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LETTERS TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 6  |  Page : 978-979

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


Division of Child Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Date of Web Publication20-Nov-2015

Correspondence Address:
Debopam Samanta
Division of Child Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.170074

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How to cite this article:
Samanta D, Willis E. 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 2015;63:978-9

How to cite this URL:
Samanta D, Willis E. 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 [serial online] 2015 [cited 2019 Dec 14];63:978-9. Available from: http://www.neurologyindia.com/text.asp?2015/63/6/978/170074


Sir,

The syndrome of transient headache and neurological deficits associated with cerebrospinal fluid lymphocytosis (HaNDL) is a self-limited, benign entity with an unknown etiology. Neuroimaging studies are usually normal and cerebrospinal fluid (CSF) culture and other tests for determining the etiology remain negative.

A 16-year-old woman, without similar previous history, had an acute onset headache for 10 days prior to her admission to the Intensive Care Unit. Without any definite preceding factor, she started to have a holocephalic stabbing headache for 2–4 h every day that was most prominent around the vertex. It was associated with periorbital pain, photophobia, and nausea. She denied the presence of any visual symptoms. The evening prior to her admission, she noticed left facio-brachial numbness, which soon involved the right side as well. She fell asleep soon after this, but was found by her mother the following morning, very much confused. On examination, she did not open her eyes on painful stimulus but had withdrawal motor response and produced some incomprehensible sounds. She was afebrile. Neck rigidity and focal motor signs were absent. Extensive laboratory work up and MRI brain were performed but were found to be normal [Table 1]. A diagnostic spinal tap was performed which revealed a markedly increased opening pressure of 38 cm H2O. Interestingly, within 1 h of her spinal tap, she had a remarkable improvement in her sensorium. CSF analysis revealed lymphocytic pleocytosis without any other abnormality. Video electroencephalography, although negative for seizures, showed [Figure 1]a and [Figure 1]b significant changes as she showed clinical improvement.
Table 1: Evaluation completed during the initial presentation

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Figure 1: (a) Low-amplitude delta activity, faster frequency beta range activities and frontally dominant intermittent rhythmic high-amplitude delta activities seen just before spinal tap. (b) Awake electroencephalography with mixed frequency background activity with prominent eye blinking artifact noted within 1 h of spinal tap

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Our patient had episodes of severe headache with transient neurologic deficits, CSF pleocytosis with lymphocyte predominance, normal brain MRI, and negative studies for any infectious etiology and therefore, met the diagnostic criteria for HaNDL syndrome. The confusional states are rarely reported as a clinical manifestation of this syndrome.[1] A 34-year-old man with three episodes of acute confusional state was previously reported with HaNDL syndrome with subsequent full recovery over 24–48 h. Spinal tap was performed during two of those episodes, but the authors did not mention the opening pressures.[2] Parissis et al., also described two cases of HaNDL syndrome associated with confusion.[3] Significantly increased CSF opening pressure, as seen in our patient, has also been described previously, but dramatic improvement in sensorium following spinal tap in HaNDL has never been described. We believe that the improvement in sensorium was secondary to reduction in the raised intracranial pressure following the lumbar puncture. Further reporting of similar cases will clarify whether there is actually a consistent correlation of a spinal tap with rapid improvement in acute confusional state in patients with HaNDL syndrome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nelson S. Confusional state in HaNDL syndrome: Case report and literature review. Case Rep Neurol Med 2013;2013:317685.  Back to cited text no. 1
    
2.
Giorgetti A, Mariani G, Patruno GM, Romorini A. The transient syndrome of headache with neurological deficits, cerebrospinal fluid pleocytosis and acute confusional state: A case report. J Headache Pain 2005;6:476.  Back to cited text no. 2
    
3.
Parissis D, Ioannidis P, Balamoutsos G, Karacostas D. Confusional state in the syndrome of HaNDL. Headache 2011;51:1285-8.  Back to cited text no. 3
    


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