on clinical features of disease in Ayurveda as mentioned earlier
===Biomarkers for diagnosis and assessment of efficacy===
Diffusion tensor imaging (DTI), diffusion-weighted imaging (DWI), T1-weighted MRI, T2 weighted MRI are biomarkers used to measure the structure or injury, whereas Electroencephalography (EEG), functional magnetic resonance imaging (fMRI), Magnetoencephalography (MEG), Positron emission tomography (PET), Transcranial magnetic stimulation (TMS) etc. are biomarkers used to measure the function.
Diffusion tensor imaging (DTI), diffusion-weighted imaging (DWI), T1-weighted MRI, T2 weighted MRI are biomarkers used to measure the structure or injury, whereas Electroencephalography (EEG), functional magnetic resonance imaging (fMRI), Magnetoencephalography (MEG), Positron emission tomography (PET), Transcranial magnetic stimulation (TMS) etc. are biomarkers used to measure the function.
==Prognosis==
''' Table 2: Prognosis'''
''' Table 2: Prognosis'''
[Ma. Ni 22/43]<ref name=":2" />
[Ma. Ni 22/43]<ref name=":2" />
==Management==
===Stagewise management of disease===
====Ⅰ. Acute condition'''====
Treatment of acute ischemic stroke (AIS) consists of a multidisciplinary approach. Early detection and early intervention can reduce the severity of neural damage. Therapies to arrest intracerebral hemorrhage and reversal of anticoagulation shall be initiated as early as possible. Neurological Institutes of Health stroke scale and several other scales are used to assess stroke severity. Arterial occlusion evaluation scale can be used to measure the degree of occlusion of large blood vessels. Neuro imaging using non contrast CT can be done. Non contrast CT scan can be used to find the Alberta Stroke Program Early CT Score (ASPECTS) which is designed to assess the severity of infarct in middle cerebral artery. CT angiography can also provide useful information about large vessel occlusion. Revascularization and limitation of neuronal injury are the next steps in acute ischemic stroke management. IV thrombolysis is used for the removal of clots, and endovascular therapy is used for revascularization. Supplementation of oxygen is required if oxygen saturation drops down to 94%. Current AHA/ASA guidelines recommends permissive hypertension with a blood pressure goal of less than or equal to 220/120mg Hg for the first 24-48 hours, until or unless acute interventions such as intravascular tissue plasminogen activator administration or endovascular interventions are administered . [D1] Anti-hypertensives should be administered only beyond this level to prevent hemorrhage. Glycemic control must be at 140-180 mg/dl and monitored frequently to avoid hypoglycemia, which may worsen the outcomes. Managing cerebral edema associated with large infarcts in the middle cerebral and internal carotid arteries is very important as it can enhance neurologic deterioration. Decompressive hemicraniectomy must be done to manage raised intracranial pressure. Early rehabilitation is also thought to have better outcomes in stroke patients. The etiology of stroke must be understood to take steps for secondary prevention. Antiplatelet therapy is a well-known and established way to prevent stroke and transient ischemic attacks. Statins, the drugs for dyslipidemia, are also used to seize the atherosclerotic progress.<ref>Franziska Herpich, Fred Rincon. Management of Acute Ischemic Stroke. Crit Med. 2020 Nov; 48(11): 1654–1663. doi: 10.1097/CCM.0000000000004597 PMCID: PMC7540624 PMID: 32947473.</ref>
Treatment of acute ischemic stroke (AIS) consists of a multidisciplinary approach. Early detection and early intervention can reduce the severity of neural damage. Therapies to arrest intracerebral hemorrhage and reversal of anticoagulation shall be initiated as early as possible. Neurological Institutes of Health stroke scale and several other scales are used to assess stroke severity. Arterial occlusion evaluation scale can be used to measure the degree of occlusion of large blood vessels. Neuro imaging using non contrast CT can be done. Non contrast CT scan can be used to find the Alberta Stroke Program Early CT Score (ASPECTS) which is designed to assess the severity of infarct in middle cerebral artery. CT angiography can also provide useful information about large vessel occlusion. Revascularization and limitation of neuronal injury are the next steps in acute ischemic stroke management. IV thrombolysis is used for the removal of clots, and endovascular therapy is used for revascularization. Supplementation of oxygen is required if oxygen saturation drops down to 94%. Current AHA/ASA guidelines recommends permissive hypertension with a blood pressure goal of less than or equal to 220/120mg Hg for the first 24-48 hours, until or unless acute interventions such as intravascular tissue plasminogen activator administration or endovascular interventions are administered . [D1] Anti-hypertensives should be administered only beyond this level to prevent hemorrhage. Glycemic control must be at 140-180 mg/dl and monitored frequently to avoid hypoglycemia, which may worsen the outcomes. Managing cerebral edema associated with large infarcts in the middle cerebral and internal carotid arteries is very important as it can enhance neurologic deterioration. Decompressive hemicraniectomy must be done to manage raised intracranial pressure. Early rehabilitation is also thought to have better outcomes in stroke patients. The etiology of stroke must be understood to take steps for secondary prevention. Antiplatelet therapy is a well-known and established way to prevent stroke and transient ischemic attacks. Statins, the drugs for dyslipidemia, are also used to seize the atherosclerotic progress.<ref>Franziska Herpich, Fred Rincon. Management of Acute Ischemic Stroke. Crit Med. 2020 Nov; 48(11): 1654–1663. doi: 10.1097/CCM.0000000000004597 PMCID: PMC7540624 PMID: 32947473.</ref>
An observational study prospectively comparing outcomes in 2 cohorts of AIS patients treated with whole-system classical Ayurveda (n = 13) or conservative (nonthrombolytic, noninterventional) western biomedicine (n = 20) has shown similarity in safety profiles of classical Ayurveda and conservative western biomedicine in AIS.<ref>J Aarthi Harini, Avineet Luthra, Shrey Madeka,et al. Ayurvedic Treatment of Acute Ischemic Stroke: A Prospective Observational Study. Glob Adv Health Med. 2019; 8: 2164956119849396. PMCID: PMC7540624 PMID: 32947473.</ref>
An observational study prospectively comparing outcomes in 2 cohorts of AIS patients treated with whole-system classical Ayurveda (n = 13) or conservative (nonthrombolytic, noninterventional) western biomedicine (n = 20) has shown similarity in safety profiles of classical Ayurveda and conservative western biomedicine in AIS.<ref>J Aarthi Harini, Avineet Luthra, Shrey Madeka,et al. Ayurvedic Treatment of Acute Ischemic Stroke: A Prospective Observational Study. Glob Adv Health Med. 2019; 8: 2164956119849396. PMCID: PMC7540624 PMID: 32947473.</ref>
====Ⅱ.Chronic condition====
Multidisciplinary rehabilitation and the drugs for secondary prevention come under the management of post-stroke patients. Physiotherapy, modified constraint-induced movement therapy, and the use of various assistive devices such as brace chains. Wheelchairs and walkers are advised for the improvement of motor function, cognition, speech, and quality of life. Mental imagery and electrical stimulation for the movement of muscles are also combined with the above. Ayurvedic management can be done at this stage. A systemic approach in the management of pakshaghata is explained in classical textbooks. [Cha.Sa. Chikitsa Sthana 28/100] [Su.Sa. Chikitsa Sthana 5/19]<ref name=":1" /> [A.Hri. Chikitsa Sthana 21/44]<ref name=":0" />
Multidisciplinary rehabilitation and the drugs for secondary prevention come under the management of post-stroke patients. Physiotherapy, modified constraint-induced movement therapy, and the use of various assistive devices such as brace chains. Wheelchairs and walkers are advised for the improvement of motor function, cognition, speech, and quality of life. Mental imagery and electrical stimulation for the movement of muscles are also combined with the above. Ayurvedic management can be done at this stage. A systemic approach in the management of pakshaghata is explained in classical textbooks. [Cha.Sa. Chikitsa Sthana 28/100] [Su.Sa. Chikitsa Sthana 5/19]<ref name=":1" /> [A.Hri. Chikitsa Sthana 21/44]<ref name=":0" />
===Principles of management===
The principles of management of pakshaghata consist of
The principles of management of pakshaghata consist of
===Therapies advised in pakshaghata:===
'''1) Snehana (therapeutic oleation):'''
'''1) Snehana (therapeutic oleation):'''
'''6)Nasya (nasal medication)''': Ksheera bala taila avartita, Dhanwantara taila avartita are used for nasal administration. Nasya provides effect on the space occupying lesion. Research is required to generate evidence on the same.
'''6)Nasya (nasal medication)''': Ksheera bala taila avartita, Dhanwantara taila avartita are used for nasal administration. Nasya provides effect on the space occupying lesion. Research is required to generate evidence on the same.
===Currently used important herbal formulations===
'''Decoctions:'''
'''Decoctions:'''
Lasuna ksheerapaka [Ca.Sa. Chikitsa Sthana 5/94-95], Prasarinyadi ksheera Kashaya [Sahasrayoga 1/59(1)]<ref name=":3" />, Masha athmagupthadi ksheera (nasapana) [Chakradatta. Vatavyadi 27], mashabaladi kwatha [Bhaishajya Ratnavali. Vatavyadhi adhikara 62-63]
Lasuna ksheerapaka [Ca.Sa. Chikitsa Sthana 5/94-95], Prasarinyadi ksheera Kashaya [Sahasrayoga 1/59(1)]<ref name=":3" />, Masha athmagupthadi ksheera (nasapana) [Chakradatta. Vatavyadi 27], mashabaladi kwatha [Bhaishajya Ratnavali. Vatavyadhi adhikara 62-63]
==Research on Ayurvedic formulations==
In a study involving 40 patients afflicted with post stroke aphasia, kalyana leha is found more effective than speech therapy on auditory and verbal comprehension as well as naming.<ref>Priyanka Patel (2017): A randomized controlled clinical trial on kalyana leha in the management of post stroke aphasia. Department of Kayachiktsa, Parul Institute of Ayurved, Limda.</ref>
In a study involving 40 patients afflicted with post stroke aphasia, kalyana leha is found more effective than speech therapy on auditory and verbal comprehension as well as naming.<ref>Priyanka Patel (2017): A randomized controlled clinical trial on kalyana leha in the management of post stroke aphasia. Department of Kayachiktsa, Parul Institute of Ayurved, Limda.</ref>
==Research on Ayurvedic treatments==
A comparative clinical study was conducted among 31 patients of pakshaghata between virechana group and koshtha shuddhi group. Both of these groups have shown marked to moderate improvements in patients with a better percentage wise improvement in the virechana group.<ref>Pandya Asutosh (2003): A comparative study of Virechana Karma and Sramsana in the management of Pakshaghata.Department of Panchakarma, ITRA, Jamnagar.</ref>
A comparative clinical study was conducted among 31 patients of pakshaghata between virechana group and koshtha shuddhi group. Both of these groups have shown marked to moderate improvements in patients with a better percentage wise improvement in the virechana group.<ref>Pandya Asutosh (2003): A comparative study of Virechana Karma and Sramsana in the management of Pakshaghata.Department of Panchakarma, ITRA, Jamnagar.</ref>
</ref>
</ref>
==Case reports==
'''1.''' A case study of 63 years old male patient who has weakness on his left side of body and unable to walk was published. His diagnosis was haemorrhagic stroke presenting with left sided hemiplegia with acute intraparenchymal haemorrhage in C.T. brain. The Ayurvedic diagnosis of pakshaghata was made and managed with treatment principle which is mentioned by Acharya Charak. Snehana, swedana and mridu virechana along with panchakarma procedures like shirodhara, shiropichu and basti for 21 days. Samshamana aushadhis (oral medicines) and physiotherapy were adopted at various stages of the diseases. Maximum improvement was noticed in upper and lower extremity functions at the end of the treatment. Patient showed remarkable recovery in speech ability and mobility.<ref>Mohan, V., B, D., & Deva, S. (2021). Ayurvedic Management of Pakshaghata (Left Hemiplegia) – A Case study. International Journal of Ayurvedic Medicine, 12(3), 733–741. <nowiki>https://doi.org/10.47552/ijam.v12i3.1954</nowiki></ref>
'''1.''' A case study of 63 years old male patient who has weakness on his left side of body and unable to walk was published. His diagnosis was haemorrhagic stroke presenting with left sided hemiplegia with acute intraparenchymal haemorrhage in C.T. brain. The Ayurvedic diagnosis of pakshaghata was made and managed with treatment principle which is mentioned by Acharya Charak. Snehana, swedana and mridu virechana along with panchakarma procedures like shirodhara, shiropichu and basti for 21 days. Samshamana aushadhis (oral medicines) and physiotherapy were adopted at various stages of the diseases. Maximum improvement was noticed in upper and lower extremity functions at the end of the treatment. Patient showed remarkable recovery in speech ability and mobility.<ref>Mohan, V., B, D., & Deva, S. (2021). Ayurvedic Management of Pakshaghata (Left Hemiplegia) – A Case study. International Journal of Ayurvedic Medicine, 12(3), 733–741. <nowiki>https://doi.org/10.47552/ijam.v12i3.1954</nowiki></ref>