Relative to control subjects, both peripheral and central pain patients showed significant opioid receptor binding decreases in a number of regions. In thecentral post-stroke pain (CPSP) group binding decrease was clearly asymmetrical (Fig. 2A) and predominated in the hemisphere contralateral to pain in the lateral prefrontal cortex, the insula, medial thalamus, posterior temporal cortex and posterior midbrain.

The only region with strictly bilateral BP decrease in CPSP patients was the anterior cingulate, in particular its perigenual region.

In contrast, the peripheral peripheral neuropathic pain (NP) group showed bilateral and symmetrical decrease in binding which concerned the insula, thalamus (mainly medial), anterior cingulate, posterior temporal and orbitofrontal cortices, posterior midbrain and striatum (Fig. 2B). No region with binding increase was noted in patients relative to controls. ^[1]

Fig. 2. Statistical parametric significance map showing sagittal, coronal and axial projections of structures with reduced opioid binding in patients relative to matched controls: Reduction in the CPSP group was asymmetrical and lateralised to the hemisphere contralateral to pain (A), while in the peripheral NP group (B) binding decrease was symmetrical. 

Dit is een belangrijke bouwsteen in het leren begrijpen waarom neuropathische pijn zo lastig te behandelen is, en soms vrijwel niet reageert op opiaten. 

Centrale diaschisis kan vaker gevonden worden bij pijnsyndrromen, zoals bij stroke patienten met conplexe regionale pijnsyndromen. ^[2] 

De geschiedenis van het diaschisis concept is door de Nederlandse neuroloog Koehler mooi beschreven. ^[3] Hij schreef daarover:

In Von Monakow’s words: “Diaschisis thus represents a ‘shut- down ofservices’, usually ofsudden onset, concerning certain widebranched central functional circuits, originating from a local le- sion. Its points of impact are not distributed through the whole cortex (as in apoplectic shock – in the corona radiata, etc) but only in places where fibres flowing out from the area ofthe lesion finally run into the primarily undamaged grey matter ofthe whole central nervous system”.He applied the term diaschisis to mark the “separation in single parts by elimination of a directing connective link”in the “local battle for the maintenance of function” to be restored.

One ofthe areas in which the the- ory can be demonstrated is aphasia. Henry Head,who visited Von Monakow in 1922, compared it with Hughlings Jackson’s principle of evolution and dissolution. Interestingly,Von Monakow was ignorant of the latter’s work with this respect. Like Jackson and Head, Von Monakow should be understood as an author with a cautiously holistic view with regard to cerebral locali- sation. 

Literatuur over Von Monakow 

1. Monakow C von (1909) Über den äusseren und den inneren “Fussrand reflex”.Neurol Centralbl 28:671 2. Monakow C von (1897) Gehirn- pathologie.Wien,Hölder 3. Monakow C von (1914) Die Lokalisa- tion im Grosshirn und der Abbau der Funktion durch kortikale Herde.Wies- baden,Bergmann 4. Monakow C von (1950) Gefühl,Gesit- tung und Gehirn.Zurich,Morgarten 5. Koehler PJ,Jagella C (in press) [The correspondence between Winkler and Von Monakow.1.Personal affairs and visions].Ned Tijdschr Geneesk 6. Koehler PJ,Jagella C (in press) [The correspondence between Winkler and Von Monakow.2.Evolution ofpsychia- try and neurology (1900–1930)] Ned Tijdschr Geneesk 7. Winkler C (1923) In:Monakow C von: Festschrift zu seinem 70.Geburtstag von Freunden,Mitarbeitern und Schülern gewidmet.Schweiz Arch Neu- rol Psych Band XIII,Heft 1 & 2,Zürich, Orell Füssli 8. Monakow C von (1905) Gehirn- pathologie.2nd edition,Wien,Hölder 9. Jagella C,Isler H,Hess K (1994) 100 Jahre Neurologie an der Universität Zürich 1894 bis 1994.Constantin von Monakow (1853 bis 1930) Hirn- forscher,Neurologe,Psychiater, Denker.Schweiz Arch Neurol Psych 145 (Suppl.1) 10. Koehler PJ,Jagella C,Isler H (1995) Zur Rezeption Von Monakows Werk. Schweiz Zeitschr Neurol Psychiatrie 145 (Suppl 1):31–39 

Auteurs: Prof.dr. Jan M. Keppel Hesselink, MD, PhD en Drs David J. Kopsky, MD, versie januari 2009   

Referenties