Migraine headache following stellate ganglion block for reflex sympathetic dystrophy

Migraine after stellate ganglion block: A case report

Stellate ganglion block-induced ipsilateral migraines are rare. We present a typical case detailing its developmental process. Abnormalities in the autonomic nervous system control and vascular and neural mechanisms may play crucial roles in the manifestation of these migraines. Postprocedural migraines necessitate anesthesiologists' awareness during stellate ganglion blocks.

Real-time ultrasound-guided stellate ganglion block for migraine: an observational study

Objective

To observe whether ultrasound-guided stellate ganglion block (SGB) can effectively relieve migraine pain and improve the quality of migraine patients’ life.

Methods

81 patients with migraines were enrolled in this study. The patients received SGB with 6 ml of 0.15% ropivacaine once every week for four times. Migraine was assessed with the Migraine Disability Assessment Scale (MIDAS) at baseline and three-months follow-up (Tm). The numerical rating scale (NRS) score at baseline, one day after treatment (Td) and Tm, the frequency of analgesic use in 3 months and the side effects were also recorded at the same time.

Results

The NRS score of migraine subjects decreased significantly from 7.0 (2.0) to 3.0 (1.0) at Td and 2.0 (2.0) at Tm (vs baseline, P < 0.01). The MIDAS total scores were 14.0 (10.5) at baseline and 7.0 (4.5) at Tm (P < 0.001). During the three months, the frequency of analgesic consumption was decreased from 6.2 ± 2.8 to 1.9 ± 1.8. There were no serious side effects.

Conclusions

This study confirmed that ultrasound-guided SGB is an effective method to treat migraines. This technique can reduce pain and disability and then improve the quality of life of patients with migraines.

Symptomatic migraine: A systematic review to establish a clinically important diagnostic entity

OBJECTIVE

To determine if a clinical presentation indistinguishable from migraine can occur due to an underlying condition or pathology, that is, "symptomatic migraine."

BACKGROUND

It is currently not clear whether migraine truly can be caused by an underlying condition or pathology. Characterization of the etiology and clinical features of possible symptomatic migraine is of significant clinical importance and further may help elucidate the pathophysiology of migraine.

METHODS

We devised operational diagnostic criteria for "symptomatic migraine" and "possible symptomatic migraine" requiring strong evidence for a causal relation between underlying cause and migraine symptoms adhering strictly to diagnostic criteria. PubMed was searched for case reports of symptomatic migraine from inception to March 2020. Only articles published in English or German were included. No restrictions were placed on study design. Relevant references in the articles were also included. Papers were systematically reviewed by two independent reviewers for detailed clinical features of migraine as well as the proposed underlying conditions and the effects of treatment of these conditions.

RESULTS

Our search retrieved 1726 items. After screening, 109 papers comprising 504 cases were reviewed in detail. Eleven patients with migraine with aura (MWA) fulfilled our working criteria for symptomatic migraine, and 39 patients fulfilled our criteria for possible symptomatic migraine. The most common etiologies of symptomatic migraine were arteriovenous malformations, carotid stenosis, dissection or aneurysm, brain infarctions, meningioma, and various intra-axial tumors.

CONCLUSIONS

Symptomatic MWA, indistinguishable from idiopathic MWA, may occur due to cortical lesions or microembolization. We found no clear evidence supporting the existence of symptomatic migraine without aura although we did identify possible cases. Our findings are limited by the available literature, and we suggest that prospective studies are needed.

NLRP3 inflammasomes are involved in the progression of postoperative cognitive dysfunction: from mechanism to treatment

Postoperative cognitive dysfunction (POCD) involves patient memory and learning decline after surgery. POCD not only presents challenges for postoperative nursing and recovery but may also cause permanent brain damage for patients, including children and the aged, with vulnerable central nervous systems. Its occurrence is mainly influenced by surgical trauma, anesthetics, and the health condition of the patient. There is a lack of imaging and experimental diagnosis; therefore, patients can only be diagnosed by clinical observation, which may underestimate the morbidity, resulting in decreased treatment efficacy. Except for symptomatic support therapy, there is a relative lack of effective drugs specific for the treatment of POCD, because the precise mechanism of POCD remains to be determined. One current hypothesis is that postoperative inflammation promotes the progression of POCD. Accumulating research has indicated that overactivation of NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasomes contribute to the POCD progression, suggesting that targeting NLRP3 inflammasomes may be an effective therapy to treat POCD. In this review, we summarize recent studies and systematically describe the pathogenesis, treatment progression, and potential treatment options of targeting NLRP3 inflammasomes in POCD patients.

Tonic-clonic seizure during the ultrasound-guided stellate ganglion block because of an injection into an unrecognized variant vertebral artery: A case report

RATIONALE

Recent years have witnessed a marked improvement in the safety and accuracy of nerve blocks with the help of ultrasound and other visualization technologies. This study reports a challenging case of a severe complication during the ultrasound-guided stellate ganglion block.

PATIENT CONCERNS

A 28-year-old male patient with refractory migraine complained episodic pulsatile pain with photophobia, haphalgesia of the scalp for 3 years.

INTERVENTIONS

Ultrasound-guided stellate ganglion block with 4 ml of 1% lidocaine was administrated.

OUTCOMES

A sudden loss of consciousness and tonic-clonic seizure was occurred after negative aspiration and test dose. Further sonographic examination revealed a variation in the left vertebral artery, which remained unrecognized during the needle insertion because of its sliding ability under the differential pressure applied by the probe.

LESSONS

Inadvertent intra-arterial injection of a local anesthetic agent could be minimized under the ultrasound guidance with various protective strategies, including the determination of any prior variation, optimizing the block route, maintaining a constant probe pressure, and using saline for the test dosage. This case resulted in the implementation of new protocols of the ultrasound-guided stellate ganglion block in our department.

Complications associated with stellate ganglion nerve block: a systematic review

Stellate ganglion nerve blockade (SGNB) is a vital tool in our armamentarium for the treatment of various chronic pain syndromes. SGNB can be performed using the traditional landmark-based approach, or with image guidance using either fluoroscopy or ultrasound. In this review, we systematically analyzed reported SGNB-related complications between 1990 and 2018. Seven databases were queried for SGNB between January 1, 1990 and November 27, 2018. Search results of the complications associated with SGNB were reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Out of a total of 1909 articles, 67 articles met our inclusion criteria, yielding 260 cases with adverse events. In 134 of the 260 (51.5%) cases, SGNB was performed with image guidance. Sixty-four (24.6%) and 70 (26.9%) of the complication cases reported the use of ultrasound and fluoroscopy guidance, respectively. One hundred and seventy-eight (68.4%) patients had medication-related or systemic side effects, and 82 (31.5%) had procedure-related or local side effects. There was one report of death due to massive hematoma leading to airway obstruction. There was one case report of quadriplegia secondary to pyogenic cervical epidural abscess and discitis following an SGNB. Complications following SGNB have been reported with both landmark-based techniques and with imaging guidance using fluoroscopy or ultrasound. In our systematic review, most adverse events that were reported occurred during or shortly after SGNB. Vigilance, American Society of Anesthesiologists standard monitors for conscious sedation, and accessibility to resuscitation equipment are vital to the safe performance of SGNB.

Complex regional pain syndrome type 1 in a child with migraine

Complex regional pain syndrome type 1 is a rare painful syndrome in children involving an extremity which consists of pain out of proportion to the cause, loss of function, and significant evidence of autonomic dysfunction. We report a child, a known case of migraine who presented with spontaneous onset pain and sudomotor changes in an extremity not preceded by any trauma. A good clinical eye is required for the identification and diagnosis of this underreported condition to prevent doing extensive investigations. The coexistence of migraine and complex regional pain syndrome type 1 in a patient is interesting and is probably due to the common underlying pathophysiological abnormalities involving central serotonin activity and neurogenic inflammatory mechanisms.

Profil autonomique des patients migraineux

OBJECT

Dysfunction of autonomic nervous system (ANS) is implicated in the genesis and persistence of migraine. The objective of this study was to compare autonomic nervous system (ANS) profile of migraineurs during headache-free periods to a group of normal subjects based on cardio-vascular reactivity.

METHODS

Patients with migraine according to the criteria of IHS 2004 were selected for the study. After a 30 min resting blood pressure (BP), the following standard tests were performed: deep-breathing (DB), hand grip (HG) of 15 s and 3 min, valsalva maneuver, echo stress, (ES) and tilt test (TT). Results were compared to 44 normal subjects, age similar, 37 female, (84.1%) using the Student test, with P < 0.005 as significant.

RESULTS

Thirty-two patients (27 female (84.38%), 16-51 years, mean 40.41 +/- 7.8) were studied. Twenty-two patients (69%) had systolic blood pressure below 94 mmHg and 25 patients (78%) had diastolic blood pressure below 60 mmHg. Compared to normal, migraineurs exhibited a significantly higher vagal response (P < 0.001) and a significantly lower alpha sympathetic response, central by using ES as well as peripheral by using HG of 3 min (P < 0.001).

CONCLUSIONS

Autonomic cardiovascular reactivity of patients with migraine showed a vagal hyperactivity and a deficiency of the alpha sympathetic system. This leads to further studies with new therapeutical approaches.

Maternal inheritance in cyclic vomiting syndrome with neuromuscular disease

Cyclic vomiting syndrome (CVS), characterized by severe discrete episodes of nausea, vomiting, and lethargy, is a predominately childhood condition associated with migraine and dysautonomic features. Disease-associated mitochondrial DNA (mtDNA) sequence variants are suggested by a strong maternal bias in the inheritance of migraine, and the recent findings of mtDNA variants in a few children with CVS and additional neuromuscular disease manifestations ("CVS+"). A clinical interview using a questionnaire was administered (generally) to one parent of 62 children with CVS+. Non-senile disease manifestations, including migraine, myopathy, seizures, and dysautonomia-like symptoms, were far more common in matrilineal versus non-matrilineal relatives, including being present in 75% of the mothers versus in only 11% of the fathers (P < 0.001). Overall, maternal inheritance is suggested in 86% of the families (in 65% strongly so). Disease manifestations in subjects and their affected matrilineal relatives are predominately intermittent and consistent with dysautonomia, including increased vital sign fluctuations. Body fluid metabolites and muscle biopsy findings are consistent with mitochondrial dysfunction in most cases tested. We conclude that mtDNA sequence variants are at least risk factors in the development of disease in most children at this "severe" end of the CVS spectrum, likely involving a maternally inherited propensity towards dysautonomia.

[Recurrent episodes of focal cerebral ischemia in a female patient with mitral valve prolapse and migraine headache]

Migraine is episodic, paroxysmal disorder where the headache represents the central symptom and is followed with different combinations of neurologic, gastrointestinal and vegetative changes. Not until the diagnostic procedures were developed, ischemic lesions were verified even in the patients with ordinary migraine. This is a report of a patient with migraine headache, followed twice by verified episodes of temporary ischemic attacks and verified focal ischemic lesion of cerebral parenchyma. The mitral valve prolapse was also detected. This all imposed the administration of combined prophylactic antimigrainous and anticoagulant therapy as an imperative because of the risk of the development of repeated ischemia of cerebral tissue. This association also confirmed an opinion that migraine is a wider disorder with the dominant dysfunction of limbic system.

Comparison of sensory and sympathetic innervation of the dura mater and posterior longitudinal ligament in the cervical spine after removal of the stellate ganglion

Although cervical spinal tissues are rich in sensory and sympathetic fibers, which play a significant role in clinical phenomena, there is little information available regarding their anatomical characteristics. In this study, we compared the innervation of the cervical dura mater and the posterior longitudinal ligament (PLL) to that after removal of the stellate ganglion to determine whether the anatomical background plays a significant role in clinical manifestations. Immunoreactivities for calcitonin gene-related peptide (CGRP) and substance P (SP) were used as sensory markers, and immunoreactivity for neuropeptide Y (NPY) was used as a sympathetic marker. Sensory fibers in the cervical dura mater were distributed within each cervical segment, but those in the PLL extended beyond the segmental borders. A dense sensory fiber network forming a single layer was seen at the intervertebral disc region in the cervical PLL, whereas sympathetic fibers in this region were sparsely distributed. Sympathetic fibers were distributed not only around the vascular wall but also in the region independent from vessels, and some occasionally ran together with sensory fibers in both the dura mater and the PLL. Removal of the stellate ganglion had little effect on the distribution of sensory fibers but denervated the sympathetic fiber networks in the region independent from vessels of the upper ipsilateral cervical PLL. In conclusion, the cervical dura mater and the PLL have different sensory and sympathetic innervations. Sympathetic fibers pass through the stellate ganglion to project to the region independent from vessels in the upper cervical PLL. Clinical symptoms may be attributed to this characteristic innervation of the cervical spine.

Anatomically and physiologically based guidelines for use of the sphenopalatine ganglion block versus the stellate ganglion block to reduce atypical facial pain

This literature review is designed to develop guidelines needed for the use of a sphenopalatine ganglion block versus a stellate ganglion block to reduce atypical facial pain. We have reviewed the basic anatomy of both ganglia and the physiological responses usually associated with each, and have given an opinion on appropriate use of these therapeutic modalities.