Guillain-Barré syndrome with absent brainstem reflexes--a report of two cases

Guillain-Barré syndrome, known for its diverse, atypical and heterogeneous range of presentations, can rarely present in an apparent comatose state with absent brainstem reflexes. Two patients presented in an unresponsive state with flaccid quadriplegia, total areflexia with no response to cephalic or peripheral painful stimuli. Pupils were mid-dilated with absent direct and consensual light reflex. All cranial nerve reflexes were absent. Preliminary laboratory investigations and complementary tests were normal. Cerebrospinal fluid evaluation showed albumincytological dissociation. Brain magnetic resonance imaging and electroencephalogram were normal. Both were diagnosed as fulminant Guillain-Barre syndrome. Despite an absence of brainstem reflexes neither patient fulfilled diagnostic criteria for brain death.