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Syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL)

Christine L Lay, MD, FRCPC
Christina Sun-Edelstein, MD
Section Editor
Jerry W Swanson, MD, MHPE
Deputy Editor
John F Dashe, MD, PhD


The syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL) is a self-limited, benign entity that was first clearly characterized in 1981 [1], when it was called a migrainous syndrome with cerebrospinal fluid (CSF) pleocytosis. It was given its current name in 1995 [2], and has also been referred to as pseudomigraine with temporary neurologic symptoms and lymphocytic pleocytosis (PMP syndrome) [3]. As the name implies, HaNDL is characterized by one or more episodes of severe headache, transient neurologic deficits, and lymphocytic pleocytosis in the CSF.


The precise etiology of HaNDL is not yet fully understood. Though some initially speculated that the syndrome represented a severe migraine [4,5], others favored an inflammatory or infectious origin, given the CSF lymphocytosis, frequent viral prodrome, and monophasic course [1,2]. However, despite extensive viral serological evaluation, there are only few reports suggesting a viral association, including isolated cases linked to echovirus 30 [6], human herpesvirus 6 infection [7], and human herpesvirus 7 infection [8].

Findings on single-photon emission computed tomography (SPECT), perfusion imaging with CT and MRI, transcranial Doppler, and electrophysiology studies of patients with HaNDL are suggestive of a migrainous pathophysiology:

SPECT studies have demonstrated focal or widespread areas of decreased blood flow on the side of origin of the neurologic deficits [9-12], suggestive of the spreading depression-like mechanism similar to that proposed for migraine.

Head CT perfusion scan showed decreased and delayed perfusion involving an entire hemisphere in a patient with HaNDL [13], while MRI perfusion-weighted imaging showed focal parieto-occipital hypoperfusion involving another patient with HaNDL [14]. In both cases, areas of reduced perfusion correlated with the neurologic deficits.


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Literature review current through: Jul 2017. | This topic last updated: Nov 17, 2016.
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