1076 Personalized Percutaneous Network Mapping Enables Acute Relief of Refractory Chronic Facial Pain

INTRODUCTION: Chronic facial pain poses a significant burden, with limited effective treatments for refractory cases. Deep brain stimulation (DBS) has shown promise, but response rates are heterogeneous, and long-term pain relief is often not achieved. We considered that personalized network mapping using intracranial stimulation may improve outcomes. METHODS: As part of an institutional innovative care trial, we enrolled our first patient with refractory right-sided atypical facial pain and left-sided anesthesia dolorosa for multisite intracranial monitoring and stimulation. Sixteen depth leads were placed percutaneously with robotic guidance, targeting affective, sensory-motor, and nociceptive regions. All consecutive electrode pairs were surveyed and candidates sites validated for pain relief. We performed 430 naturalistic (provocation induced using naturalistic stimuli) and temporally-precise assessments of pain unpleasantness and intensity over 5 inpatient days. RESULTS: Rapid bipolar stimulations were surveyed across 124 non-overlapping sites, identifying sensory changes in 55%, affective changes in 6%, and pain modifying changes in 15% of sites. Validation of candidate sites resulted in 26 distinct anatomical targets, including known (paraventricular gray matter, anterior cingulate, face motor cortex, sensory thalamus) and novel (anterior and posterior insula, caudate, inferior fronto-occipital fasciculus) sites providing pain relief. Right-sided stimulation achieved a mean pain relief of 34% for left anesthesia dolorosa from baseline (n=21, p<0.001, paired t-test) and 54% from provoked maximal pain (n=8, p<0.001). Left-sided stimulation achieved a mean pain relief of 39% for right atypical facial pain from baseline (n=23, p<0.001) and 39% from provoked maximal pain (n=9, p=0.002). Sham stimulation failed to provide significant relief (7% reduction, n=7, p=0.34). Pain alleviation was rapid in onset and reproducible. CONCLUSIONS: These findings demonstrate the feasibility of rapid, percutaneous, multisite brain mapping to identify therapeutic targets and potentially guide personalized DBS for chronic pain.