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Huang J, Ahmed IM, Wang T, Xie C. Beyond the Liver: Neurologic Manifestations of Alcohol Use. Clin Liver Dis 2024; 28:681-697. [PMID: 39362715 DOI: 10.1016/j.cld.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
Alcohol use, while commonly associated with liver damage, also has significant neurologic implications, which often mimic hepatic encephalopathy and complicate diagnosis and management. Alcohol mediates its acute central nervous system effects by altering neurotransmitter balance, notably between gamma-aminobutyric acid and glutamate. Its chronic neurotoxicity, compounded by thiamine deficiency, results in chronic neurologic complications. Clinically, alcohol-related neurologic disorders present a spectrum from acute intoxication and withdrawal to chronic conditions like Korsakoff syndrome, dementia, cerebellar degeneration, and peripheral neuropathy. This review underscores differentiating these conditions from hepatic encephalopathy and highlights the importance of history-taking and physical examination in clinical practice.
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Affiliation(s)
- Jiannan Huang
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, 1400 West 22nd Street, Sioux Falls, SD 57105, USA
| | - Ibrahim Munaf Ahmed
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, 1400 West 22nd Street, Sioux Falls, SD 57105, USA
| | - Tian Wang
- Department of Neurology, Georgetown University, Washington, DC, USA; Georgetown University Medical Center, Comprehensive Epilepsy Center, MedStar Georgetown University Hospital, MedStar Southern Maryland Hospital Center, 10401 Hospital Drive, Suite 102, Clinton, MD 20735, USA
| | - Chencheng Xie
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, 1400 West 22nd Street, Sioux Falls, SD 57105, USA; Division of Hepatology, Avera McKennan Hospital & University Health Center, 1315 South Cliff Avenue, Suite 1200 Plaza 3, Sioux Falls, SD 57105, USA.
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2
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Garrido E, Adeli A, Echeverria-Villalobos M, Fiorda J, Hannawi Y. Prevalence of Electrographic Seizures in Hospitalized Patients With Altered Mental Status With No Significant Seizure Risk Factors Who Underwent Continuous EEG Monitoring: A Retrospective Study. Cureus 2024; 16:e55903. [PMID: 38595868 PMCID: PMC11003702 DOI: 10.7759/cureus.55903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVES The objective of this study is to evaluate the prevalence of electrographic seizures in hospitalized patients with altered mental status and no significant risk factors for seizures. METHODS We retrospectively reviewed over a six-year period (2013-2019) the medical records of all adults admitted at Ohio State University Wexner Medical Center (OSUWMC), who underwent continuous electroencephalography (cEEG) monitoring for > 48 hours. Our primary objective was to identify the prevalence of electrographic seizures in patients with altered mental status and no significant acute or remote risk factors for seizures. RESULTS A total of 1966 patients were screened for the study, 1892 were excluded (96.2%) and 74 patients met inclusion criteria. Electrographic seizures were identified in seven of 74 patients (9.45%). We found a significant correlation between electrographic seizures and a history of hepatic cirrhosis, n= 4 (57%), (p=0.035), acute chronic hepatic failure during admission, 71% (n=5), (p=0.027), and hyperammonemia (p =0.009). CONCLUSION In this retrospective study of patients with altered mental status and no significant acute or remote risk factors for seizures who underwent cEEG monitoring for > 48 hours, electrographic seizures were identified in 9.45%. Electrographic seizures were associated with hepatic dysfunction and hyperammonemia. Based on our results, cEEG monitoring should be considered in patients with altered mental status and hepatic dysfunction even in the absence of other seizure risk factors.
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Affiliation(s)
- Elena Garrido
- Department of Anesthesiology, The University of Iowa Carver College of Medicine, Iowa City, USA
| | - Amir Adeli
- Department of Neurology, Division of Epilepsy, The Ohio State University Wexner Medical Center, Columbus, USA
| | | | - Juan Fiorda
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Yousef Hannawi
- Department of Neurology, Division of Cerebrovascular Diseases and Neurocritical Care, The Ohio State University Wexner Medical Center, Columbus, USA
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Hwang S, An H, Shin DW, Lee HW. Retention Rates and Successful Treatment with Antiseizure Medications in Newly-Diagnosed Epilepsy Patients. Yonsei Med J 2024; 65:89-97. [PMID: 38288649 PMCID: PMC10827640 DOI: 10.3349/ymj.2022.0539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 09/21/2023] [Accepted: 10/10/2023] [Indexed: 02/01/2024] Open
Abstract
PURPOSE Treatment for epilepsy primarily involves antiseizure medications (ASMs), which can be characterized using the clinical data warehouse (CDW) database. In this study, we compared retention rates and time to successful treatment for various ASMs to reflect both efficacy and adverse effects in patients with newly diagnosed epilepsy. MATERIALS AND METHODS We identified newly diagnosed epilepsy patients with ASM treatment for more than 12 months using CDW of a tertiary referral hospital. Clinical characteristics were compared between groups with successful and unsuccessful treatment. Cox regression analysis was performed to evaluate independent variables of age, sex, comorbidities, and attributes of ASM regimens. RESULTS Of 2515 eligible participants, 46.2% were successfully treated with the first ASM regimen, and 74.7% with all ASM regimens with the median time-to-treatment success of 14 months. Participants with second-generation ASM as the first ASM were more likely to be successfully treated with the first regimen compared to those with first-generation ASM (51.6% vs. 42.3%, p<0.001) and more successfully treated [hazard ratio (HR)=1.26; 95% confidence interval (CI): 1.15-1.39]. Overall, valproic acid was the most common ASM across a wide range of ages under 65 years, while levetiracetam in patients aged over 65 years or lamotrigine in female adult patients. Clinical factors associated with less favorable treatment outcomes included renal disease (HR=0.78; 95% CI: 0.66-0.92), liver disease (HR=0.65; 95% CI: 0.52-0.81), depression (HR=0.70; 95% CI: 0.57-0.84), and mechanical ventilation (HR=0.58; 95% CI: 0.50-0.67). CONCLUSION Second-generation ASMs have the advantage of more successful treatment with fewer ASM regimen changes compared with first-generation drugs. Various comorbid conditions as well as age and sex should be considered when selecting ASMs.
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Affiliation(s)
- Sungeun Hwang
- Department of Neurology, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Hyungmi An
- Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Dong Woo Shin
- Department of Neurology, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Hyang Woon Lee
- Department of Neurology, Ewha Womans University Mokdong Hospital, Seoul, Korea
- Department of Neurology, Ewha Womans University School of Medicine, Seoul, Korea
- Department of Medical Science, Ewha Womans University School of Medicine, Seoul, Korea
- Computational Medicine, System Health Science & Engineering, and Artificial Intelligence Convergence Graduate Programs, Ewha Womans University, Seoul, Korea.
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4
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Seizure-induced thoracolumbar burst fracture secondary to cirrhosis: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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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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KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
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7
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Tern PJW, Bryce K, Marelli L, Ruban A. Hepatic encephalopathy: a rare cause of focal seizures in chronic liver disease. BMJ Case Rep 2020; 13:13/3/e233046. [DOI: 10.1136/bcr-2019-233046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hepatic encephalopathy (HE) is an extremely rare cause of focal seizures and is usually a diagnosis of exclusion when more commoner causes such as infection, autoimmune and malignancy have been discounted. The literature reports patients with generalised cerebral oedema and rarely status epilepticus, but these are often in the context of acute liver failure as opposed to chronic liver disease. Here we discuss a case of HE leading to focal neurological deficits and seizures in a 48-year-old woman with a background of chronic alcoholic liver disease. MRI scan showed extensive left-sided tempo-parietal-occipital cortical oedema and electroencephalogram showed widespread moderate HE with runs of epileptiform discharges. The treatment involves antiepileptic therapy as well as standard management of HE with laxatives, rifaximin and optimisation of nutrition.
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8
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Gursky JM, Rossi KC, Jetté N, Dhamoon MS. Exacerbation of hepatic cirrhosis may trigger admission for epilepsy and status epilepticus. Epilepsia 2020; 61:400-407. [PMID: 31981220 DOI: 10.1111/epi.16437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine whether acute exacerbations of cirrhotic liver disease are associated with higher odds of readmission for epilepsy or status epilepticus. METHODS The New York State Inpatient Database is a statewide dataset containing data on 97% of hospitalizations for New York State. In this retrospective, case-crossover design study, we used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify index status epilepticus and epilepsy admissions. The primary exposure was defined as admission due to an acute exacerbation of cirrhotic liver disease. The case-crossover analysis tested whether exposure to a hepatic exacerbation within progressively longer case periods (14, 30, 60, 90, 120, 150, and 180 days before index admission), compared to control periods 1 year before the case period, was associated with readmission for epilepsy or status epilepticus. RESULTS The odds ratio for subsequent admission for epilepsy after exposure to an acute exacerbation of cirrhotic liver disease was significant in the 30-day window at 2.072 (95% confidence interval [CI] = 1.095-3.92, P = .0252) and peaked in the 150-day window at 2.742 (95% CI = 1.817-4.137, P < .0001). In the status epilepticus group, all case periods demonstrated significantly elevated odds of subsequent admission following hepatic exacerbation. SIGNIFICANCE Hepatic exacerbations are associated with increased odds for hospital admissions for epilepsy and status epilepticus across several timeframes.
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Affiliation(s)
- Jonathan M Gursky
- Department of Neurology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Kyle C Rossi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
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9
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Roy A, Verma N, Ahuja CK. Intracranial invasive mycosis mimicking hepatic encephalopathy in a patient with cirrhosis. BMJ Case Rep 2019; 12:12/11/e231548. [PMID: 31776153 DOI: 10.1136/bcr-2019-231548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A 45-year-old man with alcohol-related decompensated cirrhosis presented with jaundice, fever, headache and altered sensorium. At presentation, he had tachycardia, disorientation to time and place, asterixis, icterus and upgoing plantar response. Investigations showed anaemia, thrombocytopenia, leucocytosis, hyperbilirubinemia and elevated arterial ammonia. Despite management with antihepatic coma measures and normalisation of ammonia, broad-spectrum antibiotics, 20% albumin, the patient worsened. On day 3, the patient developed generalised tonic-clonic seizure prompting mechanical ventilation. Examination showed right proptosis, chemosis and pupillary anisocoria. MRI brain showed multifocal infarcts in the right temporal lobe, right cerebellum and brainstem with inflammation in the right orbit, infratemporal fossa with right internal carotid artery thrombosis, and suspicious maxillary sinus thickening. Nasal scrapings showed aseptate fungal hyphae and serum galactomannan index was positive. Despite receiving liposomal amphotericin-B, patient had an unfavourable outcome. Intracranial invasive mycosis can mimic hepatic encephalopathy and is associated with high mortality in cirrhotics. A high index of suspicion, positive biomarkers and diagnostic radiology may provide the key to the diagnosis.
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Affiliation(s)
- Akash Roy
- Hepatology, Post Graduate Institute of Medical Education and Research (PIGMER), Chandigarh, India
| | - Nipun Verma
- Hepatology, Post Graduate Institute of Medical Education and Research (PIGMER), Chandigarh, India
| | - Chirag Kamal Ahuja
- Neuroradiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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10
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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: 0.8] [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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11
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Peters J, Vijiaratnam N, Wong JZ, Jitpiriyaroj S, Chandra RV, Kempster PA. Propensity for seizure-related cortical laminar necrosis in hepatic encephalopathy. Epilepsy Behav Rep 2019; 12:100348. [PMID: 31799510 PMCID: PMC6881611 DOI: 10.1016/j.ebr.2019.100348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 11/28/2022] Open
Abstract
Hepatic encephalopathy may predispose to seizure-related cortical laminar necrosis. Elevated ammonia levels potentially compound the excitotoxic effects of epilepsy. Early identification and treatment of seizures in liver disease could be protective.
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Affiliation(s)
- James Peters
- Neurosciences Department, Monash Medical Centre, Clayton, Australia
- Corresponding author at: Monash Neurology, Monash Medical Centre, Level 2, 246 Clayton Road, Clayton, Victoria 3168, Australia.
| | | | - Joseph Z.W. Wong
- Neurosciences Department, Monash Medical Centre, Clayton, Australia
| | | | - Ronil V. Chandra
- Neurosciences Department, Monash Medical Centre, Clayton, Australia
- Department of Imaging, Monash Medical Centre, Clayton, Australia
| | - Peter A. Kempster
- Neurosciences Department, Monash Medical Centre, Clayton, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
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12
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Alkhachroum AM, Rubinos C, Kummer BR, Parikh NS, Chen M, Chatterjee A, Reynolds A, Merkler AE, Claassen J, Kamel H. Risk of seizures and status epilepticus in older patients with liver disease. Epilepsia 2018; 59:1392-1397. [PMID: 29873808 DOI: 10.1111/epi.14442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Seizures can be provoked by systemic diseases associated with metabolic derangements, but the association between liver disease and seizures remains unclear. METHODS We performed a retrospective cohort study using inpatient and outpatient claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. The primary exposure variable was cirrhosis, and the secondary exposure was mild, noncirrhotic liver disease. The primary outcome was seizure, and the secondary outcome was status epilepticus. Diagnoses were ascertained using validated International Classification of Diseases, Ninth Edition, Clinical Modification codes. Survival statistics were used to calculate incidence rates, and Cox proportional hazards models were used to examine the association between exposures and outcomes while adjusting for seizure risk factors. RESULTS Among 1 782 402 beneficiaries, we identified 10 393 (0.6%) beneficiaries with cirrhosis and 19 557 (1.1%) with mild, noncirrhotic liver disease. Individuals with liver disease were older and had more seizure risk factors than those without liver disease. Over 4.6 ± 2.2 years of follow-up, 49 843 (2.8%) individuals were diagnosed with seizures and 25 patients (0.001%) were diagnosed with status epilepticus. Cirrhosis was not associated with seizures (hazard ratio [HR] = 1.1, 95% confidence interval [CI] = 1.0-1.3), but there was an association with status epilepticus (HR = 1.9, 95% CI = 1.3-2.8). Mild liver disease was not associated with a higher risk of seizures (HR = 0.8, 95% CI = 0.6-0.9) or status epilepticus (HR = 1.1, 95% CI = 0.7-1.5). SIGNIFICANCE In a large, population-based cohort, we found an association between cirrhosis and status epilepticus, but no overall association between liver disease and seizures.
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Affiliation(s)
- Ayham M Alkhachroum
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.,Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY, USA
| | - Clio Rubinos
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.,Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY, USA
| | - Benjamin R Kummer
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY, USA
| | - Neal S Parikh
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY, USA
| | - Monica Chen
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Abhinaba Chatterjee
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Alexandra Reynolds
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.,Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.,Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.,Department of Neurology, Weill Cornell Medical College, New York, NY, USA
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13
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Affiliation(s)
- Eelco F M Wijdicks
- From the Division of Critical Care Neurology, Mayo Clinic, Rochester, MN
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14
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Mladenović D, Hrnčić D, Rašić-Marković A, Macut D, Stanojlović O. The Influence of Finasteride on Mean and Relative Spectral Density of EEG Bands in Rat Model of Thioacetamide-Induced Hepatic Encephalopathy. Neurotox Res 2016; 30:150-8. [PMID: 26951455 DOI: 10.1007/s12640-016-9610-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 12/23/2022]
Abstract
Liver failure is associated with a neuropsychiatric syndrome, known as hepatic encephalopathy (HE). Finasteride, inhibitor of neurosteroid synthesis, may improve the course of HE. The aim of our study was to investigate the influence of finasteride on mean and relative power density of EEG bands, determined by spectral analysis, in rat model of thioacetamide-induced HE. Male Wistar rats were divided into groups: (1) control; (2) thioacetamide-treated group, TAA (900 mg/kg); (3) finasteride-treated group, FIN (150 mg/kg); and (4) group treated with finasteride (150 mg/kg) and thioacetamide (900 mg/kg), FIN + TAA. Daily doses of FIN (50 mg/kg) and TAA (300 mg/kg) were administered during 3 subsequent days, and in FIN + TAA group FIN was administered 2 h before every dose of TAA. EEG was recorded 22-24 h after treatment and analyzed by fast Fourier transformation. While TAA did not induce significant changes in the beta band, mean and relative power in this band were significantly higher in FIN + TAA versus control group (p < 0.01). TAA caused a significant decline in mean power in alpha, theta, and delta band, and in FIN + TAA group the mean power in these bands was significantly higher compared with control. While in TAA group relative power was significantly decreased in theta (p < 0.01) and increased in delta band (p < 0.01) versus control, the opposite changes were found in FIN + TAA group: an increase in theta (p < 0.01) and a decrease in delta relative power (p < 0.01). In this study, finasteride pretreatment caused EEG changes that correspond to mild TAA-induced HE.
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Affiliation(s)
- D Mladenović
- Institute of Pathophysiology "Ljubodrag Buba Mihailovic", Faculty of Medicine, University of Belgrade, Dr Subotica 9, Belgrade, Serbia
| | - D Hrnčić
- Institute of Medical Physiology "Richard Burian", Faculty of Medicine, University of Belgrade, Višegradska 26/II, 11000, Belgrade, Serbia
| | - A Rašić-Marković
- Institute of Medical Physiology "Richard Burian", Faculty of Medicine, University of Belgrade, Višegradska 26/II, 11000, Belgrade, Serbia
| | - Dj Macut
- Clinic for Endocrinology, Diabetes and Diseases of Metabolism, Faculty of Medicine, University of Belgrade, Dr Subotića 13, Belgrade, Serbia
| | - O Stanojlović
- Institute of Medical Physiology "Richard Burian", Faculty of Medicine, University of Belgrade, Višegradska 26/II, 11000, Belgrade, Serbia.
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Jo YM, Lee SW, Han SY, Baek YH, Ahn JH, Choi WJ, Lee JY, Kim SH, Yoon BA. Nonconvulsive status epilepticus disguising as hepatic encephalopathy. World J Gastroenterol 2015; 21:5105-5109. [PMID: 25945028 PMCID: PMC4408487 DOI: 10.3748/wjg.v21.i16.5105] [Citation(s) in RCA: 6] [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] [Received: 09/21/2014] [Revised: 11/20/2014] [Accepted: 01/16/2015] [Indexed: 02/06/2023] Open
Abstract
Nonconvulsive status epilepticus has become an important issue in modern neurology and epileptology. This is based on difficulty in definitively elucidating the condition and its various clinical phenomena and on our inadequate insight into the intrinsic pathophysiological processes. Despite nonconvulsive status epilepticus being a situation that requires immediate treatment, this disorder may not be appreciated as the cause of mental status impairment. Although the pathophysiology of nonconvulsive status epilepticus remains unknown, this disorder is thought to lead to neuronal damage, so its identification and treatment are important. Nonconvulsive status epilepticus should be considered in the differential diagnosis of patients with liver cirrhosis presenting an altered mental status. We report a case of a 52-year-old male with liver cirrhosis presenting an altered mental status. He was initially diagnosed with hepatic encephalopathy but ultimately diagnosed with nonconvulsive status epilepticus by electroencephalogram.
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Rosenberg S, Périn B, Michel V, Debs R, Navarro V, Convers P. EEG in adults in the laboratory or at the patient's bedside. Neurophysiol Clin 2015; 45:19-37. [DOI: 10.1016/j.neucli.2014.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 11/03/2014] [Indexed: 12/25/2022] Open
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[French guidelines on electroencephalogram]. Neurophysiol Clin 2014; 44:515-612. [PMID: 25435392 DOI: 10.1016/j.neucli.2014.10.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/07/2014] [Indexed: 12/11/2022] Open
Abstract
Electroencephalography allows the functional analysis of electrical brain cortical activity and is the gold standard for analyzing electrophysiological processes involved in epilepsy but also in several other dysfunctions of the central nervous system. Morphological imaging yields complementary data, yet it cannot replace the essential functional analysis tool that is EEG. Furthermore, EEG has the great advantage of being non-invasive, easy to perform and allows control tests when follow-up is necessary, even at the patient's bedside. Faced with the advances in knowledge, techniques and indications, the Société de Neurophysiologie Clinique de Langue Française (SNCLF) and the Ligue Française Contre l'Épilepsie (LFCE) found it necessary to provide an update on EEG recommendations. This article will review the methodology applied to this work, refine the various topics detailed in the following chapters. It will go over the summary of recommendations for each of these chapters and underline proposals for writing an EEG report. Some questions could not be answered by the review of the literature; in those cases, an expert advice was given by the working and reading groups in addition to the guidelines.
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Abstract
Fulminant hepatic failure presents with a hepatic encephalopathy and may progress to coma and often brain death from cerebral edema. This natural progression in severe cases contributes to early mortality, but outcome can be good if liver transplantation is appropriately timed and increased intracranial pressure (ICP) is managed. Neurologists and neurosurgeons have become more involved in these very challenging patients and are often asked to rapidly identify patients who are at risk of cerebral edema, to carefully select the patient population who will benefit from invasive ICP monitoring, to judge the correct time to start monitoring, to participate in treatment of cerebral edema, and to manage complications such as intracranial hemorrhage or seizures. This chapter summarizes the current multidisciplinary approach to fulminant hepatic failure and how to best bridge patients to emergency liver transplantation.
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Parker T, Freilich S, Tidswell T, Angus-Leppan H. Hepatic encephalopathy with epilepsia partialis continua: A case report. Seizure 2012; 21:813-5. [DOI: 10.1016/j.seizure.2012.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 08/29/2012] [Accepted: 08/29/2012] [Indexed: 12/01/2022] Open
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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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22
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Rosenthal ES. The utility of EEG, SSEP, and other neurophysiologic tools to guide neurocritical care. Neurotherapeutics 2012; 9:24-36. [PMID: 22234455 PMCID: PMC3271154 DOI: 10.1007/s13311-011-0101-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Neuromonitoring is an emerging field that aims to characterize real-time neurophysiology to tailor therapy for acute injuries of the central nervous system. While cardiac telemetry has been used for decades among patients requiring critical care of all kinds, neurophysiology and neurotelemetry has only recently emerged as a routine screening tool in comatose patients. The increasing utilization of electroencephalography in comatose patients is primarily due to the recognition of the common occurrence of nonconvulsive seizures among comatose patients, the development of quantitative measures to detect regional ischemia, and the appreciation of electroencephalography phenotypes that indicate prognosis after cardiac arrest. Other neuromonitoring tools, such as somatosensory evoked potentials have a complementary role, surveying the integrity of the neuroaxis as an indicator of prognosis or illness progression in both acute brain and spinal injuries.
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Affiliation(s)
- Eric S Rosenthal
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
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23
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Abstract
Hepatic encephalopathy (HE) is caused by liver impairment and has a multitude of symptoms in affected patients, including change in level of consciousness, intellectual function, and neuromuscular function. Pharmacologic therapy includes use of nonabsorbable disaccharides (lactulose and lactitol), and antibiotics such as neomycin, paromycin, metronidazole, and rifaximin. Probiotics, acarbose, and drugs such as L-carnitine and flumazenil, may also be helpful in treating HE.
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Tremolizzo L, Ferrarese C, Appollonio I. Cyclic hyperammoniemic encephalopathy and epileptiform triphasic waves: problems in differential diagnosis with nonconvulsive status epilepticus, reply. Neurol Sci 2009. [DOI: 10.1007/s10072-009-0032-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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25
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Updates in the Management of Seizures and Status Epilepticus in Critically Ill Patients. Neurol Clin 2008; 26:385-408, viii. [DOI: 10.1016/j.ncl.2008.03.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Maganti R, Gerber P, Drees C, Chung S. Nonconvulsive status epilepticus. Epilepsy Behav 2008; 12:572-86. [PMID: 18248774 DOI: 10.1016/j.yebeh.2007.12.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 11/28/2007] [Accepted: 12/02/2007] [Indexed: 12/14/2022]
Abstract
Nonconvulsive status epilepticus (NCSE) is a heterogeneous disorder with multiple subtypes. Although attempts have been made to define and classify this disorder, there is yet no universally accepted definition or classification that encompasses all subtypes or electroclinical scenarios. Developing such a classification scheme is becoming increasingly important, because NCSE is more common than previously thought, with a bimodal peak, in children and the elderly. Recent studies have also shown a high incidence of NCSE in the critically ill. Although strong epidemiological data are lacking, NCSE constitutes about 25-50% of all cases of status epilepticus. For the purposes of this review, we propose an etiological classification for NCSE including NCSE in metabolic disorders, NCSE in coma, NCSE in acute cerebral lesions, and NCSE in those with preexisting epilepsy with or without epileptic encephalopathy. NCSE is still underrecognized, yet potentially fatal if untreated. Diagnosis can be established using an electroencephalogram (EEG) in most cases, sometimes requiring continuous monitoring. However, in comatose patients, diagnosis can be difficult, and the EEG can show a variety of rhythmic or periodic patterns, some of which are of unclear significance. Although some subtypes of NCSE are easily treatable, such as absence status epilepticus, others do not respond well to treatment, and debate exists over how aggressively clinicians should treat NCSE. In particular, the appropriate treatment of NCSE in patients who are critically ill and/or comatose is not well established, and large-scale trials are needed. Overall, further work is needed to better define NCSE, to determine which EEG patterns represent NCSE, and to establish treatment paradigms for different subtypes of NCSE.
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Affiliation(s)
- Rama Maganti
- Barrow Neurological Institute, Phoenix, AZ 85013, USA.
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Abou Khaled KJ, Hirsch LJ. Advances in the management of seizures and status epilepticus in critically ill patients. Crit Care Clin 2007; 22:637-59; abstract viii. [PMID: 17239748 DOI: 10.1016/j.ccc.2006.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Seizures and status epilepticus are common in critically ill patients. They can be difficult to recognize because most are non-convulsive and require electroencephalogram monitoring to detect; hence, they are currently underdiagnosed. Early recognition and treatment are essential to obtain maximal response to first-line treatment and to prevent neurologic and systemic sequelae. Anti-seizure medication should be combined with management of the underlying cause and reversal of factors that can lower the seizure threshold, including many medications, fever, hypoxia, and metabolic imbalances. This article discusses specific treatments and specific situations, such as hepatic and renal failure patients and organ transplant patients.
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Affiliation(s)
- Karine J Abou Khaled
- Comprehensive Epilepsy Center, Department of Neurology, Columbia University Neurological Institute, New York, NY 10032, USA
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Crone CC, Gabriel GM, DiMartini A. An overview of psychiatric issues in liver disease for the consultation-liaison psychiatrist. PSYCHOSOMATICS 2006; 47:188-205. [PMID: 16684936 DOI: 10.1176/appi.psy.47.3.188] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Liver disease is a common cause of morbidity and mortality in the United States and elsewhere. Arising from infectious, hereditary, or toxin-induced sources, the detection of liver disease often requires a high index of suspicion. Clinical presentations are highly variable and are often accompanied by neuropsychiatric symptoms. This fact, along with an increased incidence of liver disease among patients with primary psychiatric disorders and the presence of varied drug use, complicates the tasks of providing care to patients with liver disease. To assist the consultation-liaison psychiatrist, the authors present the first of a two-part series focused on psychiatric issues in liver disease.
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Affiliation(s)
- Catherine C Crone
- Inova Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA.
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29
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Finsterer J, Bischof M, Kopsa W. 'Trismus' after seizure from hepatopathy. Eur J Neurol 2006; 13:e1-2. [PMID: 16834684 DOI: 10.1111/j.1468-1331.2006.01154.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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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: 12] [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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Raizen DM, Brooks-Kayal A, Steinkrauss L, Tennekoon GI, Stanley CA, Kelly A. Central nervous system hyperexcitability associated with glutamate dehydrogenase gain of function mutations. J Pediatr 2005; 146:388-94. [PMID: 15756227 DOI: 10.1016/j.jpeds.2004.10.040] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe seizure phenotypes associated with the hyperinsulinism/hyperammonemia syndrome (HI/HA), which is caused by gain of function mutations in the enzyme glutamate dehydrogenase (GDH). STUDY DESIGN A retrospective review of records of 14 patients with HI/HA. RESULTS Nine patients had seizures as the first symptom of HI/HA, and six had seizures in the absence of hypoglycemia. No electroencephalogram (EEG) background abnormalities were identified. In four patients, EEG recordings during seizures in the setting of normal blood glucose contained generalized epileptiform discharges. EEGs of three of these patients showed 0.5- to 2-second generalized irregular spike-and-wave discharge at 3 to 6 Hz corresponding to eye blinks, eye rolling, or staring. The EEG of the fourth patient consisted of 20 seconds of generalized regular spike-and-wave discharge at 3 Hz in the clinical context of staring and unresponsiveness. In two patients, seizure control worsened with carbamezapine or oxcarbezapine treatment. CONCLUSIONS In patients with HI/HA, generalized seizures are common and can occur in the absence of hypoglycemia. The drugs carbamazepine and oxcarbazepine should be used with caution for treatment. Pathogenesis of epilepsy in these patients may be related to effects of GDH mutations in the brain, perhaps in combination with effects of recurrent hypoglycemia and chronic hyperammonemia.
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Affiliation(s)
- David M Raizen
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, USA
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Montagnese S, Amodio P, Morgan MY. Methods for diagnosing hepatic encephalopathy in patients with cirrhosis: a multidimensional approach. Metab Brain Dis 2004; 19:281-312. [PMID: 15554423 DOI: 10.1023/b:mebr.0000043977.11113.2a] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
There is no "gold standard" for diagnosing hepatic encephalopathy in patients with cirrhosis. In consequence, the presence of this condition, unless floridly overt, is often missed. As a result, the majority of patients are denied the benefits of treatment. There are a number of individual techniques, which access different aspects of cerebral function that can be used, singly or in combination, to provide diagnostic information in this condition, including mental state assessment, psychometric testing, electroencephalography, sensory and cognitive evoked potentials, and neuroimaging. These have been variously applied to the study of hepatic encephalopathy but fundamental differences in the essential aims of the studies, as well as differences in the patient populations and the acquisition and analysis of the data, have made comparisons difficult. Thus, there is no clear consensus as to the sensitivity, specificity, or validity of these tests when used alone or in combination. There are, however, a number of additional methods that could be used to analyze the electrophysiological data, and a number of alternative evoked potentials that could be measured to provide better diagnostic information. In addition, there are a number of techniques, such as critical flicker frequency and smooth pursuit eye movements, which have not yet been applied systematically in this condition and which may provide useful diagnostic information. Clearly the methods for assessing hepatic encephalopathy need to be reviewed, newer methods for analyzing the electrophysiological data and newer techniques for assessing alternative aspects of cerebral function need to be explored for their diagnostic utility. This process should aim at developing a multidimensional diagnostic tool.
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Affiliation(s)
- Sara Montagnese
- Centre of Hepatology, Royal Free Campus, Royal Free and University College Medical School, Rowland Hill Street, Hampstead, London, United Kingdom
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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: 27] [Impact Index Per Article: 1.2] [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
Periodic and paroxysmal EEG patterns are frequent and easily recognized. They often correlate with particular neurological or systemic conditions. We propose a reclassification and critical examination of these periodic EEG patterns by reviewing the original work presented by J. Gaches in this journal some thirty years ago. Periodic EEG activity is still classified by its localisation--generalised or focal--and by its periodicity--long or short. Periodic long-interval diffuse paroxysmal patterns are reported with rare pathologies such as SSPE, trypanosomiasis or intoxication with phencyclidine. Suppression bursts (SB) may be found in two main situations post-anoxic encephalopathies and drug-induced comas. Ohtahara syndrome is a very rare childhood epileptic syndrome with SB. Periodic short-interval diffuse pattern have been reported in Creutzfeldt-Jakob disease but also in toxic encephalopathies, such as lithium intoxication or as recently reported in acute Cefepime intoxication as well as with metabolic encephalopathies and rarely during AIDS. Periodic lateralized epileptiform discharges (PLEDs) have been classified according to their morphology and the associated condition (epileptic seizures, subtle status, "vascular" seizure). The principal etiology is cerebro-vascular disease and herpes encephalitis but it has also been reported in several other neurological diseases.
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Irie T, Miyamoto E, Kitagawa K, Maruyama Y, Inoue K, Inagaki C. An anxiolytic agent, dihydrohonokiol-B, inhibits ammonia-induced increases in the intracellular Cl(-) of cultured rat hippocampal neurons via GABA(c) receptors. Neurosci Lett 2001; 312:121-3. [PMID: 11595349 DOI: 10.1016/s0304-3940(01)02201-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The effects of an anxiolytic honokiol derivative, dihydrohonokiol-B (DHH-B) [3'-(2-propenyl)-5-propyl-(1,1'-biphenyl)-2,4'-diaol], on ammonia-induced increases in the intracellular Cl(-) concentration ([Cl(-)](i)) were examined using primary cultured rat hippocampal neurons. DHH-B (1-100 ng/ml), but not an inactive isomer of honokiol, magnolol (100 ng/ml), dose-dependently inhibited the ammonia-induced increases in [Cl(-)](i) without any changes in the control [Cl(-)](i). Such an effect of DHH-B was blocked by a gamma-aminobutylic acid A (GABA(A)) and GABA(C) Cl(-) channel blocker, 100 microM picrotoxin, and a GABA(C) receptor blocker, 10 microM (1,2,5,6-tetrahydropyridine-4-yl)methylphosphinic acid, but not by a GABA(A) receptor blocker, 10 microM bicuculline. Further, a GABA(C) receptor agonist, 200 microM cis-4-aminocrotonic acid, but not a GABA(A) receptor agonist, 10 microM muscimol, mimicked the effect of DHH-B. Thus, DHH-B appears to protect neurons from the ammonia-induced increases in [Cl(-)](i) through GABA(C) receptor stimulation.
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Affiliation(s)
- T Irie
- Department of Pharmacology, Kansai Medical University, 10-15 Fumizono-Cho, Moriguchi City, Osaka 570-8506, Japan
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Abstract
Refractory epileptic state (RES) is defined by severe seizures that are resistant to antiepileptic drug treatment. Diagnostic errors such as pseudo-seizures and encephalopathies with triphasic waves must be distinguished at an early stage from cases of RES. The latter are symptomatic of a focal brain lesion or severe systemic disease, most frequently metabolic in origin. The treatment of such conditions is aimed at correction of the underlying cause. A nosographic issue that is still a subject of discussion and which requires further study, i.e., PLEDS, will also be discussed in this article.
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Affiliation(s)
- F Assal
- Unité d'EEG, clinique de neurologie, hôpital cantonal universitaire, Genève, Suisse
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37
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Irie T, Hara M, Yasukura T, Minamino M, Omori K, Matsuda H, Inoue K, Inagaki C. Chloride concentration in cultured hippocampal neurons increases during long-term exposure to ammonia through enhanced expression of an anion exchanger. Brain Res 1998; 806:246-56. [PMID: 9739146 DOI: 10.1016/s0006-8993(98)00700-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The effects of long-term exposure to ammonia on [Cl-]i in cultured hippocampal neurons were examined. Ammonia increased the [Cl-]i time- (>/=24 h) and concentration- (>/=2 mM) dependently, resulting in a depolarizing shift of the equilibrium potential of the GABAA receptor-Cl- channel opening (EGABA). Such an effect of ammonia was diminished by the inhibitors of Cl-/HCO3- exchangers, 0.1 mM 4-acetamido-4'-isothiocyanatostilbene-2,2'-disulfonic acid (SITS) and 0.1 mM 4,4'-diisothiocyanatostilbene-2,2'-disulfonic acid (DIDS), and a carbonic anhydrase inhibitor, 2 mM acetazolamide, but not by a Na+/K+/2Cl-cotransport inhibitor, 50 microM bumetanide, suggesting an enhanced Cl-/HCO3- exchange activity by ammonia. The ammonia-induced increase in [Cl-]i was also abolished by the inhibitors of protein kinase C (PKC), 0.1 microM calphostin C and 10 microM 1-(5-isoquinolinyl-sulfonyl)-2-methylpiperazine dihydrochloride (H-7), and of transcription and de novo protein synthesis, 1 microM actinomycin D and 0.5 microg/ml cycloheximide, while a PKC activator, 0.1 h microM phorbor 12-myristate 13-acetate (PMA), increased the [Cl-]i. The mRNA level of the AE3 Cl-/HCO3- exchanger was increased by ammonia in a calphostin C- and H-7-sensitive manner. The AE3-like immunoreactivity was also increased by ammonia. These findings suggest that long-term exposure to ammonia increases the expression of AE3 through the activation of PKC, resulting in an increase in [Cl-]i in neurons and a reduction of inhibitory postsynaptic potentials.
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Affiliation(s)
- T Irie
- Department of Pharmacology, Kansai Medical University, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8506, Japan
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