Neurological and neuropsychiatric syndromes associated with liver disease.

The clinical presentation of acute liver failure and hepatic encephalopathy (HE) in patients with cirrhosis differs significantly. The most serious neurological complication of acute liver failure is the development of devastating brain oedema. Therefore, intracranial pressure monitoring is urgently needed in these patients. Brain oedema is amplified by hypoglycemia, hypoxia and seizures, which are also frequent complications of acute liver failure. Therefore, these parameters must also be monitored. In contrast to acute liver failure in which cerebral dysfunction progresses rapidly, cognitive decline may be clinically undetectable for a long time in cirrhotic patients, until clinically overt symptoms such as psychomotor slowing, disorientation, confusion, extrapyramidal and cerebellar symptoms or a decrease in consciousness occur. Clinically, overt HE is preceded by minimal alterations of cerebral function that can only be detected by neuropsychological or neurophysiological measures, but which nevertheless interfere with the patient's daily living. Rapidly progressing spastic paraparesis (hepatic myelopathy) is a rare complication of cirrhosis. In contrast to HE, it does not respond to blood ammonia lowering therapies but must be considered as an indication for urgent liver transplantation. Cognitive dysfunction has recently been detected in hepatitis C virus (HCV)-infected patients with normal liver function. The patients presented with severe fatigue, cognitive dysfunction and mood disorders. Alterations in brain metabolites, as detected by magnetic resonance spectroscopy, indicated central nervous system alteration in these patients. In contrast to patients with HE, HCV-infected patients did not show motor symptoms or deficits in visual perception, but considerable deficits in attention and concentration ability.

Hepatitis C virus infection affects the brain-evidence from psychometric studies and magnetic resonance spectroscopy.

BACKGROUND/AIMS: Up to 50% of patients infected with the hepatitis C virus (HCV) complain of chronic fatigue and difficulties in concentration and memory. The aim of the present study was to seek evidence for the presence of central nervous system involvement in HCV infected patients with only mild liver disease. METHODS: Thirty HCV infected patients with normal liver function, 15 of whom were identified as having mild and 15 moderate to severe fatigue using the fatigue impact scale, underwent neurological and neuropsychological examination, electroencephalography (EEG) and cerebral proton magnetic resonance imaging (MRI) and spectroscopy (MRS). Fifteen healthy volunteers, matched for age and educational attainment, served as controls. RESULTS: In comparison to the healthy controls the patients with HCV infection showed evidence of cognitive impairment, primarily attention and higher executive functions, higher levels of anxiety and depression and impairment of quality of life. In addition they showed a significant decrease of the N-acetyl-aspartate/creatine ratio in the cerebral cortex on 1H MRS while the EEG was slowed in 25%. In general the deficits were more marked in the patients with moderate rather than mild fatigue. CONCLUSIONS: The data provide evidence of central nervous system involvement in patients with HCV infection.

Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction.

OBJECT: Whether decompressive hemicraniectomy is an appropriate treatment for space-occupying middle cerebral artery (MCA) infarction is still a controversial issue. Previous studies are in agreement on a reduction of the mortality rate, but the reported functional outcome was highly variable. The authors sought to determine functional impairment, disability, and health-related quality of life (QOL) outcome in long-term survivors who had undergone this procedure, and tried to identify factors related to functional outcome. METHODS: The study included 36 consecutive patients (mean age 58.8 +/- 12.7 years, 20 men and 16 women) who underwent decompressive hemicraniectomy for treatment of malignant MCA infarction (29 on the right and seven on the left side; mean time to surgery 37.8 +/- 20 hours). The survival rate was determined at 6 months: 13.7 +/- 6.7 months after the stroke, a cross-sectional personal investigation of survivors was performed to assess functional impairment, disability, and health-related QOL. Survival rates were 78% at 6 months and 64% at the time of the follow-up investigation; one patient was lost to follow up. Sixteen of 22 long-term survivors lived at home. The median Barthel Index (BI) was 45 (25th and 75th percentile 19 and 71) and the BI correlated negatively with patient age (r = -0.58, p = 0.005). Three patients reached a BI of at least 90. Older age, more severe neurological deficit on admission, and longer duration of intensive care treatment and mechanical ventilation were significantly associated with worse disability (BI < 50). The health-related QOL was considerably impaired in the subscales of mobility, household management, and body care. CONCLUSIONS: Decompressive hemicraniectomy improves survival in patients with malignant MCA infarction when compared with earlier reports of conservative treatment alone. Functional outcome and QOL remain markedly impaired, especially among elderly patients and in those with a severe neurological deficit at admission.