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Days or Weeks after Stroke, Some Patients Develop Chronic, Debilitating Pain

MAYWOOD, Ill. - Nearly 1 in 10 stroke patients suffer chronic and debilitating pain, typically described as a sharp, stabbing or burning sensation.

It’s called central poststroke pain syndrome (CPSP). It was first described more than 100 years ago, and it is treatable with medications and magnetic or electrical stimulation of the brain. But physicians today often fail to correctly diagnose the condition, Loyola University Medical Center stroke specialists report in the journal Topics in Stroke Rehabilitation.

The article is written by Murray Flaster, MD, PhD; Edwin Meresh, MD; Murali Rao, MD; and José Biller, MD.

CPSP is a form of neuropathic pain caused by damage or dysfunction within the central nervous system. It typically begins days or weeks after a stroke. One study found that among patients who experience CPSP, 63 percent were affected within one month, 18 percent within six months and the remaining 18 percent after six months.

Patients can experience hyperpathia (abnormally painful reaction to a painful stimulus) or allodynia (pain in response to a light touch, contact with clothing or bedsheets, air currents, etc.) Allodynia is reported in two-thirds of CPSP patients.
The prevalence of CPSP among stroke patients is 8 percent, but can range from 1 percent to 12 percent. It is among several types of poststroke pain, which also include headache and musculoskeletal pain, especially pain related to abnormal shoulder movement.

“There are many causes of poststroke pain and these frequently coexist in our patients,” the authors write. “It is crucial to recognize CPSP and differentiate it from musculoskeletal pain or spasticity-associated pain."

First-line drug treatments for CPSP include amitriptyline (an antidepressant) and lamotrigine (an anticonvulsant). Second-line treatment includes the anticonvulsant gabapentin.

If medications don’t work, a non-invasive therapy called transcranial magnetic stimulation (TMS) should be considered. TMS sends short pulses of magnetic fields to the brain.

If drugs and TMS both fail, invasive therapies that electrically stimulate the brain should be considered in carefully selected patients. The treatments involve inserting electrodes into the membrane covering the brain (motor cortex stimulation) or into the brain itself (deep brain stimulation).

CPSP was first described in a medical journal in 1906. (It was then called “thalamic syndrome.”) More than a century later, CPSP still is frequently misdiagnosed.
“CPSP is treatable,” Flaster, Meresh, Rao and Biller write. “Recognition of the syndrome in and of itself can be reassuring to the patient."

Flaster is an associate professor in the departments of Neurology and Neurological Surgery of Loyola University Chicago Stritch School of Medicine. Meresh is an assistant professor and Rao is a professor and chair of the Department of Psychiatry and Behavioral Neurosciences. Biller is professor and chair of the Department of Neurology.

The title of their article is “Central Poststroke Pain: Current Diagnosis and Treatment.”

The Loyola University Chicago Health Sciences Division (HSD) advances interprofessional, multidisciplinary, and transformative education and research while promoting service to others through stewardship of scientific knowledge and preparation of tomorrow's leaders. The HSD is located on the Health Sciences Campus in Maywood, Illinois. It includes the Marcella Niehoff School of Nursing, the Stritch School of Medicine, the biomedical research programs of the Graduate School, and several other institutes and centers encouraging new research and interprofessional education opportunities across all of Loyola University Chicago. The faculty and staff of the HSD bring a wealth of knowledge, experience, and a strong commitment to seeing that Loyola's health sciences continue to excel and exceed the standard for academic and research excellence. For more on the HSD, visit LUC.edu/hsd.

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