Efficacy of ultrasound-guided stellate ganglion block in relieving acute postoperative pain: a systematic review and meta-analysis.

OBJECTIVE: The efficacy of ultrasound-guided stellate ganglion block (SGB) in alleviating postoperative pain remains unclear. This meta-analysis was performed to determine the efficacy of ultrasound-guided SGB in relieving acute postoperative pain in patients undergoing surgery with general anesthesia. METHODS: This systematic review and meta-analysis focused on randomized controlled trials comparing SGB with control or placebo. The primary outcome was the pain score at 24 hours after surgery. A random-effects model was used to calculate the mean difference (MD) or risk ratio with a confidence interval (CI) of 95%. RESULTS: Eight studies involving 470 patients were included in the meta-analysis. The results revealed that ultrasound-guided SGB was significantly associated with a lower pain score at 24 hours after surgery (MD = -0.74; 95% CI = -1.39, -0.08; I2 = 86%; low evidence) and at 8 hours after surgery (MD = -0.65; 95% CI = -1.03, -0.28; I2 = 29%; moderate evidence). CONCLUSION: Ultrasound-guided SGB is effective in alleviating acute postoperative pain. However, considering the limited number of trials performed to date, more large-scale and high-quality randomized controlled trials are required to confirm these findings.

Stellate Ganglion Destruction With Alcohol Versus Thermal Ablation for Chronic Post-Mastectomy Pain: A Randomized Trial.

BACKGROUND: Post-mastectomy pain syndrome (PMPS) is a persistent post-surgical neuropathic pain. Stellate ganglion (SG) block is used for diagnosis, prognosis, and treatment of pain syndrome. OBJECTIVES: We aimed to evaluate the efficacy of SG destruction with alcohol versus thermal ablation for PMPS management. STUDY DESIGN: Randomized, double-blind clinical trial. SETTING: National Cancer Institute, Cairo University, Egypt. METHODS: Female patients aged 20-65 years who underwent breast cancer surgery and suffered moderate to severe pain for more than 6 months were categorized equally into 2 groups. SG destruction was with ultrasound (US) guidance and C7 level confirmation by fluoroscopy either by alcohol injection in Group A or thermal ablation with a time of 60 seconds at 80ºC repeated twice in Group B. Follow-up was at 1, 4, 8, and 12 weeks. RESULTS: Visual analog scale (VAS) measurements after 1, 4, 8, and 12 weeks were significantly lower than pre-procedure measurements in both groups (P value < 0.001). There was a significant reduction in VAS score after 4 and 8 weeks in Group A than in Group B (P value = 0.003 and 0.018). Oxycodone and pregabalin consumption after 4 and 8 weeks were significantly lower in Group A than in Group B. Physical health, mental health, and satisfaction scores were comparable. There were no significant complications in both groups. LIMITATIONS: The relatively small sample size and short follow-up period are limitations to our study. CONCLUSION: US-guided SG destruction with alcohol was more effective than thermal radiofrequency for managing acute postoperative pain by decreasing pain score, oxycodone, and pregabalin consumption, which were consumed before the block.

Safety and Effectiveness of Stellate Ganglion Cryoablation in Complex Regional Pain Syndrome.

This was a retrospective, observational, descriptive study to evaluate the safety and 6-month effectiveness of percutaneous cryoablation of the stellate ganglion for the treatment of complex regional pain syndrome (CRPS). Eight patients with CRPS diagnosed by Budapest criteria were treated with this procedure. CRPS symptom severity was assessed prior to the procedure and at 3-month intervals after the procedure using a novel CRPS scoring system-the Budapest score-created by the authors. The mean Budapest score prior to and 6 months (187 days, SD ± 43) after stellate ganglion cryoablation was 7.0 (SD ± 2.0) (n = 6) and 3.8 (SD ± 2.3) (n = 6), respectively, showing a decrease of 3.2 (SD ± 1.7) (n = 6; P = .006). There were no major adverse events due to the procedure, and there was only 1 minor adverse event. Stellate ganglion cryoablation is a feasible, safe, and minimally invasive procedure that may represent an efficacious adjunct treatment option for select patients with CRPS.

Stellate ganglion block for the management of electrical storm: An observational study.

INTRODUCTION: Electrical storm is a life-threatening emergency with a high mortality rate. When acute conventional treatment is ineffective, stellate ganglion block can help control arrhythmia by providing a visceral cervicothoracic sympathetic block. The objective of this study is to assess the effectiveness and safety of stellate ganglion block in the management of refractory arrhythmic storm. METHOD: Follow-up of a cohort of patients with refractory electrical storm that met the criteria for performing stellate ganglion block. The block was ultrasound-guided at C6 using local anaesthetic and a steroid - left unilateral first, bilateral if no response, followed by fluoroscopy-guided radiofrequency ablation at C7 if there was a favourable response but subsequent relapse. RESULTS: Seven patients were included. The in-hospital mortality rate was 14.29%. Four patients received unilateral and 3 bilateral stellate ganglion block. Six were ablated and 1 received an implantable cardioverter-defibrillator. Electrical storm was controlled temporarily beyond the effect of the local anaesthetic in all patients. Three patients underwent radiofrequency ablation and 2 underwent surgical thoracic sympathectomy. The only side effect was Horner's syndrome, which was observed in all cases after administering a stellate ganglion block with local anaesthetic. Two patients died after discharge and 4 are alive at the time of writing, 3 of them have not been re-admitted for ventricular events for more than 2 years. CONCLUSION: Ultrasound-guided stellate ganglion block is an effective and safe complement to standard cardiological treatment of refractory electrical storm.

Stellate ganglion ablation by conventional radiofrequency in patients with electrical storm.

AIMS: We report a series of patients with Electrical Storm (ES) who underwent bilateral stellate ganglion ablation by using conventional radio frequency (RFA). METHODS AND RESULTS: The procedure was done with fluoroscopic guidance using the COSMAN™ 1A RF Generator and a 22G RF needle (5 cm length and 5 mm active tip). Six patients, four male and two female (mean age 55 ± 7 years and mean LVEF-42 ± 21%) with ES underwent the procedure under fluoroscopic guidance. All patients experienced recurrent ICD shocks or required multiple external defibrillation shocks. There were no procedural complications. All patients survived free of ES at discharge. At a mean follow-up of 22 ± 8months, all were alive free of ES but two patients received appropriate shocks for VT and one patient had VT terminated by ATP. CONCLUSION: This small series of cases is a proof of concept that neuromodulation by conventional RFA targeting bilateral stellate ganglia appears safe, feasible, and effective in treating selected unstable patients with ES.

Phrenic nerve block combined with stellate ganglion block for postoperative intractable hiccups: a case report.

Postoperative intractable hiccups slow patient recovery and generate multiple adverse effects, highlighting the importance of investigating the pathogenesis and terminating the hiccups in a timely manner. At present, medical and physical therapies account for the main treatments. We encountered a case in which postoperative intractable hiccups after biliary T-tube drainage removal ceased with the application of an ultrasound-guided block of the unilateral phrenic nerve and stellate ganglion. No complications developed, and the therapeutic effect was remarkable. To our knowledge, this approach has not been reported to date. Simultaneously blocking the phrenic nerve and stellate ganglion may be a treatment option for intractable hiccups.

[Repeated stellate ganglion blockade for the treatment of ventricular tachycardia storm in patients with nonischemic cardiomyopathy: a new therapeutic option for patients with malignant arrhythmias].

Objectives: This study sought to describe our institutional experience of repeated percutaneous stellate ganglion blockade (R-SGB) as a treatment option for drug-refractory electrical storm in patients with nonischemic cardiomyopathy (NICM). Methods: This prospective observational study included 8 consecutive NICM patients who had drug-refractory electrical storm and underwent R-SGB between June 1, 2021 and January 31, 2022. Lidocaine (5 ml, 1%) was injected in the vicinity of the left stellate ganglion under the guidance of ultrasound, once per day for 7 days. Data including clinical characteristics, immediate and long-term outcomes, and procedure related complications were collected. Results: The mean age was (51.5±13.6) years. All patients were male. 5 patients were diagnosed as dilated cardiomyopathy, 2 patients as arrhythmogenic right ventricular cardiomyopathy and 1 patient as hypertrophic cardiomyopathy. The left ventricular ejection fraction was 37.8%±6.6%. After the treatment of R-SGB, 6 (75%) patients were free of electrical storm. 24 hours Holter monitoring showed significant reduction in ventricular tachycardia (VT) episodes from 43.0 (13.3, 276.3) to 1.0 (0.3, 34.0) on the first day following R-SGB (P<0.05) and 0.5 (0.0, 19.3) after whole R-SGB process (P<0.05). There were no procedure-related major complications. The mean follow-up was (4.8±1.1) months, and the median time of recurrent VT was 2 months. Conclusion: Minimally invasive R-SGB is a safe and effective method to treat electrical storm in patients with NICM.

Acute Modulation of Left Ventricular Control by Selective Intracardiac Sympathetic Denervation.

BACKGROUND: The sympathetic nervous system plays an integral role in cardiac physiology. Nerve fibers innervating the left ventricle are amenable to transvenous catheter stimulation along the coronary sinus (CS). OBJECTIVES: The aim of the present study was to modulate left ventricular control by selective intracardiac sympathetic denervation. METHODS: First, the impact of epicardial CS ablation on cardiac electrophysiology was studied in a Langendorff model of decentralized murine hearts (n = 10 each, ablation and control groups). Second, the impact of transvenous, anatomically driven axotomy by catheter-based radiofrequency ablation via the CS was evaluated in healthy sheep (n = 8) before and during stellate ganglion stimulation. RESULTS: CS ablation prolonged epicardial ventricular refractory period without (41.8 ± 8.4 ms vs 53.0 ± 13.5 ms; P = 0.049) and with ß1-2-adrenergic receptor blockade (47.8 ± 7.8 ms vs 73.1 ± 13.2 ms; P < 0.001) in mice. Supported by neuromorphological studies illustrating a circumferential CS neural network, intracardiac axotomy by catheter ablation via the CS in healthy sheep diminished the blood pressure increase during stellate ganglion stimulation (Δ systolic blood pressure 21.9 ± 10.9 mm Hg vs 10.5 ± 12.0 mm Hg; P = 0.023; Δ diastolic blood pressure 9.0 ± 5.5 mm Hg vs 3.0 ± 3.5 mm Hg; P = 0.039). CONCLUSIONS: Transvenous, anatomically driven axotomy targeting nerve fibers along the CS enables acute modulation of left ventricular control by selective intracardiac sympathetic denervation.

Metrics of high cofluctuation and entropy to describe control of cardiac function in the stellate ganglion.

Stellate ganglia within the intrathoracic cardiac control system receive and integrate central, peripheral, and cardiopulmonary information to produce postganglionic cardiac sympathetic inputs. Pathological anatomical and structural remodeling occurs within the neurons of the stellate ganglion (SG) in the setting of heart failure (HF). A large proportion of SG neurons function as interneurons whose networking capabilities are largely unknown. Current therapies are limited to targeting sympathetic activity at the cardiac level or surgical interventions such as stellectomy, to treat HF. Future therapies that target the SG will require understanding of their networking capabilities to modify any pathological remodeling. We observe SG networking by examining cofluctuation and specificity of SG networked activity to cardiac cycle phases. We investigate network processing of cardiopulmonary transduction by SG neuronal populations in porcine with chronic pacing-induced HF and control subjects during extended in-vivo extracellular microelectrode recordings. We find that information processing and cardiac control in chronic HF by the SG, relative to controls, exhibits: (i) more frequent, short-lived, high magnitude cofluctuations, (ii) greater variation in neural specificity to cardiac cycles, and (iii) neural network activity and cardiac control linkage that depends on disease state and cofluctuation magnitude.

Impact of Stellate Ganglion Block in the Management of Cerebral Vasospasm: A Prospective Interventional Study.

Background: Stellate ganglion block (SGB) causes blockage of sympathetic nerve activity, which may lead to intracerebral vessel dilatation and relieve cerebral vasospasm in patients of aneurysmal subarachnoid hemorrhage (aSAH). Objective: The aim of this study was to evaluate the efficacy and safety of SGB to relieve cerebral vasospasm on clinicoradiological parameters. Materials and Methods: We prospectively included 20 patients with clinical and angiographic evidence of vasospasm post aneurysmal clipping. Cerebral blood flow velocity and Lindegaard ratio were assessed using transcranial Doppler (TCD). Location of vasospasm, vessel diameter, vasospasm severity, parenchymal filling time, and venous sinus filling time were assessed on digital subtraction angiography (DSA). Patients received ultrasound-guided SGB with 10 mL of 0.5% bupivacaine on the ipsilateral side of the vasospasm. After 30 minutes, the neurological status, TCD, and DSA parameters were reevaluated. Results: After SGB, there was statistically significant reduction in the middle cerebral artery (MCA) peak systolic velocity (P = 0.005), mean flow velocity (P = 0.025), and Lindegaard ratio (P = 0.022) on TCD. We observed significant dilatation in the mean vessel diameter measured at the mid-M1 segment of MCA (P = 0.003) and mid-A1 segment of ACA (P = 0.002) on DSA. The mean parenchymal filling time and mean venous sinus filling time decreased nonsignificantly after SGB (P = 0.163/0.104). Neurological improvement was observed in five (25%) patients. Conclusion: SGB has positive clinicoradiological influence in the management of cerebral vasospasm of large vessels. However, its effect on cerebral microvasculature is limited and needs a larger database for further analysis.

Stellate ganglion block reduces symptoms of Long COVID: A case series.

After recovering from COVID-19, a significant proportion of symptomatic and asymptomatic individuals develop Long COVID. Fatigue, orthostatic intolerance, brain fog, anosmia, and ageusia/dysgeusia in Long COVID resemble "sickness behavior," the autonomic nervous system response to pro-inflammatory cytokines (Dantzer et al., 2008). Aberrant network adaptation to sympathetic/parasympathetic imbalance is expected to produce long-standing dysautonomia. Cervical sympathetic chain activity can be blocked with local anesthetic, allowing the regional autonomic nervous system to "reboot." In this case series, we successfully treated two Long COVID patients using stellate ganglion block, implicating dysautonomia in the pathophysiology of Long COVID and suggesting a novel treatment.

Successful treatment of complex regional pain syndrome type 1 of upper limb with cryoneurolysis of the stellate ganglion: A rare case report.

Complex regional pain syndrome type I (CRPS I) is a multifactorial condition that is related to neural damage, and leads to chronic neuropathic pain. Due to its multifactorial nature, there are many methods that have been recruited for its management. Most of them limit the symptoms to some degree, but the most effective of them so far seems to be blockade of the sympathetic innervation of the region. We present the case of a 71-year-old woman, with an upper limb fracture which was treated conservatively, and later on developed CRPS type I. Analgesic medications and pregabalin were ineffective in controlling her symptoms. Blockade of the stellate ganglion was performed with local anesthetic and dexamethasone. After the stellate ganglion blockade was marked as successful in relieving her symptoms, cryoneurolysis was performed which was very effective. There are not many cases that have been treated with cryoneurolysis, and this is what makes this case interesting.

Aorticorenal ganglion as a novel target for renal neuromodulation.

BACKGROUND: Clinical trials for renal artery (RA) ablation have shown limited efficacy. OBJECTIVE: The purpose of this study was to investigate whether the aorticorenal ganglion (ARG) can be targeted for renal denervation. METHODS: Twenty-eight pigs were studied under isoflurane or alpha-chloralose to examine hemodynamic responses and catecholamine release in response to RA or ARG stimulation. To assess the efficacy of ARG ablation, we randomized 16 pigs to either sham, RA, or ARG ablation, followed by occlusion of the left anterior descending coronary artery (LAD). Hemodynamic responses, cardiac electrophysiological parameters, and arrhythmias/sudden cardiac death were assessed following LAD occlusion. Absent hemodynamic responses to stimulation confirmed ARG or RA ablation. In vivo stellate ganglion neural activity was recorded to assess cardiac sympathetic signaling. Cadaveric dissections were performed to localize the ARG in humans for comparison to swine. RESULTS: The ARG is a purely sympathetic ganglion with cholinergic inputs and pass-through sensory afferent fibers. Compared to RA stimulation, ARG stimulation yielded greater hemodynamic responses during alpha-chloralose anesthesia. However, neither site yielded significant responses under isoflurane. Radiofrequency ablation of the ARG eliminated responses to both RA and ARG stimulation, whereas RA ablation did not eliminate responses to ARG stimulation. Ablation of the ARG did not impact the kidneys or adrenal glands. Compared to control and RA ablation, ARG ablation was protective against ventricular arrhythmias and sudden death. Human and swine ARG are similarly located in the aorticorenal region. CONCLUSION: Our findings indicate that the ARG may be a novel target for renal neuromodulation. Further studies are warranted to validate these findings.

Sympathetic Blockade for the Management of Refractory Ventricular Tachycardia: A Case Report.

A 64-year-old man with a history of nonischemic cardiomyopathy (NICM) presented with electrical storm (ES). Episodes of ventricular tachycardia (VT) persisted despite endocardial catheter ablations and exhaustive pharmacotherapy. We used alternating regional anesthesia techniques, left stellate ganglion block, and proximal intercostal block to reduce sympathetic input to the heart, resulting in a significant decrease in VT burden. By using alternating catheter locations, we were able to maintain continuous sympathetic blockade for 31 days and bridge the patient to a successful orthotopic heart transplant.

Left Stellate Ganglion Ablation Inhibits Ventricular Arrhythmias through Macrophage Regulation in Canines with Acute Ischemic Stroke.

AIMS: To investigate the potential mechanism of ventricular arrhythmias (VAs) after acute ischemic stroke and explore the effects of left stellate gangling (LSG) ablation on VAs induced by stroke in canines. Materials and Methods: Twenty canines were randomly divided into the sham-operated group (n=6), AS group (n=7) and SGA group (n=7). Cerebral ischemic model was established in the AS group and the SGA group by right acute middle cerebral artery occlusion (MCAO). LSG ablation was performed in the SGA group as soon as MCAO. After 3 days, atrial electrophysiology and neural activity were measured in vivo. The levels of norepinephrine (NE) in plasma and ventricle were detected by ELISA. The levels of monocyte chemotactic protein-1 (MCP-1), tumor necrosis factor-α (TNF-α) and NF-κB p65 in ventricle were detected by western blotting. The pro-inflammatory polarization of macrophages in ventricle was detected by immunofluorescence. Results: Higher ventricular tachycardia (VT) inducibility and lower ventricular fibrillation threshold (VFT) were observed in the AS group compared with those in the sham-operated group, associated with higher LSG activity and NE levels, increased number of M1 macrophages and secretion of inflammatory cytokines in ventricle (all P<0.001). Compared with the AS group, the SGA group had lower VT inducibility and higher VFT, combined with lower NE levels, and reduced number of M1 macrophages and secretion of inflammatory cytokines in ventricle (all P<0.001). Conclusion: LSG ablation could reduce VAs vulnerability after acute stroke by preventing the macrophages polarization and activation induced by sympathetic hyperactivity.

Minimally Invasive Bilateral Stellate Ganglionectomy for Refractory Ventricular Tachycardia.

Cardiac sympathetic denervation (CSD) for refractory ventricular tachycardia (VT) has been shown to decrease VT recurrence and defibrillator shocks in patients with ischemic and nonischemic cardiomyopathy. Here and in the accompanying Video, we demonstrate the technique for minimally invasive CSD, highlight important technical points, and report surgical outcomes. CSD is accomplished through bilateral resection of the inferior one-third to one-half of the stellate ganglion en bloc with T2-T4 sympathectomy. Despite the high potential for perioperative risk, most patients do not have serious complications. We find that surgical CSD can be performed safely in an attempt to liberate patients from refractory VT.

Multipronged approach to a patient with ventricular tachycardia storm.

Management of ventricular tachycardia storm requires multimodal aggressive therapeutic interventions for a successful outcome. A 39-year-old man with dilated cardiomyopathy and severe left ventricular dysfunction presented with refractory ventricular tachycardia unresponsive to conventional treatment. He underwent an electrophysiology study and radiofrequency ablation with 3-dimensional mapping with partial control of the ventricular tachycardia. Further left sympathetic ganglion block followed by left cardiac sympathetic denervation also did not totally control the ventricular tachycardia. Right cardiac sympathetic denervation resulting in bilateral cardiac sympathetic denervation controlled the ventricular tachycardia.

Emergent Phenol Injection of Bilateral Stellate Ganglion for Management of Refractory Malignant Ventricular Arrhythmias.

BACKGROUND Management of incessant electrical storm is poorly defined. These 2 case studies demonstrate a simplified percutaneous approach to achieve stellate ganglion ablation (SGA) and to promptly control malignant ventricular arrhythmias. CASE REPORT This report describes 2 patients with deteriorating hemodynamics, progressive ventricular arrhythmias, and worsening heart failure, managed with emergent percutaneous fluoroscopically-guided bilateral SGA to achieve bilateral cardiac sympathetic denervation. While supine and intubated, the left and then right stellate ganglion were identified guided by anatomic landmarks. Using a 22-guage, 3.5-inch spinal needle, contrast dye was injected with appropriate outline of the stellate ganglion at the uncinate process of the C6 vertebra. Bupivacaine 0.5% was injected, followed by phenol 6%. Successful SGA was confirmed by intentional Horner's syndrome with bilateral eye lag. The procedures were completed in about 30 min without complications and there was a dramatic reduction in ventricular arrhythmias. CONCLUSIONS Emergent percutaneous bilateral SGA can be accomplished with a brief procedure resulting in management of electrical storm.

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

RATIONALE: Recent years have witnessed a marked improvement in the safety and accuracy of nerve blocks with the help of ultrasound and other visualization technologies. This study reports a challenging case of a severe complication during the ultrasound-guided stellate ganglion block. PATIENT CONCERNS: A 28-year-old male patient with refractory migraine complained episodic pulsatile pain with photophobia, haphalgesia of the scalp for 3 years. INTERVENTIONS: Ultrasound-guided stellate ganglion block with 4 ml of 1% lidocaine was administrated. OUTCOMES: A sudden loss of consciousness and tonic-clonic seizure was occurred after negative aspiration and test dose. Further sonographic examination revealed a variation in the left vertebral artery, which remained unrecognized during the needle insertion because of its sliding ability under the differential pressure applied by the probe. LESSONS: Inadvertent intra-arterial injection of a local anesthetic agent could be minimized under the ultrasound guidance with various protective strategies, including the determination of any prior variation, optimizing the block route, maintaining a constant probe pressure, and using saline for the test dosage. This case resulted in the implementation of new protocols of the ultrasound-guided stellate ganglion block in our department.