Role of EEG in Predicting Outcome of Hepatic Encephalopathy Patients

Introduction: A retrospective analysis of 151 patients with hepatic encephalopathy (HE) who were admitted to the liver intensive care unit (LICU) and liver transplant intensive care unit (TICU) and underwent electroencephalographic (EEG) testing was performed. We describe a method of grading the EEGs of patients with HE and predicting their subsequent outcomes. Methods: All liver failure patients with HE who underwent routine EEG testing in the LICU or TICU between October 1, 2018 and March 31, 2019, at the Institute of Liver and Biliary Sciences (ILBS) were enrolled in this analysis. The data was analyzed using Statistical Package for the Social Sciences (SPSS). The patients were divided into four grades of HE based on established EEG criteria (HE-EEG). Results: One hundred fifty-one patients [127 Male (84%), 24 Female (16%)] with HE who underwent EEG testing were enrolled. Ages ranged from 3 to 74 years, with a mean age of 48.34 years and median interquartile range (IQR) of 49 years (38-60 years). Ninety-five patients (62.9%) had grade 1 and 2 hepatic encephalopathy, with a statistically significant, worse outcome seen in grades 3 and 4 HE patients. Seizures were seen in 30 (20.1%) of HE patients. Fifteen of 30 patients with seizures (50%) were in the ethanol and nonalcoholic steatohepatitis (NASH) groups. Forty-four of 59 (74.6%) MRIs and 35 of 60 (58.3%) CTs demonstrated some type of brain abnormality in these patients. Imaging abnormalities and the presence of seizures did not contribute to a statistically worse outcome. Conclusion: EEG has an important role in predicting the outcome and prognosis in HE. Patients with grade 3 or 4 HE-EEG, or with progressive worsening of HE-EEG grading were associated with the highest mortality rates.

A double-blind randomized controlled trial to assess efficacy of bromocriptine in cirrhotic patients with hepatic parkinsonism

BACKGROUND

Parkinsonism like features can be seen in cirrhotics, possibly related to alterations in brain dopamine metabolism, transport and receptor integrity at basal ganglia. Hepatic parkinsonism is often not suspected and only ammonia-reducing therapies are given to such patients. We investigated the efficacy and safety of bromocriptine, a dopaminergic agent, in patients with hepatic parkinsonism.

PATIENTS AND METHODS

Cirrhotics were screened for the presence of extrapyramidal symptoms and were diagnosed as hepatic parkinsonism if any two of tremor, bradykinesia and/or rigidity were present, supported by MRI brain showing T1 hyperintensities in basal ganglia and substantia nigra. Patients were randomized to receive placebo (Gr A, n = 22) or bromocriptine (Gr B, n = 24) for 12 weeks. Complete, partial and non-response were defined as 30%, 10%-30% and <10% reduction,respectively, in Unified Parkinson's Disease Rating Scale motor score.

RESULTS

Of 1016 cirrhotics, 50 (4.9%) had hepatic parkinsonism. Patients in two treatment groups were comparable for MELD score, arterial NH3 and frequency of portosystemic shunts. Bromocriptine therapy for 12 weeks resulted in improvement in rigidity, tremors, bradykinesia and gait compared to placebo with complete and partial response in seven vs none (29.1%, 0%, P < 0.01) and 12 vs one (50%, 4.5%, P < 0.01) patients. Prolonged and more severe motor symptoms were associated with non-response to bromocriptine therapy. There were no major side effects in either treatment group.

CONCLUSIONS

Hepatic parkinsonism is seen in ~5% cirrhotics. Bromocriptine is a safe and effective therapy for these patients and is more effective in mild to moderate hepatic parkinsonism.

Albendazole therapy for neurocysticercosis

Based on clinical evaluation and computed tomography (CT) of the brain, 30 cases of neurocysticercosis were diagnosed. Diagnosis was supported by presence of histopathologically proven subcutaneous cysticerci in 12 cases. Three primary neurological syndromes were established i.e. epilepsy in 22 cases, increased intracranial tension in 6 cases and meningoencephalitis in 2 cases. Albendazole was administered orally in a dose of 15 mg/kg bodyweight/day for 30 days without prophylactic steroids. Follow up CT study at 3 months and 12 months revealed complete regression of all lesions in 2 cases, partial regressions in 14 cases and change in morphology in 4 cases. Transient appearence of fresh subcutaneous cysticerci as a side effect of therapy was noted in 4 cases. Albendazole, though acting slow, is considered a suitable alternative to praziquantel in medical management of parenchymal neurocysticercosis.

Peripartum cerebral venous thrombosis

The clinical and computed tomography (CT) features of 25 patients with peripartum CVT are described. Majority of the patients presented in postpartum period and did not receive proper antenatal care. Headache (92%), altered sensorium (80%, seizures (76%), papilloedema (80%) and hemiplegia (52%) were the common modes of presentation. CT findings included diffuse brain oedema (52%), haemorrhagic or nonhaemorrhagic infarctions on one or both sides of brain (48%), gyral enhancement (40%) and tentorial enhancement (16%). While 15 patients made good recovery, 3 cases (12%) died during acute stage of illness.

Auditory evoked response in patients of diabetes mellitus

Brainstem auditory evoked response (BAER) and the mid latency response (MLR) were recorded in 25 diabetic men and compared with a group of 25 control subjects. The threshold of hearing was higher (P less than 0.001) in the patients. The BAER peak latencies were also significantly prolonged in both the ears; however, the degree of prolongation was more prominent in the right ear. The interpeak latencies of waves I-III were also prolonged (P less than 0.01) in the left ear, with non significant increase noticed in the right ear also. The wave V amplitude was lower (P less than 0.05) in diabetics. The MLR, on the other hand, was not affected in patients. These findings suggest functional impairment in the auditory pathway in patients of diabetes mellitus.

Optic nerve cysticercosis: a case report

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Epilepsy as a manifestation of neurocysticercosis

Epilepsy is the commonest manifestation of neurocysticercosis. Epilepsy was observed in 127 of 150 cases (84.7%) of neurocysticercosis seen over a period of 17 years. The basis of diagnosis was clinical presentation and concomitant evidence of extraneural cysticercosis in the pre-computed tomography (CT) scan era, and typical CT findings in later years. Eighty one cases (54%) who primarily presented as epilepsy without any neurological deficit have been analysed in detail. In the pre-CT period the occurrence of epilepsy as a presenting feature in neurocysticercosis was 43.5% whereas in later years it was 61.4%. Primary generalised seizure (49 cases) was more common than partial seizure (29) and partial complex seizure (3). Status epilepticus was seen in 6 cases. Magnetic resonance imaging, done in 8 cases, proved to be more sensitive in demonstrating various stages in the development of noncalcified cysticercosis. The new larvicidal drugs offer a potential cure and cysticercosis should be entertained as a cause of epilepsy especially in endemic areas.

Clinical spectrum of myasthenia gravis and problems of management

Seventeen cases of myasthenia gravis, aged 20-79 years, including one case of ocular myasthenia gravis, seen over a 3 year period, were analysed. Dysphagia was the presenting symptom in two cases. One patient had ectopic thymus gland in relation to the cardiac border, which posed difficulty in diagnosis. A majority of the patients were on medical treatment, including neostigmine, prednisolone and azathioprim. Plasmapheresis was done in 4 cases during crisis, with significant benefit. One patient was put on intermittent ventilatory support for 14-16 hours a day for over 2 years; she died during a power failure. Seven patients were subjected to thymectomy.

Acute paralysis due to barium carbonate

Poisoning due to barium carbonate (rat poison) resulting in areflexic quadriplegia and respiratory muscle paresis in a young patient is described. The various effects of barium salts on the human body and their treatment are highlighted.

Cysticercal meningoencephalitis

Meningoencephalitic syndrome can be caused by many infective agents. Over a period of 13 years, 15 of 170 cases of neurocysticercosis (NCC) presented as meningoencephalitis. The basis of diagnosis of NCC was positive subcutaneous nodule histopathology (4), CT scan (9) and autopsy (3) findings. The age of the patients ranged from 7-68 years (mean 32). Fever was encountered in 12, altered sensorium in 7, seizures in 10 and abnormal behaviour in 3 cases. All cases had papilloedema. Focal neurological signs included optic atrophy, lateral rectus palsy, hemiplegia, internuclear ophthalmoplegia and cerebellar ataxia. Cerebrospinal fluid was abnormal in 8 of 13 cases, leading to a suspicion of tuberculous meningitis. Twelve patients improved with therapy. Three cases ended fatally and autopsy confirmed the diagnosis.

Computed tomographic spectrum of neurocysticercosis

Computed tomography (CT) is a very sensitive modality for the diagnosis of neurocysticercosis. Fifty eight patients were evaluated by plain radiography and CT scans. The initial presentation was as seizure disorder (33), raised intracranial tension (19), meningoencephalitis (5) and psychiatric manifestation (1). Histologically confirmed subcutaneous nodules were seen in 20 cases and ocular cyst in 2 cases. CT scan showed multiple calcification in 8 cases, disc lesions in 30,ring lesions in 3, and a combination of disc and ring lesions in another 13 cases. Low attenuation lesions were seen in 4 cases in combination with disc/disc and ring lesions. All 58 cases had supratentorial lesions while 19 cases had infratentorial lesions in addition. Perifocal or generalised oedema was seen in 33 and 11 cases respectively. The ventricles were compressed in one case, large in 2 cases and normal in the rest. CT scan is valuable in the diagnosis of neurocysticercosis. Its significance is different in the various clinical and radiological groups.

Lumbosacral plexopathy following regional paracervical block anaesthesia

We report a 35 year old lady who developed lumbosacral plexopathy immediately following regional paracervical block anaesthesia for medical termination of pregnancy. There was only partial recovery at one year. The neurological deficit and its mechanisms are discussed.

Pure motor hemiparesis due to hypertensive putaminal haemorrhage

A hypertensive woman presenting as pure motor hemiparesis with rapid and complete recovery from the neurological deficit is described. The probable aetiology was primary hypertensive putaminal haemorrhage, as revealed by CT scan. This rare presentation has been described only once earlier and emphasizes the value of CT scanning as a tool for diagnosis of such cases.