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Jokubaitis M, Lengvenis G, Burnytė B, Audronytė E, Ryliškienė K. Case report: Late onset type 3 hemiplegic migraine with permanent neurologic sequelae after attacks. Front Neurol 2024; 15:1359994. [PMID: 38405404 PMCID: PMC10884170 DOI: 10.3389/fneur.2024.1359994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/19/2024] [Indexed: 02/27/2024] Open
Abstract
This case study describes a 57-year-old woman with a six-year history of recurrent episodes characterized by visual, sensory, speech disturbances, hemiparesis and severe one-sided headaches accompanied by fever and altered consciousness. Initially misdiagnosed as a stroke, the atypical disease course and MRI findings led to additional genetic testing which revealed a sodium voltage-gated channel gene mutation (T1174S), confirming a diagnosis of sporadic hemiplegic migraine. The migraine prophylaxis showed some improvement in episode frequency and severity. Despite an initial improvement, the patient underwent severe cognitive decline and developed new permanent neurological symptoms during the subsequent 7 years of follow-up.
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Affiliation(s)
- Mantas Jokubaitis
- Center of Neurology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Givi Lengvenis
- Department of Radiology, Nuclear Medicine and Medical Physics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Birutė Burnytė
- Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Eglė Audronytė
- Center of Neurology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kristina Ryliškienė
- Center of Neurology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Moya-Mendez ME, Mueller DM, Pratt M, Bonner M, Elliott C, Hunanyan A, Kucera G, Bock C, Prange L, Jasien J, Keough K, Shashi V, McDonald M, Mikati MA. Early onset severe ATP1A2 epileptic encephalopathy: Clinical characteristics and underlying mutations. Epilepsy Behav 2021; 116:107732. [PMID: 33493807 PMCID: PMC7940561 DOI: 10.1016/j.yebeh.2020.107732] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/09/2020] [Accepted: 12/20/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND ATP1A2 mutations cause hemiplegic migraine with or without epilepsy or acute reversible encephalopathy. Typical onset is in adulthood or older childhood without subsequent severe long-term developmental impairments. AIM We aimed to describe the manifestations of early onset severe ATP1A2-related epileptic encephalopathy and its underlying mutations in a cohort of seven patients. METHODS A retrospective chart review of a cohort of seven patients was conducted. Response to open-label memantine therapy, used off-label due to its NMDA receptor antagonist effects, was assessed by the Global Rating Scale of Change (GRSC) and Clinical Global Impression Scale of Improvement (CGI-I) methodologies. Molecular modeling was performed using PyMol program. RESULTS Patients (age 2.5-20 years) had symptom onset at an early age (6 days-1 year). Seizures were either focal or generalized. Common features were: drug resistance, recurrent status epilepticus, etc., severe developmental delay with episodes of acute severe encephalopathy often with headaches, dystonias, hemiplegias, seizures, and developmental regression. All had variants predicted to be disease causing (p.Ile293Met, p.Glu1000Lys, c.1017+5G>A, p.Leu809Arg, and 3 patients with p.Met813Lys). Modeling revealed that mutations interfered with ATP1A2 ion binding and translocation sites. Memantine, given to five, was tolerated in all (mean treatment: 2.3 years, range 6 weeks-4.8 years) with some improvements reported in all five. CONCLUSIONS Our observations describe a distinctive clinical profile of seven unrelated probands with early onset severe ATP1A2-related epileptic encephalopathy, provide insights into structure-function relationships of ATP1A2 mutations, and support further studies of NMDAR antagonist therapy in ATP1A2-encephalopathy.
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Affiliation(s)
- Mary E. Moya-Mendez
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - David M. Mueller
- Center for Genetic Diseases, The Chicago Medical School, Rosalind Franklin University of Medicine and Science, Chicago, IL, United States
| | - Milton Pratt
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - Melanie Bonner
- Department of Psychiatry, Duke University, Durham, NC, United States
| | - Courtney Elliott
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - Arsen Hunanyan
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - Gary Kucera
- Duke Cancer Institute Rodent Cancer Models Shared Resource, Duke University Medical Center, Durham, NC, United States
| | - Cheryl Bock
- Duke Cancer Institute Rodent Cancer Models Shared Resource, Duke University Medical Center, Durham, NC, United States
| | - Lyndsey Prange
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - Joan Jasien
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - Karen Keough
- Dell Medical School at the University of Texas, Austin TX, United States
| | - Vandana Shashi
- Dell Medical School at the University of Texas, Austin TX, United States
| | - Marie McDonald
- Dell Medical School at the University of Texas, Austin TX, United States
| | - Mohamad A. Mikati
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States,Department of Neurobiology, Duke University, Durham, NC, United States,Corresponding Author: Mohamad Mikati, MD, Children Health Center, T913J, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, Phone: 919-668-4073, Fax: 919-681-8943,
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Drazyk AM, Tan RY, Tay J, Traylor M, Das T, Markus HS. Encephalopathy in a Large Cohort of British Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy Patients. Stroke 2019; 50:283-290. [PMID: 30636574 PMCID: PMC6358181 DOI: 10.1161/strokeaha.118.023661] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/27/2018] [Accepted: 12/11/2018] [Indexed: 01/03/2023]
Abstract
Background and Purpose- Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common monogenic form of stroke usually presenting with migraine with aura, lacunar infarcts, and cognitive impairment. Acute encephalopathy is a less recognized presentation of the disease. Methods- Data collected prospectively from 340 consecutively recruited symptomatic patients with diagnosis of CADASIL seen in a British National CADASIL clinic was retrospectively reviewed and original clinical records and imaging obtained. An encephalopathic event was defined as an acute event of an altered state of consciousness in a patient with CADASIL, manifesting with signs of brain dysfunction, which warranted hospital admission in the absence of any other cause. Clinical characteristics, risk factors, and outcome of encephalopathic presentations were studied. Results- A total of 35 of 340 (10.3%) participants had a history of 50 encephalopathic events which was the first hospital presentation of CADASIL in 33 (94.3%) patients. Most commonly reported features during episodes were visual hallucinations (44%), seizures (22%), and focal neurological deficits (60%).Complete recovery within 3 months was reported in 48(96%) episodes. In 62% of episodes, there was a history of migraine or migraine aura directly preceding the encephalopathy. In 2 out of 15 cases where magnetic resonance imaging during episodes was available, unilateral focal cortical swelling was seen. A past history of migraine was independently associated with encephalopathy (odds ratio=12.3 [95% CI, 1.6-93.7]; P=0.015). Conclusions- In up to 10% of CADASIL patients, a reversible encephalopathy is the first presentation leading to diagnosis. The strong association with migraine suggests a shared pathogenesis. Focal cortical swelling may be seen on magnetic resonance imaging during the acute episode.
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Affiliation(s)
- Anna M. Drazyk
- From the Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, United Kingdom (A.M.D., R.Y.Y.T., J.T., M.T., H.S.M.)
| | - Rhea Y.Y. Tan
- From the Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, United Kingdom (A.M.D., R.Y.Y.T., J.T., M.T., H.S.M.)
| | - Jonathan Tay
- From the Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, United Kingdom (A.M.D., R.Y.Y.T., J.T., M.T., H.S.M.)
| | - Matthew Traylor
- From the Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, United Kingdom (A.M.D., R.Y.Y.T., J.T., M.T., H.S.M.)
| | - Tilak Das
- Department of Radiology, Cambridge University Hospital NHS Foundation Trust, United Kingdom (T.D.)
| | - Hugh S. Markus
- From the Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, United Kingdom (A.M.D., R.Y.Y.T., J.T., M.T., H.S.M.)
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Multimodal imaging findings during severe attacks of familial hemiplegic migraine type 2. J Neurol Sci 2018; 392:22-27. [DOI: 10.1016/j.jns.2018.06.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/09/2018] [Accepted: 06/23/2018] [Indexed: 11/24/2022]
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Prasad M, Seal A, Mordekar SR. Fifteen-minute consultation: Approach to the child with an acute confusional state. Arch Dis Child Educ Pract Ed 2017; 102:72-77. [PMID: 27799152 DOI: 10.1136/archdischild-2016-311068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/06/2016] [Accepted: 10/04/2016] [Indexed: 12/19/2022]
Abstract
Acute confusional state (ACS) refers to sudden impairment of cognitive function and represents a major medical emergency. The impairment may be global or confined specifically to a particular faculty of higher mental function, such as memory. This review highlights the importance of relevant medical history and clinical signs and symptoms in reaching the correct diagnosis. In this review, we have presented a diagnostic approach to a child presenting with ACS and described commonly encountered causes, their treatments and outcomes. We have also presented an algorithm for the diagnostic approach to the child with ACS.
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Affiliation(s)
- Manish Prasad
- Paediatric Neurology Department, Queen's Medical Centre, Nottingham, UK
| | - Arnab Seal
- Children's Services, Wortley Beck Health Centre, Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Santosh R Mordekar
- Paediatric Neurology Department, Sheffield Children's NHS Foundation Trust, Ryegate Children's Centre, Sheffield, UK
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Cha YH, Millett D, Kane M, Jen J, Baloh R. Adult-Onset Hemiplegic Migraine with Cortical Enhancement and Oedema. Cephalalgia 2016; 27:1166-70. [PMID: 17645764 DOI: 10.1111/j.1468-2982.2007.01369.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We present genetically identical twin patients who experienced late-onset migraine with visual and somatosensory auras and later developed hemiplegic migraines associated with severe cortical oedema and enhancement. Both positron emission tomography and electroencephalography showed an increase in activity contralateral to the hemiplegic side. Brain biopsy during the attack showed reactive astrogliosis and microgliosis. Mutations in CACNA1A, ATP1A2, SLC1A3 and NOTCH3 were ruled out by sequencing. This report shows the clinical and genetic evaluation of a severe form of familial hemiplegic migraine as well as the evolution of the imaging changes.
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Affiliation(s)
- Y-H Cha
- Department of Neurology, University of California-Los Angeles, 710 Westwood Plaza, Los Angeles, CA 90095, USA.
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Pellacani S, Sicca F, Di Lorenzo C, Grieco GS, Valvo G, Cereda C, Rubegni A, Santorelli FM. The Revolution in Migraine Genetics: From Aching Channels Disorders to a Next-Generation Medicine. Front Cell Neurosci 2016; 10:156. [PMID: 27378853 PMCID: PMC4904011 DOI: 10.3389/fncel.2016.00156] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/30/2016] [Indexed: 12/14/2022] Open
Abstract
Channelopathies are a heterogeneous group of neurological disorders resulting from dysfunction of ion channels located in cell membranes and organelles. The clinical scenario is broad and symptoms such as generalized epilepsy (with or without fever), migraine (with or without aura), episodic ataxia and periodic muscle paralysis are some of the best known consequences of gain- or loss-of-function mutations in ion channels. We review the main clinical effects of ion channel mutations associated with a significant impact on migraine headache. Given the increasing and evolving use of genetic analysis in migraine research-greater emphasis is now placed on genetic markers of dysfunctional biological systems-we also show how novel information in rare monogenic forms of migraine might help to clarify the disease mechanisms in the general population of migraineurs. Next-generation sequencing (NGS) and more accurate and precise phenotyping strategies are expected to further increase understanding of migraine pathophysiology and genetics.
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Affiliation(s)
- Simona Pellacani
- Clinical Neurophysiology Laboratory, IRCCS Stella Maris FoundationPisa, Italy
| | - Federico Sicca
- Clinical Neurophysiology Laboratory, IRCCS Stella Maris FoundationPisa, Italy
- Molecular Medicine, IRCCS Stella Maris FoundationPisa, Italy
| | | | - Gaetano S. Grieco
- Genomic and Post-Genomic Center, C. Mondino National Institute of NeurologyPavia, Italy
| | - Giulia Valvo
- Clinical Neurophysiology Laboratory, IRCCS Stella Maris FoundationPisa, Italy
| | - Cristina Cereda
- Genomic and Post-Genomic Center, C. Mondino National Institute of NeurologyPavia, Italy
| | - Anna Rubegni
- Molecular Medicine, IRCCS Stella Maris FoundationPisa, Italy
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Tashiro Y, Yamazaki T, Nagamine S, Mizuno Y, Yoshiki A, Okamoto K. Repeated encephalopathy and hemicerebral atrophy in a patient with familial hemiplegic migraine type 1. Intern Med 2014; 53:2245-50. [PMID: 25274239 DOI: 10.2169/internalmedicine.53.0295] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein describe a case of a 38-year-old man with familial hemiplegic migraine with a T666M mutation in the electrical potential-dependent calcium ion channel (CACNA1A) gene. His migraine was accompanied by hemiparesis and impaired consciousness. Brain magnetic resonance imaging revealed abnormalities in the right cortical hemisphere. Single-photon emission computed tomography demonstrated a decrease in iomazenil uptake and an increase in (99m)Tc-ethyl cysteinate dimer uptake at the ipsilateral site. Positron emission tomography showed a decrease in 18F-fluorodeoxyglucose uptake in the same area, which later showed atrophic changes. The patient's brain atrophy ceased after treatment with sodium valproate. This case suggests that the progression of brain atrophy can be prevented with adequate prophylaxis.
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Affiliation(s)
- Yuichi Tashiro
- Department of Neurology, Gunma University Graduate School of Medicine, Japan
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Merwick A, Fernandez D, McNamara B, Harrington H. Acute encephalopathy in familial hemiplegic migraine with ATP1A2 mutation. BMJ Case Rep 2013; 2013:bcr-2013-009750. [PMID: 23761507 DOI: 10.1136/bcr-2013-009750] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Familial hemiplegic migraine is a rare subtype of migraine with aura which includes motor weakness. A 32-year-old woman with known familial hemiplegic migraine (point mutation in Exon 22 of the ATP1A2 gene) presented with an acute confusional state, after an initially typical migraine. On examination, she had fever (38°C), agitated, with a right hemiparesis and dysphasia. Electroencephalography showed slowing of α rhythm and continuous rhythmical δ activity in the left hemisphere. She recovered 48 h after the onset of encephalopathic episode. Electroencephalography after recovery showed resolution of the abnormal slowing of the α waveforms.
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Affiliation(s)
- Aine Merwick
- Neurology Department, National Hospital for Neurology and Neurosurgery, London, UK.
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Pelzer N, Stam AH, Haan J, Ferrari MD, Terwindt GM. Familial and sporadic hemiplegic migraine: diagnosis and treatment. Curr Treat Options Neurol 2013. [PMID: 23203776 DOI: 10.1007/s11940-012-0208-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT Hemiplegic migraine (HM) is a rare subtype of migraine with aura, characterized by transient hemiparesis during attacks. Diagnosis is based on the International Classification of Headache Disorders criteria (ICHD-II). Two types of HM are recognized: familial (FHM) and sporadic hemiplegic migraine (SHM). HM is genetically heterogeneous. Three genes have been identified (CACNA1A, ATP1A2, and SCN1A) but more, so far unknown genes, are involved. Clinically, attacks of the 3 subtypes cannot be distinguished. The diagnosis can be confirmed but not ruled out by genetic testing, because in some HM patients other, not yet identified, genes are involved. The presence of additional symptoms (such as chronic ataxia or epilepsy) may increase the likelihood of identifying a mutation. Additional diagnostics like imaging, CSF analysis, or an EEG are mainly performed to exclude other causes of focal neurological symptoms associated with headache. Conventional cerebral angiography is contraindicated in HM because this may provoke an attack. Because HM is a rare condition, no clinical treatment trials are available in this specific subgroup of migraine patients. Thus, the treatment of HM is based on empirical data, personal experience of the treating neurologist, and involves a trial-and-error strategy. Acetaminophen and NSAIDs often are the first choice in acute treatment. Although controversial in HM, triptans can be prescribed when headaches are not relieved sufficiently with common analgesics. An effective treatment for the severe and often prolonged aura symptoms is more warranted, but currently no such acute treatment is available. Prophylactic treatment can be considered when attack frequency exceeds 2 attacks per month, or when severe attacks pose a great burden that requires reduction of severity and frequency. In no strictly preferred order, flunarizine, sodium valproate, lamotrigine, verapamil, and acetazolamide can be tried. While less evidence is available for prophylactic treatment with topiramate, candesartan, and pizotifen, these drugs can also be considered. The use of propranolol in HM is more controversial, but evidence of adverse effects is insufficient to contraindicate beta-blockers.
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Affiliation(s)
- Nadine Pelzer
- Department of Neurology, Leiden University Medical Center, P.O. Box 9600, 2300, RC Leiden, The Netherlands
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Russell MB, Ducros A. Sporadic and familial hemiplegic migraine: pathophysiological mechanisms, clinical characteristics, diagnosis, and management. Lancet Neurol 2011; 10:457-70. [DOI: 10.1016/s1474-4422(11)70048-5] [Citation(s) in RCA: 265] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Weng TH, Chiu WT, Afilalo M, Choy CS, Tselios C, Yip PK, Lam C. A young man presenting with acute encephalopathy, hemiparesis, and headache. J Emerg Med 2009; 43:258-62. [PMID: 19782500 DOI: 10.1016/j.jemermed.2009.07.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Revised: 05/06/2009] [Accepted: 07/23/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND Familial hemiplegic migraine (FHM) is a rare type of migraine. Correct diagnosis is challenging for emergency physicians (EPs) due to its variable clinical picture, as well as its lack of diagnostic biological markers. OBJECTIVES To raise awareness among EPs regarding FHM's diverse clinical picture, and to highlight FHM's diagnostic criteria to facilitate an accurate and timely diagnosis of FHM in patients presenting to the emergency department (ED) with indicative symptomatology. CASE REPORT A 24-year-old male student presented to the ED complaining of dizziness, general weakness, and blurred vision that had developed the previous night. The initial physical examination revealed drowsiness, slow speech production, and slight weakness with paresthesia in all limbs. Detailed communication with the patient's aunt revealed that he had experienced several similar attacks since the age of 12 years, and that there was also an extensive family history of the same symptoms. In addition, 2 h after arrival, the patient experienced severe throbbing headache, vomiting, severe dysphasia, and the weakness shifted to the right side. A computed tomography scan of the brain showed no anomalies. He was admitted with a tentative diagnosis of FHM. CONCLUSION A diagnosis of FHM should be considered if the patient's clinical features include headache and weakness, with a family history of similar symptomatology. However, atypical symptoms of FHM may present as recurrent episodes of unexplained encephalopathy. Crucial elements for making an accurate and timely diagnosis of FHM include a detailed knowledge of weakness-related diseases and an ability to consider FHM in the differential diagnosis, as well as obtaining a thorough family history with repeated neurologic assessments.
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Affiliation(s)
- Tzu-Hsuan Weng
- Department of Emergency Medicine, Wanfang Medical Center, Taipei Medical University, Taipei, Taiwan
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Ducros A. Hemiplegic Migraine: Clinical Features, Links with Basilar-type Migraine, Current and Future Treatment. ACTA ACUST UNITED AC 2006. [DOI: 10.1111/j.1743-5013.2006.00037.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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