Guillain-Barrè syndrome (GBS) is an immune-mediated rapidly developed polyneuropathy whose etiology and pathogenesis are not yet entirely comprehended. Guillain–Barré syndrome (GBS) manifests clinically as acute flaccid paralysis, marked by the symmetrical weakness of the limbs, and hyporeflexia or areflexia, which arrives full harshness within 4 weeks (1).

Sensory symptoms, such as paraesthesia or insensibility, begin distally and have a symmetrical extension.

Among pediatric patients in the zenith phase of the syndrome, 75% are unable to walk unsupported, 30% are quadriplegic, 35–50% show cranial nerves involvement, and 15–20% have respiratory failure and/or autonomic dysfunctions (2, 3). Mortality, or severe disability due to GBS, occurs in ~20% of patients (4).

Epidemiological analyses have documented that the incidence of GBS increases with age. In children from 0 to 9 years, it occurs with an incidence of 0.62 cases per 100,000 person-year (py) (5, 6).

Diagnosis of GBS is based on the patient's family history, physical and neurological assessment with sensorial and motor disturbances, electrodiagnostic exams, and cerebrospinal fluid (CSF) which reveals the classical pattern of albumin-cytologic dissociation.

The prognosis of the GBS is linked to the severity of clinical signs and unclear to the presence of autonomic nerve dysfunction (7). Predictors of poor outcomes are defined as a GBS Disability Scale score ≥3 after either 2 weeks or 6 months (8).

We evaluated the correlation among CSF analysis, imaging, and the severity of the GBS in the acute phase to predict a short-term outcome.

We aimed to evaluate CSF analysis and imaging to determine the severity of the GBS in the acute phase and to predict a short-term outcome.

A systematic revision of the current literature was conducted using Cochrane, EMBASE, and MEDLINE. In addition to official websites of highly qualified journals which were expected to publish studies related to this topic, for example, the New England Journal of Medicine, The Lancet, PLOS Medicine, Neurology, and Pediatrics were also searched for relevant studies. The words used to search were: “Child; Guillain-Barrè; Neurology; Prognosis; Disability; Laboratory; MRI; cerebrospinal fluid.” We found little evidence regarding laboratory tests, imaging, and prognosis. Following, we cite the most recent evidence regarding prognosis and imaging and prognosis and CSF.

Althubaiti et al. in a recent publication on the prognosis value of MRI in children with GBS advise that brain and spinal MRI is a recommended supportive test but a predictive value for clinical and therapeutic outcomes in the short or long term has not yet been proved (9).

Regarding the proteins in the CSF, we want to mention the most recent evidence proposed by Kasser et al. In their letter to the editor, the authors affirmed CSF protein levels seemed to be potentially associated with the need for mechanical ventilation (10).

We performed an extensive literature search and found no publications evaluating a possible correlation among the clinical severity of GBS, imaging, and laboratory values of CSF proteins combined in the same population.

Two children showed notable signs of respiratory impairment and were intubated. Three children showed involvement of the cranial nerves. Children with respiratory disturbances involving the cranial nerves had a worse clinical course (Table 1). Trigger events were represented by gastrointestinal infections, high airway infections, and vaccination of 3, 8, and 1 cases, respectively (Table 5).

We executed the statistical analysis to measure the potential relationship among the clinical assessment of children with GBS, MRI imaging, and CSF protein levels.

It seems that these parameters have a parallel trend and a good correlation in each patient. The values of r calculated for all correlations are close to unity and therefore indicate a strong correlation value between them. We developed a graph to see the trend of the disability values, proteins in the CSF, and damage assessed with MRI (Figure 4).

Staging the pediatric patient affected by GBS assumes an important value both in the general evaluation of the patient and in the prognosis. Currently, prognostic scores are based exclusively on clinical parameters, such as the GBS disability scale and the Erasmus GBS scale. There is no clinical-prognostic score that takes into consideration radiological or laboratory parameters.

To fill this gap, we tried to evaluate the correlation between the imaging staging of GBS on MRI and the chemical-physical examination of the CSF of 12 pediatric patients treated.

In our evaluations, we were able to evaluate a good correlation between them.

We assessed that MRI should be considered an essential and effective exam in the diagnostic and prognostic evaluation process in GBS. The involvement of the anterior and posterior nerve root is associated with severe clinical conditions and, consequently, with a worse prognosis (17).

Brain MRI then should be performed routinely in children with GBS to estimate the possible evolution of the clinical condition.

Regarding the CFS analysis, we observed that among the various elements of cerebral liquor, the best indication for clinical condition and prognostic evaluation were related mainly to the high level of CFS protein, it has also been reported in the literature (18, 19).

The MRI and CSF laboratory parameters can be important tools for the clinician not only for diagnosis but also for having an estimate of the possible worsening of general conditions or the need to prepare measures to support life parameters.

We believe it is important to establish how early the need for ventilatory support in the most severe patient is or to be able to decide to start physiotherapy in less severe cases. The need for this study also arises to give indications to the clinician in the sub-acute phase of the disease.

Our study aimed to predict outcomes in GBS by the use of acute phase clinical features, laboratory analysis, and imaging. We have not found in the literature other studies that use laboratory, imaging, and clinical parameters to stage GBS together.

On the other hand, our systematic search of the literature did not reveal studies that simultaneously evaluate the laboratory aspects of CSF and imaging and their relationship to the clinical conditions of children with GBS.

Especially considering the ongoing International GBS Outcome Study, the potential association among CSF protein, imaging, and disability score may be worthy of further exploration (20).

The study has several limitations in our opinion: the population has a heterogeneous age and this could vary the response to the disease of different patients. In the literature, the early age of onset is a negative prognostic factor (11). The sample is numerically small, and a larger sample of patients coming from different centers would be needed for the next studies.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The study was conducted ethically in accordance with the World Medical Association Declaration of Helsinki and approved by the Ethics Committee of the University of Catania, Italy (Ethical Committee Catania 1 Clinical Registration No. 95/2018/PO). Written informed consent was obtained from the parents.

PP, FP, AF, and MR worked with and helped gather patient data. FG, TT, RR, AG, GC, and ADN drafted the present manuscript. AB, GB, and ADM were the radiologist consultant. PP, ET, MS, and AG were responsible for revising the work critically for important intellectual content. All authors read and approved the final manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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