Percutaneous Cervical Sympathetic Block for Pain Control after Internal Carotid Artery Dissection. A Report of Two Cases 1
2
3
1
Omar Saeed, MD , Asif A. Khan, MD , Nabeel A. Herial, MD , Emrah Aytac, MD , and Adnan 1 I. Qureshi, MD 1Zeenat
Qureshi Stroke Institute, St. Cloud, MN 56303, USA
2University
of Illinois College of Medicine, Rockford, IL 60612, USA
3University
of California, San Diego, La Jolla, CA 92093, USA
4University
of Minnesota, Minneapolis, MN 55455, USA
Journal of Vascular and Interventional Neurology, Vol. 9
Abstract Background—Medical treatment of cranio-cervical pain can be suboptimal in patients with internal carotid artery (ICA) dissection. We report the use of cervical sympathetic block for treatment of pain in two patients with ICA dissection. Case Reports—A 58-year-old man and a 43-year-old woman presented with severe cranio-cervical pain associated with left and right ICA dissection confirmed by magnetic resonance imaging and cerebral angiography. Due to suboptimal control of pain with medical treatment, cervical sympathetic block was performed under fluoroscopic guidance using 20 ml of bupivacaine injected lateral to the posterior aspect of sixth vertebral body in both patients. On self-reported pain scale, the 58-year-old man reported improvement in pain intensity from 8/10 pain to 0/10 within 1 h of blockade. The patient remained relatively pain free for the 24-h post blockade. Mild recurrence of pain was noted on Day 2. The 43-year-old woman reported improvement in pain intensity from 6/10 pain to 0/10 within 1 h of blockade. The patient remained pain free for five days with recurrence to previous intensity. Conclusion—Cervical sympathetic blockade in patients with ICA dissection may be an effective option in the event of suboptimal pain control with medical treatment; however, the technique may be limited due to relatively short duration of action. Conflict of Interest—The authors have no conflict of interest to report. Conflict of interest—Each author certifies that he or she has no commercial association that might pose a conflict of interest in connection with the submitted manuscript. Financial Disclosure/Funding—The authors have no financial disclosures. Keywords Internal carotid artery (ICA); dissection; cervical sympathetic block; neck pain; headache; Horner’s syndrome; sympathetic pain
INTRODUCTION The most common presentation of internal carotid artery (ICA) dissection is head and neck pain, and depending on the site of dissection, the pain can radiate to many different locations, including facial, cervical, or even the auricular regions. The pain has been known to last anywhere from 90 min to 30 days, and can be very severe in
intensity [1,2]. It is secondary to excessive stimulation of sympathetic pain pathways that are located in the vicinity of the involved segment of the ICA due to stretching of wall caused by the dissection [3]. The current practice involves use of pharmaceutical analgesics,
Vol. 9, No. 3, pp. 36–40. Published January, 2017. All Rights Reserved by JVIN. Unauthorized reproduction of this article is prohibited Corresponding Author: Omar Saeed MD, Zeenat Qureshi Stroke Institute, 925 Delaware St SE, Suite 300B, Minneapolis, MN 55414, USA. Tel.: (612) 626-8221; fax: (612) 625-7950. [email protected].
Saeed et al.
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Journal of Vascular and Interventional Neurology, Vol. 9
Figure 1. (A) Oblique view: arterial dissection (arrow) extending from cervical segment to petrous segment of left ICA
in Patient 1. (B) Lateral view: arterial dissection (arrow) extending from cervical segment to petrous segment of right ICA in Patient 2.
such as non-steroidal anti-inflammatory medication and narcotics [4,5], although failure rates can be high [5]. We describe two cases who presented with severe headache, which were later found to have an ICA dissection and underwent cervical sympathetic block for pain control.
CASE REPORT Patient 1 A 57-year-old man presented with severe throbbing leftsided headache with radiation into his neck and associated blurred vision in the left eye. He also complained of ear pain since the previous month. He tried several oral non-steroidal anti-inflammatory medications with little benefit. On physical examination, his left pupil measured approximately 4 mm and the right pupil was
approximately 7 mm. There was also slight ptosis of the left eyelid consistent with ipsilateral Horner’s syndrome. In addition, his electrocardiogram showed sinus bradycardia, and the patient had no other neurological deficits on examination. The patient continued to complain of severe headache and neck pain despite multiple doses of intravenous (IV) and oral narcotic analgesics including oxycodone/acetaminophen combination and hydromorphone. A diagnostic catheter angiogram was performed which demonstrated tapering stenosis with irregularity sparing the carotid bifurcation consistent with ICA dissection [see Figure 1(A)] and maximum stenosis measuring 83% using Zeenat Qureshi Stroke Institute (ZQSI) criteria [6,7]. Patient 2 A 43-year-old woman developed right ICA dissection six months ago with initial manifestation consisting of
38
Journal of Vascular and Interventional Neurology, Vol. 9
Figure 2. (A) Fluoroscopic confirmation of needle placement at the level of left C6 vertebral body in Patient 1. (B) Contrast injection from needle placed at the level of right C6 vertebral body in Patient 2. The linear contrast spread along the caudocephalic axis within the paravertebral fascial compartment.
right Horner's syndrome and followed by worsening right-sided headaches. Since the initial occurrence, the patient had intractable headaches with variable response to medications. The headache was described as right sided with sharp characteristics varying between 3–6/10 intensity daily involving right cranium and orbital regions. The headache was persistent and sometimes interfered with sleep. The patient was unable to work due to the severe headaches. There was improvement in lumen diameter at site of arterial dissections based on findings of magnetic resonance angiogram (Day 2 since initial symptom occurrence), catheter angiogram (Day 10), and catheter angiogram (Day 40). A diagnostic catheter angiogram performed on Day 40 demonstrated minimal stenosis with irregularity sparing the carotid
bifurcation [see Figure 1(B)] and maximum stenosis measuring 54% using ZQSI criteria [6,7]. The patient continued to complain of severe headaches despite multiple doses of IV lidocaine infusions, IV dihydroergotamine, local botulinum injections, and IV/oral Ketorolac. The patient reported 6/10 intensity headache prior to the procedure. On physical examination, the patient had no other neurological deficits.
PROCEDURE A cervical sympathetic blockade with fluoroscopic guidance was performed to improve pain control [see Figure 2(A and B)]. The appropriate side of the neck was prepped and draped while the patient remained in supine
Saeed et al.
Journal of Vascular and Interventional Neurology, Vol. 9
position; 3 ml of 1% of lidocaine was administered locally in the subcutaneous tissue. A 20-gauge spinal needle was advanced under fluoroscopic guidance, lateral, to posterior aspect of cervical 6th vertebral body while laterally manually displacing the ICA away from the needle trajectory. The needle placement was confirmed by injection 0.75 and 2 ml of radio-opaque omnipaque with linear contrast spread along the caudocephalic axis within the paravertebral fascial compartment. A total 10 ml of 0.25% bupivacaine was then injected over 5 min followed by fluoroscopically confirmation of needle position. Another 10 ml of 0.25% bupivacaine was then slowly injected over 5 min. The needle was then removed, and pressure was applied to the lateral aspect of the neck.
POST PROCEDURE RESPONSE On immediate post-procedural assessment, Patient 1 reported a significant reduction in headache pain. On self-reported pain scale, the patient reported improvement in pain intensity from 8/10 pain to 0/10 within 1 h of blockade. The patient remained relatively pain free for the 24-h post blockade. Mild recurrence of pain was noted on Day 2. On telephonic follow-up on Day 5, he reported that the pain was only concerning when he was lying down but was relatively pain free when standing up or sitting upright. Adequate pain management from then onward was continued with oral ibuprofen. Patient 2 reported complete resolution of headache immediately after procedure. The effectiveness of sympathetic blockade was confirmed by post-procedure development of ptosis and miosis in the right eye, which lasted for 6 h post procedure. On telephonic follow-up on Day 3, she reported that she was headache free. On telephonic follow-up on Day 7, the patient reported that on Day 5, the pain had started again and now was at the same intensity as pre-procedure pain. She requested another block procedure be performed which was not performed due to lack of persistent relief in her case.
DISCUSSION To the best of our knowledge, we did not find any case reports or studies that described the use of cervical sympathetic blockage for pain control in a patient who presented with ICA dissection. A previous study demonstrated effectiveness of cervical sympathetic blockade for pain control after thyroidectomy with reduction of symptoms including post-operative nausea and vomiting [8]. Others have described the use of cervical and stellate sympathetic ganglion block for pain control follow-
39
ing spinal surgery and peripheral vascular disease with good outcomes [9,10]. The disruption of either pre-ganglionic or post-ganglionic neurons of the cervical sympathetic plexus surrounding the ICA is the presumed reason for sympathetic dysfunction in patients with ICA dissection [11]. The damage to sympathetic plexus during carotid endarterectomy can also result in similar headaches [12]. However, the fibers of the trigeminal nerve, superior cervical ganglion, and sphenopalatine ganglion are located in superior pericarotid cavernous sinus plexus and may be infrequently involved [13,14]. We observed a consistent and complete resolution of pain following sympathetic blockade in both patients. The current data suggest that sympathetic activity is impaired in ICA dissection; therefore, further reduction in activity by blockage may not reduce pain [12]. The pain in ICA dissection can be associated with autonomic hyperactivity secondary to impaired post-ganglionic cervical sympathetic fibers such as those seen with cluster headaches [15,16]. It is possible that initial injury may result in inflammation within the plexus leading to hyperexcitability of certain sympathetic pathways such as those seen in Herpes Zoster infection; therefore, sympathetic blockade is beneficial [17]. The effect lasted for at least five days in both patients, which is consistent with duration of relief seen with sympathetic blockade for other indications [18].
CONCLUSION The use of cervical sympathetic blockade for pain control showed short-term benefit in our patient with ICA dissection. Further studies are warranted to assess the effectiveness of ipsilateral cervical sympathetic block in patients with cervical and facial pain associated with underlying ICA dissection.
REFERENCES 1. Silbert PL, et al. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology 1995;45(8): 1517–1522. 2. Biousse V, et al. Head pain in non-traumatic carotid artery dissection: a series of 65 patients. Cephalalgia: an international journal of headache 1994;14(1):33–36. 3. Haneline MT, Rosner AL. The etiology of cervical artery dissection. J Chiropr Med 2007;6(3):110–120. 4. Straube S, et al. Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome. Cochrane Database Syst Rev 2013;9:CD002918. 5. Kalashnikova LA, et al. [Neck pain and headache as the only manifestation of cervical artery dissection]. Zhurnal nevrologii i psikhiatrii imeni SS Korsakova / Ministerstvo zdravookhraneniia i meditsinskoi promyshlennosti Rossiiskoi Federatsii, Vserossiiskoe
40
Journal of Vascular and Interventional Neurology, Vol. 9
obshchestvo nevrologov [i] Vserossiiskoe obshchestvo psikhiat 2015;115(3):9–16. 6. Hassan AE, et al. Long-term clinical and angiographic outcomes in patients with spontaneous cervico-cranial arterial dissections treated with stent placement. J Neuroimaging: an official journal of the American Society of Neuroimaging 2012;22(4):384–393. 7. Hassan AE, et al. Comparison of single versus multiple spontaneous extra- and/or intracranial arterial dissection. J Stroke Cerebrovasc Dis.: an official journal of National Stroke Association 2013;22(1): 42–48. 8. Cai HD, et al. Bilateral superficial cervical plexus block reduces postoperative nausea and vomiting and early postoperative pain after thyroidectomy. J Int Med Res 2012;40(4):1390–1398. 9. Woo JH, Park HS. Successful treatment of severe sympathetically maintained pain following anterior spine surgery. J Korean Neurosurg Soc 2014;56(1):66–70. 10. Kulkarni KR, et al. Efficacy of stellate ganglion block with an adjuvant ketamine for peripheral vascular disease of the upper limbs. Indian J Anaesth 2010;54(6):546–551. 11. Qureshi MH, et al. Horner’s syndrome following internal carotid artery stent placement. J Vasc Interv Neurol 2014;7(4):36–37.
12. De Marinis M, et al. Post-endarterectomy headache and the role of the oculosympathetic system. J Neurol Neurosurg Psychiatry 1991;54(4):314–317. 13. Hardebo JE, et al. Pathways of parasympathetic and sensory cerebrovascular nerves in monkeys. Stroke: a journal of cerebral circulation 1991;22(3):331–342. 14. Candeloro E, et al. Carotid dissection mimicking a new attack of cluster headache. J Headache Pain 2013;14:84. 15. Rigamonti A, et al. Cluster headache and internal carotid artery dissection: two cases and review of the literature. Headache 2008;48(3):467–470. 16. Drummond PD. Autonomic disturbances in cluster headache. Brain: a journal of neurology 1988;111(Pt 5):1199–11209. 17. Makharita MY, et al. Effect of early stellate ganglion blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia. Pain Physician 2012;15(6):467–474. 18. Price DD, et al. Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients. Clin J Pain 1998;14(3):216–226.
2
3
1
Omar Saeed, MD , Asif A. Khan, MD , Nabeel A. Herial, MD , Emrah Aytac, MD , and Adnan 1 I. Qureshi, MD 1Zeenat
Qureshi Stroke Institute, St. Cloud, MN 56303, USA
2University
of Illinois College of Medicine, Rockford, IL 60612, USA
3University
of California, San Diego, La Jolla, CA 92093, USA
4University
of Minnesota, Minneapolis, MN 55455, USA
Journal of Vascular and Interventional Neurology, Vol. 9
Abstract Background—Medical treatment of cranio-cervical pain can be suboptimal in patients with internal carotid artery (ICA) dissection. We report the use of cervical sympathetic block for treatment of pain in two patients with ICA dissection. Case Reports—A 58-year-old man and a 43-year-old woman presented with severe cranio-cervical pain associated with left and right ICA dissection confirmed by magnetic resonance imaging and cerebral angiography. Due to suboptimal control of pain with medical treatment, cervical sympathetic block was performed under fluoroscopic guidance using 20 ml of bupivacaine injected lateral to the posterior aspect of sixth vertebral body in both patients. On self-reported pain scale, the 58-year-old man reported improvement in pain intensity from 8/10 pain to 0/10 within 1 h of blockade. The patient remained relatively pain free for the 24-h post blockade. Mild recurrence of pain was noted on Day 2. The 43-year-old woman reported improvement in pain intensity from 6/10 pain to 0/10 within 1 h of blockade. The patient remained pain free for five days with recurrence to previous intensity. Conclusion—Cervical sympathetic blockade in patients with ICA dissection may be an effective option in the event of suboptimal pain control with medical treatment; however, the technique may be limited due to relatively short duration of action. Conflict of Interest—The authors have no conflict of interest to report. Conflict of interest—Each author certifies that he or she has no commercial association that might pose a conflict of interest in connection with the submitted manuscript. Financial Disclosure/Funding—The authors have no financial disclosures. Keywords Internal carotid artery (ICA); dissection; cervical sympathetic block; neck pain; headache; Horner’s syndrome; sympathetic pain
INTRODUCTION The most common presentation of internal carotid artery (ICA) dissection is head and neck pain, and depending on the site of dissection, the pain can radiate to many different locations, including facial, cervical, or even the auricular regions. The pain has been known to last anywhere from 90 min to 30 days, and can be very severe in
intensity [1,2]. It is secondary to excessive stimulation of sympathetic pain pathways that are located in the vicinity of the involved segment of the ICA due to stretching of wall caused by the dissection [3]. The current practice involves use of pharmaceutical analgesics,
Vol. 9, No. 3, pp. 36–40. Published January, 2017. All Rights Reserved by JVIN. Unauthorized reproduction of this article is prohibited Corresponding Author: Omar Saeed MD, Zeenat Qureshi Stroke Institute, 925 Delaware St SE, Suite 300B, Minneapolis, MN 55414, USA. Tel.: (612) 626-8221; fax: (612) 625-7950. [email protected].
Saeed et al.
37
Journal of Vascular and Interventional Neurology, Vol. 9
Figure 1. (A) Oblique view: arterial dissection (arrow) extending from cervical segment to petrous segment of left ICA
in Patient 1. (B) Lateral view: arterial dissection (arrow) extending from cervical segment to petrous segment of right ICA in Patient 2.
such as non-steroidal anti-inflammatory medication and narcotics [4,5], although failure rates can be high [5]. We describe two cases who presented with severe headache, which were later found to have an ICA dissection and underwent cervical sympathetic block for pain control.
CASE REPORT Patient 1 A 57-year-old man presented with severe throbbing leftsided headache with radiation into his neck and associated blurred vision in the left eye. He also complained of ear pain since the previous month. He tried several oral non-steroidal anti-inflammatory medications with little benefit. On physical examination, his left pupil measured approximately 4 mm and the right pupil was
approximately 7 mm. There was also slight ptosis of the left eyelid consistent with ipsilateral Horner’s syndrome. In addition, his electrocardiogram showed sinus bradycardia, and the patient had no other neurological deficits on examination. The patient continued to complain of severe headache and neck pain despite multiple doses of intravenous (IV) and oral narcotic analgesics including oxycodone/acetaminophen combination and hydromorphone. A diagnostic catheter angiogram was performed which demonstrated tapering stenosis with irregularity sparing the carotid bifurcation consistent with ICA dissection [see Figure 1(A)] and maximum stenosis measuring 83% using Zeenat Qureshi Stroke Institute (ZQSI) criteria [6,7]. Patient 2 A 43-year-old woman developed right ICA dissection six months ago with initial manifestation consisting of
38
Journal of Vascular and Interventional Neurology, Vol. 9
Figure 2. (A) Fluoroscopic confirmation of needle placement at the level of left C6 vertebral body in Patient 1. (B) Contrast injection from needle placed at the level of right C6 vertebral body in Patient 2. The linear contrast spread along the caudocephalic axis within the paravertebral fascial compartment.
right Horner's syndrome and followed by worsening right-sided headaches. Since the initial occurrence, the patient had intractable headaches with variable response to medications. The headache was described as right sided with sharp characteristics varying between 3–6/10 intensity daily involving right cranium and orbital regions. The headache was persistent and sometimes interfered with sleep. The patient was unable to work due to the severe headaches. There was improvement in lumen diameter at site of arterial dissections based on findings of magnetic resonance angiogram (Day 2 since initial symptom occurrence), catheter angiogram (Day 10), and catheter angiogram (Day 40). A diagnostic catheter angiogram performed on Day 40 demonstrated minimal stenosis with irregularity sparing the carotid
bifurcation [see Figure 1(B)] and maximum stenosis measuring 54% using ZQSI criteria [6,7]. The patient continued to complain of severe headaches despite multiple doses of IV lidocaine infusions, IV dihydroergotamine, local botulinum injections, and IV/oral Ketorolac. The patient reported 6/10 intensity headache prior to the procedure. On physical examination, the patient had no other neurological deficits.
PROCEDURE A cervical sympathetic blockade with fluoroscopic guidance was performed to improve pain control [see Figure 2(A and B)]. The appropriate side of the neck was prepped and draped while the patient remained in supine
Saeed et al.
Journal of Vascular and Interventional Neurology, Vol. 9
position; 3 ml of 1% of lidocaine was administered locally in the subcutaneous tissue. A 20-gauge spinal needle was advanced under fluoroscopic guidance, lateral, to posterior aspect of cervical 6th vertebral body while laterally manually displacing the ICA away from the needle trajectory. The needle placement was confirmed by injection 0.75 and 2 ml of radio-opaque omnipaque with linear contrast spread along the caudocephalic axis within the paravertebral fascial compartment. A total 10 ml of 0.25% bupivacaine was then injected over 5 min followed by fluoroscopically confirmation of needle position. Another 10 ml of 0.25% bupivacaine was then slowly injected over 5 min. The needle was then removed, and pressure was applied to the lateral aspect of the neck.
POST PROCEDURE RESPONSE On immediate post-procedural assessment, Patient 1 reported a significant reduction in headache pain. On self-reported pain scale, the patient reported improvement in pain intensity from 8/10 pain to 0/10 within 1 h of blockade. The patient remained relatively pain free for the 24-h post blockade. Mild recurrence of pain was noted on Day 2. On telephonic follow-up on Day 5, he reported that the pain was only concerning when he was lying down but was relatively pain free when standing up or sitting upright. Adequate pain management from then onward was continued with oral ibuprofen. Patient 2 reported complete resolution of headache immediately after procedure. The effectiveness of sympathetic blockade was confirmed by post-procedure development of ptosis and miosis in the right eye, which lasted for 6 h post procedure. On telephonic follow-up on Day 3, she reported that she was headache free. On telephonic follow-up on Day 7, the patient reported that on Day 5, the pain had started again and now was at the same intensity as pre-procedure pain. She requested another block procedure be performed which was not performed due to lack of persistent relief in her case.
DISCUSSION To the best of our knowledge, we did not find any case reports or studies that described the use of cervical sympathetic blockage for pain control in a patient who presented with ICA dissection. A previous study demonstrated effectiveness of cervical sympathetic blockade for pain control after thyroidectomy with reduction of symptoms including post-operative nausea and vomiting [8]. Others have described the use of cervical and stellate sympathetic ganglion block for pain control follow-
39
ing spinal surgery and peripheral vascular disease with good outcomes [9,10]. The disruption of either pre-ganglionic or post-ganglionic neurons of the cervical sympathetic plexus surrounding the ICA is the presumed reason for sympathetic dysfunction in patients with ICA dissection [11]. The damage to sympathetic plexus during carotid endarterectomy can also result in similar headaches [12]. However, the fibers of the trigeminal nerve, superior cervical ganglion, and sphenopalatine ganglion are located in superior pericarotid cavernous sinus plexus and may be infrequently involved [13,14]. We observed a consistent and complete resolution of pain following sympathetic blockade in both patients. The current data suggest that sympathetic activity is impaired in ICA dissection; therefore, further reduction in activity by blockage may not reduce pain [12]. The pain in ICA dissection can be associated with autonomic hyperactivity secondary to impaired post-ganglionic cervical sympathetic fibers such as those seen with cluster headaches [15,16]. It is possible that initial injury may result in inflammation within the plexus leading to hyperexcitability of certain sympathetic pathways such as those seen in Herpes Zoster infection; therefore, sympathetic blockade is beneficial [17]. The effect lasted for at least five days in both patients, which is consistent with duration of relief seen with sympathetic blockade for other indications [18].
CONCLUSION The use of cervical sympathetic blockade for pain control showed short-term benefit in our patient with ICA dissection. Further studies are warranted to assess the effectiveness of ipsilateral cervical sympathetic block in patients with cervical and facial pain associated with underlying ICA dissection.
REFERENCES 1. Silbert PL, et al. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology 1995;45(8): 1517–1522. 2. Biousse V, et al. Head pain in non-traumatic carotid artery dissection: a series of 65 patients. Cephalalgia: an international journal of headache 1994;14(1):33–36. 3. Haneline MT, Rosner AL. The etiology of cervical artery dissection. J Chiropr Med 2007;6(3):110–120. 4. Straube S, et al. Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome. Cochrane Database Syst Rev 2013;9:CD002918. 5. Kalashnikova LA, et al. [Neck pain and headache as the only manifestation of cervical artery dissection]. Zhurnal nevrologii i psikhiatrii imeni SS Korsakova / Ministerstvo zdravookhraneniia i meditsinskoi promyshlennosti Rossiiskoi Federatsii, Vserossiiskoe
40
Journal of Vascular and Interventional Neurology, Vol. 9
obshchestvo nevrologov [i] Vserossiiskoe obshchestvo psikhiat 2015;115(3):9–16. 6. Hassan AE, et al. Long-term clinical and angiographic outcomes in patients with spontaneous cervico-cranial arterial dissections treated with stent placement. J Neuroimaging: an official journal of the American Society of Neuroimaging 2012;22(4):384–393. 7. Hassan AE, et al. Comparison of single versus multiple spontaneous extra- and/or intracranial arterial dissection. J Stroke Cerebrovasc Dis.: an official journal of National Stroke Association 2013;22(1): 42–48. 8. Cai HD, et al. Bilateral superficial cervical plexus block reduces postoperative nausea and vomiting and early postoperative pain after thyroidectomy. J Int Med Res 2012;40(4):1390–1398. 9. Woo JH, Park HS. Successful treatment of severe sympathetically maintained pain following anterior spine surgery. J Korean Neurosurg Soc 2014;56(1):66–70. 10. Kulkarni KR, et al. Efficacy of stellate ganglion block with an adjuvant ketamine for peripheral vascular disease of the upper limbs. Indian J Anaesth 2010;54(6):546–551. 11. Qureshi MH, et al. Horner’s syndrome following internal carotid artery stent placement. J Vasc Interv Neurol 2014;7(4):36–37.
12. De Marinis M, et al. Post-endarterectomy headache and the role of the oculosympathetic system. J Neurol Neurosurg Psychiatry 1991;54(4):314–317. 13. Hardebo JE, et al. Pathways of parasympathetic and sensory cerebrovascular nerves in monkeys. Stroke: a journal of cerebral circulation 1991;22(3):331–342. 14. Candeloro E, et al. Carotid dissection mimicking a new attack of cluster headache. J Headache Pain 2013;14:84. 15. Rigamonti A, et al. Cluster headache and internal carotid artery dissection: two cases and review of the literature. Headache 2008;48(3):467–470. 16. Drummond PD. Autonomic disturbances in cluster headache. Brain: a journal of neurology 1988;111(Pt 5):1199–11209. 17. Makharita MY, et al. Effect of early stellate ganglion blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia. Pain Physician 2012;15(6):467–474. 18. Price DD, et al. Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients. Clin J Pain 1998;14(3):216–226.
