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Strategies for post-COVID-19 infection associated neurological dysfunctions

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Hi, welcome to this week’s live show brought to you by American Acupuncture Council. I’m your host for today, Poney Chiang, coming to you from Toronto Canada. I’m a continuing education provider, and if you’d like more information about me, you can find it on the title slide.

Today, I’m going to talk to you about strategies for dealing with neurological complications and neurological symptoms as a direct result of patients that have unfortunately been afflicted with COVID-19. And there’s actually a growing amount of literature in this area and since my interest and expertise in the area of neurology and acupuncture, naturally this is a area that I’m very passionate about. So I’d like to show you some of the readings and research and strategies that are applied in my own clinic.

The first paper that we’re going to look at comes to us directly from [Wuhan 00:01:43]. This paper was published in just March, and it is a retrospective observational study conducted from three different centers. So these patients were tested positive for COVID in the month of January and February this year, and there were a total of 200 plus patients. And they were all assessed by neurologists, and their neurological manifestations were categorized into three different subtypes.

The first type is called the central type, and the central nervous system type gives you symptoms such as headache, impaired consciousness, if you can have an acute cerebrovascular disease, that’s another word for stroke, and you can have ataxia and seizures. The second type of classification is peripheral nervous system symptoms. And the most famous one that you may have already heard about is lack of smell or lack of taste. And sometimes there can be vision-related impairment as well. The third type of dysfunction is have to do with skeletal muscle injury. So patients would complain about pain. Those of us that know people who have been infected with COVID will tell you it’s like a flu like none other. You’re just hit with it. Your entire body hurts. I even had a friend tell me that it feels like shards of glass in his joints. That’s how painful it is. Okay?

So those are the three main neurological classifications. And as I said, this is a study of 214 people. And what the research found was that 36% of these patients all exhibited neurological symptoms. And what was interesting is that those with more severe infections, defined by having more poor respiratory status, which was in this case 41% of the patients in this study, they were more likely to develop neurological problems. So somehow, the harder you’re being hit by this disease, the more likely you’re going to have neurological symptoms. Just so you have a breakdown of roughly the proportions of the three different classifications I mentioned, about 25% of these patients had central nervous system symptoms. About 10% of the patients had peripheral nervous system symptoms, and another 10% or so have muscular skeletal symptoms. So, you can see why this is something that we as acupuncturists should be aware of because oftentimes patients with CMS and peripheral nervous and now of course muscle-related problems, want to come to us for support.

Of the central nervous system symptoms, the most common ones were headache and dizziness. Whereas, in the group for the peripheral nervous system, the most common symptoms were impaired taste, which is called dysgeusia, and impaired smell which is anosmia. And a patient who had muscle injury as compared to those who had no muscular pain symptoms, were found to have higher C-reactive protein levels and higher D-dimer levels. C-reactive protein is a marker for systemic inflammation in the body. So, patients who had more inflammation in the body was more likely to have muscle pain. And D-dimers is a breakdown product that the body makes when blood clots have been broken down, which is indirectly a measure of how much coagulation there is in the body.

So in other words, those with more coagulation, think in terms of [T-blastocysts 00:05:26] and TCM, those with C-reactive protein, indicative inflammation, thinking in terms of blood heat in TCM. These patients are far more likely to develop muscle injury related symptoms. Now, I want to emphasize that neurological symptoms is not just limited to the central nervous system. We mentioned it’s the peripheral and there’s the musculoskeletal. So I don’t want you to have an impression that show COVID patients are more, are oft being afflicted with strokes. Okay? That was the picture that was being passed around in the early stages when we didn’t know what was happening. But now we’re seeing, it seems to be that they are more likely to develop central nervous system symptoms, such as acute cerebrovascular disease like stroke, but it’s not the entire spectrum of neurological symptomologies that these COVID patients have.

So, as an example, in the Wuhan study, there are six patients out of only 200, only six patients out of 214 had acute cerebrovascular disease. And two of them actually arrived at the ER with sudden hemiplegia, paralysis, weakness of one side of the body, but they did not have many COVID symptoms. That is to say, no fever, no cough, no anorexia, no diarrhea. And they were only found to be suspected of having COVID from CT scans of the lung that found there’s some lesions. And then they were subsequently tested with PCR based assays to confirm that they had indeed were infected with COVID. So this is important because one, we need to realize that patients may never have gone to the hospital because they’re afraid of going to the hospital because they were going to get COVID, you can contract COVID in a hospital, they may have neurological symptoms and they will go to the community for care, even though they are positive and not because they’re, but being asymptomatic positive.

Another interesting finding was that some patients that did present with fever and headache were presented to neurologic ward in Wuhan, and they were initially positive-negative. So either their viral titers were high enough to be detected by the assays, or it was a false negative. And then only when the symptoms really started come on like coughs, and the dyspnea, then they were retest [inaudible 00:08:00] found to be positive. So that’s important to keep in mind as conditions that we need to be aware of. Possibly the patient come to us with neurological symptoms, but may actually be symptom negative, but in fact positive COVID patients.

So in summary, from this paper, they found that all the patients that had neurological problems, tend to have lower lymphocyte counts, white blood cell counts, which is indicative of some level of immunosuppression, and therefore, they are more likely, for mechanisms that scientists are still starting to study, more likely to be afflicted with central nervous system symptoms.

And now patients who have more severe infections, meaning worse outcomes with their respiratory integrity, have higher D-dimer levels. That, again, it’s a measure of how much coagulation there was in the patient’s body, and this can explain why those with more severe infection, meaning more worse lung function, having more D-dimers, are they more likely to develop occlusion or clot-type of strokes.

[inaudible 00:09:16] reminder that the authors of this paper wanted to show us is that… I put this in red, in quotation, that during the epidemical period of COVID-19, when seeing patients with neurological manifestations, physicians should consider the COVID-19 infection as a differential diagnosis. You want to avoid the late diagnosis or misdiagnosing and prevention of transmission. So this is an important wisdom for all of us to take to heart as practices start to open and you’re seeing patients with neurological issues. You might want to gently remind them to go get tested, because it’s possibly that they could be positive and just be asymptomatic.

Now, a group in Spain replicated this type of study, but this time with a larger n size of 841 patients, and this time around with a larger sample size, they actually found that close to 60% of COVID-positive patients now presented with neurological symptoms. And this was data collected across two different institutions.

And Harvard, okay, I don’t want to be an alumnus, not all neurological symptoms associated with COVID are struck. If you look at these numbers here, only 11 out of 840 actually presented with ischemic stroke and three presented with hemorrhagic stroke. So that’s only 14 out of 840.

The mean time of occurrence was approximately 10 days after the development of the COVID symptoms. So they started having stroke 10 days later after personally having a cough, [inaudible 00:11:07] a fever and as such. And again, there was a very strong correlation between those that who had the stroke, in other words, the cerebrovascular disease, and those with higher D-dimer levels, meaning that’s the byproduct of the breakdown [inaudible 00:11:23] in the body. So in other words, no surprise, more [inaudible 00:11:26] in their body, more likely to have a stroke presentation.

Now on this side, we’re looking at a paper published in Germany, and this paper was a attempt to summarizing the amount of ischemic stroke that was being seen in patients with the COVID from three different countries. As in first column you can see from the United States, second column from China.

So this China column is actually the paper I just presented from Wuhan. And then another paper, which I’m not presenting today, is of n size of 206 from Singapore. And what I wish to point out, is that you can see the number of people having strokes in relation to the total [inaudible 00:12:22] positive number of COVID patients. It’s relatively small. Now they all have associated risk factors that we know of: have they been hypertensive, being obese, be having diabetes mellitus. These are predisposed youth to more higher incidents or infection in this diseases.

And what these researchers have found was that, in the overall picture, if you look at the type of stroke, that the patients are having, there is a preference or a more heavily weighted manifestation of large artery occlusions in contrast to small vessel types, in contrast to blockages in their heart or cardiac embolisms. Okay.

So even though the number of strokes that COVID patients have is not very high, and it really depends on the severity of the infection, it depends on how much D-dimers they have, if they were to get a stroke, based on the limited amount of data we have to date, it appears that there is a preponderance towards large artery occlusion type. And now let’s take a look at the outcome of these patients.

In China, of the 11 people that had stroke-related presentations, four of them died. In Singapore of the five people, three of them died. In the United States, none of them died, and they were then subsequently sent to ICU stroke units we have, or went to go home. So we can potentially, as acupuncture, be seeing these patients that are being sent back to the community for rehabilitation purposes.

Now, I want to talk a little bit more about this large party ischemic stroke. This paper that was talking about the five people from the United States is summarized in this tabulated form in the next slide. So this is a paper that was published in “The New England Journal of Medicine”. And this is physicians in New York were noticing that, “Wait a minute, young people are getting strokes. This is not expected.” So if you look at the first row, you can see the patients one through five. These are patients that are under the fifties. Most of them actually in their thirties or early forties. Young people should not be getting stroke. So even though I said repeatedly, that strokes are not the most predominant type of neurological symptoms in patients with COVID, it is kind of sad and devastating that these can affect young people. And not all of them had the risk factors we talked about, such as hypertension and diabetes. Look at the second, third row here.

Medical history and risk factors for stroke, there was none, these people had none, undiagnosed … One of them has undiagnosed diabetes and some of them have hypertension, but some people had no symptoms whatsoever. A lot of them weren’t even on any medication. So relatively healthy people, young people can get this.

So another thing I wanted to bring to your attention, is look at the symptoms that these patients present. So they present with hemiplegia, loss of consciousness. They can have difficulty speaking, or they can have altered sensation. They can have something called gaze preference, issues to do with the eyes, we’re going to go … and also hemianopia, which is also a vision [inaudible 00:16:47] symptom. We’re going to talk a little bit more about the visual aspect of stroke and have some strategies you can deal with that in the upcoming slides.

If you look at the vascular territory, the ones that the strokes involve, you’ll see that it is affecting the internal carotid, infecting the middle cerebral artery. Most of them are affecting middle cerebral artery with one exception here, here is affecting posterior cerebral artery. I’m going to also talk a lot about that. It means that patient that have stroke, these large vessel type of strokes, tend to be getting it in the internal carotid and its derivative, such as the middle cerebral artery.

Let’s look at the symptoms of these patients. So some patients have cough, headache and chills in the first column, patient one. Patient two has no symptoms. Patient three had no symptoms. Patient four was tired, that’s it. Other than that, no fever, no cough. I want to just stress upon you, maybe you want to take this into consideration when you screen patients, whether you accept these type of patients in your clinic or not. If somebody comes in with neurological symptoms needing help and this developed in the last two, three months, it could very possibly be asymptomatic COVID patients who’ve had this, and they’ve never had a reason to go get tested because they had no symptoms. So it’s up to you whether you want to open up your clinic to help these type of patients, or maybe request they’re tested before that you’re able to help them, et cetera.

So a little bit more about this large occlusion, artery type of occlusion. What is it exactly? [inaudible 00:18:40] saw some embolization of atherosclerotic debris. So if you think about plaques inside your blood vessel and embolization means these plaques have become free, dislodged. Usually they originated from the common or internal carotid artery in your neck, the common carotid artery divides into internal, external. I’m going to show you some pictures about that in a moment. Sometimes it can actually come from the heart itself, the vessels of the heart and they become dislodged. The large vessel ischemic strokes that develop are most likely to affect the medial cerebral artery territory.

In other words, the symptoms, the neurological symptoms the patients are going to manifest, are going to be whichever part of the cortex that the medial cerebral artery supplies. So this is why it’s important to know the anatomy, knowing which part of the vessels are more likely to be affected in COVID stroke type of patients, we can then predict what is the most likely type of symptoms or neurological dysfunctions that this patient going to have based on the vascularization of relevant function area, corresponding function areas in the brain.

So this is just a quick review of the circulation of the brain. What you see here in the center is the circle of Willis that we all learn about in school. What I love about this slide is that they color coded it as such that in purple, I’ll call the posterior circulation, and it’s called posterior circulation because comes from the vertebral artery in the back. If you look at the patient on the right side over here, VA stands for vertebral artery. Whereas the green shade, called the interior circulation, which subsequently divided into anterior cerebral and medial cerebral, also, ICS stands for internal carotid artery. These green ones come from … so you’ve color coded over here, comes from the carotid, common carotid artery, which divides into ECA, CCA is the common carotid artery, which divides into ECA for external carotid artery, this goes round the face, outside your skull and then the internal carotid artery, which as you can see is now green, and then goes into the brain and divides into enter in medial carotid artery.

So here is the picture of the internal carotid artery label over here, this big one over here in green, the biggest one, the biggest cross-section green. You can see it divides into anterior … the anterior cerebral artery, ACA over here. Then going left and right laterally, this one here is the middle cerebral artery.

So patients are most likely to have clots in here before the division, or somewhere in the neck here. Or after the internal carotid has bifurcated into the middle cerebral artery, you can have occlusions in the middle cerebral artery.

So now we’re going to take a look at where the middle cerebral artery supplies. So this is a very nice picture that shows you in a color coded manner different areas of the brain compartmentalized, based on its source of vascularization. So on the bottom here, you can see A, this is turquoise color, A part. These all supply the interior cerebral artery, it’s not relevant to our discussion. All the P part, all the red parts are all supplied by the posterior circulation. That’s also not relevant to what we’re talking about here. All the yellow ones, labeled N, shows us where the middle cerebral artery supplies.

So as you can see, it supplies a large portion of the lateral surface of the cortex, both the frontal, the parietal, and even the temporal lobe. So it is a very important area. If you look at the cross-section over here, you can see here’s the internal carotid artery and it divides into … this tiny little guy here is the anterior cerebral artery, and then it divides into common carotid artery. So patients with COVID are most likely having large vessel strokes, what that means is that most likely cause is in here before bifurcation, or in here in the middle cerebral artery. Why is it not in the interior? Because the interior is small. So therefore it doesn’t qualify as the large vessel type.

Now, as you can see, the middle cerebral artery then divides and wraps upwards to cover the parietal lobes and wraps downwards here to cover that the temporary lobes. So here’s a side view of this side here, very beautiful picture, I love this picture. You can see that if the occlusion is happening in the common carotid or middle cerebral, then all of these [inaudible 00:23:49] are going to be shut off. That means all the neuro cortical areas that are in this region are going to be hypoxic, and therefore going to go show [inaudible 00:24:00]

Now what’s in this area. If you remember your scalp acupuncture, there is the sensory line, the motor line, and that’s in relation to the central sulcus. So, where is the central sulcus? The central socket is in here. Okay. There’s just most promise sulcus over here. So interior that to the motor [inaudible 00:24:23], that is a somato sensory. So this means that somebody who suffers with a middle cerebral artery stroke is going to have sensory and motor dysfunction.

Okay. And even though the medial part, which is the blue “A” part, this is the region that’s more where the lower extremities are located, even though it is not part of the middle cerebral artery distribution, there is some overlap. So you can still expect patients to have lower extremity problems. And I’m of course, referring to the homonculus map, along the central sulcus, where if you recall the medial one-fifth is supposed to be the lower extremity, the middle two-fifth would be the upper extremity, and the lateral one-fifth would be the face.

So let’s approximate that on the picture here on the top right, in this area over here would probably be the lower extremity around here. Around here, would be the upper extremity. And when you get down to the park, closer to the Sylvian fissure over here, which separates the parietal lobe and the temporal lobe, you’re going to get closer to the facial areas. So these patients can obviously expect facial drooping, facial motor deficit, upper extremity, and to some extent, low extremity also.

Now I’m going to take a little segue now and talk about what other things are involved other than just the occlusion. There’s something that is called SIC, which stands for Sepsis Induced Coagulopathy. So this means it is a coagulation of blood clot that’s induced by having a bloodborne infection. So scientists now know how the virus gets into our bodies, through a type of receptor and uncertain cells called ACE2 receptors. “ACE” stands for Angiotensin Converting Enzyme. And these type of cells I’ve found on lung cells. So no surprise COVID is primarily an upper respiratory airway disease. It’s found in the small intestine. So perhaps this can explain why some patients have gastrointestinal symptoms with this disease. It’s found in endothelial cells, meaning these are the lining cells of your blood vessels in the dyadic system.

So now we can see how this actually can attack the vascular system and lead to severe vascular events. And it’s found in smooth muscles in the brain. So no wonder people can develop neurological central member system symptoms as a result of this infection. Now I’m no expert on the complicated receptor cascade that regulates the inflammation and coagulation in the body. So I’ll just summarize it for you: it’s two types of receptors are known to activate cardio-protected or neuro-protected effects inside the body. Now, when COVID-19 infects us through ACE2 receptors, it depletes the receptors. Meaning whichever function that these receptors are supposed to do physiologically can no longer be accessed. So what this means is that our body is in a less, or more compromised cardio-protected in your particular state, leaving us one type of receptor to act unopposed thinking about Yin and Yang regulation.

So what is one activating? A swine type of receptor, ultimately results in cascades, sickening cascades, that activate genes that lead to inflammation, and coagulation, and even hypertension’s that embody. So, as the cognition is not bad enough, now you have high blood pressure – you’re more likely to cause a stroke, right? So it is because this virus has the taste for these two receptors that is supposed to be neuroprotective for us. But, as a consequence of these receptors being also found in the brain, it’s a double whammy. You are now set up for inflammatory and coagulatory disaster.

Now scientists are proposing different ideas of how this lead to damage to the brain. We now know that there is more inflammation in the body, because of the unopposed ACE1 cascades inside the body. But what that inflammation does, is that it can actually lead to damage, or breakdown of the blood brain barrier. So the bumping barrier is a very delicate piece of barrier inside our body. And if it is broken down because of inflammation, that spells doom. What happens is then the inflammatory cytokines in your body, now can cross the blood brain barrier, and reach the central nervous system. So it’s, it’s just bad on top of that. You may have heard about cytokine storms that happen in this patient is actually your body’s immune response. That is hyper immunity response towards the virus that is actually causing damage to tissues and organs that certainly can also affect the brain now ,because it’s got causing breakdown of the blood brain barrier.

So I think that’s really interesting information about the neuro-physiological mechanism. How this virus affects us and it gives us a epidemiological appreciation of how this disease can manifest in neurological ways. Now I’m going to share with you some of my ideas about how we can help these type of patients using areas in my research that I’ve done about the peripheral nervous system and the [inaudible 00:30:54] system. This is a map called a Brahman area map where the different processes of the brain had been compartmentalized based on different functions. I showed that here, just as a quick reference for you, because in my upcoming slides, I will be talking a little bit about some of these areas.

So one of the most common peripheral nervous system functions was Anosmia, which is loss of smell and Ageusia, or hypergeusia, which is loss of taste. So how can we possibly help patients with this? First of all, we need to say the [inaudible 00:31:38] nerve one, which is our olefactory nerve, is way deep inside the brain. It’s not accessible. And unfortunately the olfactory cortex is also not accessible. It’s not posting up to the surface in the brain for us to be able to affect it through scalp cap acupuncture. If you go back to the previous slide, you’ll see that olfactory is a dark orange. The dark orange is actually area 34.

Okay, so if you see this, this is actually in the midline. This is the lateral surface, this is the midline. So it’s actually on the inside of the temporal lobe. It’s not accessible, to too far in for acupuncture, [inaudible 00:32:11] . So what can we do? Fortunately, we have points that have been passed down that are supposed to have some effect on the nose and sense of smell. That’s over, located on the midline of the scalp. But let’s take a look at the new anatomy and see if it actually makes sense based on what we know about the new anatomy of the nerve supply for the nose. I want to talk about the anterior ethmoid nerve, which is actually from the opthalmic division V one of cranial nerve five. And, let’s take a look at that.

So, anterior ethmoid nerve, here’s the ganglion of the trigeminal nerve and there’s, there’s your V one, V two and V three. So as part of the V one, you have this nerve here that branches into the posterior ethmoid, anterior ethmoid, see how it goes and makes it a little hole in the foramen, in the back of the eyes. So from here, it goes into the cranial vault. I’m going to give you a different view at the next slide here.

So it comes out of these foramens over here and these nerves actually supply the meninges. So here’s the interior meningial branches and anterior ethmoid nerve, that supplies the meninges. But, because this cross section is horizontal, you don’t appreciate how high up this innovation goes. So this next picture shows you that the opthalmic division of V one and specifically the anterior ethmoid nerve, innovate this bony membrane called the falx cerebri along the midline.

And, it gives credence to the notion that these points that have been passed down to us, global area 20, all the way to 23, 24, which is on the midline, or which is innovated by the anterior ethmoid nerve, can possibly affect this nerve. So, what’s the big deal about affecting these nerves? Well, this anterior ethmoid nerve not only just innovates the meniges, these same nerves or branches now innovate the nasal cavity and septum. So as you can see here, the anterior ethmoid nerve, after it innovates the meninges up here, comes very close to the olfactory ball, by the way. So, we don’t currently don’t have permission to confirm this, but normally what we know about the nervous system, oftentimes there are communication branches that might be able to affect the cranial nerve of one olfactory nerve.

But, even if it doesn’t, this nerve, has an external branch that goes outside the [inaudible 00:34:59] of skin, but an internal branch that innovates the septum and also the nasal cavity. So this nerve gets information about the amount of mucus or dryness there is in the nasal cavity, and, presumably, your nervous system can regulate the amount of moisture in your cavity. And, we know that dry nose is related to, mucus member is needed, moisture is needed for fragrance particles to adhere, and therefore more likely for us to detect the smell. Perhaps by modifying the internal conditions of the nasal cavity, even though we’re not affecting the cranial nerve one directly, we are making it more favorable for the cranial nerve one to actually be able to detect smells and fragrances. I thought it was pretty crazy that these points that we learned on the anterior aspect of the midline of the scalp, to do with the nose, actually has hard cranial nerve-related explanations for how they can affect the nose.

Now, a couple of case. The gustatory cortex is something that is accessible. So, the gustatory cortex is actually Brodmann area 43. It’s a tiny, tiny little area, basically at the junction of the Sylvian fissure and the central sulcus. So you can see here, this part here is the central sulcus. So, anterior to that is a motor, posterior is a motor sensory. If you continue all the way down, where the motor sensory and the temporary lobe meets, that’s Brodmann area 43, which is the gustatory cortex.

And, based on the MRI research that I’ve done, and talked about it elsewhere, we have a chance to affect this area, but it requires a special needle technique, called a cross threading technique, where you would thread down from global area five and thread anteriorly from global area six, and that will allow you to cross intersect of over Brodmann area 43, which is a gustatory cortex. So if you’ve reviewed the vascularization of the middle cerebral artery, and with the parts that it affects, you can see why it would affect the taste, because that’s the gustatory area is part of the middle cerebral artery domain. And, therefore can explain why patients with COVID may have loss of taste, if they developed central nervous system type of symptoms.

Now, another way we can possibly affect the taste is using nerves called lingual nerves. And, these lingual nerves ara a branch of the mandibular division of the trigeminal nerve. So remember, the trigeminal nerve has three divisions, the mandibular is V3. Now, even though this is, strictly speaking again, a sensory nerve, it is not responsible for taste. In fact, the tastes of the anterior third of the tongue, as the comments here are written down for you, is supplied by the facial nerve. So, just sensation is supplied by the lingual nerve, but the taste, special sense taste, it’s essentially beneficial there. However, the facial nerve relies on the lingual nerve to convey its nerve fibers back to the brain. So, this is the reason why patients who have damage in the lingual nerve, either due to dental procedures and whatnot, can oftentimes cause them to feel like there’s a metallic taste in their mouth, or a foreign taste, or a lack of ability to taste.

And, so fortunately for us, we have acupuncture points located right below the tongue to affect these lingual nerves, and that’s the extra points Gingy [inaudible 00:39:01] . So, puncturing these points, even though it doesn’t affect the special sense directly, it provides conveyance of the special sense nerve fibers back to the brain, which might be able to help to receive more signal about taste to the brain. Now, early on, patient people also published ocular motor dysfunctions associated with patients who have COVID-19. Two different research groups have presented information how these patients may develop ocular motility deficits or ocular motor palsies. And, even though the case number is not very high at this point, again, you’ve got to think about this. People who present with either of the issues, and if they’re asymptomatic, are not going to be sent to isolation or sent to the infectious diseases.

They’re going to be going to the neurologist, or even in this case, ophthalmologist. By the way, the first doctor in China who blew the alarm on the COVID-19 was an Asian ophthalmologist. So, don’t let the fact that these cases don’t seem very high dissuade you, because it might simply be a case of lack of reporting. So in any case, how may we as acupuncturists help patients who are suffering Oculomotor Palsy, possibly as a consequence of having neurological dysfunctions from COVID infections?

I need to briefly introduce you to something called a frontal eye field. The frontal eye field, we talk of the Brodmann areas, right? It’s located in Brodmann area 6, so you can have a look at that in the map in a moment. And what happens is that this part of the brain is responsible for controlling rapid changes in your eyes in the left and right direction. It’s called saccadic movements. So patients who have dysfunction in this areas of the brain, affecting this area of the brain, may manifest inability to have rapid eye movements. This is also called contralateral horizontal conjugate gaze palsy. So if you recall, the American paper show you the five different patient cases. One of the symptoms that they had was gaze preference. Okay? It’s because they are lacking the ability to see both sides so they have a preference for one side.

Now, how does this affect the parts of the brain that actually controls cranial nerves III, IV, and VI, that actually is responsible for the eye movement? Based on tractology or connectivity studies, neurologists have found that the frontal eye field actually makes connections with the midbrain, where these cranial nerves can make the eyes form.

So again, these midbrain structures and cranial nerves are too deep for us to get affect directly. But pressed indirectly through the cortical connections, neurocortical connections, we can have a fighting chance to affect ocular motor systems. I’m going to show you my research about this. You’re looking at the correspondence of the scalp and the cortex, specifically operators 16. And I was really cool about this and I love the chorus, but that when, when the Eastern West converged gallbladder 16 in Chinese is more strong. It means I window. Hello? The name is telling you that this point can do with the vision and that it actually correspond to frontal eye field, based on modern research, is just too good to be true. So where is this specific to this front IFU in humans? A lot of research in animals suggest that it’s in Brodmann eight, but we now know that’s incorrect.

It’s in problem in six. And so where is that? If you look at the yellow data line, it’s where the superior frontal sulcus meets the precentral sulcus. So here’s the central sulcus, okay. Where we divide the motor sensory and there’s an OMP. So, and then you have the premotor area or the pieces of gyrus right in front of that, it’s called a precentral sulcus where the precentral sulcus meets the superior frontal sulcus. This is superior frontal sulcus there. This one over here look other broken is the inferior frontal sulcus. So in a case where the front end superior from this office meets the precentral sulcus. Now the bird side view superior frontal sulcus meets the precentral sulcus. This area is where Brodmann six or prefrontal sorry the frontal eye field is located. And we have a point called LAR 16, which is just right in this area. If you thread it, if you’re familiar, scalp acupuncture along the Meridian, you will cover this area beautifully. And therefore you will be able to affect from the eye field and affect ibogaine and movements.

I’m going to just finish up with a case that I recently saw of a showcase. I tongue in cheek, call it the case of shotgun at time of Corona. And this was an 86 year old male patient who in early April, he, he and his family cannot be exactly sure exactly. When, where he started have developed slurred speech. Now he has the risk factors such as hypertension, diabetes, mellitus, and other non directly related symptoms. And nursing does comorbidities such as them freaking urination as a result of enlarged prostate. He’s had a history of Bell’s Palsy in his forties. Now several weeks before he had a stroke, he has some poor sleep. So it’s not sure whether that sleep was related to that’s just a coincidence or related to poor sleep having caused hypertension poorly managed by any case, he was admitted to the hospital for one night.

And because of symptoms was start to already showing signs of very fortunate men or already showing signs of improvement. He was discharged the next day. And, and which is atypical should typically, when you have a symptom of stroke, you are in the hospital for very longer. Not sure this is change in policies is dependent on the fact that there’s some lack of resources and the staffing during this time of COVID that the patient, since it was not life threatening was sent back home, by any case in addition to star specie also presented with left sided arm and leg paresis, and he felt extremely tired. I remember one of the symptoms, one of the only symptoms that, one of the five Americans that had the show with just lethargy, right? There’s no other covert, listen to this, man didn’t have any respiratory problems’ fever and such, but it doesn’t mean he’s not positive.

And for all the research that we’ve seen so far and the family noticed that ever since having a stroke is, can seem to have Mark and the aged. And, is just complaining about tiring all the time. He has a dark tongue okay a dark purple tongue [inaudible 00:46:46] that we talked about things like coral coding, which means a lot of phlegm cold phlegm inside of the body, which is we know cold, also contributes to [inaudible 00:46:58], right? So the pictures are triangulating quite nicely, unfortunately this is actually a family friend of my receptionist, and because the clinics closed due to mandating to be closed because of public health policies, he’s unable to make an acupuncture appointment with me or with anybody.

So it wasn’t until we will reopen on June 2nd, he was able to get his appointment. And so on the very first day that I was back on June 6th, he saw me for acupuncture and to date, we’ve had four sessions so far, and I’m happy to say that the results have been quite favorable after one treatment he said that his left leg, which is the afflictive site actually now feel stronger than in his right side. Okay. So patients, maybe there’s a little bit of a, a good patient and practice rapport there, maybe a little bit of psychological effect, but Hey, I’ll take it. And, but so far there’s no change in the arm strength just yet, which is actually expected those of us that have experience doing neuro rehab know that arm loss of function or paralysis is harder to regain than leg paralysis. But by the end of the fourth session, patient Ashley left the treatment room without taking or, quote unquote, needing his cane. So presumably that is indicative that his legs felt so strong that he forgot that he needed the cane.

So, that’s the latest case I can share with you all. I don’t know for certain that it is a case of COVID, but I’m using extreme PPE precautions, and I am suggesting that this case should go get tested despite being asymptomatic. So I thank you very much for your attention. And if you have any questions, just message me. If you like this presentation, don’t forget to tell your colleagues, don’t forget to let others know about it. And if you enjoyed it, show us some love. Thank you very much.

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