Abstract
Cluster headache (CH) is among the most common and debilitating autonomic cephalalgias. We characterize clinical outcomes of deep brain stimulation (DBS) to the posterior hypothalamic region through a novel analysis of the electrophysiological topography and tractography-based structural connectivity. The left posterior hypothalamus was targeted ipsilateral to the refractory CH symptoms. Intraoperatively, field potentials were captured in 1 mm depth increments. Whole-brain probabilistic tractography was conducted to assess the structural connectivity of the estimated volume of activated tissue (VAT) associated with therapeutic response. Stimulation of the posterior hypothalamic region led to the resolution of CH symptoms, and this benefit has persisted for 1.5-years post-surgically. Active contacts were within the posterior hypothalamus and dorsoposterior border of the ventral anterior thalamus (VAp). Delta- (3 Hz) and alpha-band (8 Hz) powers increased and peaked with proximity to the posterior hypothalamus. In the posterior hypothalamus, the delta-band phase was coupled to beta-band amplitude, the latter of which has been shown to increase during CH attacks. Finally, we identified that the VAT encompassing these regions had a high proportion of streamlines of pain processing regions, including the insula, anterior cingulate gyrus, inferior parietal lobe, precentral gyrus, and the brainstem. Our unique case study of posterior hypothalamic region DBS supports durable efficacy and provides a platform using electrophysiological topography and structural connectivity, to improve mechanistic understanding of CH and this promising therapy.
Highlights
Cluster headache (CH) is a severe trigeminal autonomic cephalalgia and often considered among the most difficult types of headaches to manage
Contacts were found to be in the midbrain, posterior hypothalamus (C1), and ventral anterior thalamus (VAp; contact 2 (C2) and C3; Figure 1A)
Electrophysiological mapping along the posterior hypothalamus trajectory suggests a topological correspondence between field potential activity and the position of clinically therapeutic contacts
Summary
Cluster headache (CH) is a severe trigeminal autonomic cephalalgia and often considered among the most difficult types of headaches to manage. Varying approaches have been taken in attempts to treat CH, poor understanding of the underlying mechanism has led to limited improvement in management (Leone et al, 2001; Vyas et al, 2019). DBS targeting the posterior hypothalamic region has had some success in mitigating CH with some variability in targeting strategies across groups (Leone et al, 2001; Broggi et al, 2007; Bartsch et al, 2008; Franzini et al, 2010; Leone et al, 2010; Clelland et al, 2014). We use probabilistic tractography to estimate the structural connectivity of the targeted region
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