J Neurol Neurophysiol

ISSN: 2155-9562 JNN, an open

Volume 4 Issue 1
Research Ar ticle Open Access
Neurology &
Neurophysiology
Geetanali et al!, J Neurol
Neurophysiol 2"1#, 4:1
http:$$%&!%oi!or'$1"!41(2$2155-
9562!1"""142
R e s e a r c h A r t i c l e O p e n A c c e s
s
Early Electrodiagnostic Findings of Guillain Barre Syndrome
Sharma Geetanjali
1
*, Sood Sushma
1
and Sharma Sudhir
2
1
Department of Physiology, University of Health Sciences, Haryana, India
2
Department of Medicine, University of Health Sciences, Haryana, India
Abstract
Purpose: Guillain Barre Syndrome (GBS) is an acute immune mediated de-mylelinating poly-radiculo-
neuropathy. As early diagnosis favors a good outcome after treatment, this study was carried out to analye the
electro-physiological a!normalities in the first wee" of GBS in this region.
Basic procedures: #he study was carried out for early confirmation of GBS in $% clinically diagnosed patients
reporting within a wee" of muscle wea"ness !y electro-physiological tests in the years &'('-(&.
Results: Slowing of motor conduction velocities, decreased amplitude and increased distal motor latencies
()*+) was seen in peroneal, ti!ial, median and ulnar nerves in descending order of severity. ,onduction !loc"
was seen in the lower lim! in (' ((%.-./) patients. 0-wave was completely a!sent in upper and lower lim!s in %'
(1$.2&/) patients while (% patients (&-.'1/) showed decreased 0-wave conduction velocity in !oth lim!s. Sensory
conduction velocity of median nerve was less compared to sural. 3*G studies showed that demyelinating type of
neuropathy was predominant (.-.--/).
Discussion: 3lectro-physiological studies play an important role in the early detection4 characteriation 5
treatment of GBS !ecause timely intervention reduces mor!idity and disa!ility. 6ncreased )*+, a!sent 0- wave,
decreased median with normal Sural S,7 (sensory conduction velocity) is diagnostic of early GBS.
Keywords: Peripheral neuropathic weakness; Electro-diagnosis;
Early signs
Introduction
GBS is an auto-immune mediated de-myelinating polyradiculo-
neuropathy. Males females are e!ually at risk. "linical features
include progressi#e$ symmetrical ascending muscle weakness of more
than two lim%s$ arefle&ia with or without sensory$ autonomic and
%rainstem a%normalities '(a%le )*. +eakness is prominent in leg
muscles as compared to arms; there is a%sence of fe#er at the onset
of neural symptoms. "ranial ner#e in#ol#ement may affect airway and
facial muscles$ eye mo#ements and swallowing ,)-. .t usually presents
with num%ness and tingling in the feet ,/-.
.n )010$ 2aymaker and 3ernohan reported the histo-pathological
features of 45 fatal cases of GBS. (he earliest features were edema of
pro&imal ner#es followed %y degeneration of myelin sheath within the
)st week of illness ,6-.
Electro-diagnosis plays an important role in early detection and
characteri7ation of inflammatory de-myelinating polyradiculopathies
,1-.
8er#e conduction a%normalities %ecome more prominent
during the initial weeks of the disease e#en if patients clinical status
sent to the 9epartment of Physiology for ner#e conduction. (he study
was conducted on these :4 su%;ects '1/ males /6 females* %etween
the age group of :-<5 years using =MS EMG EP Mark-.. "handigarh.
(he criteria for clinical diagnosis of GBS were rapidly progressi#e lim%
weakness with or without distal lim% paresthesias and reduced deep
tendon refle&es.
(he parameters considered were di#ided into four ma;or groups>
). Motor conduction studies included? Median$ ulnar$ ti%ial and
peroneal conduction #elocities$ amplitude and their distal
motor latencies.
/. Sensory conduction studies included? Medial and sural ner#e
conduction #elocities.
6. F wa#e studies? F wa#e studies included F wa#e conduction
#elocity F wa#e latency. 'F wa#e is a late response resulting
from antidromic acti#ation of motor neurons in#ol#ing
conduction to and from spinal cord. F wa#e studies ha#e %een
esta%lished as a #alua%le tool in clinical neuro-physiology ,0-.
Prominent slowing of F wa#es has %een reported in GBS where
the demyelination may affect the pro&imal segment of ner#e
and e#en the roots which cannot %e assessed %y routine ner#e
conduction studies ,)5-.
is impro#ing ,4$:-. Early ner#e conduction findings include a%normal
or a%sent F wa#es with low "8@PAs$ an a%normal upper e&tremity
sensory ner#e action potential com%ined with normal sural response
and multiple indirect discharges ,1$<$B-.
Material and Methods
Ethics committee appro#al? (here was no issue of ethical
committee appro#al during this study as the patients were referred
from department of Medicine of our .nstitute for electro-diagnostic
e#aluation '(a%le /*.
(he present study was carried out to facilitate early confirmation
of clinically diagnosed cases of GBS in the )st week of illness that
were
J Neurol Neurophysiol
ISSN: 2155-9562 JNN, an open
Volume 4 Issue 1
*Corresponding author Geetan8ali Sharma, )epartment of 9hysiology,
:niversity of ;ealth Sciences, ;aryana, 6ndia4 #el: 2((&$&&(-($4 3-mail:
drgeeta(&(&<yahoo.co m
Recei!ed =ovem!er &., &'(&4 Accepted )ecem!er &2, &'(&4 Published
>anuary
(%, &'(-
Citation Geetan8ali S, Sushma S, Sudhir S (&'(-) 3arly 3lectrodiagnostic
0indings of Guillain Barre Syndrome. > =eurol =europhysiol ?: (?&.
doi:('.?(1&@&(%%-
2%$&.('''(?&
Cop"right A &'(- Geetan8ali S, et al. #his is an open-access article distri!uted
under the terms of the ,reative ,ommons Attri!ution +icense, which permits
unrestricted use, distri!ution, and reproduction in any medium, provided the
original author and source are credited.
Citation Geetan8ali S, Sushma S, Sudhir S (&'(-) 3arly 3lectrodiagnostic 0indings of Guillain Barre Syndrome. > =eurol =europhysiol ?: (?&.
doi:('.?(1&@&(%%-2%$&.('''(?&
)a'e 2 o* #
#ariables $o% o& patients
*ales@females ?&@&-
Age range $-1'
AgeB$' %2
Cea"ness $%@$%
ArefleDia %.@$%
'able 1 ,linical features in $% patients of GBS.
#ariable $o ()* o& patients
(. 0 waves A!normal, total
a. :pper lim!
A!sent %' (1$.2&/)
9rolonged latency (% (&-.'1/)
=ormal '
!. +ower lim!
A!sent %' (1$.2&/)
9rolonged latency (% (&-.'1/)
=ormal '
&. S,7
a. :pper lim!
=ormal %% (.?.$(/)
)ecrease '% (1.$2/)
A!sent '% (1.$2/)
!. +ower +im! (Sural)
=ormal ?' ($(.&2/)
)ecrease &' (-'.1$/)
A!sent % (1.$2/)
-. ,*A9 (compound muscle action potential)
A.,onduction velocity
(,7) 5 amplitude
a. :pper lim!
)ecrease in !oth :lnar 5
median nerves
?? ($1.$/)
)ecrease in only ulnar nerve . ((&.-/)
=ormal ,7 (- (&'.(/)
!. +ower lim!
)ecrease in !oth ti!ial 5
peroneal nerves
)ecrease in only ti!ial nerve
%' (1$.2&/)
% (1.$2/)
,onduction !loc" (' ((%.-./)
B. )istal motor latency
a. :pper lim!
6ncrease in !oth :lnar 5
median nerves
?& ($?/)
6ncrease in only ulnar nerve . ((&/)
!. +ower lim!
6ncrease in !oth ti!ial 5
peroneal nerves
%' (1$.2&/)
6ncrease in only ti!ial
nerve
% (1.$2/)
,onduction !loc" (' ((%.-./)
?. 3*G
)emyelinating type $' (2&.-'/)
ADonal type % (1.$2/)
'able 2 3lectro-diagnostic findings in patients with Guillain Barre Syndrome within
( wee".
1. EMG studies 'Electro-myographic studies*? "onducted in
9eltoid @%ductor digiti minimii 'Cpper Dim%* and (i%ialis
anterior Peroneus longus muscles 'lower lim%*.
Electro-diagnostic criteria
@ccording to 9utch Guillain Barre study group criteria only one
of the following a%normalities in at least two ner#es should %e
considered ,))-.
). .ncreased distal motor latencyE)45F of upper limit of normal
/. 9ecreased conduction #elocityG<5F of lower limit of normal
6. .ncreased F wa#e latencyE)45 of upper limit of normal
1. 9ecreased compound muscle action potential amplitudeEupper
limit of normal.
(he placement of electrodes was done on the %asis of the
techni!ue descri%ed %y Mishra and 3alita ,)/-.
Results
Distal motor latency
.ncreased distal motor latency '9MD* was seen in 1/ ':1F*
patients for %oth ulnar median ner#es and e&clusi#ely for ulnar
ner#e in B ')/F* patients. )4 '/6.5<F* patients had normal 9MD. Hn
the case of the lower lim%s$ increased distal motor latency was seen in
45 '<:.0/F* patients for %oth ti%ial peroneal ner#es and
e&clusi#ely for ti%ial ner#e in 4 '<.:0F* patients.
Conduction velocity and amplitude
9ecreased conduction #elocity amplitude was seen in 11
':<.:F* for %oth median ulnar ner#es and e&clusi#ely for ulnar
ner#e in B ')/.6F* patients while )6 '/5.)F* patients had normal
conduction #elocities .n lower lim%s$ decreased conduction #elocity
amplitude was seen in 45 '<:.0/F* for %oth ti%ial peroneal ner#es
and e&clusi#ely for ti%ial ner#e in 4 '<.:0F* patients. "onduction
%lock was seen in the lower lim% in )5 ')4.6BF* patients.
So$ slowing of motor conduction #elocities$ decreased amplitude
as well as increase in distal motor latencies were o%ser#ed$ %eing more
pronounced in the lower lim%s.
-wave
F-wa#e was completely a%sent in %oth upper and lower lim%s in
45 '<:.0/F* patients while )4 patients '/6.5<F* showed decreased
conduction #elocity with prolonged latency and decreased amplitude
in %oth upper and lower lim%s.
!ensory nerve action potential
9ecreased sensory conduction #elocity 'S"I* was seen in 15
':)./0F*$ a%sent S"I in /5 '65.<:F* and normal S"I in 4 '<.:0F*
patients in the upper lim%. Hn the other hand$ normal Sural ner#e S"I
,SS"I- was seen in 44 'B1.:)F*$ decreased SS"I in 4 '<.:0F* and
a%sent SS"I in 4 '<.:0F* patients in the lower lim%.
So$ sensory conduction #elocity of median ner#e was slightly less
as compared to Sural ner#e in lower lim%s.
EM"
EMG studies were carried out in 65 of the :4 patients of the
GBS group$ of which /4 'B6.66F* showed demyelinating type of
polyneuropathy with reduced #oluntary motor unit recruitment
while the remaining 4 '):.::F* patients showed a&onal type of
polyneuropathy showing dener#ation pattern.
Discussion
Electro-diagnostic studies are helpful in diagnosis and
differentiating demyelinating #ariety of GBS which responds to
treatment and has a %etter prognosis ,)6-. Electro-physiological
hallmarks of early demyelination include prolonged distal motor
latencies$ prolongedJa%sent F wa#e latencies mainly in the lower lim%s$
slow motor conduction #elocitiesJconduction %lock with a%sent F
wa#e$ and a%normal upper e&tremity sensory ner#e action potential as
compared to the sural ner#e.
)a'e # o* #
F wa#e is the most sensiti#e diagnostic test for early GBS. .n
our study$ motor conduction #elocity was decreased and pro&imal
conduction %lock was noticed mainly in the lower lim%s. (he a%o#e
results are in tandem with findings of Gordon$ Kun 3imura and
3uwahara ,1$)5$)1-. .n a study done %y =opper et al. on 1) patients of
GBS who underwent electro-diagnostic studies within a week of onset
of symptoms$ ): patients had a%normalities of compound muscle
action potentials including dispersion$ delayed latency$ low amplitude$
conduction #elocity slowing$ conduction %lock or a%normal F-wa#es
,)4-. Similar results ha#e %een !uoted %y "louston et al. ,):-.
Prolonged distal motor latencies prolonged or a%sent F wa#es
reflect early predilection for in#ol#ement of pro&imal spinal roots and
distal motor terminals. Cpper lim% S8@PAs particularly of the median
ner#e can %e affected more se#erely and earlier than those of the sural
ner#e. (he e&planation of this finding is multifactorial. Entrapment
sites are more prone i.e. median ner#e in "arpal (unnel. =educed
S8@P amplitudes can %e the result of secondary a&onal degeneration
and conduction %lock ,)<-. (he conduction %lock was ma&imal in the
terminal segment in the upper and lower lim%s$ more so in the lower
lim%. (hese findings were consistent with those of Brown ,)B-. 2e
attri%uted %eing due to relati#e deficiency of the %lood ner#e %arrier.
9ecrease in conduction #elocity is damage to the myelin sheath;
%oth cellular and immune mechanisms play important roles in it.
Early inflammatory lesions consist of lymphocytic infiltrate; later on
macrophages %ecome prominent. (he peripheral ner#e changes
consist of peri#ascular oedema$ accumulation of mono-nuclear cells
and para- nodal less commonly segmental demyelination ,)0-.
(he EMG studies were conducted on 65 of the :4 patients
%ecause of pro&imity of electro-diagnosis to the symptom onset.
EMG studies showed that demyelinating type of neuropathy was the
predominant form of GBS 'B6.66F* in our series. (his was in
consistence with the results of Lakoo% et al. ,/5-.
Conclusion
(he glo%al incidence of Guillain Barre Syndrome has %een
estimated %etween ).)J)55$555Jyear to ).BJ)55$555Jyear ,/)-. (hus$
this syndrome constitutes a ma;or load of demyelinating
polyneuropathy cases worldwide. (here seems to %e a slight
preponderance of @.9P 'acute inflammatory demyelinating
polyneuropathy* #ariety in .ndia as suggested %y Gupta et al. and
Meena et al. ,//$/6- @.9P was the preponderant #ariant in our study
i.e. in the state of 2aryana. (he results were in line with the electro-
diagnostic criteria for early diagnosis of GBS as descri%ed in
literature. Electro-diagnostic techni!ues play an important role in
the early detection and characteri7ation of inflammatory
demyelinating poly-radiculopathy in the first week of symptomology
and assume importance in treatment of this syndrome %ecause timely
inter#ention reduces mor%idity and disa%ility.
Ac+no,ledgements
#he authors sincerely than" *r. Eandhir Singh, Senior +a!oratory #echnician,
)epartment of 9hysiology, :niversity of ;ealth Sciences, for his untiring co-
operation during nerve conduction studies of the patients.
Re&erences
(. ;auser S+, As!ury AF (&''2) Guillain-Barre Syndrome 5 other immune-
mediated neuropathies: &$$1-&$1(.
&. Amato AA (&''%) Guillain Barre syndrome 5 related disorders. Eev *eD
=euroci $: ?%%- ?$2.
-. ;ayma"er C, Fernohan >C ((2?2) #he +andry-Guillain-BarrG syndrome4
a clinicopathologic report of %' fatal cases and a critiHue of the literature.
*edicine (Baltimore) &.: %2-(?(.
?. Gordon 9;, Cil!ourn A> (&''() 3arly electrodiagnostic findings in Guillain-
BarrG syndrome. Arch =eurol %.: 2(--2(1.
%. Al!ers >C ((2.2) AA3* ,ase report I?- Guillain Barre Syndrome (&: 1'%J1((.
$. *c+eod >G ((22%) 6nvestigation of peripheral neuropathy. > =eurol =eurosurg
9sychiatry %.: &1?-&.-.
1. Eoth G, *agistris *E ((222) 6ndirect discharges as an early nerve conduction
a!normality in the Guillain-BarrG syndrome. 3ur =eurol ?&: .--.2.
.. Aminoff *>, Green!erg )A, Simon E9 (&''%) 6n ,linical =eurology. $th ed.
*cGraw-;ill *edical, =ew Kor".
2. 0isher *A (&''&) ; refleDes and 0 wave fundamentals normal and a!normal
patterns. =eurol ,lin = Am &': --2.
('. Fimura >, Buter >0 ((21%) 0-wave conduction velocity in Guillain-BarrG
syndrome. Assessment of nerve segment !etween aDilla and spinal cord. Arch
=eurol -&: %&?-%&2.
((. *eulstee >, 7an )er *eche 0G ((22%) 3lectrodiagnostic criteria for
polyneuropathy and demyelination: application in (-% patients with Guillain-
BarrG syndrome. )utch Guillain-BarrG Study Group. > =eurol =euro Surg
9sychiat %2: ?.&-?.$.
(&. *ishra 7A, Falita > (&''$) ,linical =europhysiology, (&ndedn). 3lsevier ;ealth
Sciences, Gurgaon: &-%.
(-. =adir LF, =arullah * ((22.) 3lectrodiagnostic study of ?' cases presenting as
Guillain Barre Syndrome. 9a" > =eurol ?: %'-%?.
(?. Fuwa!ara S, Mgawara F, *io!uchi F, Foga *, *ori *, et al. (&''') 6solated
a!sence of 0 waves and proDimal aDonal dysfunction in Guillain-BarrG
syndrome with antiganglioside anti!odies. > =eurol =eurosurg 9sychiatry $.:
(2(-(2%.
(%. Eopper A;, Ci8dic"s 30, Shahani B# ((22') 3lectrodiagnostic a!normalities in
((- consecutive patients with Guillain-BarrG syndrome. Arch =eurol ?1: ..(-
..1.
($. ,louston 9), Fiers +, Luniga G, ,ros ) ((22?) Nuantitative analysis of the
compound muscle action potential in early acute inflammatory demyelinating
polyneuropathy. 3lectroencephalogr ,lin =europhysiol 2-: &?%-&%?.
(1. Amato AA, )umitru ) (&''&) AcHuired neuropathies. 6n: )umitru ), Amato AA,
Lwarts *>. 3ditor. 3lectrodiagnostic medicine, (&ndedn). 9hiladelphia: ;anley
5 Belfus, 6nc: 2-1J('?(.
(.. Brown C0, Snow E ((22() 9atterns and severity of conduction a!normalities in
Guillain-BarrG syndrome. > =eurol =eurosurg 9sychiatry %?: 1$.-11?.
(2. Eamachandran #S, +oreno =K (&'(() Acute 6nflammatory )emyelinating
9olyradiculoneuropathy.
&'. Ka"oo! *K, Eahman A, >amil B, Syed =A (&''%) ,haracteristics of patients
with Guillain Barre Syndrome at a tertiary care centre in 9a"istan, (22%-&''-.
> 9a" *ed Assoc %%: ?2--?2$.
&(. *cGrogan A, *adle G,, Seaman ;3, de 7ries ,S (&''2) #he epidemiology
of Guillain-BarrG syndrome worldwide. A systematic literature review.
=euroepidemiology -&: (%'-($-.
&&. Gupta ), =air *, Baheti ==, Sarma 9S, Furuvilla A, et al. (&''.) )iplomate-
American Board (&''.) 3lectrodiagnostic and clinical aspects of Guillain-BarrG
syndrome: an analysis of (?& cases. > ,lin =euromuscul )is (': ?&-%(.
&-. *eena AF, Fhadil"ar S7, *urthy >* (&'(() #reatment guidelines for Guillain-
BarrG Syndrome. Ann 6ndian Acad =eurol.
Citation Geetan8ali S, Sushma S, Sudhir S (&'(-) 3arly 3lectrodiagnostic
0indings of Guillain Barre Syndrome. > =eurol =europhysiol ?: (?&.
doi:('.?(1&@&(%%-2%$&.('''(?&