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Mehnert J, Tinnermann A, Basedau H, May A. Functional representation of trigeminal nociceptive input in the human periaqueductal gray. Sci Adv 2024; 10:eadj8213. [PMID: 38507498 PMCID: PMC10954197 DOI: 10.1126/sciadv.adj8213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 02/13/2024] [Indexed: 03/22/2024]
Abstract
The periaqueductal gray (PAG) is located in the mesencephalon in the upper brainstem and, as part of the descending pain modulation, is considered a crucial structure for pain control. Its modulatory effect on painful sensation is often seen as a systemic function affecting the whole body similarly. However, recent animal data suggest some kind of somatotopy in the PAG. This would make the PAG capable of dermatome-specific analgesic function. We electrically stimulated the three peripheral dermatomes of the trigemino-cervical complex and the greater occipital nerve in 61 humans during optimized brainstem functional magnetic resonance imaging. We provide evidence for a fine-grained and highly specific somatotopic representation of nociceptive input in the PAG in humans and a functional connectivity between the individual representations of the peripheral nerves in the PAG and the brainstem nuclei of these nerves. Our data suggest that the downstream antinociceptive properties of the PAG may be rather specific down to the level of individual dermatomes.
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Affiliation(s)
| | | | - Hauke Basedau
- Department of Systems Neuroscience, University Medical Center Eppendorf, 20146 Hamburg, Germany
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Huang Y, Green AL, Hyam J, Fitzgerald J, Aziz TZ, Wang S. Oscillatory neural representations in the sensory thalamus predict neuropathic pain relief by deep brain stimulation. Neurobiol Dis 2017; 109:117-126. [PMID: 29031639 DOI: 10.1016/j.nbd.2017.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/25/2017] [Accepted: 10/11/2017] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Understanding the function of sensory thalamic neural activity is essential for developing and improving interventions for neuropathic pain. However, there is a lack of investigation of the relationship between sensory thalamic oscillations and pain relief in patients with neuropathic pain. This study aims to identify the oscillatory neural characteristics correlated with pain relief induced by deep brain stimulation (DBS), and develop a quantitative model to predict pain relief by integrating characteristic measures of the neural oscillations. APPROACH Measures of sensory thalamic local field potentials (LFPs) in thirteen patients with neuropathic pain were screened in three dimensional feature space according to the rhythm, balancing, and coupling neural behaviours, and correlated with pain relief. An integrated approach based on principal component analysis (PCA) and multiple regression analysis is proposed to integrate the multiple measures and provide a predictive model. MAIN RESULTS This study reveals distinct thalamic rhythms of theta, alpha, high beta and high gamma oscillations correlating with pain relief. The balancing and coupling measures between these neural oscillations were also significantly correlated with pain relief. SIGNIFICANCE The study enriches the series research on the function of thalamic neural oscillations in neuropathic pain and relief, and provides a quantitative approach for predicting pain relief by DBS using thalamic neural oscillations.
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Affiliation(s)
- Yongzhi Huang
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China; Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Alexander L Green
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jonathan Hyam
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - James Fitzgerald
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Tipu Z Aziz
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Shouyan Wang
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China; Institute of Science and Technology for Brain-inspired Intelligence, Fudan University, Shanghai 200433, China.
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Barbaresi P, Mensà E. Connections from the rat dorsal column nuclei (DCN) to the periaqueductal gray matter (PAG). Neurosci Res 2016; 109:35-47. [PMID: 26902642 DOI: 10.1016/j.neures.2016.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 11/30/2022]
Abstract
Electrical stimulation of the dorsal columns (DCs; spinal cord stimulation; SCS) has been proposed to treat chronic neuropathic pain. SCS may activate a dual mechanism that would affect both the spinal cord and supraspinal levels. Stimulation of DCs or DC nuclei (DCN) in animals where neuropathic pain has been induced causes activation of brainstem centers including the periaqueductal gray (PAG), which is involved in the endogenous pain suppression system. Biotinylated dextran-amine (BDA) was iontophoretically injected into the DCN to analyze the ascending projection directed to the PAG. Separate injections into the gracile nucleus (GrN) and the cuneate nucleus (CunN) showed BDA-positive fibers terminating in different regions of the contralateral PAG. GrN-PAG afferents terminated in the caudal and middle portions of PAG-l, whereas CunN-PAG fibers terminated in the middle and rostral portions of PAG-l. Based on the DCN somatotopic map, the GrN sends information to the PAG from the contralateral hindlimb and the tail and the CunN from the contralateral forelimb, shoulder, neck and ear. This somatotopic organization is consistent with earlier electrophysiological and PAG stimulation studies. These fibers could form part of the DCs-brainstem-spinal cord loop, which may be involved in the inhibitory effects of SCS on neuropathic pain.
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Affiliation(s)
- Paolo Barbaresi
- Department of Experimental and Clinical Medicine, Section of Neuroscience and Cell Biology, Marche Polytechnic University, Via Tronto 10/A, Torrette di Ancona, I-60020 Ancona, Italy.
| | - Emanuela Mensà
- Department of Experimental and Clinical Medicine, Section of Neuroscience and Cell Biology, Marche Polytechnic University, Via Tronto 10/A, Torrette di Ancona, I-60020 Ancona, Italy
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Boccard SGJ, Fernandes HM, Jbabdi S, Van Hartevelt TJ, Kringelbach ML, Quaghebeur G, Moir L, Mancebo VP, Pereira EAC, Fitzgerald JJ, Green AL, Stein J, Aziz TZ. Tractography Study of Deep Brain Stimulation of the Anterior Cingulate Cortex in Chronic Pain: Key to Improve the Targeting. World Neurosurg 2015; 86:361-70.e1-3. [PMID: 26344354 DOI: 10.1016/j.wneu.2015.08.065] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the anterior cingulate cortex (ACC) is a new treatment for alleviating intractable neuropathic pain. However, it fails to help some patients. The large size of the ACC and the intersubject variability make it difficult to determine the optimal site to position DBS electrodes. The aim of this work was therefore to compare the ACC connectivity of patients with successful versus unsuccessful DBS outcomes to help guide future electrode placement. METHODS Diffusion magnetic resonance imaging (dMRI) and probabilistic tractography were performed preoperatively in 8 chronic pain patients (age 53.4 ± 6.1 years, 2 females) with ACC DBS, of whom 6 had successful (SO) and 2 unsuccessful outcomes (UOs) during a period of trialing. RESULTS The number of patients was too small to demonstrate any statistically significant differences. Nevertheless, we observed differences between patients with successful and unsuccessful outcomes in the fiber tract projections emanating from the volume of activated tissue around the electrodes. A strong connectivity to the precuneus area seems to predict unsuccessful outcomes in our patients (UO: 160n/SO: 27n), with (n), the number of streamlines per nonzero voxel. On the other hand, connectivity to the thalamus and brainstem through the medial forebrain bundle (MFB) was only observed in SO patients. CONCLUSIONS These findings could help improve presurgical planning by optimizing electrode placement, to selectively target the tracts that help to relieve patients' pain and to avoid those leading to unwanted effects.
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Affiliation(s)
- Sandra G J Boccard
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom.
| | - Henrique M Fernandes
- Department of Psychiatry, University of Oxford, United Kingdom; CFIN/MindLab, Aarhus University, Aarhus, Denmark
| | - Saad Jbabdi
- Centre for Functional MRI of the Brain (FMRIB), University of Oxford, United Kingdom
| | - Tim J Van Hartevelt
- Department of Psychiatry, University of Oxford, United Kingdom; CFIN/MindLab, Aarhus University, Aarhus, Denmark
| | - Morten L Kringelbach
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom; Department of Psychiatry, University of Oxford, United Kingdom; CFIN/MindLab, Aarhus University, Aarhus, Denmark
| | | | - Liz Moir
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
| | - Victor Piqueras Mancebo
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
| | - Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
| | - James J Fitzgerald
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
| | - Alexander L Green
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
| | - John Stein
- Department of Physiology, Anatomy, & Genetics, University of Oxford, United Kingdom
| | - Tipu Z Aziz
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
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Pereira EAC, Boccard SG, Aziz TZ. Deep brain stimulation for pain: distinguishing dorsolateral somesthetic and ventromedial affective targets. Neurosurgery 2015; 61 Suppl 1:175-81. [PMID: 25032548 DOI: 10.1227/neu.0000000000000397] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Erlick A C Pereira
- *Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, United Kingdom; ‡Department of Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Portugal
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Abstract
Deep brain stimulation (DBS) is a neurosurgical intervention the efficacy, safety, and utility of which are established in the treatment of Parkinson's disease. For the treatment of chronic, neuropathic pain refractory to medical therapies, many prospective case series have been reported, but few have published findings from patients treated with current standards of neuroimaging and stimulator technology over the last decade . We summarize the history, science, selection, assessment, surgery, programming, and personal clinical experience of DBS of the ventral posterior thalamus, periventricular/periaqueductal gray matter, and latterly rostral anterior cingulate cortex (Cg24) in 113 patients treated at 2 centers (John Radcliffe, Oxford, UK, and Hospital de São João, Porto, Portugal) over 13 years. Several experienced centers continue DBS for chronic pain, with success in selected patients, in particular those with pain after amputation, brachial plexus injury, stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury. Somatotopic coverage during awake surgery is important in our technique, with cingulate DBS under general anesthesia considered for whole or hemibody pain, or after unsuccessful DBS of other targets. Findings discussed from neuroimaging modalities, invasive neurophysiological insights from local field potential recording, and autonomic assessments may translate into improved patient selection and enhanced efficacy, encouraging larger clinical trials.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, OX3 9DU, UK,
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Boccard SGJ, Pereira EAC, Moir L, Aziz TZ, Green AL. Long-term outcomes of deep brain stimulation for neuropathic pain. Neurosurgery 2013; 72:221-30; discussion 231. [PMID: 23149975 DOI: 10.1227/neu.0b013e31827b97d6] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) to treat neuropathic pain refractory to pharmacotherapy has reported variable outcomes and has gained United Kingdom but not USA regulatory approval. OBJECTIVE To prospectively assess long-term efficacy of DBS for chronic neuropathic pain in a single-center case series. METHODS Patient reported outcome measures were collated before and after surgery, using a visual analog score, short-form 36-question quality-of-life survey, McGill pain questionnaire, and EuroQol-5D questionnaires (EQ-5D and health state). RESULTS One hundred ninety-seven patients were referred over 12 years, of whom 85 received DBS for various etiologies: 9 amputees, 7 brachial plexus injuries, 31 after stroke, 13 with spinal pathology, 15 with head and face pain, and 10 miscellaneous. Mean age at surgery was 52 years, and mean follow-up was 19.6 months. Contralateral DBS targeted the periventricular gray area (n = 33), the ventral posterior nuclei of the thalamus (n = 15), or both targets (n = 37). Almost 70% (69.4%) of patients retained implants 6 months after surgery. Thirty-nine of 59 (66%) of those implanted gained benefit and efficacy varied by etiology, improving outcomes in 89% after amputation and 70% after stroke. In this cohort, >30% improvements sustained in visual analog score, McGill pain questionnaire, short-form 36-question quality-of-life survey, and EuroQol-5D questionnaire were observed in 15 patients with >42 months of follow-up, with several outcome measures improving from those assessed at 1 year. CONCLUSION DBS for pain has long-term efficacy for select etiologies. Clinical trials retaining patients in long-term follow-up are desirable to confirm findings from prospectively assessed case series.
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Affiliation(s)
- Sandra G J Boccard
- Department of Physiology, Anatomy and Genetics, University of Oxford, United Kingdom.
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Pereira EAC, Wang S, Owen SLF, Aziz TZ, Green AL. Human periventricular grey somatosensory evoked potentials suggest rostrocaudally inverted somatotopy. Stereotact Funct Neurosurg 2013; 91:290-7. [PMID: 23797328 DOI: 10.1159/000348324] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 01/20/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Somatosensory homunculi have been demonstrated in primary somatosensory cortex and ventral posterior thalamus but not periaqueductal and periventricular grey matter (PAVG), a therapeutic target for deep brain stimulation (DBS) in chronic pain. AIMS The study is an investigation of somatotopic representation in PAVG and assessment for a somatosensory homunculus. METHODS Five human subjects were investigated using electrical somatosensory stimulation and deep brain macroelectrode recording. DBS were implanted in the contralateral PAVG. Cutaneous arm, leg and face regions were stimulated while event-related potentials were recorded from deep brain electrodes. Electrode contact positions were mapped using MRI and brain atlas information. RESULTS Monopolar P1 somatosensory evoked potential amplitudes were highest and onset latencies shortest in contralateral caudal PAVG with facial stimulation and rostral with leg stimulation, in agreement with reported subjective sensation during intra-operative electrode advancement. CONCLUSIONS A rostrocaudally inverted somatosensory homunculus exists in the human PAVG region. Objective human evidence of PAVG somatotopy increases understanding of a brainstem region important to pain and autonomic control that is a clinical target for both pharmacological and neurosurgical therapies. Such knowledge may assist DBS target localisation for neuropathic pain syndromes related to particular body regions like brachial plexopathies, anaesthesia dolorosa and phantom limb pain.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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9
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Abstract
Deep brain stimulation (DBS) is a neurosurgical intervention whose efficacy, safety, and utility have been shown in the treatment of movement disorders. For the treatment of chronic pain refractory to medical therapies, many prospective case series have been reported, but few have published findings from patients treated during the past decade using current standards of neuroimaging and stimulator technology. We summarize the history, science, selection, assessment, surgery, and personal clinical experience of DBS of the ventral posterior thalamus, periventricular/periaqueductal gray matter, and, latterly, the rostral anterior cingulate cortex (Cg24) in 100 patients treated now at two centers (John Radcliffe Hospital, Oxford, UK, and Hospital de São João, Porto, Portugal) over 12 years. Several experienced centers continue DBS for chronic pain with success in selected patients, in particular those with pain after amputation, brachial plexus injury, stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury. Somatotopic coverage during awake surgery is important in our technique, with cingulate DBS considered for whole-body pain or after unsuccessful DBS of other targets. Findings discussed from neuroimaging modalities, invasive neurophysiological insights from local field potential recording, and autonomic assessments may translate into improved patient selection and enhanced efficacy, encouraging larger clinical trials.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, UK
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Pereira EA, Wang S, Peachey T, Lu G, Shlugman D, Stein JF, Aziz TZ, Green AL. Elevated gamma band power in humans receiving naloxone suggests dorsal periaqueductal and periventricular gray deep brain stimulation produced analgesia is opioid mediated. Exp Neurol 2013; 239:248-55. [DOI: 10.1016/j.expneurol.2012.10.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 10/03/2012] [Accepted: 10/24/2012] [Indexed: 11/29/2022]
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Lopez C, Schreyer HM, Preuss N, Mast FW. Vestibular stimulation modifies the body schema. Neuropsychologia 2012; 50:1830-7. [DOI: 10.1016/j.neuropsychologia.2012.04.008] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 03/21/2012] [Accepted: 04/10/2012] [Indexed: 10/28/2022]
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Leone M, Franzini A, Proietti Cecchini A, Mea E, Broggi G, Bussone G. Deep brain stimulation in trigeminal autonomic cephalalgias. Neurotherapeutics 2010; 7:220-8. [PMID: 20430322 PMCID: PMC5084104 DOI: 10.1016/j.nurt.2010.02.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Accepted: 02/11/2010] [Indexed: 11/24/2022] Open
Abstract
Cluster headache (CH), paroxysmal hemicrania (PH), and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome) are primary headaches grouped together as trigeminal autonomic cephalalgias (TACs). All are characterized by short-lived unilateral head pain attacks associated with oculofacial autonomic phenomena. Neuroimaging studies have demonstrated that the posterior hypothalamus is activated during attacks, implicating hypothalamic hyperactivity in TAC pathophysiology and suggesting stimulation of the ipsilateral posterior hypothalamus as a means of preventing intractable CH. After almost 10 years of experience, hypothalamic stimulation has proved successful in preventing pain attacks in approximately 60% of the 58 documented chronic drug-resistant CH patients implanted at various centers. Positive results have also been reported in drug-resistant SUNCT and PH. Microrecording studies on hypothalamic neurons are increasingly being performed and promise to make it possible to more precisely identify the target site. The implantation procedure has generally proved safe, although it carries a small risk of brain hemorrhage. Long-term stimulation is proving to be safe: studies on patients under continuous hypothalamic stimulation have identified nonsymptomatic impairment of orthostatic adaptation as the only noteworthy change. Studies on pain threshold in chronically stimulated patients show increased threshold for cold pain in the distribution of the first trigeminal branch ipsilateral to stimulation. When the stimulator is switched off, changes in sensory and pain thresholds do not occur immediately, indicating that long-term hypothalamic stimulation is necessary to produce sensory and nociceptive changes, as also indicated by clinical experience that CH attacks are brought under control only after weeks of stimulation. Infection, transient loss of consciousness, and micturition syncope have been reported, but treatment interruption usually is not required.
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Affiliation(s)
- Massimo Leone
- Headache Center, Neuromodulation Unit, Department of Neurology, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, via Celoria 11, 20133 Milan, Italy.
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Pickering AE, Thornton SR, Love-Jones SJ, Steeds C, Patel NK. Analgesia in conjunction with normalisation of thermal sensation following deep brain stimulation for central post-stroke pain. Pain 2009; 147:299-304. [PMID: 19833434 DOI: 10.1016/j.pain.2009.09.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Owen SLF, Heath J, Kringelbach M, Green AL, Pereira EAC, Jenkinson N, Jegan T, Stein JF, Aziz TZ. Pre-operative DTI and probabilisitic tractography in four patients with deep brain stimulation for chronic pain. J Clin Neurosci 2008; 15:801-5. [PMID: 18495481 DOI: 10.1016/j.jocn.2007.06.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Accepted: 06/11/2007] [Indexed: 10/22/2022]
Abstract
This study aimed to examine, using diffusion tensor imaging (DTI), differences in electrode placement in four patients undergoing deep brain stimulation for chronic neuropathic pain of varying aetiology. A pre-operative DTI was obtained for each patient, who was then implanted with deep brain stimulation electrodes in the periventricular/periaqueductal grey area with good pain relief. Using seeds from the postoperative MRI scan, probabilistic tractography was performed from the pre-operative DTI.
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Affiliation(s)
- S L F Owen
- Oxford Functional Neurosurgery, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK.
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Abstract
BACKGROUND The therapeutic use of deep brain stimulation to relieve intractable pain began in the 1950s. In some patients, stimulation of the periaqueductal grey matter induced headache with migrainous features, indicating a pathophysiological link between neuromodulation of certain brain structures and headache. RECENT DEVELOPMENTS Neuroimaging studies have revealed specific activation patterns in various primary headaches. In the trigeminal autonomic cephalgias, neuroimaging findings support the hypothesis that activation of posterior hypothalamic neurons have a pivotal role in the pathophysiology and prompted the idea that hypothalamic stimulation might inhibit this activation to improve or eliminate the pain in intractable chronic cluster headache and other trigeminal autonomic cephalgias. Over the past 6 years, hypothalamic implants have been used in various centres in patients with intractable chronic cluster headache. The results are encouraging: most patients achieved stable and notable pain reduction and many became pain free. All deep-brain-electrode implantation procedures carry a small risk of mortality due to intracerebral haemorrhage. Before implantation, all patients must undergo complete preoperative neuroimaging to exclude disorders associated with increased haemorrhagic risk. No substantial changes in hypothalamus-controlled functions have been reported during hypothalamic stimulation. Hypothalamic stimulation may also be beneficial in patients with SUNCT (short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing)--a disorder with close clinical and neuroimaging similarities to the cluster headache. WHERE NEXT?: Neuroimaging findings in patients undergoing posterior hypothalamic stimulation have shown activation of the trigeminal nucleus and ganglion. This evidence supports the hypothesis that hypothalamic stimulation exerts its effect by modulating the activity of the trigeminal nucleus caudalis, which in turn might control the brainstem trigeminofacial reflex--thought to cause cluster headache pain. Future studies might determine whether other areas of the pain matrix are suitable targets for neuromodulation in patients with cluster headache who do not respond to hypothalamic modulation.
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Affiliation(s)
- Massimo Leone
- Department of Neurology and Headache Centre, Istituto Nazionale Neurologico Carlo Besta, via Celoria 11, 20133 Milano, Italy.
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Laser literature watch. Photomed Laser Surg 2006; 24:424-53. [PMID: 16875454 DOI: 10.1089/pho.2006.24.424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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