One course of intravenous immunoglobulins (IVIg) of 2 g/kg is standard treatment in Guillain-Barré syndrome (GBS) patients unable to walk independently. Despite treatment some patients recover poorly, in part related to rapid consumption of IVIg, indicating that they may benefit from a second course of IVIg. The aim of the study is to determine whether a second course of IVIg, administered 1 week after start of the first course in patients with GBS and predicted poor outcome improves functional outcome on the GBS disability scale after 4 weeks. Secondary outcome measures include adverse events (AEs), Medical Research Council sumscore and GBS disability score after 8, 12, and 26 weeks, length of hospital and ICU admission, mortality, and changes in serum IgG levels. GBS patients of 12 years and older with a poor prognosis, based on the modified Erasmus GBS outcome score (mEGOS) at 1 week after start of the first IVIg course are eligible for randomization in this double-blind, placebo-controlled (IVIg or albumin) clinical trial. This study will determine if a second course of IVIg administered in the acute phase of the disease is safe, feasible, and effective in patients with GBS and a poor prognosis. This Dutch trial is registered prospectively as NTR 2224 in the Netherlands National Trial Register (NTR) which is the Primary Registry in the WHO Registry Network for the Netherlands.

Second intravenous immunoglobulin dose in patients with Guillain-Barre syndrome with poor prognosis (SID-GBS): a double-blind, randomised, placebo-controlled trial. Lancet Neurology, 20(4), 275-283.

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With 12 FiguresPathological changes in the area of the lower cervical spine producing circulatory disturbances of the spinal cord may give rise to syndromes presenting their upper limit at about the C4 level. These types of disturbance are thought to be due to an impeded blood flow in the lower cervical portion of the anterior spinal artery, sometimes caused by a diminished blood supply by a major radicular artery.In some cases of low cervical pathology, however, neurological examination discloses a neurological deficit at a higher level due to decreased blood supply in the upper part of the cervical spinal cord.The two principal causes of these circulatory disturbances are compression by distortion of the bony structures and primary or secondary stenotic or occlusive lesions of the arteries. Both pathological agents may be active at the same time with varying predominance (Hutchinson and others). Case ReportsPatient I, female aged 46, sustained an accident in 1967 in which she fell on the right side of the head, followed by a brief loss of consciousness. After regaining consciousness the patient suffered from transient tetraparesis and paraesthesiae in the extremities, more in the arms than in the legs. The paraesthesiae disappeared after resting for three weeks. (After six weeks the patient felt pain in the left half of the body.) Maximum flexion of the neck was followed by a shooting pain in the trunk and left leg. There was some diminution of strength in both arms. Other symptoms were pain radiating from the neck to the occipital region, tinnitus and right-sided deafness.Neurological examination: Limitation, especially of flexion, of the cervical spine, associated with pain in the left half of the body. Positive Spurling sign on the left. Tendon reflexes of the arms slightly brisker in the left than in the right. Sensation disturbed to all modalities on the left in segments C6-C7. The head and segments C2-C3 showed diminution of only temperature and pain sense, with no perioral sensory disorders. The corneal reflex was diminished on the left (Fig. 9).