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Trimboli M, Troisi L, Caricato A, Della Marca G, Pennisi MA. Acute confusional state in HaNDL syndrome. Neurol Sci 2023; 44:3017-3028. [PMID: 37010670 DOI: 10.1007/s10072-023-06788-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/27/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE To assess epidemiological, clinical and neuroimaging features of acute confusional state in the Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis (HaNDL) syndrome. BACKGROUND HaNDL is an increasingly recognized syndrome in which migraine-like headache episodes accompanied by hemiparaesthesia and/or hemiparesis and/or dysphasia are associated to CSF lymphocytic pleocytosis. The International Classification of Headache Disorders (ICHD-3) includes HaNDL syndrome in group 7 "headache attributed to non-vascular intracranial disorder" code 7.3.5, and lists the HaNDL-associated signs/symptoms that may be found less frequently. Confusional state is not mentioned in the 7.3.5-ICHD-3 "notes" or "comments" section as part of the HaNDL neurological spectrum. Moreover, the acute confusional state pathogenesis in HaNDL syndrome remains still uncertain and debated. METHODS Here, we report a 32-year-old male who complained episodes of migraine-like headache and left hemiparaesthesia complicated by confusional state which led to discovering CSF lymphocytosis. Since other workup to determine the cause of his symptoms was otherwise negative, he was diagnosed as having HaNDL syndrome. We also ascertained and reviewed all available reports of HaNDL to assess the significance of confusional state in this syndrome. RESULTS The search yielded 159 HaNDL cases among single reports and small/large series. Out of 159 patients who fulfilled the inclusion criteria for HaNDL according to the current ICHD at the time of diagnosis, 41 (25.7%) presented with acute confusional state. Among 41 HaNDL patients with confusional state, 16 (66.6%) out of 24 who underwent spinal tap had increased opening pressure. CONCLUSION We propose that a mention of acute confusional state may be included in the "comments" section of "7.3.5-syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL)," when ICHD-3 diagnostic criteria will be updated. Moreover, we speculate that intracranial hypertension may play a role in the pathogenesis of the acute confusional state associated to HaNDL syndrome. Larger case series are needed to evaluate this hypothesis.
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Affiliation(s)
- Michele Trimboli
- Institute of Neurology, AOU Mater Domini, Magna Graecia University, Catanzaro, Italy.
| | - Letizia Troisi
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care, IRCCS, A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Giacomo Della Marca
- Department of Neuroscience, IRCCS, A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Anesthesia and Critical Care, IRCCS, A. Gemelli University Polyclinic Foundation, Rome, Italy
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Fernández-Rodríguez P, Lojo-Ramírez JA, Medina Rodríguez M, Jiménez-Hoyuela García JM, García-Solís D. Differential diagnosis of HaNDL syndrome in a case report of a pediatric patient: The role of SPECT with 99mTc-HMPAO. eNeurologicalSci 2020; 19:100240. [PMID: 32368627 PMCID: PMC7184255 DOI: 10.1016/j.ensci.2020.100240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/18/2020] [Accepted: 04/21/2020] [Indexed: 11/21/2022] Open
Abstract
•HaNDL syndrome may be a condition probably underdiagnosed in pediatric age.•A differential diagnosis with viral, vascular or autoimmune etiology is necessary.•Epileptiform alterations in EEG could be possible in this infrequent syndrome.•99mTc-HMPAO SPECT provides a potential role in the differential diagnostic and management.
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Affiliation(s)
| | | | | | | | - David García-Solís
- Department of Nuclear Medicine, Virgen del Rocío University Hospital, Seville, Spain
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Hidalgo de la Cruz M, Domínguez Rubio R, Luque Buzo E, Díaz Otero F, Vázquez Alén P, Orcajo Rincón J, Prieto Montalvo J, Contreras Chicote A, Grandas Pérez F. Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) in a patient with confusional symptoms, diffuse EEG abnormalities, and bilateral vasospasm in transcranial Doppler ultrasound: A case report and literature review. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
Transient disturbances in neurologic function are disturbing features of migraine attacks. Aura types include binocular visual, hemi-sensory, language and unilateral motor symptoms. Because of the gradual spreading quality of visual and sensory symptoms, they were thought to arise from the cerebral cortex. Motor symptoms previously included as a type of migraine aura were reclassified as a component of hemiplegic migraine. ICHD-3 criteria of the International Headache Society, added brainstem aura and retinal aura as separate subtypes. The susceptibility to all types of aura is likely to be included by complex and perhaps epigenetic factors.
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Affiliation(s)
- Rod Foroozan
- Baylor College of Medicine, 6565 Fannin NC-205, Houston, TX 77030, USA.
| | - F Michael Cutrer
- Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA
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Hidalgo de la Cruz M, Domínguez Rubio R, Luque Buzo E, Díaz Otero F, Vázquez Alén P, Orcajo Rincón J, Prieto Montalvo J, Contreras Chicote A, Grandas Pérez F. Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) in a patient with confusional symptoms, diffuse EEG abnormalities, and bilateral vasospasm in transcranial Doppler ultrasound: A case report and literature review. Neurologia 2017; 34:536-542. [PMID: 28427768 DOI: 10.1016/j.nrl.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/18/2017] [Accepted: 02/05/2017] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION HaNDL syndrome (transient headache and neurological deficits with cerebrospinal fluid lymphocytosis) is characterised by one or more episodes of headache and transient neurological deficits associated with cerebrospinal fluid lymphocytosis. To date, few cases of HaNDL manifesting with confusional symptoms have been described. Likewise, very few patients with HaNDL and confusional symptoms have been evaluated with transcranial Doppler ultrasound (TCD). TCD data from patients with focal involvement reveal changes consistent with vasomotor alterations. DEVELOPMENT We present the case of a 42-year-old man who experienced headache and confusional symptoms and displayed pleocytosis, diffuse slow activity on EEG, increased blood flow velocity in both middle cerebral arteries on TCD, and single-photon emission computed tomography (SPECT) findings suggestive of diffuse involvement, especially in the left hemisphere. CONCLUSIONS To our knowledge, this is the first description of a patient with HaNDL, confusional symptoms, diffuse slow activity on EEG, and increased blood flow velocity in TCD. Our findings suggest a relationship between cerebral vasomotor changes and the pathophysiology of HaNDL. TCD may be a useful tool for early diagnosis of HaNDL.
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Affiliation(s)
- M Hidalgo de la Cruz
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - R Domínguez Rubio
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - E Luque Buzo
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - F Díaz Otero
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - P Vázquez Alén
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J Orcajo Rincón
- Servicio de Radiodiagnóstico, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J Prieto Montalvo
- Servicio de Neurofisiología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - A Contreras Chicote
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - F Grandas Pérez
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
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Shibata M, Suzuki N. Exploring the role of microglia in cortical spreading depression in neurological disease. J Cereb Blood Flow Metab 2017; 37:1182-1191. [PMID: 28155572 PMCID: PMC5414895 DOI: 10.1177/0271678x17690537] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Microglia play a pivotal role in innate immunity in the brain. During development, they mature from myeloerythroid progenitor cells in the yolk sac and colonize the brain to establish a resident population of tissue macrophages. In the postnatal brain, they exert phagocytosis and induce inflammatory response against invading pathogens. Microglia also act as guardians of brain homeostasis by surveying the microenvironment using motile processes. Cortical spreading depression (CSD) is a slowly propagating (2-5 mm/min) wave of rapid, near-complete depolarization of neurons and astrocytes followed by a period of electrical suppression of a distinct population of cortical neurons. Not only has CSD been implicated in brain migraine aura, but CSD-like events have also been detected in stroke and traumatic injury. CSD causes a considerable perturbation of the ionic environment in the brain, which may be readily detected by microglia. Although CSD is known to activate microglia, the role of microglial activation in CSD-related neurological disorders remains poorly understood. In this article, we first provide an overview of microglial development and the multiple functions of microglia. Then, we review existing data on the relationship between microglia and CSD and discuss the relevance of CSD-induced microglial activation in neurological disease.
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Affiliation(s)
- Mamoru Shibata
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Norihiro Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
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Fumal A, Vandenheede M, Coppola G, Di Clemente L, Jacquart J, Gérard P, de Noordhout AM, Schoenen J. The Syndrome of Transient Headache with Neurological Deficits and CSF Lymphocytosis (HaNDL): Electrophysiological Findings Suggesting a Migrainous Pathophysiology. Cephalalgia 2016; 25:754-8. [PMID: 16109060 DOI: 10.1111/j.1468-2982.2004.00945.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- A Fumal
- Department of Neurology, University of Liege, Liege, Belgium
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Confusional State in HaNDL Syndrome: Case Report and Literature Review. Case Rep Neurol Med 2013; 2013:317685. [PMID: 23991343 PMCID: PMC3749557 DOI: 10.1155/2013/317685] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 07/18/2013] [Indexed: 11/18/2022] Open
Abstract
The syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL syndrome) is a self-limited condition. Confusional states are uncommonly reported as a clinical manifestation of this syndrome. Here, I report a 76-year-old female who presented with headache, confusion, and agitation with a mild CSF lymphocytosis. Other workup to determine the cause of her altered mental status was otherwise negative. The literature available in the English language on HaNDL syndrome is reviewed, including its history, pathophysiology, possible associations with migraine and stroke, and previously reported cases of confusional states in this syndrome. While HaNDL syndrome has been a described entity since the 1980s, its pathophysiology has yet to be clearly defined.
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Çoban A, Shugaiv E, Tüzün E. Syndrome of Headache Accompanied with Transient Neurologic Deficits and Cerebrospinal Fluid Lymphocytosis. Noro Psikiyatr Ars 2013; 50:S52-S55. [PMID: 28360585 DOI: 10.4274/npa.y7228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 06/07/2013] [Indexed: 12/01/2022] Open
Abstract
The syndrome of headache accompanied with transient neurologic deficits and cerebrospinal fluid lymphocytosis (HaNDL), is a rare, benign and self limiting syndrome. In the 2nd Edition of the International Classification of Headache Disorders, HaNDL syndrome was defined in secondary headache group as "Headache attributed to non-vascular intracranial disorder". The etiology of HaNDL is still unknown. In recent years, some authors have shown that ion channel autoimmunity might at least partially contribute to HaNDL pathogenesis. In this paper, the definition of HaNDL syndrome, clinical picture and epidemiology of HaNDL syndrome, etiopathogenesis, differential diagnosis and treatment will be reviewed with the recent literature.
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Affiliation(s)
- Arzu Çoban
- İstanbul University Istanbul Medical Faculty, Department of Neurology, İstanbul, Turkey
| | - Erkingül Shugaiv
- İstanbul University Istanbul Medical Faculty, Department of Neurology, İstanbul, Turkey
| | - Erdem Tüzün
- İstanbul University Experimental Research Institute (DETAE), Department of Neuroscience, İstanbul, Turkey
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Tsang BKT, Kwong JC, Dewey HM. Case of syndrome of headache with neurological deficits and cerebrospinal fluid lymphocytosis (HaNDL) with focal slowing on electroencephalogram. Intern Med J 2012; 42:944-7. [DOI: 10.1111/j.1445-5994.2012.02856.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Diffusion restriction in the splenium of the corpus callosum in a patient with the syndrome of transient headache with neurological deficits and CSF lymphocytosis (HaNDL): a challenge to the diagnostic criteria? Acta Neurol Belg 2012; 112:67-9. [PMID: 22427293 DOI: 10.1007/s13760-012-0018-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Accepted: 08/28/2011] [Indexed: 10/14/2022]
Abstract
The diagnosis of transient headache with neurological deficits and CSF lymphocytosis (HaNDL) is essentially based on the clinical and CSF findings, and the absence of MRI abnormalities. We present a young man with the clinical characteristics of HaNDL, but also an area of diffusion restriction in the splenium of the corpus callosum (SCC). When considering the limited experience with this MRI technique in this disorder, we wonder if a normal MRI can be maintained as an indispensable criterion for diagnosis. Similar MRI abnormalities limited to the SCC have been found in mild forms of meningoencephalitis, but their origin remains obscure. In at least some cases not only a clinical, but also a radiological overlap could exist between both disorders.
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Abstract
Recurrent episodes of transient focal neurologic symptoms, known as aura, occur in association with migraine headache in about 11.9 million people in the United States. At present, the International Headache Society has recognized 3 "typical" auras: visual, sensory, and language. Increasing evidence from investigations in human subjects suggests that typical auras may be the clinical manifestation of a cortical spreading depression (CSD)-like phenomenon. Other studies have shown altered reactivity and processing within the cortices of migraineurs who experience an aura, which might render them more vulnerable to CSD-like events. Recent investigations also support the hypothesis that events intrinsic to the cerebral cortex are capable of activating trigeminal nociceptive neurons and of affecting the caliber of vascular structures innervated by them. A better understanding of the mechanisms underlying the aura may potentially lead to more effective therapies, which will aim at preventing migraine headaches before they start.
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Affiliation(s)
- F Michael Cutrer
- Department of Neurology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Abstract
Pseudomigraine with temporary neurologic symptoms and lymphocytic pleocytosis is a self-limited syndrome of unknown origin characterized by headache accompanied by transient neurologic symptoms and cerebrospinal fluid lymphocytosis. Patients with this condition are between 15 and 40 years of age. The syndrome is more frequent in men. The clinical picture encompasses one to 12 episodes of changing variable neurologic deficits accompanied by moderate to severe headache and occasional fever. These headaches are described as predominantly throbbing and bilateral with a variable duration (mean, 19 hours). The average duration of the transient neurologic deficit is 5 hours. Sensory (78% episodes), aphasic (66%), and motor (56%) disturbances are the most common. Migraine-like visual symptoms are relatively rare (18% episodes). Patients are asymptomatic between episodes and after the symptomatic period (duration > 3 months). Lymphocytic pleocytosis (10 to 760 cells mm(3)) and increased cerebrospinal fluid protein are found with negative bacteriologic, viral, fungal, and immunologic studies. Brain computed tomography and magnetic resonance imaging are normal, but an electroencephalogram frequently shows focal slowing over the symptomatic brain area. Single photon emission computed tomography reveals transient focal areas of decreased uptake consistent with the clinical symptoms. It is possible that pseudomigraine with temporary neurologic symptoms and lymphocytic pleocytosis could result from an activation of the immune system secondary to a recent viral infection, which would produce antibodies against neuronal or vascular antigens. This autoimmune attack may induce an aseptic leptomeningeal vasculitis, accounting for the headache and the transient symptoms likely through a spreading depression-like mechanism.
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Affiliation(s)
- Julio Pascual
- Service of Neurology, University Hospital Marqués de Valdecilla (UC), 39008 Santander, Spain.
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