Management of Abdominal Pain Following Posterior Circulation Stroke

Diagnostic Approach

The American Heart Association recommends establishing if pain is central poststroke pain by confirming it occurred after stroke, is located in an area corresponding to the central nervous system lesion, and cannot be accounted for by nociceptive or peripheral neuropathic causes 1, 2
The American College of Radiology suggests ruling out mesenteric ischemia, which may present with abdominal pain and requires urgent intervention with angiography and possible revascularization 4
Assess for urinary retention, which can cause abdominal discomfort and is common after stroke, according to the American Heart Association 5

The American Heart Association recommends amitriptyline 75 mg at bedtime as a first-line treatment, which has been shown to lower daily pain ratings and improve global functioning 1, 3
The American Heart Association also recommends lamotrigine as a first-line treatment, which can reduce daily pain ratings and cold-induced pain, though only 44% of patients have a good clinical response 1, 3
Choose between these two options based on patient comorbidities, potential side effects, and drug interactions, as suggested by the American Heart Association 1, 3

The American Heart Association suggests that for intractable central poststroke pain not responsive to other treatments, motor cortex stimulation might be reasonable in carefully selected patients 1, 3
Motor cortex stimulation can achieve pain reductions of >50% in 50-83% of patients for up to 2 years, according to the American Heart Association 1, 3

The American Heart Association notes that posterior circulation strokes account for approximately 20% of all ischemic strokes and may present with unique symptoms, although this fact is also mentioned in Praxis Medical Insights, the American Heart Association is the preferred source 7
The Journal of Neurointerventional Surgery suggests that cerebellar infarction can cause mass effect and hydrocephalus, potentially requiring surgical decompression if clinical deterioration occurs 8

The American Heart Association warns that central poststroke pain is often underdiagnosed or misdiagnosed as musculoskeletal or visceral pain 1, 3
The American College of Radiology advises avoiding attributing all abdominal pain to central poststroke pain without excluding other serious causes 4
The American Heart Association recommends not using TENS as it has been shown to be ineffective in a small trial 1, 3
The American Heart Association also advises being cautious with medication side effects, particularly anticholinergic effects of amitriptyline in elderly patients 1, 3