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.
Similar content being viewed by others
Data availability
The data that support the findings of this study are available on request from the corresponding author.
References
Bartleson D, Swanson JW, Whisnant JP (1981) A migrainous syndrome with cerebrospinal fluid pleocytosis. Neurology 31:1257–1262
Moavero R, Papetti L, Tarantino S et al (2018) Syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocitosis should be considered in children presenting with acute confusional state. Headache 58:438–442
Chalupka Devetag F (2002) Headache with temporary neurological symptoms and lymphocytic pleocytosis. Neurol Sci 23:123–125
Pascual J, Valle N (2003) Pseudomigraine with lymphocytic pleocytosis. Curr Pain Headache Rep 7:224–228
Qureshi DR, Samanta D (2022) Headache with neurological deficits and CSF lymphocytosis. In: StatPearls [Internet]; PMID: 32965821;
Giorgetti A, Mariani G, Patruno GM et al (2005) The transient syndrome of headache with neurological deficits, cerebrospinal fluid pleocytosis and acute confusional state: a case report. J Headache Pain 6:476
Headache Classification Committee of the International Headache Society 3rd edition (2018) The international classification of headache disorders. Cephalalgia 38:1–211
Parissis D, Ioannidis P, Balamoutsos G, Karacostas D (2011) Confusional state in the syndrome of HaNDL. Headache 51:1285–1288
Berg MJ, Williams LS (1995) The transient syndrome of headache with neurologic deficits and CSF lymphocytosis. Neurology 45:1648–1654
Nelson S (2013) Confusional state in HaNDL syndrome: case report and literature review. Case Rep Neurol Med 2013:317685
Frediani F, Bussone G (2015) Confusional state as first symptom of HaNDL syndrome. Neurol Sci 1:71–74
Berthold O, Theophil M, Von Moers A (2018) HaNDL syndrome with fever in a 12-year-old boy - a case report. Headache 58:597–598
Armstrong-Javors A, Krishnamoorthy K (2019) HaNDL syndrome: case report and literature review. J Child Neurol 34:161–167
Fiamingo G, Canavero I, Gastaldi M (2022) HaNDL syndrome: a reversible cerebral vasoconstriction triggered by an infection? A case report and a case-based review. Eur J Med Res 27:196
Babi M-A, Applebee A, Shapiro R, Waheed W (2017) Syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis presenting as acute neurological emergencies. Cephalalgia 37:284–289
Adib-Samii P, Little S, Vincent A, Nirmalananthan N (2020) Case report: headache and neurological deficits with CSF lymphocytosis (HaNDL) associated with P/Q type voltage-gated calcium channel antibodies (CACNA1A). Cephalalgia 40:1003–1007
Chapman KM, Szczygielski BI, Toth C et al (2003) Pseudomigraine with lymphocytic pleocytosis: a calcium channelopathy? Clinical description of 10 cases and genetic analysis of the familial hemiplegic migraine gene CACNA1A. Headache 43:892–895
Guillan M, De Felipe-Mimbrera A, Alonso-Canovas A et al (2016) The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis mimicking an acute stroke. Eur J Neurol 23:1235–1240
Quintas S, López Ruiz R, Trillo S et al (2018) Clinical, imaging and electroencephalographic characterization of three cases of HaNDL syndrome. Cephalalgia 38:1402–1406
Gómez-Aranda F, Cañadillas F, Martí-Massó JF et al (1997) Pseudomigraine with temporary neurological symptoms and lymphocytic pleocytosis. A report of 50 cases. Brain 120:1105–1113
García-Esperón C, Carrera D, Prats-Sánchez L, Lozano M (2017) Escudero D (2017) Focal leptomeningeal uptake, a new radiological finding in pseudomigraine with pleocytosis. Neurologia 32:63–65
Fuentes B, Diez Tejedor E, Pascual J et al (1998) Cerebral blood flow changes in pseudomigraine with pleocytosis analyzed by single photon emission computed tomography. A spreading depression mechanism? Cephalalgia 18:570–573
Tada Y, Negoro K, Abe M et al (2005) A patient of migraine-like headache with amnesia, pleocytosis and transient hypoperfusion of cerebral blood flow. Intern Med 44:743–746
Gekeler F, Holtmannspötter M, Straube A, Klopstock T (2002) Diffusion-weighted magnetic resonance imaging during the aura of pseudomigraine with temporary neurologic symptoms and lymphocytic pleocytosis. Headache 42:294–296
Serrano-Castro PJ, Amrani Y, Olivares-Romero J (2000) Cerebral hemodynamics in the syndrome of pseudomigraine with CSF-pleocytosis:a transcranial doppler study. Rev Neurol 31:407–411
Ruiz S, Peraire J, Ramírez R, Richart C (2007) Headaches with focal neurological deficits and lymphocytic pleocytosis. An underdiagnosed entity? Neurologia 22:130–132
Fernandes L, Cosgrove J (2020) A Case of HaNDL presenting with papilledema. Headache 60:1196–1197
Parasram M, Malhotra A, Yoo AS, Mir SA (2021) HaNDL syndrome presenting with thunderclap headache. Case Rep Neurol Med 2021:9925004
Rivero-Sanz E, Pias-Peleteiro L, Gonzalez-Alvarez V (2016) HaNDL syndrome in a 14-year-old girl. BMJ Case Rep 2016:bcr2015213018;
McKay SE, Greenway MRF (2020) A case report: the CSF characteristics of HaNDL syndrome. J Dr Nurs Pract 13:103–107
Sisman AB, Bayar MD, İçöz S et al (2020) A case of HaNDL with low cerebrospinal fluid level of neurofilament light chain. Case Rep Neurol 12:334–338
Rivas Ruvalcaba F, Moreno-Cortez KM, Badial-Ochoa S, Rodriguez-Leyva I (2022) Optic ataxia in a patient with HaNDL syndrome. BMJ Case Rep 15:e252055
Gabaldon-Albero A, Bernad-Mecho D, Alemany-Albert M et al (2019) HaNDL syndrome in a 12-year-old girl. Rev Neurol 69:332–336
Erdağ E, Çelebisoy N, Yüceyar AN et al (2015) Antibodies to DNA repair proteins in headache with neurological deficits and cerebrospinal fluid lymphocytosis (HaNDL) patients. Acta Neurol Belg 115:137–140
Zhao L, Wang R, Fang H et al (2019) Chorea and the effectiveness of steroids in a patient with the syndrome of transient headache with neurologic deficits and cerebrospinal fluid lymphocytosis: a case report. J Pain Res 12:2247–2250
Rodríguez-López C, Garzo Caldas N, Pérez U, de Urabayen D et al (2019) A new MR radiological sign in HaNDL syndrome. A case report J Clin Neurosci 61:274–276
Cruz-Culebras A, Vera R (2020) Selective aphasia and focal hypoperfusion in a bilingual patient with HaNDL syndrome. eNurologicalSci 20:100259
Lansberg MG, Woolfenden AR, Norbash AM et al (1999) Headache with neurological deficits and CSF lymphocytosis: a transient ischemic attack mimic. J Stroke Cerebrovasc Dis 8:42–44
Hutton J, Wellington D, Miller S (2017) HaNDL syndrome: transient headache and neurological deficits with cerebrospinal fluid lymphocytosis. N Z Med J 130:67–69
Barragán NG, Guillán M, Zarza B et al (2012) Focal CT hypoperfusion in HaNDL. J Neurol 259:1755–1757
Kotan D, Sayan S, Koksal SA (2016) A rare neurologic deficiency in HaNDL syndrome: cranial neuropathy. Arch Med Sci Atheroscler Dis 1:e49–e52
Çoban E, Teker SR, Serindağ H et al (2020) To handle the HaNDL syndrome through a case: the syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis. Ideggyogy Sz 73:135–139
Abkur TM, McGowan E, Kearney H, Counihan TJ (2015) Getting a handle on complicated migraine. BMJ Case Rep 2015:bcr2015210763;
Segura T, Hernandez-Fernandez F, Sanchez-Ayaso P et al (2010) Usefulness of multimodal MR imaging in the differential diagnosis of HaNDL and acute ischemic stroke. BMC Neurol 10:120
Gonçalves D, Meireles J, Rocha R et al (2013) Syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL): a pediatric case report. J Child Neurol 28:1661–1663
Salazar-Orellana JLI, Prado-Miranda G, Maldonado-Ortiz A (2021) Agraphia: presenting feature of syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL). Cureus 13:e13178
Saini L, Kumar RM, Chakrabarty B, Gulati S (2016) Recurrent headache in a five years old boy. Ann Indian Acad Neurol 19:143–145
Krause T, Nolte CH (2012) The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) as an acute ischemic stroke mimic leading to systemic thrombolysis: a case report. Clin Neurol Neurosurg 114:689–690
Morrison DG, Phuah HK, Reddy AT et al (2003) Ophthalmologic involvement in the syndrome of headache, neurologic deficits, and cerebrospinal fluid lymphocytosis. Ophthalmology 110:115–118
Barón J, Mulero P, Pedraza MI et al (2016) Síndrome HaNDL: correlación entre la topografía del déficit neurológico y las alteraciones en electroencefalograma y SPECT en una serie de 5 nuevos casos. Neurologia 31:305–310
Cifelli A, Vaithianathar L (2011) Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL). BMJ Case Rep 2011:bcr0320102862;
Apetse K, Breynaert L, Butaud C et al (2013) Transient headache and neurological deficits with cerebrospinal fluid lymphocytosis associated with IgM antibodies to the Epstein-Barr virus viral capsid antigen. Case Rep Neurol Med 2013:975709
Chan JW, Cheng C (2010) Complete external ophthalmoplegia in headache, neurologic deficits, and cerebrospinal fluid lymphocytosis (HaNDL) syndrome. Eye (Lond) 24:198–199
Raets I (2012) 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 112:67–69
Tsang BK, Kwong JC, Dewey HM (2012) Case of syndrome of headache with neurological deficits and cerebrospinal fluid lymphocytosis (HaNDL) with focal slowing on electroencephalogram. Intern Med J 42:944–947
Emond H, Schnorf H, Poloni C, Vulliemoz S, Lalive PH (2009) Syndrome of transient headache and neurological deficits with CSF lymphocytosis (HaNDL) associated with recent human herpesvirus-6 infection. Cephalalgia 29:487–491
Walter CT, Grogan WA (1986) Migraine with tardy pleocytosis. Neurology 36:733
Mateo I, Pinedo A, Gòmez-Beldarrain M et al (2004) Acute confusional state secondary to transient headache and neurological deficits with cerebrospinal fluid lymphocytosis. Neurologia 19:763–765
Ho BL, Lai CL, Hsu CY (2012) Acute confusion in headache with neurologic deficits and cerebrospinal fluid lymphocytosis syndrome. Am J Emerg Med 30:2078.e7-2078.e8
Lo Re M, Di Sapio A, Malentacchi M et al (2015) Acute confusional state in HaNDL syndrome (transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis). Neurol Sci 36:477–478
Martínez-Velasco E, Mulero P, Barón J et al (2016) Confusional state in HaNDL syndrome: an uncommon clinical manifestation. Neurol Sci 37:483–485
Verentzioti A, Tavernarakis A, Mamali M et al (2017) Pseudomigraine with transient neurological deficits and cerebrospinal fluid lymphocytosis or HaNDL syndrome: a case report with confusion and positive IgM antibodies to CMV in serum. Cephalalgia 37:99–100
Mulroy E, Yap J, Danesh-Meyer H et al (2017) Symptomatic intracranial hypertension during recovery from the syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis (HANDL). Pract Neurol 17:145–148
Hidalgo de la Cruz M, Domínguez Rubio R, Luque Buzo E et al (2019) 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 34:536–542
Acar T, Acar BA, Karabacak M (2018) HaNDL syndrome presenting with confusion: a rare case report. Noro Psikiyatr Ars 57:340–342
Bedoya-Sommerkamp M, Medina-Ranilla J, Chau-Rodríguez V (2022) HaNDL syndrome and seizures: an unusual presentation. Clin Neurol Neurosurg 223:107515
Soto-Insuga V, López-Villanueva L, Rodrigo M et al (2014) Confusion as a presentation symptom of pseudomigraine with pleocytosis in a paediatric patient. An Pediatr (Barc) 80:394–398
Samanta D, Willis E (2015) Rapid improvement of the confusional state and electroencephalography after spinal tap in a patient with headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL) syndrome. Neurol India 63:978–979
Filina T, Feja KN, Tolan RW Jr (2013) An adolescent with pseudomigraine, transient headache, neurological deficits, and lymphocytic pleocytosis (HaNDL Syndrome): case report and review of the literature. Clin Pediatr (Phila) 52:496–502
Armiento R, Kornberg AJ (2016) Altered conscious state as a presentation of the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL syndrome) in a paediatric patient. J Paediatr Child Health 52:774–776
Silvestro M, Tessitore A, De Mase A et al (2020) A 67-year-old woman with recurrent headache, migratory focal symptoms, and impaired consciousness. Headache 60:2622–2630
Sánchez-Miranda Román I, Muñoz García AA, Díaz Díaz A, Amela Peris R (2021) Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis and human herpesvirus 7; cause or coincidence? A case report. Headache 61:399–401
Kürtüncü M, Kaya D, Zuliani L et al (2013) CACNA1H antibodies associated with headache with neurological deficits and cerebrospinal fluid lymphocytosis (HaNDL). Cephalalgia 33:123–129
Burke MJ, Lamb MJ, Hohol M, Lay C (2017) Unique CT perfusion imaging in a case of HaNDL: new insight into HaNDL pathophysiology and vasomotor principles of cortical spreading depression. Headache 57:129–134
Fernández-Rodríguez P, Lojo-Ramírez JA, Medina Rodríguez M et al (2020) Differential diagnosis of HaNDL syndrome in a case report of a pediatric patient: the role of SPECT with 99mTc-HMPAO. eNeurologicalSci 19:100240
Ferrante E, Prone V (2018) Possible clinical marker of first attack of HaNDL syndrome (stroke-like mimics) in emergency room: a case report. Neurol Sci 39:2003–2005
Sveinsson O, Säflund M, Sjöstrand C (2019) Moderate to high levels of neurofilament light in two patients with HaNDL. Headache 59:266–267
Stelten BM, Venhovens J, van der Velden LB et al (2016) Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL): a case report with serial electroencephalography (EEG) recordings. is there an association with human herpes virus type 7 (HHV-7) infection? Cephalalgia 36:1296–1301
Smail RC, Baird-Gunning J, Drummond J, Ng K (2020) A case report of a transient splenial lesion related to HaNDL syndrome. Cephalalgia 40:1119–1122
Kappler J, Mohr S, Steinmetz H (1997) Cerebral vasomotor changes in the transient syndrome of headache with neurologic deficits and CSF lymphocytosis (HaNDL). Headache 37:516–518
Biçakci Ş, Kurtaran B, Over MF, Biçakci YK (2014) Are the comments on HaNDL syndrome in the ICHD-II sufficient? Noro Psikiyatr Ars 51:178–180
Yilmaz A, Kaleagasi H, Dogu O, Kara E, Ozge A (2010) Abnormal MRI in a patient with ‘headache with neurological deficits and CSF lymphocytosis (HaNDL).’ Cephalalgia 30:615–619
Ktsoyan Z, Budaghyan L, Agababova M et al (2019) Potential involvement of Salmonella infection in autoimmunity. Pathogens 8:96
Bono F, Salvino D, Tallarico T et al (2010) Abnormal pressure waves in headache sufferers with bilateral transverse sinus stenosis. Cephalalgia 30:1419–1425
Konstantinopoulou E, Kosmidis MH, Ioannidis P et al (2011) Adaptation of Addenbrooke’s cognitive examination-revised for the Greek population. Eur J Neurol 18:442–447
Hajj-Ali RA, Singhal AB, Benseler S et al (2011) Primary angiitis of the CNS. Lancet Neurol 10:561–572
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare no competing interests.
Ethical approval
This study was approved by local ethics committee.
Informed consent
Written informed consent was obtained from the patient for the publication of this case report.
Consent to participate
Written informed consent was obtained from the patient.
Additional information
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Trimboli, M., Troisi, L., Caricato, A. et al. Acute confusional state in HaNDL syndrome. Neurol Sci 44, 3017–3028 (2023). https://doi.org/10.1007/s10072-023-06788-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10072-023-06788-8