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      <h1 class="highwire-cite-title" id="page-title">Thickening and Contrast Enhancement of Spinal Roots on MR Imaging in Guillain-Barré Syndrome: Thoughts on Pathologic Background</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">J. Berciano</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">October 2011,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">32 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(9) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E179; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A2754 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-12197--6236086949" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">J. Berciano </div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=J.%2BBerciano%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Berciano%20J&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AJ.%2BBerciano%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div></div></div>  </div>

  
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    <div data-panels-ajax-tab-preloaded="jnl_ajnr_tab_art" id="panels-ajax-tab-container-highwire_article_tabs" class="panels-ajax-tab-container"><div class="panels-ajax-tab-loading" style ="display:none"><img class="loading" src="http://ajnr-stage2.stage.highwire.org/sites/all/modules/contrib/panels_ajax_tab/images/loading.gif" alt="Loading" title="Loading" /></div><div class="panels-ajax-tab-wrap-jnl_ajnr_tab_art"><div class="panel-display panel-1col clearfix" >
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view"><span class="highwire-journal-article-marker-start"></span><p id="p-1">I read with interest the article by Zuccoli et al<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup> evaluating the MR imaging findings in 17 children affected by Guillain-Barré syndrome (GBS) or Miller Fisher syndrome. Fourteen patients demonstrated cauda equina enhancement, with predominant involvement of the anterior roots. Furthermore, isolated enhancement of the anterior spinal roots was observed in 3 patients. Given that the authors make no reference to the pathologic hallmark of such neuroimaging findings, I wish to comment on this question.</p><p id="p-2">In 4 detailed clinicopathologic studies in GBS, including complete transverse semithin sections of lumbosacral roots, we found constant but variable radicular lesions ranging from widespread inflammatory demyelination to scattered inflammatory infiltrates.<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a><a id="xref-ref-3-1" class="xref-bibr" href="#ref-3"></a><a id="xref-ref-4-1" class="xref-bibr" href="#ref-4"></a>–<a id="xref-ref-5-1" class="xref-bibr" href="#ref-5">5</a></sup> In 1 study from a patient presenting with pure motor GBS, inflammatory demyelination with secondary axonal degeneration was restricted to ventral spinal roots.<sup><a id="xref-ref-2-2" class="xref-bibr" href="#ref-2">2</a></sup> <a id="xref-fig-1-1" class="xref-fig" href="#F1">Figure 1</a> illustrates typical findings in the L5 ventral root. Considering the constancy of radicular inflammation, the reported MR imaging findings are not unexpected in any form of GBS. Absence of an epi-perineurium in the preforaminal spinal roots and, by extension, in the cranial nerves in their subarachnoid trajectory accounts for the observed thickening on MR imaging. External to the subarachnoid angle, the peripheral nerve trunks possess epi-perineurium, which is relatively inelastic, thus not allowing any significant increase of their diameters. Precise inflammatory demyelination of these nerve trunks may imply an increase of endoneurial fluid nerve pressure potentially causing endoneurial ischemia and wallerian-like degeneration.<sup><a id="xref-ref-3-2" class="xref-bibr" href="#ref-3">3</a><a id="xref-ref-4-2" class="xref-bibr" href="#ref-4"></a>–<a id="xref-ref-5-2" class="xref-bibr" href="#ref-5">5</a></sup></p><div id="F1" class="fig pos-float odd"><div class="highwire-figure"><div class="fig-inline-img-wrapper"><div class="fig-inline-img"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/32/9/E179/F1.large.jpg?width=800&amp;height=600&amp;carousel=1" title="A, Complete semithin transverse section of the L5 ventral root in a control subject with no pathology. B, Complete semithin transverse section of the L5 ventral root from the patient reported in reference 3. Note that despite apparent severe reduction of myelinated fibers, the transverse fascicular area is preserved or even increased (A and B, toluidine blue, original magnification, &#xD7;10 objective). C, At higher magnification, note extensive inflammatory demyelination with numerous denuded axons and foamy laden macrophages (toluidine blue, original magnification, &#xD7;63 oil immersion objective)." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-1015290343" data-figure-caption="&lt;div class=&quot;highwire-markup&quot;&gt;A, Complete semithin transverse section of the L5 ventral root in a control subject with no pathology. B, Complete semithin transverse section of the L5 ventral root from the patient reported in reference 3. Note that despite apparent severe reduction of myelinated fibers, the transverse fascicular area is preserved or even increased (A and B, toluidine blue, original magnification, &#xD7;10 objective). C, At higher magnification, note extensive inflammatory demyelination with numerous denuded axons and foamy laden macrophages (toluidine blue, original magnification, &#xD7;63 oil immersion objective).&lt;/div&gt;" data-icon-position="" data-hide-link-title="0"><span class="hw-responsive-img"><img class="highwire-fragment fragment-image lazyload" alt="Fig 1." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" data-src="http://ajnr-stage2.stage.highwire.org/content/ajnr/32/9/E179/F1.medium.gif" width="202" height="440"/><noscript><img class="highwire-fragment fragment-image" alt="Fig 1." src="http://ajnr-stage2.stage.highwire.org/content/ajnr/32/9/E179/F1.medium.gif" width="202" height="440"/></noscript></span></a></div></div><ul class="highwire-figure-links inline"><li class="download-fig first"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/32/9/E179/F1.large.jpg?download=true" class="highwire-figure-link highwire-figure-link-download" title="Download Fig 1." data-icon-position="" data-hide-link-title="0">Download figure</a></li><li class="new-tab"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/32/9/E179/F1.large.jpg" class="highwire-figure-link highwire-figure-link-newtab" target="_blank" data-icon-position="" data-hide-link-title="0">Open in new tab</a></li><li class="download-ppt last"><a href="/highwire/powerpoint/36867" class="highwire-figure-link highwire-figure-link-ppt" data-icon-position="" data-hide-link-title="0">Download powerpoint</a></li></ul></div><div class="fig-caption" xmlns:xhtml="http://www.w3.org/1999/xhtml"><span class="fig-label">Fig 1.</span> <p id="p-3" class="first-child"><em>A</em>, Complete semithin transverse section of the L5 ventral root in a control subject with no pathology. <em>B</em>, Complete semithin transverse section of the L5 ventral root from the patient reported in reference <a id="xref-ref-3-3" class="xref-bibr" href="#ref-3">3</a>. Note that despite apparent severe reduction of myelinated fibers, the transverse fascicular area is preserved or even increased (<em>A</em> and <em>B</em>, toluidine blue, original magnification, ×10 objective). <em>C</em>, At higher magnification, note extensive inflammatory demyelination with numerous denuded axons and foamy laden macrophages (toluidine blue, original magnification, ×63 oil immersion objective).</p><div class="sb-div caption-clear"></div></div></div><p id="p-4">The predominance of inflammatory lesions in spinal roots and particularly in the ventral ones is an outstanding feature in GBS and in experimental allergic neuritis. Antigen differences between motor and sensory neurons probably account for greater and selective motor involvement. Moreover, it could be pathogenetically relevant that the richest source of P<sub>2</sub>, the major antigen for producing experimental allergic neuritis, is in the ventral roots of the cauda equina.<sup><a id="xref-ref-2-3" class="xref-bibr" href="#ref-2">2</a></sup> Finally, predominance of lesions in spinal roots may be correlated with their less efficient blood-nerve barrier compared with more distal nerve trunks.</p><div class="section ref-list" id="ref-list-1"><h2>References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a>

<div class="cit ref-cit ref-journal" id="cit-32.9.E179.1" data-doi="10.3174/ajnr.A2358"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Zuccoli</span>  <span class="cit-name-given-names">G</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Panigrahy</span>  <span class="cit-name-given-names">A</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Bailey</span>  <span class="cit-name-given-names">A</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>.
<span class="cit-article-title">Redefining the Guillain-Barré spectrum in children: neuroimaging findings of cranial nerve involvement</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2011</span>; <span class="cit-vol">32</span>: <span class="cit-fpage">639</span>–<span class="cit-lpage">42</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo4OiIzMi80LzYzOSI7czo0OiJhdG9tIjtzOjIwOiIvYWpuci8zMi85L0UxNzkuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a>

<div class="cit ref-cit ref-journal" id="cit-32.9.E179.2" data-doi="10.1002/mus.880160709"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Berciano</span>  <span class="cit-name-given-names">J</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Coria</span>  <span class="cit-name-given-names">F</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Montón</span>  <span class="cit-name-given-names">F</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>.
<span class="cit-article-title">Axonal form of Guillain-Barré syndrome: evidence for macrophage-associated demyelination</span>. <abbr class="cit-jnl-abbrev">Muscle Nerve</abbr> <span class="cit-pub-date">1993</span>; <span class="cit-vol">16</span>: <span class="cit-fpage">744</span>–<span class="cit-lpage">51</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1002/mus.880160709&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=8505931&amp;link_type=MED&amp;atom=%2Fajnr%2F32%2F9%2FE179.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">3.</span><a class="rev-xref-ref" href="#xref-ref-3-1" title="View reference 3. in text" id="ref-3">↵</a>

<div class="cit ref-cit ref-journal" id="cit-32.9.E179.3" data-doi="10.1002/(SICI)1097-4598(199707)20:7&lt;846::AID-MUS9&gt;3.0.CO;2-7"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Berciano</span>  <span class="cit-name-given-names">J</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Figols</span>  <span class="cit-name-given-names">J</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">García</span>  <span class="cit-name-given-names">A</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>.
<span class="cit-article-title">Fulminant Guillain-Barré syndrome with universal inexcitability of peripheral nerves: a clinicopathological study</span>. <abbr class="cit-jnl-abbrev">Muscle Nerve</abbr> <span class="cit-pub-date">1997</span>; <span class="cit-vol">20</span>: <span class="cit-fpage">846</span>–<span class="cit-lpage">57</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1002/(SICI)1097-4598(199707)20:7&lt;846::AID-MUS9&gt;3.0.CO;2-7&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=9179157&amp;link_type=MED&amp;atom=%2Fajnr%2F32%2F9%2FE179.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">4.</span><a class="rev-xref-ref" href="#xref-ref-4-1" title="View reference 4. in text" id="ref-4">↵</a>

<div class="cit ref-cit ref-journal" id="cit-32.9.E179.4"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Berciano</span>  <span class="cit-name-given-names">J</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">García</span>  <span class="cit-name-given-names">A</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Figols</span>  <span class="cit-name-given-names">J</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>.
<span class="cit-article-title">Perineurium contributes to axonal damage in acute inflammatory demyelinating polyneuropathy</span>. <abbr class="cit-jnl-abbrev">Neurology</abbr> <span class="cit-pub-date">2000</span>; <span class="cit-vol">55</span>: <span class="cit-fpage">552</span>–<span class="cit-lpage">59</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6OToibmV1cm9sb2d5IjtzOjU6InJlc2lkIjtzOjg6IjU1LzQvNTUyIjtzOjQ6ImF0b20iO3M6MjA6Ii9ham5yLzMyLzkvRTE3OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">5.</span><a class="rev-xref-ref" href="#xref-ref-5-1" title="View reference 5. in text" id="ref-5">↵</a>

<div class="cit ref-cit ref-journal" id="cit-32.9.E179.5" data-doi="10.1111/j.1529-8027.2009.00206.x"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Berciano</span>  <span class="cit-name-given-names">J</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">García</span>  <span class="cit-name-given-names">A</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Villagrá</span>  <span class="cit-name-given-names">NT</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>.
<span class="cit-article-title">Severe Guillain-Barré syndrome: sorting out the pathological hallmark in an electrophysiological axonal case</span>. <abbr class="cit-jnl-abbrev">J Peripher Nerv Syst</abbr> <span class="cit-pub-date">2009</span>; <span class="cit-vol">14</span>: <span class="cit-fpage">54</span>–<span class="cit-lpage">63</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1111/j.1529-8027.2009.00206.x&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=19335540&amp;link_type=MED&amp;atom=%2Fajnr%2F32%2F9%2FE179.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li></ol></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">© 2011 by American Journal of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div>  </div>

  
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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 32</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 9 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Oct 2011 </div></div>
      
      
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    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Oct 2011, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">32 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(9) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E179; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A2754 </span></div>
  
  
  
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