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Jia et al. GBS after cerebral hemorrhage or trauma

some support and hold light objects. are elevated in patients with post traumatic head
injury. Some studies have shown that nearly 80% of
[3]
DISCUSSION AMAN patients are anti-ganglioside antibody positive,
especially within the first week of onset. The best
[4]
We reported two patients with severe GBS following treatment for GBS is IVIg or plasma exchange, both
cerebral hemorrhage or head trauma. In the two of which aim to remove antibodies. However, serum
cases above, typical clinical manifestations were the anti-ganglioside antibodies were negative in case 1.
sudden occurrence of flaccid tetraplegia, areflexia, We postulate 2 possible explanations: one is that the
hypomyotonia, and respiratory failure, without any antibody level had decreased sharply after 2 courses
sensory dysfunction. NCS of both patients showed of IVIg when it was obtained 17 days after onset; the
decreased CMAP and prolonged distal F wave other is the patient suffered from anti-ganglioside
latencies, indicating motor axon injury, which are antibody negative GBS. The 2 patients reported
common electrophysiological features of AMAN. showed significant recovery due to prompt diagnosis
In addition, the result of the CSF tests indicated and treatment.
albumino-cytologic dissociation, and IVIg proved to be
efficient in both patients. In clinical practice, if a sudden bilateral limb weakness
occurs after traumatic injury or hemorrhage, which
The most common subtypes of GBS are acute cannot be explained by findings of imaging and routine
inflammatory demyelinating polyradiculoneuropathy laboratory examinations, GBS should be considered.
[14]
(AIDP) and AMAN. In contrast to North America and Early examination of the nervous system, EMG, CSF
Europe, where more than 90% of the patients are test, and search for anti-ganglioside antibodies can
classified as AIDP, approximately 65% of patients in support the diagnosis of peripheral nerve demyelinating
China suffer from AMAN, a subtype of GBS with only disease. For patients diagnosed with GBS, gamma
motor fiber damage. Analogous to our cases, the globulin should be given as soon as possible, if there are
[8]
features of nerve conduction studies demonstrated no contraindications, otherwise plasma exchange can
decreased motor amplitudes with an absence of F be used. Despite the rare reports of GBS following
[15]
waves. head trauma or brain hemorrhage, we find that it is
not as rare as we thought in clinical practice. GBS is
The exact pathogenesis of GBS following brain trauma not a common disease and it is easy to be ignored
and hemorrhage is not completely clear. Tan et al. or misdiagnosed, especially following other severe
[6]
performed sural nerve biopsy and found phagocytosis situations like trauma and brain hemorrhage. Thus,
of myelin sheath debris in the endoneurium. Tan it is of great significance to enhance the awareness
suggested that head trauma and surgery had elevated of early diagnosis and early treatment of this special
serum and CSF myelin basic protein levels, which pathogenic GBS, which will increase the survival rate
led to immune system activation to produce anti- and improve the quality of patients’ life.
myelin antibodies that cause demyelination. Moreover,
relevant literature indicates that blood-brain barrier Authors’ contributions
(BBB) damage plays an important role in post- Collection of study cases and problem analysis: H. Jia
traumatic GBS pathogenesis. [9,10] Disintegration of the Writing of the paper and critical revision of the article:
BBB during neurotrauma leads to the accumulation H. Jia, B. Li
of localized T lymphocytes and macrophages, which Revised article: H. Jia, Y. Tian, Y.M. Wu
may induce the transformation of microglial cells in
the nervous system into antigen presenting cells. [3,11,12] Financial support and sponsorship
Activated microglia can present post traumatic neuronal None.
debris to the immune system and stimulate B cells to
produce antibodies against the myelin sheath, causing Conflicts of interest
demyelination, especially in the peripheral nervous There are no conflicts of interest.
system. The explanation of GBS following head
[13]
trauma or hemorrhage may be that some substances Patient consent
originating in the central nervous system, usually being Consent was approved by patients in both cases.
weakly immunogenic, are transported through the
disrupted BBB to the peripheral nervous system where Ethics approval
they cause demyelination or axonal damage. Data collection in our study involving the patient is
consistent with the ethical standards of the institution’s
It has been reported that anti-ganglioside antibodies ethics committee.
Neuroimmunology and Neuroinflammation ¦ Volume 4 ¦ April 12, 2017 63