Alternating Hemiplegia of Childhood

Disease Overview

Alternating hemiplegia of childhood (AHC) is a rare neurodevelopmental disorder characterized by repeated episodes of weakness or paralysis that may affect one side of the body or the other (hemiplegia) or both sides of the body at once (quadriplegia). Additional episodic symptoms usually include intermittent abnormal eye movements, episodes of muscle stiffness or posturing (dystonia), and in a substantial percentage of cases, seizures. Delays in attaining developmental milestones (developmental delays), cognitive impairment, and persistent issues with balance and the presence of continuous dance-like movements of limbs or facial muscles (chorea) may occur independently of episodes of paralysis, weakness or stiffness and persist between episodes. The severity of AHC and the specific types of episodes that occur can vary dramatically from one individual to another. First symptoms usually begin before the age of 18 months. AHC is caused by mutations in the ATP1A3 gene in the majority of those affected. AHC is a rare disorder that was first reported in the medical literature in 1971 by doctors Simon Verret and John C. Steele. They described an unusual disorder in eight children who demonstrated intermittent episodes of weakness, affecting first one side of the body, then the other, with onset in early childhood, including one child who manifested symptoms as early as 3 months of age. However, the disorder remained poorly understood for many years, in part, because of its rarity and complex and highly variable symptoms. More research is necessary to improve early diagnosis, understand the full range of symptoms, and develop more effective treatments. The identification of a causative gene for AHC should lead to a better understanding of the disorder and open new avenues for treatment. The spectrum of related disorders with overlapping symptoms continues to expand, and has led to the increasingly common use of the term “ATP1A3-related neurologic disorders”. This umbrella includes patients with rapid-onset dystonia-parkinsonism (RDP), alternating hemiplegia of childhood (AHC), and cerebellar ataxia, areflexia, pes cavus, optic atrophy, and sensorineural hearing loss (CAPOS) syndrome. However, an increasing number of patients with overlapping symptoms that further expand the phenotypes even beyond these well-described disorders, initially thought to be completely distinct, continues to expand.

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Synonyms

• AHC
• alternating hemiplegia syndrome

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Signs & Symptoms

AHC is a highly variable and unpredictable disorder and the specific symptoms and severity of the disorder can vary greatly from one person to another. Some individuals may have mild forms of the disorder with a good prognosis, and develop almost normally. However, others may have a severe form with the potential for serious and disabling complications that can disrupt various aspects of life and manifest as persistent neurologic disability.

It is important to note that affected individuals may not have all of the symptoms discussed below. Affected individuals should talk to their physician and medical team about their specific case, associated symptoms and overall prognosis. Symptoms usually develop before 18 months of age.

The most prominent symptom is repeated episodes of weakness or paralysis affecting one side of the body at a time in an alternating fashion (alternating hemiplegia or hemiparesis). Weakness or paralysis may also sometimes affect both sides of the body (quadriplegia) or rapidly transition from one side to the other. These episodes typically last for minutes to hours, but in some children under certain circumstances can persist for several days or even weeks in some cases. They may occur daily, weekly or once every few months. In some individuals one side of the body is affected more than the other. In episodes when both sides are involved, one side may recover more quickly than the other. The face may be spared during an episode, but weakness of facial muscles (facial paresis) can occur with mouth deviation, slurred speech, and difficulty swallowing. The intensity of individual episodes varies as well and can range from numbness to a complete loss of feeling and movement. Episodes often begin to appear in early infancy, and sometimes even in the first few days of life.

During an episode, affected individuals usually remain alert and may be able to communicate verbally. A unique aspect of these episodes is that they cease when sleeping and may not resume for approximately 15-20 minutes upon waking. In severe, prolonged cases, this window of time may allow affected individuals to eat and drink. Episodes can become worse over time and, in severe cases, can make walking unassisted difficult. Some affected individuals may feel tired or unwell shortly before a hemiplegic episode occurs.

Some individuals with AHC may also have additional neurologic symptoms that may occur isolated from or during hemiplegic episodes. These symptoms include sudden, dance-like, involuntary movements of the limbs and facial muscles (choreoathetosis), difficulty breathing (dyspnea), difficulty coordinating muscles (ataxia) causing walking and balance problems, and dystonia. Dystonia is a general term for a group of muscle disorders generally characterized by involuntary muscle contractions that force the body into abnormal, sometimes painful, movements and positions (postures). Dystonic attacks can involve the tongue potentially causing breathing and swallowing difficulties.

During these episodes, some affected individuals may experience dysfunction of the autonomic nervous system, which regulates certain involuntary body functions such as heart rate, blood pressure, sweating, and bowel and bladder control. Symptoms associated with autonomic dysfunction can vary greatly, but may include excessive or lack of sweating, changes in body temperature, skin discoloration, altered pain perception and gastrointestinal problems. Cardiorespiratory problems such as a slow heartbeat (bradycardia), a high-pitched wheezing (stridor), sudden constriction of the walls of the tiny airway branches called bronchioles (bronchospasm), and difficulty breathing or gasping for breath may also develop.

The characteristic episodes that define AHC are not epileptic in nature, although are frequently mistaken for epileptic seizures early in life. However, 50% or more of affected individuals develop epilepsy as they get older. Epileptic seizures typically occur much less frequently than hemiplegic episodes, but when they do, may result in status epilepticus, or persistent seizure activity requiring medical intervention. Epilepsy in children with AHC is often treated with standard antiepileptic medications, but may sometimes prove resistant to traditional epilepsy treatments (intractable epilepsy).

Some infants and children with AHC exhibit developmental delays. In addition, some children who experience prolonged, recurrent episodes may develop slowly progressive neurological problems including loss of previously acquired skills (psychomotor regression) and cognitive impairment. Behavioral or psychiatric issues such as impulsivity, short-temperedness, poor communication and poor concentration may also occur. Some affected children may have learning disabilities and issues with skills that require movement and coordination (dyspraxia).

A common, frequent type of spell in infants with AHC results in irregular eye movements including rapid, involuntary, “jerking” eye movements that may be side to side, up and down or rotary (episodic nystagmus). Nystagmus often affects only one eye (monocular). In some patients, these irregular eye movements are the first noticeable symptom of AHC, but they often go unrecognized, or are considered most likely to represent seizure activity. Some affected individuals may intermittently appear crossed-eyed, where the eyes are misaligned either outward (exotropia) or inward (esotropia). With exotropia, one eye drifts outward toward the ear, while the other eye faces straight ahead. With esotropia, one eye drifts inward toward the nose, while the other eye faces straight ahead.

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Causes

In at least 2/3 of individuals, AHC is caused by a mutation in the ATP1A3 gene. Genes provide instructions for creating proteins that play a critical role in many functions of the body. When a mutation of a gene occurs, the protein product may be faulty, inefficient, or absent. Depending upon the functions of the particular protein, this can affect many organ systems of the body, including the brain.

In cases where a mutation in ATP1a3 is disease causing, AHC almost always occurs as a new (sporadic or de novo) mutation, which means that in nearly all cases the gene mutation has occurred at the time of the formation of the egg or sperm for that child only, and no other family member will be affected. The disorder is usually not inherited from or “carried” by a healthy parent, and in AHC, de novo mutations are more common than inherited mutations. However, dominant inheritance (where a trait is transmitted from either an affected mother or father to their child) has been documented in at least one affected family with classic AHC, and in a number of patients with rapid onset dystonia parkinsonism, also due to mutations in ATP1A3.

The ATP1A3 gene is responsible for the production of the protein, ATPase, Na+K+ transporting, alpha 3 polypeptide, that is required for the normal function of nerve cells in the brain. This protein plays a role in the transport of sodium and potassium ions across a channel that connects nerve cells (neurons), helping to regulate brain activity. Consequently, AHC may be classified as a channelopathy, a group of disorders characterized by abnormalities in the flow of electrically charged particles known as ions (commonly calcium, sodium, and potassium) through pores in cell membranes (ion channels). These channels are involved in various functions of the body and, therefore, channelopathies can potentially cause a wide variety of symptoms.

Because some individuals with AHC do not have an identifiable mutation of the ATP1A3 gene, it is possible that mutations in other, yet to be discovered, genes may also be associated with AHC. Other genes which cause AHC or a disorder with similar symptoms include the CACNA1A, SLC1A3, and ATP1A2 in less than 1% of patients.

In rare cases where AHC runs in families, it is thought that the disorder is inherited as an autosomal dominant trait. Genetic diseases are determined by the combination of genes for a particular trait that are on the chromosomes received from the father and the mother. Dominant genetic disorders occur when only a single copy of an abnormal gene is necessary for the appearance of the disease. The abnormal gene can be inherited from either parent, or can be the result of a new mutation (gene change) in the affected individual. The risk of passing the abnormal gene from affected parent to offspring is 50% for each pregnancy regardless of the sex of the resulting child. The spectrum of ATP1A3-related neurologic disorders includes rapid-onset dystonia-parkinsonism (RDP), alternating hemiplegia of childhood (AHC), and cerebellar ataxia, areflexia, pes cavus, optic atrophy, and sensorineural hearing loss (CAPOS) syndrome.

Families have noted that individuals may have “triggers” that precede a hemiplegic episode. Identified triggers for AHC include certain environmental situations such as extreme temperatures, crowds, irregular sleep habits, or specific odors; certain physical activities such as exercise: water exposure including bathing, swimming or showering; bright sunlight or fluorescent bulbs; certain foods such as chocolate or food dyes; certain medications; childhood illnesses and infections: and certain emotional situations such as stress, anxiety or fright. Although many different triggers have been reported, many episodes occur with no identifiable trigger.

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Affected populations

AHC affects males and females in equal numbers. It is estimated to occur in approximately 1 in 1,000,000 births. However, since cases may go unrecognized or misdiagnosed, it is difficult to determine the true frequency of AHC in the general population. Symptoms usually become apparent within the first 18 months.

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Disorders with Similar Symptoms

Symptoms of the following disorders can be similar to those of AHC. Comparisons may be useful for a differential diagnosis.

Familial hemiplegic migraine (FHM) is a rare genetic form of migraine headache. The disorder is characterized be recurrent episodes of migraine and additional symptoms. Onset is usually within the first or second decade of life. The frequency of these episodes can range from one per day to fewer than several in a lifetime. Long-term episode free intervals have been reported. The duration of an episode also varies as well, ranging from a few hours to a few days. Triggers that normally induce a migraine such as certain odors and food, minor head trauma, and emotional situations causing stress or anxiety can also induce an episode of FHM. Additional symptoms can vary from one person to another. Affected individuals may also develop vision abnormalities, sensory issues such as numbness or a sensation of tingling or burning of the extremities or face, and motor problems such as temporary weakness or paralysis of one side of the body (hemiplegia). Confusion and drowsiness and difficulties with speech (dysphasia) have also been reported. Approximately 40-50 percent of affected individuals may develop such as irregular, involuntary eye movements (nystagmus) or an inability to coordinate voluntary movements (ataxia). FHM is inherited as an autosomal dominant trait. To date, several different genes including CACNA1A, ATP1A2, and SCN1A have been identified as causes of FHM.

Cerebral palsy is a relatively rare (approximately 3 per 1000 live births) non-progressive neuromuscular disorder that results in impaired movement. Infants with cerebral palsy may display developmental delays before the third year of life and may have abnormally low (hypotonia) or high (hypertonia) muscle tone. Affected infants and children often have some combination of impaired movements including tremors, an inability to coordinate voluntary movements (ataxia), unsteadiness when walking or inability to walk, exaggerated reflexes (hyperreflexia), involuntary muscle spasms (spasticity) that result in slow, stiff rigid movements. Additional characteristics may include difficulty chewing and swallowing, difficulty in gaining bladder or bowel control, convulsions, and/or poor vision and hearing. Since cerebral palsy primarily involves movement and motor function, intelligence may be average to above average, or there may be mild to severe mental impairment. Cerebral palsy may be caused by brain injury during the early stages of fetal development, at birth, or after birth (postnatal). Injury may result from maternal/fetal infection, lack of oxygen (hypoxia), or bleeding into the brain. (For more information on this disorder, choose “Cerebral Palsy” as your search term in the Rare Disease Database.)

Epilepsy is a general term for a group of neurological disorders characterized by recurrent seizures and associated with abnormal electrical discharges in the brain. The appearance of an epileptic seizure may be highly variable, but can include loss of consciousness, convulsions, spasms, sensory symptoms, and disturbances in the autonomic nervous system. Attacks may be preceded by an “aura”, a feeling of unease or sensory discomfort; the aura marks the beginning of the seizure in the brain. This is typically seen in partial-onset seizures. There are many different causes of epilepsy, including head injuries, brain malformations, and metabolic syndromes in which the body is unable to use certain energy sources correctly, making it easier for seizures to happen; however in many cases of epilepsy the exact cause is unknown (idiopathic). Epilepsy can also occur as part of larger syndromes. Types of epilepsy or disorders associated with epilepsy include Lennox-Gestaut syndrome, Rett syndrome, Angelman syndrome, Landau-Kleffner syndrome, Dravet syndrome, and the neuronal ceroid lipofuscinoses. (For more information on these disorders, choose the specific disorder name as your search term in the Rare Disease Database.)

A wide variety of additional disorders may have signs or symptoms that are similar to those seen in some individuals with AHC including vascular disorders such as Moyamoya disease and arteriovenous malformations; certain metabolic disorders such as glucose transporter type 1 deficiency syndrome, aromatic l-amino acid decarboxylase (AADC) deficiency, homocystinuria, congenital disorders of glycosylation and mitochondrial disorders such as MELAS or pyruvate dehydrogenase deficiency; and neurotransmitter deficiency disorders such as aromatic L-amino acid decarboxylase deficiency. (For more information on these disorders, choose the specific disorder name as your search term in the Rare Disease Database.)

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Diagnosis

A diagnosis of AHC is based upon identification of characteristic symptoms, a detailed patient history, a thorough clinical evaluation and a variety of specialized tests. Specific diagnostic criteria have been proposed for AHC. The seven criteria are: (1) onset of symptoms before 18 months; (2) repeated episodes of hemiplegia that sometimes involve both sides of the body; (3) quadriplegia that occurs as an isolated incident or as part of a hemiplegic attack; (4) relief from symptoms upon sleeping; (5) additional paroxysmal attacks such as dystonia, tonic episodes, abnormal eye movements or autonomic dysfunction; (6) evidence of developmental delay or neurological abnormalities such as choreoathetosis, ataxia or cognitive disability; (7) cannot be attributed to another cause.

Clinical Testing and Work-up

A diagnosis of AHC is primarily one of exclusion. A wide variety of specialized tests may be used to rule out other conditions. Such tests include magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and magnetic resonance spectroscopy (MRS). An MRI uses a magnetic field and radio waves to produce cross-sectional images of particular organs and bodily tissues such as brain tissue. An MRA, images are produced to evaluate the blood vessels. An MRS is used to detect metabolic changes in the brain and other organs.

Additional tests may include electroencephalogram (EEG), which measures electrical responses in the brain, and is typically used to identify epilepsy; metabolic screening to detect urine organic acids, which is indicative of certain metabolic disorders; studies of cerebrospinal fluid (CSF), which can exclude neurotransmitter deficiency disorders with similar episodic oculomotor abnormalities; erythrocyte sedimentation rates, which measures how long it takes red blood cells to settle in a test tube over a given period to detect inflammatory disorders; and hypercoagulable studies to detect disorders with a predisposition to forming blood clots.

Molecular genetic testing for mutations in the ATP1A3 gene is available on a clinical basis via individual targeted gene sequencing or as part of larger gene panels. Increasingly, ATP1A3 mutations are identified in the context of clinical exome sequencing.

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Standard Therapies

Treatment

No specific therapy exists for individuals with AHC. Treatment is directed toward the specific symptoms apparent in each individual. Treatment may require the coordinated efforts of a team of specialists. Pediatricians, pediatric neurologists, neurologists, ophthalmologists, and other healthcare professionals may need to systematically and comprehensively plan an affected child’s treatment. Because AHC is highly variable, an individualized treatment program needs to be devised for each child. The effectiveness of current therapies for AHC will vary greatly among affected individuals. What is effective for one person may not be effective for another.

Treatment is generally focused on trying to reduce the frequency and severity of the characteristic episodes and the management of episodes when they occur. Triggers include psychological stress/excitement; environmental stressors (e.g., bright light, excessive heat or cold, excessive sound, crowds); water exposure (e.g., bathing, swimming); certain foods or odors (e.g., chocolate, food dyes, missed meals); excessive or atypically strenuous exercise; illness; irregular sleep (missing a nap, delayed bedtime. Avoiding triggers to the extent possible is recommended for individuals with AHC. In addition, long-term drug therapy may be recommended to help lessen the frequency of episodes.

A medication which has proved effective in reducing the frequency or severity of episodes in some individuals is a drug called flunarizine, a drug with calcium channel blocking properties. Flunarizine is given as a preventive (prophylactic) agent and has lessened the frequency, duration and severity of non-epileptic episodes in some individuals with AHC. Flunarizine is not readily available in the US. However, flunarizine is available in other countries for the treatment of migraine and other neurological symptoms.

Anti-seizure medications (anti-convulsants) are also used either alone or in combination to treat individuals with AHC who also have epilepsy and to prevent non-epileptic symptoms such as hemiplegia and dystonia. The effectiveness of these medications is highly variable and they are often minimally effective or ineffective. Benzodiazepines such as diazepam have been used to reduce the duration of dystonic episodes.

Because some hemiplegic episodes have an early phase where individuals feel unwell, some researchers have recommended using certain medications to prematurely induce sleep. This can lessen the duration and severity of an episode. Such medications include buccal midazolam, chloral hydrate, melatonin, niaprazine or rectal diazepam.

Severe episodes of AHC can require hospitalization. In some cases, epileptic seizures can necessitate urgent medical intervention including intravenous to halt seizures or induce sleep in the setting of severe prolonged dystonia.

The various symptoms of AHC can affect a child’s growth and development. Episodes can disrupt daily life and impact a child’s ability to learn and participate in various activities. Proactive management of potential complications is required. A supportive team approach for children with AHC is of benefit and may include special education, physical therapy, and additional social, medical or vocational services. Genetic counseling may be of benefit for affected individuals and their families.

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Clinical Trials and Studies

Well designed clinical trials have proved challenging to perform in AHC due to both the rarity of the disorder and the difficulty in clearly showing long-term improvement. Flunarizine has been the most well studied, but published reports include a relatively small number of patients. However, because there are currently no approved treatments proven to improve symptoms in AHC, many individuals undergo treatment trials with the supervision of their physician to try to determine whether a given medication might be helpful in reducing the frequency and/or severity of either the episodes of weakness or seizure like episodes. A few reports have indicated that a drug called topiramate, usually used to treat epilepsy, might improve the frequency and severity of both non-epileptic paroxysmal symptoms, as well as seizure-like episodes, in individuals with AHC. More research is necessary to determine the long-term safety and true effectiveness of flunarizine, topiramate and other investigational therapies such as sodium oxybate in the treatment of individuals with AHC.

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Toll-free: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov

For information about clinical trials sponsored by private sources, in the main, contact:
www.centerwatch.com

For more information about clinical trials conducted in Europe, contact: https://www.clinicaltrialsregister.eu/
For more information, or to enroll in the AHCF US and International Registry:
Kathryn J. Swoboda MD, FACMG
MGH Neurogenetics Research Program
Center for Human Genetics Research
Simches 5-238
185 Cambridge Street
Boston, MA 02114
Telephone: (617) 312-8318
kswoboda@mgh.harvard.edu

OR
The Alternating Hemiplegia of Childhood Foundation (see contact below)

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Resources

RareConnect offers a safe patient-hosted online community for patients and caregivers affected by this rare disease.  For more information, visit www.rareconnect.org.

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References

TEXTBOOKS
Dangond F. Alternating hemiplegia of childhood. In: NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:512-513.

JOURNAL ARTICLES
Heinzen EL, Swoboda KJ, Hitomi Y, et al. De novo mutations in ATP1A3 cause alternating hemiplegia of childhood. Nat Genet. 2012;44(9):1030-4. The National Center for Biotechnology Information advances science and healthhttps://www.ncbi.nlm.nih.gov/pubmed/22842232

Rosewich H, Thiele H, Ohlenbusch A, et al. Heterozygous mutations in ATP1A3 in patients with alternating hemiplegia of childhood: a whole-exome sequencing gene-identification study. Lancet Neurol. 2012;11:764-763. https://www.ncbi.nlm.nih.gov/pubmed/22850527

Panagiotakaki E, Gobbi G, Neville B, et al. Evidence of a non-progressive course of alternating hemiplegia of childhood: study of a large cohort of children and adults. Brain. 2010;133:3598-3610. https://www.ncbi.nlm.nih.gov/pubmed/20974617

Tenney JR, Schapiro MB. Child neurology: alternating hemiplegia of childhood. Neurology. 2010;74:e57. https://www.ncbi.nlm.nih.gov/pubmed/20368625

Sweney MT, Silver K, Gerard-Blanluet M, et al. Alternating hemiplegia of childhood: early characteristics and evolution of a neurodevelopmental syndrome. Pediatrics. 2009;123:e534-e541. https://pediatrics.aappublications.org/content/123/3/e534

Neville BG, Ninan M. The treatment and management of alternating hemiplegia of childhood. Dev Med Clin Neurol. 2007;49:777-780. https://www.ncbi.nlm.nih.gov/pubmed/17880649

Jiang W, Chi Z, Du B, et al. Topiramate: a new agent for patients with alternating hemiplegia of childhood. Neuropediatrics. 2006;37:229-233. https://www.ncbi.nlm.nih.gov/pubmed/17177149

Di Rosa G, Spano M, Pustorino G, et al. Alternating hemiplegia of childhood successfully treated with topiramate: 18 months of follow-up. Neurology. 2006;66:146. https://www.ncbi.nlm.nih.gov/pubmed/16401872

Bassi MT, Bresolin N, Tonelli A, et al. A novel mutation in the ATP1A2 gene causes alternating hemiplegia of childhood. J Med Genet. 2004;41:621-628. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1735877/?tool=pmcentrez

Swoboda KJ, Kanavakis E, Xaidara A, et al. Alternating hemiplegia of childhood or familial hemiplegic migraine? A novel ATP1A2 mutation. Ann Neurol. 2004;55:884-887. https://www.ncbi.nlm.nih.gov/pubmed/15174025

Mikati MA, Maguire H, Barlow CF, et al. A syndrome of autosomal dominant alternating hemiplegia: clinical presentation mimicking intractable epilepsy, chromosomal studies; and physiologic investigations. Neurology. 1992;42:2251-2257. https://www.ncbi.nlm.nih.gov/pubmed/1361034

Verret S, Steele JC. Alternating hemiplegia in childhood: a report of eight patients with complicated migraine beginning in infancy. Pediatrics. 1971;47(4):675-80. https://www.ncbi.nlm.nih.gov/pubmed/5089756

INTERNET
Brashear A, Sweadner KJ, Cook JF, et al. ATP1A3-Related Neurologic Disorders. 2008 Feb 7 [Updated 2014 Nov 6]. In: Pagon RA, Adam MP, Ardinger HH, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2016.Available from: https://www.ncbi.nlm.nih.gov/books/NBK1115/ Accessed April 4, 2016.

National Institute of Neurological Disorders and Stroke. Alternating Hemiplegia Information Page. September 16, 2011. Available at: https://www.ninds.nih.gov/disorders/alternatinghemiplegia/alternatinghemiplegia.htm Accessed April 4, 2016.

Schyns T. Alternating hemiplegia of childhood. Orphanet Encyclopedia, June 2009. Available at: https://www.orpha.net/consor/cgi-bin/Disease_Search.php?lng=EN&data_id=748&Disease_Disease_Search_diseaseGroup=Alternating-hemiplegia-of-childhood&Disease_Disease_Search_diseaseType=Pat&Disease(s)/group%20of%20diseases=Alternating-hemiplegia-of-childhood&title=Alternating-hemiplegia-of-childhood&search=Disease_Search_Simple Accessed April 4, 2016.

McKusick VA., ed. Online Mendelian Inheritance in Man (OMIM). Baltimore. MD: The Johns Hopkins University; Entry No:104290; Last Update:09/14/2012. Available at: https://omim.org/entry/104290 Accessed April 4, 2016.

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Programs & Resources

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