How to manage a 49-year-old patient with a history of recurrent stroke, resolved left hemiparesis, and current symptoms of severe burning sensation in the right lower limb and loss of balance, with lab results showing normal B12 levels and an HbA1c (hemoglobin A1c) of 6.3, and imaging showing encephalomalacia with gliosis in the left cerebellar hemisphere?

Management of Post-Stroke Neuropathic Pain (Central Post-Stroke Pain)

The severe burning sensation in this patient's right lower limb represents central post-stroke pain (CPSP) secondary to the cerebellar/vermis stroke, and should be treated with gabapentinoids (gabapentin or pregabalin) as first-line therapy, with tricyclic antididepressants (amitriptyline) as an alternative if gabapentinoids are ineffective or not tolerated.

Understanding the Clinical Picture

This patient's burning sensation from the medial thigh to great toe, occurring after a stroke affecting the posterior medial cerebellar hemisphere and vermis, represents central neuropathic pain (also called central post-stroke pain or thalamic pain syndrome, though it can occur with non-thalamic lesions). 1

• The encephalomalacia with gliosis indicates chronic stroke changes, and the development of burning pain weeks to months after stroke is characteristic of CPSP 1
• The HbA1c of 6.3% indicates prediabetes, which requires attention for secondary stroke prevention but is not high enough to cause diabetic neuropathy as the primary cause of symptoms 1, 2
• Normal B12 excludes B12 deficiency neuropathy as a contributor

Primary Treatment: Pharmacological Management of Central Post-Stroke Pain

First-Line Agents

Gabapentinoids are the recommended first-line treatment:

• Gabapentin: Start 300 mg at bedtime, titrate up to 300-600 mg three times daily (maximum 3600 mg/day) 1
• Pregabalin: Start 75 mg twice daily, can increase to 150-300 mg twice daily based on response and tolerability 1
• These agents work by modulating calcium channels and reducing central sensitization 1

Second-Line Agents

Tricyclic antidepressants if gabapentinoids fail or are not tolerated:

• Amitriptyline: Start 10-25 mg at bedtime, gradually increase to 75-150 mg as tolerated 1
• Use caution in elderly patients or those with cardiac conduction abnormalities 1
• Anticholinergic side effects (dry mouth, constipation, urinary retention) may limit use 1

Additional Considerations

• SNRIs (duloxetine, venlafaxine) may be considered as alternatives, though evidence is stronger for gabapentinoids and TCAs in CPSP 1
• Avoid benzodiazepines as they have deleterious effects on stroke recovery and cause problematic sedation 3

Management of Balance Impairment

The loss of balance is directly related to the cerebellar stroke:

• Postural training and task-oriented therapy should be implemented for rehabilitation of ataxia 1
• Balance training programs have demonstrated benefit after stroke, though no specific approach is superior 1
• Physical therapy should include balance-specific activities and strengthening exercises 1
• Standardized balance testing should guide intervention selection and monitor fall risk 1

Critical Secondary Stroke Prevention

Given the history of recurrent stroke, aggressive secondary prevention is essential:

Blood Pressure Management

• Target BP <130/80 mm Hg for secondary stroke prevention 1
• Antihypertensive treatment is recommended for all ischemic stroke patients beyond the hyperacute period 1
• Use diuretics combined with ACE inhibitors or ARBs as preferred agents 1

Glycemic Control

• Target HbA1c <7% given the current value of 6.3% indicates prediabetes 1
• More rigorous control of blood pressure and lipids should be pursued in patients with diabetes/prediabetes 1
• Higher HbA1c levels are independently associated with poor functional outcomes after stroke 2, 4

Lipid Management

• Statin therapy is recommended for atherosclerotic stroke prevention 1
• Target LDL-C <100 mg/dL, or <70 mg/dL if very high risk with multiple risk factors 1
• This patient with recurrent stroke qualifies as very high risk 1

Antiplatelet Therapy

• Continue appropriate antiplatelet therapy (aspirin, clopidogrel, or combination based on stroke mechanism) for secondary prevention 1

Important Pitfalls to Avoid

• Do not dismiss burning pain as "just nerve pain" - CPSP significantly impacts quality of life and requires aggressive treatment 1
• Do not use opioids as first-line therapy - they are less effective for neuropathic pain and carry addiction risk 1
• Do not neglect fall prevention - cerebellar ataxia with balance impairment increases fall and fracture risk substantially 1
• Do not delay physical therapy - early mobilization and balance training improve outcomes 1
• Do not undertreated secondary prevention - this patient has had recurrent strokes and requires maximal risk factor modification 1

Treatment Algorithm Summary

1. Initiate gabapentin 300 mg at bedtime, titrate to effect (up to 1800-3600 mg/day in divided doses) 1
2. If inadequate response after 4-6 weeks, switch to pregabalin or add/switch to amitriptyline 1
3. Simultaneously begin intensive physical therapy with focus on balance training and ataxia rehabilitation 1
4. Optimize secondary stroke prevention: BP control (<130/80), statin therapy (LDL <70), glycemic control (HbA1c <7%), and antiplatelet therapy 1
5. Monitor and adjust medications based on pain relief and functional improvement 1