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Huang CH, Yu TY, Tseng WEJ, Huang YT, Chang SH, Hsieh SY, Chien RN, Amodio P. Animal naming test is a simple and valid tool for detecting covert hepatic encephalopathy and predicting outcomes in Chinese-speaking regions: a preliminary study. Ann Med 2023; 55:2236013. [PMID: 37494454 PMCID: PMC10373624 DOI: 10.1080/07853890.2023.2236013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/19/2023] [Accepted: 07/09/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND AND AIMS Hepatic encephalopathy (HE) implies high morbidity and mortality. The assessment of covert HE (CHE) [i.e. minimal HE (MHE) plus grade 1 HE] is often neglected in Taiwan. Therefore, the aim was to investigate the potential of the animal naming test (ANT1 and simplified ANT1 (S-ANT1)) for assessing CHE in Chinese-speaking regions, specifically Taiwan. METHODS A prospective cohort study was conducted, comprising 65 cirrhotic patients and 29 healthy controls (relatives of the patients). Patients were followed up every three months and censored after two years or until death. Hospitalization for overt HE (OHE) and mortality were considered. All subjects underwent ANT1, psychometric HE score (PHES), and mini-mental state examination (MMSE). The patients underwent an electroencephalogram (EEG) to detect slowing indicative of MHE. Cut-off values for ANT1 and S-ANT1 were assessed by ROC analysis and Youden's index, considering CHE as a reference. The prognostic values for OHE and OHE-free survival were assessed. RESULTS Preliminary analysis confirmed that PHES ≤-4 is a good discriminant point for abnormal results. CHE was found in 29 patients: 9 had MHE (PHES ≤ -4 or altered EEG) and 20 had grade 1 HE. ANT1 and S-ANT1 were found to have diagnostic values for CHE: AUC = 0.807, 0.786; cut off: 18 and 19, respectively. ANT1 and S-ANT1 were found to have prognostic value for OHE, number of hospitalization episodes for OHE, and OHE recurrence-free survival. CONCLUSIONS ANT1 shows promise as a tool for CHE detection, quantification, and follow-up in Taiwan and other Chinese-speaking regions.Key messagesThe animal naming test (ANT1) is a simple and valid semantic fluency test that can be easily performed in outpatient or bedside settings in one minute and can also be used as a tool for covert hepatic encephalopathy (CHE) detection, quantification, and follow-up in Taiwan, other Chinese-speaking regions, and many other countries.The diagnostic value of ANT1 and S-ANT1 for CHE were found to be significant, with area under the receiver operating characteristic curve (AUROC) values of 0.807 and 0.786 respectively, and cut-off scores of 18 and 19.ANT1 and S-ANT1 have prognostic value for the first breakthrough of overt hepatic encephalopathy (OHE), number of hospitalization episodes for OHE, and OHE recurrence-free survival, independent of the MELD score.
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Affiliation(s)
- Chien-Hao Huang
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Tung-Yang Yu
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wei-En Johnny Tseng
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Department of Medical Research and Development, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Shang-Hung Chang
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
- Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
- Cardiovascular Division, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Sen-Yung Hsieh
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Rong-Nan Chien
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Piero Amodio
- Department of Medicine, University of Padova, Padova, Italy
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Cittolin-Santos G, Guazzelli P, Nonose Y, Almeida R, Fontella F, Pasquetti M, Ferreira-Lima F, Lazzaroto G, Berlezi R, Osvaldt A, Calcagnotto M, de Assis A, Souza D. Behavioral, Neurochemical and Brain Oscillation Abnormalities in an Experimental Model of Acute Liver Failure. Neuroscience 2019; 401:117-129. [DOI: 10.1016/j.neuroscience.2018.12.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 01/17/2023]
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Hepatic encephalopathy 2018: A clinical practice guideline by the Italian Association for the Study of the Liver (AISF). Dig Liver Dis 2019; 51:190-205. [PMID: 30606696 DOI: 10.1016/j.dld.2018.11.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 12/11/2022]
Abstract
Hepatic encephalopathy (HE) is a common, worrisome and sometimes difficult to manage complication of end-stage liver disease. HE is often recurrent, requiring multiple hospital admissions. It can have serious implications in terms of a patient's ability to perform complex tasks (for example driving), their earning capacity, their social and family roles. This guideline reviews current knowledge on HE definition, pathophysiology, diagnosis and treatment, both by general principles and by way of a summary of available drugs and treatment strategies. The quality of the published, pertinent evidence is graded, and practical recommendations are made. Where possible, these are placed within the Italian health service context, with reference to local diagnosis and management experience.
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Planas-Ballvé A, Grau-López L, Morillas RM, Planas R. Neurological manifestations of excessive alcohol consumption. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:709-717. [PMID: 28651796 DOI: 10.1016/j.gastrohep.2017.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 05/10/2017] [Accepted: 05/19/2017] [Indexed: 12/28/2022]
Abstract
This article reviews the different acute and chronic neurological manifestations of excessive alcohol consumption that affect the central or peripheral nervous system. Several mechanisms can be implicated depending on the disorder, ranging from nutritional factors, alcohol-related toxicity, metabolic changes and immune-mediated mechanisms. Recognition and early treatment of these manifestations is essential given their association with high morbidity and significantly increased mortality.
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Affiliation(s)
- Anna Planas-Ballvé
- Unidad de Neurociencias, Servicio de Neurología, Hospital Germans Trias i Pujol, Badalona (Barcelona), España.
| | - Laia Grau-López
- Unidad de Neurociencias, Servicio de Neurología, Hospital Germans Trias i Pujol, Badalona (Barcelona), España
| | - Rosa María Morillas
- Unidad de Hepatología, CIBERehd, Servicio de Aparato Digestivo, Hospital Germans Trias i Pujol, Badalona (Barcelona), España
| | - Ramón Planas
- Unidad de Hepatología, CIBERehd, Servicio de Aparato Digestivo, Hospital Germans Trias i Pujol, Badalona (Barcelona), España
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Cittolin-Santos GF, de Assis AM, Guazzelli PA, Paniz LG, da Silva JS, Calcagnotto ME, Hansel G, Zenki KC, Kalinine E, Duarte MM, Souza DO. Guanosine Exerts Neuroprotective Effect in an Experimental Model of Acute Ammonia Intoxication. Mol Neurobiol 2016; 54:3137-3148. [PMID: 27052954 DOI: 10.1007/s12035-016-9892-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 03/28/2016] [Indexed: 12/20/2022]
Abstract
The nucleoside guanosine (GUO) increases glutamate uptake by astrocytes and acts as antioxidant, thereby providing neuroprotection against glutamatergic excitotoxicity, as we have recently demonstrated in an animal model of chronic hepatic encephalopathy. Here, we investigated the neuroprotective effect of GUO in an acute ammonia intoxication model. Adult male Wistar rats received an intraperitoneal (i.p.) injection of vehicle or GUO 60 mg/kg, followed 20 min later by an i.p. injection of vehicle or 550 mg/kg of ammonium acetate. Afterwards, animals were observed for 45 min, being evaluated as normal, coma (i.e., absence of corneal reflex), or death status. In a second cohort of rats, video-electroencephalogram (EEG) recordings were performed. In a third cohort of rats, the following were measured: (i) plasma levels of glucose, transaminases, and urea; (ii) cerebrospinal fluid (CSF) levels of ammonia, glutamine, glutamate, and alanine; (iii) glutamate uptake in brain slices; and (iv) brain redox status and glutamine synthetase activity in cerebral cortex. GUO drastically reduced the lethality rate and the duration of coma. Animals treated with GUO had improved EEG traces, decreased CSF levels of glutamate and alanine, lowered oxidative stress in the cerebral cortex, and increased glutamate uptake by astrocytes in brain slices compared with animals that received vehicle prior to ammonium acetate administration. This study provides new evidence on mechanisms of guanine-derived purines in their potential modulation of glutamatergic system, contributing to GUO neuroprotective effects in a rodent model of by acute ammonia intoxication.
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Affiliation(s)
- G F Cittolin-Santos
- Postgraduate Program in Biological Sciences: Biochemistry, ICBS, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
| | - A M de Assis
- Postgraduate Program in Biological Sciences: Biochemistry, ICBS, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
| | - P A Guazzelli
- Postgraduate Program in Biological Sciences: Biochemistry, ICBS, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
| | - L G Paniz
- Postgraduate Program in Biological Sciences: Biochemistry, ICBS, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
| | - J S da Silva
- Postgraduate Program in Biological Sciences: Biochemistry, ICBS, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
| | - M E Calcagnotto
- Postgraduate Program in Biological Sciences: Biochemistry, ICBS, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil.,Department of Biochemistry, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
| | - G Hansel
- Postgraduate Program in Biological Sciences: Biochemistry, ICBS, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
| | - K C Zenki
- Postgraduate Program in Biological Sciences: Biochemistry, ICBS, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil.,Department of Physiology, Federal University of Sergipe, São Cristovão, SE, 49100-000, Brazil
| | - E Kalinine
- Postgraduate Program in Biological Sciences: Biochemistry, ICBS, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil.,Department of Physiology, Federal University of Sergipe, São Cristovão, SE, 49100-000, Brazil
| | - M M Duarte
- Health Sciences Center, Lutheran University of Brazil (ULBRA), Campus Santa Maria, Santa Maria, RS, 97020-001, Brazil
| | - D O Souza
- Postgraduate Program in Biological Sciences: Biochemistry, ICBS, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil. .,Department of Biochemistry, Federal University of Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil.
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Thuluvath PJ, Nuthalapati A, Price J, Maheshwari A. Driving Performance Among Patients with Cirrhosis Who Drove to Their Outpatient Hepatology Clinic Appointments. J Clin Exp Hepatol 2016; 6:3-9. [PMID: 27194889 PMCID: PMC4862017 DOI: 10.1016/j.jceh.2015.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 09/18/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Minimal hepatic encephalopathy (MHE) may adversely affect driving skills. AIMS To compare the driving performance of cirrhotic patients with and without prior HE as well as controls using a driving stimulator and to correlate psychometric testing with driving performance. METHODS Adult patients with cirrhosis, who drove to the outpatient clinic for their routine appointments underwent a battery of driving and psychometric tests including number connection tests A & B (NCT-A and NCT-B), digit symbol test (DST) and critical flicker and fusion frequency (CFF) testing. RESULTS Cirrhotics had significantly higher NCT-A (39.3 s vs. 31.2 s, P = 0.006) and DST scores (317 s vs. 245 s, P = 0.012), and lower CFF scores Fusion (33 vs. 36 Hz, P = 0.05), Flicker (35 vs. 42 Hz, P = 0.007) than controls. There was no difference in NCT-A, DST and CFF scores between patients with and without HE. Ten (22%) patients, 7 (27%) with prior HE and 3 (15%) without prior HE, had abnormal NCT-A scores (i.e. >control mean ± 2SD), and 12% of patients with prior HE had one or more driving test accidents, while controls and patients without prior HE had none. Patients with cirrhosis were more likely to hit pedestrians compared to controls (P = 0.05). There was no correlation between CFF, DST and NCTB scores with driving performance test results. CONCLUSIONS Unlike previous reports, no significant differences were noted between the patients with and without prior HE on psychometric testing, and on the driving simulator, but driving accidents were seen in only those with previous history of HE.
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Affiliation(s)
- Paul J. Thuluvath
- University of Maryland School of Medicine & Mercy Medical Center, Medicine, 301 Saint Paul Place, Baltimore, MD 21202, United States,Address for correspondence: Paul J. Thuluvath, University of Maryland School of Medicine & Mercy Medical Center, Medicine, 301 Saint Paul Place, Baltimore, MD 21202, United States.
| | | | - Jennifer Price
- Department of Medicine, University of San Francisco School of Medicine, San Francisco, CA, United States
| | - Anurag Maheshwari
- University of Maryland School of Medicine & Mercy Medical Center, Medicine, 301 Saint Paul Place, Baltimore, MD 21202, United States
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Affair With Triphasic Waves—Their Striking Presence, Mysterious Significance, and Cryptic Origins. J Clin Neurophysiol 2015; 32:401-5. [DOI: 10.1097/wnp.0000000000000151] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Edula RGR, Pyrsopoulos NT. New Methods of Testing and Brain Imaging in Hepatic Encephalopathy: A Review. Clin Liver Dis 2015. [PMID: 26195200 DOI: 10.1016/j.cld.2015.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The diagnosis of hepatic encephalopathy is predominantly clinical, and the tests available assist in the diagnosis only by excluding other causes. Covert hepatic encephalopathy, which is defined as abnormal performance on psychometric tests when standard neurologic examination is completely normal, has gained widespread attention in recent years due to its effect on quality of life. This review focuses on the tests available to aid in the diagnosis of this significant complication of liver disease, and discusses the complex pathophysiologic mechanisms identified through new imaging techniques and their significance toward development of new therapeutic targets for this condition.
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Affiliation(s)
- Raja G R Edula
- Division of Gastroenterology & Hepatology, Rutgers New Jersey Medical School, 185 South Orange Avenue, MSB H 538, Newark, NJ 07103, USA
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology & Hepatology, Rutgers New Jersey Medical School, 185 South Orange Avenue, MSB H 538, Newark, NJ 07103, USA.
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9
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Paniz LG, Calcagnotto ME, Pandolfo P, Machado DG, Santos GF, Hansel G, Almeida RF, Bruch RS, Brum LM, Torres FV, de Assis AM, Rico EP, Souza DO. Neuroprotective effects of guanosine administration on behavioral, brain activity, neurochemical and redox parameters in a rat model of chronic hepatic encephalopathy. Metab Brain Dis 2014; 29:645-54. [PMID: 24788896 DOI: 10.1007/s11011-014-9548-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
Abstract
It is well known that glutamatergic excitotoxicity and oxidative stress are implicated in the pathogenesis of hepatic encephalopathy (HE). The nucleoside guanosine exerts neuroprotective effects through the antagonism against glutamate neurotoxicity and antioxidant properties. In this study, we evaluated the neuroprotective effect of guanosine in an animal model of chronic HE. Rats underwent bile duct ligation (BDL) and 2 weeks later they were treated with i.p. injection of guanosine 7.5 mg/kg once a day for 1-week. We evaluated the effects of guanosine in HE studying several aspects: a) animal behavior using open field and Y-maze tasks; b) brain rhythm changes in electroencephalogram (EEG) recordings; c) purines and glutamate levels in the cerebral spinal fluid (CSF); and d) oxidative stress parameters in the brain. BDL rats presented increased levels of glutamate, purines and metabolites in the CSF, as well as increased oxidative damage. Guanosine was able not only to prevent these effects but also to attenuate the behavioral and EEG impairment induced by BDL. Our study shows the neuroprotective effects of systemic administration of guanosine in a rat model of HE and highlights the involvement of purinergic system in the physiopathology of this disease.
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Affiliation(s)
- L G Paniz
- Programa de Pós-graduação em Bioquímica, Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul-UFRGS, Rua Ramiro Barcelos 2600 Anexo, 90035-003, Porto Alegre, RS, Brazil,
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EEG abnormalities are associated with increased risk of transplant or poor outcome in children with acute liver failure. J Pediatr Gastroenterol Nutr 2014; 58:449-56. [PMID: 24345828 DOI: 10.1097/mpg.0000000000000271] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES There are limited data on the incidence of seizures and utility of brain imaging and electroencephalogram (EEG) to predict outcome of children with acute liver failure (ALF). We investigated the association between hepatic encephalopathy (HE) scores, abnormal EEG or neuroimaging, and short-term outcome. METHODS Single-center retrospective observational study of infants and children with ALF who underwent continuous EEG monitoring and brain imaging within 24 hours of admission to the intensive care unit (ICU). RESULTS A total of 19 patients with ALF with a mean age of 6.8 ± 1.5 years were evaluated. The majority of cases (74%) were indeterminate. Of the total, 10 patients (53%) survived to discharge without liver transplant (LT), 5 (26%) received LT, and 4 (21%) died without LT. Seizures occurred in only 2 cases (19%). Patients who had an abnormal EEG on admission (n = 7) were significantly more likely to die or require LT (P < 0.05, Fisher exact test). Patients with either an admission HE score ≤ 2, or liver injury unit score <222, combined with a normal or mildly abnormal EEG were more likely to survive without LT. Neuroimaging was normal in the majority of cases (87%) and was not associated with outcome. CONCLUSIONS Children with a moderate or severe abnormality of EEG background on admission were significantly more likely to require LT or to die. Children with an HE score ≤ 2, and a normal or only mildly abnormal EEG, were significantly more likely to survive without needing LT. These findings are an initial step toward distinguishing patients with ALF who may recover spontaneously from those who will require LT.
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Cona G, Montagnese S, Bisiacchi PS, Gatta A, Cillo U, Angeli P, Amodio P, Schiff S. Early markers of neural dysfunction and compensation: a model from minimal hepatic encephalopathy. Clin Neurophysiol 2013; 125:1138-44. [PMID: 24333166 DOI: 10.1016/j.clinph.2013.10.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 10/24/2013] [Accepted: 10/26/2013] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The Inhibitory Control Task (ICT) was used to detect minimal hepatic encephalopathy (MHE). ICT assesses attention, working memory and inhibition by evaluating performance in detect, go and nogo trials, respectively. The event-related potentials (ERPs) elicited by the ICT provide insight into neural mechanisms underlying the cognitive alterations associated with MHE. METHODS The performance and the ERPs elicited by ICT were measured in 31 patients with cirrhosis (13 with and 18 without MHE) and in 17 controls. The latency and amplitude of the N2, P3a, P3b and nogo-P3 were compared among the groups. RESULTS Patients with MHE performed worse in all ICT trials compared to patients without MHE and controls. Cirrhotic patients, both with and without MHE, displayed a reduction in P3a amplitude, selectively in the detect trials. Patients without MHE exhibited greater N2 and nogo-P3 amplitudes compared to patients with MHE and controls. CONCLUSIONS Both patients with and without MHE displayed neural alterations reflecting attentional deficits (i.e., P3a attenuation). However, patients without MHE coped with such dysfunctions by recruiting compensatory neural mechanisms, as suggested by the enhancement of the nogo-P3 and N2 amplitudes coupled with a normal ICT performance. SIGNIFICANCE The study suggests how initial brain dysfunction might be compensated for by recruitment of additional neurocognitive resources.
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Affiliation(s)
- Giorgia Cona
- Department of General Psychology, University of Padua, Via Venezia 8, 35131 Padua, Italy; CIRMANMEC, Via Giustiniani 2, 35128 Padua, Italy.
| | - Sara Montagnese
- Department of Medicine, University of Padua, Via Giustiniani 2, 35128 Padua, Italy; CIRMANMEC, Via Giustiniani 2, 35128 Padua, Italy.
| | - Patrizia Silvia Bisiacchi
- Department of General Psychology, University of Padua, Via Venezia 8, 35131 Padua, Italy; CIRMANMEC, Via Giustiniani 2, 35128 Padua, Italy.
| | - Angelo Gatta
- Department of Medicine, University of Padua, Via Giustiniani 2, 35128 Padua, Italy; CIRMANMEC, Via Giustiniani 2, 35128 Padua, Italy.
| | - Umberto Cillo
- Hepatobiliary Surgery, Department of Surgery, University of Padua, Via Giustiniani 2, 35128 Padua, Italy.
| | - Paolo Angeli
- Department of Medicine, University of Padua, Via Giustiniani 2, 35128 Padua, Italy.
| | - Piero Amodio
- Department of Medicine, University of Padua, Via Giustiniani 2, 35128 Padua, Italy; CIRMANMEC, Via Giustiniani 2, 35128 Padua, Italy.
| | - Sami Schiff
- Department of Medicine, University of Padua, Via Giustiniani 2, 35128 Padua, Italy; CIRMANMEC, Via Giustiniani 2, 35128 Padua, Italy.
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Butz M, May ES, Häussinger D, Schnitzler A. The slowed brain: Cortical oscillatory activity in hepatic encephalopathy. Arch Biochem Biophys 2013; 536:197-203. [DOI: 10.1016/j.abb.2013.04.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 04/04/2013] [Accepted: 04/08/2013] [Indexed: 12/12/2022]
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Mladenović D, Hrnčić D, Rašić-Marković A, Puškaš N, Petrovich S, Stanojlović O. Spectral analysis of thioacetamide-induced electroencephalographic changes in rats. Hum Exp Toxicol 2012; 32:90-100. [DOI: 10.1177/0960327112456312] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Thioacetamide (TAA) is widely used as a model of hepatic encephalopathy (HE). The aim of our study was to investigate the effects of TAA on electroencephalographic (EEG) changes in rats and to compare them with human HE. Male Wistar rats were divided into groups: (1) saline-treated group and (2) TAA-treated groups: TAA300 (300 mg/kg), TAA600 (600 mg/kg), and TAA900 (900 mg/kg). Daily dose of TAA (300 mg/kg) was administered intraperitoneally once (TAA300), twice (TAA600), or thrice (TAA900) in subsequent days. EEG changes were recorded about 24 h after the last dose of TAA. Absolute and relative power density in alpha bands were significantly higher in TAA300 versus control group. In TAA300, absolute beta power density was higher and relative beta power density was lower versus control group. Absolute alpha, theta, delta, and relative theta power were significantly lower, while relative power in delta band was significantly higher in TAA900 versus control group ( p < 0.01). In conclusion, decrease in EEG voltage with an increase in delta relative power, which correspond to the EEG manifestations of severe HE in humans, was observed in TAA900 group. Electrical activity in TAA300 group correlates with mild HE in humans.
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Affiliation(s)
- D Mladenović
- Institute of Pathophysiology, 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, Belgrade, Serbia
| | - A Rašić-Marković
- Institute of Medical Physiology “Richard Burian”, Faculty of Medicine, University of Belgrade, Višegradska 26/II, Belgrade, Serbia
| | - N Puškaš
- Institute of Histology and Embryology, Faculty of Medicine, University of Belgrade, Višegradska 26, Belgrade, Serbia
| | - S Petrovich
- Laboratory of Molecular Biology and Endocrinology, Vinča Institute of Nuclear Sciences, University of Belgrade, Serbia
| | - O Stanojlović
- Institute of Medical Physiology “Richard Burian”, Faculty of Medicine, University of Belgrade, Višegradska 26/II, Belgrade, Serbia
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Kahlbrock N, Butz M, May ES, Brenner M, Kircheis G, Häussinger D, Schnitzler A. Lowered frequency and impaired modulation of gamma band oscillations in a bimodal attention task are associated with reduced critical flicker frequency. Neuroimage 2012; 61:216-27. [DOI: 10.1016/j.neuroimage.2012.02.063] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 01/31/2012] [Accepted: 02/21/2012] [Indexed: 10/28/2022] Open
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Management of hepatic encephalopathy by traditional chinese medicine. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2012; 2012:835686. [PMID: 22567035 PMCID: PMC3328926 DOI: 10.1155/2012/835686] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 02/09/2012] [Indexed: 12/14/2022]
Abstract
In spite of the impressive progress in the investigation of hepatic encephalopathy (HE), the complex mechanisms underlying the onset and deterioration of HE are still not fully understood. Currently, none of the existing theories provide conclusive explanations on the symptoms that link liver dysfunction to nervous system disorders and clinical manifestations. This paper summarized the diagnostic and therapeutic approaches used for HE in modern medicine and traditional Chinese medicine and provided future perspective in HE therapies from the viewpoint of holistic and personalized Chinese medicine.
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Marchetti P, D'Avanzo C, Orsato R, Montagnese S, Schiff S, Kaplan PW, Piccione F, Merkel C, Gatta A, Sparacino G, Toffolo GM, Amodio P. Electroencephalography in patients with cirrhosis. Gastroenterology 2011; 141:1680-9.e1-2. [PMID: 21763244 DOI: 10.1053/j.gastro.2011.06.085] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 06/04/2011] [Accepted: 06/28/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Electroencephalography has not been completely quantified in patients with cirrhosis. We investigated the electroencephalogram (EEG) dynamics in patients with cirrhosis. METHODS We performed closed-eye EEGs on 175 patients with cirrhosis (age, 55 ± 11 years; 24% Child-Pugh class A, 48% class B, and 285 class C), conducted clinical and psychometric assessments for hepatic encephalopathy (HE), and followed the patients for 1 year. EEG characteristics were assessed in the frequency domain, in the frontal (F3-F4) and parietal (P3-P4) derivations. Intrahemispheric (frontoparietal, right, and left) and interhemispheric (F3-F4 and P3-P4) coherence were computed. The EEGs of 50 healthy volunteers (age, 56 ± 17 years) served as controls. RESULTS Compared with controls, the EEGs of patients with cirrhosis had a reduced frequency in the posterior derivations (P3/P4 mean dominant frequency, 9.1 ± 1.8 and 8.9 ± 1.7 Hz vs 10.4 ± 1.3 and 10.2 ± 1.3 Hz, respectively; P < .01) and an increase in interhemispheric parietal relative coherence within the theta band (22.3% ± 5.5% vs 18.9% ± 3.5%; P < .01). These features were more prominent in patients with Child class C and in patients with a history of overt HE; they correlated with hyperammonemia and hyponatremia. The decrease in EEG frequency, along with the increase in interhemispheric theta coherence in the posterior derivations, was inversely associated with survival and the occurrence of overt HE during the follow-up period. CONCLUSIONS In patients with cirrhosis, alterations in the EEG were significantly associated with the severity of liver disease and HE; the EEG might be used in determining prognosis.
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Olesen SS, Graversen C, Hansen TM, Blauenfeldt RA, Hansen JB, Steimle K, Drewes AM. Spectral and dynamic electroencephalogram abnormalities are correlated to psychometric test performance in hepatic encephalopathy. Scand J Gastroenterol 2011; 46:988-96. [PMID: 21612322 DOI: 10.3109/00365521.2011.579160] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Alterations of the electroencephalogram (EEG) have been reported in patients with hepatic encephalopathy (HE). However, previous methods have not assessed transient phenomena in the EEG signal (dynamics) and associations to psychometric test performance have in general been poor. The aims were to quantify spectral and dynamic EEG abnormalities in patients with HE and to correlate putative findings to psychometric test performances. METHODS Multichannel EEG (64 electrodes) was recorded in 24 cirrhotic patients with various grades of HE and 26 healthy volunteers. Spectral and dynamic EEG indices were quantified by continues wavelet analysis. In addition, the psychometric hepatic encephalopathy score (PHES), continues reaction time, and biochemical profile were assessed. RESULTS Compared with healthy volunteers, patients had progressively slowing of the EEG (all p ≤ 0.004) (spectral EEG indices) and increased variability in the alpha [7.5-13.5 Hz] (p = 0.001) and beta bands [13.5-32 Hz] (p = 0.02) (dynamic EEG indices). In addition, anteriorization and dissociation of the basic posterior alpha rhythm, along with dissociation of frontal delta activities [1-3.5 Hz] were seen with worsening of HE. Spectral EEG indices (all frequency bands) as well as dynamic EEG indices (alpha and beta bands) were correlated to PHES scores (all p < 0.05). CONCLUSION EEG analysis, based on continues wavelet transform, provides quantifiable information on static as well as dynamic features of the EEG in patients with HE. EEG abnormalities were correlated to psychometric test performance and may provide valuable clinical biomarkers for surveillance, prognostication and treatment of this entity.
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Affiliation(s)
- Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg Hospital, Aarhus University Hospital, Denmark
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Córdoba J. New assessment of hepatic encephalopathy. J Hepatol 2011; 54:1030-40. [PMID: 21145874 DOI: 10.1016/j.jhep.2010.11.015] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Revised: 11/22/2010] [Accepted: 11/23/2010] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is a common complication of cirrhosis that requires careful appraisal of the clinical manifestations, evaluation of the underlying neurological disorders, and assessment of liver function and the portal-systemic circulation. This article reviews recent developments in the assessment of HE and discusses the controversy regarding the use of a categorical or a continuous approach in measuring the severity of this condition. New scales facilitate effective monitoring and assessment of episodic HE. Neuropsychological test batteries and neurophysiological tests are of value for evaluating cognitive function in outpatients and can establish the diagnosis of minimal HE, and the severity of low-grade HE. These tools allow better evaluation of the origin of cognitive complaints and help in estimating the risk of accidents. It is now possible to complete the evaluation with measurement of the effects of cognitive impairment on daily living. In difficult cases, imaging of the brain and portal-systemic circulation with magnetic resonance imaging is especially helpful. Based on these studies, neurological signs and symptoms can be attributed to HE in patients with mild liver disease and in those with complex neurological manifestations. The new methods presented are also valuable for investigating the neurological manifestations occurring after liver transplantation.
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Affiliation(s)
- Juan Córdoba
- Servei de Medicina Interna-Hepatologia, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Paseo Vall d'Hebron 119, Barcelona 08035, Spain.
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Amodio P, Ridola L, Schiff S, Montagnese S, Pasquale C, Nardelli S, Pentassuglio I, Trezza M, Marzano C, Flaiban C, Angeli P, Cona G, Bisiacchi P, Gatta A, Riggio O. Improving the inhibitory control task to detect minimal hepatic encephalopathy. Gastroenterology 2010; 139:510-8, 518.e1-2. [PMID: 20470775 DOI: 10.1053/j.gastro.2010.04.057] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Revised: 03/30/2010] [Accepted: 04/29/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Quantification of the number of noninhibited responses (lures) in the inhibitory control task (ICT) has been proposed for the diagnosis of minimal hepatic encephalopathy (MHE). We assessed the efficacy of ICT compared with recommended diagnostic standards. METHODS We studied patients with cirrhosis and healthy individuals (controls) who underwent the ICT at 2 centers (center A: n=51 patients and 41 controls, center B: n=24 patients and 14 controls). Subjects were evaluated for MHE by psychometric hepatic encephalopathy score (PHES). Patients from center B also were assessed for MHE by critical flicker frequency and spectral electroencephalogram analyses. RESULTS Patients with cirrhosis had higher ICT lures (23.2+/-12.8 vs 12.9+/-5.8, respectively, P<.01) and lower ICT target accuracy (0.88+/-0.17 vs 0.96+/-0.03, respectively, P<.01) compared with controls. However, lures were comparable (25.2+/-12.5 vs 21.4+/-13.9, respectively, P=.32) among patients with/without altered PHES (center A). There was a reverse, U-shaped relationship between ICT lure and target accuracy; a variable adjusting lures was devised based on target accuracy (weighted lures at center B). This variable differed between patients with and without MHE. The variable weighted lures was then validated from data collected at center A by receiver operator characteristic curve analysis; it discriminated between patients with and without PHES alterations (area under the curve=0.71+/-0.07). However, target accuracy alone was as effective as a stand-alone variable (area under the curve=0.81+/-0.06). CONCLUSIONS The ICT is not useful for the diagnosis of MHE, unless adjusted by target accuracy. Testing inhibition (lures) does not seem to be superior to testing attention (target accuracy) for the detection of MHE.
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Affiliation(s)
- Piero Amodio
- Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy.
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20
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Dhiman RK, Saraswat VA, Sharma BK, Sarin SK, Chawla YK, Butterworth R, Duseja A, Aggarwal R, Amarapurkar D, Sharma P, Madan K, Shah S, Seth AK, Gupta RK, Koshy A, Rai RR, Dilawari JB, Mishra SP, Acharya SK. Minimal hepatic encephalopathy: consensus statement of a working party of the Indian National Association for Study of the Liver. J Gastroenterol Hepatol 2010; 25:1029-41. [PMID: 20594216 DOI: 10.1111/j.1440-1746.2010.06318.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Hepatic encephalopathy (HE) is a major complication that develops in some form and at some stage in a majority of patients with liver cirrhosis. Overt HE occurs in approximately 30-45% of cirrhotic patients. Minimal HE (MHE), the mildest form of HE, is characterized by subtle motor and cognitive deficits and impairs health-related quality of life. The Indian National Association for Study of the Liver (INASL) set up a Working Party on MHE in 2008 with a mandate to develop consensus guidelines on various aspects of MHE relevant to clinical practice. Questions related to the definition of MHE, its prevalence, diagnosis, clinical characteristics, pathogenesis, natural history and treatment were addressed by the members of the Working Party.
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Affiliation(s)
- Radha K Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
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Das A, Cherian A, Dash GK, Radhakrishnan A. Alpha coma evolving into spindle coma in a case of acute fulminant hepatic failure: What does it signify? Ann Indian Acad Neurol 2010; 13:69-71. [PMID: 20436753 PMCID: PMC2859594 DOI: 10.4103/0972-2327.61285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 10/02/2008] [Accepted: 11/23/2008] [Indexed: 11/04/2022] Open
Abstract
A 44-year-old male developed acute fulminant hepatic failure of unknown etiology and expired within four days. His serial electroencephalograms (EEGs) showed diffuse background slowing on day one, which evolved into "alpha coma" and later into "spindle coma" over the ensuing two days. Such EEG transition is hitherto undescribed in patients with hepatic encephalopathy and gives fresh insight into the etiopathogenesis of specific EEG patterns in diffuse encephalopathy.
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Affiliation(s)
- Abhijit Das
- Department of Neurology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, India
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22
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Arul-Anandam AP, Loo C. Transcranial direct current stimulation: a new tool for the treatment of depression? J Affect Disord 2009; 117:137-45. [PMID: 19201483 DOI: 10.1016/j.jad.2009.01.016] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 01/16/2009] [Accepted: 01/16/2009] [Indexed: 11/19/2022]
Abstract
Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that applies mild (typically 1-2 mA) direct currents via the scalp to enhance or diminish neuronal excitability. The technique has a dual function: on the one hand, it has been used to investigate the functions of various cortical regions; on the other, it has been used as an experimental treatment modality, most notably for Major Depressive Disorder (MDD). With the growing utility of tDCS in psychiatry, it is important from the vantage of safety and effectiveness to understand its underlying neurobiological mechanisms. In this respect, researchers have made significant progress in recent years, highlighting changes in resting membrane potential, spontaneous neuronal firing rates, synaptic strength, cerebral blood flow and metabolism subsequent to tDCS. We briefly review tDCS clinical trials for MDD, and then consider its mechanisms of action, identifying potential avenues for future research.
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Randolph C, Hilsabeck R, Kato A, Kharbanda P, Li YY, Mapelli D, Ravdin LD, Romero-Gomez M, Stracciari A, Weissenborn K. Neuropsychological assessment of hepatic encephalopathy: ISHEN practice guidelines. Liver Int 2009; 29:629-35. [PMID: 19302444 DOI: 10.1111/j.1478-3231.2009.02009.x] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Low-grade or minimal hepatic encephalopathy (MHE) is characterised by relatively mild neurocognitive impairments, and occurs in a substantial percentage of patients with liver disease. The presence of MHE is associated with a significant compromise of quality of life, is predictive of the onset of overt hepatic encephalopathy and is associated with a poorer prognosis for outcome. Early identification and treatment of MHE can improve quality of life and may prevent the onset of overt encephalopathy, but to date, there has been little agreement regarding the optimum method for detecting MHE. The International Society on Hepatic Encephalopathy and Nitrogen Metabolism convened a group of experts for the purpose of reviewing available data and making recommendations for a standardised approach for neuropsychological assessment of patients with liver disease who are at risk of MHE. Specific recommendations are presented, along with a proposed methodology for further refining these assessment procedures through prospective research.
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Reeves RR, Struve FA, Rash CJ, Burke RS. P300 cognitive evoked potentials before and after liver transplantation. Metab Brain Dis 2007; 22:139-44. [PMID: 17457666 DOI: 10.1007/s11011-007-9055-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Accepted: 11/01/2006] [Indexed: 01/23/2023]
Abstract
P300 cognitive evoked potentials have been shown to be effective for the assessment of mild hepatic encephalopathy but no investigations of their use with liver transplantation has been conducted. In this pilot study 12 subjects (7 male, 5 female, average age 43.9-years-old) underwent recording of auditory and visual P300 cognitive evoked potentials prior to liver transplantation and again 3-6 months subsequent to transplantation. Significant increases (p < 0.01) in P300 visual amplitude, as well as significant decreases in visual (p < 0.01) and auditory latencies (p < 0.01) were observed following transplantation. Auditory amplitudes increased but not to a statistically significant degree. P300 cognitive evoked potentials may provide a useful tool for monitoring the cerebral status of liver transplantation patients if combined with established methods such as cognitive testing and EEG. Further research of their usage with these patients is warranted.
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Affiliation(s)
- Roy R Reeves
- VA Medical Center, 1500 E. Woodrow Wilson Drive, Jackson, MS 39216, USA.
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Amodio P, Pellegrini A, Ubiali E, Mathy I, Piccolo FD, Orsato R, Gatta A, Guerit JM. The EEG assessment of low-grade hepatic encephalopathy: Comparison of an artificial neural network-expert system (ANNES) based evaluation with visual EEG readings and EEG spectral analysis. Clin Neurophysiol 2006; 117:2243-51. [PMID: 16931145 DOI: 10.1016/j.clinph.2006.06.714] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Revised: 06/21/2006] [Accepted: 06/28/2006] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The EEG provides an objective staging of hepatic encephalopathy (HE), but its interpretation may be biased by inter-observer variability. This study aims at comparing an entirely automatic EEG classification of HE based on an artificial neural network-expert system procedure (ANNES) with visual and spectral analysis based EEG classifications. METHODS Two hundred and thirty-eight consecutive cirrhotic patients underwent closed-eye EEG. They were followed up for up to one-year to detect bouts of overt HE and death. The EEG was classified by ANNES, qualitative visual reading, main basic rhythm frequency and spectral analysis. The classifications were assessed on the basis of: (i) match with liver function, (ii) prognostic value and (iii) repeatability. RESULTS All classifications were found to be related to the severity of liver failure, with cognitive findings and a history of previous bouts of HE. All of them had prognostic value on the occurrence of overt HE and on survival. The ANNES based classification was more repeatable than the qualitative visual one, and had the advantage of detecting low power EEG, but its efficiency in analyzing low-grade alterations was questionable. CONCLUSIONS An entirely automatic - ANNES based - EEG classification of HE can improve the repeatability of EEG assessment, but further improvement of the device is required to classify mild alterations. SIGNIFICANCE The ANNES based EEG grading of HE needs further improvements to be recommended in clinical practice, but it is already sufficient for detecting normal and clearly altered EEG tracings.
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Affiliation(s)
- P Amodio
- Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy.
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