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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 1  |  Issue : 4  |  Page : 283-285

Stroke after cold bath


Department of Neurology, Stroke Unit, Christian Medical College, Ludhiana, Punjab, India

Date of Web Publication16-Oct-2014

Correspondence Address:
Dr. Paulin S Benedict
Department of Neurology, Stroke Unit, Christian Medical College, Ludhiana - 141 008, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.143007

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  Abstract 

Seasonal variation in stroke occurrence is well described. However, correlation between sudden cold water exposure and stroke is not documented in literature. We report two cases of ischemic stroke on sudden cold water exposure. Case 1: A 73-year-old male developed sudden left face, arm and leg weakness immediately after taking a dip in the holy waters of Amritsar Golden Temple, during peak winter. Case 2: A 48-year-old male developed right side weakness and fell in bathroom while taking bath in cold water at 6am. Studies show that both stroke and atrial fibrillation peak in winter. Pathophysiologically, sudden cold water exposure increases sympathetic tone, which is mediated by thermo-receptors, activated by the rapid fall in skin temperature. Superimposed on the hyper-dynamic circulatory situation during short-term cold water immersion, it induces a further increase in blood pressure. Cold water immersion or simply an exposure might increase the propensity for stroke, especially in high risk individuals.

Keywords: Atrial fibrillation, cold water exposure, hypertension, stroke


How to cite this article:
Benedict PS, Pandian JD. Stroke after cold bath. CHRISMED J Health Res 2014;1:283-5

How to cite this URL:
Benedict PS, Pandian JD. Stroke after cold bath. CHRISMED J Health Res [serial online] 2014 [cited 2019 Sep 19];1:283-5. Available from: http://www.cjhr.org/text.asp?2014/1/4/283/143007


  Introduction Top


Seasonal variation in stroke occurrence is well documented. It has already been reported that sudden submersion in cold water may provoke myocardial infarction. Furthermore, some neurological disorders such as transient global amnesia (TGI) have also been reported after swimming in cold water. Nevertheless, no previous report has been published on the relationship between cold water exposure and risk of stroke. We report two cases of ischemic stroke on sudden cold water exposure.


  Case Reports Top


Case 1

A 73-year-old gentleman, with known risk factors such as diabetes, hypertension and coronary artery disease, took a dip in the Sarovar (Holy Lake) waters of the Golden Temple, Amritsar and immediately while coming out developed left-sided weakness and fell down. He presented with left-sided face, arm and leg weakness of 9 hours duration. On admission, the National Institute of Health Stroke Scale (NIHSS) was fifteen. Initial computerised tomography (CT) head showed right MCA territory infarct with midline shift of 0.4 cm. On the third day, his conditioned detoriated and NIHSS worsened to 32. A repeat CT [Figure 1] showed right middle cerebral artery (MCA) infarct with a mid-line shift of 1.4 cm. Decompressive hemi-craniectomy was done for the same. During his hospital stay, clectrocardiography (ECG) showed atrial fibrillation. Echocardiogram and carotid vertebral Doppler (CVD) were normal. He was discharged in a satisfactory condition (modified Rankin scale (MRS) 3).
Figure 1: CT head: Pre- and post-hemi-craniectomy showing right MCA infarct of case 1

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Case 2

A 48-year-old gentleman came with history of developing weakness and fall while bathing with cold water early in the morning around 6 am. He presented with right face, arm and leg weakness, facial deviation with global aphasia for duration of two hours. On admission, his NIHSS was sixteen. His blood pressure was 140/90. His magnetic resonance imaging (MRI) brain [Figure 2] revealed acute infarct in the left middle cerebral artery (MCA) territory. Atrial fibrillation was present in ECG. Investigations revealed hypercholesterolemia. His echocardiography and cardiovascular disease (CVD) were normal. He was discharged with a MRS 2.
Figure 2: MRI brain of case 2

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  Discussion Top


The Golden Temple is a prominent Sikh Gurdwara located in the city of Amritsar, Punjab, India. It is surrounded by holy waters called Sarovar. The patient developed stroke after he took a dip in this water in December during peak winter when temperature was around 6˚C. The second patient developed stroke and fell in bathroom while bathing at 6 am with cold water stored in an overhead tank, when there was a steep fall in local temperature from 26˚ C to 14˚C approximately, due to snow fall in Himalayas and local rainfall.

Epidemiologically, stroke shows clear seasonal variation. The incidence of stroke was higher in winter when compared to summer. Ischemic stroke was more common in winter and hemorrhagic stroke more common in spring. [1] Also the prognosis was poor with patients who had stroke in winter. [2] Mortality also showed seasonal variations with peaks in winter [3] In a landmark study, it was found that a 5°C drop in temperature was associated with a 7% increase in admissions for stroke. [4] The authors attributed the high incidence of stroke to changes in lipid profile, blood pressure and coagulation during winter.

It has already been reported that sudden submersion in cold water may provoke myocardial infarction. Furthermore, some neurological disorders such as transient global amnesia (TGI) have been reported after swimming in cold water. Nevertheless, no previous report has been published on the relationship between cold water exposure and risk of stroke. An experiment done in which 9 young men underwent lower body immersion in cold water (13˚C) and warm water (35˚C) subsequently for 60 minutes, showed that immersion in cold water reduces core body temperature and increases total peripheral vascular resistance, which subsequently increases arterial blood pressure. [5] Hypothetically, this might trigger stroke.

Pathophysiologically, activation of the sympathetic nervous system and secretion of catecholamine are increased in response to cold temperatures, which could result in increase in blood pressure through increased heart rate and peripheral vascular resistance. The hyperdynamic circulation during short-term cold water immersion further increases in blood pressure. Experimental studies suggest that alterations in temperature might also influence vascular function through an effect on endothelial nitric-oxide synthase and bioavailability of NO. Repeated cold exposure in animal models has been shown to develop hypertension and impaired endothelial vasodilator function in isolated arterial tissue. These responses to immersion in cold water can place a significant strain on cardiovascular system. Furthermore, during cold water immersion, the fall in skin temperature elicits a powerful cardiorespiratory response, termed "cold shock," comprising an inspiratory gasp, hyperventilation, hypocapnia, tachycardia, peripheral vasoconstriction, and hypertension. These respiratory responses and the subsequent changes in cerebral blood flow could lead to neurological injuries. It is well demonstrated that cold water increases sympathetic hyperactivity. Nevertheless, it can also trigger cardiac parasympathetic activity. These factors could have contributed to stroke in the patients described in the report.

The incidence of atrial fibrillation also peaks in winter. A study done in Denmark and New Zealand has recorded a marked winter peak in incidence rates of hospitalization with stroke in atrial fibrillation patients. [6] Atrial irritability in early hypothermia often induces atrial fibrillation. In a prospective study of seasonal patterns in hemostatic factors in older men, the circulating concentrations of tissue plasminogen activator (t-PA), Von Willebrand factor (VWF) and Fibrin D-dimer were found to peak in winter. [7]

Both the cases showed atrial fibrillation in ECG and their brain imaging revealed a large infarct in the MCA territory, all suggestive of cardio-embolic stroke, though atherosclerotic cause cannot be ruled out. They both had risk factors for stroke, hypertension in particular, which as per the discussion above might have enhanced the risk of stroke on exposure to cold water. Superimposing on it, sympathetic hyperactivity, cold shock, increased hemostasic factors are good postulates to explain the mechanism of stroke on exposure to cold water.


  Conclusion Top


The effect of cold weather on stroke is already proven. This case report reveals that cold water immersion or even a cold water exposure might increase the propensity for stroke in patients having risk factors for stroke. But further studies are needed to prove the association.

 
  References Top

1.
Palm F, Dos Santos M, Urbanek C, Greulich M, Zimmer K, Safer A, et al . Stroke seasonality associations with subtype, etiology and laboratory results in the Ludwigshafen Stroke Study. Eur J Epidemiol 2013;20:117-23.  Back to cited text no. 1
    
2.
Turin TC, Kita Y, Rumana N, Murakami Y, Ichikawa M, Sugihara H, et al . Stroke case fatality shows seasonal variation regardless of risk factor status in a Japanese population: 15-year results from the Takashima Stroke Registry. Neuroepidemiology 2009;32:53-60.  Back to cited text no. 2
    
3.
Lichtman JH, Jones SB, Wang Y, Leifheit-Limson EC, Goldstein LB. Seasonal variation in 30-day mortality after stroke: Teaching versus non-teaching hospitals. Stroke 2013;44:531-3.  Back to cited text no. 3
    
4.
Chang CL, Shipley M, Marmot M, Poulter N. Lower ambient temperature was associated with an increased risk of hospitalization for stroke and acute myocardial infarction in young women. J Clin Epidemiol 2004;57:749-57  Back to cited text no. 4
    
5.
Muller MD, Kim CH, Seo Y, Ryan EJ, Glickman EL. Hemodynamic and thermoregulatory responses to lower body water immersion. Aviat Space Environ Med 2012;83:935-41.  Back to cited text no. 5
    
6.
Christensen AL, Rasmussen LH, Baker MG, Lip GY, Dethlefsen C, Larsen TB. Seasonality, incidence and prognosis in atrial fibrillation and stroke in Denmark and New Zealand. BMJ Open 2012;2:e001210.  Back to cited text no. 6
    
7.
Ghebre MA, Wannamethee SG, Rumley A, Whincup PH, Lowe GD, Morris RW. Prospective study of seasonal patterns in hemostatic factors in older men and their relation to excess winter coronary heart disease deaths. J Thromb Haemost 2012;10:352-8.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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