MR-Guided Laser Interstitial Thermal Therapy Mesencephalotomy for Medically Intractable Malignant Pain

MR-Guided Laser Interstitial Thermal Therapy Mesencephalotomy for Medically Intractable Malignant Pain | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report MR-Guided Laser Interstitial Thermal Therapy Mesencephalotomy for Medically Intractable Malignant Pain Mickael Aubignat, Jean-Marc Constans, Martial Ouendo, Jean-Philippe Arnault, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5911997/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 May, 2025 Read the published version in Acta Neurochirurgica → Version 1 posted 6 You are reading this latest preprint version Abstract Stereotactic mesencephalotomy is a neurosurgical technique designed to sever spinothalamic pain transmission pathways for medically intractable pain. This report presents the first case of Magnetic Resonance-guided Laser Interstitial Thermal Therapy (MRgLITT) mesencephalotomy for severe malignant pain due to metastatic melanoma. The procedure significantly reduced the patient’s pain, with a postoperative visual analog scale (VAS) score decreasing from > 7 to < 3. No adverse effects were observed. The case underscores the potential of MRgLITT mesencephalotomy as a precise, minimally invasive option for pain management in palliative care settings. mesencephalotomy Laser Interstitial Thermal Therapy MRI pain melanoma cancer Figures Figure 1 Figure 2 Figure 3 Introduction Stereotactic mesencephalotomy, first described in the 1950s, targets spinothalamic and trigeminothalamic pathways to manage intractable pain 1 – 3 . Its use declined due to morbidity associated with early methods and the rise of neuromodulation techniques 4 . However, advances in imaging and minimally invasive technologies, such as MRgLITT, have renewed interest in this procedure. MRgLITT offers real-time imaging-guided precision, making it a promising option for palliative pain management 5 , 6 . This report details the first documented case of robot-assisted MRgLITT mesencephalotomy in a patient with metastatic melanoma and refractory pain. Clinical Presentation A 47-year-old male with a history of metastatic melanoma presented with severe, treatment-resistant pain. Despite numerous therapeutic interventions, including high-dose corticosteroids, opioids, ketamine, and topical anesthetics, pain control remained inadequate. The patient’s melanoma had progressed unfavorably, resulting in multiple atypical subcutaneous inflammatory and painful lesions located on the lower right side of the neck, the right upper limb, and the right side of the thorax and abdomen. Pain scores consistently exceeded 7 on the visual analog scale (VAS), significantly impairing quality of life. Given the refractory nature of the pain and the palliative care context, a stereotactic robot-assisted MRgLITT mesencephalotomy was proposed. The patient provided informed consent for the procedure and its subsequent publication. Intervention and Outcome Preoperative imaging included high-resolution MRI with 3D-T1 gradient-echo sequences post-gadolinium injection, 3D-SWAN, 3D-T1 inversion recovery, and diffusion tensor imaging (DTI). These were complemented by a thin-slice CT scan. These datasets were integrated into the ROSANA planning software (Zimmer Biomet, Warsaw, IN, USA), which reformatted the images into a plane parallel to the anterior commissure-posterior commissure (AC-PC) line. Target coordinates were calculated to localize the spinothalamic tract just before its entry into the thalamus (1 mm anterior to the tangent to the mesencephalic aqueduct, 5 mm posterior to the CP, 5 mm below the CA-CP line, and 8 mm lateral). Under local anesthesia, the Leksell Series G stereotactic frame was attached to the patient’s head. Using the ROSA robotic platform, a 3.2-mm burr hole was drilled at the calculated entry point. A robotic microdrive placed a microelectrode (microTargeting model 22670, FHC Inc., Bowdoin, USA) into the target, allowing macrostimulation testing at 50 Hz up to 2.5 V. Tests performed 3 mm above, at, and 3 mm below the target showed no adverse effects, confirming optimal placement. The electrode was replaced with a laser catheter (Visualase 1.65 mm with a 3-mm laser diffusing tip, Medtronic, Minneapolis, MN, USA), which was positioned to ensure a therapeutic margin while safeguarding critical structures. Repeated flat-panel CT imaging verified the catheter’s placement. With the patient under general anesthesia, the ablation probe was connected to the MRgLITT workstation in the MRI suite. Baseline thermometry images were acquired, and six safety zones were delineated to monitor temperatures during ablation. Using a stepwise approach, thermal energy was delivered at 1.0 W, 1.5 W, and 2.0 W, each for 2 minutes, with intervals for tissue cooling. Real-time heat maps guided the creation of a spherical ablation zone approximately 5 mm in diameter, ensuring complete lesioning of the spinothalamic tract (Fig. 1 ). Automatic safety cutoffs prevented overheating, and post-ablation imaging confirmed a well-defined lesion without damage to adjacent structures (Figs. 2 and 3 ). Postoperatively, the patient experienced significant pain relief, with VAS scores decreasing from > 7 to < 3. Temperature sensation was specifically assessed using a ice tube and a warm stimulus applied to symmetric body regions. No deficits in thermal perception were observed, indicating preserved sensory discrimination postoperatively. Opioid and adjunctive medications were substantially reduced, and no neurological deficits were observed. Unfortunately, the patient succumbed to cancer progression one month later. Discussion This case highlights the potential of MRgLITT mesencephalotomy in managing intractable malignant pain. Compared to historical techniques, MRgLITT provides real-time imaging guidance and precise lesioning with minimal invasiveness 1 – 3 , 7 . Its safety profile and efficacy in reducing pain align with findings in prior literature on lesioning procedures. Alternatives such as cordotomy, total myelotomy, intrathecal baclofen, and deep brain stimulation were deemed unsuitable due to the pain’s location, systemic side effects, or hardware-related risks 4 , 7 . MRgLITT’s ability to target specific pain pathways without systemic effects makes it ideal for localized, refractory pain. This case supports the need for a multidisciplinary approach to patient selection and individualized treatment planning 8 . Future studies should evaluate long-term outcomes and broader applications of this technique. Conclusion MRgLITT mesencephalotomy represents a promising, minimally invasive option for managing intractable pain in palliative care settings. This case underscores its potential to improve quality of life in patients with refractory pain due to malignancy. Declarations Author contributions All authors contributed equally to the research project conception, organization, and execution; M.A writing the first draft and was responsible for the decision to submit the manuscript. JM.C, M.O, JP.A, C.J, C.D and ML contributed to manuscript review and critique. All authors have seen and approved of the final text. Funding No funding. Data availability No datasets were generated or analysed during the current study. Ethical Approval : Not Applicable. Consent of publication : Written consent was obtained by the patient for publication. Competing interests : The authors declare no competing interests. References Ivanishvili Z, Pujara S, Honey CM, Chang S, Honey CR (2016) Stereotactic mesencephalotomy for palliative care pain control: A case report, literature review and plea to rediscover this operation. Br J Neurosurg 30(4):444–447. 10.3109/02688697.2015.1133805 Marques RAS, Alencar HS, Bannach MA, Vilela-Filho O (2022) Semidirect targeting-based stereotactic mesencephalotomy for the treatment of refractory pain: a case series. J Neurosurg 136(4):1128–1138. 10.3171/2021.6.JNS21709 Murtagh F, Wycis HT, Spiegel EA (1951) Relief of thalamic pain by mesencephalotomy. AMA Arch Neurol Psychiatry 65(2):255–257 Sola RG, Pulido P (2022) Neurosurgical Treatment of Pain. Brain Sci 12(11):1584. 10.3390/brainsci12111584 Diaz R, Ivan ME, Hanft S et al (2016) Laser Interstitial Thermal Therapy: Lighting the Way to a New Treatment Option in Neurosurgery. Neurosurgery 79(Suppl 1):S3–S7. 10.1227/NEU.0000000000001435 Aubignat M, Tir M, Ouendo M, Boussida S, Constans JM, Lefranc M (2024) Unilateral Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy Thalamotomy for Essential Tremor. Mov Disord Off J Mov Disord Soc Published online March 26. 10.1002/mds.29790 Berger A, Hochberg U, Zegerman A, Tellem R, Strauss I (2019) Neurosurgical ablative procedures for intractable cancer pain. J Neurosurg Published online May 10:1–8. 10.3171/2019.2.JNS183159 Kluger BM, Hudson P, Hanson LC et al (2023) Palliative care to support the needs of adults with neurological disease. Lancet Neurol 22(7):619–631. 10.1016/S1474-4422(23)00129-1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 May, 2025 Read the published version in Acta Neurochirurgica → Version 1 posted Editorial decision: Accepted 23 Apr, 2025 Reviews received at journal 23 Apr, 2025 Reviewers agreed at journal 23 Apr, 2025 Reviewers invited by journal 17 Apr, 2025 Submission checks completed at journal 17 Apr, 2025 First submitted to journal 10 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5911997","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":444349875,"identity":"76302992-4c6a-4d32-a4ed-472ba365fb8a","order_by":0,"name":"Mickael Aubignat","email":"data:image/png;base64,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","orcid":"","institution":"Amiens Picardie University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Mickael","middleName":"","lastName":"Aubignat","suffix":""},{"id":444349876,"identity":"386eaf59-04b4-4565-bccd-a0f043972b23","order_by":1,"name":"Jean-Marc Constans","email":"","orcid":"","institution":"Amiens Picardie University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jean-Marc","middleName":"","lastName":"Constans","suffix":""},{"id":444349877,"identity":"bafdafc3-ef61-4c70-9ca4-05397872d1f0","order_by":2,"name":"Martial Ouendo","email":"","orcid":"","institution":"Amiens Picardie University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Martial","middleName":"","lastName":"Ouendo","suffix":""},{"id":444349878,"identity":"eef379b3-0fd8-459e-a979-f3d2ddf5e85b","order_by":3,"name":"Jean-Philippe Arnault","email":"","orcid":"","institution":"Amiens Picardie University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jean-Philippe","middleName":"","lastName":"Arnault","suffix":""},{"id":444349879,"identity":"f4b562bf-c61c-41ec-83ab-de2f461570f9","order_by":4,"name":"Claire Josse","email":"","orcid":"","institution":"Amiens Picardie University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Claire","middleName":"","lastName":"Josse","suffix":""},{"id":444349880,"identity":"e6665cff-fb75-4e3b-b4a9-5d9218df3fa2","order_by":5,"name":"Christine Desenclos","email":"","orcid":"","institution":"Amiens Picardie University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christine","middleName":"","lastName":"Desenclos","suffix":""},{"id":444349881,"identity":"0095724e-eed4-42e3-8b40-b95763d482ea","order_by":6,"name":"Michel Lefranc","email":"","orcid":"","institution":"Amiens Picardie University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Michel","middleName":"","lastName":"Lefranc","suffix":""}],"badges":[],"createdAt":"2025-01-27 11:53:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5911997/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5911997/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00701-025-06544-1","type":"published","date":"2025-05-02T15:56:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81002279,"identity":"cb16e7ce-9476-4d1e-a385-c8180c351fd9","added_by":"auto","created_at":"2025-04-21 06:32:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4408941,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImaging during MRgLITT mesencephalotomy procedure.\u003c/strong\u003e (A, B, blue) The thermal maps, (C, D, orange) the corresponding estimated thermal lesion in the left mesencephalon.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5911997/v1/e014e97e3da892436c0e7420.jpg"},{"id":81002273,"identity":"2a6fad14-cfcf-4b16-a9b8-012106e68f80","added_by":"auto","created_at":"2025-04-21 06:32:44","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2054954,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMRI images at 4 days post-mesencephalotomy.\u003c/strong\u003e(A) Diffusion-Weighted Imaging (DWI) sequence showing a hyperintense lesion indicative of restricted diffusion. (B) Apparent Diffusion Coefficient (ADC) map highlighting a central hyperintensity surrounded by a hypointense ring, suggesting central necrosis with peripheral edema. (C) T2-Weighted Fluid-Attenuated Inversion Recovery (T2 FLAIR) sequence displaying the lesion as hyperintense, along with adjacent edema. (D) Gradient Echo T2*-Weighted (T2* GRE) sequence revealing several central hypointensities, suggestive of hemorrhagic deposits at the center of the lesion. (E) T1-Weighted (T1W) sequence revealing slight hypointensity within the lesion. (F) Post-Gadolinium T1-Weighted (T1W + Gd) sequence showing a hypointense lesion without contrast enhancement, consistent with the findings on the non-enhanced T1 sequence.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5911997/v1/0c9ec6ce01776c5d58eec37f.jpg"},{"id":81002281,"identity":"e5be0ca5-94c5-4aae-a338-89d61472fb0b","added_by":"auto","created_at":"2025-04-21 06:32:45","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3345029,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePost-Gadolinium T1-Weighted MRI Images (T1W + Gd) showing enhanced visualization of neurological structures.\u003c/strong\u003e The left thalamus is highlighted in cyan, with neural fibers traversing this region, depicted using Diffusion Tensor Imaging (DTI) and visualized via tractography. (A) 3D Representation: Offers a comprehensive three-dimensional visualization of the thalamus and its associated neural pathways, elucidated by DTI tractography. (B) Axial Slice. (C) Sagittal Slice. (D) Coronal Slice.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5911997/v1/65ff1843814250c7d2ac0aed.jpg"},{"id":81987721,"identity":"9785db02-5a22-4b50-b98f-0cf23cee0b96","added_by":"auto","created_at":"2025-05-05 16:05:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10226232,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5911997/v1/90169008-f3af-4317-9e45-6d1ac3432682.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"MR-Guided Laser Interstitial Thermal Therapy Mesencephalotomy for Medically Intractable Malignant Pain","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStereotactic mesencephalotomy, first described in the 1950s, targets spinothalamic and trigeminothalamic pathways to manage intractable pain\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Its use declined due to morbidity associated with early methods and the rise of neuromodulation techniques\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. However, advances in imaging and minimally invasive technologies, such as MRgLITT, have renewed interest in this procedure. MRgLITT offers real-time imaging-guided precision, making it a promising option for palliative pain management\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. This report details the first documented case of robot-assisted MRgLITT mesencephalotomy in a patient with metastatic melanoma and refractory pain.\u003c/p\u003e"},{"header":"Clinical Presentation","content":"\u003cp\u003eA 47-year-old male with a history of metastatic melanoma presented with severe, treatment-resistant pain. Despite numerous therapeutic interventions, including high-dose corticosteroids, opioids, ketamine, and topical anesthetics, pain control remained inadequate. The patient\u0026rsquo;s melanoma had progressed unfavorably, resulting in multiple atypical subcutaneous inflammatory and painful lesions located on the lower right side of the neck, the right upper limb, and the right side of the thorax and abdomen. Pain scores consistently exceeded 7 on the visual analog scale (VAS), significantly impairing quality of life. Given the refractory nature of the pain and the palliative care context, a stereotactic robot-assisted MRgLITT mesencephalotomy was proposed. The patient provided informed consent for the procedure and its subsequent publication.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eIntervention and Outcome\u003c/h2\u003e \u003cp\u003ePreoperative imaging included high-resolution MRI with 3D-T1 gradient-echo sequences post-gadolinium injection, 3D-SWAN, 3D-T1 inversion recovery, and diffusion tensor imaging (DTI). These were complemented by a thin-slice CT scan. These datasets were integrated into the ROSANA planning software (Zimmer Biomet, Warsaw, IN, USA), which reformatted the images into a plane parallel to the anterior commissure-posterior commissure (AC-PC) line. Target coordinates were calculated to localize the spinothalamic tract just before its entry into the thalamus (1 mm anterior to the tangent to the mesencephalic aqueduct, 5 mm posterior to the CP, 5 mm below the CA-CP line, and 8 mm lateral). Under local anesthesia, the Leksell Series G stereotactic frame was attached to the patient\u0026rsquo;s head. Using the ROSA robotic platform, a 3.2-mm burr hole was drilled at the calculated entry point. A robotic microdrive placed a microelectrode (microTargeting model 22670, FHC Inc., Bowdoin, USA) into the target, allowing macrostimulation testing at 50 Hz up to 2.5 V. Tests performed 3 mm above, at, and 3 mm below the target showed no adverse effects, confirming optimal placement. The electrode was replaced with a laser catheter (Visualase 1.65 mm with a 3-mm laser diffusing tip, Medtronic, Minneapolis, MN, USA), which was positioned to ensure a therapeutic margin while safeguarding critical structures. Repeated flat-panel CT imaging verified the catheter\u0026rsquo;s placement. With the patient under general anesthesia, the ablation probe was connected to the MRgLITT workstation in the MRI suite. Baseline thermometry images were acquired, and six safety zones were delineated to monitor temperatures during ablation. Using a stepwise approach, thermal energy was delivered at 1.0 W, 1.5 W, and 2.0 W, each for 2 minutes, with intervals for tissue cooling. Real-time heat maps guided the creation of a spherical ablation zone approximately 5 mm in diameter, ensuring complete lesioning of the spinothalamic tract (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Automatic safety cutoffs prevented overheating, and post-ablation imaging confirmed a well-defined lesion without damage to adjacent structures (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Postoperatively, the patient experienced significant pain relief, with VAS scores decreasing from \u0026gt;\u0026thinsp;7 to \u0026lt;\u0026thinsp;3. Temperature sensation was specifically assessed using a ice tube and a warm stimulus applied to symmetric body regions. No deficits in thermal perception were observed, indicating preserved sensory discrimination postoperatively. Opioid and adjunctive medications were substantially reduced, and no neurological deficits were observed. Unfortunately, the patient succumbed to cancer progression one month later.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case highlights the potential of MRgLITT mesencephalotomy in managing intractable malignant pain. Compared to historical techniques, MRgLITT provides real-time imaging guidance and precise lesioning with minimal invasiveness\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Its safety profile and efficacy in reducing pain align with findings in prior literature on lesioning procedures. Alternatives such as cordotomy, total myelotomy, intrathecal baclofen, and deep brain stimulation were deemed unsuitable due to the pain\u0026rsquo;s location, systemic side effects, or hardware-related risks\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. MRgLITT\u0026rsquo;s ability to target specific pain pathways without systemic effects makes it ideal for localized, refractory pain. This case supports the need for a multidisciplinary approach to patient selection and individualized treatment planning\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Future studies should evaluate long-term outcomes and broader applications of this technique.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMRgLITT mesencephalotomy represents a promising, minimally invasive option for managing intractable pain in palliative care settings. This case underscores its potential to improve quality of life in patients with refractory pain due to malignancy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed equally to the research project conception, organization, and execution; M.A writing the first draft and was responsible for the decision to submit the manuscript. JM.C, M.O, JP.A, C.J, C.D and ML contributed to manuscript review and critique. All authors have seen and approved of the final text.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e: Not Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent of publication\u003c/strong\u003e: Written consent was obtained by the patient for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIvanishvili Z, Pujara S, Honey CM, Chang S, Honey CR (2016) Stereotactic mesencephalotomy for palliative care pain control: A case report, literature review and plea to rediscover this operation. Br J Neurosurg 30(4):444\u0026ndash;447. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/02688697.2015.1133805\u003c/span\u003e\u003cspan address=\"10.3109/02688697.2015.1133805\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarques RAS, Alencar HS, Bannach MA, Vilela-Filho O (2022) Semidirect targeting-based stereotactic mesencephalotomy for the treatment of refractory pain: a case series. J Neurosurg 136(4):1128\u0026ndash;1138. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2021.6.JNS21709\u003c/span\u003e\u003cspan address=\"10.3171/2021.6.JNS21709\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurtagh F, Wycis HT, Spiegel EA (1951) Relief of thalamic pain by mesencephalotomy. AMA Arch Neurol Psychiatry 65(2):255\u0026ndash;257\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSola RG, Pulido P (2022) Neurosurgical Treatment of Pain. Brain Sci 12(11):1584. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/brainsci12111584\u003c/span\u003e\u003cspan address=\"10.3390/brainsci12111584\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiaz R, Ivan ME, Hanft S et al (2016) Laser Interstitial Thermal Therapy: Lighting the Way to a New Treatment Option in Neurosurgery. 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Lancet Neurol 22(7):619\u0026ndash;631. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S1474-4422(23)00129-1\u003c/span\u003e\u003cspan address=\"10.1016/S1474-4422(23)00129-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"mesencephalotomy, Laser Interstitial Thermal Therapy, MRI, pain, melanoma, cancer","lastPublishedDoi":"10.21203/rs.3.rs-5911997/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5911997/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eStereotactic mesencephalotomy is a neurosurgical technique designed to sever spinothalamic pain transmission pathways for medically intractable pain. This report presents the first case of Magnetic Resonance-guided Laser Interstitial Thermal Therapy (MRgLITT) mesencephalotomy for severe malignant pain due to metastatic melanoma. The procedure significantly reduced the patient\u0026rsquo;s pain, with a postoperative visual analog scale (VAS) score decreasing from \u0026gt;\u0026thinsp;7 to \u0026lt;\u0026thinsp;3. No adverse effects were observed. The case underscores the potential of MRgLITT mesencephalotomy as a precise, minimally invasive option for pain management in palliative care settings.\u003c/p\u003e","manuscriptTitle":"MR-Guided Laser Interstitial Thermal Therapy Mesencephalotomy for Medically Intractable Malignant Pain","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 06:32:40","doi":"10.21203/rs.3.rs-5911997/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-04-23T07:42:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-23T07:34:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313243120358810661662703178783967331520","date":"2025-04-23T07:30:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-17T11:05:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-17T06:47:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"Acta Neurochirurgica","date":"2025-04-10T09:09:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"627e130f-09c4-43f9-ba6e-6098faaa3d36","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-05T16:00:37+00:00","versionOfRecord":{"articleIdentity":"rs-5911997","link":"https://doi.org/10.1007/s00701-025-06544-1","journal":{"identity":"acta-neurochirurgica","isVorOnly":false,"title":"Acta Neurochirurgica"},"publishedOn":"2025-05-02 15:56:54","publishedOnDateReadable":"May 2nd, 2025"},"versionCreatedAt":"2025-04-21 06:32:40","video":"","vorDoi":"10.1007/s00701-025-06544-1","vorDoiUrl":"https://doi.org/10.1007/s00701-025-06544-1","workflowStages":[]},"version":"v1","identity":"rs-5911997","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5911997","identity":"rs-5911997","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}