Case report

Directional sensory thalamus deep brain stimulation
in poststroke refractory pain
Timo Rafael ten Brinke ‍ ‍,1 Hisse Arnts,2 Rick Schuurman,2 Pepijn van den Munckhof2
1

Neurology, Amsterdam UMC-­
Locatie AMC, Amsterdam, The
Netherlands
2
Neurosurgery, Amsterdam
UMC-­Locatie AMC, Amsterdam,
The Netherlands
Correspondence to
Mr Timo Rafael ten Brinke;
​t.​r.t​ enbrinke@​amsterdamumc.​nl
Accepted 8 May 2020

SUMMARY
Thalamic deep brain stimulation (DBS) for chronic pain
is performed in selected patients with a variable success
rate. We report the use of recently developed directional
DBS in a patient with hemibody central poststroke
pain (CPSP) and its added value in the induction of
pleasant, pain-­distracting paresthesia’s throughout the
contralateral body side. A 68-­year-­old man suffered
from multiple strokes in the left hemisphere 11 years
before presentation, resulting in medically refractory
right-­sided hemibody CPSP. He was implanted with a
directional DBS electrode in the left ventrocaudal nucleus
of the thalamus. A directional single-­segment contact
configuration produced a better improvement throughout
the contralateral body side than ring-­mode and other
directional configurations. Treatment led to a reduction
of almost 50% in pain. This case demonstrates the value
of directional DBS in the treatment of chronic pain, as
steering increases selectivity and reduces side effects in
a small target area surrounded by structures with high
functional diversity.

Background

© BMJ Publishing Group
Limited 2020. No commercial
re-­use. See rights and
permissions. Published by BMJ.
To cite: ten Brinke TR,
Arnts H, Schuurman R,
et al. BMJ Case Rep
2020;13:e233254.
doi:10.1136/bcr-2019233254

Central poststroke pain (CPSP), first described
in 1906 by Déjerine and Roussy as Le Syndrome
Thalamique, is a chronic central neuropathic pain
disorder.1 2 Its occurrence and symptomatology are
linked to the location of the lesion, with particularly high occurrence after infarction of the lateral
medulla and the ventrocaudal nucleus (Vc) of the
thalamus.2 The Vc serves as the somatosensory
relay nucleus of the thalamus. The medial part, also
known as ventral posteromedial nucleus, is involved
in the sensation of the contralateral head and upper
extremity, while the lateral part, also known as
ventral posterolateral nucleus, is involved with the
sensation of the contralateral lower extremity.
CPSP can be a great burden for the patient, as the
response to medication is usually low and limited
by the side effects.2 3 Thalamic deep brain stimulation (DBS), a neurosurgical treatment involving
the implantation of electrodes that send electrical
impulses to specific locations in the brain (figure 1A),
may be a useful tool in the treatment of CPSP when
all other treatment modalities have failed.4 5 The goal
of DBS in CPSP is to induce pleasant, pain-­distracting
paresthesias in the affected body part. The characteristic anatomical topology of Vc led to recommendations on where to treat patients with DBS for
thalamic pain syndromes.6 However, DBS treatment
of hemibody CPSP can be very challenging as a result

of the inherent complex and small functional Vc
target area; it may not be possible to induce pleasant,
pain-­distracting paresthesias in the leg, when the DBS
electrode is located preferentially in the face or arm
area of Vc and vice versa.
In the past decennia, only traditional ring-­shaped
electrodes were available for DBS, applying spherical stimulation of surrounding brain tissue. With
recent technological advancement, ‘directional’
DBS electrodes were shown the ability to steer
current in a certain direction (figure 1B). Here,
we report the first case of a patient with hemibody
CPSPs in whom directional DBS allowed for selective induction of pleasant, pain-­distracting paresthesias throughout the contralateral body side at
very low amplitudes.

Case presentation
A 68-­year-­old man with a history of hypertension
and diabetes suffered multiple strokes 11 years
before presentation. He reported slowly progressive neuropathic pain on the right side of the body
since 10 years, with the pain being most severe in
the right hand and the right leg. On a scale from
0 to 10 (with 10 being the most severe pain the
patient had ever felt), he reported variable levels
of pain intensity over the day, with a maximum
value of 9. In the past, he tried multiple pain medications including paracetamol, gabapentin, pregabalin, codeine, morphine, lidocaine and ketamine.
No medication regimen significantly reduced the
pain. Transcutaneous electrical nerve stimulation
was applied without success. Physical examination
revealed a right arm motor drift and a symmetrical
decreased sensitivity of the distal part of the legs and
feet, attributed to the patient’s history of diabetes.
MRI showed generalised cerebral atrophy, multiple
vascular white matter lesions in left- and right-­sided
corona radiata and a small infarction of the right
ventral intermediate nucleus of the thalamus.
The patient was implanted with two DBS electrodes (Cartesia; Boston Scientific, Marlborough,
Massachusetts, USA): one in the left Vc, and one in
the left periventricular grey matter (PVG), another
well-­established anatomical target for DBS in the
treatment of intractable pain syndromes.7 8 For the
PVG electrode (targeted at 8 mm lateral, 3 mm anterior and 0 mm relative to the posterior commissure
(PC)), intraoperative test stimulation was set to a
frequency of 30 Hz and a pulse width of 450 µs,
which elicited a cold feeling in the right arm (and to
a lesser extent in the right side of the face and the

ten Brinke TR, et al. BMJ Case Rep 2020;13:e233254. doi:10.1136/bcr-2019-233254

1

BMJ Case Rep: first published as 10.1136/bcr-2019-233254 on 24 August 2020. Downloaded from http://casereports.bmj.com/ on August 26, 2020 at University of Rochester Medical Center.
Protected by copyright.

Innovations in treatment

Figure 1 (A) Schematic of implanted deep brain stimulation (DBS) system, consisting of brain electrodes which are connected to an implantable
pulse generator by subcutaneous extension cables. (B) Schematic comparison of traditional ring-­shaped four-­contact DBS electrode and directional
eight-­segment DBS electrode (Cartesia, Boston Scientific, Marlborough, Massachusetts, USA). (C) Fused axial images of stereotactic T2-­weighted MRI
and coregistered postoperative CT showing implantation of DBS electrodes in the left periventricular grey matter (PVG (e1) and left ventrocaudal
nucleus of the thalamus (Vc (e2)). (D) Schematic axial representation of PVG and Vc DBS electrodes into Fig. 29 (this was adapted from Hassler et al,15
p315 copyright 1979).

2

ten Brinke TR, et al. BMJ Case Rep 2020;13:e233254. doi:10.1136/bcr-2019-233254

BMJ Case Rep: first published as 10.1136/bcr-2019-233254 on 24 August 2020. Downloaded from http://casereports.bmj.com/ on August 26, 2020 at University of Rochester Medical Center.
Protected by copyright.

Innovations in treatment

right leg) at an amplitude of 2 mA. The tip of the PVG electrode
was implanted at 2.5 mm lateral, 4.5 mm posterior and 6 mm
inferior relative to PC. For the Vc electrode (targeted at 17 mm
lateral, 3 mm anterior and 0 mm relative to PC, with a third
ventricle width of 11 mm), test stimulation was set to a frequency
of 100 Hz and a pulse width of 100 µs, which elicited a cramping
contraction of the right hand at an amplitude of 1.5 mA. It was
concluded that the Vc electrode was positioned too closely to
the motor pathways in the nearby internal capsule. Subsequently,
a 3 mm more medial trajectory was explored. Test stimulation
at target depth elicited pleasant paresthesias in right arm and
hand. At deeper levels, the patient also reported paresthesias in
his right leg and foot. The tip of the Vc electrode was implanted
at 11 mm lateral, 0 mm anterior and 5 mm inferior relative to
PC. The leads were fixed and connected to an implantable pulse
generator (Vercise PC; Boston Scientific, Marlborough, Massachusetts, USA), which was placed subclavicularly. Postoperative
CT was coregistered to stereotactic MRI to evaluate the position
of the electrodes (figure 1C,D). The stimulation was not turned
on, and the patient was discharged the day after the operation.
Nine days postoperatively, we performed a monopolar
review on ring-­mode on the lower three levels of the electrode
of the left Vc with frequency set to 99 Hz, pulse width to 100
µs (online supplementary file 1). The patient was blinded for
the programming settings. We recorded the localisation and
intensity of paresthesia’s reported by the patient at 0.5 mA, and
subsequently increased the amplitude to 0.8 mA. Afterwards,
we performed a directional review of the individual segments
on the steerable electrode levels, recording the localisation and
nature of the effect of DBS on the patient when turning on each
segment at 0.5 mA. We then performed a new directional review
in six directions on the level with the best results during the
directional review; three directions allocating all stimulation to
one segment and three directions allocating 50% of current to
each of two adjacent segments using the multiple independent
current control feature. During the monopolar review in ring
mode, the best effect on both arm and leg was found on the
second level from the bottom of the electrode, with segments
numbered 2–3–4. Directional review on this level showed a
differential effect on arm and leg depending on which directional contact was used (online supplementary file 1). In the
same session, a monopolar review in ring mode of the electrode
in the left PVG (with frequency set to 30 Hz, and pulse width to
450 µs) did not produce additional beneficial clinical effects, and
no further directional testing was done.

Outcome and follow-up
DBS on the Vc electrode was set to contact 3, located at 12.5 mm
lateral, 2.5 mm anterior and 2 mm inferior relative to PC, that is,
in the ventral part of Vc. Stimulation was set at 0.5 mA at 99 Hz,
pulse width of 100 µs, with a cycle of 30 s ON, 10 s OFF. Stimulation was turned off at night. At visit 3 weeks postoperative,
the patientreported that the effect of DBS was waning. Amplitude was increased to 0.6 mA, and OFF time in the cycle was
increased to 30 s. In the following week, the patient reported
a good effect of DBS on the pain, but also bothersome paresthesia’s. The stimulation was lowered to 0.3 mA (6 weeks after
surgery), and then to 0.1 mA (12 weeks after surgery). The
patient’s maximum pain score was 5 and overall reported pain
intensity reduced by almost 50%. Because of the good effects
of Vc DBS, the PVG electrode remained OFF. At 16 months
follow-­up, cycling DBS was still set at 0.1 mA at contact 3, his
pain intensity was still reduced by approximately 50%.
ten Brinke TR, et al. BMJ Case Rep 2020;13:e233254. doi:10.1136/bcr-2019-233254

Learning points
►► Deep brain stimulation (DBS) treatment of central poststroke

pain remains challenging, because of a small target area
in a complex of thalamic subregions with high functional
diversity.
►► The use of only one-­directional segment of an electrode
can be enough to produce good clinical outcome when
stimulating a very small and complex target area.
►► Directional DBS increases the therapeutic possibilities of
electrical stimulation in a complex functional target area.

Discussion
The anatomical topology of Vc has been studied by measuring
thalamic activity while providing sensory stimuli to the skin and
deep tissue.9 These findings have led to recommendations on
the anatomical DBS targets for patients with neuropathic pain
syndromes. During implantation of DBS electrodes for CPSP,
test stimulation is routinely used to determine the borders
and anatomical topology of Vc.10 However, the intraoperative and postoperative treatments of CPSP remain challenging,
because of a small target area in a complex of thalamic subregions with high functional diversity, often resulting in failure
of treatment or low-­threshold side-­effects. To our knowledge,
this is the first study showing directional threshold differences
for producing sensory effects in arm and leg by Vc stimulation
using an implanted directional DBS electrode. Threshold differences using directional DBS electrodes were also reported in
patients undergoing DBS of the subthalamic nucleus for Parkinson’s disease.11–13 In addition, we showed that the use of only
one small segment of a directional electrode can be enough to
produce good clinical outcome when stimulating a very small
and complex target area in the treatment of chronic pain. In
our current surgical approach of CPSP patients, we try to maximise chances of good clinical outcome by implanting both a
PVG and Vc electrode when test stimulation (at both targets)
induces somatotopic coverage of the painful area. If directional
Vc DBS is shown to be successful in more CPSP patients, we
might consider omitting PVG test stimulation. Directional DBS
may also be targeted to the thalamocortical tract in the posterior
limb of the internal capsule, for example in cases where infarction destroyed a vital portion of Vc.14
In the current CPSP case, directional DBS allowed us to
tailor the stimulation as much as possible to the patient’s needs,
covering the full hemibody with pleasant paresthesias without
causing bothersome side-­effects due to spread of the current into
adjacent structures.
Contributors TRtB and PvdM were involved in the treatment of the patient, data
acquisition, interpretation of the data and writing of the manuscript. HA and RS
critically revised the paper and participated in discussions about the case.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests TRtB has received non-­financial support from Boston
Scientific in the form of a travel grant. RS acts as an independent advisor for
Medtronic, Elekta, and Boston Scientific.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
ORCID iD
Timo Rafael ten Brinke http://​orcid.​org/​0000-​0002-​8049-​0454
3

BMJ Case Rep: first published as 10.1136/bcr-2019-233254 on 24 August 2020. Downloaded from http://casereports.bmj.com/ on August 26, 2020 at University of Rochester Medical Center.
Protected by copyright.

Innovations in treatment

References

1 Déjerine J, Roussy G. Le syndrome Thalamique. Rev Neurol 1906;14:521–32.
2 Klit H, Finnerup NB, Jensen TS. Central post-­stroke pain: clinical characteristics,
pathophysiology, and management. Lancet Neurol 2009;8:857–68.
3 Leijon G, Boivie J, Johansson I. Central post-­stroke pain--neurological symptoms and
pain characteristics. Pain 1989;36:13–25.
4 Pereira EAC, Aziz TZ. Neuropathic pain and deep brain stimulation. Neurotherapeutics
2014;11:496–507.
5 Alves RV, Asfora WT. Deep brain stimulation for Dejerine-­Roussy syndrome: case
report. Minim Invasive Neurosurg 2011;54:183–6.
6 MARK VH. Clinical aspects of stereotactic thalamotomy in the human. Arch Neurol
1960;3:351.
7 Ward M, Mammis A. Deep brain stimulation for the treatment of Dejerine-­Roussy
syndrome. Stereotact Funct Neurosurg 2017;95:298–306.
8 Frizon LA, Yamamoto EA, Nagel SJ, et al. Deep brain stimulation for pain in the
modern era: a systematic review. Neurosurgery 2019;10.
9 Lenz FA, Dostrovsky JO, Tasker RR, et al. Single-­Unit analysis of the human ventral
thalamic nuclear group: somatosensory responses. J Neurophysiol 1988;59:299–316.

10 Kiss ZHT, Anderson T, Hansen T, et al. Neural substrates of microstimulation-­evoked
tingling: a chronaxie study in human somatosensory thalamus. Eur J Neurosci
2003;18:728–32.
11 Steigerwald F, Müller L, Johannes S, et al. Directional deep brain stimulation of the
subthalamic nucleus: a pilot study using a novel neurostimulation device. Mov Disord
2016;31:1240–3.
12 Nguyen TAK, Djilas M, Nowacki A, et al. Analysis of patient-­specific stimulation with
segmented leads in the subthalamic nucleus. PLoS One 2019;14:e0217985.
13 Dembek TA, Reker P, Visser-­Vandewalle V, et al. Directional DBS increases side-­effect
thresholds-­A prospective, double-­blind trial. Mov Disord 2017;32:1380–8.
14 Franzini A, Messina G, Levi V, et al. Deep brain stimulation of the posterior limb of
the internal capsule in the treatment of central poststroke neuropathic pain of the
lower limb: case series with long-­term follow-­up and literature review. J Neurosurg
2019:1–9.
15 Hassler RG, Rolf G, Mundinger F, et al. Adapted by permission from Springer Nature.
In: Stereotaxis in Parkinson syndrome: clinical-­anatomicalcontributions to its
pathophysiology. Springer-­Verlag, 1979: 315.

Copyright 2020 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit
https://www.bmj.com/company/products-services/rights-and-licensing/permissions/
BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission.
Become a Fellow of BMJ Case Reports today and you can:
►► Submit as many cases as you like
►► Enjoy fast sympathetic peer review and rapid publication of accepted articles
►► Access all the published articles
►► Re-use any of the published material for personal use and teaching without further permission
Customer Service
If you have any further queries about your subscription, please contact our customer services team on +44 (0) 207111 1105 or via email at support@bmj.com.
Visit casereports.bmj.com for more articles like this and to become a Fellow

4

ten Brinke TR, et al. BMJ Case Rep 2020;13:e233254. doi:10.1136/bcr-2019-233254

BMJ Case Rep: first published as 10.1136/bcr-2019-233254 on 24 August 2020. Downloaded from http://casereports.bmj.com/ on August 26, 2020 at University of Rochester Medical Center.
Protected by copyright.

Innovations in treatment