Systemic complications of neurologic diseases

Early-Onset Seizures After Orthotopic Liver Transplantation: A Single-Center Retrospective Study

BACKGROUND

After encephalopathy, epileptic seizures (ES) are the second most common neurologic complication after orthotopic liver transplantation (OLT) and may announce a disabling/fatal neurologic disease.

METHODS

In this retrospective study, we collected clinical information from patients who underwent OLT at our institution and analyzed outcomes and potential risk factors for developing ES after OLT.

RESULTS

Fourteen of our 376 patients (3.72%) who underwent OLT had ES. After excluding 2 patients with already known epilepsy, among the other 12 patients, 2 were diagnosed with nonanoxic cerebral edema, 2 with anoxic damage, 1 with intracranial hemorrhage, 1 with metabolic derangement, and 4 with neurotoxicity; 2 did not receive a diagnosis of certainty. 9 of 12 patients had structural abnormalities on neuroimaging exams. Patients with ES had lower body mass index, higher rate of pretransplant portal thrombosis, and lower pre-transplant plasma concentration of albumin than patients without ES. Multiple post-transplantation systemic complications, postoperative infections, and graft rejection were correlated with a significantly higher risk of ES. Compared with patients without seizures, patients with ES had longer in-hospital and intensive care unit (ICU) length of stay, higher probability of ICU readmission, in-hospital death, and need for rehabilitation. Just 3 of the 12 patients with ES had a good prognosis, while the other 9 had at least mild neurologic sequelae, 5 of whom died because of the underlying neurologic disease.

CONCLUSIONS

ES after OLT may announce detrimental neurologic disease. When an underlying neurologic disease is excluded, prognosis in terms of seizure recurrence and long-term antiseizure medication need is warranted.

Hyponatremia following esclicarbazepine therapy

PURPOSE

To evaluate the safety of eslicarbazepine acetate (ESL) in new onset elderly poststroke seizure patients, especially with respect to hyponatremia.

METHOD

In a two year, single center open labeled observational study of ESL in patients with imaging proven stroke with new onset post stroke seizure were included. ESL was titrated between 400mg and 1200 mg once daily during 1 month observation period. The titrated dose of ESL was continued during 96-week maintenance period. The patients were followed up for seizure control and side effects, including serum sodium on first examination, at the end of 1 month and then at three monthly intervals for 24 months (total eight visits).

RESULT

Hyponatremia developed in four out of 32 (12.5%) patients; it was symptomatic in three and asymptomatic in one patient. No statistically significant difference between mean sodium levels at different time period, compared to baseline was found.

CONCLUSION

High incidence of hyponatremia in ESL treated post stroke patients, was found, hyponatremia symptoms since can be subtle and delayed, so monitoring of serum sodium in the patients on ESL treatment is recommended especially in elderly.

Hyponatremia in patients with neurologic disorders

The kidney and the brain play a major role in maintaining normal homeostasis of the extracellular fluid by neuroendocrine regulation of sodium and water balance. Therefore, disturbances of sodium balance are common in patients with central nervous system (CNS) disorders and clinicians should focus not only on the CNS lesion, but also on the potentially deleterious complications. Hyponatremia is the most common and important electrolyte disorder affecting patients with critical neurologic diseases. In these patients, the maladaptation to hyponatremia by impaired osmoregulation in pathologic lesions of brain may cause more aggressive cerebral edema and increased intracranial pressure due to hypoosmolality induced by hyponatremia. Furthermore, hyponatremia accompanied by CNS disorders has shown to increase delayed cerebral ischemia and mortality rates. Two main pathophysiologies of hyponatremia, excluding iatrogenic causes, are inappropriate secretion of antidiuretic hormone (SIADH) and cerebral salt wasting (CSW) syndrome. Differential diagnosis between these two entities can be difficult due to considerable overlap in the laboratory findings and clinical situations. SIADH is in a volume expanded status due to inappropriately secreted arginine vasopressin (AVP) and requires water restriction. However, CSW syndrome is characterized by renal sodium wasting mainly due to increased natriuretic peptides resulting in volume depletion and follows appropriate secretion of AVP. Therefore, maintenance of volume status and sodium replacement is the mainstay of treatment in CSW syndrome. In this review, we aimed to describe the regulation of sodium and water balance, and pathophysiology, diagnosis and treatment of hyponatremia in neurologic patients, especially focusing on SIADH and CSW syndrome.