Fulminant Guillain-Barré syndrome mimicking cerebral death: case report and literature review

Guillain Barre syndrome mimicking brain death

A 49-year-old female patient presented at the hospital with a history of herpetic blisters, frequent episodes of vomiting and loose stools, bilateral upper and lower limb weakness, and diminishing sensorium. She was diagnosed with hyponatraemia and respiratory failure and later became unconscious with absent brainstem reflexes. The patient was initially treated for herpetic encephalitis, a chronic obstructive pulmonary disease with acute exacerbation, hyponatraemia and neuroparalytic snake bite. Further evaluation, however, identified the uncommon Guillain Barre syndrome presentation with overlap of Bickerstaff brainstem encephalitis. This is an uncommon disorder characterised by the involvement of higher mental functions, fixed dilated pupils, absent brainstem reflexes and quadriplegia that resembles a neuroparalytic snake bite and brain death. After receiving intravenous immunoglobulins for treatment, the patient completely recovered.

New developments in guidelines for brain death/death by neurological criteria

The declaration of brain death (BD), or death by neurological criteria (DNC), is medically and legally accepted throughout much of the world. However, inconsistencies in national and international policies have prompted efforts to harmonize practice and central concepts, both between and within countries. The World Brain Death Project was published in 2020, followed by notable revisions to the Canadian and US guidelines in 2023. The mission of these initiatives was to ensure accurate and conservative determination of BD/DNC, as false-positive determinations could have major negative implications for the medical field and the public's trust in our ability to accurately declare death. In this Review, we review the changes that were introduced in the 2023 US BD/DNC guidelines and consider how these guidelines compare with those formulated in Canada and elsewhere in the world. We address controversies in BD/DNC determination, including neuroendocrine function, consent and accommodation of objections, summarize the legal status of BD/DNC internationally and discuss areas for further BD/DNC research.

What happens in the brain when we die? Deciphering the neurophysiology of the final moments in life

When do we die and what happens in the brain when we die? The mystery around these questions has engaged mankind for centuries. Despite the challenges to obtain recordings of the dying brain, recent studies have contributed to better understand the processes occurring during the last moments of life. In this review, we summarize the literature on neurophysiological changes around the time of death. Perhaps the only subjective description of death stems from survivors of near-death experiences (NDEs). Hallmarks of NDEs include memory recall, out-of-body experiences, dreaming, and meditative states. We survey the evidence investigating neurophysiological changes of these experiences in healthy subjects and attempt to incorporate this knowledge into the existing literature investigating the dying brain to provide valuations for the neurophysiological footprint and timeline of death. We aim to identify reasons explaining the variations of data between studies investigating this field and provide suggestions to standardize research and reduce data variability.

Computed Tomography Angiography (CTA) in Selected Scenarios with Risk of Possible False-Positive or False-Negative Conclusions in Diagnosing Brain Death

It is widely accepted that brain death (BD) is a diagnosis based on clinical examination. However, false-positive and false-negative evaluation results may be serious limitations. Ancillary tests are used when there is uncertainty about the reliability of the neurologic examination. Computed tomography angiography (CTA) is an ancillary test that tends to have the lowest false-positive rates. However, there are various influencing factors that can have an unfavorable effect on the validity of the examination method. There are inconsistent protocols regarding the evaluation criteria such as scoring systems. Among the most widely used different scoring systems the 4-point CTA-scoring system has been accepted as the most reliable method. Appropriate timing and/or Doppler pre-testing could reduce the number of possible premature examinations and increase the sensitivity of CTA in diagnosing cerebral circulatory arrest (CCA). In some cases of inconclusive CTA, the whole brain computed tomography perfusion (CTP) could be a crucial adjunct. Due to the increasing significance of CTA/CTP in determining BD, the methodology (including benefits and limitations) should also be conveyed via innovative electronic training tools, such as the BRAINDEXweb teaching tool based on an expert system.

Brain death: a clinical overview

Brain death, also commonly referred to as death by neurologic criteria, has been considered a legal definition of death for decades. Its determination involves many considerations and subtleties. In this review, we discuss the philosophy and history of brain death, its clinical determination, and special considerations. We discuss performance of the main clinical components of the brain death exam: assessment of coma, cranial nerves, motor testing, and apnea testing. We also discuss common ancillary tests, including advantages and pitfalls. Special discussion is given to extracorporeal membrane oxygenation, target temperature management, and determination of brain death in pediatric populations. Lastly, we discuss existing controversies and future directions in the field.

Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project

IMPORTANCE

There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries.

OBJECTIVE

To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel.

PROCESS

Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery.

EVIDENCE SYNTHESIS

Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed.

RECOMMENDATIONS

Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability.

CONCLUSIONS AND RELEVANCE

This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.

Misinterpretations of Guidelines Leading to Incorrect Diagnosis of Brain Death: A Case Report and Discussion

Guidelines describe the process necessary for the diagnosis of brain death. We present a case of a 3-month-old former 36-week-gestation infant after a prolonged out-of-hospital cardiac arrest of 37 minutes who was clinically diagnosed as brain dead at 120 hours after the event. Unusual findings included a normal slightly sunken anterior fontanelle, normal cerebral blood flow perfusion scan at 73 hours after the event, only localized parieto-temporal edema on the latest computed tomographic (CT) scan of the brain at 48 hours after the event, and discussion of whether nonconvulsive seizures could have confounded the examination for brain death. In light of these unusual findings, we discuss and highlight what may be common misinterpretations of brain death guidelines that led to the mistaken diagnosis of death (as opposed to severe neurologic injury) in this child.

What to exclude when brain death is suspected

BACKGROUND

With advances in critical care and organ donation, diagnosis of brain death is gaining importance. We aimed to assess potential brain death confounders from the literature, elucidating clinical presentation and diagnostic approaches in these cases.

METHODS

PubMed and Embase were screened using 37 predefined search terms to identify suitable articles reporting cases, case series, or cohort studies in adults.

RESULTS

Out of 4769 articles, 40 case reports or case series describing 45 patients with 19 critical conditions were identified. Mortality was 11% and full recovery 33%. Intoxications (42%; mainly anti-seizure drugs and baclofen) and polyneuritis (37%) were most frequent. Brainstem reflex tests were reported in 96%, apnoea test in 16% and ancillary tests in all but one patient. Full recovery mainly occurred with intoxications. Quality of evidence regarding frequency of confounders is very low and risk of bias high.

CONCLUSIONS

Brain death confounders are infrequently reported and formal studies are lacking. Mainly younger patients with polyneuritis and intoxications are described. As outcome, especially in the latter, is often favourable, high awareness and strict adherence to guidelines is crucial. The importance of identifying pathologies compatible with extensive and irreversible brain damage before proceeding to diagnostic tests should be emphasized.

Fulminant Guillain-Barré syndrome showing severe pharyngeal-cervical-brachial weakness in the recovery phase: a case report

Background

Fulminant Guillain-Barré syndrome (GBS) is characterized clinically by rapid progression of severe symptoms, such as the absence of brainstem reflexes, complete tetraplegia and respiratory arrest. The clinical course of fulminant GBS remains unclear. Here, we report a patient with fulminant GBS, who showed severe weakness of the pharyngeal-cervical-branchial (PCB) area in the recovery phase.

Case presentation

A 38-year-old man rapidly developed fulminant GBS. In blood examination, he was positive for a broad range of anti-ganglioside antibodies, including anti-GQ1b, GT1a, GT1b, GD1a, GD1b and GD3 IgG antibodies. We performed immunosuppressive therapies using intravenous immunoglobulin and intravenous methylprednisolone. Although disturbance of consciousness and weakness of the distal upper and lower limbs improved gradually, weakness of the oropharynx, neck, and proximal upper limbs were resistant to these therapies. Anti-GT1a IgG antibodies remained persistently positive. Consequently, mechanical ventilation and tube feeding were required for 7 and 10 months, respectively. Two years later, weakness of the proximal upper limbs and mild respiratory dysfunction remained as sequelae.

Conclusion

Anti-GT1a IgG antibodies are known to be detected in patients with the PCB variant of GBS. In fulminant GBS, the persistent presence of anti-GT1a IgG antibodies may be associated with occurrence of severe PCB-like weakness in the recovery phase.

Guillain-Barré syndrome as a complication of hypertensive basal ganglia haemorrhage

We aimed to study the potential relationship of Guillain-Barré syndrome (GBS) and intracranial haemorrhage (ICH). We present a case of a 70-year-old hypertensive woman who developed global weakness, eventually becoming quadriplegic, during an inpatient stay for treatment of a basal ganglia haemorrhagic stroke. Guillain-Barré syndrome was confirmed and treatment initiated. She responded well to intravenous immunoglobulin treatment and then subsequently continued with rehabilitation. There have been a few case reports of GBS as a complication of spontaneous intracranial haemorrhage (ICH) or traumatic brain injury. It may not be a coincidence that our patient developed GBS shortly after presentation. There may be an immunological explanation with immune activation following neuronal injury after ICH with associated blood-brain barrier breakdown. GBS following ICH adds further complexity to treating patients who are already critically ill. If patients develop new weakness after ICH, there should be a high index of suspicion for GBS. It should be distinguished from critical illness neuropathy/myopathy and other causes of weakness in critical care patients because the treatment is very different. Immune activation and sensitization to myelin-associated proteins may be the underlying pathophysiological basis.

Successful Management of Fulminant Guillain-Barré Syndrome and Its Complications

A 3-year-old girl presented with muscle weakness of her limbs and trunk 6 days after developing symptoms of common cold. Two days later, she experienced respiratory arrest with a Glasgow Coma Scale score of 3, necessitating endotracheal intubation. Therefore, she was transferred to our hospital with suspected acute encephalopathy. Although no abnormalities were observed on brain and spinal magnetic resonance imaging and electroencephalography, peripheral nerve conduction velocity tests failed to evoke motor and sensory nerve action potentials. Thus, we gave a diagnosis of fulminant Guillain-Barré syndrome and initiated immunoglobulin therapy. On day 3 of admission, she developed sinus tachycardia that induced circulatory failure and oliguria, which was successfully treated with landiolol. Subsequently, we performed plasmapheresis followed by immunoglobulin and steroid pulse therapies. She was weaned off the mechanical ventilator by day 20 of admission, was ambulatory by day 44, and had completely recovered without any adverse sequelae by day 55. In conclusion, landiolol was effective for treating acute sinus tachycardia-induced circulatory failure and played a key role in saving the life of this patient.

Case report: subacute tetraplegia in an immunocompromised patient

Background

Clinical reasoning in Neurology is based on general associations which help to deduce the site of the lesion. However, even “golden principles” may occasionally be deceptive. Here, we describe the case of subacute flaccid tetraparesis due to motor cortical lesions. To our knowledge, this is the first report to include an impressive illustration of nearly symmetric motor cortical involvement of encephalitis on brain MRI.

Case presentation

A 51 year old immunocompromized man developed a high-grade pure motor flaccid tetraparesis over few days. Based on clinical presentation, critical illness polyneuromyopathy was suspected. However, brain MRI revealed symmetrical hyperintensities strictly limited to the subcortical precentral gyrus. An encephalitis, possibly due to CMV infection, turned out to be the most likely cause.

Conclusion

While recognition of basic clinical patterns is indispensable in neurological reasoning, awareness of central conditions mimicking peripheral nervous disease may be crucial to detect unsuspected, potentially treatable conditions.

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.

A case of severe chronic inflammatory demyelinating polyradiculoneuropathy with monoclonal gammopathy of undetermined significance with alternating immunoglobulin class to IgM from IgA

A 71-year-old woman with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) with IgA-λ monoclonal gammopathy of undetermined significance (MGUS) showed the acute development of tetraplegia, respiratory failure, and a marked fluctuation of the blood pressure. Intravenous (IV) high-dose steroid therapy (methylprednisolone: 1 g/day × 3 days), followed by oral prednisolone (PSL) (40 mg/day), and IV immunoglobulin (IVIg, 0.4 g/kg/day × 5 days) administrations resulted in the amelioration of these symptoms. However, they soon relapsed, which eventually led to complete tetraplegia and the need for mechanical ventilation. At this time, serum components of IgA-λ and IgM-λ were biclonally positive. Seven courses of plasma exchange and the alternative administration of dexamethasone (12 mg/day) and methtorexate (15 mg/week) were conducted, but with no significant improvement. Nine months after admission, she showed totally-locked in syndrome. Cryo-preserved serum obtained at this time showed high titers of IgM class antibodies against ganglioside (GD3 +++, GT1a ++++, GT1b ++, GQ1b +++, and GD1b +++), which had been negative on admission. Biopsy of the left sural nerve showed moderate reductions of large and small myelinated fibers with no inflammation, no depositions of amyloid, IgG, IgA, or IgM, and teased fiber findings revealed neither myelin ovoids nor segmental demyelination. Alternatively, melphalan at 5 mg and PSL at 32 mg were administered, with no amelioration, while serum IgA-λ monoclonal protein diminished, and IgM-λ M protein positivity was continuously observed. She frequently developed sepsis; therefore, we could no longer continue any immunosupressive therapies, but monthly IVIg administrations were given. Twelve months after admission, her neurological symptoms gradually improved and she was weaned off of mechanical ventilation. Eighteen months after admission, her muscle strength corresponded to 2 on manual muscle testing, and wheelchair transfer became possible. To the best of our knowledge, the present case is the first report of CIDP with MGUS showing an alternating immunoglobulin class.

Brain death

Since the Harvard report of 1968, the concept of brain death has become widely recognized throughout the world. Most developed countries have accepted brain death as constituting death of the individual, and allow such patients to be used as ‘heart-beating’ organ donors. Although the US and most other countries accept a ‘whole-brain’ definition of brain death, the concept of brainstem death has been adopted in the UK. This article describes the UK diagnostic criteria in detail, and compares these with the criteria used in other countries. Management of the brain dead organ donor is described, and controversies relating to the concept of brain death are also discussed.

A Case of Acute Motor Axonal Neuropathy Mimicking Brain Death and Review of the Literature

We describe a case report of fulminant Guillain-Barré syndrome (GBS) mimicking brain death. A previously healthy 60-year-old male was admitted to the neurointensive care unit after developing rapidly progressive weakness and respiratory failure. On presentation, the patient was found to have absent brainstem and spinal cord reflexes resembling that of brain death. Acute motor axonal neuropathy, a subtype of GBS, was diagnosed by cerebrospinal fluid and nerve conduction velocity testing. An electroencephalogram showed that the patient had normal, appropriately reactive brain function. Transcranial Doppler (TCD) ultrasound showed appropriate blood flow to the brain. GBS rarely presents with weakness so severe as to mimic brain death. This article provides a review of similar literature. This case demonstrates the importance of performing a proper brain death examination, which includes evaluation for irreversible cerebral injury, exclusion of any confounding conditions, and performance of tests such as electroencephalography and TCDs when uncertainty exists about the reliability of the clinical exam.

Locked-in-like fulminant infantile Guillain-Barré syndrome associated with herpes simplex virus 1 infection

INTRODUCTION

Guillain-Barré syndrome (GBS) may rarely manifest as a peripheral locked-in syndrome.

METHODS

Clinical and instrumental features of a fulminant form of infantile GBS were assessed.

RESULTS

After 2 days of rhinitis, a 6-month-old infant was intubated in the emergency room for sudden-onset respiratory failure. Neurological examination showed generalized areflexic flaccid paralysis with no detectable interaction, which resembled a coma. Brain MRI was normal. Lumbar puncture showed pleocytosis (43 cells/mm(3)) and herpes simplex virus 1 (HSV1) PCR positivity. EEG showed normal sleep-wake cycles, and EMG demonstrated nerve inexcitability. Acyclovir and immunoglobulins provided no benefit. After 1 week, lumbar puncture showed albuminocytological dissociation (protein 217 mg/dl). Plasmapheresis was then started, and progressive improvement occurred. At age 1 year, the child had recovered well with residual distal lower limb hyporeflexic weakness.

CONCLUSIONS

A fulminant infantile GBS variant presenting as peripheral locked-in syndrome can be associated with HSV1 infection likely due to autoimmune cross-reactivity.

Simulation of Brain Death from Fulminant De-efferentation

Background:

Guillain-BarrÈ syndrome (GBS) classically presents with a subacutely evolving areflexic paralysis, with typical laboratory findings of elevated cerebrospinal fluid protein and abnormal nerve conduction studies. There is now an increasing recognition of GBS variants that differ in clinical presentation, prognosis, electrophysiology and presumed pathogenesis. Fulminant cases of GBS have been reported in which a rapid deterioration evolves to a clinical state resembling ìbrain deathî.

Methods:

A retrospective analysis of two such cases of fulminant neuropathy are described, that includes the clinical course, electrophysiology and neuropathology where available.

Results:

We describe two patients that presented with a rapid course of neurological deterioration, lapsing into what resembled a ìclinically brain-deadî state that was subsequently ascribed to a fulminant polyneuropathy. Investigations (electrophysiological, pathological) and the clinical course suggested an axonal neuropathy.

Conclusion:

A fulminant neuropathy can result in a clinical state resembling ìbrain deathî through diffuse de-efferentation. Although generally attributed to aggressive demyelination with secondary axonal degeneration, a primary axonopathy can also lead to a similar clinical presentation.

Difference in central and peripheral recovery in a patient with severe axonal motor neuropathy and central nervous system involvement and review of literature

In the literature, the term fulminant Guillain-Barré syndrome is used to refer to patients with Guillain-Barré syndrome with rapidly progressive and severe weakness and/or comatose state mimicking brain death. We present the case of a 53-year-old man with fulminant Guillain-Barré syndrome with discrepancy in central nervous system and peripheral nervous system recovery. Our review of literature confirms that these patients often have good and relatively rapid recovery of central nervous system function, whereas peripheral nervous system function is relatively delayed and often incomplete.

Fulminant inflammatory neuropathy mimicking cerebral death

We report a case of a 44-year-old woman who developed rapidly progressive tetraparesis followed by respiratory failure and abolition of brainstem reflexes. Electrodiagnostic studies excluded the possibility of cerebral death and confirmed the diagnosis of acute motor-sensory axonal neuropathy. The initial fulminant course of the disease was followed by slow recovery to independence in daily activities.

Locked-in syndrome in three children with Guillain-Barré syndrome

Locked-in syndrome is a rare disorder in childhood. It resembles brain death, but patients are fully conscious, and incapable of communicating because of the complete paralysis of voluntary muscles. Although it can be caused by Guillain-Barré syndrome, it is rarely reported in pediatrics. We describe three pediatric cases of locked-in syndrome in patients with Guillain-Barré syndrome presenting acute tetraplegia, areflexia, cranial nerve involvement, and albuminocytologic dissociation in the cerebrospinal fluid. Electrophysiologic studies indicated acute motor axonal polyradiculoneuropathy in one patient, and acute motor sensory axonal polyradiculoneuropathy in the other two. Most Guillain-Barré syndrome patients with locked-in syndrome demonstrate nerve inexcitability in neurophysiologic studies, poor clinical outcomes, and increased risk of sequelae.

Diagnosis of brain death

Brain death (BD) should be understood as the ultimate clinical expression of a brain catastrophe characterized by a complete and irreversible neurological stoppage, recognized by irreversible coma, absent brainstem reflexes, and apnea. The most common pattern is manifested by an elevation of intracranial pressure to a point beyond the mean arterial pressure, and hence cerebral perfusion pressure falls and, as a result, no net cerebral blood flow is present, in due course leading to permanent cytotoxic injury of the intracranial neuronal tissue. A second mechanism is an intrinsic injury affecting the nervous tissue at a cellular level which, if extensive and unremitting, can also lead to BD. We review here the methodology of diagnosing death, based on finding any of the signs of death. The irreversible loss of cardio-circulatory and respiratory functions can cause death only when ischemia and anoxia are prolonged enough to produce an irreversible destruction of the brain. The sign of such loss of brain functions, that is to say BD diagnosis, is fully reviewed.

Guillain-Barré syndrome with absent brainstem reflexes--a report of two cases

Guillain-Barré syndrome, known for its diverse, atypical and heterogeneous range of presentations, can rarely present in an apparent comatose state with absent brainstem reflexes. Two patients presented in an unresponsive state with flaccid quadriplegia, total areflexia with no response to cephalic or peripheral painful stimuli. Pupils were mid-dilated with absent direct and consensual light reflex. All cranial nerve reflexes were absent. Preliminary laboratory investigations and complementary tests were normal. Cerebrospinal fluid evaluation showed albumincytological dissociation. Brain magnetic resonance imaging and electroencephalogram were normal. Both were diagnosed as fulminant Guillain-Barre syndrome. Despite an absence of brainstem reflexes neither patient fulfilled diagnostic criteria for brain death.

Fulminant Guillain–Barré syndrome after closed head injury: a potentially reversible cause of an ominous examination

✓ Fulminant Guillain–Barré syndrome (GBS) is a rapidly progressive form of polyneuropathy in which patients demonstrate eventual flaccid quadriplegia and an absence of brainstem function. Most patients present after a mild upper respiratory or gastrointestinal illness and have nondiagnostic cerebral imaging studies. The authors present a case of fulminant GBS that developed in a 55-year-old alcoholic man 1 week after admission for a closed head injury. The details of this case and a discussion of GBS will be presented. This case provides evidence for combined central and peripheral nervous system involvement in severe cases of GBS. Recognition of fulminant GBS is important to prevent inappropriate declaration of brain death or withdrawal of support in the face of a potentially reversible process.

Fulminant guillain-barré syndrome mimicking cerebral death following acute viral hepatitis a

A 32-year-old man was transferred to an intensive care unit due to respiratory difficulties with a 4-day history of progressive areflexic quadriparesis following acute hepatitis A. A nerve-conduction study revealed inexcitability of most nerves. The cerebrospinal fluid showed albuminocytologic dissociation, suggesting Guillain-Barré syndrome (GBS). The patient appeared brain dead on day 4, showing absent brainstem reflexes, respiratory failure, and fully dilated and fixed pupils. This case is an example of how GBS can evolve and simulate a brain-dead state from fulminant deafferentation following acute hepatitis A.

Approach to the comatose patient

BACKGROUND

Coma is a medical emergency and may constitute a diagnostic and therapeutic challenge for the intensivist.

OBJECTIVE

To review currently available data on the etiology, diagnosis, and outcome of coma. To propose an evidence-based approach for the clinical management of the comatose patient.

DATA SOURCE

Search of Medline and Cochrane databases; manual review of bibliographies from selected articles and monographs.

DATA SYNTHESIS AND CONCLUSIONS

Coma and other states of impaired consciousness are signs of extensive dysfunction or injury involving the brainstem, diencephalon, or cerebral cortex and are associated with a substantial risk of death and disability. Management of impaired consciousness includes prompt stabilization of vital physiologic functions to prevent secondary neurologic injury, etiological diagnosis, and the institution of brain-directed therapeutic or preventive measures. Neurologic prognosis is determined by the underlying etiology and may be predicted by the combination of clinical signs and electrophysiological tests.

The interpretation of the EEG in stupor and coma

This review discusses a variety of causes of stupor and coma and associated electroencephalographic (EEG) findings. These include metabolic disturbances such as hepatic or renal dysfunction, which are often characterized by slowing of background rhythms and triphasic waves. Hypoxia and drug intoxications can produce a number of abnormal EEG patterns such as burst suppression, alpha coma, and spindle coma. Structural lesions, either supra- or infratentorial, are reviewed. EEGs in the former may show focal disturbances such as delta and theta activity, epileptiform abnormalities, and attenuation of faster frequencies. In infratentorial lesions, the EEG may appear normal, particularly with a pontine lesion. Some patients may be encephalopathic because of ongoing epileptic activity with minimal or no motor movements. This entity, nonconvulsive status epilepticus (NCSE), is difficult to diagnose in obtunded/comatose patients, and an EEG is required to verify the diagnosis and to monitor treatment. Several EEG patterns and their interpretation in suspected cases of NCSE such as periodic lateralized epileptiform discharges (PLEDs), bilateral independent periodic lateralized epileptiform discharges (BIPLEDs), generalized periodic epileptiform discharges (GPEDs), and triphasic waves are reviewed. Other entities discussed include the locked-in syndrome, neocortical death, persistent vegetative state, brainstem death, and brain death.

Anti-phospholipid antibodies in serum from patients with Guillain-Barré syndrome

OBJECTIVE

The Guillain-Barré syndrome (GBS) is an acute inflammatory polyneuropathy related to autoimmunity. However, no conclusive etiological concept has yet been found. We examined the variation in autoantibodies to lipids in serum of GBS patients in response to the course of the disease but investigated titer modifications during treatment with gamma-globulin.

DESIGN AND SETTING

Prospective clinical study in a 14-bed general ICU.

PATIENTS

Nine patients with GBS and nine controls were included in the study.

MEASUREMENTS AND RESULTS

Four blood samples were obtained before and after treatment. Serum samples, diluted 1:60, were tested by enzyme-linked immunosorbent assay for IgM, IgA, and IgG antibodies to phosphatidylcholine, phosphatidylinositol, cardiolipin, phosphatidic acid, phosphatidylserine, phosphatidylglycerol, phosphatidylethanolamine, sphingomyelin, and gangliosides. Anti-phospholipid antibodies of the IgM, IgA, and IgG families were detected in all GBS patients but in none of the controls. Phosphatidylinositol, cardiolipin, phosphatidylcholine, and phosphatidic acid were the main antigens. All patients developed anti-phosphatidylinositol antibodies of the IgM family and anti-cardiolipin antibodies of the IgA and IgG families. A decrease in the level of anti-phospholipid autoantibodies was observed after 1 day of treatment with gamma-globulin. Two days after ending gamma-globulin administration the IgG antibodies increased again.

CONCLUSIONS

Our findings suggest that in GBS there is an extensive immune reaction, which is altered after gamma-globulin treatment. Anti-cardiolipin and anti-phosphatidylinositol antibodies could be useful markers for the response to treatment.

Variability among hospital policies for determining brain death in adults*

OBJECTIVE

In the absence of federal requirements or state statutes, criteria to certify brain death are specified by medical staff and administrative policies in individual hospitals. Variability among such policies may allow inconsistency in the declaration of death by neurologic criteria. Our intent was to partially quantify diversity among hospital standards used in brain death certification.

DESIGN

Survey.

SETTING

Six hundred randomly selected hospitals.

PATIENTS

None.

INTERVENTIONS

A survey was conducted of 600 hospitals randomly selected from the American Hospital Association registry representing 200 hospitals each of <300 beds, 300-500 beds, and >500 beds. One hundred six policies submitted by these institutions comprised the final study group. Policies were reviewed for criteria of interest and were compared against variables recommended by the American Academy of Neurology.

MEASUREMENTS AND MAIN RESULTS

Significant variability in policy criteria was found compared with the American Academy of Neurology and other authoritative standards. Differences were greatest in specifying conditions to be excluded before testing and in specific testing methods during a detailed physical examination. The few differences noted between larger vs. smaller hospitals most likely reflect greater availability of resources in larger institutions.

CONCLUSIONS

Differences among hospital policies for certification of brain death may permit variability among hospitals throughout the United States in the pronouncement of death by neurologic criteria. Standardization and enforcement of policies that ensure the highest possible accuracy should be considered.

Brainstem death testing in the UK'time for reappraisal? †

BACKGROUND

A diagnosis of brainstem death in the UK is based on clinical assessment rather than technical investigations, but is considered rigorous enough to be legally synonymous with death.

METHODS

A questionnaire in five sections concerning clinician details, initiation of support, criteria for testing, conduct of the tests, and the process of organ donation, was sent to all members of the Neuroanaesthesia Society.

RESULTS

The survey reveals evidence of failure to apply existing guidelines accurately and a wide variation in practice where the recommendations are not specific.

CONCLUSIONS

In an era of scrutiny of medical process, it is timely to consider whether the current guidelines should be revisited. Clarification of the approach to biochemical derangement, and the role of confirmatory tests when the residual effect of sedative agents cannot be excluded, are two areas worthy of debate.

Clinical deterioration in Bickerstaff's brainstem encephalitis caused by overlapping Guillain-Barré syndrome

A 37-year-old man developed an acute encephalitic condition after respiratory infection. His condition rapidly deteriorated, and he experienced ophthalmoplegia, tetraplegia, loss of brainstem reflexes and deep tendon reflexes, and deep coma. Electrophysiological evaluations indicated involvement of the peripheral nerve as well as the brainstem. Follow-up studies found acute progression of peripheral nerve damage. Serum anti-GQ1b IgG antibody was present. The initial condition was diagnosed as Bickerstaff's brainstem encephalitis, and subsequent overlapping of Guillain-Barré syndrome probably was responsible for the clinical deterioration. When unusual worsening is observed in clinically suspected encephalitis, neurologists must take into account the possibility of associated Guillain-Barré syndrome and related disorders.

Outcomes of patients referred for confirmation of brain death by 99mTc-exametazime scintigraphy

OBJECTIVE

To review clinical outcomes in patients referred for confirmation of brain death by (99m)Tc-labelled exametazime scintigraphy and to assess any tangible benefit.

DESIGN AND SETTING

A retrospective casenote review in the intensive care unit and nuclear medicine department of a tertiary-level acute care hospital.

PATIENTS AND PARTICIPANTS

66 consecutive patients, in whom a clinical diagnosis of brain death was not possible, undergoing (99m)Tc-labelled exametazime scintigraphy from February 1993 to March 2002, and for 56 of whom casenotes were available for review.

MEASUREMENTS AND RESULTS

Brain death was confirmed in 77% on the basis of absent supratentorial and infratentorial uptake. Where brain death was not confirmed, a normal scan was seen in 30%, the remainder showing patchy reduced infratentorial and/or supratentorial uptake. All patients with the scintigraphic appearance of brain death subsequently died. Even when brain death could not be confirmed, 11 of 13 patients died soon afterwards. Two patients with normal brain scintigraphy regained consciousness and survived for an extended period. When brain death was not confirmed by scintigraphy, elapsed time to certification of death was longer (44.7 vs. 7 h) and organ donation was less common even when a subsequent clinical diagnosis was made.

CONCLUSIONS

The results indicate that patient prognosis remains poor regardless of the findings on (99m)Tc-labelled exametazime scintigraphy, but that the scan result influences the elapsed time to withdrawal of therapy or organ donation, providing a significant cost benefit, and occasionally a long-term survivor is seen.

Major surgery with Guillain-Barré syndrome: a case report

Guillain-Barré syndrome (GBS) is an acute demyelinating polyneuropathy characterized by progressive muscle weakness and areflexia. The pathogenesis of GBS is unknown, but it is generally believed to result from aberrant humoral and cellular immune responses against components of the peripheral nervous system. The overall prognosis of GBS is quite good with approximately 85% of survivors making a good functional recovery. When a diagnosis of GBS has been made, appropriate treatment should be started as early as possible. This may include supportive care in intensive care units, ventilatory assistance, monitoring of blood pressure, fluid status, cardiac rhythm, nutritional supports and medical therapy. Our patient reached maximum deficiency 3 weeks after the onset of GBS. Full recovery took 8 months. The occurrence of GBS after major surgery is rare. We believe that major surgical stress may be the potential triggering factor for the occurrence of GBS in this case report.