Guillain–Barré syndrome: Difference between revisions

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→‎Associated problems: difficult to find a good secondary source for this (loads of case reports) but it is mentioned in the European CPG for hypontraemia - perhaps a recent general review on GBS could also be found
some additions from 2010 review by expert group, replacing a primary prognostic study
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==Signs and symptoms==
==Signs and symptoms==
The disorder is characterized by symmetrical weakness that usually affects the lower limbs first, and rapidly progresses in an ascending fashion. Patients generally notice weakness in their legs, manifesting as "rubbery legs" or legs that tend to buckle, with or without [[dysesthesias]] (numbness or tingling). As the weakness progresses upward, usually over periods of hours to days, the arms and facial muscles also become affected. Frequently, the lower [[cranial nerves]] may be affected, leading to [[bulbar]] weakness, [[oropharyngeal]] [[dysphagia]] (drooling, or difficulty swallowing and/or maintaining an open airway) and respiratory difficulties. Most patients require hospitalization and about 30% require [[mechanical ventilation|ventilatory assistance]] for treatment of type II [[respiratory failure]].<ref>{{cite journal | author = Burt CC, Arrowsmith JE | title = Respiratory failure | journal = Surgery (Oxford) | date = 1 November 2009 | volume = 27 | issue = 11 | pages = 475–479 | doi = 10.1016/j.mpsur.2009.09.007 }}</ref> Facial weakness is also common. Eye movement abnormalities are not commonly seen in ascending GBS, but are a prominent feature in the Miller-Fisher variant.
The disorder is characterized by symmetrical weakness that usually affects the lower limbs first, and rapidly progresses in an ascending fashion. Patients generally notice weakness in their legs, manifesting as "rubbery legs" or legs that tend to buckle, with or without [[dysesthesias]] (numbness or tingling). As the weakness progresses upward, usually over periods of hours to days, the arms and facial muscles also become affected. Frequently, the lower [[cranial nerves]] may be affected, leading to [[bulbar]] weakness, [[oropharyngeal]] [[dysphagia]] (drooling, or difficulty swallowing and/or maintaining an open airway) and respiratory difficulties. Most patients require hospitalization and about 25–30% require [[mechanical ventilation|ventilatory assistance]] for treatment of type II [[respiratory failure]].<ref name=vanDoorn2010>{{cite journal | author=van Doorn PA, Kuitwaard K, Walgaard C ''et al'' | title=IVIG treatment and prognosis in Guillain-Barré syndrome | journal=J Clin Immunol | date=May 2010 | volume=30 Suppl 1 | pages=S74–8 | doi=10.1007/s10875-010-9407-4 | pmid=20396937 | pmc=2883091}}</ref><ref>{{cite journal | author = Burt CC, Arrowsmith JE | title = Respiratory failure | journal = Surgery (Oxford) | date = 1 November 2009 | volume = 27 | issue = 11 | pages = 475–479 | doi = 10.1016/j.mpsur.2009.09.007 }}</ref> Facial weakness is also common. Eye movement abnormalities are not commonly seen in ascending GBS, but are a prominent feature in the Miller-Fisher variant.{{citation needed|date=October 2014}}


Sensory loss, if present, usually takes the form of loss of [[proprioception]] (position sense) and [[hyporeflexia|areflexia]] (complete loss of deep tendon reflexes), an important feature of GBS. Loss of pain and temperature sensation is usually mild. In fact, pain is a common symptom in GBS, presenting as deep aching pain, usually in the weakened muscles, which patients compare to the pain from overexercising. These pains are self-limited and may be treated with standard [[analgesic]]s. [[Urinary bladder|Bladder]] dysfunction may occur in severe cases, but is usually short-lived.
Sensory loss, if present, usually takes the form of loss of [[proprioception]] (position sense) and [[hyporeflexia|areflexia]] (complete loss of deep tendon reflexes), an important feature of GBS. Loss of pain and temperature sensation is usually mild. In fact, pain is a common symptom in GBS, presenting as deep aching pain, usually in the weakened muscles, which patients compare to the pain from overexercising. These pains are self-limited and may be treated with standard [[analgesic]]s. [[Urinary bladder|Bladder]] dysfunction may occur in severe cases, but is usually short-lived.{{citation needed|date=October 2014}}


In severe cases of GBS, loss of [[autonomic nervous system|autonomic]] function is common, manifesting as wide fluctuations in [[blood pressure]], [[orthostatic hypotension]] (a fall in blood pressure on standing, leading to an increased risk of collapse), and [[sinus tachycardia]]<ref>{{cite journal | author = Flachenecker P, Toyka KV, Reiners K | title = [Cardiac arrhythmias in Guillain-Barre syndrome. An overview of the diagnosis of a rare but potentially life-threatening complication]. | journal = Der Nervenarzt | volume = 72 | issue = 8 | pages = 610–7 | date = Aug 2001 | pmid = 11519201 }}</ref> among other [[cardiac arrhythmia]]s.<ref>{{cite journal | author = Zochodne DW | title = Autonomic involvement in Guillain-Barré syndrome: a review. | journal = Muscle & nerve | volume = 17 | issue = 10 | pages = 1145–55 | date = Oct 1994 | pmid = 7935521 | doi=10.1002/mus.880171004}}</ref>
In severe cases of GBS, loss of [[autonomic nervous system|autonomic]] function is common, manifesting as wide fluctuations in [[blood pressure]], [[orthostatic hypotension]] (a fall in blood pressure on standing, leading to an increased risk of collapse), and [[sinus tachycardia]]<ref>{{cite journal | author = Flachenecker P, Toyka KV, Reiners K | title = Cardiac arrhythmias in Guillain-Barre syndrome. An overview of the diagnosis of a rare but potentially life-threatening complication | journal = Der Nervenarzt | volume = 72 | issue = 8 | pages = 610–7 | date = Aug 2001 | pmid = 11519201 | language=German}}</ref> among other [[cardiac arrhythmia]]s.<ref>{{cite journal | author = Zochodne DW | title = Autonomic involvement in Guillain-Barré syndrome: a review. | journal = Muscle & nerve | volume = 17 | issue = 10 | pages = 1145–55 | date = Oct 1994 | pmid = 7935521 | doi=10.1002/mus.880171004}}</ref>


==Cause==
==Cause==
Line 77: Line 77:
In research studies, the outcome from an episode of Guillain-Barré syndrome is recorded on a scale from 0-6, where 0 denotes completely healthy, 1 very minor symptoms but able to run, 2 able to walk but not to run, 3 requiring a stick or other support, 4 confined to bed or chair, 5 requiring long-term respiratory support, 6 death.<ref>{{cite journal | author=Hughes RA, Swan AV, Raphaël JC, Annane D, van Koningsveld R, van Doorn PA | title=Immunotherapy for Guillain-Barré syndrome: a systematic review | journal=Brain | date=Sep 2007 | volume=130 | pages=2245-57 | pmid=17337484 | doi=10.1093/brain/awm004 | url=http://brain.oxfordjournals.org/content/130/9/2245}}</ref>
In research studies, the outcome from an episode of Guillain-Barré syndrome is recorded on a scale from 0-6, where 0 denotes completely healthy, 1 very minor symptoms but able to run, 2 able to walk but not to run, 3 requiring a stick or other support, 4 confined to bed or chair, 5 requiring long-term respiratory support, 6 death.<ref>{{cite journal | author=Hughes RA, Swan AV, Raphaël JC, Annane D, van Koningsveld R, van Doorn PA | title=Immunotherapy for Guillain-Barré syndrome: a systematic review | journal=Brain | date=Sep 2007 | volume=130 | pages=2245-57 | pmid=17337484 | doi=10.1093/brain/awm004 | url=http://brain.oxfordjournals.org/content/130/9/2245}}</ref>


The prognosis of Guillain-Barré syndrome is determined mainly by age (those over 40 may have a poorer outcome), and by the severity of symptoms after two weeks. Furthermore, those who experienced diarrhea in the prodrome have a worse prognosis.
Poor prognostic factors include age over 40 years, duration of active disease, history of preceding diarrheal illness, disability, electrophysiological signs of axonopathy, requiring ventilator support, high anti-GM1 [[titre]], and poor upper-limb muscle strength. The main treatments did not affect the chance of recovery<ref>The prognosis and main prognostic indicators of Guillain-Barré syndrome. A multicentre prospective study of 297 patients
<ref name=vanDoorn2010/> On the nerve conduction study, the presence of conduction block predicts poorer outcome at 6 months.<ref name=vanDoorn2010/> In those who have received intravenous immunoglobulins, a small increase in IgG in the blood two weeks after administration with associated with poorer mobility outcomes at six months than those whose IgG level increased substantially.<ref name=vanDoorn2010/>
The Italian Guillain-Barre Study Group. ''Brain'', 1996 119: 2053-61</ref>



==Epidemiology==
==Epidemiology==

Revision as of 13:00, 29 October 2014

Guillain–Barré syndrome
SpecialtyNeurology Edit this on Wikidata

Guillain–Barré syndrome (GBS) (French pronunciation: [ɡiˈlɛ̃ baˈʁe], English: /ˈɡiːjænˈbɑːreɪ/), sometimes Landry's paralysis or Guillain–Barré–Strohl syndrome, is an acute polyneuropathy, a disorder affecting the peripheral nervous system. Ascending paralysis, weakness beginning in the feet and hands and migrating towards the trunk, is the most typical symptom, and some subtypes cause change in sensation or pain, as well as dysfunction of the autonomic nervous system. It can cause life-threatening complications, in particular if the respiratory muscles are affected or if the autonomic nervous system is involved. The disease is usually triggered by an infection.

The diagnosis is usually made by nerve conduction studies and with studies of the cerebrospinal fluid. With prompt treatment by intravenous immunoglobulins or plasmapheresis, together with supportive care, the majority will recover completely. Guillain–Barré syndrome is rare, at one to two cases per 100,000 people annually, but is the most common cause of acute non-trauma-related paralysis. The syndrome is named after the French physicians Georges Guillain and Jean Alexandre Barré, who described it in 1916.

Signs and symptoms

The disorder is characterized by symmetrical weakness that usually affects the lower limbs first, and rapidly progresses in an ascending fashion. Patients generally notice weakness in their legs, manifesting as "rubbery legs" or legs that tend to buckle, with or without dysesthesias (numbness or tingling). As the weakness progresses upward, usually over periods of hours to days, the arms and facial muscles also become affected. Frequently, the lower cranial nerves may be affected, leading to bulbar weakness, oropharyngeal dysphagia (drooling, or difficulty swallowing and/or maintaining an open airway) and respiratory difficulties. Most patients require hospitalization and about 25–30% require ventilatory assistance for treatment of type II respiratory failure.[1][2] Facial weakness is also common. Eye movement abnormalities are not commonly seen in ascending GBS, but are a prominent feature in the Miller-Fisher variant.[citation needed]

Sensory loss, if present, usually takes the form of loss of proprioception (position sense) and areflexia (complete loss of deep tendon reflexes), an important feature of GBS. Loss of pain and temperature sensation is usually mild. In fact, pain is a common symptom in GBS, presenting as deep aching pain, usually in the weakened muscles, which patients compare to the pain from overexercising. These pains are self-limited and may be treated with standard analgesics. Bladder dysfunction may occur in severe cases, but is usually short-lived.[citation needed]

In severe cases of GBS, loss of autonomic function is common, manifesting as wide fluctuations in blood pressure, orthostatic hypotension (a fall in blood pressure on standing, leading to an increased risk of collapse), and sinus tachycardia[3] among other cardiac arrhythmias.[4]

Cause

Neuron

All forms of Guillain–Barré syndrome are autoimmune diseases, due to an immune response to foreign antigens (such as infectious agents) that mistargets host nerve tissues through a mechanism known as molecular mimicry.[5] The targets of such immune attack are thought to be gangliosides, compounds naturally present in large quantities in human peripheral nerve tissues. The most well-described antecedent infection is the bacterium Campylobacter jejuni.[6][7] In addition, cytomegalovirus has a known association with GBS.[8] In many cases, identification of a specific cause is impossible. Some cases may be triggered by the influenza virus,[9] or by an immune reaction to the influenza virus.[citation needed] An increased incidence of Guillain–Barré syndrome followed influenza immunization during the 1976-1977 swine flu pandemic;[10] however, some epidemiological studies since then have demonstrated either an extremely small increased risk following immunization (under one additional case per million vaccinations) or no increased risk.[11][12]

The end result of this autoimmune process is an attack on the peripheral nerves and damage to myelin, the fatty insulating layer of the nerve, and a nerve-conduction block leading to muscle paralysis that may be accompanied by sensory or autonomic disturbances.[citation needed]

In mild cases, nerve axon (the long slender conducting portion of a nerve) function remains intact and recovery can be rapid if remyelination occurs. In severe cases, axonal damage occurs, and recovery depends on the regeneration of this important tissue. About 80% of patients have myelin loss; in the remaining 20%, the pathological hallmark is axon loss.[citation needed]

Guillain–Barré, unlike disorders such as multiple sclerosis (MS) and Lou Gehrig's disease (ALS), is a purely peripheral nerve disorder and does not in general cause nerve damage to the brain or spinal cord.[citation needed]

Diagnosis

The diagnosis of GBS depends on findings such as rapid development of muscle paralysis, areflexia, absence of fever, and a likely inciting event. Cerebrospinal fluid analysis (through a lumbar spinal puncture) and electrodiagnostic tests of nerves and muscles (such as nerve conduction studies) are common tests ordered in the diagnosis of GBS.[citation needed]

Testing

In cerebrospinal fluid (CSF), characteristic findings include albumino-cytological dissociation. As opposed to infectious causes, this is an elevated protein level (100–1000 mg/dl), without an accompanying increased cell count (absence of pleocytosis). A sustained increased white blood cell count may indicate an alternative diagnosis such as infection.[citation needed]

Electromyography (EMG) and nerve conduction studies may show prolonged distal latencies, conduction slowing, conduction block, and temporal dispersion of compound action potential in demyelinating cases. F waves and H-reflexes may be prolonged or absent. Needle EMG is frequently normal in acute cases. Reduced, neuropathic recruitment in weak muscles can be seen. Fibrillations will be seen on needle EMG if some axonal injury occurs after three to four weeks. In primary axonal damage, the findings include reduced amplitude of the action potentials without conduction slowing.[citation needed]

Criteria

Features required for diagnosis are progressive weakness in legs and often arms, and areflexia (the absence of deep tendon reflexes).[13][14]

Features that strongly support diagnosis are progression of symptoms over days to four weeks, relative symmetry of symptoms, mild sensory symptoms or signs, cranial nerve involvement (especially bilateral weakness of facial muscles), autonomic dysfunction, pain (often present), high concentration of protein in CSF, and typical electrodiagnostic features.[13][14]

Features that should raise doubt about the diagnosis include severe pulmonary dysfunction with limited limb weakness at onset, severe sensory signs with limited weakness at onset, bladder or bowel dysfunction at onset, fever at onset, sharp sensory level, slow progression with limited weakness without respiratory involvement (subacute inflammatory demyelinating polyneuropathy or CIDP is more likely), marked persistent asymmetry of weakness, persistent bladder or bowel dysfunction, increased number of mononuclear cells in CSF (>50×106/L), and polymorphonuclear cells in CSF.[13][14]

Classification

Six different subtypes of Guillain–Barré syndrome exist:[citation needed]

  • Acute inflammatory demyelinating polyneuropathy (AIDP) is the most common form of GBS, and the term is often used synonymously with GBS. It is caused by an autoimmune response directed against Schwann cell membranes.
  • Miller Fisher syndrome (MFS) is a rare variant of GBS. Accounting for about 5% of GBS cases, it manifests as a descending paralysis, proceeding in the reverse order of the more common form of GBS.[15] It usually affects the eye muscles first and presents with the triad of ophthalmoplegia, ataxia, and areflexia.[16] The ataxia predominantly affects the gait and trunk, with the limbs relatively spared. Anti-GQ1b antibodies are present in 90% of cases.
  • Acute motor axonal neuropathy (AMAN),[17] also known as Chinese paralytic syndrome, attacks motor nodes of Ranvier and is prevalent in China and Mexico. It is probably due to an auto-immune response directed against the axoplasm of peripheral nerves. The disease may be seasonal and recovery can be rapid. Anti-GD1a antibodies[18] are present. Anti-GD3 antibodies are found more frequently in AMAN.
  • Acute motor sensory axonal neuropathy (AMSAN) is similar to AMAN, but also affects sensory nerves with severe axonal damage. Like AMAN, it is probably due to an autoimmune response directed against the axoplasm of peripheral nerves. Recovery is slow and often incomplete.[19]
  • Acute panautonomic neuropathy is the rarest variant of GBS, sometimes accompanied by encephalopathy. It is associated with a high mortality rate, owing to cardiovascular involvement, and associated dysrhythmias. Frequently occurring symptoms include impaired sweating, lack of tear formation, photophobia, dryness of nasal and oral mucosa, itching and peeling of skin, nausea, dysphagia, and constipation unrelieved by laxatives or alternating with diarrhea. Initial nonspecific symptoms of lethargy, fatigue, headache, and decreased initiative are followed by autonomic symptoms including orthostatic lightheadedness, blurring of vision, abdominal pain, diarrhea, dryness of eyes, and disturbed micturition. The most common symptoms at onset are related to orthostatic intolerance, as well as gastrointestinal and sudomotor dysfunction.[20][full citation needed] Parasympathetic impairment (abdominal pain, vomiting, constipation, ileus, urinary retention, dilated unreactive pupils; loss of accommodation) may also be observed.
  • Bickerstaff's brainstem encephalitis (BBE), a further variant of Guillain–Barré syndrome, is characterized by acute onset of ophthalmoplegia, ataxia, disturbance of consciousness, hyperreflexia or Babinski's sign. The course of the disease can be monophasic or remitting-relapsing. Large, irregular hyperintense lesions located mainly in the brainstem, especially in the pons, midbrain and medulla, are described in the literature. Despite severe initial presentation, BBE usually has a good prognosis. Magnetic resonance imaging plays a critical role in the diagnosis of BBE. A considerable number of BBE patients have associated axonal Guillain–Barré syndrome, indicative that the two disorders are closely related and form a continuous spectrum.

Associated problems

Hyponatremia (abnormally low levels of sodium in the blood) is often encountered in Guillain–Barré syndrome. This has been attributed to the inappropriate secretion of antidiuretic hormone, leading to relative retention of water.[21]

Treatment

Supportive care is important for the successful management in the person with significant symptoms. Of greatest concern is respiratory failure due to paralysis of the diaphragm, the muscle most important for breathing. Intubation may be needed when evidence of impending failure of the muscles of breathing is present – when the vital capacity (VC) is less than 20 ml/kg, the negative inspiratory force (NIF) is less negative (i.e., closer to zero) than −25 cmH2O, more than 30% decrease in either VC or NIF within 24 hours, rapid progression of disorder, or autonomic instability.

Subsequent treatment consists of attempting to reduce the body's attack on the nervous system, either by plasmapheresis, filtering antibodies out of the blood stream, or by administering intravenous immunoglobulins (IVIg), to neutralize harmful antibodies and inflammation causing disease. These two treatments are equally effective and a combination of the two is not significantly better than either alone.[22] Plasmapheresis hastens recovery when used within four weeks of the onset of symptoms.[23] IVIg has equivalent efficacy to plasmapheresis when started within two weeks of the onset of symptoms, and has fewer complications.[23] IVIg is usually used first because of its ease of administration and safety profile. Its use is not without risk; occasionally it causes hepatitis, or in rare cases, renal failure if used for longer than five days.

Glucocorticoids have not been found to be effective in GBS.[23][24]

Following the acute phase, treatment often consists of rehabilitation with the help of a multidisciplinary team to focus on improving activities of daily living (ADLs). Occupational therapists may offer equipment (such as wheelchair and special cutlery) to help the patient achieve ADL independence. Physiotherapists assist to correct functional movement, avoiding harmful compensations that might have a negative effect in the long run. Also, some evidence supports physiotherapy in helping patients with Guillain–Barré syndrome to regain strength, endurance, and gait quality,[25] as well as helping them prevent contractures, bedsores, and cardiopulmonary difficulties.[26] Speech and language therapists help regain speaking and swallowing abilities, especially if the patient was intubated or received a tracheostomy.

Prognosis

Recovery usually starts after the fourth week from the onset of the disorder. About 80% of patients have a complete recovery within a few months to a year, although minor findings may persist, such as areflexia. About 5–10% recover with severe disability, with most of such cases involving severe proximal motor and sensory axonal damage with inability of axonal regeneration. Despite all improvements in treatment and supportive care, the death rate is still about 2–3%, even in the best intensive care units. Worldwide, the death rate runs slightly higher (4%), mostly from a lack of availability of life-support equipment during the lengthy plateau lasting four to six weeks, and in some cases up to one year, when a ventilator is needed in the worst cases. About 5–10% of patients have one or more late relapses, in which case they are then classified as having chronic inflammatory demyelinating polyneuropathy.[citation needed]

In research studies, the outcome from an episode of Guillain-Barré syndrome is recorded on a scale from 0-6, where 0 denotes completely healthy, 1 very minor symptoms but able to run, 2 able to walk but not to run, 3 requiring a stick or other support, 4 confined to bed or chair, 5 requiring long-term respiratory support, 6 death.[27]

The prognosis of Guillain-Barré syndrome is determined mainly by age (those over 40 may have a poorer outcome), and by the severity of symptoms after two weeks. Furthermore, those who experienced diarrhea in the prodrome have a worse prognosis. [1] On the nerve conduction study, the presence of conduction block predicts poorer outcome at 6 months.[1] In those who have received intravenous immunoglobulins, a small increase in IgG in the blood two weeks after administration with associated with poorer mobility outcomes at six months than those whose IgG level increased substantially.[1]

Epidemiology

Worldwide, the annual incidence is about 0.6–4.0 occurrences per 100,000 people. Men are one and a half times more likely to be affected than women. The incidence increases with age; about one case per 100,000 occurs in people aged below 30 years and about four cases per 100,000 in those older than 75 years.[28]

The incidence of GBS during pregnancy is 1.7 cases per 100,000 of the population.[29] Congenital and neonatal Guillain–Barré syndrome have also been reported.[30]

History

French physician Jean Landry first described the disorder in 1859. In 1916, Georges Guillain, Jean Alexandre Barré, and André Strohl diagnosed two soldiers with the illness and described the key diagnostic abnormality of increased spinal-fluid protein production, but normal cell count.[31]

GBS is also known as acute idiopathic polyradiculoneuritis, acute idiopathic polyneuritis, French polio, Landry's ascending paralysis and Landry–Guillain–Barré syndrome.[citation needed]

Canadian neurologist C. Miller Fisher described the variant that bears his name in 1956.[32]

Notable cases

American actor Andy Griffith developed Guillain-Barré syndrome in 1983. Griffith is seen here receiving an award at the White House in 2005.

References

  1. ^ a b c d van Doorn PA, Kuitwaard K, Walgaard C; et al. (May 2010). "IVIG treatment and prognosis in Guillain-Barré syndrome". J Clin Immunol. 30 Suppl 1: S74–8. doi:10.1007/s10875-010-9407-4. PMC 2883091. PMID 20396937. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  2. ^ Burt CC, Arrowsmith JE (1 November 2009). "Respiratory failure". Surgery (Oxford). 27 (11): 475–479. doi:10.1016/j.mpsur.2009.09.007.
  3. ^ Flachenecker P, Toyka KV, Reiners K (Aug 2001). "Cardiac arrhythmias in Guillain-Barre syndrome. An overview of the diagnosis of a rare but potentially life-threatening complication". Der Nervenarzt (in German). 72 (8): 610–7. PMID 11519201.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  4. ^ Zochodne DW (Oct 1994). "Autonomic involvement in Guillain-Barré syndrome: a review". Muscle & nerve. 17 (10): 1145–55. doi:10.1002/mus.880171004. PMID 7935521.
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  15. ^ Davids, H. "Guillain-Barre Syndrome". Medscape Reference. Retrieved 3 Jan 2012.
  16. ^ Mori M, Kuwabara S, Fukutake T, Hattori T (2002). "Plasmapheresis and Miller Fisher syndrome: analysis of 50 consecutive cases". Journal of neurology, neurosurgery, and psychiatry. 72 (5): 680. doi:10.1136/jnnp.72.5.680. PMC 1737859. PMID 11971070.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  18. ^ Ho TW, Mishu B, Li CY, Gao CY, Cornblath DR, Griffin JW, Asbury AK, Blaser MJ, McKhann GM (1995). "Guillain-Barré syndrome in northern China. Relationship to Campylobacter jejuni infection and anti-glycolipid antibodies". Brain. 118 (3): 597–605. doi:10.1093/brain/118.3.597. PMID 7600081.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Griffin JW, Li CY, Ho TW, Xue P, Macko C, Gao CY, Yang C, Tian M, Mishu B, Cornblath DR (1995). "Guillain–Barré syndrome in northern China. The spectrum of neuropathological changes in clinically defined cases". Brain. 118 (3): 577–95. doi:10.1093/brain/118.3.577. PMID 7600080.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  20. ^ Suarez et al. 1994
  21. ^ Spasovski G, Vanholder R, Allolio B; et al. (25 Feb 2014). "Clinical practice guideline on diagnosis and treatment of hyponatraemia". Eur J Endocrinol. 170 (3): G1-47. doi:10.1530/EJE-13-1020. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  22. ^ Hughes, RA; Swan, AV; van Doorn, PA (Sep 19, 2014). "Intravenous immunoglobulin for Guillain-Barré syndrome". The Cochrane database of systematic reviews. 9: CD002063. PMID 25238327.
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Further reading

External links

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