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Osterman PE for GBS

Treatment of the Guillain-Barré Syndrome by Plasmapheresis

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Year of Publication: 1982

Authors: Per Olof Osterman, Jan Fagius, Jan Säfwenberg, ..., Lars-Olof Nordesjö

Journal: Archives of Neurology

Citation: Arch Neurol 1982;39:148-154

Clinical Question

Can plasmapheresis improve outcomes in patients with acute and chronic relapsing Guillain-Barré syndrome?

Bottom Line

Plasmapheresis showed consistent benefit in chronic relapsing GBS with marked improvement after each treatment course. In acute GBS, results were variable with 43% showing marked improvement, 14% partial improvement, and 43% no improvement. No clinical or neurophysiologic parameters predicted response to treatment.

Major Points

  • First systematic case series evaluating plasmapheresis for GBS from a single center
  • 8 patients treated: 1 chronic relapsing, 7 acute GBS
  • Chronic relapsing patient underwent 4 separate courses with marked improvement each time, suggesting consistent treatment effect
  • In acute GBS, 3/7 (43%) markedly improved, 1/7 (14%) partially improved, 3/7 (43%) unchanged or worse
  • Improvement typically began within 1-2 days of starting treatment in responders
  • No clinical or neurophysiologic parameters distinguished responders from non-responders
  • The rapid muscle strength recovery in responders suggests GBS weakness may partly reflect functional nerve conduction block
  • One patient (Case 3) died from sepsis after bilateral pneumothoraces while on ventilator; autopsy confirmed demyelinating polyneuropathy
  • Authors concluded plasmapheresis appears beneficial for chronic relapsing polyneuropathy but response in acute GBS is difficult to evaluate without controlled trials
  • Study called for randomized controlled trials to clarify role of plasmapheresis in GBS

Design

Study Type: Prospective uncontrolled case series

Randomization:

Blinding: None (open-label)

Enrollment Period: October 1979 to November 1980

Follow-up Duration: Variable, up to several months

Centers: 1

Countries: Sweden

Sample Size: 8

Analysis: Descriptive; clinical assessments, neurophysiologic testing (EMG, motor conduction velocities), isokinetic dynamometry for objective muscle strength measurement

Inclusion Criteria

  • Adults meeting NINCDS diagnostic criteria for GBS
  • Pronounced disability with progressive or stationary symptoms
  • No signs of improvement before start of treatment
  • Informed consent for plasma exchange treatment

Exclusion Criteria

  • Patients showing signs of improvement before treatment
  • Patients with mild symptoms only

Arms

FieldPlasmapheresis
InterventionIntermittent flow plasmapheresis; approximately 1,200 g plasma removed per session; citrate anticoagulant; replacement with normal saline and 5% albumin or plasma (not fresh frozen)
Duration5-10 sessions over 7-16 days; total plasma removed 5,700-12,800 g per course

Outcomes

OutcomeTypeControlInterventionHR / OR / RRP-value
Clinical response during plasmapheresis course assessed by neurologic examination and isokinetic dynamometryPrimary
Motor conduction velocity changes | Result: Variable correlation with clinical course; sometimes improved with clinical improvement (Cases 1, 4), sometimes unchanged despite clinical improvement (Cases 2, 6)Secondary
Isokinetic dynamometry (objective muscle strength) | Result: Provided objective documentation of rapid improvement in responders; used to track knee flexion/extension and elbow flexionSecondary
Time to improvement onset in responders | Result: Rapid improvement began within 1-2 days of starting treatment in marked respondersSecondary
Venous access difficultyAdverseCases affected: 2 patients; Details: Case 3 required arterial needle and central venous catheter; Case 5 required Scribner shunt
HemolysisAdverseCases affected: 1 patient (Case 6); Details: Appeared in bowl during one session, probable line obstruction
Exhaustion during treatmentAdverseCases affected: 1 patient (Case 7); Details: Patient had advanced respiratory distress at time of treatment
DeathAdverseCases affected: 1 patient (Case 3); Details: Died 2 weeks after bilateral pneumothoraces from sepsis after 2 months on ventilator; unrelated to plasmapheresis

Subgroup Analysis

No systematic differences identified between responders and non-responders based on clinical presentation, disease duration, CSF findings, or neurophysiologic parameters. Authors noted inability to predict treatment response.

Criticisms

  • Uncontrolled case series - no comparison group to assess natural history
  • Small sample size (n=8) limits generalizability
  • Variable disease duration before treatment (5 days to 4 months)
  • Cannot exclude that improvements were coincidental spontaneous recovery
  • Heterogeneous patient population (mixed acute and chronic forms)
  • No standardized outcome measures or functional grading scale
  • Single-center study from one Swedish hospital
  • Selection bias - only patients with pronounced disability and no improvement were included
  • No blinding of outcome assessments

Funding

Not specified

Based on: Osterman PE for GBS (Archives of Neurology, 1982)

Authors: Per Olof Osterman, Jan Fagius, Jan Säfwenberg, ..., Lars-Olof Nordesjö

Citation: Arch Neurol 1982;39:148-154

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