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Clinical Features of Acute Ischemic Stroke Patients with Hypoesthesia as an Initial Symptom. Neurol Int 2023; 15:508-517. [PMID: 36976673 PMCID: PMC10052980 DOI: 10.3390/neurolint15010030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
This study aimed to evaluate the clinical characteristics of acute ischemic stroke (AIS) patients who experienced hypoesthesia as the initial symptom. We retrospectively analyzed the medical records of 176 hospitalized AIS patients who met our inclusion and exclusion criteria and evaluated their clinical features and MRI findings. Among this cohort, 20 (11%) patients presented with hypoesthesia as the initial symptom. MRI scans of these 20 patients identified lesions in the thalamus or pontine tegmentum in 14 and brain lesions at other sites in 6. The 20 hypoesthesia patients had higher systolic (p = 0.031) and diastolic blood pressure (p = 0.037) on admission, and a higher rate of small-vessel occlusion (p < 0.001) than patients without hypoesthesia. The patients with hypoesthesia had a significantly shorter average hospital stay (p = 0.007) but did not differ significantly from those without hypoesthesia in National Institutes of Health Stroke Scale scores on admission (p = 0.182) or the modified Rankin Scale scores for neurologic disability on discharge (p = 0.319). In the patients with acute onset hypoesthesia, high blood pressure, and neurological deficits were more likely to be due to AIS than other causes. Since most of the lesions in AIS patients with hypoesthesia as the initial symptom were found to be small, we recommend performing MRI scans with such patients to confirm AIS.
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Barbosa LM, Valerio F, Pereira SLA, da Silva VA, de Lima Rodrigues AL, Galhardoni R, Yeng LT, Rosi J, Conforto AB, Lucato LT, Lemos MD, Teixeira MJ, de Andrade DC. Site matters: Central neuropathic pain characteristics and somatosensory findings after brain and spinal cord lesions. Eur J Neurol 2023; 30:1443-1452. [PMID: 36773324 DOI: 10.1111/ene.15744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/09/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND It is unknown if different etiologies or lesion topographies influence central neuropathic pain (CNP) clinical manifestation. METHODS We explored the symptom-somatosensory profile relationships in CNP patients with different types of lesions to the central nervous system to gain insight into CNP mechanisms. We compared the CNP profile through pain descriptors, standardized bedside examination, and quantitative sensory test in two different etiologies with segregated lesion locations: the brain, central poststroke pain (CPSP, n = 39), and the spinal cord central pain due to spinal cord injury (CPSCI, n = 40) in neuromyelitis optica. RESULTS Results are expressed as median (25th to 75th percentiles). CPSP presented higher evoked and paroxysmal pain scores compared to CPSCI (p < 0.001), and lower cold thermal limen (5.6°C [0.0-12.9]) compared to CPSCI (20.0°C [4.2-22.9]; p = 0.004). CPSCI also had higher mechanical pain thresholds (784.5 mN [255.0-1078.0]) compared to CPSP (235.2 mN [81.4-1078.0], p = 0.006) and higher mechanical detection threshold compared to control areas (2.7 [1.5-6.2] vs. 1.0 [1.0-3.3], p = 0.007). Evoked pain scores negatively correlated with mechanical pain thresholds (r = -0.38, p < 0.001) and wind-up ratio (r = -0.57, p < 0.001). CONCLUSIONS CNP of different etiologies may present different pain descriptors and somatosensory profiles, which is likely due to injury site differences within the neuroaxis. This information may help better design phenotype mechanism correlations and impact trial designs for the main etiologies of CNP, namely stroke and spinal cord lesions. This study provides evidence that topography may influence pain symptoms and sensory profile. The findings suggest that CNP mechanisms might vary according to pain etiology or lesion topography, impacting future mechanism-based treatment choices.
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Affiliation(s)
- Luciana Mendonça Barbosa
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil.,Department of Neurology, University of São Paulo, São Paulo, Brazil
| | - Fernanda Valerio
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil
| | | | | | | | - Ricardo Galhardoni
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil
| | - Lin Tchia Yeng
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil
| | - Jefferson Rosi
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil
| | | | | | | | - Manoel Jacobsen Teixeira
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil.,Department of Neurology, University of São Paulo, São Paulo, Brazil
| | - Daniel Ciampi de Andrade
- Department of Neurology, University of São Paulo, São Paulo, Brazil.,Center for Neuroplasticity and Pain, Department of Health Sciences and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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Eckenrode BJ, Kietrys DM, Brown A, Parrott JS, Noehren B. Signs of Nervous System Sensitization in Female Runners with Chronic Patellofemoral Pain. Int J Sports Phys Ther 2023; 18:132-144. [PMID: 36793566 PMCID: PMC9897008 DOI: 10.26603/001c.57603] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/10/2022] [Indexed: 02/04/2023] Open
Abstract
Background Patellofemoral pain (PFP) is a common overuse injury among runners, affecting females at a higher rate than males. PFP can often become chronic, with evidence suggesting it may be linked to both peripheral and central sensitization of the nervous system. Sensitization of the nervous system can be identified through quantitative sensory testing (QST). Hypothesis/Purpose The primary objective of this pilot study was to quantify and compare pain sensitivity as identified through QST measures, in active female runners with and without PFP. Study Design Cohort Study. Methods Twenty healthy female runners and 17 female runners with chronic PFP symptoms were enrolled. Subjects completed the Knee injury and Osteoarthritis Outcome Score for Patellofemoral Pain (KOOS-PF), University of Wisconsin Running Injury and Recovery Index (UWRI), and the Brief Pain Inventory (BPI). QST consisted of pressure pain threshold testing to three local and three distant sites to the knee, heat temporal summation, heat pain threshold, and conditioned pain modulation. Data was analyzed utilizing independent t-tests for comparison of between-group data, effect sizes for QST measures (Pearson's r), and Pearson's correlation coefficient between pressure pain threshold values at the knee and functional testing. Results The PFP group exhibited significantly lower scores on the KOOS-PF (p<0.001), BPI Pain Severity and Interference Scores (p<0.001), and UWRI (p<0.001). Primary hyperalgesia, identified through decreased pressure pain threshold at the knee, was detected in the PFP group at the central patella (p<0.001), lateral patellar retinaculum (p=0.003), and patellar tendon (p=0.006). Secondary hyperalgesia, a sign of central sensitization, was observed via differences in pressure pain threshold testing for the PFP group at the uninvolved knee (p=0.012 to p=0.042), involved extremity remote sites (p=0.001 to p=0.006), and uninvolved extremity remote sites (p=0.013 to p=0.021). Conclusion Compared to healthy controls, female runners with chronic PFP symptoms exhibit signs of both peripheral sensitization. Despite actively participating in running, nervous system sensitization may contribute to continued pain in these individuals. For female runners with chronic PFP, physical therapy management may need to include interventions which address signs of central and peripheral sensitization. Level of Evidence Level 3.
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Affiliation(s)
- Brian J Eckenrode
- Department of Physical Therapy Arcadia University
- Department of Rehabilitation and Movement Sciences Rutgers School of Health Professions
| | - David M Kietrys
- Department of Rehabilitation and Movement Sciences Rutgers School of Health Professions
| | - Allison Brown
- Department of Rehabilitation and Movement Sciences Rutgers School of Health Professions
| | - J Scott Parrott
- Department of Interdisciplinary Studies Rutgers School of Health Professions
| | - Brian Noehren
- Department of Physical Therapy University of Kentucky
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Ri S. The Management of Poststroke Thalamic Pain: Update in Clinical Practice. Diagnostics (Basel) 2022; 12:diagnostics12061439. [PMID: 35741249 PMCID: PMC9222201 DOI: 10.3390/diagnostics12061439] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/29/2022] [Accepted: 06/08/2022] [Indexed: 11/16/2022] Open
Abstract
Poststroke thalamic pain (PS-TP), a type of central poststroke pain, has been challenged to improve the rehabilitation outcomes and quality of life after a stroke. It has been shown in 2.7–25% of stroke survivors; however, the treatment of PS-TP remains difficult, and in majority of them it often failed to manage the pain and hypersensitivity effectively, despite the different pharmacotherapies as well as invasive interventions. Central imbalance, central disinhibition, central sensitization, other thalamic adaptative changes, and local inflammatory responses have been considered as its possible pathogenesis. Allodynia and hyperalgesia, as well as the chronic sensitization of pain, are mainly targeted in the management of PS-TP. Commonly recommended first- and second-lines of pharmacological therapies, including traditional medications, e.g., antidepressants, anticonvulsants, opioid analgesics, and lamotrigine, were more effective than others. Nonpharmacological interventions, such as transcranial magnetic or direct current brain stimulations, vestibular caloric stimulation, epidural motor cortex stimulation, and deep brain stimulation, were effective in some cases/small-sized studies and can be recommended in the management of therapy-resistant PS-TP. Interestingly, the stimulation to other areas, e.g., the motor cortex, periventricular/periaqueductal gray matter, and thalamus/internal capsule, showed more effect than the stimulation to the thalamus alone. Further studies on brain or spinal stimulation are required for evidence.
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Affiliation(s)
- Songjin Ri
- Department for Neurology, Meoclinic, Berlin, Friedrichstraße 71, 10117 Berlin, Germany;
- Department of Neurology, Charité University Hospital (CBS), 12203 Berlin, Germany
- Outpatient Clinic for Neurology, Manfred-von-Richthofen-Straße 15, 12101 Berlin, Germany
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Guo S, Zhang X, Tao W, Zhu H, Hu Y. Long-term follow-up of motor cortex stimulation on central poststroke pain in thalamic and extrathalamic stroke. Pain Pract 2022; 22:610-620. [PMID: 35686377 DOI: 10.1111/papr.13137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 05/18/2022] [Accepted: 06/02/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the long-term effects of motor cortex stimulation (MCS) on central poststroke pain (CPSP) in patients with thalamic and extrathalamic stroke. MATERIALS AND METHODS We retrospectively analyzed 21 cases of CPSP patients who were treated with MCS. Pain intensity was evaluated using the visual analog scale (VAS) and Neuropathic Pain Symptom Inventory (NPSI) before the operation and at follow-up assessments. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI). RESULTS The average follow-up time was 65.43 ± 26.12 months. In the thalamus stroke group (n = 11), the mean preoperative VAS score was 8.18 ± 0.75 and the final mean follow-up VAS score was 4.0 ± 2.14. The mean total NPSI score at the last follow-up (20.45 ± 12.7) was significantly reduced relative to the pre-MCS score (30.27 ± 8.97, p < 0.001). Similarly, the mean PSQI value at the last follow-up (12.63 ± 1.91) was significantly reduced compared with the pre-MCS value (16.55 ± 1.97, p < 0.001). In the extrathalamic stroke group (n = 11), the mean preoperative VAS score was 8.2 ± 0.79 and the final mean follow-up VAS score was 6.6 ± 2.12. The mean total NPSI score before MCS was not statistically different from that at the last follow-up. There were no statistical differences in sleep quality before versus after surgery. CONCLUSION Motor cortex stimulation has higher long-term efficacy in CPSP patients with stroke confined to the thalamus than in CPSP patients with stroke involving extrathalamic structures.
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Affiliation(s)
- Song Guo
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaolei Zhang
- Department of Neurosurgery, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Wei Tao
- Department of Neurosurgery, Shenzhen University General Hospital, Shenzhen University, Shenzhen, China
| | - Hongwei Zhu
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongsheng Hu
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Quantitative and Fiber-Selective Evaluation for Central Poststroke Pain. Neural Plast 2022; 2022:1507291. [PMID: 35707518 PMCID: PMC9192306 DOI: 10.1155/2022/1507291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 04/24/2022] [Accepted: 05/13/2022] [Indexed: 11/18/2022] Open
Abstract
The electrophysiological recording can be used to quantify the clinical features of central poststroke pain (CPSP) caused by different lesion locations. We aimed to explore the relationship between clinical features and lesion location in patients with CPSP using the current perception threshold (CPT) approach. Here, patients underwent the standardized CPT measure at five detection sites on both the contralesional and ipsilesional sides, using a constant alternating-current sinusoid waveform stimulus at three frequencies: 2000 Hz, 250 Hz, and 5 Hz. 57 CPSP patients were recruited in this cross-sectional study, including 13 patients with thalamic lesions and 44 patients with internal capsule lesions. Patients with a thalamic lesion had more frequent abnormal Aδ and C fibers than those with an internal capsule lesion (69.2% versus 36.4%, p value = 0.038; 53.8% versus 63.6%, p value = 0.038). The patients with internal capsule lesions had more frequent abnormal Aβ fibers than those with thalamic lesions (53.8% versus 63.6%, p value < 0.001). The sensory dysfunction in the patients with thalamic lesions was more likely to occur in the upper limbs (i.e., the shoulder (p value = 0.027) and the finger (p value = 0.040)). The lower limbs (i.e., the knee (p value = 0.040) and the toe (p value = 0.005)) were more likely to experience sensory dysfunction in the patients with internal capsule lesions. Hyperesthesia was more likely to occur in the thalamic patients, and hypoesthesia was more likely to occur in the patients with internal capsule lesions (p value < 0.001). In patients with thalamic lesions, Visual Analogue Scale (VAS) had a positive correlation with 5 Hz CPT on the shoulder (r = 0.010, p value = 0.005), 250 Hz CPT on the finger (r = 0.690, p value = 0.009) from the contralesional side, and 2000 Hz CPT on the knee (r = 0.690, p value = 0.009). In patients with internal capsule lesions, VAS had a positive correlation with 2000 Hz CPT on the knee (r = 0.312, p value = 0.039) and foot (r = 0.538, p value < 0.001). In conclusion, the abnormal fiber types, sensory dysfunction territory, and clinical signs of CPSP in thalamic stroke differ from those in internal capsule stroke. Implementation of the portable and convenient CPT protocol may help clarify the locations of different stroke lesions in various clinical settings.
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Barbosa LM, da Silva VA, de Lima Rodrigues AL, Mendes Fernandes DTR, de Oliveira RAA, Galhardoni R, Yeng LT, Junior JR, Conforto AB, Lucato LT, Lemos MD, Peyron R, Garcia-Larrea L, Teixeira MJ, de Andrade DC. Dissecting central post-stroke pain: a controlled symptom-psychophysical characterization. Brain Commun 2022; 4:fcac090. [PMID: 35528229 PMCID: PMC9070496 DOI: 10.1093/braincomms/fcac090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/21/2021] [Accepted: 03/31/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Central post-stroke pain affects up to 12% of stroke survivors and is notoriously refractory to treatment. However, stroke patients often suffer from other types of pain of non- neuropathic nature (musculoskeletal, inflammatory, complex regional) and no head-to-head comparison of their respective clinical and somatosensory profiles has been performed so far.
We compared 39 patients with definite central neuropathic post-stroke pain with two matched- control groups: 32 patients with exclusively non-neuropathic pain developed after stroke and 31 stroke patients not complaining of pain. Patients underwent deep phenotyping via a comprehensive assessment including clinical exam, questionnaires and quantitative sensory testing to dissect central post-stroke pain from chronic pain in general and stroke.
While central post-stroke pain was mostly located in the face and limbs, non-neuropathic pain was predominantly axial and located in neck, shoulders and knees (p<0.05). Neuropathic Pain Symptom Inventory clusters burning (82.1%, n=32, p<0.001), tingling (66.7%, n= 26, p<0.001) and evoked by cold (64.1%, n=25, p<0.001) occurred more frequently in central post-stroke pain. Hyperpathia, thermal and mechanical allodynia also occurred more commonly in this group (p<0.001), which also presented higher levels of deafferentation (p<0.012) with more asymmetric cold and warm detection thresholds compared to controls. In particular, cold hypoesthesia (considered when the threshold of the affected side was less than 41% of the contralateral threshold) odds ratio was 12 (95%CI: 3.8-41.6) for neuropathic pain. Additionally, cold detection threshold/ warm detection threshold ratio correlated with the presence of neuropathic pain (ρ=-0.4, p< 0.001). Correlations were found between specific neuropathic pain symptom clusters and quantitative sensory testing: paroxysmal pain with cold (ρ=-0.4; p=0.008) and heat pain thresholds (ρ=0.5; p=0.003), burning pain with mechanical detection (ρ= -0.4; p=0.015) and mechanical pain thresholds (ρ=-0.4, p<0.013), evoked pain with mechanical pain threshold (ρ= -0.3; p=0.047). Logistic regression showed that the combination of cold hypoesthesia on quantitative sensory testing, the Neuropathic Pain Symptom Inventory, and the allodynia intensity on bedside examination explained 77% of the occurrence of neuropathic pain.
These findings provide insights into the clinical-psychophysics relationships in central post-stroke pain and may assist more precise distinction of neuropathic from non-neuropathic post-stroke pain in clinical practice and in future trials.
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Affiliation(s)
| | | | | | | | | | - Ricardo Galhardoni
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, Brazil
| | - Lin Tchia Yeng
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, Brazil
| | - Jefferson Rosi Junior
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, Brazil
| | | | | | - Marcelo Delboni Lemos
- Department of Radiology, LIM-44, University of São Paulo, 05403-900, São Paulo, Brazil
| | - Roland Peyron
- NeuroPain team, Lyon Neuroscience Research Center (CRNL), Inserm U1028, CNRS UMR5292, UCBL1, UJM, F-6900, Lyon, France
| | - Luis Garcia-Larrea
- NeuroPain team, Lyon Neuroscience Research Center (CRNL), Inserm U1028, CNRS UMR5292, UCBL1, UJM, F-6900, Lyon, France
| | - Manoel Jacobsen Teixeira
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, Brazil
- Department of Neurology, LIM-62, University of São Paulo, 05403-900, São Paulo, Brazil
| | - Daniel Ciampi de Andrade
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, Brazil
- Center for Neuroplasticity and Pain, Department of Health Sciences and Technology, Faculty of Medicine, Aalborg University, DK-9220, Aalborg, Denmark
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Dissecting neuropathic from poststroke pain: the white matter within. Pain 2022; 163:765-778. [PMID: 35302975 DOI: 10.1097/j.pain.0000000000002427] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/27/2021] [Indexed: 12/13/2022]
Abstract
ABSTRACT Poststroke pain (PSP) is a heterogeneous term encompassing both central neuropathic (ie, central poststroke pain [CPSP]) and nonneuropathic poststroke pain (CNNP) syndromes. Central poststroke pain is classically related to damage in the lateral brainstem, posterior thalamus, and parietoinsular areas, whereas the role of white matter connecting these structures is frequently ignored. In addition, the relationship between stroke topography and CNNP is not completely understood. In this study, we address these issues comparing stroke location in a CPSP group of 35 patients with 2 control groups: 27 patients with CNNP and 27 patients with stroke without pain. Brain MRI images were analyzed by 2 complementary approaches: an exploratory analysis using voxel-wise lesion symptom mapping, to detect significant voxels damaged in CPSP across the whole brain, and a hypothesis-driven, region of interest-based analysis, to replicate previously reported sites involved in CPSP. Odds ratio maps were also calculated to demonstrate the risk for CPSP in each damaged voxel. Our exploratory analysis showed that, besides known thalamic and parietoinsular areas, significant voxels carrying a high risk for CPSP were located in the white matter encompassing thalamoinsular connections (one-tailed threshold Z > 3.96, corrected P value <0.05, odds ratio = 39.7). These results show that the interruption of thalamocortical white matter connections is an important component of CPSP, which is in contrast with findings from nonneuropathic PSP and from strokes without pain. These data can aid in the selection of patients at risk to develop CPSP who could be candidates to pre-emptive or therapeutic interventions.
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Kim JS. Posterior Cerebral Artery Disease. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00025-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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10
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Malhotra A, Weaver J. Approach to Neuropathic Pain. Semin Neurol 2021; 41:744-759. [PMID: 34826876 DOI: 10.1055/s-0041-1726361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Neuropathic pain is a common chief complaint encountered by neurologists and primary care providers. It is caused by disorders involving the somatosensory nervous system. The clinical evaluation of neuropathic pain is challenging and requires a multifaceted systematic approach with an emphasis on a thorough history and physical examination to identify characteristic signs and symptoms. Ancillary laboratory investigations, targeted imaging, and electrodiagnostic studies further help identify underlying etiologies to guide specific treatments. Management of neuropathic pain encompasses treating the underlying pathology as well as symptomatic control with nonpharmacological, pharmacological, and interventional therapies. Here, we present an approach to help evaluate patients with neuropathic pain.
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Affiliation(s)
- Ashwin Malhotra
- Department of Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joshua Weaver
- Department of Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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Hirato M, Miyagishima T, Takahashi A, Yoshimoto Y. Thalamic anterior part of the ventral posterolateral nucleus and central lateral nucleus in the genesis of central post-stroke pain. Acta Neurochir (Wien) 2021; 163:2121-2133. [PMID: 33990885 DOI: 10.1007/s00701-021-04743-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 01/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The genesis of central post-stroke pain (CPSP) is important but difficult to understand. We evaluated the involvement of the thalamic anterior part of the ventral posterolateral nucleus (VPLa) and central lateral nucleus (CL) in the occurrence of CPSP. METHOD Stereotactic thalamotomy was performed on the posterior part of the ventral lateral nucleus (VLp)-VPLa and CL in 9 patients with CPSP caused by deep-seated intracerebral hemorrhage. Computed tomography (CT) did not reveal definite thalamic lesion in 5 patients but did in 4 patients. Electrophysiological studies of these thalamic nuclei were carried out during the surgery. Anatomical studies using CT were performed in another 20 patients with thalamic hemorrhage who had clear consciousness but had sensory disturbance at onset. RESULTS Neural activities were preserved and hyperactive and unstable discharges (HUDs) were often recognized along the trajectory in the thalamic VLp-VPLa in 5 patients without thalamic lesion. Surgical modification of this area ameliorated pain, particularly movement-related pain. Neural activities were hypoactive in the other 4 patients with thalamic lesion. However, neural activities were preserved and HUDs were sometimes recognized in the CL. Sensory responses were seen, but at low rate, in the sensory thalamus. Anatomical study showed that the thalamic lesion was obviously smaller in the patients with developing pain in the chronic stage. CONCLUSIONS Change in neural activities around the cerebrovascular disease lesion in the thalamic VPLa or CL might affect the perception of sensory impulses or sensory processing in those thalamic nuclei, resulting in the genesis of CPSP.
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Affiliation(s)
- Masafumi Hirato
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
- Department of Neurosurgery, National Hospital Organization Shibukawa Medical Center, Shibukawa, Gunma, Japan.
| | - Takaaki Miyagishima
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Akio Takahashi
- Department of Neurosurgery, National Hospital Organization Shibukawa Medical Center, Shibukawa, Gunma, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Park JG, Hong BY, Park HY, Yoo YJ, Yoon MJ, Kim JS, Lim SH. Alteration of White Matter in Patients with Central Post-Stroke Pain. J Pers Med 2021; 11:417. [PMID: 34063462 PMCID: PMC8156708 DOI: 10.3390/jpm11050417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/06/2021] [Accepted: 05/13/2021] [Indexed: 11/25/2022] Open
Abstract
A stroke may be followed by central post-stroke pain (CPSP), which is characterized by chronic neuropathic pain. The exact mechanism has not yet been fully uncovered. We investigated alterations in the white matters in patients with CPSP, compared with stroke patients without CPSP and normal controls. Our retrospective cross-sectional, case-control study participants were assigned to three groups: CPSP (stroke patients with CPSP (n = 17)); stroke control (stroke patients without CPSP (n = 26)); and normal control (normal subjects (n = 34)). The investigation of white matter for CPSP was focused on the values of fiber numbers (FN) and fractional anisotrophy (FA) for spinothalamic tract (STT), anterior thalamic radiation (ATR), superior thalamic radiation (STR) and posterior thalamic radiation (PTR), and corticospinal tract (CST) was measured. The FA for the STT and STR of the CPSP group were lower than those for the stroke control and normal control groups. The FA of CST and ATR did not differ between the CPSP and stroke groups, but both differed from the normal control. The FA of PTR in the stroke control group differed from the normal control group, but not from the CPSP group. The FN of CST, STT, ATR, and STR for the CPSP and stroke control groups did not differ from each other, but both differed from those of normal controls. FN of PTR did not differ between the CPSP and normal control groups. The alterations in the spinothalamic tract and superior thalamic radiation after stroke would play a role in the pathogenesis of CPSP.
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Affiliation(s)
- Jung Geun Park
- Department of Rehabilitation Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea; (J.G.P.); (B.Y.H.); (Y.J.Y.); (M.-J.Y.); (J.-S.K.)
| | - Bo Young Hong
- Department of Rehabilitation Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea; (J.G.P.); (B.Y.H.); (Y.J.Y.); (M.-J.Y.); (J.-S.K.)
| | - Hae-Yeon Park
- Department of Rehabilitation Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Yeun Jie Yoo
- Department of Rehabilitation Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea; (J.G.P.); (B.Y.H.); (Y.J.Y.); (M.-J.Y.); (J.-S.K.)
| | - Mi-Jeong Yoon
- Department of Rehabilitation Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea; (J.G.P.); (B.Y.H.); (Y.J.Y.); (M.-J.Y.); (J.-S.K.)
| | - Joon-Sung Kim
- Department of Rehabilitation Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea; (J.G.P.); (B.Y.H.); (Y.J.Y.); (M.-J.Y.); (J.-S.K.)
| | - Seong Hoon Lim
- Department of Rehabilitation Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea; (J.G.P.); (B.Y.H.); (Y.J.Y.); (M.-J.Y.); (J.-S.K.)
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Liampas A, Velidakis N, Georgiou T, Vadalouca A, Varrassi G, Hadjigeorgiou GM, Tsivgoulis G, Zis P. Prevalence and Management Challenges in Central Post-Stroke Neuropathic Pain: A Systematic Review and Meta-analysis. Adv Ther 2020; 37:3278-3291. [PMID: 32451951 PMCID: PMC7467424 DOI: 10.1007/s12325-020-01388-w] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Indexed: 01/30/2023]
Abstract
Introduction Central post-stroke pain (CPSP) is defined as the neuropathic pain that arises either acutely or in the chronic phase of a cerebrovascular event and is a result of central lesions of the somatosensory tract. The aim of this systematic review and meta-analysis was to establish the prevalence of CPSP, to describe its characteristics, and to discuss the associated management challenges. Methods After a systematic Medline search, we identified 69 papers eligible to be included. Results The pooled prevalence of CPSP in patients with stroke at any location was 11% (95% CI 7–18%), which can increase to more than 50% in the subgroups of patients with medullary or thalamic strokes. CPSP onset coincides with stroke occurrence in 26% of patients (95% CI 18–35%); CPSP manifests within a month since symptom onset in 31% of patients (95% CI 22–42%), and occurs between the first month and the first year in 41% of patients (95% CI 33.9–49.0%). CPSP develops more than 12 months after stroke onset in 5% of patients (95% CI 3–8%). Conclusions Clinicians should look for any evidence of central neuropathic pain for at least 12 months after stroke. Both pharmacological and non-pharmacological interventions can be used for the management of CPSP. Lamotrigine has the strongest evidence (Level II of evidence, derived from small randomized controlled trials) for being effective in the management of CPSP. Future research should focus on well-designed trials of pharmacological and non-pharmacological interventions aiming to relief CPSP, which is a very common but often neglected pain syndrome. Electronic supplementary material The online version of this article (10.1007/s12325-020-01388-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andreas Liampas
- Academic Directorate of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Athina Vadalouca
- Pain and Palliative Care Center, Athens Medical Center, Athens, Greece
| | | | | | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Jang SH, Seo JP, Lee SJ. Diffusion Tensor Tractography Studies of Central Post-stroke Pain Due to the Spinothalamic Tract Injury: A Mini-Review. Front Neurol 2019; 10:787. [PMID: 31428032 PMCID: PMC6688072 DOI: 10.3389/fneur.2019.00787] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/08/2019] [Indexed: 11/18/2022] Open
Abstract
Elucidation of the pathophysiological mechanism of central post-stroke pain (CPSP) is essential to the development of effective therapeutic modalities for CPSP. However, the pathophysiological mechanism of CPSP has not yet been clearly elucidated. The recent development of diffusion tensor tractography (DTT), derived from diffusion tensor imaging (DTI), has allowed visualization and estimation of the spinothalamic tract (STT), which has been considered the most plausible neural tract responsible for the pathogenesis of CPSP. In this mini-review, six DTT studies in which CPSP due to STT injury in stroke patients was demonstrated are reviewed. The information provided in the reviewed studies suggests that DTT is useful in the elucidation of the pathophysiological mechanism associated with CPSP. We believe that the reviewed studies will facilitate neurorehabilitation of stroke patients with CPSP. However, DTT studies of CPSP are still in the beginning stage because the total number (six studies) of the reviewed studies is very low and half were case reports. Therefore, further studies involving large numbers of subjects are warranted.
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Affiliation(s)
- Sung Ho Jang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Jeong Pyo Seo
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Sung Jun Lee
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, South Korea
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Quantitative sensory testing profiles in children, adolescents and young adults (6-20 years) with cerebral palsy: Hints for a neuropathic genesis of pain syndromes. Eur J Paediatr Neurol 2018; 22:470-481. [PMID: 29337004 DOI: 10.1016/j.ejpn.2017.12.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 09/20/2017] [Accepted: 12/19/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Many patients with cerebral palsy (CP) suffer chronic pain as one of the most limiting factors in their quality of life. In CP patients, pain mechanisms are not well understood, and pain therapy remains a challenge. Quantitative sensory testing (QST) might provide unique information about the functional status of the somatosensory system and therefore better guide pain treatment. OBJECTIVES To understand better the underlying pain mechanisms in pediatric CP patients, we aimed to assess clinical and pain parameters, as well as QST profiles, which were matched to the patients' cerebral imaging pathology. PATIENTS AND METHODS Thirty CP patients aged 6-20 years old (mean age 12 years) without intellectual impairment underwent standardized assessments of QST. Cerebral imaging was reassessed. QST results were compared to age- and sex-matched controls (multiple linear regression; Fisher's exact test; linear correlation analysis). RESULTS CP patients were less sensitive to all mechanical and thermal stimuli than healthy controls but more sensitive to all mechanical pain stimuli (each p < 0.001). Fifty percent of CP patients showed a combination of mechanical hypoesthesia, thermal hypoesthesia and mechanical hyperalgesia; 67% of CP patients had periventricular leukomalacia (PVL), which was correlated with mechanic (r = 0.661; p < 0.001) and thermal (r = 0.624; p = 0.001) hypoesthesia. CONCLUSION The combination of mechanical hypoesthesia, thermal hypoesthesia and mechanical hyperalgesia in our CP patients implicates lemniscal and extralemniscal neuron dysfunction in the thalamus region, likely due to PVL. We suspect that extralemniscal tracts are involved in the original of pain in our CP patients, as in adults.
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Singer J, Conigliaro A, Spina E, Law SW, Levine SR. Central poststroke pain: A systematic review. Int J Stroke 2017; 12:343-355. [PMID: 28494691 DOI: 10.1177/1747493017701149] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Physical, psychological, and/or social impairment can result after a stroke and can be exacerbated by pain. One type of pain after stroke, central poststroke pain, is believed to be due to primary central nervous system mechanisms. Estimated prevalence of central poststroke pain ranges widely from 8% to 55% of stroke patients, suggesting a difficulty in reliably, accurately, and consistently identifying central poststroke pain. This may be due to the absence of a generally accepted definition. Aim We aimed to clarify the role of thalamic strokes and damage to the spinothalamic pathway in central poststroke pain patients. Also, we aimed to gain a current understanding of anatomic substrates, brain imaging, and treatment of central poststroke pain. Summary of review Two independent reviewers identified 10,144 publications. Based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we extracted data from 23 papers and categorized the articles' aims into four sections: somatosensory deficits, pathway stimulation, clinical trials, and brain imaging. Conclusions Our systematic review suggests that damage to the spinothalamic pathway is associated with central poststroke pain and this link could provide insights into mechanisms and treatment. Moreover, historical connection of strokes in the thalamic region of the brain and central poststroke pain should be reevaluated as many studies noted that strokes in other regions of the brain have high occurrence of central poststroke pain as well.
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Affiliation(s)
- Jonathan Singer
- 1 Department of Neurology, SUNY Downstate Medical Center & Stroke Center, Brooklyn, NY, USA
| | - Alyssa Conigliaro
- 2 Department of Emergency Medicine, Kings County Hospital Center & SUNY Downstate Medical Center, Brooklyn, NY, USA
| | | | - Susan W Law
- 4 Department of Neurology, Kings County Hospital Center and SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Steven R Levine
- 5 SUNY Downstate Medical Center and Stroke Center and Kings County Hospital Center, Brooklyn, NY, USA
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Treister AK, Hatch MN, Cramer SC, Chang EY. Demystifying Poststroke Pain: From Etiology to Treatment. PM R 2017; 9:63-75. [PMID: 27317916 PMCID: PMC5161714 DOI: 10.1016/j.pmrj.2016.05.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/24/2016] [Accepted: 05/29/2016] [Indexed: 01/30/2023]
Abstract
Pain after stroke is commonly reported but often incompletely managed, which prevents optimal recovery. This situation occurs in part because of the esoteric nature of poststroke pain and its limited presence in current discussions of stroke management. The major specific afflictions that affect patients with stroke who experience pain include central poststroke pain, complex regional pain syndrome, and pain associated with spasticity and shoulder subluxation. Each disorder carries its own intricacies that require specific approaches to treatment and understanding. This review aims to present and clarify the major pain syndromes that affect patients who have experienced a stroke in order to aid in their diagnosis and treatment.
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Affiliation(s)
- Andrew K Treister
- Division of Neurology, Department of Neuroscience, University of California, San Diego, 200 West Arbor Drive, MC 8465, San Diego, CA 92103-8465(∗).
| | - Maya N Hatch
- Long Beach VA, SCI/D Healthcare System, Long Beach, CA(†)
| | - Steven C Cramer
- Department of Neurobiology and Anatomy, University of California, Irvine, CA; Department of Neurology, University of California, Irvine, CA(‡)
| | - Eric Y Chang
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Care, Reeve-Irvine Research Center for Spinal Cord Injury, University of California, Irvine, CA; Department of Physical Medicine and Rehabilitation, School of Medicine, University of California Irvine Medical Center, Irvine, CA(¶)
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Spitoni GF, Pireddu G, Galati G, Sulpizio V, Paolucci S, Pizzamiglio L. Caloric Vestibular Stimulation Reduces Pain and Somatoparaphrenia in a Severe Chronic Central Post-Stroke Pain Patient: A Case Study. PLoS One 2016; 11:e0151213. [PMID: 27028404 PMCID: PMC4814090 DOI: 10.1371/journal.pone.0151213] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 02/23/2016] [Indexed: 02/08/2023] Open
Abstract
Central post-stroke pain is a neuropathic syndrome characterized by intolerable contralesional pain and, in rare cases, somatic delusions. To date, there is limited evidence for the effective treatments of this disease. Here we used caloric vestibular stimulation to reduce pain and somatoparaphrenia in a 57-year-old woman suffering from central post-stroke pain. Resting-state functional magnetic resonance imaging was used to assess the neurological effects of this treatment. Following vestibular stimulation we observed impressive improvements in motor skills, pain, and somatic delusions. In the functional connectivity study before the vestibular stimulation, we observed differences in the patient's left thalamus functional connectivity, with respect to the thalamus connectivity of a control group (N = 20), in the bilateral cingulate cortex and left insula. After the caloric stimulation, the left thalamus functional connectivity with these regions, which are known to be involved in the cortical response to pain, disappeared as in the control group. The beneficial use of vestibular stimulation in the reduction of pain and somatic delusion in a CPSP patient is now documented by behavioral and imaging data. This evidence can be applied to theoretical models of pain and body delusions.
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Affiliation(s)
- Grazia Fernanda Spitoni
- Department of Psychology–Sapienza University of Rome, Rome, Italy
- Laboratory of Neuropsychology, IRCCS Santa Lucia Foundation, Rome, Italy
- * E-mail:
| | - Giorgio Pireddu
- Department of Psychology–Sapienza University of Rome, Rome, Italy
- Laboratory of Neuropsychology, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Gaspare Galati
- Department of Psychology–Sapienza University of Rome, Rome, Italy
- Laboratory of Neuropsychology, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Valentina Sulpizio
- Department of Psychology–Sapienza University of Rome, Rome, Italy
- Laboratory of Neuropsychology, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Stefano Paolucci
- Laboratory of Neuropsychology, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Luigi Pizzamiglio
- Laboratory of Neuropsychology, IRCCS Santa Lucia Foundation, Rome, Italy
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Watson JC, Sandroni P. Central Neuropathic Pain Syndromes. Mayo Clin Proc 2016; 91:372-85. [PMID: 26944242 DOI: 10.1016/j.mayocp.2016.01.017] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/24/2016] [Accepted: 01/25/2016] [Indexed: 10/22/2022]
Abstract
Chronic pain is common in patients with neurologic complications of a central nervous system insult such as stroke. The pain is most commonly musculoskeletal or related to obligatory overuse of neurologically unaffected limbs. However, neuropathic pain can result directly from the central nervous system injury. Impaired sensory discrimination can make it challenging to differentiate central neuropathic pain from other pain types or spasticity. Central neuropathic pain may also begin months to years after the injury, further obscuring recognition of its association with a past neurologic injury. This review focuses on unique clinical features that help distinguish central neuropathic pain. The most common clinical central pain syndromes-central poststroke pain, multiple sclerosis-related pain, and spinal cord injury-related pain-are reviewed in detail. Recent progress in understanding of the pathogenesis of central neuropathic pain is reviewed, and pharmacological, surgical, and neuromodulatory treatments of this notoriously difficult to treat pain syndrome are discussed.
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Affiliation(s)
- James C Watson
- Department of Neurology, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN.
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Vartiainen N, Perchet C, Magnin M, Creac'h C, Convers P, Nighoghossian N, Mauguière F, Peyron R, Garcia-Larrea L. Thalamic pain: anatomical and physiological indices of prediction. Brain 2016; 139:708-22. [PMID: 26912644 DOI: 10.1093/brain/awv389] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 11/16/2015] [Indexed: 11/14/2022] Open
Abstract
Thalamic pain is a severe and treatment-resistant type of central pain that may develop after thalamic stroke. Lesions within the ventrocaudal regions of the thalamus carry the highest risk to develop pain, but its emergence in individual patients remains impossible to predict. Because damage to the spino-thalamo-cortical system is a crucial factor in the development of central pain, in this study we combined detailed anatomical atlas-based mapping of thalamic lesions and assessment of spinothalamic integrity using quantitative sensory analysis and laser-evoked potentials in 42 thalamic stroke patients, of whom 31 had developed thalamic pain. More than 97% of lesions involved an area between 2 and 7 mm above the anterior-posterior commissural plane. Although most thalamic lesions affected several nuclei, patients with central pain showed maximal lesion convergence on the anterior pulvinar nucleus (a major spinothalamic target) while the convergence area lay within the ventral posterior lateral nucleus in pain-free patients. Both involvement of the anterior pulvinar nucleus and spinothalamic dysfunction (nociceptive thresholds, laser-evoked potentials) were significantly associated with the development of thalamic pain, whereas involvement of ventral posterior lateral nucleus and lemniscal dysfunction (position sense, graphaesthesia, pallaesthesia, stereognosis, standard somatosensory potentials) were similarly distributed in patients with or without pain. A logistic regression model combining spinothalamic dysfunction and anterior pulvinar nucleus involvement as regressors had 93% sensitivity and 87% positive predictive value for thalamic pain. Lesion of spinothalamic afferents to the posterior thalamus appears therefore determinant to the development of central pain after thalamic stroke. Sorting out of patients at different risks of developing thalamic pain may be achievable at the individual level by combining lesion localization and functional investigation of the spinothalamic system. As the methods proposed here do not need complex manipulations, they can be added to routine patients' work up, and the results replicated by other investigators in the field.
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Affiliation(s)
- Nuutti Vartiainen
- 1 Central Integration of Pain in Humans (NeuroPain), Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR 5092, University Claude Bernard Lyon 1, France
| | - Caroline Perchet
- 1 Central Integration of Pain in Humans (NeuroPain), Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR 5092, University Claude Bernard Lyon 1, France
| | - Michel Magnin
- 1 Central Integration of Pain in Humans (NeuroPain), Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR 5092, University Claude Bernard Lyon 1, France
| | - Christelle Creac'h
- 1 Central Integration of Pain in Humans (NeuroPain), Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR 5092, University Claude Bernard Lyon 1, France 2 Department of Neurology, University Hospital St Etienne, France
| | - Philippe Convers
- 1 Central Integration of Pain in Humans (NeuroPain), Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR 5092, University Claude Bernard Lyon 1, France 2 Department of Neurology, University Hospital St Etienne, France
| | | | - François Mauguière
- 1 Central Integration of Pain in Humans (NeuroPain), Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR 5092, University Claude Bernard Lyon 1, France 4 Pain Clinic (CETD) and Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, France
| | - Roland Peyron
- 1 Central Integration of Pain in Humans (NeuroPain), Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR 5092, University Claude Bernard Lyon 1, France 2 Department of Neurology, University Hospital St Etienne, France
| | - Luis Garcia-Larrea
- 1 Central Integration of Pain in Humans (NeuroPain), Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR 5092, University Claude Bernard Lyon 1, France 4 Pain Clinic (CETD) and Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, France
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Kim JS. Posterior Cerebral Artery Disease. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00025-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Goswami S, Bhattacharyya R, Ghosh K, Ghosh S, Mondal G. Clinical features and imaging of central poststroke pain. INDIAN JOURNAL OF PAIN 2016. [DOI: 10.4103/0970-5333.173462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Oh H, Seo W. A Comprehensive Review of Central Post-Stroke Pain. Pain Manag Nurs 2015; 16:804-18. [PMID: 25962545 DOI: 10.1016/j.pmn.2015.03.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 02/25/2015] [Accepted: 03/05/2015] [Indexed: 01/08/2023]
Abstract
Although central post-stroke pain is widely recognized as a severe chronic neuropathic pain condition, its consolidated definition, clinical characteristics, and diagnostic criteria have not been defined due to its clinically diverse features. The present study was undertaken to comprehensively review current literature and provide a more complete picture of central post-stroke pain with respect to its definition, prevalence, pathophysiology, clinical characteristics, and diagnostic problems, and to describe the range of therapies currently available. In particular, nursing care perspectives are addressed. It is hoped that this review will help nurses become knowledgeable about central post-stroke pain and provide valuable information for the drafting of effective nursing care plans that improve outcomes and quality of life for patients with central post-stroke pain.
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Affiliation(s)
- HyunSoo Oh
- Department of Nursing, Inha University, Incheon, Republic of Korea
| | - WhaSook Seo
- Department of Nursing, Inha University, Incheon, Republic of Korea.
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Hosomi K, Seymour B, Saitoh Y. Modulating the pain network—neurostimulation for central poststroke pain. Nat Rev Neurol 2015; 11:290-9. [DOI: 10.1038/nrneurol.2015.58] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Chronic Pain Syndromes, Mechanisms, and Current Treatments. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2015; 131:565-611. [DOI: 10.1016/bs.pmbts.2015.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Pain is one of the most troublesome sequelae of stroke. Some of this post-stroke pain is caused by the brain lesion itself; this is called central post-stroke pain (CPSP). Although the prevalence of CPSP is low (1-8 %), persistent, often treatment-resistant, painful sensations are a major problem for stroke patients. The pathogenesis of CPSP remains unknown, but suggested underlying causes include hyperexcitation in the damaged sensory pathways, damage to the central inhibitory pathways, or a combination of the two. For pharmacological treatment, amitriptyline, an adrenergic antidepressant, is currently the first-line drug for CPSP. However, its effect is frequently incomplete and a high dose is commonly not tolerated in stroke patients. Lamotrigine, an antiepileptic, was also found to be effective in a controlled trial and can be used as an alternative or additive therapy. GABAergic drugs with potential calcium channel-blocking effects, such as gabapentin or pregabalin, have recently emerged as a potentially useful therapy. These drugs are effective in various neuropathic pain syndromes, but their effect on CPSP remains to be proven. Pregabalin may improve pain-related anxiety and sleep disturbances. Fluvoxamine and mexiletine may be used adjunctively in some patients. Non-pharmacological treatments such as motor cortex stimulation or deep brain stimulation are used in some centers, but are not proven to be effective. Further well designed clinical trials as well as basic research should be performed to improve our understanding of the pathophysiology of CPSP and to develop better treatment strategies.
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Affiliation(s)
- Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan, Songpa-Gu, 388-1 Pungnap-Dong, Seoul, 138-736, Korea,
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Leung A, Shukla S, Li E, Duann JR, Yaksh T. Supraspinal characterization of the thermal grill illusion with fMRI. Mol Pain 2014; 10:18. [PMID: 24612493 PMCID: PMC3995740 DOI: 10.1186/1744-8069-10-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 03/02/2014] [Indexed: 12/22/2022] Open
Abstract
Background Simultaneous presentation of non-noxious warm (40°C) and cold (20°C) stimuli in an interlacing fashion results in a transient hot burning noxious sensation (matched at 46°C) known as the thermal grill (TG) illusion. Functional magnetic resonance imaging and psychophysical assessments were utilized to compare the supraspinal events related to the spatial summation effect of three TG presentations: 20°C/20°C (G2020), 20°C/40°C (G2040) and 40°C/40°C (G4040) with corresponding matched thermode stimuli: 20°C (P20), 46°C (P46) and 40°C (P40) and hot pain (HP) stimuli. Results For G2040, the hot burning sensation was only noted during the initial off-line assessment. In comparison to P40, G4040 resulted in an equally enhanced response from all supraspinal regions associated with both pain sensory/discriminatory and noxious modulatory response. In comparison to P20, G2020 presentation resulted in a much earlier diminished/sedative response leading to a statistically significantly (P < 0.01) higher degree of deactivation in modulatory supraspinal areas activated by G4040. Granger Causality Analysis showed that while thalamic activation in HP may cast activation inference in all hot pain related somatosensory, affective and modulatory areas, similar activation in G2040 and G2020 resulted in deactivation inference in the corresponding areas. Conclusions In short, the transient TG sensation is caused by a dissociated state derived from non-noxious warm and cold spatial summation interaction. The observed central dissociated state may share some parallels in certain chronic neuropathic pain states.
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Affiliation(s)
- Albert Leung
- Department of Anesthesiology, University of California, San Diego, School of Medicine, 9500 Gilman Drive, MC 0818, 92093 La Jolla, CA, USA.
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Castel A, Hélie P, Beaudry F, Vachon P. Bilateral central pain sensitization in rats following a unilateral thalamic lesion may be treated with high doses of ketamine. BMC Vet Res 2013; 9:59. [PMID: 23537119 PMCID: PMC3618296 DOI: 10.1186/1746-6148-9-59] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 03/19/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Central post-stroke pain is a neuropathic pain condition caused by a vascular lesion, of either ischemic or hemorrhagic origin, in the central nervous system and more precisely involving the spinothalamocortical pathway responsible for the transmission of painful sensations. Few animal models have been developed to study this problem. The objectives of this study were to evaluate different modalities of pain in a central neuropathic pain rat model and to assess the effects of ketamine administered at different doses. Animals were evaluated on the rotarod, Hargreaves, Von Frey and acetone tests. A very small hemorrhage was created by injecting a collagenase solution in the right ventral posterolateral thalamic nucleus. Following the establishment of the neuropathy, ketamine was evaluated as a therapeutic drug for this condition. RESULTS Histopathological observations showed a well localized lesion with neuronal necrosis and astrocytosis following the collagenase injection that was localized within the VPL. No significant change in motor coordination was observed following surgery in either the saline or collagensae groups. In the collagenase group, a significant decrease in mechanical allodynia threshold was observed. A sporadic and transient cold allodynia was also noted. No thermal hyperalgesia was seen following the collagenase injection. Ketamine was then tested as a potential therapeutic drug. A significant decrease in motor coordination was seen only following the administration of 25 mg/kg of ketamine in both groups. An alleviation of mechanical allodynia was achieved only with the high ketamine dose. The minimal effective ketamine serum concentration (150 ng/mL) was only achieved in animals that received 25 mg/kg. CONCLUSIONS An intrathalamic hemorrhage induced a bilateral mechanical allodynia in rats. Cold hyperalgesia was observed in 60% of these animals. Mechanical allodynia was alleviated with high doses of ketamine which corresponded with therapeutic plasmatic concentrations.
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Affiliation(s)
- Aude Castel
- Faculty of Veterinary Medicine, Departments of Veterinary Biomedicine, Saint-Hyacinthe, Quebec, Canada
| | - Pierre Hélie
- Pathology & Microbiology, University of Montreal, Saint-Hyacinthe, Quebec, Canada
| | - Francis Beaudry
- Faculty of Veterinary Medicine, Departments of Veterinary Biomedicine, Saint-Hyacinthe, Quebec, Canada
| | - Pascal Vachon
- Faculty of Veterinary Medicine, Departments of Veterinary Biomedicine, Saint-Hyacinthe, Quebec, Canada
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de Oliveira RAA, de Andrade DC, Machado AGG, Teixeira MJ. Central poststroke pain: somatosensory abnormalities and the presence of associated myofascial pain syndrome. BMC Neurol 2012; 12:89. [PMID: 22966989 PMCID: PMC3475118 DOI: 10.1186/1471-2377-12-89] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 08/31/2012] [Indexed: 11/18/2022] Open
Abstract
Background Central post-stroke pain (CPSP) is a neuropathic pain syndrome associated with somatosensory abnormalities due to central nervous system lesion following a cerebrovascular insult. Post-stroke pain (PSP) refers to a broader range of clinical conditions leading to pain after stroke, but not restricted to CPSP, including other types of pain such as myofascial pain syndrome (MPS), painful shoulder, lumbar and dorsal pain, complex regional pain syndrome, and spasticity-related pain. Despite its recognition as part of the general PSP diagnostic possibilities, the prevalence of MPS has never been characterized in patients with CPSP patients. We performed a cross-sectional standardized clinical and radiological evaluation of patients with definite CPSP in order to assess the presence of other non-neuropathic pain syndromes, and in particular, the role of myofascial pain syndrome in these patients. Methods CPSP patients underwent a standardized sensory and motor neurological evaluation, and were classified according to stroke mechanism, neurological deficits, presence and profile of MPS. The Visual Analogic Scale (VAS), McGill Pain Questionnaire (MPQ), and Beck Depression Scale (BDS) were filled out by all participants. Results Forty CPSP patients were included. Thirty-six (90.0%) had one single ischemic stroke. Pain presented during the first three months after stroke in 75.0%. Median pain intensity was 10 (5 to 10). There was no difference in pain intensity among the different lesion site groups. Neuropathic pain was continuous-ongoing in 34 (85.0%) patients and intermittent in the remainder. Burning was the most common descriptor (70%). Main aggravating factors were contact to cold (62.5%). Thermo-sensory abnormalities were universal. MPS was diagnosed in 27 (67.5%) patients and was more common in the supratentorial extra-thalamic group (P <0.001). No significant differences were observed among the different stroke location groups and pain questionnaires and scales scores. Importantly, CPSP patients with and without MPS did not differ in pain intensity (VAS), MPQ or BDS scores. Conclusions The presence of MPS is not an exception after stroke and may present in association with CPSP as a common comorbid condition. Further studies are necessary to clarify the role of MPS in CPSP.
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Sprenger T, Seifert CL, Valet M, Andreou AP, Foerschler A, Zimmer C, Collins DL, Goadsby PJ, Tölle TR, Chakravarty MM. Assessing the risk of central post-stroke pain of thalamic origin by lesion mapping. Brain 2012; 135:2536-45. [DOI: 10.1093/brain/aws153] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Garcia-Larrea L. Insights gained into pain processing from patients with focal brain lesions. Neurosci Lett 2012; 520:188-91. [DOI: 10.1016/j.neulet.2012.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 05/01/2012] [Accepted: 05/02/2012] [Indexed: 10/28/2022]
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Casey KL, Geisser M, Lorenz J, Morrow TJ, Paulson P, Minoshima S. Psychophysical and cerebral responses to heat stimulation in patients with central pain, painless central sensory loss, and in healthy persons. Pain 2012; 153:331-341. [PMID: 22130307 PMCID: PMC3406931 DOI: 10.1016/j.pain.2011.10.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Revised: 08/18/2011] [Accepted: 10/20/2011] [Indexed: 01/02/2023]
Abstract
Patients with central pain (CP) typically have chronic pain within an area of reduced pain and temperature sensation, suggesting an impairment of endogenous pain modulation mechanisms. We tested the hypothesis that some brain structures normally activated by cutaneous heat stimulation would be hyperresponsive among patients with CP but not among patients with a central nervous system lesion causing a loss of heat or nociceptive sensation with no pain (NP). We used H(2)(15)O positron emission tomography to measure, in 15 healthy control participants, 10 NP patients, and 10 CP patients, increases in regional cerebral blood flow among volumes of interest (VOI) from the resting (no stimulus) condition during bilateral contact heat stimulation at heat detection, heat pain threshold, and heat pain tolerance levels. Both patient groups had a reduced perception of heat intensity and unpleasantness on the clinically affected side and a bilateral impairment of heat detection. Compared with the HC group, both NP and CP patients had more hyperactive and hypoactive VOI in the resting state and more hyperresponsive and hyporesponsive VOI during heat stimulation. Compared with NP patients, CP patients had more hyperresponsive VOI in the intralaminar thalamus and sensory-motor cortex during heat stimulation. Our results show that focal CNS lesions produce bilateral sensory deficits and widespread changes in the nociceptive excitability of the brain. The increased nociceptive excitability within the intralaminar thalamus and sensory-motor cortex of our sample of CP patients suggests an underlying pathophysiology for the pain in some central pain syndromes.
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Affiliation(s)
- Kenneth L. Casey
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
- Neurology Research, Veteran’s Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Michael Geisser
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Jürgen Lorenz
- Faculty of Life Sciences, Hamburg University of Applied Sciences, Hamburg, Germany
| | - Thomas J. Morrow
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
- Neurology Research, Veteran’s Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Pamela Paulson
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
- Neurology Research, Veteran’s Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Satoshi Minoshima
- Department of Radiology, University of Washington, Seattle, Washington, USA
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Hong JH, Choi BY, Chang CH, Kim SH, Jung YJ, Lee DG, Kwon YH, Jang SH. The prevalence of central poststroke pain according to the integrity of the spino-thalamo-cortical pathway. Eur Neurol 2011; 67:12-7. [PMID: 22142796 DOI: 10.1159/000333012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 09/12/2011] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Little is known about the prevalence of central poststroke pain (CPSP) according to the integrity of the spino-thalamo-cortical pathway (STP). Using diffusion tensor tractography, we investigated the prevalence of CPSP according to the integrity of the STP in patients with intracerebral hemorrhage. METHODS We recruited 52 consecutive chronic patients and 10 normal control subjects. Patients were classified into two groups according to preservation of the integrity of the STP. Each group was divided into two subgroups according to the presence of CPSP. RESULTS The preserved group included 34 patients [CPSP subgroup, 16 (47%) patients; non-CPSP subgroup, 18 (53%) patients], and 18 patients were enrolled into the disrupted group [CPSP subgroup, 3 (17%) patients; non-CPSP subgroup, 15 (83%) patients]. The fractional anisotropy and mean diffusivity values of the CPSP and non-CPSP subgroups of the preserved group were decreased and increased when compared with those of the control group, respectively (p < 0.05). CONCLUSIONS We found that the prevalence of CPSP in patients with partial injury of the STP was higher than that of patients with complete injury of the STP. Partial injury of the STP appears to be more vulnerable to development of CPSP than complete injury of the STP in patients with intracerebral hemorrhage.
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Affiliation(s)
- Ji Heon Hong
- Department of Physical Therapy, Yeungnam College of Science and Technology, Yeungnam University, Taegu, Republic of Korea
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Abstract
Chronic pain is a frequent component of many neurological disorders, affecting 20-40% of patients for many primary neurological diseases. These diseases result from a wide range of pathophysiologies including traumatic injury to the central nervous system, neurodegeneration and neuroinflammation, and exploring the aetiology of pain in these disorders is an opportunity to achieve new insight into pain processing. Whether pain originates in the central or peripheral nervous system, it frequently becomes centralized through maladaptive responses within the central nervous system that can profoundly alter brain systems and thereby behaviour (e.g. depression). Chronic pain should thus be considered a brain disease in which alterations in neural networks affect multiple aspects of brain function, structure and chemistry. The study and treatment of this disease is greatly complicated by the lack of objective measures for either the symptoms or the underlying mechanisms of chronic pain. In pain associated with neurological disease, it is sometimes difficult to obtain even a subjective evaluation of pain, as is the case for patients in a vegetative state or end-stage Alzheimer's disease. It is critical that neurologists become more involved in chronic pain treatment and research (already significant in the fields of migraine and peripheral neuropathies). To achieve this goal, greater efforts are needed to enhance training for neurologists in pain treatment and promote greater interest in the field. This review describes examples of pain in different neurological diseases including primary neurological pain conditions, discusses the therapeutic potential of brain-targeted therapies and highlights the need for objective measures of pain.
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Affiliation(s)
- David Borsook
- MD Center for Pain and the Brain C/O Brain Imaging Center, McLean Hospital Belmont, MA 02478, USA.
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Central poststroke pain: A population-based study. Pain 2011; 152:818-824. [DOI: 10.1016/j.pain.2010.12.030] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 12/17/2010] [Accepted: 12/17/2010] [Indexed: 11/22/2022]
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Rehabilitation and Recovery of the Patient with Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Roosink M, Renzenbrink GJ, Buitenweg JR, van Dongen RTM, Geurts ACH, Ijzerman MJ. Somatosensory symptoms and signs and conditioned pain modulation in chronic post-stroke shoulder pain. THE JOURNAL OF PAIN 2010; 12:476-85. [PMID: 21167792 DOI: 10.1016/j.jpain.2010.10.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 10/10/2010] [Accepted: 10/29/2010] [Indexed: 10/18/2022]
Abstract
UNLABELLED Persistent shoulder pain is a common complication after stroke. Its etiology and underlying mechanisms are not well understood and treatment is generally unsatisfactory. The objective of this study was to assess the role of central sensitization and disinhibition in chronic stroke patients with chronic PSSP (n = 19), pain-free stroke patients (n = 29), and healthy controls (n = 23). Positive and negative somatosensory symptoms and signs were assessed using clinical examination and electrical and mechanical quantitative sensory testing (QST). Conditioned pain modulation (CPM) was assessed by comparing QST thresholds before and after applying a cold pressor test. Sensory abnormalities were more frequently observed and more severe in patients with PSSP, including positive signs such as allodynia at the affected side and generalized hyperalgesia at the unaffected side. CPM was similar in stroke patients and healthy controls. This study showed that chronic PSSP was associated with several positive and negative somatosensory signs, implicating a role for central sensitization and possibly for disinhibition. Since the causal relationship remains unclear, and may be related to either neuroplasticity induced by ongoing nociception as well as to the neuropathic brain lesion, prospective studies are warranted. PERSPECTIVE The assessment of somatosensory symptoms and signs and endogenous pain modulation demonstrated a role for central sensitization and possibly for disinhibition in chronic PSSP. Prevention and treatment of PSSP could benefit from a more detailed analysis of both peripheral and central pain mechanisms.
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Affiliation(s)
- Meyke Roosink
- Biomedical Signals & Systems, MIRA institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands.
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Garcia-Larrea L, Perchet C, Creac'h C, Convers P, Peyron R, Laurent B, Mauguière F, Magnin M. Operculo-insular pain (parasylvian pain): a distinct central pain syndrome. Brain 2010; 133:2528-39. [PMID: 20724291 DOI: 10.1093/brain/awq220] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Central pain with dissociated thermoalgesic sensory loss is common in spinal and brainstem syndromes but not in cortical lesions. Out of a series of 270 patients investigated because of somatosensory abnormalities, we identified five subjects presenting with central pain and pure thermoalgesic sensory loss contralateral to cortical stroke. All of the patients had involvement of the posterior insula and inner parietal operculum. Lemniscal sensory modalities (position sense, graphaestesia, stereognosis) and somatosensory evoked potentials to non-noxious inputs were always preserved, while thermal and pain sensations were profoundly altered, and laser-evoked potentials to thermo-nocoiceptive stimuli were always abnormal. Central pain resulting from posterior parasylvian lesions appears to be a distinct entity that can be identified unambiguously on the basis of clinical, radiological and electrophysiological data. It presents with predominant or isolated deficits for pain and temperature sensations, and is paradoxically closer to pain syndromes from brainstem lesions affecting selectively the spinothalamic pathways than to those caused by focal lesions of the posterior thalamus. The term 'pseudo-thalamic' is therefore inappropriate to describe it, and we propose parasylvian or operculo-insular pain as appropriate labels. Parasylvian pain may be extremely difficult to treat; the magnitude of pain-temperature sensory disturbances may be prognostic for its development, hence the importance of early sensory assessment with quantitative methods.
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Affiliation(s)
- Luis Garcia-Larrea
- Central Integration of Pain Unit, U879 INSERM & University Claude Bernard, Lyon 1, Neurological Hospital, Lyon, France.
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Burkey AR, Abla-Yao S. Successful treatment of central pain in a multiple sclerosis patient with epidural stimulation of the dorsal root entry zone. PAIN MEDICINE 2010; 11:127-32. [PMID: 20447296 DOI: 10.1111/j.1526-4637.2009.00764.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We report a case of central pain successfully treated by epidural placement of spinal cord stimulator electrodes. Neuromodulation of primary afferent fibers and the underlying dorsal root entry zone provided effective analgesia whereas traditional lead placement over the dorsal columns on a prior occasion had not been effective. The rationale for this technique based on current understanding of the mechanisms of central pain and the risk/benefit considerations are discussed. CASE REPORT A 52-year-old woman presented with a 2-year history of pain in the lateral hand secondary to a demyelinating episode in the C2-4 spinal cord secondary to multiple sclerosis. Medications, sympathetic blocks, and acupuncture had been ineffective. One year after an unsuccessful single-lead trial of spinal cord stimulation over the cervical dorsal columns, a dual-lead trial of spinal cord stimulation over the lateral cervical spinal cord and dorsal roots provided significant analgesia, prompting a successful permanent implant. OUTCOME MEASURES Responses on the Brief Pain Inventory short form and quantitative thermosensory testing data were collected at two timepoints 16 days apart under two conditions: no stimulation and single-lead stimulation of cervical primary afferents and underlying spinal cord. RESULTS The patient's questionnaire responses indicated significantly improved pain scores with lateral-lead neuromodulation that was associated with a reduction in her baseline heat hypoalgesia. CONCLUSIONS Lateral-lead spinal cord stimulation may be effective for some central pain syndromes through a partial restoration of homeostatic small-fiber signaling. Neuroanatomical and physiological data in a larger population of patients will be required to predict the best responders to this therapeutic modality.
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Affiliation(s)
- Adam R Burkey
- Department of Anesthesiology, University of Pennsylvania Health System, Philadelphia, PA 19146, USA.
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Veldhuijzen DS, Greenspan JD, Kim JH, Lenz FA. Altered pain and thermal sensation in subjects with isolated parietal and insular cortical lesions. Eur J Pain 2010; 14:535.e1-11. [PMID: 19939715 PMCID: PMC2872197 DOI: 10.1016/j.ejpain.2009.10.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 09/04/2009] [Accepted: 10/02/2009] [Indexed: 11/21/2022]
Abstract
Studies of sensory function following cortical lesions have often included lesions which multiple cortical, white matter, and thalamic structures. We now test the hypothesis that lesions anatomically constrained to particular insular and parietal structures and their subjacent white matter are associated with different patterns of sensory loss. Sensory loss was measured by quantitative sensory testing (QST), and evaluated statistically within patients relative to normal values. All seven subjects with insular and/or parietal lesions demonstrated thermal hypoesthesia, although the etiology of the lesions was heterogeneous. Cold and heat hypoalgesia were only found in the subject with the most extensive parietal and insular lesion, which occurred in utero. Cold allodynia occurred clinically and by thresholds in two subjects with isolated ischemic lesions of the posterior insular/retroinsular cortex, and by thresholds in two subjects with a lesion of parietal cortex with little or no insular involvement. Central pain occurred in the two subjects with clinical allodynia secondary to isolated lesions of the posterior insular/retroinsular cortex, which spared the anterior and posterior parietal cortex. These results suggest that nonpainful cold and heat sensations are jointly mediated by parietal and insular cortical structures so that lesions anywhere in this system may diminish sensitivity. In contrast, thermal pain is more robust requiring larger cortical lesions of these same structures to produce hypoalgesia. In addition, cold allodynia can result from restricted lesions that also produce thermal hypoesthesia, but not from all such lesions.
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Affiliation(s)
- D S Veldhuijzen
- Division of Perioperative Care and Emergency Medicine, Rudolf Magus Institute of Neuroscience, Pain Clinic, University Medical Center Utrecht, Utrecht, Netherlands
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Abstract
All kinds of lesions in the central nervous system can induce central neuropathic pain (e.g., stroke, multiple sclerosis, spinal cord injury, syringobulbia, syringomyelia). The location is the most important feature of the lesion. In stroke, the onset of pain is often delayed. It is mostly constant, but it may be intermittent or paroxysmal. In stroke patients the pain is frequently a hemipain (75%), whereas in the 28% of all multiple sclerosis patients who develop central pain it dominates in the legs (87%) and 5% have trigeminal neuralgia caused by lesions in the brainstem. There is a large variation in the quality of central pain. Central pain is associated with abnormalities in sensitivity to temperature and pain. It is hypothesized that central pain is caused by lesions of the spinothalamic pathways, including their thalamocortical projections, but some other (unknown) factors appear to be crucial for the development of the pain because many patients with such lesions do not develop central pain. Central pain usually responds poorly to analgesics. The first-line treatments are tricyclic antidepressants and antiepileptic drugs.
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Affiliation(s)
- Jörgen Boivie
- Department of Neurology, University Hospital, Uppsala, Sweden.
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Analgesia in conjunction with normalisation of thermal sensation following deep brain stimulation for central post-stroke pain. Pain 2009; 147:299-304. [PMID: 19833434 PMCID: PMC2789248 DOI: 10.1016/j.pain.2009.09.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Revised: 09/08/2009] [Accepted: 09/10/2009] [Indexed: 11/22/2022]
Abstract
The aetiology of central post-stroke pain (CPSP) is poorly understood and such pains are often refractory to treatment. We report the case of a 56-year-old man, who, following a temporo-parietal infarct, suffered from debilitating and refractory hemi-body cold dysaesthesia and severe tactile allodynia. This was associated with thermal and tactile hypoaesthesia and hypoalgesia on his affected side. Implantation of a deep brain stimulating electrode in his periventricular gray (PVG) region produced an improvement in his pain that was associated with a striking normalisation of his deficits in somatosensory perception. This improvement in pain and thermal sensibility was reversed as stimulation became less effective, because of increased electrode impedance. Therefore, we postulate that the analgesic benefit may have occurred as a consequence of the normalisation of somatosensory function and we discuss these findings in relation to the theories of central pain generation and the potential to engage useful plasticity in central circuits.
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Central post-stroke pain: Current evidence. J Neurol Sci 2009; 284:10-7. [DOI: 10.1016/j.jns.2009.04.030] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Revised: 03/18/2009] [Accepted: 04/21/2009] [Indexed: 11/18/2022]
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Changes in brain function and morphology in patients with recurring herpes simplex virus infections and chronic pain. Pain 2009; 144:200-8. [DOI: 10.1016/j.pain.2009.04.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 04/06/2009] [Accepted: 04/16/2009] [Indexed: 11/20/2022]
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Kumar B, Kalita J, Kumar G, Misra UK. Central Poststroke Pain: A Review of Pathophysiology and Treatment. Anesth Analg 2009; 108:1645-57. [DOI: 10.1213/ane.0b013e31819d644c] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Osterberg A, Boivie J. Central pain in multiple sclerosis - sensory abnormalities. Eur J Pain 2009; 14:104-10. [PMID: 19359204 DOI: 10.1016/j.ejpain.2009.03.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 02/04/2009] [Accepted: 03/08/2009] [Indexed: 11/26/2022]
Abstract
Many patients with multiple sclerosis (MS) develop central neuropathic pain (CP). In the present study somatosensory abnormalities have been analysed in detail in 62 patients with MS and CP (42 women, 20 men; mean age 52 years) and in a control group of 10 women and 6 men (mean age 47 years) with MS and sensory symptoms, but without pain. Assessment included clinical testing and quantitative methods (QST) for the measurement of perception thresholds for touch, vibration, and temperatures. All CP patients except two (97%) had abnormal thresholds for innoxious and/or noxious temperatures, compared to 81% in the control group (p<0.05). There was a tendency towards the opposite regarding sensibility to touch, which was decreased in 66% vs. 87% (n.s.), vibration (55% vs. 81%; n.s.) and to joint movement (32% vs. 62%; p<0.04). Comparisons between painful and non-painful regions showed both the absolute threshold values and the index values to be significantly more abnormal, in the CP regions, for warmth (p<0.001), cold (p<0.05), difference limen (innoxious warmth and cold, p<0.01), cold pain (p<0.01) and heat pain/cold pain combined (p<0.001). Also the comparisons between regions with central pain and regions with sensory symptoms in the controls showed significantly more abnormal thresholds in the CP patients for warmth (p<0.05), cold (p<0.01), difference limen (innoxious warmth and cold, p<0.01) and heat pain/cold pain combined (p<0.001). The results support the general hypothesis that only patients who have lesions affecting the spinothalamo-cortical pathways run the risk of developing central pain.
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Affiliation(s)
- A Osterberg
- Department of Neurology, University Hospital, Linköping, Sweden
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