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Abstract Details

Lasting Relief from Chronic Pain after Cerebral Infarction
Ethics, Pain and Palliative Care
P02 - (-)
005
BACKGROUND: Isolated ACA strokes are uncommon, with bilateral ACA infarction occurring considerably less often. The reported mechanisms underlying this pathology vary, with embolism and intrinsic atherothrombotic disease most commonly found. Although the consequences of ACA stroke frequently include apathy and lower extremity weakness, relief of chronic pain is not well-recognized.
DESIGN/METHODS: Case study.
RESULTS: A 59-year-old man on methadone for chronic back pain presented with confusion and bilateral lower extremity weakness. MRI demonstrated a bilateral medial frontal infarct involving both anterior cingulate gyri, the anterior corpus callosum, and the ventral striatum bilaterally. MRA demonstrated a markedly narrowed A1 segment of the right ACA, and the left A1 segment of the ACA was not visualized. Bilateral irregular narrowing of the carotid siphons was attributed to atheromatous disease. Further evaluation disclosed normal echocardiogram, cerebrospinal fluid, and tests for autoimmune disease. Remarkably, immediate and total relief of his pain followed stroke onset. Two-year follow-up revealed persistent apathy and amnesia, moderate improvement in lower extremity weakness, and the continued absence of pain and any need for opiate medication.
CONCLUSIONS: This patient's stroke appeared to produce the beneficial and persistent effect of dramatic pain relief, enabling him to discontinue all analgesic medications, including methadone. The alleviation of pain after ischemic infarction is highly unusual, and possible explanations include 1) damage to both anterior cingulate gyri producing apathy of such severity that the experience of pain was markedly blunted, and 2) bilateral injury to the nucleus accumbens abolishing a cerebral region critical for the appreciation of pain and opiate-related reward.
Authors/Disclosures
Haley Burke, MD (Colorado Rehabilitation and Occupational Medicine)
PRESENTER 		No disclosure on file
C. A. Anderson, MD, FAAN (University of Colorado) Dr. Anderson has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Psychiatric Association Publishing. The institution of Dr. Anderson has received research support from Department of Defense. Dr. Anderson has received publishing royalties from a publication relating to health care. An immediate family member of Dr. Anderson has received personal compensation in the range of $500-$4,999 for serving as a Question writer for the pediatrics boards with American Board of Pediatrics. An immediate family member of Dr. Anderson has received personal compensation in the range of $500-$4,999 for serving as a Lecturer at pediatric conference with Creighton University .
Christopher M. Filley, MD, FAAN Dr. Filley has received personal compensation for serving as an employee of University of Colorado Press. Dr. Filley has received personal compensation for serving as an employee of Oxford University Press. Dr. Filley has received personal compensation for serving as an employee of Cambridge University Press . Dr. Filley has received personal compensation for serving as an employee of Elsevier, Inc.. Dr. Filley has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Wheeler Trigg O'Donnell LLP. Dr. Filley has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Evans Case LLP. The institution of Dr. Filley has received research support from Department of Defense. Dr. Filley has received publishing royalties from a publication relating to health care. Dr. Filley has received publishing royalties from a publication relating to health care. Dr. Filley has received publishing royalties from a publication relating to health care. Dr. Filley has received publishing royalties from a publication relating to health care.
Jan Claassen, MD, PhD (Columbia University College of Physicians & Surgeons) Dr. Claassen has stock in iCE Neurosystems. The institution of Dr. Claassen has received research support from NINDS. The institution of Dr. Claassen has received research support from McDonnel Foundation. Dr. Claassen has received publishing royalties from a publication relating to health care. Dr. Claassen has received publishing royalties from a publication relating to health care.