Cingulotomy: the last man standing in the battle against medically refractory poststroke pain.

Introduction: Central poststroke pain (CPSP) places a huge burden on patient lives because patients are often refractory to conventional strategies and have little chance for spontaneous recovery. A subset of patients is even given approval for euthanasia and is without any perspective. Because the anterior cingulate cortex historically seems to be a promising target for patients with both mental and chronic pain disorders, lesioning of this central "hub" with cingulotomy may be a useful strategy for medically refractory CPSP. However, limited research is available on cingulotomy for central pain. Hence, we represent a rare case in which cingulotomy is performed on a patient with CPSP. Objectives: To describe the potential of cingulotomy in a case with CPSP. Methods: The case presented in this study concerns a 60-year-old woman who experienced CPSP, caused by a hemorrhagic stroke in the basal ganglia and thalamus. The patient visited several centers and tried multiple off-label treatments; however, she was told nothing else could be done and was even given approval for euthanasia. Hence, anterior cingulotomy was performed. Results: After surgery, no transient adverse events occurred, except for vocabulary disturbances post stroke, which disappeared after several weeks. After 14 weeks, changes in pain behavior were observed, followed by a decreased pain intensity. At a later follow-up, the pain had completely disappeared. Conclusion: Anterior cingulotomy seems to be a suitable "last-resort" option for patients with CPSP. Future research, including homogenous groups, to define the best location for lesioning is required to allow the revival of this "old" technique in the current era.

The Untold Story of Occipital Nerve Stimulation in Patients With Cluster Headache: Surgical Technique in Relation to Clinical Efficacy.

OBJECTIVES: Approximately one in every 1000 adults experiences cluster headache (CH). Although occipital nerve stimulation (ONS) appears encouraging in treatment for most patients with refractory CH, some patients do not reach adequate pain relief with ONS. A reason for failure of ONS might be anatomical variations and different surgical approaches. Therefore, an extensive literature analysis was performed, and cadaveric experimentation was combined with our clinical experience to provide a standardized proposal for ONS and obtain optimal management of patients with refractory CH. MATERIALS AND METHODS: Data from 36 articles published between 1998 and 2023 were analyzed to retrieve information on the anatomical landmarks and surgical technique of ONS. For the cadaveric experimentation (N = 1), two electrodes were inserted from the region over the foramen magnum and projected toward the lower third of the mastoid process. RESULTS: The existence of multiple approaches of ONS has been confirmed by the present analysis. Discrepancies have been found in the anatomical locations and corresponding landmarks of the greater and lesser occipital nerve. The surgical approaches differed in patient positioning, electrode placement, and imaging techniques, with an overall efficacy range of 35.7% to 90%. CONCLUSIONS: Reports on the surgical approach of ONS remain contradictory, hence emphasizing the need for standardization. Only if all implanting physicians perform the ONS surgery using a standardized protocol, can future data be combined and outcomes compared and analyzed.

Accuracy, precision, and safety of stereotactic, frame-based, intraoperative MRI-guided and MRI-verified deep brain stimulation in 650 consecutive procedures.

OBJECTIVE: Suboptimal lead placement is one of the most common indications for deep brain stimulation (DBS) revision procedures. Confirming lead placement in relation to the visible anatomical target with dedicated stereotactic imaging before terminating the procedure can mitigate this risk. In this study, the authors examined the accuracy, precision, and safety of intraoperative MRI (iMRI) to both guide and verify lead placement during frame-based stereotactic surgery. METHODS: A retrospective analysis of 650 consecutive DBS procedures for targeting accuracy, precision, and perioperative complications was performed. Frame-based lead placement took place in an operating room equipped with an MRI machine using stereotactic images to verify lead placement before removing the stereotactic frame. Immediate lead relocation was performed when necessary. Systematic analysis of the targeting error was calculated. RESULTS: Verification of 1201 DBS leads with stereotactic MRI was performed in 643 procedures and with stereotactic CT in 7. The mean ± SD of the final targeting error was 0.9 ± 0.3 mm (range 0.1-2.3 mm). Anatomically acceptable lead placement was achieved with a single brain pass for 97% (n = 1164) of leads; immediate intraoperative relocation was performed in 37 leads (3%) to obtain satisfactory anatomical placement. General anesthesia was used in 91% (n = 593) of the procedures. Hemorrhage was noted after 4 procedures (0.6%); 3 patients (0.4% of procedures) presented with transient neurological symptoms, and 1 experienced delayed cognitive decline. Two bleeds coincided with immediate relocation (2 of 37 leads, 5.4%), which contrasts with hemorrhage in 2 (0.2%) of 1164 leads implanted on the first pass (p = 0.0058). Three patients had transient seizures in the postoperative period. The seizures coincided with hemorrhage in 2 of these patients and with immediate lead relocation in the other. There were 21 infections (3.2% of procedures, 1.5% in 3 months) leading to hardware removal. Delayed (> 3 months) retargeting of 6 leads (0.5%) in 4 patients (0.6% of procedures) was performed because of suboptimal stimulation benefit. There were no MRI-related complications, no permanent motor deficits, and no deaths. CONCLUSIONS: To the authors' knowledge, this is the largest series reporting the use of iMRI to guide and verify lead location during DBS surgery. It demonstrates a high level of accuracy, precision, and safety. Significantly higher hemorrhage was encountered when multiple brain passes were required for lead implantation, although none led to permanent deficit. Meticulous audit and calibration can improve precision and maximize safety.

Spinal cord stimulation in patients suffering from chronic pain after surgery for spinal intradural tumors: A case report and literature summary.

BACKGROUND: The prevalence of pain after treatment of a spinal intradural tumor is remarkably high, approximately up to 40% of the patients suffer from central neuropathic pain. Publications on spinal cord stimulation (SCS) and its effect on pain caused by intradural spinal tumors are rare. We discuss the case of a patient suffering from chronic pain after removal of a Th7 level meningioma who was successfully treated with SCS and give an overview of the literature. METHODS: MEDLINE database was searched for neuropathic pain and intradural tumors. RESULTS: The initial search identified 35 articles, including hand-searched manuscripts. Six articles were included for analysis. CASE REPORT: A 57-year-old female suffers from neuropathic pain in both legs after surgical removal of a Th7 level intradural meningioma. Postoperative magnetic resonance imaging shows no gross abnormalities, although she developed chronic pain in both legs. Pain in combination with side effects of analgesic intake are too disabling to have decent quality of life. A successful implantation of SCS is achieved at Th5 level as a treatment for the central neuropathic pain, and, at 36 months follow-up, there is significant pain relief and almost complete discontinuation of analgesics. DISCUSSION: Central pain from spinal intradural tumors may have a different mechanism of origin than pain seen after an acute spinal cord injury (SCI). However, the basic principles of neuromodulation are the same in both etiologies, as for successful stimulation intact pathways in the spinal cord are necessary. The efficacy of SCS as treatment in intradural spinal tumors is rarely described as only a handful of case reports are published. Interestingly, the case reports show that stimulation both above and below the lesion can be effective. In patients with incomplete SCI or intradural tumor resection stimulation below the lesion could be considered and tried in a trial setting before definitive implantation.