Neuropsychological deficits and morphological MRI brain scan abnormalities in apparently healthy non-encephalopathic patients with cirrhosis. A controlled study

Neurocritical care monitoring of encephalopathic children with acute liver failure: A systematic review

Research on non-invasive neuromonitoring specific to PALF is limited. This systematic review identifies and synthesis the existing literature on non-invasive approaches to monitoring for neurological sequelae in patients with PALF. A series of literature searches were performed to identify all publications pertaining to five different non-invasive neuromonitoring modalities, in line with PRISMA guidelines. Each modality was selected on the basis of its potential for direct or indirect measurement of cerebral perfusion; studies on electroencephalographic monitoring were therefore not sought. Data were recorded on study design, patient population, comparator groups, and outcomes. A preponderance of observational studies was observed, most with a small sample size. Few incorporated direct comparisons of different modalities; in particular, comparison to invasive intracranial pressure monitoring was largely lacking. The integration of current evidence is considered in the context of the clinically significant distinctions between pediatric and adult ALF, as well as the implications for planning of future investigations to best support the evidence-based clinical care of these patients.

Regional cerebral blood flow assessed by single photon emission computed tomography (SPECT) in dogs with congenital portosystemic shunt and hepatic encephalopathy

Regional cerebral blood flow (rCBF) in eight dogs with congenital portosystemic shunt (PSS) and hepatic encephalopathy (HE) was compared with rCBF in eight healthy control dogs using single photon emission computed tomography (SPECT) with a ^99mtechnetium-hexamethylpropylene amine oxime (^99mTc-HMPAO) tracer. SPECT scans were abnormal in all PSS dogs. Compared to the control group, rCBF in PSS dogs was significantly decreased in the temporal lobes and increased in the subcortical (thalamic and striatal) area. Brain perfusion imaging alterations observed in the dogs with PSS and HE are similar to those in human patients with HE. These findings suggest that dogs with HE and PSS have altered perfusion of mainly the subcortical and the temporal regions of the brain.

Prevalence of Insomnia and Sleep Patterns among Liver Cirrhosis Patients

Background:

Few studies are available regarding the prevalence of sleep disturbance in cirrhotic patients without overt hepatic encephalopathy. This study aimed to assess the prevalence of insomnia in stable liver cirrhosis patients who are attending the outpatient clinics at King Abdulaziz Medical City, Riyadh (KAMC-KFNGH).

Methods:

A cross-sectional study enrolled 200 stable patients with confirmed liver cirrhosis. We used the ICSD-2 definition to assess the prevalence of insomnia. We also collected information about sleep patterns, demographic data, the underlying cause of liver cirrhosis and the severity of liver cirrhosis using Child-Pugh scores (CTP).

Results:

The mean age was 58.9 (SD ± 12.2) years. Hepatitis C was the most common (60.2%) cause of liver cirrhosis among respondents. The prevalence of insomnia was 42% (84/200). Univarite analysis shows association between coffee intake and the presence of insomnia (56.9% vs. 35.9%, p-value = 0.006). The prevalence of insomnia was higher in hepatitis C (51.7%) compared to hepatitis B (36.8%) and other hepatitis (15%), p-value = 0.001. There was a significant relationship between severity of liver cirrhosis (CTP-A, CTP-C, CTP-B) and prevalence of insomnia: 55%, 36.1% and 32.1% respectively, p-value = 0.009. Insomniac patients were significantly older than non-insomniac (61.6 ± 12.0 vs. 57.0 ± 12.0 years, p = 0.008). Results from the multivariate stepwise analysis showed coffee intake (OR=2.7), hepatitis C (OR = 7.2), CTP-A (OR = 1.9), excessive daytime sleepiness (OR = 5.3) and short sleep duration (OR = 5.7) were the most strongly associated with the presence of insomnia.

Conclusion:

Our study showed a high prevalence of insomnia in patients with liver cirrhosis.

Hepatic Encephalopathy: From the Pathogenesis to the New Treatments

Hepatic encephalopathy is a frequent and serious complication of liver cirrhosis; the pathophysiology of this complication is not fully understood although great efforts have been made during the last years. There are few prospective studies on the epidemiology of this complication; however, it is known that it confers with high short-term mortality. Hepatic encephalopathy has been classified into different groups depending on the degree of hepatic dysfunction, the presence of portal-systemic shunts, and the number of episodes. Due to the large clinical spectra of overt EH and the complexity of cirrhotic patients, it is very difficult to perform quality clinical trials for assessing the efficacy of the treatments proposed. The physiopathology, clinical manifestation, and the treatment of HE is a challenge because of the multiple factors that converge and coexist in an episode of overt HE.

Grey and white matter abnormalities in minimal hepatic encephalopathy: a study combining voxel-based morphometry and tract-based spatial statistics

OBJECTIVES

Low-grade cerebral oedema is considered to be pathognomonic of minimal hepatic encephalopathy (MHE) in cirrhotic patients. The purpose of this study was to investigate both the grey matter (GM) and white matter (WM) changes in a homogeneous cohort of patients with MHE by combining voxel-based morphometry (VBM) and tract-based spatial statistics (TBSS).

METHODS

Twenty-five MHE patients and 25 healthy controls participated in the study with three-dimensional T1 and diffusion-tensor imaging. Group differences in regional GM volume were assessed using VBM analysis while differences in fractional anisotropy (FA), mean diffusivity (MD) of WM were compared using TBSS analysis.

RESULTS

VBM displayed extensively decreased GM volume in MHE, mainly located in the frontal and temporal cortices, paracentral lobule, caudate, putamen and amygdale, and increased GM volume in the thalamus. TBSS showed decreased FA in MHE patients in the corpus callosum, cingulum, internal/external capsule, corticospinal tract, superior longitudinal fasciculus and posterior corona radiata. Areas of increased MD in MHE patients were more extensive and included, in addition to all the areas of decreased FA, the anterior corona radiata, inferior fronto-occipital fasciculus, fornix and the middle cerebellar peduncle.

CONCLUSION

The results suggest that cortical atrophy and low-grade brain oedema in WM co-exist in MHE.

Disrupted thalamic resting-state functional connectivity in patients with minimal hepatic encephalopathy

BACKGROUND AND PURPOSE

Little is known about the role of thalamus in the pathophysiology of minimal hepatic encephalopathy (MHE). The purpose of this study was to investigate whether the thalamic functional connectivity was disrupted in cirrhotic patients with MHE by using resting-state functional magnetic resonance imaging (rs-fMRI).

MATERIALS AND METHODS

Twenty seven MHE patients and twenty seven age- and gender- matched healthy controls participated in the rs-fMRI scans. The functional connectivity of 11 thalamic nuclei were characterized by using a standard seed-based whole-brain correlation method and compared between MHE patients and healthy controls. Pearson correlation analysis was performed between the thalamic functional connectivity and venous blood ammonia levels/neuropsychological tests scores of patients.

RESULTS

The ventral anterior nucleus (VAN) and the ventral posterior medial nucleus (VPMN) in each side of thalamus showed abnormal functional connectivities in MHE. Compared with healthy controls, MHE patients demonstrated significant decreased functional connectivity between the right/left VAN and the bilateral putamen/pallidum, inferior frontal gyri, insula, supplementary motor area, right middle frontal gyrus, medial frontal gyrus. In addition, MHE patients showed significantly decreased functional connectivity with the right/left VPMN in the bilateral middle temporal gyri (MTG), temporal lobe, and right superior temporal gyrus. The venous blood ammonia levels of MHE patients negatively correlated with the functional connectivity between the VAN and the insula. Number connecting test scores showed negative correlation with the functional connectivity between the VAN and the insula, and between the VPMN and the MTG.

CONCLUSION

MHE patients had disrupted thalamic functional connectivity, which mainly located in the bilateral ventral anterior nuclei and ventral posterior medial nuclei. The decreased connectivity between thalamus and many cortices, and basal ganglia indicated reduced integrity of thalamic RSN in MHE.

Brain perfusion single photon emission computed tomography abnormalities in patients with minimal hepatic encephalopathy

BACKGROUND

Minimal hepatic encephalopathy (MHE) is the mildest form of hepatic encephalopathy (HE). Minimal hepatic encephalopathy patients do not demonstrate clinically overt symptoms of HE but present with abnormal neuropsychological and/or neurophysiological tests indicative of cerebral dysfunction. This study was performed in such patients to identify regions of abnormal cerebral perfusion and to correlate regional cerebral blood flow (rCBF) changes with psychometric hepatic encephalopathy score (PHES), Child-Turcotte-Pugh's score (CTP), and model for end-stage liver disease (MELD) score. We also compared abnormal patterns of rCBF in cirrhotic patients of alcoholic etiology with non-alcoholic etiology.

METHODS

This prospective study was performed to evaluate rCBF in 50 cirrhotic patients and 13 controls using technetium-99m ethyl cysteinate dimer (Tc-99m ECD) brain single photon emission computed tomography. All the patients underwent a battery of psychometry tests, PHES. Minimal hepatic encephalopathy was diagnosed if PHES was ≤-5. The rCBF changes were evaluated using region of interest (ROI) based semi-quantitative method of region/cerebellum and region/cortex ratios in 16 regions of the brain.

RESULTS

Cirrhotic patients with MHE showed impaired perfusion in the superior prefrontal cortex and increased perfusion in the thalamus, brain-stem, medial temporal cortex, and the hippocampus when compared with the controls. Cerebral perfusion in superior prefrontal cortex correlated negatively with MELD score (r=-0.323, P=0.022). We found significant positive correlation between PHES score and rCBF values in the left superior prefrontal cortex (r=0.385, P=0.006). Cirrhotic patients with alcohol etiology showed significantly decreased rCBF in right inferior prefrontal cortex, right superior prefrontal cortex, and the anterior cingulate cortex while increased rCBF was noted in the right medial temporal cortex and hippocampus.

CONCLUSION

Our results suggest that alterations in cognition in cirrhotic patients with MHE may be associated with impaired abnormalities of rCBF.

Selective impairments of resting-state networks in minimal hepatic encephalopathy

BACKGROUND

Minimal hepatic encephalopathy (MHE) is a neuro-cognitive dysfunction characterized by impairment in attention, vigilance and integrative functions, while the sensorimotor function was often unaffected. Little is known, so far, about the exact neuro-pathophysiological mechanisms of aberrant cognition function in this disease.

METHODOLOGY/PRINCIPAL FINDINGS

To investigate how the brain function is changed in MHE, we applied a resting-state fMRI approach with independent component analysis (ICA) to assess the differences of resting-state networks (RSNs) between MHE patients and healthy controls. Fourteen MHE patients and 14 age-and sex-matched healthy subjects underwent resting-state fMRI scans. ICA was used to identify six RSNs [dorsal attention network (DAN), default mode network (DMN), visual network (VN), auditory network (AN), sensorimotor network (SMN), self-referential network (SRN)] in each subject. Group maps of each RSN were compared between the MHE and healthy control groups. Pearson correlation analysis was performed between the RSNs functional connectivity (FC) and venous blood ammonia levels, and neuropsychological tests scores for all patients. Compared with the healthy controls, MHE patients showed significantly decreased FC in DAN, both decreased and increased FC in DMN, AN and VN. No significant differences were found in SRN and SMN between two groups. A relationship between FC and blood ammonia levels/neuropsychological tests scores were found in specific regions of RSNs, including middle and medial frontal gyrus, inferior parietal lobule, as well as anterior and posterior cingulate cortex/precuneus.

CONCLUSIONS/SIGNIFICANCE

MHE patients have selective impairments of RSNs intrinsic functional connectivity, with aberrant functional connectivity in DAN, DMN, VN, AN, and spared SMN and SRN. Our fMRI study might supply a novel way to understand the neuropathophysiological mechanism of cognition function changes in MHE.

Focal cortical damage parallels cognitive impairment in minimal hepatic encephalopathy

Little attention has been paid to cortical integrity in patients with minimal hepatic encephalopathy (MHE), although cognitive functions affected in early stages of liver disease are mainly allocated in different neocortical structures. Here we used cortical surface-based analysis techniques to investigate if patterns of cortical thinning accompany the mildest form of HE. To aim this goal, cortical thickness obtained from high-resolution 3T magnetic resonance imaging (MRI) was measured in patients with no MHE (NMHE), MHE, and healthy controls. Further correlation analyses were performed to examine whether scores in the critical flicker frequency (CFF) test, and blood ammonia levels accounted for the loss of cortical integrity in different stages of liver disease. Finally, we assessed group differences in volume of different subcortical regions and their potential relationships with CFF scores/blood ammonia levels. Results showed a focal thinning of the superior temporal cortex and precuneus in MHE patients when compared with NMHE and controls. Relationships between blood ammonia levels and cortical thickness of the calcarine sulcus accounted for impaired visual judgment in patients with MHE when compared to NMHE. Regression analyses between cortical thickness and CFF predicted differences between controls and the two groups of HE patients, but failed to discriminate between patients with NMHE and MHE. Taking together, these findings provide the first report of cortical thinning in MHE patients, and they yield novel insights into the neurobiological basis of cognitive impairment associated with early stages of liver diseases.

Assessment and usefulness of clinical scales for semiquantification of overt hepatic encephalopathy

Hepatic encephalopathy (HE) represents the effects of liver dysfunction on the brain. When HE is clinically obvious (eg, confusion, poor judgment, personality change), it is termed overt HE. The severity of HE is measured by different methods. Assessing the severity of HE is important for determining patient prognosis and effectiveness of therapy. This article discusses the different methods for grading HE, including clinical rating scales, neuropsychological tests, and neurophysiologic measures.

Voxel-based analyses of magnetization transfer imaging of the brain in hepatic encephalopathy

AIM: To evaluate the spatial distribution of cerebral abnormalities in cirrhotic subjects with and without hepatic encephalopathy (HE) found with magnetization transfer imaging (MTI).

METHODS: Nineteen cirrhotic patients graded from neurologically normal to HE grade 2 and 18 healthy control subjects underwent magnetic resonance imaging. They gave institutional-review-board-approved written consent. Magnetization transfer ratio (MTR) maps were generated from MTI. We tested for significant differences compared to the control group using statistical non-parametric mapping (SnPM) for a voxel-based evaluation.

RESULTS: The MTR of grey and white matter was lower in subjects with more severe HE. Changes were found in patients with cirrhosis without neurological deficits in the basal ganglia and bilateral white matter. The loss in magnetization transfer increased in severity and spatial extent in patients with overt HE. Patients with HE grade 2 showed an MTR decrease in white and grey matter: the maximum loss of magnetization transfer effect was located in the basal ganglia [SnPM (pseudo-)t = 17.98, P = 0.0001].

CONCLUSION: The distribution of MTR changes in HE points to an early involvement of basal ganglia and white matter in HE.

Detecção de encefalopatia hepática mínima através de testes neuropsicológicos e neurofisiológicos e o papel da amônia no seu diagnóstico

CONTEXTO: A encefalopatia hepática mínima vem sendo sistematicamente investigada em pacientes com cirrose hepática. Entretanto, existem controvérsias quanto aos melhores métodos, bem como o papel da amônia para seu diagnóstico. OBJETIVO: Avaliar a frequência de encefalopatia hepática mínima diagnosticada através de testes neuropsicológicos e neurofisiológicos em cirróticos, bem como os possíveis fatores de risco para esta condição, incluindo o papel da concentração arterial de amônia em seu diagnóstico. MÉTODOS: Indivíduos com cirrose hepática foram avaliados através do teste de conexão numérica partes A e B (TCN-A e TCN-B) e potencial evocado relacionado a eventos (P300). O diagnóstico de encefalopatia hepática mínima foi feito quando da presença de anormalidade no P300 e em, pelo menos, um dos testes neuropsicológicos. As concentrações arteriais de amônia, a escolaridade e a gravidade da cirrose hepática também foram avaliadas em todos. RESULTADOS: Foram avaliados 48 pacientes cirróticos, com média de idade 50 ± 8 anos, sendo 79% do sexo masculino. As principais causas foram a alcoólica e a viral. O P300 foi anormal em 75% dos casos e o TCN-A e TCN-B anormais em 58% e 65% dos casos, respectivamente. Os resultados do TCN-B foram influenciados pela escolaridade. A frequência de encefalopatia hepática mínima foi de 50%. A concentração arterial de amônia não foi significantemente maior em pacientes com diagnóstico de encefalopatia hepática mínima (195 ± 152 mmol/L versus 148 ± 146 mmol/L; P>0,05). Não houve diferença significante entre os grupos com e sem encefalopatia hepática mínima quanto às demais variáveis estudadas. CONCLUSÃO:A encefalopatia hepática mínima é condição frequente em pacientes com cirrose hepática. A concentração arterial de amônia não parece ter papel importante no seu diagnóstico.

Dopamine transporter SPECT of a liver cirrhotic with atypical parkinsonism

High level of exposure to manganese (Mn) can cause a clinically and pathophysiologically distinct syndrome from idiopathic Parkinson's disease (PD). We describe the clinical features and results of [123I]-fluoropropyl (FP)-CIT SPECT of a liver cirrhotic with atypical parkinsonism. The patient developed atypical parkinsonian features associated with elevated blood Mn from hepatic dysfunction. [123I]-FP-CIT brain SPECT images of dopamine transporter (DAT) demonstrated overall normal range of DAT uptake in the striatum although there were scattered small hypodense regions. The globus pallidum had increased signal on T1-weighted magnetic resonance imaging (MRI). All these findings are compatible with those of manganism, and are remarkably different from that in PD.

Characteristics of minimal hepatic encephalopathy

The term minimal hepatic encephalopathy refers to the subtle changes in cognitive function, electrophysiological parameters, cerebral neurochemical/neurotransmitter homeostasis, cerebral blood flow, metabolism, and fluid homeostasis that can be observed in patients with cirrhosis who have no clinical evidence of hepatic encephalopathy. Use of this term emphasizes the fact that the entity of hepatic encephalopathy is a single syndrome with quantitatively distinct features relating to severity. The absence of clinical evidence of hepatic encephalopathy is key to the diagnosis and can only be determined by a detailed assessment of the patients' history and a comprehensive neurological assessment of consciousness, cognitive, and motor function. The neuropsychological features of minimal hepatic encephalopathy point to a disorder of executive functioning, particularly selective attention and psychomotor speed, but other abnormalities may be observed. Alterations in electrophysiological variables have been described; endogenous evoked potentials are, in principle, more likely to reflect the presence of minimal hepatic encephalopathy, since they reflect cognitive phenomena rather than mere stimulus conduction but the specificity of the changes observed is unclear at present. Changes have also been described in the execution of diadochokinetic movements and in the capacity to discriminate flickering light, both of which may have diagnostic potential. The changes observed in cerebral blood flow and metabolism in SPET, PET, and 1H and 31P MRS studies reflect the pathogenic process that underlies the condition rather than providing diagnostic information. Similarly, the morphological brain abnormalities identified in this population, including mild brain oedema, hyperintensity of the globus pallidus and other subcortical nuclei observed in cerebral MR studies, and the central and cortical atrophy observed in neural imaging studies, are unlikely to have diagnostic utility. The presence of minimal hepatic encephalopathy is not without clinical consequence; it has a detrimental effect on health-related quality of life, the ability to perform complex tasks such as driving, and on outcome.

Oral tryptophan challenge studies in cirrhotic patients: no evidence of neuropsychiatric changes

Hepatic encephalopathy is a frequent complication of cirrhosis. Abnormalities of 5-hydroxytryptamine (5-HT) and its metabolites are recognized and may contribute to its pathogenesis. We therefore studied the effect of an oral tryptophan load (6-18 g) upon psychometric test scores and analyzed EEG's in alcoholic cirrhotic patients. Eight patients had had previous encephalopathic episodes related to variceal bleeds and one patient was awaiting a liver transplant. Five out of the 10 patients had at least one abnormal baseline psychometric test. Following tryptophan challenge there were no changes in blood ammonia but plasma tryptophan levels were elevated approximately 10-fold (p < 0.01 x 10(-7)). Nevertheless, there were no statistically significant changes in psychometric testing or analyzed EEG frequency distribution. All patients reported nausea or vomiting while one patient developed a short-lived serotonin like syndrome. We conclude that in this group of patients, an oral tryptophan load does not induce or worsen subclinical hepatic encephalopathy. If the high blood levels of tryptophan seen in these studies are able to influence cerebral neurotransmitter synthesis, the results do not support a primary role for abnormalities of 5-HT neurotransmission in hepatic encephalopathy.

Electrophysiological and neuropsychological tests for the diagnosis of subclinical hepatic encephalopathy and prediction of overt encephalopathy

BACKGROUND

Subclinical hepatic encephalopathy (SHE) features in 30-84% of patients with cirrhosis of the liver. Its clinical significance with regards to progression to overt encephalopathy has however, not been established.

AIMS

The present study was conducted (i) to compare the diagnostic usefulness of neuropsychological tests with that of electrophysiological (EP) tests in detection of SHE, and (ii) to examine the natural course of SHE.

METHODS

Seventy-five-nonencephalopathic cirrhotics (11 females, 64 males; mean (+/- SD) age 43.6 (+/- 11.7) years; mean (+/- SD) education 11(+/- 3) years) were studied using a battery of tests for intelligence and memory, the number connection test (NCT), and EP tests viz. electroencephalogram (EEG) and auditory P300 event related potentials (P3ERP). All the patients were followed up for a period of 6 months to 2 years for development of overt encephalopathy.

RESULTS

Thirty-five out of 75(47%) patients were diagnosed to have SHE based on at least one abnormal test result. The P3ERP latencies detected SHE in maximum number of patients (23%) followed by EEG (21%). Nearly 59% of patients with SHE progressed to overt encephalopathy within a mean duration of 4 months. Multivariate analysis showed that prior episode of encephalopathy (RR = 6.3; 95% CI = 2.0-19.7), abnormality on EEG (RR = 7.5; 95% CI = 2.2-25.3), abnormal performance on psychometric battery of tests (RR = 35.2; 95% CI = 4.3-287.3), occurrence of gastrointestinal bleed (RR = 19.3; 95% CI = 4.1-88.9), occurrence of dehydration (RR = 10.7; 95% CI = 2.5-45.4) and infection (RR = 11.4; 95% CI = 2.0-64.4) had significantly higher risk for development of overt encephalopathy.

CONCLUSIONS

EP methods were more sensitive in detection of SHE. Amongst all the tests used, presence of only an abnormal EEG was significantly associated with development of overt encephalopathy along with the precipitating factors.

Amino acid challenge in patients with cirrhosis: a model for the assessment of treatments for hepatic encephalopathy

BACKGROUND/AIMS

To mimic episodic hepatic encephalopathy after gastrointestinal bleeding under controlled conditions, cirrhotic patients were challenged with an amino acid mixture of comparable composition to haemoglobin.

METHODS

Basal EEG, psychometric score (HE test), reaction times and venous blood ammonia were recorded. Following a 54 or 108 gm oral amino acid challenge, blood ammonia levels and EEG were recorded at 30-min intervals, and psychometric testing was repeated at 180 min. Ten controls (57 +/- 2) and 31 cirrhotics (52 +/- 2) of which 21 were Child's grade A or B and 10 grade C underwent the challenge. Nine had a transjugular intrahepatic porta-systemic shunt in situ.

RESULTS

Seventeen patients had abnormal baseline HE scores. Basal blood ammonia and reaction time A were significantly greater in patients (52 +/- 5 micromol/l and 478 +/- 20 ms, respectively) than controls (19 +/- 2 micromol/l and 372 +/- 14 ms) (P < 0.001). Following the challenge, in patients with advanced liver disease (Child's grade B and C) the slowing of reaction time A (+85 +/- 38 and +71 +/- 31 ms, respectively; P < 0.03) and EEG (ratio of slow to fast wave activity +0.31 +/- 0.12 and +0.58 +/- 0.19; P < 0.02) were significantly greater than in controls (-3.3 +/- 8 ms and 0.00 +/- 0.03, respectively). Patients with an abnormal basal HE score had the most pronounced changes (reaction time A +110 +/- 39 ms, P < 0.01, EEG +0.52 +/- 13, P < 0.01, respectively). The change in EEG ratio correlated with the dose of amino acid administered (r = 0.96; P < 0.008).

CONCLUSION

The amino acid challenge constitutes a reproducible human model of episodic, Type C hepatic encephalopathy unaffected by the complications usually encountered in clinical practice.

Neurological examinations after liver transplantation concerning patients under corticosteroid immunosuppression and either FK 506 or cyclosporin

To study the neurological sequelae in liver transplanted recipients, 25 patients were followed up between 5 and 30 months after transplantation and another 14 patients were seen before and after transplantation. Physical examination took special note of tremor and polyneuropathy; additionally, patients estimated concentration and memory, tremor, paraesthesias and sleep disturbances on a self-rating scale. Tremor was reported to be preexistent in 50% of the later FK 506 and cyclosporin group and only temporarily rose afterwards. Twenty-eight percent complained of tremor and 20% said that it interfered mildly with daily activity. Only 2 of 39 patients showed new signs of polyneuropathy. Concentration and memory improved significantly after transplantation. In the second group of patients, MRI, EEG, lumbar puncture and neuropsychological tests were done just before and routinely after transplantation, revealing numerous preexisting neurological deficits with only singular changes afterwards.

Chronic liver disease: relaxometry in the brain after liver transplantation

Relaxometry revealed changes in the basal ganglia in T(1) and T(2) relaxation times due to liver disease. Manganese is probably responsible for T(1) and T(2) shortening (as the concentration is known to be higher in both the liver and blood due to hepatic cirrhosis). The aim of this study was to follow possible recovery after liver transplantation by MR relaxometry. Together with a group of 20 healthy volunteers we scanned 53 patients before and after liver transplantation (some of them repeatedly). Both T(1) and T(2) values were evaluated in the basal ganglia, thalamus, and frontal white matter. T(1) relaxation time was shortened by approx. 20-25% compared to the control group, probably the result of manganese deposition in the brain caused by hepatic cirrhosis. After liver transplantation the relaxation time recovered gradually with almost normal values reached approx. 2 years after surgery. T(1) recovery was observed in all evaluated structures. Similar results were observed with T(2) relaxation in the basal ganglia and thalamus. In the white matter T(2) remained low even 2 years after surgery.

Auditory P300 event-related potentials and number connection test for evaluation of subclinical hepatic encephalopathy in patients with cirrhosis of the liver: a follow-up study

BACKGROUND AND AIMS

The P300 event-related potentials (P3ERP) have been recently advocated for detection of cognitive disturbances in early encephalopathy. However, no systematic follow-up study has been conducted to understand the clinical significance of subclinical hepatic encephalopathy (SHE) detected by this or other methods. The present study was therefore undertaken to examine the diagnostic usefulness of auditory P3ERP in the detection of SHE, to compare it with that of the number connection test (NCT), and to investigate the clinical outcome of patients with SHE in terms of progression to overt encephalopathy.

METHODS

P300 event-related potential latencies were measured and the NCT time was recorded in 81 non-encephalopathic cirrhotic patients (Aged 43.8 +/- 11 years, 23 alcoholic and 58 non-alcoholics) attending the outpatient department at our tertiary care hospital (All India Institute of Medical Sciences Hospital). Cut-off values for abnormality in the tests were developed from age-, sex- and education-matched controls. Patients were followed up at regular intervals for the development of overt encephalopathy, and the identifiable precipitating factors were noted. The P3ERP latencies (363 +/- 34 msec vs 349 +/- 23 msec), as well as NCT time (54.6 +/- 30.6 s vs 39.5 +/- 15.8 s) were significantly prolonged (P< 0.01) in patients with liver cirrhosis when compared with the non-cirrhotic controls.

RESULTS

The P3ERP defects were seen in 24.6% of cirrhotic patients, while NCT time was prolonged in 19.7% of the patients. Nearly 43% of the patients with SHE progressed to overt encephalopathy within a mean duration of 5 months, while only 3.9% of the non-SHE patients did so. Of the patients who developed overt encephalopathy, 64.2% had P3ERP latency prolongations while 35.7% had abnormal NCT.

CONCLUSIONS

The results of the present study suggest that P3ERP and NCT are valid tools for the screening of SHE in cirrhotic patients as there is a greater likelihood of overt encephalopathy development in patients with an abnormality detected by these tests than in patients with no such abnormality.

Liver disease in Navajo neuropathy

OBJECTIVE

To describe clinical and histologic features of liver disease in infants and children with Navajo neuropathy (NN).

METHODS

Physicians at Navajo Area Indian Health Service facilities and neurologists and gastroenterologists at regional referral hospitals were surveyed for identification of patients born between 1980 and 1994 with known or suspected NN. Clinical records and liver histologic findings were reviewed.

RESULTS

Liver disease was present in all children with NN. Three clinical phenotypes of NN were observed, based on age at presentation and course: infantile NN presented in 5 infants before 6 months of age with jaundice and failure to thrive and progressed to liver failure before 2 years of age; childhood NN presented in 6 children between 1 and 5 years of age with liver dysfunction, which progressed to liver failure and death within 6 months; and classical NN presented in 9 children with variable onset of liver disease but progressive neurologic deterioration. Liver histologic findings were characterized by multinucleate giant cells, macrovesicular and microvesicular steatosis, pseudo-acini, inflammation, cholestasis, and bridging fibrosis and cirrhosis. Cases of all 3 phenotypes occurred within the same kindred.

CONCLUSIONS

Liver disease is an important component of NN and may be the predominant feature in infants and young children. We propose changing the name of this disease to Navajo neurohepatopathy.

Clinical features and survivial of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests

The prevalence and the clinical implications of subclinical cognitive alterations in cirrhotic patients have not been well defined as yet. Therefore, we performed a study to assess the clinical features and the survival of cirrhotic patients with cognitive alterations detected by the number connection test (NCT) and a set of computerized psychometric tests (Scan, Choice1, and Choice2) measuring the reaction times and the percentage of errors in performing specific tasks. Ninety-four cirrhotic patients (aged 58 +/- 9 years) without overt hepatic encephalopathy and 80 controls (aged 53 +/- 15 years) were consecutively enrolled. The median follow-up in cirrhotic patients was 426 days (lower quartile = 213 days; upper quartile = 718 days). Results of the NCT, Scan test, and Choice2 test were significantly worse in cirrhotic patients, whereas Choice1 did not differ significantly from the controls. In cirrhotic patients, the prevalence of altered psychometric tests was 21% (CI95% = 14%-31%) by NCT, 23% (CI95% =15%-33%) by Scan test, and 20% (CI95% =16%-30%) by Choice2 test. The alterations of NCT, Scan, and Choice2 were found to be related to the severity of liver disease, independently of its etiology. Increased risk of death was found to be associated with altered Scan test (hazard ratio = 2.4; CI95% =1. 1-5.3), or altered Choice2 test (hazard ratio = 2.8; CI95% = 1.2-6. 3). Multivariate regression showed that Scan and Choice2 tests had prognostic value on survival, in addition to Child-Pugh classes in the first year of follow-up.

Cerebral magnetic resonance imaging in patients with chronic liver disease

Bilateral, symmetrical hyperintensity of the globus pallidus is observed in T1-weighted cerebral magnetic resonance images in from 52 to 100% of patients with chronic liver disease. No significant relationship exists between the presence of these cerebral changes in image signal intensity and the patients' neuropsychiatric status. However, their presence significantly relates to both the severity of the liver disease and the presence and degree of portal-systemic shunting of blood. This shortening of the T1-relaxation time is associated with pallidal deposition of manganese most likely reflecting the presence of an adaptive process designed to improve the efficacy of ammonia detoxification by astrocytes. Future studies employing magnetic resonance imaging techniques to obtain information on cerebral function or combined with magnetic resonance spectroscopy to obtain localized biochemical information might further our understanding of the pathogenesis of hepatic encephalopathy in cirrhotic patients.

Psychiatric aspects of portal-systemic encephalopathy

This paper focuses on psychiatric aspects of portal-systemic encephalopathy (PSE) due to chronic liver disease and/or portal-systemic shunting. Clinical syndromes of PSE are discussed from the point of view of biological psychiatry, but, psychological consequences of concomitant cognitive disorders are also addressed. Psychiatric symptoms of early PSE and sleep disorders in patients with chronic liver disease are of specific interest.

Portosystemic hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with cirrhosis: clinical, laboratory, psychometric, and electroencephalographic investigations

A prospective study of hepatic encephalopathy (HE) including neuropsychiatric and psychometric evaluation, electroencephalography, and determination of arterial ammonia levels was performed in 55 cirrhotic patients treated consecutively by transjugular intrahepatic portosystemic shunt (TIPS). The cumulative HE rate increased from 23.6% within the 3-month interval before TIPS to 50. 9% within the first 3-month interval post-TIPS (P = .003). Significant and independent predictors of HE post-TIPS were the presence of HE pre-TIPS and reduced liver function. The cumulative HE rate declined in the second 3-month interval post-TIPS and reached the pre-TIPS level. Chronic forms of HE exceeding grade I were not observed. In a subgroup of 22 nonencephalopathic TIPS patients, the prevalence of subclinical HE did not change after TIPS. Among individual psychometric tests, the block design test gave the highest proportion of pathological results (about 50%), whereas selective reminding gave the lowest (10%-25%). Electroencephalography (EEG) showed a temporary increase of pathological results at 1 month after TIPS, when patients with overt HE (grade I) were included (proportion of 21.1% before vs. 57.1%, P = .005). Arterial ammonia concentration increased from a mean of 94 +/- 26 microgram/dL to 140 +/- 28 microgram/dL at 3 months after TIPS (P < .001). Elevated ammonia levels persisted. TIPS led to a temporary increase of HE incidence within 3 months. The decline of the HE rate beyond 3 months despite a sustained increase of arterial ammonia levels could not entirely be explained by reduction of shunt flow, nor by alteration of liver function. Instead, cerebral adaptation to gut-derived neurotoxins might be anticipated.

Subclinical hepatic encephalopathy impairs daily functioning

Subclinical hepatic encephalopathy (SHE) is assumed to have a negative effect on patients' daily functioning; therefore, treatment is recommended. However, no studies have been performed that document the clinical relevance of SHE. We performed a study in which the prevalence of SHE was determined in 179 outpatients with cirrhosis using two psychometric tests (Number Connection Test Part A [NCT-A] and the Digit Symbol Test [DGT]) and automated analysis of the electroencephalogram (EEG). SHE was defined by the presence of at least one abnormal psychometric test and/or abnormal slowing of the EEG. The influence of cirrhosis and SHE on patients' daily functioning was assessed using the Sickness Impact Profile (SIP) questionnaire. The distribution of SIP scores of the patients with cirrhosis differed from the reference scores of the general population. Patients with cirrhosis and SHE (n = 48) reported significantly more impairment in all 12 scales of the SIP, in the psychosocial subscore, the physical subscore, as well as in the total SIP score, compared with cirrhotic patients without SHE (n = 131). Multivariate analysis taking into account severity of liver disease (Child-Pugh score), presence of varices, and alcoholic etiology, showed that SHE independently was related to a diminished total SIP score. The reproducibility of the SIP was high when the test was repeated after a 3-month period. We conclude that SHE implies impaired daily functioning and warrants attempts at treatment.

Regional cerebral blood flow changes in patients with cirrhosis assessed with 99mTc-HM-PAO single-photon emission computed tomography: effect of liver transplantation

BACKGROUND/AIMS

Previous studies showed contrasting results with regard to alterations of regional cerebral blood flow/metabolism in subjects with liver cirrhosis. The aim of the study was to extend these findings in a larger series of patients. In addition, we wanted to determine whether such alterations are reversed by successful liver transplantation.

METHODS

The study group comprised 23 patients with liver cirrhosis and 13 normal controls. At entry to the study, all subjects underwent a complete neurological examination, EEG recordings and SPECT scanning. The severity of liver disease was determined according to the Child-Pugh score. Fourteen patients underwent a second SPECT examination 1 year after liver transplantation.

RESULTS

Significant rCBF reductions, ranging from 6% to 7%, were found in the majority of the cortical regions of the whole group of patients with cirrhosis, as compared to controls. These reductions were more diffuse in patients with alcoholic liver disease, comprising almost all the assayed regions. Liver transplantation normalized cortical rCBF deficits so that postoperative perfusion indexes were superimposable on control values. However, the frontal cortex remained significantly more impaired in patients with alcoholic cirrhosis than in those with non-alcoholic cirrhosis. The differences in frontal rCBF between the two groups of patients ranged from 6 to 11%.

CONCLUSIONS

Liver cirrhosis was associated with rCBF defects that depend upon the etiology of liver disease and that subsided after successful liver transplantation. The frontal defects in alcoholic cirrhosis either before or after surgery may imply a neurotoxic, possibly irreversible, action of ethanol.

Cerebral changes in hepatic encephalopathy

Hepatic encephalopathy (HE) accompanied by an impairment of consciousness from orientation disorder (grade II) to coma (grade IV) is considered to be overt HE and is treated as an emergency. However, subclinical hepatic encephalopathy (SHE) can be detected by sensitive and quantitative neuropsychological examinations in cirrhotic patients without overt HE. The introduction of the SHE concept is clinically important for preventing the deterioration of SHE (grades 0 and I) to overt HE (grade II and more severe), prolonging the compensated state of cirrhosis without its deterioration to hepatic failure, and the continuation of patient treatment at home. We developed a new diagnostic method for SHE using a quantitative neuropsychological test, with the computerization of all operations. Evaluations of cerebral function and morphology are useful for the determination of the pathophysiology of HE, and assist the diagnosis of SHE. The latencies of the P3 wave in the visually evoked potential and the P300 wave in the event-related potential are prolonged in cirrhotic patients with SHE and are well expressed in three-dimensional coloured topograms (brain mapping). Automated polysomnographic analysis is useful for continuous-monitoring electroencephalograms (EEG) and for the detection of the sleep disturbance observed in cirrhotic patients with SHE. Brain atrophy in computed tomography (CT), magnetic resonance imaging (MRI) and high signals in the basal ganglia in the MR-T1-weighted images have frequently been observed in patients with SHE. The reduction of regional cerebral blood flow (rCBF) by 99mtechnetium-1, 1-ethylcysteinate dimer (99mTc-ECD)-single photon emission computed tomography (SPECT) and the choline/N-acetylaspartic acid ratio by proton-magnetic resonance spectroscopy (1H-MRS) were observed in the hippocampus in patients with SHE. These approaches (cerebral function tests and imaging diagnoses of the brain) can also be used to evaluate the effectiveness of treatments for HE; for example, branched-chain amino acid (BCAA) was shown by automated continuous polysomnographic analysis to be a psychotropic drug which acts directly on the central nervous system and the clinical significance of choline administration to HE patients is now being evaluated by 1H-MRS and neuropsychological tests.

Visual attention in cirrhotic patients: a study on covert visual attention orienting

Attentional dysfunction, which influences overall cognitive productivity, is not well characterized in cirrhotic patients. The aim of this study was to clarify the features of covert visual attention orienting in cirrhotics without overt hepatic encephalopathy. One hundred consecutive cirrhotic patients and 40 controls were enrolled. Visual covert attention orienting was assessed by the Posner test, which evaluates the effect of a cue on visual reaction times. Patients were characterized by the number connection test (NCT) and electroencephalographic (EEG) spectral analysis. The severity of liver disease was graded using standard laboratory parameters and the Child-Pugh's classification. Fifty-five psychometric and EEG evaluations were performed in the follow-up of 17 patients to assess the relationship between the variations of psychometric and neurophysiological findings. NCT and quantified-EEG parameters (altered in 19% and 40% of cirrhotic patients, respectively) were linked to each other and to the severity of liver disease. The Posner test showed a delay of visual reaction times in class B-C cirrhotic patients. Reaction times were correlated with ammonia and EEG parameters. The effect of the cue was higher in cirrhotic patients than in controls, particularly in the invalid position. This study suggests that cirrhotic patients have a reduced activity rate and reduced capacity to disengage attention previously focused on a cue. Such alterations are linked to NCT and EEG findings.

Study on the Sternberg paradigm in cirrhotic patients without overt hepatic encephalopathy

Memory dysfunction is reported in cirrhotics. The aim of this paper was to increase insight into memory function of cirrhotic patients without overt hepatic encephalopathy. Eighty-six consecutive cirrhotics without overt hepatic encephalopathy (aged 54+/-10 yr., mean+/-s.d.) and 28 controls (52+/-10 yr.) with comparable education level were enrolled. Seventeen patients were class A, 55 class B, 14 class C according to Child-Pugh classification; 29 had alcoholic cirrhosis. The presence of subclinical signs of central nervous system dysfunction were assessed by Number Connection Test (NCT) and quantified EEG analysis. Memory scanning was evaluated by reaction times (RTs) in the Sternberg paradigm. MANOVA analysis showed that RTs were higher (F1,99=11, p<0.01) and time outs (TOs) more frequent (F1,110=10, p<0.01) in cirrhotics than in controls, whereas button press errors (BPEs) did not differ significantly (F1,110=2, p=n.s.). In cirrhotics, an interaction Child-Pugh class x memory set size was found (F2,146=4, p<0.05), showing exceedingly delayed RTs with greater memory set size in class C patients. Patients with altered NCT had significantly prolonged RTs (F1,71=4, p<0.05) and more TOs (F1,82=11, p<0.01) than patients with normal NCT. Cirrhotics with altered EEG had significantly prolonged RTs (F2,70=6, p<0.01). RTs were found to be correlated to alpha relative power (r=-0.4, p<0.01) and theta relative power (r=0.4, p<0.01). In conclusion, cirrhotics without over encephalopathy, but with NCT or EEG alterations, perform a computerized digit recognition task more slowly and with higher TOs than cirrhotic patients with normal NCT or EEG. In severe liver insufficiency (class C cirrhotics) also an impairment of memory scanning was detected. Sternberg test performance correlates with NCT and quantitative EEG parameters.

Pallidal lesions in patients with liver cirrhosis: clinical and MRI evaluation

Fifty patients with liver cirrhosis underwent neurological, psychometric, electroencephalographic and biochemical examination as well as cranial magnetic resonance imaging (MRI) to study the incidence of pallidal lesions in cirrhotics and their correlation to liver function, as well as to neurological and mental state. In one patient a histopathological study of the brain was performed. The vast majority of the patients with liver cirrhosis (92%) present with bilateral symmetric pallidal hyperintensities in the T1-weighted MR spin echo sequence, while the T2-weighted images are normal. On the whole there was no correlation between the signal intensity of the pallidal lesions and measures of liver function, neurological status or grade of encephalopathy. As could be shown in follow-up examinations the signal intensity of the lesions increased with decreasing liver function and decreased with normalization of liver function after liver transplantation. The substrate of the lesions remains unclear. However, regions which show alterations in the MRI are histopathologically characterized by the appearance of Alzheimer-type-II cells.

Evaluation of neuropsychological function in patients with liver cirrhosis with special reference to their driving ability

Ability to drive an automobile was evaluated in 16 patients with well compensated liver cirrhosis. Four tests were performed, namely the emergency reaction test, the continuous emergency reaction test, the signal confirmation test and the accelerator reaction test. Test scores were compared to those of a group of age-matched healthy volunteers. 31% of patients were found to be unfit to drive. Alcoholic cirrhotics fared as poorly as non-alcoholic cirrhotics. In patients with subclinical hepatic encephalopathy (defined by neuropsychologic testing), 44% were unfit to drive. Routine testing of cirrhotic patients for ability to drive could have a major impact on motor vehicle accident rates.

Benzodiazepine receptor antagonism improves reaction time in latent hepatic encephalopathy

Endogenous benzodiazepine-like substances are thought to play a role in the development of hepatic encephalopathy (HE). Ten patients with sub-clinical or latent hepatic encephalopathy (LHE) and ten normal controls were cognitively assessed pre- and post-infusion of 0.2 mg of the benzodiazepine (BZ) antagonist flumazenil in a placebo-controlled, cross-over, double-blind design. Flumazenil infusion resulted in a significant improvement in simple reaction time in patients, but not in controls. Saline infusion had no effect on any of the cognitive measures in either group. Flumazenil appeared to have a particular enhancing effect on the cognitive, as opposed to the motor, component of the reaction time task. This finding supports the view that the benzodiazepine/GABA system is implicated in the bradyphrenia that is characteristic of chronic liver disease, even before hepatic encephalopathy is apparent. We conclude that benzodiazepine receptor antagonism may improve cognitive function, particularly speed of information processing, in patients with latent hepatic encephalopathy.

Fitness to drive in patients with cirrhosis and portal-systemic shunting: a pilot study evaluating driving performance

It has been suggested that some patients with cirrhosis are unfit to operate a motor vehicle. However, performance while driving a motor vehicle has not been evaluated in such patients. In this pilot study, we assessed the fitness to drive of stable individuals with cirrhosis and clinical evidence of portal hypertension, portal-systemic shunting and no prior history of hepatic encephalopathy. We examined 15 ambulatory patients with cirrhosis together with 15 age-, educational level- and driving experience-matched healthy controls. Neuropsychological testing was performed with the Reitan trail test, block design and digit symbol tests as well as visual reaction time. A driving test in the laboratory used a film to measure complex visual reaction time (reaction to road symbols) and threat recognition (accident avoidance). Driving on the road was assessed by a licensed Illinois state driving evaluator. Penalty points were given according to 11 standardized driving categories. As a group, patients with cirrhosis had no significant differences in their performance on a simulator or during actual driving conditions when compared to matched controls. Sixty-six percent of the subjects with cirrhosis had two or more abnormal neuropsychological tests, a criterion used to define the presence of subclinical encephalopathy. No deficiencies in simulated or real driving performance was seen when compared to patients with cirrhosis with normal neuropsychological tests. In this study, stable subjects with cirrhosis and evidence of portal hypertension, portal-systemic shunting, abnormal neuropsychological tests and no prior history of overt encephalopathy did not exhibit a major impairment in their fitness to drive.

A quantitative evaluation of magnetic resonance image signal changes of the brain in chronic hepatic encephalopathy

Hyperintensity in the basal ganglia of patients with serious liver disease is a common finding on T1-weighted magnetic resonance images. In this study, we used optical densitometry to quantitatively evaluate the hyperintense magnetic resonance image signal changes in the various regions of the brain of patients with chronic hepatic encephalopathy. The incidence and morphological distribution of the magnetic resonance signal changes were evaluated from T1-weighted magnetic resonance images of the brain from seven non-alcoholic patients and six healthy controls. Significant differences (p < 0.05) between the patient group and controls were found in the limbic system (hippocampus, temporal lobe, cingulate gyrus, and fornix), extrapyramidal system and associated myelinated pathways (lentiform nucleus, tectum, tegmentum, cerebral peduncles, internal capsule and the corpus callosum). No measurable differences were observed in the frontal, parietal, and occipital cortex, or the dorsomedial thalamus. The presence of the high signal intensity changes on T1-weighted magnetic resonance image suggests that characteristics alterations occur in functional regions of the brain in chronic hepatic encephalopathy.

Selective loss of pallidal dopamine D2 receptor density in hepatic encephalopathy

The binding parameters of [3H]SCH 23390 and [3H]spiperone (radioligands for dopamine D1 and D2 receptors, respectively) were investigated in autopsied frontal cortex, caudate nucleus and globus pallidus/putamen of cirrhotic patients who died in hepatic coma as well as in age- and sex-matched controls. Specific [3H]SCH 23390 binding site densities were unchanged in all regions; in contrast, specific [3H]spiperone binding site density was decreased (by 44%, P < 0.001) in the globus pallidus/putamen of patients with HE. Decreased densities of pallidal D2 binding sites could relate to the motor dysfunctions commonly encountered in human HE.

Positron-emission tomographic localization of abnormalities of brain metabolism in patients with minimal hepatic encephalopathy

Many patients with compensated cirrhosis without overt hepatic encephalopathy have deficits in visual-spatial perception, a condition we call minimal hepatic encephalopathy. Five patients with alcohol-induced cirrhosis and nine control subjects underwent positron-emission tomographic imaging of the brain with 18F-fluorodeoxyglucose. Patients also underwent neuropsychological and clinical chemistry tests. The patients had mild arterial hyperammonemia (62 +/- 13 mumol/L, range = 11 to 35 mumol/L) and other abnormalities typical of patients with cirrhosis. The patients' mean percentile scores on the digit symbol and block design subtests, from the Wechsler Adult Intelligence Scale (revised), and Purdue pegboard test were 11 +/- 7, 24 +/- 7 and 7 +/- 8 (right hand). Tests of vocabulary, memory, and new learning were normal. The technique of statistical parametric mapping was used to identify regions where cerebral 18F-fluorodeoxyglucose uptake and metabolism were abnormal. We noted significant reductions in the cingulate gyrus, a center mediating attention, target analysis and response formulation and significant increases in visual associative regions subserving motion and color perception and object orientation. We suggest that minimal hepatic encephalopathy is due to a deficit in the detection and formulation of responses to visual stimuli, a function of the cingulate, which is a part of the anterior attentional system of the brain. Increases in 18F-fluorodeoxyglucose metabolism may be compensatory. These studies show that brain regions differ in their sensitivity to the agents that cause hepatic encephalopathy and that positron-emission tomography is useful in studying the pathophysiology of this disorder.

Pallidal hyperintensity on magnetic resonance imaging in cirrhotic patients: clinical correlations

Patients with cirrhosis show increased signal intensity in the globus pallidus on T1-weighted magnetic resonance imaging of the brain. This abnormal appearance of the basal ganglia has been related to the severity of liver failure and to the presence of portal-systemic shunting, although its cause and clinical significance remain unknown. We prospectively assessed the metabolic, neurological and neuropsychological statuses of 30 stable cirrhotic patients and correlated these clinical variables with computed measurements of globus pallidus signals. Some metabolic variables denoting disease severity appeared to be significantly related to image changes, although the strongest association was found with plasma ammonia levels. After adjustment for ammonia level, on multiple regression analysis, the other variables were not significant. Furthermore, pallidal changes were associated with specific neurological symptoms and neurological functions, symptoms and functions that also had a significant correlation with ammonia levels. Our findings suggest that globus pallidus signal abnormality could arise as a marker of brain impairment related to hyperammonemia.

Neurotoxicity of solvent mixtures in spray painters. II. Neurologic, psychiatric, psychological, and neuroradiologic findings

A multidisciplinary cross-sectional study was performed to examine the chronic neurotoxicity of organic solvents. Participating in the study were 105 persons employed as spray painters and having long-term solvent exposure (10-44 years) and a control group consisting of 58 construction workers, electricians, and plumbers without occupational contact to solvents. Samples were matched for age, preexposure intelligence level, occupation, and socioeconomic status. After controlling for potentially non occupational confounding factors (neuropsychiatric diseases, metabolic disorders, high blood pressure, alcohol intake) 83 spray painters and 42 controls were entered finally into the study. The evaluation included work history, self-rating questionnaire, neurologic investigation, psychiatric analysis using the Present State Examination (PSE), psychological testing, and computerized axial tomography (CAT) of the brain. Physical and neurologic examinations demonstrated no case of overt disorders of the central or peripheral nervous system. An important result of the psychiatric analysis was that the syndromes "special features of depression" and "loss of interest and concentration" occurred significantly more frequently among spray painters than among controls. Further analyses demonstrated an association with chronic exposure over 30 years and repeated acute neurotoxic effects during solvent exposures. Neither psychological nor performance tests demonstrated any statistically significant differences in the performance sets after adjustment according to premorbid intelligence level; this finding supports the presumption of only a low grade of mental dysfunction. Correlation analyses indicated a relationship between subjective health complaints and long-term solvent exposure; however, the effect of age cannot be completely ruled out.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain morphologic characteristics of cirrhotic alcoholics and cirrhotic nonalcoholics: an MRI study

Cirrhotic alcoholics, cirrhotic nonalcoholics, and normal controls were compared on planimetric and subjective ratings of the MRI of the brain. The results indicated that the cirrhotic alcoholics exhibited more gross pathology than the nonalcoholic cirrhotics on ratings of frontal, parietal, and cerebellar atrophy; however, these groups were more similar to each other than they were different on planimetric measurements. The results are discussed in terms of the etiology and localization of the neuropathologic sequelae found commonly among alcoholics.

Psychiatric aspects of liver disease

This paper reviews the literature on the effects of liver disease on mental health, a topic which has been relatively neglected in the recent psychiatric literature. It discusses both the encephalopathy which may be associated with liver disease of almost any type and the psychological consequences of specific liver disorders. Also considered are the effects of liver disease on sexual function; the relationship between alcohol and hepatic disorder in causing mental disturbance; the effects of childhood liver disease; psychiatric aspects of liver transplantation; and the use of psychotropic drugs in patients with hepatic dysfunction.

Regional cerebral blood flow and cognitive function in patients with chronic liver disease

Subtle impairments of cognitive function may be an important cause of occupational and psychosocial morbidity in patients with chronic liver disease. Correlation of structural brain abnormalities with cognitive deficits has yielded inconsistent results. 10 patients with cirrhotic liver disease were compared with 10 age, education, and intelligence matched control subjects. Neuropsychological assessment revealed significant overall cognitive impairments in cirrhotic patients compared with controls (p = 0.02). Regional cerebral blood flow was measured by single photon emission computed tomography (SPET or SPECT) and showed increased uptake of radiotracer in the right and left posterior parts of the basal ganglia and right occipital lobe, together with reduced uptake in the right anterior cingulate region. The degree of cognitive impairment was directly correlated with functional abnormalities in the basal ganglia and limbic cortex (p less than 0.05). Our results suggest that impaired cognitive status may be associated with abnormalities of regional brain function in patients with chronic liver disease. Since these deficits are clinically inapparent, our findings have important implications for identification and management of patients with chronic liver disease.

Globus pallidus alterations and brain atrophy in liver cirrhosis patients with encephalopathy: an MR imaging study

Brain magnetic resonance (MR) was performed in 29 liver cirrhosis patients without (N = 10) and with hepatic encephalopathy (HE) of chronic recurrent (N = 10) and of chronic persistent (N = 9) type. Sixty percent of the patients with chronic recurrent HE and 100% of the patients with chronic persistent HE showed a bilateral and symmetrical hyperintensity of the globus pallidus in the T1-weighted images while the T2-weighted images were normal, suggesting the possibility of the accumulation of a paramagnetic compound in this brain area during HE. Other findings of the study were evidence of brain atrophy of mild or moderate degree in 70% of patients with chronic recurrent HE and in 77% with chronic persistent HE and patients with liver cirrhosis without HE appeared normal on MR examination.