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De Lucia F, Boucquey D, Coolen T. A stroke mimic with left-hemispheric leptomeningeal vessel paucity and hypoperfusion. Radiol Case Rep 2023; 18:3438-3441. [PMID: 37502472 PMCID: PMC10369385 DOI: 10.1016/j.radcr.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023] Open
Abstract
In the neuroimaging workup of a suspected ischemic stroke, the involvement of more than one arterial territory without an anatomical substrate should raise the suspicion of a stroke mimic. We report the case of a 61-year-old male with a new-onset headache and transient phasic disturbances who presented a pattern of vascular abnormalities characterized by left-hemispheric leptomeningeal vessel paucity and hypoperfusion.
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Affiliation(s)
- Federico De Lucia
- Department of Radiology, Centre Hospitalier Interrégional Edith Cavell (CHIREC), Site Delta, Brussels, Belgium
| | - Dominique Boucquey
- Department of Neurology, Centre Hospitalier Interrégional Edith Cavell (CHIREC), Site Delta, Brussels, Belgium
| | - Tim Coolen
- Department of Radiology, Centre Hospitalier Interrégional Edith Cavell (CHIREC), Site Delta, Brussels, Belgium
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2
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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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3
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Kizilkilic EK, Kılboz BB, Ucler S. Syndrome of Transient Headache and Neurological Deficits with Cerebrospinal Fluid Lymphocytosis (HaNDL): A Case Report - Is there an Association with the COVID-19 Vaccine? Ann Indian Acad Neurol 2023; 26:310-312. [PMID: 37538407 PMCID: PMC10394446 DOI: 10.4103/aian.aian_1002_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/02/2023] [Accepted: 01/31/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Esra Kochan Kizilkilic
- Department of Neurology, University of Health Sciences, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
| | - Bekir Burak Kılboz
- Department of Neurology, University of Health Sciences, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
| | - Serap Ucler
- Department of Neurology, University of Health Sciences, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
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Al-Chalabi M, Hegde P, Asghar F, Aladamat N, Delcimmuto N, Gharaibeh K, Samara M, Esengul Y, Mahfooz N, Sheikh A. Transient headache and neurological deficits with cerebrospinal fluid lymphocytosis syndrome: A comprehensive systematic review of 93 patients from 57 studies. Cephalalgia 2023; 43:3331024231157694. [PMID: 36856002 DOI: 10.1177/03331024231157694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Headache with neurologic deficits and cerebrospinal fluid lymphocytosis, previously also termed pseudomigraine with temporary neurologic symptoms and lymphocytic pleocytosis, is a self-limiting syndrome characterized by moderate to severe headache associated with focal neurological deficits occurring in the context of lymphocytosis in the cerebrospinal fluid. As a consequence of its rarity, data regarding headache with neurologic deficits and cerebrospinal fluid lymphocytosis is sparse. Therefore, we conducted this review to analyze data related to 93 patients of headache with neurologic deficits and cerebrospinal fluid lymphocytosis, to characterize their demographics, clinical manifestations, investigations and treatment options. METHODS We performed a systematic review of cases reported through PubMed and Google scholar database, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Keywords used were 'Headache with Neurologic Deficits and cerebrospinal fluid lymphocytosis', 'Headache with neurologic deficits and cerebrospinal fluid lymphocytosis syndrome'. The quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal Tool. RESULTS We analyzed a total of 93 cases of headache with neurologic deficits and cerebrospinal fluid lymphocytosis with a mean age of 28.8 years at onset. Seventy patients (75.2%) were adults, while 23 (24.7%) belonged to the pediatric age group. Comparing these groups, mean age at onset was 32.5 years and 14.3 years, respectively. The average duration of follow-up was 11.08 months. Thirty percent of patients experienced relapsing episodes of headache with neurologic deficits and cerebrospinal fluid lymphocytosis symptoms. The most common type of headache reported was unilateral severe throbbing episodic headache. Other associated symptoms included sensory deficit (60%) and motor deficits (54.8%). The least common symptoms were nystagmus and agraphia, which were reported in one patient each. Antiviral agents were a common treatment option in the acute phase (n = 23 patients [23.6%]), while Flunarizine was the most commonly used agent in the chronic setting (n = 3 patients [3.2%]). While most of the patients had normal brain magnetic resonance imaging, 20 patients had magnetic resonance imaging abnormalities, including (but not limited to) non-specific white matter lesions (eight patients) and meningeal enhancement (six patients). The most common electroencephalographic findings included diffuse and focal slowing. The mean cerebrospinal fluid opening-pressure was 240.5 mmH2O. Cerebrospinal fluid protein was elevated in 59 (63.4%) patients, with a mean value of 114 mg/dL. Two patients in our cohort were found to have cerebrospinal fluid oligoclonal bands. CONCLUSION Headache with neurologic deficits and cerebrospinal fluid lymphocytosis tends to affect young individuals with a slight male predominance. Unilateral severe throbbing episodic headache with associated hemi-paresthesia and hemiparesis were the most common symptoms based on our review. Elevated cerebrospinal fluid opening-pressure can be seen in headache with neurologic deficits and cerebrospinal fluid lymphocytosis syndrome. Early recognition of the syndrome is paramount. Antivirals were found to be among the most widely used treatments in the acute setting. Magnetic resonance imaging of the brain is mostly normal. Diffuse and focal slowing were among the most common electroencephalographic findings. Cerebral flow abnormalities on perfusion scans are not uncommon in headache with neurologic deficits and cerebrospinal fluid lymphocytosis. Prospective studies with a larger sample size are needed to validate our findings and guide the clinical care of these patients.
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Affiliation(s)
| | - Prajwal Hegde
- College of Medicine and Life Sciences, University of Toledo, OH, USA
| | - Fahham Asghar
- Department of Neurology, University of Toledo, Toledo, OH, USA
| | - Nameer Aladamat
- Department of Neurology, University of Toledo, Toledo, OH, USA
| | | | | | - Mohammad Samara
- Department of Neurology, University of Toledo, Toledo, OH, USA
| | - Yasar Esengul
- Department of Neurology, University of Toledo, Toledo, OH, USA
| | - Naeem Mahfooz
- Department of Neurology, University of Toledo, Toledo, OH, USA.,College of Medicine and Life Sciences, University of Toledo, OH, USA
| | - Ajaz Sheikh
- College of Medicine and Life Sciences, University of Toledo, OH, USA
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Khalili N, Wang R, Garg T, Ahmed A, Hoseinyazdi M, Sair HI, Luna LP, Intrapiromkul J, Deng F, Yedavalli V. Clinical application of brain perfusion imaging in detecting stroke mimics: A review. J Neuroimaging 2023; 33:44-57. [PMID: 36207276 DOI: 10.1111/jon.13061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 02/01/2023] Open
Abstract
Stroke mimics constitute a significant proportion of patients with suspected acute ischemic stroke. These conditions may resemble acute ischemic stroke and demonstrate abnormalities on perfusion imaging sequences. The most common stroke mimics include seizure/epilepsy, migraine with aura, brain tumors, functional disorders, infectious encephalopathies, Wernicke's encephalopathy, and metabolic abnormalities. Brain perfusion imaging techniques, particularly computed tomography perfusion and magnetic resonance perfusion, are being widely used in routine clinical practice for treatment selection in patients presenting with large vessel occlusion. At the same time, the utilization of these imaging modalities enables the opportunity to better diagnose patients with stroke mimics in a time-sensitive setting, leading to appropriate management, decision-making, and resource allocation. In this review, we describe patterns of perfusion abnormalities that could discriminate patients with stroke mimics from those with acute ischemic stroke and provide specific case examples to illustrate these perfusion abnormalities. In addition, we discuss the challenges associated with interpretation of perfusion images in stroke-related pathologies. In general, perfusion imaging can provide additional information in some cases-when used in combination with conventional magnetic resonance imaging and computed tomography-and might help in detecting stroke mimics among patients who present with acute onset focal neurological symptoms.
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Affiliation(s)
- Neda Khalili
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Richard Wang
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Tushar Garg
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Amara Ahmed
- Department of Radiology, Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Meisam Hoseinyazdi
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Haris I Sair
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Licia P Luna
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jarunee Intrapiromkul
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Francis Deng
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Alungulese AL, García Soldevilla MÁ, Izquierdo Esteban L, Jiménez Jurado MD, Gordo Mañas R. Index Vein in Headache and Neurologic Deficits With CSF Lymphocytosis. Neurol Clin Pract 2021; 11:e347-e349. [PMID: 34484910 DOI: 10.1212/cpj.0000000000001030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/19/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Anca Loredana Alungulese
- Department of Neurology (ALA, MÁGS, LIE, RGM), Principe de Asturias University Hospital; and Department of Radiology (MDJJ), Principe de Asturias University Hospital, Madrid, Spain
| | - Miguel Ángel García Soldevilla
- Department of Neurology (ALA, MÁGS, LIE, RGM), Principe de Asturias University Hospital; and Department of Radiology (MDJJ), Principe de Asturias University Hospital, Madrid, Spain
| | - Laura Izquierdo Esteban
- Department of Neurology (ALA, MÁGS, LIE, RGM), Principe de Asturias University Hospital; and Department of Radiology (MDJJ), Principe de Asturias University Hospital, Madrid, Spain
| | - María Dolores Jiménez Jurado
- Department of Neurology (ALA, MÁGS, LIE, RGM), Principe de Asturias University Hospital; and Department of Radiology (MDJJ), Principe de Asturias University Hospital, Madrid, Spain
| | - Ricardo Gordo Mañas
- Department of Neurology (ALA, MÁGS, LIE, RGM), Principe de Asturias University Hospital; and Department of Radiology (MDJJ), Principe de Asturias University Hospital, Madrid, Spain
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Gonzalez-Martinez A, Trillo S, Benavides-Bernaldo de Quirós C, Casado-Fernández L, De Toledo M, Barbosa-Del Olmo A, Vega Piris L, Ramos C, Manzanares-Soler R, Ximénez-Carrillo Á, Vivancos J. Predictors of perfusion computed tomography alterations in stroke mimics attended as stroke code. Eur J Neurol 2021; 28:1939-1948. [PMID: 33609295 DOI: 10.1111/ene.14783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Stroke mimics (SMs) account for a significant number of patients attended as stroke code (SC) with an increasing number over the years. Recent studies show perfusion computed tomography (PCT) alterations in some SMs, especially in seizures. The objective of our study was to evaluate the clinical characteristics and PCT alterations in SMs attended as SC in order to identify potential predictors of PCT alterations in SMs. METHODS A retrospective study was performed including all SC activations undergoing a multimodal CT study including non-enhanced computed tomography (CT), CT angiography and PCT, as part of our SC protocol, over 39 months. Patients with a final diagnosis of SM after complete diagnosis work-up were therefore selected. Clinical variables, diagnosis, PCT alteration patterns and type of map affected (Tmax or time to peak, cerebral blood flow and cerebral blood volume) were registered. RESULTS Stroke mimics represent up to 16% (284/1761) of SCs with a complete multimodal study according to our series. Amongst SMs, 26% (74/284) showed PCT alterations. PCT abnormalities are more prevalent in seizures and status epilepticus and the main pattern is alteration of the time to peak map, of unilateral hemispheric distribution or of non-vascular territory. In our series, the independent predictors of alteration in PCT in SMs are aphasia, female sex and older age. CONCLUSIONS Perfusion computed tomography alterations can be found amongst almost a third of SMs attended as SC, especially older women presenting with aphasia with a final diagnosis of epileptic seizures and status epilepticus.
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Affiliation(s)
- Alicia Gonzalez-Martinez
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - Santiago Trillo
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | | | - Laura Casado-Fernández
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - María De Toledo
- Epilepsy Unit, Department of Neurology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Antonio Barbosa-Del Olmo
- Neuroradiology Unit, Department of Radiology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Lorena Vega Piris
- Methodological Support Unit, Hospital Universitario de La Princesa, Madrid, Spain
| | - Carmen Ramos
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - Rafael Manzanares-Soler
- Neuroradiology Unit, Department of Radiology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Álvaro Ximénez-Carrillo
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - José Vivancos
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
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Salazar-Orellana JLI, Prado-Miranda G, Maldonado-Ortiz A. Agraphia: Presenting Feature of Syndrome of Transient Headache and Neurological Deficits With Cerebrospinal Fluid Lymphocytosis (HaNDL). Cureus 2021; 13:e13178. [PMID: 33717723 PMCID: PMC7941604 DOI: 10.7759/cureus.13178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We report a case of a 48-year-old man with a history of episodes of severe headache, accompanied by motor aphasia and agraphia, with complete recovery between episodes. The neurological examination revealed no abnormality. A lumbar puncture was performed and showed lymphocytic pleocytosis. Cerebrospinal fluid analysis ruled out viral, bacterial, mycobacterial, fungal, treponemal, and NMDA receptor antibodies. Brain magnetic resonance imaging and electroencephalogram revealed no abnormalities. A focal frontotemporal area of hypoperfusion was detected in brain single-photon emission tomography. A diagnosis of syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) was made to the patient and then treated with ibuprofen 400 mg three times per day with excellent response. He remained asymptomatic and free of any relapse during six months of following. We presented a typical case of HaNDL that manifests with agraphia, a transient focal neurological deficit non previously reported. Showing that the clinical picture could probably be any sign and symptom related to focal cortical alteration due to cortical transient hypoperfusion.
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Affiliation(s)
| | - Gala Prado-Miranda
- Department of Neurology, Hospital General de México Dr. Eduardo Liceaga, Mexico City, MEX
| | - Amelia Maldonado-Ortiz
- Department of Neurology, Hospital General de México Dr. Eduardo Liceaga, Mexico City, MEX
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9
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Silvestro M, Tessitore A, De Mase A, Cirillo M, Tedeschi G, Russo A. A 67‐Year‐Old Woman With Recurrent Headache, Migratory Focal Symptoms, and Impaired Consciousness. Headache 2020; 60:2622-2630. [DOI: 10.1111/head.13995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Marcello Silvestro
- Headache Center Department of Advanced Medical and Surgical Sciences University of Campania Luigi Vanvitelli Napoli Italy
| | - Alessandro Tessitore
- Headache Center Department of Advanced Medical and Surgical Sciences University of Campania Luigi Vanvitelli Napoli Italy
| | - Antonio De Mase
- Headache Center Department of Advanced Medical and Surgical Sciences University of Campania Luigi Vanvitelli Napoli Italy
| | - Mario Cirillo
- Headache Center Department of Advanced Medical and Surgical Sciences University of Campania Luigi Vanvitelli Napoli Italy
| | - Gioacchino Tedeschi
- Headache Center Department of Advanced Medical and Surgical Sciences University of Campania Luigi Vanvitelli Napoli Italy
| | - Antonio Russo
- Headache Center Department of Advanced Medical and Surgical Sciences University of Campania Luigi Vanvitelli Napoli Italy
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10
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Fernandes L, Cosgrove J. A Case of HaNDL Presenting With Papilledema. Headache 2020; 60:1196-1197. [DOI: 10.1111/head.13787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | - Jeremy Cosgrove
- Department of Neurology Leeds Teaching Hospitals NHS Trust Leeds UK
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11
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Smail RC, Baird-Gunning J, Drummond J, Ng K. A case report of a transient splenial lesion related to HaNDL syndrome. Cephalalgia 2020; 40:1119-1122. [PMID: 32443964 DOI: 10.1177/0333102420927023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Transient lesions in the splenium of the corpus callosum have been identified in many clinical cases, and often correspond to a metabolic insult to the brain. The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL syndrome) is a rare but under-recognised headache syndrome. CASE A 47-year-old man presented to our hospital with a 2-week history of intermittent headache, and acute right sided hemisensory deficit. A CSF lymphocytosis was found and a diagnosis of HaNDL was made. A lesion in the splenium of the corpus callosum was identified on MRI. CSF lymphocytosis and the splenial lesion resolved on follow up 4 weeks later. CONCLUSION These two entities are uncommon but increasingly recognised. The co-incidence in this patient raises the possibility of similar underlying pathological mechanisms, including vasomotor changes in blood vessels, cortical spreading depression and glutamate excitotoxicity leading to intra-myelinic oedema. Awareness of these entities will allow prompt diagnosis, preventing unnecessary tests and treatment, and allow appropriate patient management.
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Affiliation(s)
- Ruaridh Cameron Smail
- Department of Neurology and Neurophysiology, Royal North Shore Hospital, St Leonards, NSW, Australia.,Northern Clinical School, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Jonathan Baird-Gunning
- Department of Neurology and Neurophysiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - James Drummond
- Department of Neuroradiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Karl Ng
- Department of Neurology and Neurophysiology, Royal North Shore Hospital, St Leonards, NSW, Australia.,Northern Clinical School, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,Sydney Medical School, University of Sydney, NSW, Australia
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12
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Abstract
Headache and Neurologic Deficits with cerebrospinal fluid Lymphocytosis (HaNDL) syndrome is a rare stroke mimicker characterized by moderate to severe headache temporally associated with transient neurologic deficits, typically hemiparesis, hemisensory disturbance, and/or aphasia. Cerebrospinal fluid studies reveal a lymphocytosis and elevated protein. Episodes recur over a period no longer than 3 months. Here we describe the case of a 16-year-old boy who presented with 3 episodes of self-resolving neurologic deficits, papilledema on fundoscopic examination, and leptomeningeal enhancement on magnetic resonance imaging (MRI). We additionally review the 30 previously reported pediatric cases of HaNDL syndrome, with a focus on possible etiologic and pathophysiologic mechanisms of disease. The reported case and literature review highlight the benign episodic nature of this likely underrecognized syndrome as well as the higher than expected frequency of abnormal neuroimaging findings.
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Affiliation(s)
- Amy Armstrong-Javors
- 1 Department of Pediatric Neurology, Massachusetts General Hospital, Boston, MA, USA
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13
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Quintas S, López Ruiz R, Trillo S, Gago-Veiga AB, Zapata-Wainberg G, Dotor García-Soto J, Ximénez-Carrillo Á, Vivancos J. Clinical, imaging and electroencephalographic characterization of three cases of HaNDL syndrome. Cephalalgia 2017; 38:1402-1406. [DOI: 10.1177/0333102417735846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) may mimic stroke when patients present with acute/subacute focal neurological deficits. It would be helpful to identify investigations that assist the neurologist in differentiating between HaNDL and stroke. Case reports We describe three cases that proved to be HaNDL, but were initially considered to be strokes. Hypoperfusion was noted in the CT perfusion (CTP) studies in all three cases, which extended beyond any single cerebral arterial supply. The CTP findings suggested a stroke mimic, and there was no improvement on thrombolysis. MRI failed to show any abnormalities in diffusion and EEGs showed non-epileptiform changes. Lumbar punctures demonstrated a lymphocytic pleocytosis. Conclusion The diagnosis of HaNDL is based on clinical and CSF criteria, but neuroimaging, including CT perfusion, can be helpful in differentiating the clinical syndrome from stroke.
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Affiliation(s)
- Sonia Quintas
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Rocío López Ruiz
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Santiago Trillo
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Ana Beatriz Gago-Veiga
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Gustavo Zapata-Wainberg
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Julio Dotor García-Soto
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Álvaro Ximénez-Carrillo
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Jose Vivancos
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
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14
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Mulroy E, Yap J, Danesh-Meyer H, Anderson N. Symptomatic intracranial hypertension during recovery from the syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis (HANDL). Pract Neurol 2017; 17:145-148. [DOI: 10.1136/practneurol-2016-001539] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2017] [Indexed: 01/03/2023]
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