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Cui B, Wei L, Sun LY, Qu W, Zeng ZG, Liu Y, Zhu ZJ. Status epilepticus as an initial manifestation of hepatic encephalopathy: A case report. World J Clin Cases 2020; 8:6480-6486. [PMID: 33392334 PMCID: PMC7760455 DOI: 10.12998/wjcc.v8.i24.6480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 09/28/2020] [Accepted: 10/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Status epilepticus in patients with hepatic encephalopathy (HE) is a rare but serious condition that is refractory to antiepileptic drugs, and current treatment plans are vague. Diagnosis may be difficult without a clear history of cirrhosis. Liver transplantation (LT) is effective to alleviate symptoms, however, there are few reports about LT in the treatment of status epilepticus with HE. To our knowledge, this is the first report of status epilepticus present as initial manifestation of HE.
CASE SUMMARY A 59-year-old woman with a 20-year history of heavy drinking was hospitalized for generalized tonic-clonic seizures. She reported no history of episodes of HE, stroke, spontaneous bacterial peritonitis, ascites or gastrointestinal bleeding. Neurological examination revealed a comatose patient, without papilledema. Laboratory examination suggested liver cirrhosis. Plasma ammonia levels upon admission were five times normal. Brain computed tomography (CT) was normal, while abdominal CT and ultrasound revealed mild ascites, liver cirrhosis and splenomegaly. Electroencephalography (EEG)showed diffuse slow waves rhythm, consistent with HE, and sharp waves during ictal EEG corresponding to clinical semiology of focal tonic seizures. The symptoms were reversed by continuous antiepileptic treatment and lactulose. She was given oral levetiracetam, and focal aware seizures occasionally affected her 10 mo after LT.
CONCLUSION Status epilepticus could be an initial manifestation of HE. Antiepileptic drugs combined with lactulose are essential for treatment of status epilepticus with HE, and LT is effective to prevent the relapse.
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Affiliation(s)
- Bin Cui
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lin Wei
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Li-Ying Sun
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Wei Qu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhi-Gui Zeng
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Ying Liu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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2
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Newey CR, George P, Sarwal A, So N, Hantus S. Electro-Radiological Observations of Grade III/IV Hepatic Encephalopathy Patients with Seizures. Neurocrit Care 2019; 28:97-103. [PMID: 28791561 DOI: 10.1007/s12028-017-0435-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neurological complications in liver failure are common. Often under-recognized neurological complications are seizures and status epilepticus. These may go unrecognized without continuous electroencephalography (CEEG). We highlight the observed electro-radiological changes in patients with grade III/IV hepatic encephalopathy (HE) found to have seizures and/or status epilepticus on CEEG and the associated neuroimaging. METHODS This study was a retrospective review of patients with West Haven grade III/IV HE and seizures/status epilepticus on CEEG. RESULTS Eleven patients were included. Alcohol was the most common cause of HE (54.5%). All patients were either stuporous/comatose. The most common CEEG pattern was diffuse slowing (100%) followed by generalized periodic discharges (GPDs; 36.4%) and lateralized periodic discharges (LPDs, 36.4%). The subtype of GPDs with triphasic morphology was only seen in 27.3%. All seizures and/or status epilepticus were without clinical signs. Magnetic resonance imaging (MRI) was available in six patients. Cortical hyperintensities on diffusion weighted imaging sequence were seen in all six patients. One patient had CEEG seizure concomitantly with the MRI. Seven patients died prior to discharge. CONCLUSION Seizures or status epilepticus in the setting of HE were without clinical findings and could go unrecognized without CEEG. The finding of cortical hyperintensity on MRI should lead to further evaluation for unrecognized seizure or status epilepticus.
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Affiliation(s)
- Christopher R Newey
- Department of Neurology, University of Missouri, 1 Hospital Drive, Columbia, MO, 65211, USA. .,Neurological Institute, Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195-5245, USA.
| | - Pravin George
- Neurological Institute, Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195-5245, USA
| | - Aarti Sarwal
- Neurology and Critical Care (Anesthesia), Wake Forest University School of Medicine, Reynolds M, Medical Center Blvd, Winston Salem, NC, 27157, USA
| | - Norman So
- Neurological Institute, Epilepsy Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195-5245, USA
| | - Stephen Hantus
- Neurological Institute, Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195-5245, USA.,Neurological Institute, Epilepsy Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195-5245, USA
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3
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Abstract
Neurologic complications are common side-effects of immunosuppressive medications used in the prevention of graft rejection after organ transplantation. The medications most commonly encountered include the calcineurin inhibitors and mycophenolate mofetil. Depression is the most commonly encountered neurotoxicity; however, severe but rare adverse neurological effects related to these therapies have been reported. Interferons, ribavirin, and protease inhibitors are therapeutic options commonly encountered in the treatment of hepatitis. Nucleoside analogs such as adefovir dipivoxil and entecavir carry significant risks for the development of lactic acidosis and hepatic dysfunction; however, most common adverse effects to these therapies in general are mild. While the mechanisms of action are poorly elucidated, they are discussed along with treatment strategies.
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Affiliation(s)
| | - Edward M Manno
- Neurological Intensive Care Unit, Cleveland Clinic, Cleveland, OH, USA.
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Jhun P, Kim H. Nonconvulsive status epilepticus in hepatic encephalopathy. West J Emerg Med 2012; 12:372-4. [PMID: 22224122 PMCID: PMC3236148 DOI: 10.5811/westjem.2011.1.2125] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Revised: 12/29/2010] [Accepted: 01/25/2011] [Indexed: 01/05/2023] Open
Abstract
We discuss a case of a 64-year-old male with a history of liver failure presenting with altered mental status, initially diagnosed with hepatic encephalopathy but ultimately diagnosed with nonconvulsive status epilepticus (NCSE) by electroencephalogram (EEG). NCSE is a difficult diagnosis to make, given no clear consensus on diagnostic criteria. Especially in the intensive care unit setting of persistent altered mental status with no clear etiology, NCSE must be considered in the differential diagnosis, as the consequences of delayed diagnosis and treatment can be substantial. EEG can be useful in the evaluation of patients with hepatic encephalopathy who have persistently altered levels of consciousness despite optimal medical management.
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Affiliation(s)
- Paul Jhun
- University of Southern California, Department of Emergency Medicine, Los Angeles, California
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5
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Abstract
BACKGROUND Neurologists are frequently called to evaluate patients in the intensive care units who are not waking up. This often poses a diagnostic and prognostic dilemma. REVIEW SUMMARY The initial evaluation starts with abstracting the prehospital and in-hospital history, followed by bedside clinical and neurologic examination to establish a differential diagnosis. The subsequent work-up is based on clinical suspicion where reversible life-threatening causes should be immediately identified. After confirming the diagnosis and implementation of the appropriate medical management, a prompt family meeting and counseling is recommended. The role of neurologists in clinical diagnosis and prognostication of the coma patient, as well as diagnosing brain death is instrumental. CONCLUSIONS In this review, we explore a practical systematic approach to patients with decreased level of consciousness. The most common causes of impaired alertness in different non-neurologic critical care units and commonly used prognostication tools are presented. Finally a brief introduction of hypothermia, a novel therapeutic approach is also discussed.
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Senzolo M, Marco S, Ferronato C, Cecilia F, Burra P, Patrizia B. Neurologic complications after solid organ transplantation. Transpl Int 2008; 22:269-78. [PMID: 19076332 DOI: 10.1111/j.1432-2277.2008.00780.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Neurologic complications are common after solid organ transplantation and are associated with significant morbidity. Approximately one-third of transplant recipients experiences neurologic alterations with incidence ranging from 10% to 59%. The complications can be divided into such of those common to all types of transplant and others of those specific to transplanted organ. The most common complication seen with all types of transplanted organ is neurotoxicity attributable to immunosuppressive drugs, followed by seizures, opportunistic central nervous system (CNS) infections, cardiovascular events, encephalopathy and de novo CNS neoplasms. Amongst immunosuppressants, calcineurin inhibitors are the main drugs involved in neurotoxicity, leading to complications which ranges from mild symptoms, such as tremors and paresthesia to severe symptoms, such as disabling pain syndrome and leukoencephalopathy. Neurologic complications of liver transplantation are more common than that of other solid organ transplants (13-47%); encephalopathy is the most common CNS complication, followed by seizures; however, central pontine myelinolysis can appear in 1-8% of the patients leading to permanent disabilities or death. In kidney transplanted patients, stroke is the most common neurologic complication, whereas cerebral infarction and bleeding are more typical after heart transplantation. Metabolic, electrolyte and infectious anomalies represent common risk factors; however, identification of specific causes and early diagnosis are still difficult, because of patient's poor clinical status and concomitant systemic and metabolic disorders, which may obscure symptoms.
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Affiliation(s)
- Marco Senzolo
- Gastroenterology, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy
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Tanaka H, Ueda H, Kida Y, Hamagami H, Tsuji T, Ichinose M. Hepatic encephalopathy with status epileptics: A case report. World J Gastroenterol 2006; 12:1793-4. [PMID: 16586556 PMCID: PMC4124362 DOI: 10.3748/wjg.v12.i11.1793] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A 62-year-old male with decompensated liver cirrhosis due to hepatitis C virus developed severe hepatic encephalopathy with status epileptic us. The blood ammonia level on admission was more than twice the normal level. Brain computed tomography and magnetic resonance imaging were normal. In addition, electroencephalogram showed diffuse sharp waves, consistent with hepatic encephalopathy. The status epilepticus was resolved after antiepileptic therapy (phenytoin sodium) and treatment for hepatic encephalopathy (Branched chain amino acids). The blood ammonia level normalized with the clinical improvement and the patient did not have a recurrence of status epilepticus after the end of the antiepileptic treatment. Additionally, the electroencephalogram showed normal findings. Thus, we diagnosed the patient as hepatic encephalopathy with status epilepticus. We consider the status epilepticus of this patient to a rare and interesting finding in hepatic encephalopathy.
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Affiliation(s)
- Hiroto Tanaka
- Third Department of Internal Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City 641-0015, Japan.
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Choi EJ, Kang JK, Lee SA, Kim KH, Lee SG, Andermann F. New-onset seizures after liver transplantation: clinical implications and prognosis in survivors. Eur Neurol 2004; 52:230-6. [PMID: 15550761 DOI: 10.1159/000082163] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2004] [Accepted: 09/02/2004] [Indexed: 11/19/2022]
Abstract
PURPOSE To identify the probable etiologies and characteristics of new-onset seizures after orthotopic liver transplantation (OLT) and to assess their clinical implications and prognosis. METHODS We retrospectively analyzed the clinical, electrophysiologic and laboratory data of 17 patients with new-onset seizures after OLT among 367 adult and pediatric patients who underwent OLT between 1999 and 2001. RESULTS A suspected etiology of seizures was identified in most patients, including 6 (35.2%) with neurotoxicity due to immunosuppressive therapy, 4 (23.5%) with cerebrovascular disease, 3 (17.6%) with severe metabolic derangement by sepsis or rejection, and 1 each (5.8%) with hyperglycemia and brain edema due to fulminant hepatic failure. Causative factors could not be identified in 2 patients (11.8%). Seizures recurred in 15 patients (88.2%), with 9 occurring on the same day as the original seizure. Attacks caused by neurotoxicity tended to have an earlier onset, within 1 week in 4 of 6 patients, than those caused by cerebrovascular disease and sepsis/rejection, but this was not statistically significant. A total of 21 EEGs were performed in 13 patients. Eleven patients had abnormal EEG findings, of whom 4 (30.7%) showed epileptiform discharges, but the outcome of patients with epileptiform activity did not differ statistically from that of patients without such discharges (p > 0.6). The incidence of poor outcome (death or persistent vegetative state) in the group with seizures was almost 10 times higher than in the group without seizures (52.9 vs. 5.7%, p < 0.001). The prognosis of patients with seizures due to cerebrovascular disease and severe metabolic derangement by sepsis/rejection was poorer than that of patients with seizures caused by the neurotoxicity of immunosuppressive drugs (p < 0.02), suggesting that the underlying cause of seizures is important in determining prognosis. Of 8 patients who survived, 1 was lost to follow-up. The long-term outcome of seizures in surviving patients was excellent, with all survivors available for follow-up being seizure-free for a mean follow-up of 42.5 months (range, 16-58 months). CONCLUSION New-onset seizures after OLT may herald fatal outcome, especially in patients with cerebrovascular disease or sepsis. The prognosis of seizures in survivors is excellent, and long-term antiepileptic drugs are not required in most cases.
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Affiliation(s)
- Eun Jung Choi
- Department of Neurology, University of Korea College of Medicine, Guro Hospital, Seoul, Korea
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Paul F, Müller J, Christe W, Steinmüller T, Poewe W, Wissel J. Postural hand tremor before and following liver transplantation and immunosuppression with cyclosporine or tacrolimus in patients without clinical signs of hepatic encephalopathy. Clin Transplant 2004; 18:429-33. [PMID: 15233821 DOI: 10.1111/j.1399-0012.2004.00184.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess tremor characteristics and severity in patients with severe liver disease without hepatic encephalopathy and following orthotopic liver transplantation (LTX) and immunosuppression (IS) with cyclosporin A (CsA) or tacrolimus (FK 506). METHODS A total of 35 consecutive patients were included into the prospective study and serum levels of CsA (n = 29) or FK 506 (n = 6) were monitored following LTX. Tremor characteristics and severity were assessed by two-blinded raters before and following LTX. In addition, accelerometric recordings were taken before and after LTX, and compared with 16 normal controls without tremor and without clinical signs of hepatic encephalopathy or liver disease. Accelerometry was performed while sitting in a comfortable chair with the forearms supported and included rest and postural condition with and without weight load (500 g) on each hand. Kolmogorov-Smirnov test, paired t-test and t-test for independent samples were used for statistical analysis. RESULTS The clinical rating revealed no rest but a mild postural hand tremor before LTX with a significant increase following LTX (p < 0.001). After LTX the mean score of postural tremor was significantly (p < 0.05) higher in patients with plasma levels of >850 ng CsA/ml compared with patients with lower levels. Patients and normal controls showed comparable mean peak frequencies of rest and postural hand tremor. The mean amplitude of postural hand tremor was significantly higher in patients before and after LTX compared with controls. In the majority of patients (89%) and controls (88%), the dominant tremor frequency decreased significantly (>1.5 Hz) when applying a weight load on each hand. CONCLUSION The present study is the first to describe hand tremor characteristics in patients with severe liver disease without clinical signs of hepatic encephalopathy and in patients following LTX and IS. Compared with normal controls the patients showed a significant postural hand tremor prior and post-LTX and an increase of mean tremor amplitude following LTX and CsA/FK 506 treatment. The decrease of the dominant tremor frequency with weight load and an increase of tremor amplitude with higher plasma levels of CsA are both indicative of an enhanced physiological or toxic tremor.
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Affiliation(s)
- Friedemann Paul
- Department of Neurology, Hospital Königin Elisabeth Herzberge, Berlin, Germany
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10
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Eleftheriadis N, Fourla E, Eleftheriadis D, Karlovasitou A. Status epilepticus as a manifestation of hepatic encephalopathy. Acta Neurol Scand 2003; 107:142-4. [PMID: 12580865 DOI: 10.1034/j.1600-0404.2003.02092.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Seizures have been described as a rare manifestation of hepatic encephalopathy. MATERIAL AND METHODS We present a 54-year-old female, with 6-year history of decompensated, hepatitis B liver cirrhosis, admitted with generalized seizures. She reported a history of recurrent episodes of hepatic encephalopathy, spontaneous bacterial peritonitis, tense ascites and variceal hemorrhage. Neurologic examination revealed a comatose patient, without papilledema. Laboratory examinations were suitable with cirrhosis and mild renal failure. Blood gas examination revealed severe metabolic acidosis and hypoxemia. Plasma NH3+ levels upon admission were twice normal. Brain computed tomography and magnetic resonance imaging were normal. Electroencephalogram showed diffuse sharp waves, consistent with hepatic encephalopathy, grades III-IV. RESULTS Status epilepticus was refractory to continuous antiepileptic treatment. However, it was resolved after 24-h therapy with lactulose. Blood NH3 levels were simultaneously normalized with clinical improvement. CONCLUSIONS We consider the status epilepticus of our patient to be a rare manifestation of hepatic encephalopathy.
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Abstract
BACKGROUND Organ transplantation is one of the most dynamic fields in medicine and has evolved into a life-saving option for thousands of patients with previously fatal conditions. The posttransplantation clinical course is frequently associated with neurologic complications that are usually related to pretransplant morbidity, the surgical procedure of transplantation, immunosuppression, and opportunistic infection. REVIEW SUMMARY Neurologic complications of organ transplantation may be divided into complications common to all types of allografts and complications that are specific for a particular type of organ transplantation. The most common complications include seizures, opportunistic central nervous system (CNS) infection, metabolic encephalopathy, stroke, intracranial hemorrhage, and drug-related adverse events. Opportunistic CNS infection may have a subtle presentation and should not be overlooked, as the consequences of delayed treatment may be grave. Neurotoxicity of immunosuppressive agents is also a frequent cause of neurologic complications and may occur in the setting of normal serum drug levels. The clinical course of transplant patients is frequently complex, requiring close cooperation between the transplant team and specialty consultants. Prolonged survival of transplant patients will shift the focus of neurologic complications from acute, perioperative to chronic complications of immunosuppression. CONCLUSIONS Neurologic complications of organ transplantation are commonly related to opportunistic infection or neurotoxicity of immunosuppressive agents, requiring careful titration of immunosuppression. Timely diagnosis of CNS infection or other causes of neurologic dysfunction may significantly improve recovery and outcome in these patients.
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Affiliation(s)
- Misha Pless
- Eye and Ear Institute, and the Department of Neurology, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15203, USA.
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13
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Abstract
This article focuses on the subject of iatrogenic seizures, particularly those that are potentially avoidable. Seizures due to medications, surgical therapy, medical procedures, and diagnostic tests are all examined. Withdrawing antiepileptic drug (AED) therapy from epileptic patients who are undergoing inpatient evaluation for epilepsy surgery is also discussed.
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Affiliation(s)
- S C Schachter
- Department of Neurology, Harvard Medical School, Boston, Massachusetts 02215, USA
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Ficker DM, Westmoreland BF, Sharbrough FW. Epileptiform abnormalities in hepatic encephalopathy. J Clin Neurophysiol 1997; 14:230-4. [PMID: 9244163 DOI: 10.1097/00004691-199705000-00008] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Epileptiform abnormalities are uncommon in patients with hepatic encephalopathy. A review of EEGs in patients with hepatic encephalopathy over a 10-year period identified 18 (15%) with epileptiform abnormalities. Thirteen patients had interictal discharges consisting of focal spike and sharp wave discharges, bilateral independent discharges, and generalized spike and wave discharges. A total of 10 patients had electrographic seizure discharges, focal in 6 and generalized in 5 (some patients had more than one abnormality). Twelve patients had clinical seizures, partial in four and generalized in eight. Neuroimaging failed to provide an etiology for the generation of epileptiform discharges in most patients, including those with focal abnormalities. Most patients with epileptiform discharges died or deteriorated. We conclude that epileptiform can be seen in patients with hepatic encephalopathy, and when present imply a poor prognosis.
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Affiliation(s)
- D M Ficker
- Mayo Clinic Department of Neurology, Rochester, Minnesota, USA
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15
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Abstract
Orthotopic liver transplantation is the accepted treatment for endstage liver disease. In the US alone, more than 3000 patients receive liver transplants yearly distributed through more than 100 liver transplant programmes. Neurological complications occur in up to 47% of these patients. Among them, seizures are one of the most common. They tend to occur during the first few weeks after transplantation. Generalized seizures are the most frequently encountered. Their aetiology is usually multifactorial requiring a comprehensive diagnostic and therapeutic approach. Seizures must be differentiated from a variety of behavioural and movement disorders. In this review article, the frequency and time of occurrence of seizures, their types and aetiology, diagnostic approaches and treatment are discussed.
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Affiliation(s)
- Z K Wszolek
- Division of Neurology, University of Nebraska Medical Center, Omaha 68198-2045, USA
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16
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Abstract
Seizures are not an uncommon complication of medical conditions and should not be ascribed simply to "multifactorial" causes. Although many interacting factors may contribute to a lowered threshold for seizures, a careful systems-oriented search usually yields specific factors that are of primary importance. Not all medically complex patients with seizures have persistent or irreversible processes that lead to recurrent seizures or a need for maintenance antiepileptic drugs (AEDs). Because AEDs contribute to the potential for drug interactions, side effects, and toxicities in situations already encumbered with significant polypharmacy, the decision not to initiate such therapy can be even more important than selecting the best agent, best route of administration, and best dose from a growing list of AEDs.
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Affiliation(s)
- J G Boggs
- Department of Neurology, Medical College of Virginia, Richmond, USA
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17
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Vaughn BV, Ali II, Olivier KN, Lackner RP, Robertson KR, Messenheimer JA, Paradowski LJ, Egan TM. Seizures in lung transplant recipients. Epilepsia 1996; 37:1175-9. [PMID: 8956848 DOI: 10.1111/j.1528-1157.1996.tb00549.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE We wished to assess organ transplant recipients, who incur a significant risk for seizures. METHOD We reviewed 85 lung transplants performed in 81 patients at the University of North Carolina hospitals between 1991 and 1994. All patients were reviewed for age, reason for transplant, detailed description of seizures, neurological examination, medications, and laboratory results, including cyclosporine level, EEG, and brain imaging. RESULTS Eighteen of 81 (22%) patients experienced seizures. Patients aged < 25 years had the greatest risk of seizures and 15 of the 18 patients had cystic fibrosis. Sixteen of the 18 (89%) patients, by history, had partial-onset seizures. Eleven of the 18 (61%) patients had seizures < or = 10 days after initiation of intravenous methylprednisolone for allograft rejection. Two patients had seizures associated with sustained hypertension: 1 of these patients was simultaneously being treated for rejection. Four patients had strokes (1 before transplant) and seizures. Two patients were receiving imipenem. Magnetic resonance imaging (MRI) of the brain demonstrated areas of increased T2 signal in 8 of 9 patients. CONCLUSIONS Our findings demonstrate multiple etiologies for seizures in our transplant recipients. However, we believe that patients, especially those aged < 25 years, being treated with intravenous methylprednisolone for rejection may be at increased risk of seizures. We hypothesize that the focal loss of blood-brain barrier (BBB) may play a significant role in the development of partial seizures in lung transplant recipients.
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Affiliation(s)
- B V Vaughn
- Department of Neurology, University of North Carolina at Chapel Hill, 27599-7025, USA
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18
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Affiliation(s)
- E F Wijdicks
- Department of Neurology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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19
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20
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Steg RE, Wszolek ZK. Electroencephalographic abnormalities in liver transplant recipients: practical considerations and review. J Clin Neurophysiol 1996; 13:60-8. [PMID: 8988286 DOI: 10.1097/00004691-199601000-00006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
This article reviews the central nervous system complications of orthotopic liver transplantation (OLT) and the contribution of EEG in their assessment. The utility of EEG in the evaluation of disturbances of the level of consciousness, cerebrovascular disorders, infections, seizures, medication effects, and central pontine myelinolysis is discussed. EEG may aid in the assessment of altered levels of consciousness, correlate a variety of behavioral manifestations, demonstrate the presence of subclinical seizure patterns, and monitor the treatment response, thus contributing to the management of the OLT patient.
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Affiliation(s)
- R E Steg
- Department of Neurology, Creighton University School of Medicine, Omaha, Nebraska 68131-2197, USA
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21
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Wijdicks EF. Impaired consciousness after liver transplantation. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1995; 1:329-34. [PMID: 9346591 DOI: 10.1002/lt.500010511] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- E F Wijdicks
- Department of Neurology (Neurology Critical Care Service), Mayo Clinic, Rochester, MN, USA
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Wszolek ZK, Steg RE. Seizures after liver transplantation. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1995; 1:334-9. [PMID: 9346592 DOI: 10.1002/lt.500010512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Z K Wszolek
- Section of Neurology, University of Nebraska College of Medicine, Omaha, USA
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23
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Von Rosen F, Bleck TP. Neurologic Complications in Organ Transplantation. Neurocrit Care 1994. [DOI: 10.1007/978-3-642-87602-8_93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Garg BP, Walsh LE, Pescovitz MD, Patel H, Chong S, Filo RS, Fitzgerald J. Neurologic complications of pediatric liver transplantation. Pediatr Neurol 1993; 9:444-8. [PMID: 7605552 DOI: 10.1016/0887-8994(93)90023-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The neurologic complications of 24 children, ages 5 months to 18 years, following orthotopic liver transplantation at the Indiana University hospitals are reported. Biliary atresia (14 patients) was the most common cause for orthotopic liver transplantation. Three children died. Seventeen children (70%) had no neurologic deficit on follow-up 6 months or longer after transplantation. Eleven children (46%), including 4 of 16 patients (25%) who had received OKT3, had neurologic complications. Seven children (29%) had new-onset seizures; 4 of these patients had status epilepticus. Two children had intracranial hemorrhage. Seizures occurred later in children than in adults following orthotopic liver transplantation and were not associated with poor prognosis. Longer term follow-up is indicated to assess subtle, cognitive deficits following liver transplantation in children.
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Affiliation(s)
- B P Garg
- Department of Neurology, Indiana University Medical Center, Indianapolis, USA
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25
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Bicknese AR, May W, Hickey WF, Dodson WE. Early childhood hepatocerebral degeneration misdiagnosed as valproate hepatotoxicity. Ann Neurol 1992; 32:767-75. [PMID: 1471867 DOI: 10.1002/ana.410320610] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Four unrelated children were thought to have valproate-associated hepatotoxicity. They presented with recurrent partial secondarily generalized status epilepticus and epilepsia partialis continua followed by mental and motor regression. Despite treatment with multiple antiepileptic medications, they continued to have seizures. After initiation of valproic acid (VPA), all 4 manifested liver failure within 3 months. Two of these children each had 1 sibling who was not exposed to VPA, but who developed the same clinical picture including liver failure. At the time of autopsy, all 6 children had similar neuropathological findings with focal areas of spongiosis and neuronal loss, diffuse gliosis, and Alzheimer type II cells. One VPA-treated patient underwent a successful liver transplantation only to die from relentlessly progressive neurological deterioration. We propose that many of the reported patients with VPA-associated hepatotoxicity represent undiagnosed patients with early childhood hepatocerebral degeneration, the Huttenlocher variant of Alpers' syndrome. This disease manifests by obstinate partial seizures, recurrent partial secondarily generalized status epilepticus, epilepsia partialis continua, psychomotor deterioration, and hepatic dysfunction that is exacerbated by VPA administration. The accelerated demise from liver failure in the nontransplanted patients before the central nervous system pathology fully evolves makes the diagnosis of this rare condition difficult. The occurrence of disease in the unexposed siblings suggests recessive inheritance.
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Affiliation(s)
- A R Bicknese
- Department of Neurology, University of Tennessee, Memphis
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