Cerebrospinal Fluid Findings in Relation to Clinical Characteristics, Subtype, and Disease Course in Patients With Guillain-Barré Syndrome.
Al-Hakem H., Doets AY., Stino AM., Zivkovic SA., Andersen H., Willison HJ., Cornblath DR., Gorson KC., Islam Z., Mohammad QD., Sindrup SH., Kusunoki S., Davidson A., Casasnovas C., Bateman K., Miller JA., van den Berg B., Verboon C., Roodbol J., Leonhard SE., Arends S., Luijten LWG., Benedetti L., Kuwabara S., Van den Bergh P., Monges S., Marfia GA., Shahrizaila N., Galassi G., Pereon Y., Bürmann J., Kuitwaard K., Kleyweg RP., Marchesoni C., Sedano Tous MJ., Querol L., Martín-Aguilar L., Wang Y., Nobile-Orazio E., Rinaldi S., Schenone A., Pardo J., Vermeij FH., Waheed W., Lehmann HC., Granit V., Stein B., Cavaletti G., Gutiérrez-Gutiérrez G., Barroso FA., Visser LH., Katzberg HD., Dardiotis E., Attarian S., van der Kooi AJ., Eftimov F., Wirtz PW., Pa Samijn J., Gilhuis HJ., Dm Hadden R., Holt JK., Sheikh KA., Kolb N., Karafiath S., Vytopil M., Antonini G., Feasby TE., Faber C., Kramers H., Busby M., Roberts RC., Silvestri NJ., Fazio R., van Dijk GW., Garssen MP., Verschuuren J., Harbo T., Jacobs BC.
OBJECTIVE: To investigate cerebrospinal fluid findings in relation to clinical and electrodiagnostic subtypes, severity, and outcome of Guillain-Barré syndrome based on 1500 patients in the International GBS Outcome Study. METHODS: Albuminocytological dissociation was defined as an increased protein level (>0.45 g/L) in absence of elevated white cell count (<50 cells/µL). We excluded 124 (8%) patients due to other diagnoses, protocol violation or insufficient data. CSF was examined in 1231 patients (89%). RESULTS: In 846 (70%) patients CSF examination showed albuminocytological dissociation, which increased with time from weakness onset: ≤4 days 57%, >4 days 84%. High CSF protein levels were associated with a demyelinating subtype, proximal or global muscle weakness and a reduced likelihood of being able to run at week 2 (OR: 0.42 (95% CI 0.25-0.70; p = 0.001) and week 4 (OR: 0.44 (95% CI 0.27-0.72; p = 0.001). Patients with the Miller Fisher syndrome, distal predominant weakness and normal or equivocal nerve conduction studies were more likely to have lower CSF protein levels. CSF cell count was <5 cells/µL in 1005 patients (83%), 5-49 cells/µL in 200 patients (16%) and ≥50 cells/µL in 13 patients (1%). INTERPRETATION: Albuminocytological dissociation is a common finding in Guillain-Barré syndrome, but normal protein levels do not exclude this diagnosis. High CSF protein level is associated with an early severe disease course and a demyelinating subtype. Elevated CSF cell count, rarely ≥50 cells/µL, is compatible with GBS after thorough exclusion of alternative diagnoses. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that CSF albuminocytologic dissociation (defined by the Brighton Collaboration) is common in patients with GBS.