以急性脑病为主要表现的儿童偏瘫型偏头痛五例临床及遗传学分析

Clinical and genetic analysis of 5 pediatric patients with hemiplegic migraine presenting as acute encephalopathy

目的总结分析以急性脑病为主要表现的偏瘫型偏头痛的临床特征、遗传学特点及诊疗,提高对该病的认识。方法回顾性分析2018年8月至2020年6月在首都医科大学附属北京儿童医院住院治疗的5例以急性脑病为主要表现的偏瘫型偏头痛患儿的临床病例及随访资料。结果 5例患儿中男3例、女2例,年龄9.7(3.9~12.7)岁,发病年龄7.0(2.1~12.7)岁。5例患儿高峰期症状均有嗜睡、昏迷等脑病表现,其他临床表现包括头痛、视觉异常、偏瘫、失语、抽搐和发热等,高峰出现时间在病程第2~6天。发病前2例有轻度头外伤,2例有既往类似病史。5例患儿头颅磁共振成像表现为半侧或部分大脑皮层肿胀及皮层下白质弥散受限,3例合并小脑萎缩。5例患儿均经对症治疗,其中2例使用小剂量糖皮质激素,均恢复到基线水平,1例头颅磁共振成像示遗留病灶区萎缩改变。5例患儿全外显子组基因测序提示均为CACNA1A基因变异,1例为新生变异,1例遗传自无先兆偏头痛的母亲。诊断明确后5例患儿均长期口服氟桂利嗪,通过电话及门诊随访22(7~29)个月,至末次随访5例患儿均未再发肢体无力或脑病表现。1例仍有间断头痛,偶有一过性右侧肢体麻木。结论偏瘫型偏头痛重度发作除表现为头痛、偏瘫、失语、视觉异常等,常伴随意识障碍。多数短期内完全恢复,极少数恢复缓慢,遗留脑萎缩、认知障碍甚至死亡。以CACNA1A基因变异为最常见。氟桂利嗪可预防复发。

Objective To analyze the clinical and genetic characteristics,diagnosis and treatment of hemiplegic migraine(HM)manifested as acute encephalopathy in children,so as to improve the understanding of this disease.Methods The clinical data of 5 children diagnosed with HM characterized by acute encephalopathy who were admitted to Beijing Children′s Hospital affiliated to Capital Medical University from August 2018 to June 2020 were retrospectively analyzed.Results Among the 5 cases,3 were males and 2 females with an age of 9.7(3.9-12.7)years.The age of disease onset was 7.0(2.1-12.7)years.The peak symptoms of 5 children showed encephalopathy such as drowsiness and coma,as well as other clinical manifestations including headache,visual abnormality,hemiplegia,aphasia,convulsions,and fever,etc.The time to reach the peak was on the 2nd-6th day of the course of the disease.Before the onset of the disease 2 cases were found to have mild brain trauma and 2 cases had similar attacks in the past.Brain magnetic resonance imaging(MRI)showed hemispheric or partial cerebral cortex swelling and restricted diffusion of subcortical white matter in all cases,and cerebellar atrophy in 3 cases.All children received symptomatic treatment,and 2 of them were also treated with low-dose corticosteroids in the meantime.Finally all cases recovered clinically from the attack,but one had atrophic changes left in the affected area on brain MRI.Whole exon sequencing revealed variations of CACNA1A gene in all cases,among which 4 were de novo mutations and 1 case inherited from the mother who had migraine without aura.After the diagnosis,the 5 children were treated with long-term flunarizine and followed up for 22(7-29)months by telephone or in the outpatient clinic.Before the last follow-up,none of them showed weakness or encephalopathy,but one still had intermittent headaches and occasional transient right limb numbness.Conclusions Hemipleg is often accompanied by impaired consciousness in addition to headache,hemiplegia,aphasia,visual abnormality,etc.Most patients recover completely after a short period,while a few recover slowly and may suffer sequelae such as brain atrophy and cognitive impairment and even death.CACNA1A gene variation is the most common genetic variation.Flunarizine could prevent recurrence of severe attack.