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Dissociated quadriceps-hamstring weakness A clue to the clinical diagnosis of Guillain-Barr syndrome.

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which was spent in stage I non-REM sleep, 64% in stage 11,
15(7 i n stage 111, and 754, in REM sleep. During tonic REM
sleep the electroencephalogram contained rhythms in the
theta and beta frequencies; the electromyograrn showed
marked inhibition of tonic activities (Fig 2). During phasic
REM sleep, frequent rapid eye movements in clusters were
seen and the chin rlectromyogram showed phasic inspiratory bursts.
The presence of REM sleep in this and other patients [ 2 ]
with degenerative diseases and slow saccadic eye movements is not incompatible with Osorio and Daroff’s observations. Since their patients had even slower saccades and a
longer clinical course than ours, it is possible that as the
disease advances, REM sleep is gradually lost. Time and
more study will tell.
Neurology Ser7 zce (127)
VeteranJ Admtnzstratzon Medzcal Center
Hine!, IL 60141
Fig 2. Sleep recordings sbow theta and beta rhythm during
tonic REM sleep and frequent REM clusters during phasic
REM sleep. Tonic activity is inhibited on the chin electromyogram obtained during tonic REM deep; in phasic REM
sleep it shows phasic inspimtory bursts.
Dissociated QuadricepsHamstring Weakness:
A Clue to the
Clinical Diagnosis of
Guillain-Ba& Syndrome
Elmo F. Masucci, M D , and John F. Kurtzke, M D
1. Osorio I , Daroff RB: Absence of REM and altered NREM
sleep in patients with spinocerebellar degeneration and slow
saccades. Ann Neurol 7:277-280, 1980
2. Starr A: A disorder of rapid eye movements in Huntington’s
chorea. Brain 90:545-564, 1967
96 Annals of Neurology Vol 9 No 1 January 1981
Acute idiopathic polyneuritis (Guillain-Bark syndrome)
poses problems in diagnosis as well as nomenclature [21.
The clinical involvement varies notably in terms of severity
and distribution of dysfunction. Motor impairment may be
proximal, distal, o r combined proximal and distal. We have
found one common pattern for distribution of the weakness to be almost unique to this syndrome, and that is
selective impairment of the hamstring muscles concomitant
with selective sparing of the quadriceps.
Brown and Baker [ l ] described a predilection for involvement of the triceps, deltoids, extensors of the wrist
and fingers, and of the iliopsoas, hamstrings, and peroneal
muscles in this disorder. It was their impression that regardless of the regions of the body otherwise involved, the
triceps muscles were generally the most affected. In 197 1
we [ 3 ] reported that 23 of 50 patients with Guillain-Bar&
syndrome had weakness that predominated in selected
muscle groups; these were the thigh flexors, hamstrings,
foot dorsiflexors, or wrist extensors. Particular affinity for
triceps involvement was not observed.
Since then we have paid particular attention to evidence
of selective weakness in Guillain-Bar& syndrome. Sixteen
of the subsequent 20 patients with Guillain-Bark syndrome admitted to our service also showed dissociated
muscle weakness, most prominently in the lower extremities. In 14 of the 16 patients the weakest muscle
groups were the hamstring muscles. This was especially
noteworthy when hamstring function was compared with
that of the quadriceps. There was dissociation between
these two groups, with little weakness of the quadriceps
and marked weakness of the hamstrings.
In contradistinction, in only 1 instance among our last 15
patients with polymyositis, was any appreciable dissociation
found between quadriceps and hamstrings, and in this patient the hamstrings were the weaker. Among the last 20
patients with a diagnosis of diabetic mononeuritis multiplex, the well-known predilection for quadriceps involvement over that of the hamstrings was found in all but 1
instance. In this single case the predilection was for the
hamstrings, the same as in Guillain-Bur6 syndrome.
Occasionally in porphyric neuropathy and often in lead
neuropathy, extensor muscles are mainly involved [ 4 ] . In
periodic paralysis, extensor muscles are more affected than
flexors, while in myasthenia gravis the flexor thigh muscles
are often the weakest [5]. However, selective hamstring involvement is unusual in any of these conditions.
Dissociated weakness, preferentially involving the hamstring muscles in contradistinction to the quadriceps, appears to be a valuable clue to the clinical diagnosis of
Guillain-Bar& syndrome.
Lithium Carbonate
in Pseudobulbar Palsy
Neurology Service
Veterans Administration Medical Center
50 lrving St, NW
Washington, DC 20422
E. Wayne Massey, MD, and Stephen Lowe, M D
Lithium carbonate has been of therapeutic value in a variety
of psychoneurological entities and has recently been shown
to be efficacious in emotionally unstable individuals [4].
We have seen good results in treating the emotional lability
of four patients with pseudobulbar palsy. One patient is
A 57-year-old man was referred with a left paraparesis of
approximately four weeks’ duration. Three years previously he had had a right hemiparesis and associated mild,
nonfluent aphasia which had improved enough that he was
able to work part-time. With the onset of his second stroke
he developed pseudobulbar palsy with hypernasal speech,
oropharyngeal spasticity, signs of cortical bulbar tract involvement, and emotional lability. On his transfer to the
Rehabilitation Unit it was difficult to elicit a good therapeutic response due to the patient’s emotional lability.
Therefore lithium carbonate, 300 mg twice daily, was initiated and a blood level of 0.42 mg/dl was obtained within
72 hours (therapeutic range, 0.05 to 1.61). H e remained
without heightened emotional lability in the subsequent six
weeks and experienced no untoward side effects from the
lithium carbonate,
The rationale for using lithium in affective disorders is
reasonably well established, but its use in aggressive patients [51 or emotionally unstable patients with personality
disorders has been unclear. One proposed mode of
psychopharmacological action is derived from the observation that an epileptoid disorder [ l , 31 may be present, although lithium’s anticonvulsant properties are controversial [2]. In patients with pseudobulbar palsy, lithium carbonate may function as a mood stabilizer.
Department of Neurology
Duke University Medical Center
Durham, NC 27710
1. Bach-y-Rita G, Lion JR, Climent CE, Ervin FR: Episodic dys-
1. Brown JR, Baker AB: The diagnosis of Guillain-Barre disease.
Am J Med 2:45-52, 1947
Masucci EF: Idiopathic polyneuritis. In Corm HF, Conn RB
(eds): Current Diagnosis. Sixth edition. Philadelphia, Saunders,
1980, pp 912-915
Masucci EF, Kurtzke JF: Diagnostic criteria for the GuillainBarre syndrome. J Neurol Sci 13:483-501, 1971
Ridley A: Porphyric neuropathy. In Dyck PJ, Thomas PK,
Lambert E H (eds): Peripheral Neuropathy. Philadelphia, Saunders, 1975, vol 2, p 949
Simpson JA: Myasthenia gravis and myasthenic syndromes. In
Walton J N (ed): Disorders of Voluntary Muscle. Third edition.
Edinburgh and London, Churchill/Livingstone, 1974, p 657
control a study of 130 violent patients. Am J Psychiatry
127:1473-1478, 1971
Jus A, Villeneuve A, Gautier J, Pires A, Cate JM: Some remarks on the influence of lithium carbonate on patients with
temporal lobe epilepsy. Int J Clin Pharmacol 7:67-74, 1973
Monroe RR: Episodic Behavior Disorders. Cambridge, MA,
Harvard University Press, 1970
Riflcin A, Quitkin F, Carrillo C, Blumberg AG, Klein D F
Lithium carbonate in emotionally unstable character disorders.
Arch Gen Psychiatry 27:519-523, 1972
Sheard MH: Effect of lithium in human aggression. Nature
230:113-114, 1971
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barry, weakness, hamstring, quadriceps, clinical, syndrome, guillain, dissociated, clues, diagnosis
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