Elevation of intracranial pressure following transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage

Jalan, Rajiv; Dabos, Konstantinos J.; Redhead, Doris N.; Lee, Alistair; Hayes, Peter

doi:10.1016/s0168-8278(97)80333-9

Cited by 71 publications

(46 citation statements)

References 18 publications

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“…74,77,78 A few reports have described brain edema in patients with cirrhosis 64,79 and astrocyte swelling in animal models of minimal HE. 80 In addition, the Alzheimer type II astrocyte, the characteristic neuropathologic finding in patients with cirrhosis, represents a swollen astrocyte, which can be regarded as a manifestation of cerebral edema associated with chronic liver failure.…”

Section: Diffuse Brain Edema In Chronic Liver Failurementioning

confidence: 99%

MR Imaging Findings in Hepatic Encephalopathy

Rovira¹,

Alonso²,

Córdoba³

2008

AJNR Am J Neuroradiol

306

218

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SUMMARY:The term hepatic encephalopathy (HE) includes a spectrum of neuropsychiatric abnormalities occurring in patients with liver dysfunction. Most cases are associated with cirrhosis and portal hypertension or portal-systemic shunts, but the condition can also be seen in patients with acute liver failure and, rarely, with portal-systemic bypass and no associated intrinsic hepatocellular disease. Although HE is a clinical condition, several neuroimaging techniques, particularly MR imaging, may eventually be useful for the diagnosis because they can identify and measure the consequences of central nervous system (CNS) increase in substances that under normal circumstances, are efficiently metabolized by the liver. Classic MR imaging abnormalities include high signal intensity in the globus pallidum on T1-weighted images, likely a reflection of increased tissue concentrations of manganese, and an elevated glutamine/glutamate peak coupled with decreased myo-inositol and choline signals on proton MR spectroscopy, representing disturbances in cell-volume homeostasis secondary to brain hyperammonemia. Recent data have shown that white matter abnormalities, also related to increased CNS ammonia concentration, can also be detected with several MR imaging techniques such as magnetization transfer ratio measurements, fast fluid-attenuated inversion recovery sequences, and diffusion-weighted images. All these MR imaging abnormalities, which return to normal with restoration of liver function, probably reflect the presence of mild diffuse brain edema, which seems to play an essential role in the pathogenesis of HE. It is likely that MR imaging will be increasingly used to evaluate the mechanisms involved in the pathogenesis of HE and to assess the effects of therapeutic measures focused on correcting brain edema in these patients. Hepatic encephalopathy (HE) reflects a spectrum of neuropsychiatric abnormalities occurring in patients with liver dysfunction. Most cases are associated with cirrhosis and portal hypertension or portal-systemic shunts, but the condition can also be seen in patients with acute liver failure and, rarely, with portal-systemic bypass and no associated intrinsic hepatocellular disease.1,2 The most common clinical pattern in these patients is the development of confusion or coma precipitated by gastrointestinal bleeding, acute superimposed hepatitis, or concomitant infection in a previously asymptomatic patient with cirrhosis. The neurologic manifestations are mainly due to shunt of blood arising from the portal venous bed into the systemic circulation and are reversible once the liver function abnormality or precipitating factor has been corrected. HE can be classified according to the underlying liver disease and the evolution of the neurologic manifestations (Table 1). Clinical FeaturesClinically, HE manifests as a neuropsychiatric syndrome encompassing a wide spectrum of mental and motor disorders.2,3 The changes in mental status range from subtle cognitive dysfunction to severe coma, whereas the...

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Section: Diffuse Brain Edema In Chronic Liver Failurementioning

confidence: 99%

MR Imaging Findings in Hepatic Encephalopathy

Rovira¹,

Alonso²,

Córdoba³

2008

AJNR Am J Neuroradiol

306

218

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“…Overt brain edema with intracranial hypertension has been reported in patients with cirrhosis and deep coma. 20,21 How has this knowledge on astrocyte swelling translated into newer therapeutic developments? Selective inhibition of brain glutamine synthetase is still not available in the clinical realm.…”

Section: The Swollen Astrocytementioning

confidence: 99%

Medical Therapy of Brain Edema in Fulminant Hepatic Failure

Blei

2000

Hepatology

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“…13,14 Overt brain swelling and increases in intracranial pressure are characteristic of patients with acute liver failure but have also been reported to occur in the context of cirrhosis of the liver. 15 Magnetization transfer imaging is an application of magnetic resonance (MR) imaging designed as a means of exploring characteristics of nonwater components in tissue. Compared with conventional MR imaging, in which differences in brightness on images reflect differences in observed relaxation times, magnetization transfer imaging theory incorporates the influence of additional parameters, specifically those reflecting the exchange of protons between molecules of water and molecules of more solid, structural components.…”

mentioning

confidence: 99%

Induced Hyperammonemia Alters Neuropsychology, Brain Mr Spectroscopy and Magnetization Transfer in Cirrhosis

et al. 2003

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Hyperammonemia is a universal finding after gastrointestinal hemorrhage in cirrhosis. We administered an oral amino acid solution mimicking the hemoglobin molecule to examine neuropsychological changes, brain glutamine levels, and brain magnetization transfer ratio (MTR). Forty-eight metabolically stable patients with cirrhosis and no evidence of "overt" hepatic encephalopathy (HE) were randomized to receive 75 g of amino acid solution or placebo; measurements were performed before and 4 hours after administration. Neuropsychological tests included the Trails B Test, Digit Symbol Substitution Test, memory subtest of the Randt battery, and reaction time. Plasma was collected for ammonia and amino acid measurements, and brain metabolism was studied using proton magnetic resonance (MR) spectroscopy in the first 16 randomized patients. In 7 other patients, MTR was measured. A significant increase in ammonia levels was observed in the amino acid group (amino acid group, 76 ؎ 7.3 to 121 ؎ 6.4 mol/L; placebo, 83 ؎ 3.3 to 78 ؎ 2.9 mol/L; P < .001). Neuropsychological function improved significantly in the placebo group, but no significant change in neuropsychological function was observed in the amino acid group. Brain glutamate/glutamine (Glx)/creatine (Cr) ratio increased significantly in the amino acid group. MTR decreased significantly from 30 ؎2.9 to 23 ؎ 4 (P < .01) after administration of the amino acid solution. In conclusion, an improvement in neuropsychological test results followed placebo, which was not observed in patients administered the amino acid solution. Induced hyperammonemia resulted in an increase in brain Glx/Cr ratio and a decrease in MTR, which may indicate an increase in brain water as the operative mechanism. A mmonia is believed to be central in the pathogenesis of hepatic encephalopathy (HE). [1][2][3][4] It is well known that upper gastrointestinal bleeding in cirrhotic patients produces hyperammonemia and precipitates HE. [1][2][3][4][5][6] Simulating the metabolic effects of upper gastrointestinal bleeding by oral administration of erythrocytes has been shown to induce hyperammonemia and behavioral disturbance in portacaval-shunted rats. 7 In an uncontrolled study, we showed that oral administration of an amino acid solution that is identical to the amino acid profile of hemoglobin results in deterioration in memory test results, suggesting that this may be a clinically valid model to study the pathogenesis of HE. 8 Although the data relating arterial ammonia concentration to the severity of HE are controversial, there is growing evidence that greater arterial ammonia concentrations are observed in more severe states of HE. 3,4,9 In a recent study in patients with acute liver failure, an arterial concentration of ammonia greater

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Elevation of intracranial pressure following transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage

Cited by 71 publications

References 18 publications

MR Imaging Findings in Hepatic Encephalopathy

MR Imaging Findings in Hepatic Encephalopathy

Medical Therapy of Brain Edema in Fulminant Hepatic Failure

Induced Hyperammonemia Alters Neuropsychology, Brain Mr Spectroscopy and Magnetization Transfer in Cirrhosis

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