Nerve Pain       Central Post Stroke Pain      
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  • Central Post Stroke Pain (CPSP) or Thalamic Pain Syndrome is a type of chronic nerve pain that starts when part of the central nervous system has been injured.
  • It is commonly seen after a stroke or cerebrovascular accident (CVA). A stroke implies there has been an injury (infarction, cell death) to part of the central nervous system, caused by either lack of blood flow (thrombosis) or lack of oxygen (ischaemia).
  • As well as the usual stroke features caused by infarction in the cerebral hemispheres (symptoms of weakness, numbness, paralysis, speech difficulties, confusion), up to 10% of people develop CPSP when the infarction also involves the thalamus (brain stem sensory processing area).
  • Some authorities have suggested that  minor CPSP symptoms are reported by 50% of stroke victims. Thankfully the full blown syndrome is less common.
  • CPSP occurs more commonly when the right hand side of the brain becomes infarcted (left sided stroke). The onset time for symptoms to develop is variable, ranging from days to years. Pain can be felt in the face, arm, leg, trunk on the stroke side. The unfortunate may have symptoms affecting the whole of one side of the body.
  • The pain has been described as burning, aching, or pricking in nature, although the character of the pain can be widely variable. It's usually constant and unrelenting, with a tendency to increase in intensity over time. Movement, changes in temperature, or other unrelated stimuli may aggravate the symptoms. It is often accompanied by abnormal sensation in the affected body part.
  • It is very important to differentiate between CPSP and other forms of musculoskeletal pain that commonly occur in stroke victims e.g. frozen shoulder, tight muscles. These musculoskeletal problems often resolve with physiotherapy and injections, whereas relief from CPSP is usually achieved with oral medications.
  • Oral Medications
    • CPSP presents a challenge to the pain management clinic. Clinical experience would suggest that the combination of low dose amitriptyline (10 - 50 mg at night) plus gabapentin (300 - 1800 mg per day) or pregabalin (50 - 600 mg per day) produces the best pain relief with the lowest incidence of side effects.
    • For other oral medication options - see Anti-convulsants, Anti-depressants, Anti-arrhythmics.
  • Intravenous Lignocaine Infusions are useful for some patients.
  • Surgery
    • Deep Brain Stimulation has been shown to provide some measure of pain relief for at least 50% of patients, with some achieving excellent relief of pain.
    • Motor cortex stimulation is a newer procedure which is now being used in the treatment of post-stroke pain. The results appear to be comparable to deep brain stimulation, with about 50% of patients achieving good pain relief and a smaller percentage achieving excellent or complete relief.
    • The selection of deep brain stimulation versus motor cortex stimulation depends on the character and distribution of the pain, as well as the extent of the stroke and other factors.
    • As with all chronic pain syndromes, psychological factors play a major role in the intensity of the pain. It is recommended that all patients with post-stroke pain consult with a psychologist specializing in the evaluation and treatment of chronic pain. although post-stroke pain is a challenging problem, surgical procedures offer some hope for relief.
    • Surgical and anaesthetic risk assessment is required before undertaking any surgical procedure. Detailed counselling is essential before proceeding.
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