Severe Guillain-Barré syndrome following head trauma

Guillain-Barré syndrome: immunopathogenesis and therapeutic targets

INTRODUCTION

Guillain-Barré syndrome (GBS) is a group of acute immune-mediated disorders in the peripheral nervous system. Both infectious and noninfectious factors are associated with GBS, which may act as triggers of autoimmune responses leading to neural damage and dysfunction.

AREAS COVERED

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its vaccines as well as flaviviruses have been associated with GBS, although a robust conclusion has yet to be reached. Immunomodulatory treatments, including intravenous immunoglobulins (IVIg) and plasma exchange (PE), have long been the first-line therapies for GBS. Depending on GBS subtype and severity at initial presentation, the efficacy of IVIg and PE can be variable. Several new therapies showing benefits to experimental animals merit further investigation before translation into clinical practice. We review the state-of-the-art knowledge on the immunopathogenesis of GBS in the context of coronavirus disease 2019 (COVID-19). Immunomodulatory therapies in GBS, including IVIg, PE, corticosteroids, and potential therapies, are summarized.

EXPERT OPINION

The association with SARS-CoV-2 remains uncertain, with geographical differences that are difficult to explain. Evidence and guidelines are lacking for the decision-making of initiating immunomodulatory therapies in mildly affected patients or patients with regional subtypes of GBS.

Guillain-Barré Syndrome with Incomplete Oculomotor Nerve Palsy after Traumatic Brain Injury: Case Report and Literature Review

Guillain-Barré syndrome (GBS) is a severe peripheral neuroinflammatory demyelinating disease characterized by symmetrical progressive limb weakness, which can be accompanied by cranial nerve and sensory disturbances. There is usually a history of bacterial or viral infection prior to onset. GBS is rarely seen after traumatic brain injury (TBI). We report a case of a 66-year-old male patient who presented with dilated pupils, followed by respiratory failure and symmetrical quadriplegia during a conservative treatment for TBI. He was eventually diagnosed with GBS and was treated with intravenous immunoglobulin, followed by rehabilitation therapy with a good recovery. We summarize previous similar cases and analyze possible causes. It is suggested that the possibility of GBS should be considered when unexplained symptoms occurred in patients with TBI, such as respiratory failure, dilated pupils, and limb weakness.

Sub-acute Onset of Guillain-Barré Syndrome Post-mRNA-1273 Vaccination: a Case Report

Ever since the start of the pandemic, SARS-CoV-2 has taken the lives of millions of people around the globe. Several COVID-19 vaccines have been developed with rapidity to prevent acquiring COVID-19 infection, hospitalizations, and deaths. The routine side effects of these vaccines are commonly known and non-severe. Few serious side effects such as thrombosis with thrombocytopenia syndrome (TTS) and Guillain-Barré syndrome (GBS) are increasingly reported particularly after inoculation with ChAdOx1 nCoV-19 (Oxford/AstraZeneca) and Ad26.COV 2.S (Johnson & Johnson's Janssen). Rare cases of GBS after BNT162b2 (Pfizer-BioNTech), an mRNA vaccine, are also reported. However, the true association of these cases to COVID-19 continues to be unclear and the safety of these vaccines continues to be great in preventing deaths from COVID-19 infection. We report a case of middle-aged female who had a gradual onset of lower extremity weakness with a nadir of symptoms reached 10 and 12 weeks after the onset. This protracted course (sub-acute) is atypical for a "classical" GBS. The presence of an antecedent event, autonomic symptoms such as hypotension, and the need for ventilator support favored the diagnosis of GBS than chronic inflammatory demyelinating polyneuropathy (CIDP). This is the first known case to be reported of sub-acute onset of Guillain-Barré syndrome after receiving the mRNA-1273 vaccine.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s42399-022-01124-1.

Intracerebral haemorrhage and Guillain-Barré syndrome: an exploration of potential pathophysiology

Guillain-Barré syndrome (GBS) is an immune-mediated polyneuropathy classically thought to be caused by infections through the process of molecular mimicry. We report a case of GBS caused by intracerebral haemorrhage and postulate potential theories for the development of GBS following intracerebral haemorrhage and other non-infectious aetiologies by association. We highlight that GBS is an important differential diagnosis in patients developing generalised paresis following intracerebral haemorrhage.

Fulminant Guillain-Barré Syndrome Post Hemorrhagic Stroke: Two Case Reports

Guillain-Barré syndrome (GBS) is an acute, immune-mediated inflammatory peripheral polyneuropathy characterized by ascending paralysis. Most GBS cases follow gastrointestinal or chest infections. Some patients have been reported either following or concomitant with head trauma, neurosurgical procedures, and rarely hemorrhagic stroke. The exact pathogenesis is not entirely understood. However, blood-brain barrier damage may play an essential role in triggering the autoimmune activation that leads to post-stroke GBS. Here, we present two cases of fulminant GBS following hemorrhagic stroke to remind clinicians to be aware of this rare treatable complication if a stroke patient develops unexplainable flaccid paralysis with or without respiratory distress.

Guillain-Barré Syndrome and Other Acute Polyneuropathies

Guillain-Barré syndrome (GBS) is an acute autoimmune neuropathy that can cause motor, sensory, and autonomic symptoms. Although GBS primarily is a neuropathic disorder, multiple organ systems can be affected during the disease course, and older patients may be more vulnerable to systemic complications. Close clinical monitoring and early interventions using pharmacologic and nonpharmacological treatments may lead to an improved long-term outcome.

Trauma-Related Guillain-Barré Syndrome: Systematic Review of an Emerging Concept

Guillain-Barré syndrome (GBS) is mainly associated with preceding exposure to an infectious agent, although the precise pathogenic mechanisms and causes remain unknown. Increasing evidence indicates an association between trauma-related factors and GBS. Here, we performed a systematic review, summarized the current scientific literature related to the onset of GBS associated with trauma, and explored the possible pathogenesis. A literature search of various electronic databases was performed up to May 2020 to identify studies reporting diverse trauma-related triggers of GBS. Data were extracted, summarized descriptively, and evaluated with respect to possible mechanisms. In total, 100 publications, including 136 cases and 6 case series involving GBS triggered by injury, surgery, intracranial hemorrhage, and heatstroke, met our eligibility criteria. The median age of the patients was 53 [interquartile range (IQR) 45-63] years, and 72.1% of the patients were male. The median number of days between the trigger to onset of GBS symptoms was 9 (IQR 6.5-13). Overall, 121 patients (89.0%) developed post-injury/surgical GBS, whereas 13 (9.6%) and 2 (1.5%) patients had preexisting spontaneous intracranial hemorrhage and heatstroke, respectively. The main locations of injury or surgeries preceding GBS were the spine and brain. Based on available evidence, we highlight possible mechanisms of GBS induced by these triggers. Moreover, we propose the concept of "trauma-related GBS" as a new research direction, which may help uncover more pathogenic mechanisms than previously considered for typical GBS triggered by infection or vaccination.

Fulminant Guillain-Barré Syndrome and Spontaneous Intraventricular Hemorrhage: A Case Report and Literature Review

Guillain–Barré syndrome (GBS) is an acute, immune-mediated inflammatory peripheral polyneuropathy that is characterized by flaccid paralysis. A few cases have reported that GBS can be caused by head trauma or neurosurgery, but it has never been associated with intraventricular hemorrhage. Here, we report an uncommon case of fulminant GBS that occurred after spontaneous intraventricular hemorrhage. A 73-year-old woman was admitted to the hospital after sudden unconsciousness and vomiting. A head computed tomography (CT) scan following the incident showed a newly developed intraventricular hemorrhage, which led to an immediate ventriculostomy. After 5 days, the endotracheal tube was removed. Two days later, the external ventricular drainage tube was also removed. At this time, the patient was alert and the neurological examination was normal. However, the patient suddenly presented with acute respiratory failure and bilateral limb weakness 3 days later. An analysis of the patient’s cerebrospinal fluid (CSF) revealed that albuminocytologic dissociation was present. The patient was treated with intravenous immunoglobulin (0.4 g/kg/day) for 5 days. Despite timely medical intervention in the hospital, the patient passed away 2 months later. After a cerebral hemorrhagic injury, limb and respiratory muscle weakness can occur on occasion in the ICU. In this context, the potential involvement of GBS should not be ignored. Importantly, the pathogenic mechanism of GBS has been discussed for over a century, and it still remains a mystery. We speculate that the TLR4/NF-κB signaling pathway may be involved in the pathogenesis of GBS following intraventricular hemorrhage. The prognosis of most patients with GBS is usually good, but cerebral hemorrhage and mechanical ventilation may serve as risk factors that exacerbate the condition. This case is reported to remind clinicians to consider the possibility of GBS when patients present limb and respiratory muscle weakness after intraventricular hemorrhage, and to provide a starting point to discuss potential mechanisms of GBS after intraventricular hemorrhage.

Guillain-Barre Syndrome After Craniocerebral Gunshot Injury: First Report

BACKGROUND

Guillain-Barre syndrome (GBS) is a rare but serious disorder involving peripheral nerve inflammatory demyelination characterized by acute onset tetraparesis and areflexia. Generally, GBS is preceded by a bacterial or viral infection, and post-traumatic or postsurgical GBS is rarely seen.

CASE DESCRIPTION

A 41-year-old man with severe craniocerebral gunshot injury and open depressed occipital bone fracture was operated urgently. Two weeks postoperatively, he suffered from sudden quadriparesis. He had flaccid paralysis of his bilateral muscle lower extremities (0/5), along with bilateral upper extremity weakness (2/5).

CONCLUSIONS

We report the first case, to our knowledge, with post-traumatic GBS after craniocerebral gunshot injury. We want to indicate the possibility of post-traumatic GBS in cases of unexplained quadriparesis or quadriplegia after trauma or surgery.

Guillain-Barré syndrome and posterior reversible leukoencephalopathy syndrome: a rare association

A 69-year-old woman presented with headaches and visual disturbance in the context of marked hypertension secondary to non-compliance with antihypertensive medications. She developed seizures and hyperreflexia, and MRI brain showed changes consistent with posterior reversible encephalopathy syndrome (PRES). She was treated with antihypertensives with the resolution of symptoms. Over the following week, she developed progressive distal sensory loss, weakness and areflexia. The cerebrospinal fluid examination demonstrated albuminocytologic dissociation, and electrophysiological findings were in keeping with a diagnosis of Guillain-Barré syndrome (GBS). She was treated with intravenous immunoglobulin with gradual recovery. The co-occurrence of PRES and GBS has only been described in a handful of cases. In the majority of these, the dysautonomia of GBS leads to profound hypertension and subsequently PRES. This is a rare case of PRES preceding and possibly even triggering the onset of GBS. In this report, we review the literature and discuss the potential pathogenic mechanisms for this unusual association.

Superimposed Guillain-Barré Syndrome (GBS) in pediatric hypoxic brain injury

BACKGROUND

Hypoxic brain injury results in severe disabilities that require extensive acute inpatient and outpatient rehabilitation to promote maximal functional and cognitive recovery. Brain hypoxemia can result from a multitude of causes, including but not limited to cardiac arrest, drug overdose, and/or shock. While recovery from a hypoxic brain injury alone can be challenging, dealing with concurrent debilitative diagnoses such as Guillain Barré Syndrome (GBS) further complicates the recovery and rehabilitation course.

CASE REPORT

The current case study highlights the acute inpatient rehabilitation course of a 16 year old male who presented with cerebral hypoxia secondary to strangulation and subsequently developed GBS. Physical examination of the patient upon rehabilitation consult was inconsistent with a purely hypoxic brain injury, including the absence of rectal tone. This prompted further potential spinal cord injury evaluation and work up, with diagnostic testing confirmatory of GBS.

RELEVANCE

This case is important as, to our knowledge from literature review, the first known documented instance of hypoxic brain injury complicated by GBS. Moreover, it highlights the importance of identifying all potential causes of functional disability, particularly when presented with physical exam findings inconsistent with chief diagnosis, in order to maximize functional recovery and rehabilitative gains during acute inpatient rehabilitation.

Posterior Reversible Encephalopathy Syndrome and Guillain-Barré Syndrome after Head Injury: Case Report

We report a case of head injury with posterior reversible encephalopathy syndrome (PRES), followed by Guillain-Barré syndrome (GBS). A 74-year-old man was brought to our hospital after a fall. Computed tomography revealed intracranial hemorrhage. Magnetic resonance imaging showed bilateral reversible intensities with features of vasogenic edema in parietooccipital areas, suggesting PRES. After admission, weakness and areflexia of extremities and respiratory muscles developed gradually, which favored a diagnosis of GBS. Common etiologies of PRES were absent. Concurrent occurrence of PRES and GBS is rare. Given that PRES can be an initial manifestation of GBS, GBS must be considered in head trauma patients with PRES.

Effector/memory CD8+ T cells synergize with co-stimulation competent macrophages to trigger autoimmune peripheral neuropathy

Autoimmune peripheral neuropathy (APN) such as Guillain Barre Syndrome (GBS) is a debilitating illness and sometimes life threatening. The molecular and cellular mechanisms remain elusive but exposure to environmental factors including viral/bacterial infection and injury is highly associated with disease incidence. We demonstrated previously that both male and female B7.2 (CD86) transgenic L31 and L31/CD4KO mice develop spontaneous APN. Here we further reveal that CD8⁺ T cells in these mice exhibit an effector/memory phenotype, which bears a resemblance to the CD8⁺ T cell response following persistent cytomegalovirus (CMV) infection in humans and mice, whilst CMV has been considered as one of the most relevant pathogens in APN development. These activated, peripheral myelin Ag specific CD8⁺ T cells are required for the disease initiation. While an injury to a peripheral nerve results in Wallerian degeneration in control littermates, the same injury accelerates the development of APN in other non-injured nerves of L31 mice which have a predisposed inflammatory background consisting of effector/memory CD8⁺ T (CD8⁺ T_EM) cells. However, CD8⁺ T_EM cells alone are not sufficient. A certain threshold of B7.2 expression on nerve macrophages is an additional requisite. Our findings reveal that indeed, the synergism between CD8⁺ T_EM cells and co-stimulation competent macrophages is crucial in inducing autoimmune-mediated peripheral neuropathy. The identification of decisive molecular/cellular players connecting environmental triggers and the occurrence of APN provides opportunities to prevent disease onset, reduce relapses and develop new therapeutic strategies.

Posttraumatic Guillain-Barré Syndrome Immediately Following a Traffic Accident

Guillain-Barré syndrome (GBS) is an inflammatory demyelinating polyneuropathy characterized by areflexic paralysis. Most cases of GBS are preceded by an infection, however, posttraumatic GBS has also recently been reported. We report a case of posttraumatic GBS immediately following a traffic accident. We think this case is of clinical significance for practitioners because of the rare cause of a sudden flaccid paralysis following trauma.

Clinical and electrophysiological features of post-traumatic Guillain-Barré syndrome

BACKGROUND

Post-traumatic Guillain-Barré syndrome (GBS) is a rarely described potentially life-threatening cause of weakness. We sought to elucidate the clinical features and electrophysiological patterns of post-traumatic GBS as an aid to diagnosis.

METHODS

We retrospectively studied six patients diagnosed with post-traumatic GBS between 2014 and 2016 at Tianjin Medical University General Hospital, China. Clinical features, serum analysis, lumbar puncture results, electrophysiological examinations, and prognosis were assessed.

RESULTS

All six patients had different degrees of muscular atrophy at nadir and in two, respiratory muscles were involved. Five also had damaged cranial nerves and four of these had serum antibodies against gangliosides. The most common electrophysiological findings were relatively normal distal latency, prominent reduction of compound muscle action potential amplitude, and absence of F-waves, which are consistent with an axonal form of GBS.

CONCLUSIONS

It is often overlooked that GBS can be triggered by non-infectious factors such as trauma and its short-term prognosis is poor. Therefore, it is important to analyze the clinical and electrophysiological features of GBS after trauma. Here we have shown that electrophysiological evaluations are helpful for diagnosing post-traumatic GBS. Early diagnosis may support appropriate treatment to help prevent morbidity and improve prognosis.

Long-term impact after fulminant Guillain-Barré syndrome, case report and literature review

A 47-year-old man was admitted to the intensive care unit a few hours after presenting to emergency department with acute diplopia and dysphonia. Swallowing disorders and respiratory muscular weakness quickly required invasive ventilation. On day 3, the patient was in a “brain-death”-like state with deep coma and absent brainstem reflexes. Electroencephalogram ruled out brain death diagnosis as a paradoxical sleep trace was recorded. Cerebrospinal fluid analysis, electrophysiologic studies, and a recent history of diarrhea led to the diagnosis of Campylobacter jejuni-related fulminant Guillain-Barré syndrome (GBS) mimicking brain death. The outcome was favorable after long Intensive Care Unit and inpatient rehabilitation stays, despite persistent disability at 9 years follow-up. This case and the associated literature review of 34 previously reported fulminant GBS patients emphasize the importance of electrophysiological investigations during clinical brain-death states with no definite cause. Fulminant GBS has a worse outcome than “standard” GBS with higher rates of severe disability (about 50%). Long-term physiotherapy and specific rehabilitation programs appear essential to improve recovery.

Unusual Presentation of Guillain-Barré Syndrome After Mandibular Fracture Treatment: A Review of the Literature and a New Case

Guillain-Barré syndrome (GBS) is a multifactorial and lethal inflammatory demyelinating neuronal disorder with concurrent polyradiculopathy and polyneuropathy presentations. This rare syndrome affects the peripheral nerve myelin sheath and is characterized by ascending muscle weakness and paralysis. There have been rare reports of GBS after head or brachial plexus trauma, general anesthesia, neurosurgery, orthopedic surgery, cesarean section, laparoscopy, and general surgery, and the occurrence of GBS after oral and maxillofacial surgery is not common. A review of the related literature and a new case of GBS after maxillofacial surgery are presented.

Clinical features of patients with Guillain-Barré syndrome at seven hospitals on the East Coast of Australia

To document the clinical features of Guillain-Barré syndrome (GBS) in Australia, we performed a retrospective analysis of all patients admitted to several hospitals along the East Coast of Australia from 2000 to 2012. Using hospital records, we reviewed all patients with a diagnosis of GBS admitted to seven hospitals. From these, we report information of subjects who fulfilled standard diagnostic criteria. We excluded patients where inadequate information was available or who were under the age of 18. We report the features of 335 patients, in 228 of whom neurophysiological data were available. There were 168 cases of acute inflammatory demyelinating polyneuropathy (AIDP), 17 of acute motor axonal neuropathy (AMAN), 4 of acute motor and sensory axonal neuropathy (AMSAN), and 35 of Miller-Fisher syndrome (MFS). The median age at onset was 52.5 years (18-89 years) with a male : female ratio of 1.61 : 1. Upper respiratory tract infections were the most frequently identified trigger (151 subjects, 44.5%). Most patients were severely affected, with 42.7% of subjects bedbound, and an additional 24% requiring ventilatory support. GBS affects adults of all ages and usually follows a severe clinical course. In contrast to other autoimmune diseases, males are more frequently affected. A wide variety of triggering factors leads to a relatively stereotypical clinical syndrome. The most common variant of GBS in Australia is AIDP. This study shows that the clinical features of GBS in Australia are similar to that previously reported and confirms the male predominance, increased incidence with age, and frequent evidence of peripheral nerve demyelination as features of GBS.

Post-Traumatic brain injury (TBI) presenting with Guillain-Barré syndrome and elevated anti-ganglioside antibodies: a case report and review of the literature

Guillain-Barré Syndrome (GBS) is a demyelinating polyneuropathy resulting in sensory, motor and autonomic symptoms. The severity of the disease can range from mild to severe but it is classically described as an ascending demyelinating process. Initially thought to be the sequelae of a bacterial or viral infection, the clinical symptoms of post-infective GBS can present up to 4 weeks after sentinel injury. A rarely defined post-surgical GBS has been since described after major cranial, cardiothoracic and gastro-intestinal surgery. Post traumatic GBS is an even more unusual presentation with very few cases reported in contemporary academic literature. We present a case of GBS presenting two weeks after non-operative traumatic brain injury (TBI) and a review of the literature.