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Libonati L, Fiorini I, Cambieri C, Ceccanti M, Inghilleri M. A case of acute motor and sensory axonal neuropathy mimicking brain death. Neurol Sci 2021; 42:2569-2573. [PMID: 33459892 DOI: 10.1007/s10072-021-05051-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 01/08/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Laura Libonati
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Ilenia Fiorini
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Chiara Cambieri
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Marco Ceccanti
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Maurizio Inghilleri
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy.
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Arsenijević M, Berisavac I, Mladenović B, Stanarčević P, Jovanović D, Lavrnić D, Peric S. Rate of progression of Guillain-Barré syndrome is not associated with the short-term outcome of the disease. Ir J Med Sci 2020; 190:357-361. [PMID: 32666503 DOI: 10.1007/s11845-020-02310-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/11/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There are no many data on association between progression rate of Guillain-Barré syndrome (GBS) and disease outcome. AIM The aim of our study was to analyze short-term outcome of GBS in relation to the rate of disease progression. METHODS Our retrospective study included patients diagnosed with GBS in seven tertiary healthcare centers from 2009 to 2014. According to the rate of disease progression from onset of symptoms to the nadir, patients were divided in three groups: rapid-onset GBS (nadir reached in maximum 48 h), gradual-onset (nadir reached in three to 14 days), and slow-onset (nadir in 15 to 28 days). GBS disability scale (GDS) was used to assess functional disability at nadir and on discharge. RESULTS Among 380 patients included in the study, 24 (6.3%) patients had rapid-onset, 274 (72.1%) gradual-onset, and 82 (21.6%) slow-onset GBS. Time from the onset of the disease to the hospital admission was much shorter in faster-onset forms (3.0 ± 4.1 days in rapid-onset vs. 6.8 ± 9.5 days in gradual-onset and 21.0 ± 9.6 days in slow-onset GBS, p < 0.01). Preceding events were less commonly identified in slow-onset forms. Patients with rapid-onset GBS were more likely to have axonal variants (p < 0.05). All three groups of patients were treated in a similar way, and there were no differences in GDS score at nadir (p > 0.05) and on discharge (p > 0.05) and no differences in the duration of hospital stay. CONCLUSION Faster progression of GBS does not imply a poorer short-term functional outcome of the disease.
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Affiliation(s)
- Mirjana Arsenijević
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Dr Subotića 6, Belgrade, 11129, Serbia
| | - Ivana Berisavac
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Dr Subotića 6, Belgrade, 11129, Serbia
| | - Branka Mladenović
- Physical Medicine and Rehabilitation Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Predrag Stanarčević
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Dr Subotića 6, Belgrade, 11129, Serbia
| | - Dejana Jovanović
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Dr Subotića 6, Belgrade, 11129, Serbia
| | - Dragana Lavrnić
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Dr Subotića 6, Belgrade, 11129, Serbia
| | - Stojan Peric
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Dr Subotića 6, Belgrade, 11129, Serbia.
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Joffe AR, deCaen A, Garros D. Misinterpretations of Guidelines Leading to Incorrect Diagnosis of Brain Death: A Case Report and Discussion. J Child Neurol 2020; 35:49-54. [PMID: 31566107 DOI: 10.1177/0883073819876474] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
| | - Allan deCaen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
| | - Daniel Garros
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
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Bayne T, Seth AK, Massimini M. Are There Islands of Awareness? Trends Neurosci 2020; 43:6-16. [DOI: 10.1016/j.tins.2019.11.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/30/2019] [Accepted: 11/08/2019] [Indexed: 12/26/2022]
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Grzonka P, Tisljar K, Rüegg S, Marsch S, Sutter R. What to exclude when brain death is suspected. J Crit Care 2019; 53:212-217. [PMID: 31277047 DOI: 10.1016/j.jcrc.2019.06.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 06/18/2019] [Accepted: 06/28/2019] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Pascale Grzonka
- Medical Intensive Care Units, University Hospital Basel, Switzerland.
| | - Kai Tisljar
- Medical Intensive Care Units, University Hospital Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, Switzerland; Medical faculty, University of Basel, Switzerland
| | - Stephan Marsch
- Medical Intensive Care Units, University Hospital Basel, Switzerland; Medical faculty, University of Basel, Switzerland
| | - Raoul Sutter
- Medical Intensive Care Units, University Hospital Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Medical faculty, University of Basel, Switzerland
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Rougé A, Lemarié J, Gibot S, Bollaert PE. Long-term impact after fulminant Guillain-Barré syndrome, case report and literature review. Int Med Case Rep J 2016; 9:357-363. [PMID: 27853394 PMCID: PMC5106230 DOI: 10.2147/imcrj.s112050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Alain Rougé
- Medical Intensive Care Unit, Hôpital Central, University Hospital of Nancy, Nancy, France; INSERM UMRS-1116, Faculty of Medicine, University of Lorraine, Nancy, France
| | - Jérémie Lemarié
- Medical Intensive Care Unit, Hôpital Central, University Hospital of Nancy, Nancy, France; INSERM UMRS-1116, Faculty of Medicine, University of Lorraine, Nancy, France
| | - Sébastien Gibot
- Medical Intensive Care Unit, Hôpital Central, University Hospital of Nancy, Nancy, France; INSERM UMRS-1116, Faculty of Medicine, University of Lorraine, Nancy, France
| | - Pierre Edouard Bollaert
- Medical Intensive Care Unit, Hôpital Central, University Hospital of Nancy, Nancy, France; INSERM UMRS-1116, Faculty of Medicine, University of Lorraine, Nancy, France
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Ravikumar S, Poysophon P, Poblete R, Kim-Tenser M. A Case of Acute Motor Axonal Neuropathy Mimicking Brain Death and Review of the Literature. Front Neurol 2016; 7:63. [PMID: 27199887 PMCID: PMC4844925 DOI: 10.3389/fneur.2016.00063] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/11/2016] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Sandhya Ravikumar
- Department of Neurology, University of Southern California , Los Angeles, CA , USA
| | - Poysophon Poysophon
- Department of Neurology, University of Southern California , Los Angeles, CA , USA
| | - Roy Poblete
- Department of Neurology, University of Southern California , Los Angeles, CA , USA
| | - May Kim-Tenser
- Department of Neurology, University of Southern California , Los Angeles, CA , USA
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Young GB. De-efferentation and De-afferentation in Fulminant Polyneuropathy: Lessons from the Isolated Brain. Can J Neurol Sci 2014; 30:305-6. [PMID: 14672260 DOI: 10.1017/s0317167100002997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Difference in central and peripheral recovery in a patient with severe axonal motor neuropathy and central nervous system involvement and review of literature. J Clin Neuromuscul Dis 2013; 14:110-3. [PMID: 23492462 DOI: 10.1097/cnd.0b013e3182852542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Liik M, Puksa L, Lüüs SM, Haldre S, Taba P. Fulminant inflammatory neuropathy mimicking cerebral death. BMJ Case Rep 2012; 2012:bcr1020114906. [PMID: 22822111 PMCID: PMC4543139 DOI: 10.1136/bcr-10-2011-4906] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Maarika Liik
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia.
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Tan IL, Ng T, Vucic S. Severe Guillain-Barré syndrome following head trauma. J Clin Neurosci 2010; 17:1452-4. [DOI: 10.1016/j.jocn.2009.11.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 10/19/2009] [Accepted: 11/22/2009] [Indexed: 11/16/2022]
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Abstract
When patients Guillain-Barré syndrome have complete paralysis clinical measures of sedation cannot be applied. In this situation continuous EEG offers a convenient, effective method of monitoring the depth of sedation, using spectral edge frequency (SEF) to quantify EEG activity. The authors report 3 patients with severe Guillain-Barré syndrome managed with sedation aimed at a SEF95 below 4.0 Hz (delta coma), using a subhairline montage with the DATEX bedside EEG module. Two of the patients were easily managed using this system for an average of 16 days, and both were completely amnestic of this period of time with no serious complication. The third one had still some residual muscle activity and SEF was unreliable in this case, so its use was abandoned. Continuous EEG monitoring using SEF is a useful tool to manage sedation in the most severely paralyzed Guillain-Barré syndrome patients. Incorporation of a low-pass filter would be of benefit to remove any residual muscle activity, which confounds the target level of sedation with this method; SEF has theoretical advantages over the bispectral index in this population. Comparative studies of various continuous EEG monitoring methods in such patients should better define their relative effectiveness.
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Pitfalls in the Diagnosis of Brain Death. Neurocrit Care 2009; 11:276-87. [DOI: 10.1007/s12028-009-9231-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Accepted: 04/28/2009] [Indexed: 11/25/2022]
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Abstract
Coma is a state of unarousable unconsciousness due to dysfunction of the brain's ascending reticular activating system (ARAS), which is responsible for arousal and the maintenance of wakefulness. Anatomically and physiologically the ARAS has a redundancy of pathways and neurotransmitters; this may explain why coma is usually transient (seldom lasting more than 3 weeks). Emergence from coma is succeeded by outcomes ranging from the vegetative state to complete recovery, depending on the severity of damage to the cerebral cortex, the thalamus, and their integrated function. The clinical and laboratory assessments of the comatose patient are reviewed here, along with an analysis of how various conditions (structural brain lesions, metabolic and toxic disorders, trauma, infections, seizures, hypothermia, and hyperthermia) produce coma. Management issues include the determination of the cause and reversibility (prognosis) of neurological impairment, support of the patient, definitive treatment when possible, and the ethical considerations for those situations where marked disability is predicted with certainty.
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Affiliation(s)
- G Bryan Young
- Department of Neurology and Critical Care Medicine, The University of Western Ontario, London, Ontario, Canada.
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Joshi MC, Azim A, Gupta GL, Poddar BP, Baronia AK, Singh RK. Guillain-Barré syndrome with absent brainstem reflexes--a report of two cases. Anaesth Intensive Care 2009; 36:867-9. [PMID: 19115659 DOI: 10.1177/0310057x0803600619] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- M C Joshi
- Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Rivas S, Douds GL, Ostdahl RH, Harbaugh KS. Fulminant Guillain–Barré syndrome after closed head injury: a potentially reversible cause of an ominous examination. J Neurosurg 2008; 108:595-600. [DOI: 10.3171/jns/2008/108/3/0595] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
✓ 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.
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Affiliation(s)
- Sharon Rivas
- 1Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania; and
| | - G. Logan Douds
- 1Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania; and
| | | | - Kimberly S. Harbaugh
- 1Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania; and
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