Electro-Radiological Observations of Grade III/IV Hepatic Encephalopathy Patients with Seizures
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ORIGINAL ARTICLE
Electro-Radiological Observations of Grade III/IV Hepatic Encephalopathy Patients with Seizures Christopher R. Newey1,2 • Pravin George2 • Aarti Sarwal3 • Norman So4 Stephen Hantus2,4
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Ó Springer Science+Business Media, LLC 2017
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
& Christopher R. Newey [email protected] 1
Department of Neurology, University of Missouri, 1 Hospital Drive, Columbia, MO 65211, USA
2
Neurological Institute, Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195-5245, USA
3
Neurology and Critical Care (Anesthesia), Wake Forest University School of Medicine, Reynolds M, Medical Center Blvd, Winston Salem, NC 27157, USA
4
Neurological Institute, Epilepsy Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195-5245, USA
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. Keywords Status epilepticus Seizures Hepatic encephalopathy Continuous electroencephalography (CEEG) Magnetic resonance imaging (MRI)
Introduction Neurological complications of liver failure are well reported and range from mild diffuse encephalopathy to more severe complications that include cerebral edema, elevated intracranial pressure, and intracranial hemorrhage secondary to coagulopathy [1–5]. The term hepatic encephalopathy is commonly applied to an intermediate degree of cerebral dysfunction dominated by neuropsychiatric changes with confusion and tremors but can extend to a state of coma [6]. Electroencephalography (EEG) is often used to assess the degree of hepatic encephalopathy and may improve prognostic accuracy [7–9]. Slowing of
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