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Jia et al. GBS after cerebral hemorrhage or trauma

based on hypothetical mechanisms deduced from not evoked in both upper and lower limbs; and the
molecular modeling of prodromal infections, caused motor nerve conduction velocity (NCV) was close to
by pathogens such as C. jejuni, which can activate normal. The patient was transferred to the intensive
the body’s immune system to produce antibodies, care unit (ICU) right away, due to the respiratory
resulting in peripheral nerve demyelination or axonal problems, and a ventilator was used to keep him alive.
injury. In particular, serum anti-ganglioside antibodies We collected a cerebrospinal fluid (CSF) sample, and
in the acute phase are detectable in approxiately 60% the analysis showed a protein concentration of 0.56 g/L,
of GBS patients. [2] a normal cell count (4 × 10 /L) and the pressure of
6
CSF was 170 mmH O. The result of the serum anti-
2
In recent years, weakness of extremities and ganglioside antibody test was negative 17 days after
weakened, or even loss of, tendon reflexes have been the occurrence of muscle weakness. According to the
reported in some patients with traumatic brain injury, diagnostic criteria, he was diagnosed with acute motor
cerebral hemorrhage, spinal cord injury, brachial plexus axonal neuropathy (AMAN), a subtype of GBS.
injury, or pelvic fracture fixation. [3-6] In this article, we
provide detailed clinical data of two patients who were Intravenous immunoglobulin (IVIg) 0.4 g/kg per day
diagnosed with GBS following brain hemorrhage or was given to him 5 days after the occurrence of
craniocerebral injury. The diagnosis of our 2 patients quadriplegia for a consecutive 5 days of treatment.
is based on the diagnostic criteria of GBS published However, no significant improvement was observed.
in 2014, which was modified according to the criteria After 7 days, the same dose of gamma globulin was
published in 1990. [7] administered for another 5 days and rehabilitation
treatment was continued. A month later, the ventilator
CASE REPORT was gradually discontinued and the patient regained
some muscle strength (right arm 3/5, left arm 2/5, and
Case 1 both legs 1/5). Meanwhile the rehabilitation treatment
A 33-year-old male suffered from right basal ganglia continued. A 4-month follow-up revealed that he could
hemorrhage (moderate volume) and gradually walk slowly with some support by arm.
regained his muscle strength (left arm 3/5, left leg 2/5,
right limbs 5/5) (the Medical Research Council grading Case 2
system) after receiving conservative treatment. The A 41-year-old male with a left frontal contusion,
patient received conservative treatment immediately laceration, and subdural hematoma, due to a motorcycle
after brain hemorrhage including neurotrophic accident, was included into the case analysis. At first,
treatment, mannitol, antihypertensive treatment and so the patient’s conditions had improved obviously after
on, without any treatment with gangliosides injections, conservative treatment. However, 2 weeks later, he
during which there was no evidence of infection such suffered from sudden quadriplegia (muscle strength 0/5
as fever, cough, or elevation of white blood cells. for all limbs) along with areflexia, without any evidence
However, fourteen days later, the muscle strength of of antecedent infections and without treatments with
both lower limbs decreased sharply to 0/5, the left gangliosides injections. Another brain CT scan was
arm 1/5, and the right arm 2/5, accompanied with performed immediately, but no obvious changes were
hypomyotonia and the absence of tendon reflexes, observed. Then the patient was transferred to the ICU
without other pathological signs of the nervous because of respiratory failure, and a ventilator was
system. A reexamined cranial computed tomography used. NCS showed that: CMAP of the right median
(CT) scan showed there were no new lesions, but his nerve and sural nerve were not elicited; CMAP of
muscle weakness worsened rapidly. Besides, cranial the common peroneal nerve on both sides were
magnetic resonance imaging (MRI) was performed significantly decreased; F waves were not evoked in
on him, demonstrating moderate volume hemorrhage either upper or lower limbs; NCV was close to normal.
in the right basal ganglia region and no signs of new Lumbar puncture showed that the CSF pressure was
hemorrhage. MRI of the cervical vertebra showed mild 190 mmH O, protein concentration was 1.87 g/L, and
2
disc (C2-C7) herniation. Unfortunately, his muscle total nucleated cells were 2.0 × 10 /L. Diagnosis of GBS
6
strength continued to decrease, and five days later, was definite and he was treated with IVIg (0.4 g/kg per
all extremities decreased to 0/5 and respiratory failure day) for 5 days. During the treatment, his respiratory
occurred. A nerve conduction study (NCS) indicated: function recovered slightly, but with no improvement
compound muscle action potential (CMAP) amplitude in muscle strength in any limb. Over another 5-day
of the right median nerve and the common peroneal course of IVIg, his muscle strength recovered to 2/5
nerve on both sides were not elicited; CMAP of the in both arms but remained 0/5 in the lower limbs. Six
right ulnar nerve significantly decreased; F wave was months later, the patient could gradually stand up with
62 Neuroimmunology and Neuroinflammation ¦ Volume 4 ¦ April 12, 2017