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Diagnostic evaluation of the patient with suspected HaNDL syndrome

Diagnostic evaluation of the patient with suspected HaNDL syndrome
HaNDL syndrome is an uncommon condition that consists of one or more episodes of transient headache with neurologic deficits along with a CSF lymphocytic pleocytosis. Clinical symptoms typically persist for several hours, and episodes may recur before the condition resolves usually within three months. For symptomatic patients with an uncertain cause to symptoms (eg, first episode), diagnostic testing is performed to exclude other conditions such as stroke, seizure, and meningitis.

CSF: cerebrospinal fluid; CT: computed tomography; CVT: cerebral venous thrombosis; EEG: electroencephalogram; HaNDL: headache and neurologic deficits with cerebrospinal fluid lymphocytosis; ICH: intracerebral hemorrhage; LP: lumbar puncture; MRA: magnetic resonance angiography; MRI: magnetic resonance imaging; MRV: magnetic resonance venography; WBC: white blood cell.

* Migrainous features of headaches in HaNDL syndrome include throbbing quality, moderate to severe intensity, and the presence of associated nausea, vomiting, photophobia, and/or phonophobia.

¶ Neuroimaging typically includes initial noncontrast head CT to assess for intracranial hemorrhage followed by brain MRI and MRA with and without contrast to assess for acute ischemic stroke and evidence of arterial stenosis/occlusion. Brain MRV may also be needed to assess for CVT. EEG may be diagnostic for symptomatic patients with seizures. Refer to individual UpToDate topics for additonal details of the diagnostic evaluation of these conditions.

Δ Common infectious causes of a lymphocytic pleocytosis include herpes virus, enteroviruses, West Nile virus, Borrelia species, and syphilis. Cytology to assess for malignant cells should be obtained for patients with suspected leptomeningeal neoplasm. For patients who present with encephalopathy, thyroid function tests, vitamin B12 level, and antineuronal antibody testing for autoimmune encephalitis should also be obtained.
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