Sural nerve involvement in patients with acute inflammatory demyelinating polyneuropathy variant of Guillain-Barre syndrome with sural sparing at initial presentation

Abstract

INTRODUCTION: Neurophysiological testing is a valuable tool in the diagnosis of Guillain-Barre syndrome (GBS). Sural sparing is a usual feature of acute inflammatory demyelinating polyneuropathy (AIDP) type GBS. However, sural involvement has been reported in later stages of GBS. It is important to identify patterns of sural nerve involvement to differentiate GBS from its mimickers and to stage the disease. This research aimed to detect the pattern of sural nerve involvement in AIDP-GBS cases with normal electrophysiological responses in the sural nerve at the beginning. OBJECTIVES: To determine the location and timing of sural nerve involvement in AIDP-GBS. METHODS: This prospective follow up study included diagnosed cases of AIDP-GBS with preserved bilateral sural responses. Nerve conduction and somatosensory evoked potentials (SSEP) were done on admission and weekly thereafter for four consecutive weeks. The last evaluation was done four weeks after the fourth study. RESULTS: All patients (100%) showed normal distal sural responses over the initial four weeks of follow up. They continued to remain normal up to eight weeks in eight patients (53.3%). Two patients had gradual prolongation of their sural SSEP on consecutive studies. One of them had gradual reduction of sural sensory nerve action potential and nerve conduction velocity along with the prolongation of sural SSEP latencies. The difference of SSEP latency increments in the left sural nerve of these two patients was statistically significant (p<0.05). The right sural SSEP latency difference was not significant. CONCLUSION: Sparing of the distal sural sensory response was demonstrated in 100% of AIDP-GBS cases during the first four weeks of follow up. More than 50% of the cohort demonstrated preserved sural sensory responses for eight weeks from the initial presentation. Two out of fifteen patients showed statistically significant proximal sural sensory pathway involvement with increasing SSEP latencies. This finding suggests that in some patients, the sural sensory pathway may get affected at its proximal segments or at the central nervous system before the distal nerve is affected.