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Central post-stroke pain


Other Names for this Disease
  • Central pain syndrome
  • Dejerine Roussy syndrome
  • Posterior thalamic syndrome
  • Retrolenticular syndrome
  • Thalamic hyperesthetic anesthesia
More Names
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Overview



What is central post-stroke pain?

What are the signs and symptoms of central post-stroke pain?

How is central post-stroke pain diagnosed?

How might central post-stroke pain be treated?


What is central post-stroke pain?

Central post-stroke pain (CPSP) is a rare neurological disorder in which the body becomes hypersensitive to pain as a result of damage to the thalamus, a part of the brain that affects sensation. Primary symptoms are pain and loss of sensation, usually in the face, arms, and/or legs. Pain or discomfort may be felt after being mildly touched or even in the absence of a stimulus; the pain may worsen by exposure to heat or cold and by emotional distress.[1] It is caused by damage to, or dysfunction of, the central nervous system (CNS), which may be due to stroke, multiple sclerosis, tumors, epilepsy, brain or spinal cord trauma, or Parkinson's disease.[2] Treatment typically includes pain medications to provide some reduction of pain, but complete relief of pain may not be possible. Tricyclic antidepressants or anticonvulsants can sometimes be useful. Lowering stress levels appears to reduce pain.[2]
Last updated: 1/24/2011

What are the signs and symptoms of central post-stroke pain?

Central post-stroke pain (CPSP) often begins shortly after the injury or damage that caused it, but may be delayed by months or even years, especially if it is related to post-stroke pain. The character of the pain associated with CPSP differs widely among individuals, partly because of the variety of potential causes. It may affect a large portion of the body or may be more restricted to specific areas, such as hands or feet. The extent of pain is usually related to the cause of the central nervous system (CNS) injury or damage. Pain is typically constant, may be moderate to severe in intensity, and is often made worse by touch, movement, emotions, and temperature changes (usually cold temperatures). Individuals experience one or more types of pain sensations, the most prominent being burning. Mingled with the burning may be sensations of "pins and needles;" pressing, lacerating, or aching pain; and brief, intolerable bursts of sharp pain similar to the pain caused by a dental probe on an exposed nerve. Individuals may have numbness in the areas affected by the pain. The burning and loss of touch sensations are usually most severe on the distant parts of the body, such as the feet or hands.[2]
Last updated: 1/24/2011

How is central post-stroke pain diagnosed?

In a review article from 2009 in the journal Lancet Neurology, the authors discuss making a diagnosis of central post-stroke pain (CPSP). They recognize that a definite diagnosis of central post-stroke pain (CPSP) may be difficult, mainly because of the variable signs and symptoms, the frequent concurrence of several pain types, and the lack of clear diagnostic criteria for CPSP. The diagnosis may be based on a combination of the history, a clinical and sensory examination, imaging of lesions (such as CT or MRI), and other examinations. The history of stroke may be confirmed by imaging (either CT or MRI) to visualize the cause (type, location, and size) and to rule out other central causes of the pain. Details about the pain, including when and how the pain began; pain quality; and the presence of dysesthesia (impaired sensitivity) or allodynia (pain resulting from something that should not normally cause pain) are helpful in the diagnosis. Sometimes patients are asked to indicate the area of pain on a drawing of the body (a pain drawing). The clinical examination may include sensory testing to confirm and pinpoint the presence of sensory abnormalities, but also to rule out other causes of pain.[3]

Experts have proposed that mandatory criteria for the diagnosis of CPSP include:
  • Pain within an area of the body corresponding to the abnormality of the CNS
  • History suggestive of a stroke and onset of pain at or after stroke onset
  • Confirmation of a CNS lesion by imaging, or negative or positive sensory signs confined to the area of the body corresponding to the lesion
  • Other causes of pain are excluded or considered highly unlikely

Supportive criteria may include:

  • No primary relation to movement, inflammation, or other local tissue damage
  • Descriptions such as burning, painful cold, electric shocks, aching, pressing, stinging, and pins and needles, although all pain descriptions may apply
  • Allodynia or dysesthesia to touch or cold[3]
Last updated: 5/25/2011

How might central post-stroke pain be treated?

Treatment of central post-stroke pain (CPSP) is known to be challenging.[4] Pain medications (analgesics) often provide some reduction of pain, but not complete relief of pain. Tricyclic antidepressants such as nortriptyline, or anticonvulsants such as gabapentin can be useful. Lowering stress levels appears to reduce pain.[2] Other treatment alternatives have included the administration of a sympathetic blockade (a type of nerve block) and a guanethidine block, as well as psychological evaluation and treatment. Rarely, surgery is necessary.[5] Stereotactic radiosurgery of the pituitary has been used to treat CPSP with some success.[4] Other forms of potential treatments for CPSP that have been discussed in the literature include transcutaneous electrical nerve stimulation (TENS); deep brain stimulation; and motor cortex stimulation.[6]

Last updated: 1/24/2011

References
  1. Thalamic Syndrome (Dejerine Roussy). National Organization for Rare Disorders. December 31, 2010; http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Thalamic%20Syndrome%20%28Dejerine%20Roussy%29. Accessed 1/23/2011.
  2. NINDS Central Pain Syndrome Information Page. National Institute of Neurological Disorders and Stroke (NINDS). January 13, 2011; http://www.ninds.nih.gov/disorders/central_pain/central_pain.htm. Accessed 1/23/2011.
  3. Henriette Klit, Nanna B Finnerup, Troels S Jensen. Central post-stroke pain: clinical characteristics, pathophysiology, and management. Lancet Neurology. 2009; 8:859-868.
  4. YiLi Zhou. CHAPTER 48 – Principles of Pain Management. Bradley: Neurology in Clinical Practice, 5th ed.[Electronic version]. Deutschland: Butterworth-Heinemann; 2008 ; 905.
  5. Robert Gould, Susan S Barnes. Shoulder and Hemiplegia. eMedicine. February 5, 2009; http://emedicine.medscape.com/article/328793-overview. Accessed 1/23/2011.
  6. G D Schott. From thalamic syndrome to central poststroke pain. Journalof Neurology, Neurosurgery, and Psychiatry. December, 1996; 61(6):560-564. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC486645/pdf/jnnpsyc00012-0002.pdf. Accessed 1/23/2011.