Neuroscience · Year 2 · from Neuroscience
Case 1: Thalamic Stroke with Dejerine-Roussy Syndrome
Patient Presentation
Demographics: 72-year-old female with history of hypertension and atrial fibrillation
Chief Complaint: Left-sided numbness followed by severe burning pain
History of Present Illness: Three months ago, the patient experienced sudden onset of complete numbness affecting her entire left side including face, arm, and leg. She was evaluated in the emergency department where a CT head showed no hemorrhage and MRI revealed an acute infarct in the right thalamus (ventral posterolateral and ventral posteromedial nuclei). She was found to be subtherapeutic on warfarin and was transitioned to apixaban for stroke prevention. Over the following weeks, her numbness partially improved, but she developed progressively severe burning, stabbing pain throughout her left side that is constant and debilitating. Light touch, such as clothing brushing against her skin or bedsheets touching her leg, provokes excruciating pain. The pain interferes with sleep and has significantly impacted her quality of life.
Physical Examination:
- General: Appears uncomfortable, guarding left side
- Mental status: Alert, oriented, no cognitive deficits
- Cranial nerves: Intact
- Motor: Strength 5/5 throughout, no drift
- Sensory:
- Left face, arm, and leg: Diminished light touch and pinprick sensation
- Allodynia: Light touch produces severe pain throughout left hemibody
- Proprioception mildly impaired on left
- Right side: Normal sensation to all modalities
- Reflexes: 2+ and symmetric, plantar responses flexor
- Coordination: Intact
Workup:
- Original MRI brain: Right thalamic infarct involving VPL and VPM nuclei
- Follow-up MRI: Chronic right thalamic infarct with encephalomalacia
- CTA head and neck: No significant stenosis
- Echocardiogram: Mild left atrial enlargement, no thrombus
- INR: Subtherapeutic at time of stroke
Diagnosis: Dejerine-Roussy syndrome (thalamic pain syndrome) secondary to right thalamic stroke
Treatment:
- Anticoagulation with apixaban for atrial fibrillation (stroke prevention)
- Amitriptyline 25 mg at bedtime, titrated to 50 mg for central neuropathic pain
- Gabapentin 300 mg three times daily added for additional pain control
- Lamotrigine considered if insufficient response
- Referral to pain management specialist
- Physical therapy for desensitization techniques
Clinical Pearl: Dejerine-Roussy syndrome occurs in approximately 8% of thalamic stroke patients. Initial sensory loss is followed weeks to months later by severe central neuropathic pain with allodynia. The ventroposterior nucleus of the thalamus is the key structure; damage disrupts the relay of sensory information and leads to maladaptive reorganization causing spontaneous pain and hypersensitivity. Treatment is challenging and often requires combination therapy with tricyclic antidepressants, anticonvulsants (gabapentin, pregabalin, lamotrigine), and sometimes opioids or neuromodulation.