Department of Neurosurgery, CHU de Nice, Université Cote d'Azur, Nice, France.
Université Cote d'Azur, FHU INOVPAIN, CHU de Nice, Nice, France.
Brain. 2018 Apr 1;141(4):1040-1048. doi: 10.1093/brain/awy005.
Our knowledge on intracranial pain-sensitive structures in humans comes essentially from observations during neurosurgical procedures performed in awake patients. It is currently accepted that intracranial pain-sensitive structures are limited to the dura mater and its feeding vessels and that small cerebral vessels and pia mater are insensitive to pain, which is inconsistent with some neurosurgical observations during awake craniotomy procedures. We prospectively collected observations of painful events evoked by mechanical stimulation (touching, stretching, pressure, or aspiration) of intracranial structures during awake craniotomies, routinely performed for intraoperative functional mapping to tailor brain tumour resection in the eloquent area. Intraoperatively, data concerning the locations of pain-sensitive structures were drawn by the surgeon on a template and their corresponding referred pain was indicated by the patient by drawing a cross on a diagram representing the head. Ninety-three painful events were observed and collected in 53 different patients (mean age 41.2 years, 25 males) operated on awake craniotomy for left (44 cases) or right (nine cases) supra-tentorial tumour resection in eloquent areas. On average, 1.8 painful events were observed per patient (range 1-5). All the painful events were referred ipsilaterally to the stimulus. In all cases, the evoked pain was sharp, intense and brief, stopped immediately after termination of the causing action, and did not interfere with the continuation of the surgery. In 30 events, pain was induced by stimulation of the dura mater of the skull base (23 events) or of the falx (seven events) and was referred predominantly in the V1 territory and in the temporal region. In 61 cases, pain was elicited by mechanical stimulation of the pia mater or small cerebral vessels of the temporal (19 events), frontal (25 events), parietal (four events) lobes and/or the peri-sylvian region, including the insular lobe (13 events), and referred in the V1 territory. In this observational study, we confirmed that dura of the skull base and dura of the falx cerebri are sensitive to pain and that their mechanical stimulation induced pain mainly referred in the sensory territories of the V1 and V3 divisions of the trigeminal nerve. Unlike earlier studies, we observed that the pia and the small cerebral vessels were also pain-sensitive, as their mechanical stimulation induced pain referred mainly in the V1 territory. These observations suggest that small pial cerebral vessels may also be involved in the pathophysiology of primary and secondary headaches.awy005media15756834882001.
我们对人类颅内痛敏结构的认识主要来自清醒开颅手术中观察到的结果。目前普遍认为颅内痛敏结构仅限于硬脑膜及其供养血管，而小脑血管和软脑膜对疼痛不敏感，这与清醒开颅手术中的一些神经外科观察结果不一致。我们前瞻性地收集了在清醒开颅术中对颅内结构进行机械刺激（触摸、拉伸、压力或抽吸）时引起的疼痛事件的观察结果，这些手术通常是为了在语言区进行术中功能定位，以切除脑肿瘤。术中，外科医生在模板上绘制出痛敏结构的位置，患者通过在代表头部的图表上画一个十字来指示相应的牵涉痛。在 53 名不同的患者（平均年龄 41.2 岁，男性 25 名）中进行了 93 次疼痛事件观察和采集，这些患者因左（44 例）或右（9 例）顶叶肿瘤在语言区行清醒开颅手术。平均每个患者观察到 1.8 次疼痛事件（范围 1-5）。所有疼痛事件均同侧牵涉痛。在所有情况下，诱发的疼痛均为锐痛、剧烈且短暂，在引起疼痛的动作停止后立即停止，且不干扰手术的继续进行。在 30 次事件中，刺激颅底硬脑膜（23 次）或镰状突硬脑膜（7 次）引起疼痛，主要牵涉到 V1 区和颞区。在 61 次事件中，刺激颞叶（19 次）、额叶（25 次）、顶叶（4 次）和/或大脑外侧裂区的软脑膜或小脑血管引起疼痛，包括岛叶（13 次），主要牵涉到 V1 区。在这项观察性研究中，我们证实颅底硬脑膜和镰状突硬脑膜对疼痛敏感，其机械刺激引起的疼痛主要牵涉到三叉神经 V1 和 V3 分支的感觉区。与早期研究不同，我们观察到软脑膜和小脑血管也对疼痛敏感，因为它们的机械刺激引起的疼痛主要牵涉到 V1 区。这些观察结果表明，小的软脑膜脑血管可能也参与原发性和继发性头痛的病理生理学。
