Elsevier

Clinical Neurophysiology

Volume 127, Issue 2, February 2016, Pages 1657-1663
Clinical Neurophysiology

Ultrasound and electrophysiologic findings in patients with Guillain–Barré syndrome at disease onset and over a period of six months

https://doi.org/10.1016/j.clinph.2015.06.032Get rights and content

Highlights

Abstract

Objective

To investigate cross-sectional areas (CSAs) of several peripheral nerves including the vagus nerve and the diameter of spinal nerves as measured by nerve ultrasound (NUS) and nerve conduction studies (NCS) in Guillain–Barré syndrome (GBS) patients over at least six months compared to healthy controls.

Methods

NUS and/or NCS of several nerves, the vagus nerve, and the 5th/6th cervical spinal nerves were performed in patients with GBS at days 2–3 after symptom onset, at days 10–14 after immunoglobulin therapy and after six months compared to healthy controls.

Results

27 GBS-patients and 31 controls were included. Using NUS significant enlargement was found in all measured nerves (P < 0.001), except the sural nerve (P = 0.086) compared to the controls at onset. The vagus (median 3.0 mm2 vs. 2.0 mm2, P < 0.0001) and the cervical spinal nerves were significantly enlarged (median 3.5/4.0 mm vs. 2.6/3.2 mm, p < 0.0001), the vagus most obviously in patients with autonomic dysregulation (AD, 4.0 mm2). Six months later, NCS showed persisting pathology in CMAP-amplitudes with amelioration of F-wave pathology. NUS showed restitution in the spinal nerves (median 2.6/3.2 mm) and the vagus (median 2.0 mm2) in all patients excluding the vagus in those with persistent AD (median 4.0 mm2). The peripheral nerves did not change significantly (P > 0.05).

Conclusion

Ultrasonographic detection of cervical spinal nerve enlargement supports the diagnosis of GBS in the early phase. Its regression may be a good parameter for the clinical restitution over time. Vagus enlargement may be a risk marker for development of AD.

Significance

Ultrasound is a reliable diagnostic follow-up tool in early GBS.

Introduction

Diagnosis of Guillain–Barré syndrome (GBS) is based on typical history, clinical examination, and electrophysiological studies (Asbury and Cornblath, 1990, Fokke et al., 2014, Hadden et al., 1998, Hughes and Cornblath, 2005, van den Berg et al., 2014) while serologic findings usually are available later and serve for corroboration. Many variants of GBS exist, e.g. the Miller Fisher syndrome with ataxia, areflexia, and oculomotor dysfunction (Hughes and Cornblath, 2005). The most common types are the acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and the acute motor axonal neuropathy (AMAN). Autonomic dysregulation (AD) is most dangerous in the early stage of the disease. Reduced heart rate reactions to Valsalva and deep breathing as well as blood pressure measurements are suitable methods to diagnose AD. However, no clear prognostic markers exist so far to predict AD.

The value of nerve ultrasonography (NUS) in immune-mediated polyneuropathies is well described (Beekman et al., 2005, Gallardo et al., 2015, Grimm et al., 2014a, Grimm et al., 2014b, Grimm et al., 2014c, Hobson-Webb and Cartwright, 2014, Kerasnoudis et al., 2013, Kerasnoudis et al., 2014a, Kerasnoudis et al., 2014b, Padua et al., 2012, Padua et al., 2014, Scheidl et al., 2012, Scheidl et al., 2014, Zaidman et al., 2009, Zaidman et al., 2013, Zaidman and Pestronk, 2014).

In post-GBS patients patchy and slight enlargements have been reported (Kerasnoudis et al., 2013, Zaidman et al., 2009, Zaidman et al., 2013), whereas in acute stage cervical spinal nerve enlargement and hypertrophy of the vagus are probably the most obvious findings (Gallardo et al., 2014, Grimm et al., 2014d). However, only little is known about the course of nerve morphology from onset until clinical recovery. Therefore, aim of this study is to describe the time course of NUS changes in correlation to nerve conduction studies (NCS) and clinical course.

Section snippets

Subjects

Between August 2013 and December 2014, all consecutive patients suffering from acute AIDP or AM(S)AN, presenting at participating hospitals were included in this study. Inclusion criterion was the diagnosis of acute onset polyneuropathy fulfilling the published diagnostic criteria for GBS (Asbury and Cornblath, 1990, Cornblath et al., 1988, Fokke et al., 2014, Hadden et al., 1998, Hughes and Cornblath, 2005, van den Berg et al., 2014). Exclusion criterion was symptom onset >three days before

Results

27 patients with GBS and 31 controls were included in the study. Baseline characteristics of the patients and the healthy controls are shown in Table 1. Some patients and controls of this study were already described in a former study conducted in the acute phase of GBS (Grimm et al., 2014d). 25 patients fulfilled the electrophysiological criteria for a demyelinating polyneuropathy (Hadden et al., 1998), two patients had signs of a severe axonal neuropathy with typical clinical onset of a GBS,

Discussion

The current study shows, that ultrasonic enlargement of the peripheral nerves, the cervical spinal nerves as well as the vagus occurs in the very early stage of GBS, most prominently in the spinal nerves and the vagus and may, therefore, serve as an early diagnostic indicator of GBS. However, while spinal nerve enlargement and vagus nerve hypertrophy regress consistently over six months, enlargement in many peripheral nerves persists even after six months – independently from clinical

Conclusion

Although enlargement of peripheral nerves may be less pronounced than in CIDP and no significant changes have been found over a follow-up period of half a year, the ultrasonic detection of cervical spinal nerves and vagus enlargement supports the diagnosis of GBS in the early phase. The regression of this enlargement is remarkable, but must be proven in patients with worse recovery to serve as candidate prognostic marker. Moreover, detection of vagus nerve hypertrophy in early GBS may be a

Conflict of interest

The authors report no competing interests.

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