To the Editor:
Although poststroke pain is a well-known phenomenon, poststroke pruritus is a generally under-recognized poststroke symptom. We have found only 10 reported cases of poststroke pruritus in the literature.1 2 We present 2 cases of poststroke pruritus and briefly discuss its etiology and management.
Case 1: A 74-year-old female with a long-standing history of hypertension and hypercholestrolemia developed left-sided pruritus several weeks after a right thalamic stroke. The pruritus was episodic, affecting various localized areas of her left trunk and extremities while sparing the right side. The patient had no history of renal, liver, endocrine, hematologic, or skin diseases, and laboratory findings were unremarkable. Physical examination was significant for an erythematous excoriated area on the left side of the chest. Topical therapy with moisturizers and emollients helped alleviate each episode of pruritus, but the patient continued to have episodic, intense, localized pruritus on various regions of her left side. The patient refused oral medications in order to simplify her medication regimen.
Case 2: A 69-year-old male with a long-standing history of hypertension developed intense pruritus of the left thigh several days after cerebral infarction in the right middle cerebral artery distribution. The pruritus was localized and unremitting, interfering with sleep. The patient had no history of renal, liver, endocrine, hematologic, or skin diseases, and laboratory findings were unremarkable. Physical examination revealed left-sided hemiplegia and hemiparesis, and an erythematous excoriated left anterior thigh. Treatment with amitriptylene 50 mg a day resulted in resolution of the pruritus within a week.
Although the exact neuroanatomy and neurophysiology of itch perception has not been clarified, it is suggested that itch perception utilizes many of the same neural pathways used in pain sensation.2 Localized pruritus may be a symptom of any focal neurological phenomenon, such as brain tumors,3 multiple sclerosis,4 cerebral vascular aneurysms,5 and peripheral nerve entrapments.6
It is important for physicians caring for stroke patients to be aware of poststroke pruritus and to avoid ignoring the symptoms or pursuing unnecessary work-up for other etiologies. The syndrome consists of excessive localized or generalized pruritus, primarily in the side of the body contralateral to the cerebral lesion. As in poststroke pain, the onset may be from days to weeks after the stroke, and the symptoms respond to medications such as amitriptylene and carbamazepine, although topical emollients may suffice in many cases.1
- Copyright © 1999 by American Heart Association
Massey EW. Unilateral neurogenic pruritus following stroke. Stroke. 1984;15:901–903.
Yamamoto M, Yabuki S, Hayabara T, Otsuki S. Paroxysmal itching in multiple sclerosis: a report of three cases. J Neurol Neurosurg Psychiatry. 1981;44:19–22.
King CA, Huff FJ, Jorizzo JL. Unilateral neurogenic pruritus: paroxysmal itching associated with central nervous system lesions. Ann Intern Med. 1982;97:222–223.
This letter emphasizes the poststroke pruritis that can occur in patients with cerebral infarction or hemorrhage. Although not common, we continue to see several cases yearly. Although initially described in capsular infarctions, it also seems to occur in middle cerebral artery distribution vascular lesions as well. When unilateral, contralateral, and poststroke, it is easier to diagnose the cause. Obviously, there are many other causes of pruritis.
When it is localized to the lateral thigh, such as in case 2, one must consider other options such as meralgia paresthetica.
I agree that treatment with tricyclics and, more recently, neurontin, can help. Often the symptoms resolve over weeks. Conventional antipruritis treatment, orally or topically, may sometimes help.
Perhaps the greatest challenge is what Latin term to give to this poststroke symptom!
King CA, Juff FG, Jorizzo JL. Unilateral neurogenic pruritus: paroxysmal itching associated with central nervous system lesions. Ann Intern Med. 1982;97:222–223.