Clinical Observation Forty-six Cases of Acute Cerebral Infarction Treated with the Combined Use of Acupuncture and Drugs

Guo Zhili郭志力

Objective:To observe the clinical therapeutic effects of treatment for acute cerebral infarction with the combined use of acupuncture and drugs, and study the therapeutic mechanism.Methods:88 cases of acute cerebral infarction were divided randomly into two groups, a treatment group of 46 cases treated with acupuncture, Danshen Zhushe Ye(丹参注射液Saliva Injection)and routine western drugs and a control group of 42 cases treated simply with drugs. The therapeutic effects were evaluated based on the evaluation criteria for damage of the nerve function. Observation was also made on changes in the skull CT images, and in the activities of superoxide dismutase(SOD),glutathione peroxidase(GSH-px),and nitric oxide synthase (NOS)in serums,and levels of malondialdehyde(MDA)and nitric oxide(NO)in serums .Results: After treatment for 15 days, the total effective rate of the treatment group reached 80.43%,while that of the control group was 61.90%,showing significant differences. The effective rate shown by the skull CT images of the treatment group was 51.61%,while that of the control group was 45.16%,showing no significant differences But as compared with the control group, the activities of SOD and GSH-px in serums were significantly enhanced, and the levels of MDA and NO, and activity of NOS in serums were significantly decreased in the treatment group. Conclusion: The prompt acupuncture treatment of acute cerebral infarction can markedly raise the clinical therapeutic effects, improve the activity of SOD and GSH-px in serums, lower down the level of MDA in serum, and markedly decrease NO level and NOS activity in serums. From April 2000 to October 2001,the author of this essay had studied clinically 46 cases of acute cerebral infarction treated with the combined use of acupuncture and drugs, and another 42 such cases treated simply with drugs. The therapeutic effects were satisfactory and a report follows.

CLINICAL DATA

General Data

All the 88 cases selected were from the Emergency Department and Department of Internal Neurology of Jiangsu Provincial TCM Hospital, and were randomly divided into a treatment group(46 cases) treated with acupuncture and drugs in combination, and a control group(42 cases)treated only with drugs.Among the 46 cases in the treatment group,31 were males and 15 were females, ranging in age from 44 to 73 years, with a mean of 60.4±7.1 years; and ranging in duration of illness from 2 hours to 14 days, with a mean of 1.9±0.89 days. Among the 42 cases in the control group,28 were males and 14 were females, ranging in age from 44 to 74 years, with a mean of 61.5±6.8 years; and ranging in duration of illness from 4 hours to 14 days, with a mean of 2.03±0.91 days. There were no significant differences between the two groups in sex, age, duration of the illness, classification of disease which had been tested by chi-square, and in scores of dysneuria, the scores of complications, and the scores of case history which had undergone t test(P>0.05). National Symposium on Cerebrovascular Diseases in 1995. The TCM diagnosis was made by referring to the syndrome of obstruction of collaterals by wind-phlegm based on the Criteria for Diagnosis for Apoplexy and Evaluation of Therapeutic Effects set by the Cooperation Group for Cerebral Diseases of

the State Administration of TCM in 1996.

METHODS

The Control Group

Intravenous injection of routine dose of Danshen Zhushe Ye(丹参注射液Saliva Injection)was adopted in this group, combined with drugs for lowering down the intracranial pressure, relieving cerebral edema, and protecting cerebral tissues. The above treatment was successively given for 15 days.

The Treatment Group

For this group, in addition to the same treatment mentioned above to the control group, acupuncture was applied with the treating principle of calming endogenous wind and resolving phlegm, and promoting blood circulation to remove blood stasis for resuscitation. The main points: Baihui(GV 20) penetrating to Qubin(GB 7)on the affected side, Renzhong(GV 26),Lianquan(CV 23),Neiguan(PC6),Quchi(LI 11),Hegu(LI 4),Xuehai(SP 10), Zusanli(ST 36),Fenglong(ST 40),Sanyinjiao(SP 6), and Taichong(LR 3).In each treatment 3~5 of the above main points were selected and needled. The adjunct points: Baxie(EX-UE9),Huantiao(GB 30), Biguan(ST 31),Futu(ST 32),Fengshi(GB 31), Yanglingquan(GB 34),and Qiuxu(GB 40).In each treatment 3~5 of the above points were selected and punctured. The symptomatic points: for wry mouth,

Dicang(ST 40)penetrating to Jiache(ST 6)were added; for urinary incontinence, Qihai(CV 6) penetrating to Zhongji(CV 3)were added; for fecal incontinence, Tianshu(ST 25)and Qihai(CV 6)were added; for limited movement of the shoulder joints, Jianyu(LI 15),Jianliao(SJ 14)and Jianneiling(Extra) were added; for limited movement of the elbow joints, Shousanli(LI 10)was added; and for limited movement of the wrist joints, Yangxi(LI 5)and Yanggu(SI 5)were added. The needling technique:1)When Baihui(GV 20)penetrating to Qubin(GB 7) was punctured the needle should be inserted transversely, with the needle tip pointing to Qubin (GB 7).2~3 No.40 filiform needles of 1.5~2 cun in length were used in succession in the penetrating needling technique. The needles were twirled and rotated with a frequency of 150~200 times/per min., and manipulated for 1 min.2)For the body points, perpendicular, swift-twirling insertion of the needle was adopted, followed by rotating and lifting-thrusting manipulation, with even reinforcing-reducing method according to the severity of the condition and constitution of the individual patient.3)When penetrating needling technique was adopted at the body points, the needle was inserted transversely, with moderate

manipulation for 1~2 min. at each point .Upon theacquiring qi, needles were retained for 30 min. The acupuncture treatment was given once daily,5 times a week, with a break of two days before another 5 treatments started. For both groups,15 days’ treatments constituted a course, after which the therapeutic effects were observed.

Observation Indices

Scores of damage of nerve function :The activities of superoxide dismutase(SOD),glutathione peroxidase (GSH-px),and nitric oxide synthase(NOS)in serums, and the levels of malondialdehyde(MDA)and nitricoxide(NO)in serums were determined. Observation Statistics Statistics were made by adopting the PEMS medical statistical software of Huaxi Medical University, with the results shown by(x±s). The t test was used for the measurement data, and χ2 test for the enumeration data. 

DISCUSSION

Cases of acute cerebral infarction are mostly accompanied with mental symptoms. Therefore, in the acupuncture treatment Baihui(GV 20),Renzhong (GV 26)and Neiguan(PC 6)are selected. Being an important point on the Du Channel that connects with the sea of marrow, Renzhong(GV 26),when needled, can promote resuscitation. Neiguan(PC 6),a luo(connecting)point of the Pericardium Channel of Hand Jueyin, has the effect of clearing away the heart-fire to restore consciousness. Baihui(GV 20) penetrating to Qubin(GB 7)corresponds to the posterior oblique line of vertex-temporal in scalp acupuncture, and the subcutaneous transverse penetrating needling at these two points can make stimulation go through the Du,Foot Taiyang, Foot Shaoyang, Foot Yangming, and Hand Shao Yang Channels, indicated respectively for paralysis and paresthesia of the lower limbs, upper limbs, and craniofacial areas. Quchi(LI 11)and Huantiao(GB30)are used for calming the endopathic wind and dredging the collaterals; Zusanli(ST 36),Fenglong (ST 40),and Sanyinjiao(SP 6)for strengthening the spleen, removing dampness and resolving phlegm, Neiguan(PC 6)and Xuehai(SP 10)for promoting blood circulation and removing blood stasis; and Hegu(LI 4)and Taichong(LR 3)for promoting resuscitation and lowering down the adverse flow of qi. The selected adjunct points Huantiao(GB 30), Biguan(ST 31),Futu(ST 32),Fengshi(GB 31), Yanglingquan(GB 34),and Qiuxu(GB 40)are all points of the Yangming and Shaoyang Channels, which can promote circulation of qi and blood, and dredge the channels and collaterals. The combined use of these points can give the joint effects of calming the endopathic wind and resolving phlegm, and promoting blood circulation and removing blood stasis to promote resuscitation. When the cerebral tissues are in the ischemic state,

large amounts of free radicals would be produced. In the course of elimination of free radicals, the activity of SOD is obviously lowered. By means of testes on the formation and elimination of free radicals, the degree of its damage to the cerebral tissues can be deduced. MDA refers to the metabolite of lipoperoxide(LPO),and the measurement of MDA is an important method to determine the lipid peroxidation. Lipoperoxide has the oxidation function, which can make oxidation of the reduced glutathione(GSH).Whereas, GSH-px has the important function of eliminating lipid peroxide inthe human body to inhibit its harmful reaction. Through reaction with superoxide negative ion NO can form nitrogen peroxide and disturb iron metabolism so to increase oxidation damage. During cerebral ischemia, NOS, through its derivants, can bring about energy failure and damage of DNA, inhibit synthesis of DNA, and cause programming cellular death. Moreover, through enhancing the release of excitatory nerve transmitter, NO can aggravate cellular damage, while the environmental oxidation-reduction state can also influence greatly the biochemical effect of NO. The nitrate produced by NO metabolism, cGMP and NOS activity will all rise several minutes after the cerebral ischemia. The increasing of NO is closely related to the severity of ischemia.

The author’s clinical testing results of SOD,GSH-px, MDA,NO, and NOS have shown that acupuncture can markedly improve the activities of SOD and GSH-px, lower down the content of MDA, and markedly decrease the level of NO and activity of NOS. The significant differences between the two groups suggest that one of the mechanisms of the good therapeutic effect given by the early intervention of acupuncture in the treatment of acute cerebral infarction is that acupuncture can effectively improve the activity of the antioxidase SOD and GSH-px in the enzyme system of the human body, strengthen their abilities to lower the lipid peroxidation caused by free radical, reduce the content of lipoperoxide increased in the body due to the cerebral hypoxia and ischemia, and decrease the free radical reaction. It has been shown by the author’s observation results that at the acute stage of cerebral infarction the NO level and NOS activity in the patient serum will increase at the same time, and both can be made to decrease by the combined use of acupuncture and drugs, and by simple use of drugs. However, the therapeutic effect of the combined treatment has proved to be markedly superior to that of simple drug treatment. This might be one of the therapeutic mechanisms of early intervention of acupuncture in the treatment of acute cerebral infarction in lowering down the content of NO and NOS activity.