Hypothalamic Stimulation (also known as Deep Brain Stimulation) in Cluster Headache
Cephalalgia. 2008 Mar;28(3):285-95.
Hypothalamic deep brain stimulation for cluster headache: experience from
a new multicase series.
Bartsch T, Pinsker MO, Rasche D, Kinfe T, Hertel F, Diener HC, Tronnier V,
Mehdorn HM, Volkmann J, Deuschl G, Krauss JK.
Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany.
t.bartsch@neurologie.uni-kiel.de
Deep brain stimulation (DBS) of the posterior hypothalamus was found to be
effective in the treatment of drug-resistant chronic cluster headache. We report
the results of a multicentre case series of six patients with chronic cluster
headache in whom a DBS in the posterior hypothalamus was performed. Electrodes
were implanted stereotactically in the ipsilateral posterior hypothalamus
according to published coordinates 2 mm lateral, 3 mm posterior and 5 mm
inferior referenced to the mid-AC-PC line. Microelectrode recordings at the
target revealed single unit activity with a mean discharge rate of 17 Hz (range
13-35 Hz, n = 4). Out of six patients, four showed a profound decrease of
their attack frequency and pain intensity on the visual analogue scale during
the first 6 months. Of these, one patient was attack free for 6 months under
neurostimulation before returning to the baseline which led to abortion of the
DBS. Two patients had experienced only a marginal, non-significant decrease
within the first weeks under neurostimulation before returning to their former
attack frequency. After a mean follow-up of 17 months, three patients are almost
completely attack free, whereas three patients can be considered as treatment
failures. The stimulation was well tolerated and stimulation-related
side-effects were not observed on long term. DBS of the posterior inferior
hypothalamus is an effective therapeutic option in a subset of patients. Future
controlled multicentre trials will need to confirm this open-label experience
and should help to better define predictive factors for non-responders.
PMID: 18254897
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J Neurosurg. 2007 Jun;106(6):999-1005.
Chronic stimulation of the posterior hypothalamic region for cluster
headache: technique and 1-year results in four patients.
Starr PA, Barbaro NM, Raskin NH, Ostrem JL.
Departments of Neurosurgery, University of California at San Francisco,
California 94143, USA\. starrp@itsa.ucsf.edu
OBJECT: Cluster headache (CH) is the most severe of the primary headache
disorders. Based on the finding that regional cerebral blood flow is increased
in the ipsilateral posterior hypothalamic region during a CH attack, a novel
neurosurgical procedure for CH was recently introduced: hypothalamic deep brain
stimulation (DBS). Two small case series have been described. Here, the authors
report their technical approach, intraoperative physiological observations, and
1-year outcomes after hypothalamic DBS in four patients with medically
intractable CHs.
METHODS: Patients underwent unilateral magnetic resonance (MR) imaging-guided stereotactic implantation of a Medtronic DBS (model 3387) lead and Soletra pulse generator system. Intended tip coordinates were 3 mm posterior, 5 mm inferior, and 2 mm lateral to the midcommissural point. Microelectrode recording and intraoperative test stimulation were performed. Lead locations were measured on postoperative MR images. The intensity, frequency, and severity of headaches throughout a 1-week period were tracked in patient diaries immediately prior to surgery and after 1 year of continuous stimulation. At the I-year follow-up examination, DBS had produced a greater than 50% reduction in headache intensity or frequency in two of four cases. Active contacts were located 3 to 6 mm posterior to the mammillothalamic tract. Neurons in the target region showed low-frequency tonic discharge.
CONCLUSIONS: In two previously published case
series, headache relief was obtained in many but not all patients. The results
of these open-label studies justify a larger, prospective trial but do not yet
justify widespread clinical application of this technique.
PMID: 17564171
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58th Annual Meeting of the German Society of Neurosurgery, 26 - 29 April 2007, Leipzig
Meeting Abstract
Failure of deep brain stimulation of the posterior inferior hypothalamus in chronic Cluster headache: Report of two cases and review of the literature
Tiefe Hirnstimulation des posterioren inferioren Hypothalamus bei chronischem Cluster-Kopfschmerz: zwei Fallberichte und Review der Literatur
M.O. Pinsker - Klinik für Neurochirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland
T. Bartsch - Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland
D. Falk - Klinik für Neurochirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland
M. Wasner - Klinik für Neurochirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland; Present Address: Department of Neurosurgery, University Hospital Basel, Switzerland
J. Volkmann - Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland
J. Herzog - Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland
F. Steigerwald - Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland
G. Deuschl - Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland
H. M. Mehdorn - Klinik für Neurochirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland
Deutsche Gesellschaft für Neurochirurgie. 58. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie e.V. (DGNC). Leipzig, 26.-29.04.2007. Düsseldorf: German Medical Science GMS Publishing House; 2007. Doc SO.06.03
The electronic version of this article is the complete one and can be found online at: http://www.egms.de/en/meetings/dgnc2007/07dgnc248.shtml
Text
Objective: Deep brain stimulation (DBS) has become a standard procedure for movement disorders such as Parkinsons disease, essential tremor or dystonia. Recent publications have gained interest in the treatment of drug-resistant chronic cluster headache. Functional neuroimaging studies showed hypothalamus dysfunction as a possible responsible cause for chronic cluster headache attacks.
Methods: DBS of the posterior inferior hypothalamus was performed on two patients, one 55-year-old man with a severe case of cluster headache since 1996, and one 31-year-old woman with symptoms since 2002, which intensified in both cases in the last years despite high dose medical treatment. The electrodes were implanted stereotactically on the ipsilateral side in the following position in relation to Mid-AC-PC: 2 mm lateral, 3 mm posterior, 5 mm inferior.
Results: The postoperative course was uneventful, the MRI control documented regular position of the DBS electrodes. The current stimulation parameters were at 12 months postoperatively 0-; G+ 5,5 V; 60µs; 180 Hz (Case 1) and 0 -, G+ 3,0 V; 60µs; 185 Hz at 3 months postoperatively (Case 2). In summary, there was no pain control at all in both patients, the medical treatment remained unchanged. We did not observe any stimulation related side effects.
Conclusions: Deep brain stimulation of the posterior inferior hypothalamus is still an experimental procedure and should be restricted to highly experienced centres both in patient selection and stereotactic surgery. A multi-centre study is necessary to evaluate its effectiveness.
Published April 11, 2007
© 2007 Pinsker et al; licensee . This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.
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Neurology. 2006 Nov 28;67(10):1844-5.
Acute hypothalamic stimulation and ongoing cluster headache attacks.
Leone M, Franzini A, Broggi G, Mea E, Cecchini AP, Bussone G.
Department of Neurology and Headache Centre, Istituto Nazionale Neurologico Carlo Besta, via Celoria 11, 20133 Milano, Italy. leone@istituto-besta.it
Long-term hypothalamic stimulation is effective in improving drug-resistant chronic cluster headache (CH). We assessed acute hypothalamic stimulation to resolve ongoing CH attacks in 16 patients implanted to prevent chronic CH, investigating 136 attacks. A pain intensity reduction of > or =50% occurred in 25 of 108 evaluable attacks (23.1%). Acute hypothalamic stimulation is not effective in resolving ongoing CH attacks, suggesting that hypothalamic stimulation acts by complex mechanisms in CH prevention.
PMID: 17130420
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Lancet Neurol. 2006 Oct;5(10):873-7.
Deep brain stimulation in headache.
Leone M.
Department of Neurology and Headache Centre, Istituto Nazionale Neurologico Carlo Besta, via Celoria 11, 20133 Milano, Italy. leone@istituto-besta.it
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.
PMID: 16987734
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Neurology. 2006 Jul 11;67(1):150-2.
Hypothalamic stimulation for intractable cluster headache: long-term experience.
Leone M, Franzini A, Broggi G, Bussone G.
Istituto Nazionale Neurologico Carlo Besta, Milano, Italy. leone@istituto-besta.it
The authors report long-term results of continuous hypothalamic stimulation in
16 chronic drug-refractory patients with cluster headache (CH). At a mean
follow-up of 23 months, 13 patients are persistently pain-free or almost
pain-free, and the other 3 are improved. There are no persistent side effects.
Hypothalamic stimulation is an effective, safe, and well-tolerated alternative
to surgery for chronic patients with drug-refractory CH.
PMID: 16832097
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J Neurosci. 2006 Mar 29;26(13):3589-93.
Hypothalamic deep brain stimulation in positron emission tomography.
May A, Leone M, Boecker H, Sprenger T, Juergens T, Bussone G, Tolle TR.
Department of Systems Neuroscience, University of Hamburg, D-20246 Hamburg, Germany. a.may@uke.uni-hamburg.de
Recently, functional imaging data have underscored the crucial role the hypothalamus plays in cluster headache, one of the most severe forms of primary headache. This prompted the application of hypothalamic deep brain stimulation. Yet, it is not apparent how stimulation of an area that is thought to act as a pace-maker for acute headache attacks is able to prevent these attacks from occurring. We addressed this issue by examining 10 operated chronic cluster headache patients, using H2(15O)-positron emission tomography and alternately switching the hypothalamic stimulator on and off. The stimulation induced activation in the ipsilateral hypothalamic gray (the site of the stimulator tip), the ipsilateral thalamus, somatosensory cortex and praecuneus, the anterior cingulate cortex, and the ipsilateral trigeminal nucleus and ganglion. We additionally observed deactivation in the middle temporal gyrus, posterior cingulate cortex, and contralateral anterior insula. Both activation and deactivation are situated in cerebral structures belonging to neuronal circuits usually activated in pain transmission and notably in acute cluster headache attacks. Our data argue against an unspecific antinociceptive effect or pure inhibition of hypothalamic activity. Instead, the data suggest a hitherto unrecognized functional modulation of the pain processing network as the mode of action of hypothalamic deep brain stimulation in cluster headache.
PMID: 16571767
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Schmerz. 2006 Jan 11; [Epub ahead of print]
Deep brain stimulation in the posterior hypothalamus for chronic cluster headache Case report and review of the literature.
Rasche D, Foethke D, Gliemroth J, Tronnier VM.
Abteilung für Neurochirurgie, Campus Lübeck des Universitätsklinikums Schleswig-Holstein, .
Primary chronic cluster headache (CCH) is a rare but severe pain syndrome and pathophysiological explanations are still missing. PET studies revealed activation in the hypothalamus and therefore it became a target for therapeutic deep brain stimulation (DBS). A case of a 39-year-old woman and a literature review are presented. The patient suffered from left-sided primary CCH for 14 months. The headache was resistant to any pharmacological therapy or treatment was limited by major drug side effects. Using a stereotactic approach a quadripolar lead was inserted in the left posterior hypothalamus. A test trial was performed and attack frequency, intensity, and adverse events were noted. Intraoperative test stimulation evoked typical side effects like tachycardia, diplopia and panic attacks. During the trial test a marked reduction in frequency and intensity of CCH was recorded. After 7 days the stimulation device was implanted subcutaneously. DBS with implantation of a lead in the ipsilateral inferior posterior hypothalamus is an experimental treatment option and should be offered to selected patients in a prospective controlled clinical trial. Data concerning the long-term follow-up need to be collected.
PMID: 16404629
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Schmerz. 2005 Nov;19(6):544-8.
Hypothalamic deep brain stimulation in patients with chronic cluster headaches. Suggestions for patient selection.
May A, Vesper J, Hamel W, Westphal M, Weiller C, Nikkhah G.
Neurologische Universitatsklinik Hamburg Eppendorf (UKE). a.may@uke.uni-hamburg.de
Cluster headaches involve a stereotypic symptomatic and belong to the most severe primary pain syndromes. Imaging studies have demonstrated functional and structural changes in the inferior-posterior hypothalamus ipsilateral to the pain. These changes are highly specific to the syndrome, strongly suggesting that this anatomical region is the trigger or generator of the acute attacks and/or determine the duration of the acute pain. These findings have led to the successful therapy of 19 not or difficult to treat patients with hypothalamic deep brain stimulation, resulting in long-term periods without pain and without significant side effects. Recently, however, a patient was reported who died after the operation due to increased blood pressure leading to the rupture of a previously non-diagnosed aneurysm. This article offers a translated summary of the recently published criteria of an international consensus group, which, in addition to a positive ethics vote, should be fulfilled before such deep brain stimulation of the hypothalamus is carried out in such patients.
PMID: 16208520
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Neurol Sci. 2005 May;26 Suppl 2:s138-9.
Deep brain stimulation and cluster headache.
Leone M, Franzini A, Felisati G, Mea E, Curone M, Tullo V, Broggi G, Bussone G.Headache Centre, C. Besta National Neurological Institute, Via Celoria 11, I-20133, Milan, Italy. leone@istituto-besta.it
In recent years, neuroimaging data have greatly improved the knowledge on trigeminal autonomic cephalalgias' (TACs) central mechanisms. Positron emission tomography studies have shown that the posterior inferior hypothalamic grey matter is activated during cluster headache attacks as well as in short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). Voxel-based morphometric MRI has also documented alteration in the same area in cluster headache patients. These data suggest that the cluster headache generator is located in this region and leads us to hypothesise that stimulation of this brain area could relieve intractable cluster headache just as deep brain stimulation improves intractable movements disorders. This view received support by the observation that high frequency stimulation of the ipsilateral hypothalamus prevented attacks in an otherwise intractable chronic cluster headache patient previously treated unsuccessfully by surgical procedures to the trigeminal nerve. So far, 16 patients with intractable cronic cluster headache (CCH) and one intractable SUNCT patient have been successfully treated by hypothalamic stimulation. The procedures were well tolerated with no significant adverse events. Hypothalamic DBS is an efficacious and safe procedure to relieve otherwise intractable CCH and SUNCT.
PMID: 15926012
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Brain. 2005 Apr; 128(Pt4):940-7
Hypothalamic stimulation in chronic cluster headache: a pilot study of efficacy
and mode of action.
Schoenen J, Di Clemente L, Vandenheede M, Fumal A, De Pasqua V, Mouchamps M,
Remacle JM, de Noordhout AM.
University Department of Neurology, University of Liege, Liege, Belgium;
University Department of Neuroanatomy, University of Liege, Liege, Belgium.
Summary We enrolled six patients suffering from refractory chronic cluster
headache in a pilot trial of neurostimulation of the ipsilateral ventroposterior
hypothalamus using the stereotactic coordinates published previously. After the
varying durations needed to determine optimal stimulation parameters and a mean
follow-up of 14.5 months, the clinical outcome is excellent in three patients
(two are pain-free; one has fewer than three attacks per month), but
unsatisfactory in one patient, who only has had transient remissions. Mean
voltage is 3.28 V, diplopia being the major factor limiting its increase. When
the stimulator was switched off in one pain-free patient, attacks resumed after
3 months until it was turned on again. In one patient the implantation procedure
had to be interrupted because of a panic attack with autonomic disturbances.
Another patient died from an intracerebral haemorrhage that developed along the
lead tract several hours after surgery; there were no other vascular changes on
post-mortem examination. After 1 month, the hypothalamic stimulation induced
resistance against the attack-triggering agent nitroglycerin and tended to
increase pain thresholds at extracephalic, but not at cephalic, sites. It had no
detectable effect on neurohypophyseal hormones or melatonin excretion. We
conclude that hypothalamic stimulation has remarkable efficacy in most, but not
all, patients with treatment-resistant chronic cluster headache. Its efficacy is
not due to a simple analgesic effect or to hormonal changes. Intracerebral
haemorrhage cannot be neglected in the risk evaluation of the procedure. Whether
it might be more prevalent than in deep-brain stimulation for movement disorders
remains to be determined.
PMID: 15689358
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Cephalalgia. 2004 Nov;24(11):934-7.
Deep brain stimulation for intractable chronic cluster headache: proposals for patient selection
Leone M, May A, Franzini A, Broggi G, Dodick D, Rapoport A, Goadsby PJ, Schoenen J, Bonavita V, Bussone G.
Headache Centre and Cerebrovascular Disease Department, Istituto
Nazionale Neurologico Carlo Besta, Milano, Italy. leone@istituto-besta
Cluster headache is the most severe of the primary headaches. Positron emission
tomography and functional MRI studies have shown that the ipsilateral posterior
hypothalamus is activated during cluster headache attacks and is structurally
asymmetric in these patients. These changes are highly specific for the
condition and suggest that the cluster headache generator may be located in that
brain area; they further suggest that electrical stimulation of that region
might produce clinical improvement in chronic cluster headache sufferers
refractory to medical therapy. In five patients with severe intractable chronic
cluster headache, hypothalamic electrical stimulation produced complete and
long-term pain relief with no relevant side-effects. We therefore consider it
essential to propose criteria for selecting chronic cluster headache patients
for hypothalamic deep brain stimulation before this procedure is undertaken at
other academic medical centres.
PMID: 15482354
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Brain. 2004 Oct;127(Pt 10):2259-64. Epub 2004 Aug 25.
Long-term follow-up of bilateral hypothalamic stimulation for intractable cluster headache.
Leone M, Franzini A, Broggi G, May A, Bussone G.
Istituto Nazionale Neurologico Carlo Besta, via Celoria 11, 20133 Milano Italy. leone@istituto-besta.it
We provide a detailed case history of the first patient to receive bilateral hypothalamic stimulation to control severe bilateral chronic intractable cluster headaches initially occurring mostly on the left. These attacks were accompanied by life-threatening hypertensive crises and a grave deterioration in the patient's psychological state. Destructive surgery to the left trigeminal was absolutely contraindicated. Electrode implantation and continuous stimulation of the left posterior inferior hypothalamus resolved the left attacks. After four destructive operations on the right trigeminal, right side attacks recurred. Electrode implantation (with continuous stimulation) to the right resulted in immediate resolution of the right side pain and the hypertensive crises. On several occasions, both known and unknown to the patient, the stimulators were turned off: in all cases, crises reappeared and in all instances disappeared relatively quickly after turning stimulation back on. Pain crises have never reappeared when ipsilateral stimulation is ongoing. The only side effects were observed during long-term bilateral stimulation, consisting of transient vertigo and bradycardia. After 42 months (left) and 31 months (right) of follow-up, the patient remains crisis free without the need for pharmacological prophylaxis.
PMID: 15329350
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Neurol Sci. 2003 May;24 Suppl 2:S143-5.
Hypothalamic deep brain stimulation for intractable chronic cluster headache: a 3-year follow-up.
Leone M, Franzini A, Broggi G, Bussone G.
Headache Centre, Cerebrovascular Disease Department, C. Besta National Neurological Institute, Via Celoria 11, I-20133 Milan, Italy.
Cluster headache is the most severe among primary headaches. Positron emission tomography and functional MRI studies have demonstrated that the ipsilateral posterior hypothalamus is activated during cluster headache attacks and is structurally asymmetric in these patients thus indicating that cluster headache may originate at that level. These hypothalamic abnormalities in cluster headache led to the suggestion that deep brain stimulation of ipsilateral posterior inferior hypothalamus might produce clinical improvement in otherwise treatment refractory chronic cluster headache patients. In a patient with severe intractable chronic cluster headache, hypothalamic electrical stimulation produced complete and long-term pain relief with no relevant side effects. So far other operations have been performed and the results are encouraging in terms of both pain relief and safety. The efficacy of hypothalamic electrical stimulation provides some hints into cluster headache pathophysiology.
PMID: 12811614
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Neurosurgery. 2003 May;52(5):1095-9; discussion 1099-101.
Stimulation of the posterior hypothalamus for treatment of chronic intractable cluster headaches: first reported series.
Franzini A, Ferroli P, Leone M, Broggi G.
Department of Neurosurgery, Istituto Nazionale Neurologico C. Besta, Milan, Italy.
OBJECTIVE: To describe the results of deep brain stimulation of the ipsilateral posterior hypothalamus for the treatment of drug-resistant chronic cluster headaches (CHs). A technique for electrode placement is reported.
METHODS: Because recent functional studies suggested hypothalamic dysfunction as the cause of CH bouts, we explored the therapeutic effectiveness of posterior hypothalamic stimulation for the treatment of CHs. Five patients with intractable chronic CHs were treated with long-term, high-frequency, electrical stimulation of the posterior hypothalamus. Electrodes were stereotactically implanted in the following position: 3 mm behind the midcommissural point, 5 mm below the midcommissural point, and 2 mm lateral to the midline.
RESULTS: Since this treatment, all five patients continue to be pain-free after 2 to 22 months of follow-up monitoring. Two of the five patients have remained pain-free without any medication, whereas three of the five required low doses of methysergide (two patients) or verapamil (one patient). No adverse side effects of chronic, high-frequency, hypothalamic stimulation have been observed, and we have not encountered any acute complications resulting from the implant procedure. There have been no tolerance phenomena.
CONCLUSION: These preliminary results indicate a role for posterior hypothalamic stimulation, which was demonstrated to be safe and effective, in the treatment of drug-resistant chronic CHs. These data point to a central pathogenesis for chronic CHs.
PMID: 12699552
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New England Journal of Medicine 11/08/2001 Volume 345:1428-1429 Number 19
Stereotactic Stimulation of Posterior Hypothalamic Gray Matter in a Patient with Intractable Cluster Headache
Massimo Leone, M.D., Angelo Franzini, M.D., Gennaro Bussone, M.D., Carlo Besta Neurological Institute,
20133 Milan, Italy bussone@istituto-besta.it
Cluster headache is the most severe form of primary headache.1 Positron-emission tomography has shown activation of the homolateral posterior inferior hypothalamic gray matter during attacks of cluster headaches, a finding that is apparently specific to the condition,2,3 and voxel-based morphometric magnetic resonance imaging (MRI) has documented alteration of the same area,4 suggesting that cluster headache may be initiated in this area. We reasoned that stereotactic stimulation of this area might prevent activation and relieve intractable forms of cluster headache.
We report on a 39-year-old, right-handed man who had excruciatingly painful daily cluster headaches for five years. The attacks lasted between 30 minutes and 4 hours, occurred two to five times a day, and were associated with striking oculofacial swelling. Ninety percent were on the right side, and the remainder were on the left; they were never bilateral.5 Extensive investigation including cerebral MRI, magnetic resonance angiography, and catheter angiography excluded other conditions.5 No drugs produced worthwhile benefit.5 After a second percutaneous thermal rhizotomy, the right-sided headaches disappeared. Unfortunately, from that moment, the left-sided attacks worsened to mirror exactly those that had previously occurred on the right side. Left trigeminal surgery was contraindicated by the risk of corneal sequelae, which could have left the patient totally blind (he was blind in the right eye as a result of a hemorrhage in the vitreous humor).
We proposed the stereotactic implantation of an electrode, targeting the posterior inferior homolateral hypothalamic gray matter.2,3,4 After informed consent was obtained, the operation was performed with the patient under local anesthesia. The electrode (model 3089, Medtronic, Minneapolis) was inserted 6 mm posterior to the midpoint between the anterior and posterior commissures, 2 mm left of the midline, and 8 mm below the commissural plane.2,3,4 Intraoperative electrical stimulation induced no side effects. The permanent generator (Soletra, Medtronic), embedded in a subclavicular pocket, was connected through a subcutaneous tunnel.
Therapeutic stimulation was continuous and unipolar. The position of the permanent electrode was verified by postoperative MRI (Figure 1). When stimulation was provided at a frequency of 180 Hz, a voltage of 3 V, and a pulse width of 60 µsec, the attacks disappeared after 48 hours. Twice, without the patient's being aware of it, the stimulator was switched off and the left-sided attacks reappeared 48 hours later. When the stimulator was turned on again, the attacks disappeared 48 hours later. Thirteen months after the operation, the patient remains free of pain. The precision and safety of this method suggest that it should be tried in other patients with intractable chronic cluster headaches.
References
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3. May A, Bahra A, Buchel C, Frackowiak RS, Goadsby PJ. PET and MRA findings in cluster headache and MRA in experimental pain. Neurology 2000;55:1328-1335.[Abstract/Full Text]
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