Chronic stimulation of the posterior hypothalamic region for cluster headache: technique and 1-year results in four patients

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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 1-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.

Abbreviations used in this paper:AC–PC = anterior–posterior commissure; AP = anteroposterior; CH = cluster headache; DBS = deep brain stimulation; FSE = fast spin echo; MR = magnetic resonance; MTT = mammillothalamic tract; PAGM = periaqueductal gray matter; PET = positron emission tomography; PVGM = periventricular gray matter; TIA = transient ischemic attack.

Article Information

Address reprint requests to: Philip A. Starr, M.D., Ph.D., Department of Neurosurgery, University of California at San Francisco, 505 Parnassus Avenue, 779 Moffitt, San Francisco, California 94143. email: starrp@itsa.ucsf.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Photograph showing the anatomy of the hypothalamus, PVGM (PVG), and PAGM (PAG), from the Schaltenbrand and Warren human brain atlas. Myelin stained section. The asterisk marks the target point for DBS in CH, based on the work of Franzini et al., 2003. RN = red nucleus.

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    Five-second segment of single-unit microelectrode recording 1 mm dorsal to the stereotactic target. Variation in the height of the action potential occurs in synchrony with the cardiac cycle.

  • View in gallery

    Axial postoperative T2-weighted FSE MR image revealing the DBS electrode location. The white arrows indicate the locations of the MTT and the tip of the DBS electrode.

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