From the Guidelines
In Guillain-Barré Syndrome (GBS), the classic cerebrospinal fluid (CSF) analysis finding is albuminocytologic dissociation, characterized by elevated protein levels with normal white blood cell counts, and treatment primarily involves immunotherapy with either intravenous immunoglobulin (IVIG) or plasma exchange (PLEX). The typical CSF findings in GBS include elevated protein levels (typically >45 mg/dL) with normal white blood cell counts (<10 cells/μL), which may not appear until 1-2 weeks after symptom onset 1. Some key points to consider in the diagnosis and management of GBS include:
- Abnormal results in electrophysiological studies and a combination of an increased protein level and normal cell count in cerebrospinal fluid are classic features of GBS 1
- Respiratory function should be monitored in all patients as respiratory failure can occur without symptoms of dyspnoea 1
- Intravenous immunoglobulin and plasma exchange are equally effective in treating GBS; no other treatments have been proven to be effective 1
- The efficacy of repeat treatment in patients who have shown insufficient clinical response is uncertain; nevertheless, this practice is common in patients who show deterioration after an initial treatment response 1
- Clinical improvement is usually most extensive in the first year after disease onset and can continue for >5 years 1 Treatment for GBS primarily involves immunotherapy with either intravenous immunoglobulin (IVIG) at 0.4 g/kg/day for 5 consecutive days or plasma exchange (PLEX) with 5 exchanges over 2 weeks, with both treatments being equally effective when initiated within the first 2-4 weeks of symptom onset 1. Supportive care is crucial and includes:
- Respiratory monitoring (with mechanical ventilation if needed)
- DVT prophylaxis
- Pain management
- Early rehabilitation Corticosteroids are not recommended as they show no benefit and may worsen outcomes 1. Treatment should begin promptly when GBS is suspected clinically, even before CSF results confirm the diagnosis, as early intervention improves outcomes by limiting immune-mediated nerve damage. Regular monitoring of respiratory function (including vital capacity and negative inspiratory force) is essential as approximately 25% of patients require ventilatory support 1. Additionally, managing early complications such as pressure ulcers, hospital-acquired infections, and deep vein thrombosis is crucial to prevent severe morbidity and death 1.
From the Research
Typical CSF Analysis Findings in GBS
- Cerebrospinal fluid (CSF) examination is valuable in the diagnosis of Guillain-Barré Syndrome (GBS), particularly when the diagnosis is less certain 2
- CSF total protein level is related to autoimmune response and can be used as a prognostic indicator for GBS 3
- Increased CSF protein levels are associated with a poorer prognosis in GBS patients 3
- Age-adjusted upper limits for CSF total protein may have a lower sensitivity for diagnosing GBS, especially in the first week after symptom onset 4
Treatment Options for GBS
- Intravenous immunoglobulin (IVIg) 0.4 g/kg for 5 days is recommended for patients with GBS who are unable to walk unaided within 2 weeks of onset of weakness 2
- Plasma exchange (PE) is also a recommended treatment for GBS, with 12-15 L in four to five exchanges over 1-2 weeks 2, 5, 6
- Selective immune adsorption (SIA) may be an effective treatment for severe GBS, with or without IVIg 5
- Corticosteroids are not recommended for the treatment of GBS 2
Prognosis and Outcome Measures
- The modified Erasmus GBS outcome score (mEGOS) can be used to assess the outcome of GBS patients 2
- The modified Erasmus GBS Respiratory Insufficiency Score (mEGRIS) can be used to assess the risk of requiring artificial ventilation in GBS patients 2
- Plasma neutrophil/lymphocyte ratio (NLR) may be a candidate prognostic marker for GBS, with higher levels associated with a better prognosis 3