Botulinum Toxin-A for the Treatment of Neuropathic Pain after Decompressive Craniotomy in Stroke: Two Cases

Botulinum toxin-A (BoNT-A) is recommended as third-line off-label treatment for the management of neuropathic pain. BoNT-A has been reported as treatment for different neuropathic pain conditions; however, not for neuropathic pain after decompressive craniotomy for stroke. The aim of this retrospective case series is to provide information on safety, the effect, and the application method of BoNT-A in clinical practice for the treatment of neuropathic pain after trepanation. This case series describes 2 patients treated in 2021 at a BoNT outpatient clinic for chronic neuropathic pain at the incisional site after decompressive craniotomy for stroke who were resistant to pain medication. Cases were a 48-year-old woman and a 63-year-old man suffering from chronic neuropathic pain since 3 and 6 years, respectively. They were treated regularly with BoNT-A with a total dose of 100 mouse units of incobotulinumtoxin-A injected into peri-incisional sites of the scalp. Both patients reported subjective decrease in pain frequency (40% and 60%), in pain intensity (60% and 90%), and an increase of quality of life (80%). BoNT-A should be further investigated as treatment for neuropathic pain – especially in underreported conditions such as neuropathic pain after craniotomy in stroke.