Cluster headache is the most severe form of primary headache.¹ Positron-emission tomography has shown activation of the homolateral posterior inferior hypothalamic gray matter during attacks of cluster headaches, a finding that is apparently specific to the condition,^2,3 and voxel-based morphometric magnetic resonance imaging (MRI) has documented alteration of the same area,⁴ suggesting that cluster headache may be initiated in this area. We reasoned that stereotactic stimulation of this area might prevent activation and relieve intractable forms of cluster headache.

OBJECTIVE To examine surgical findings and results of microvascular decompression (MVD) for trigeminal neuralgia (TN), including patients with multiple sclerosis, to bring new insight about the role of microvascular compression in the pathogenesis of the disorder and the role of MVD in its treatment. METHODS Between 1990 and 1998, 250 patients affected by trigeminal neuralgia underwent MVD in the Department of Neurosurgery of the “Istituto Nazionale Neurologico C Besta” in Milan. Limiting the review to the period 1991–6, to exclude the “learning period” (the first 50 cases) and patients with less than 1 year follow up, surgical findings and results were critically analysed in 148 consecutive cases, including 10 patients with multiple sclerosis. RESULTS Vascular compression of the trigeminal nerve was found in all cases. The recurrence rate was 15.3% (follow up 1–7 years, mean 38 months). In five of 10 patients with multiple sclerosis an excellent result was achieved (follow up 12–39 months, mean 24 months). Patients with TN for more than 84 months did significantly worse than those with a shorter history (p<0.05). There was no mortality and most complications occurred in the learning period. Surgical complications were not related to age of the patients. CONCLUSIONS Aetiopathogenesis of trigeminal neuralgia remains a mystery. These findings suggest a common neuromodulatory role of microvascular compression in both patients with or without multiple sclerosis rather than a direct causal role. MVD was found to be a safe and effective procedure to relieve typical TN in patients of all ages. It should be proposed as first choice surgery to all patients affected by TN, even in selected cases with multiple sclerosis, to give them the opportunity of pain relief without sensory deficits.

The medical treatment of patients with chronic primary headache syndromes (chronic migraine, chronic tension-type headache, chronic cluster headache, hemicrania continua) is challenging as serious side effects frequently complicate the course of medical treatment and some patients may be even medically intractable. When a definitive lack of responsiveness to conservative treatments is ascertained and medication overuse headache is excluded, neuromodulation options can be considered in selected cases.

The authors report long-term results of continuous hypothalamic stimulation in 16 chronic drug-refractory patients with cluster headache (CH). At a mean follow-up of 23 months, 13 patients are persistently pain-free or almost pain-free, and the other 3 are improved. There are no persistent side effects. Hypothalamic stimulation is an effective, safe, and well-tolerated alternative to surgery for chronic patients with drug-refractory CH.

OBJECTIVE: To review the natural history and the long-term results of microsurgical resection of brainstem cavernous angiomas operated on in one institution. METHODS: A retrospective analysis was conducted of the preoperative and postoperative course in 52 consecutive patients who underwent microsurgical resection of a brainstem cavernoma between 1990 and 2002. The role of sex, age, cavernoma location, size, multiple bleedings, relationships to the pial-ependymal surface, surgical approach, and preoperative magnetic resonance imaging appearance were evaluated as prognostic factors possibly influencing outcome. Discrete data were compared by use of the χ2 test and Fisher's exact test as appropriate. RESULTS: The risk of hemorrhage was 3.8% per patient per year. The rebleeding rate was 34.7%. Nineteen of 29 patients who experienced new neurological deficits after surgery improved over time to their preoperative condition or better. Permanent morbidity was observed in 10 (19%) of 52 patients (follow-up: 1.5–10.5 yr; mean, 4.7 yr; median, 4.3 yr; standard deviation, 0.2 yr). The final Karnofsky Performance Scale score for these 10 patients was 90 in 2 patients, 80 in 2, 70 in 2, 60 in 2, 50 in 1, and 30 in 1. The mortality rate was 1.9%. The incidence of permanent new neurological deficits was lower in the 20 patients whose lesion could be removed through an anterolateral pontine approach (5 versus 29%; P = 0.035). CONCLUSION: Surgical resection is recommended for superficial lesions and for lesions that can be reached through the anterolateral pontine surface. Surgery is also recommended for symptomatic cavernomas with a satellite subacute hematoma.