Electro-Radiological Observations of Grade III/IV Hepatic Encephalopathy Patients with Seizures

Incidence of seizures in ICU patients with diffuse encephalopathy and its predictors

Encephalopathy is a diffuse brain dysfunction that results from systemic disorder. Patients with diffuse encephalopathy are at risk of developing clinical and electrographic seizures. The aim of this study is to assess the prevalence of electrographic seizures in a setting of encephalopathy and the clinical and electroencephalogram predictors. We retrospectively reviewed all continuous electroencephalograms done between 2019 and 2022. Continuous electroencephalograms with diffuse encephalopathy were included in the study. A total of 128 patients with diffuse encephalopathy were included in this study. Patients' ages ranged from 18 to 96 years old with a mean age of 55.3 ± 19.2 years old. Nine out of 128 patients had seizures with an incidence of 7%. Sixty-six point six percent were nonconvulsive electrographic seizures. Fourteen point three percent of the female patients with diffuse encephalopathy had seizures as compared to none of the male patients (P = .002). Also, 12% of patients with a history of epilepsy experienced seizures versus 5.8% of patients without this history (P = .049). Among electrographic features, 25% of patients with delta background had seizures versus 2.3% of the other patients (P = .048). Likewise, 90% of patients with periodic discharges developed seizures in comparison with none of the patients without (P = .001). Seizures are seen in 7% of patients with diffuse encephalopathy. Female gender, past history of epilepsy, delta background and periodic discharges are significant predictors of seizure development in patients with diffuse encephalopathy.

Toxic-metabolic encephalopathy in adults: Critical discussion and pragmatical diagnostic approach

Toxic-metabolic encephalopathy (TME) results from an acute cerebral dysfunction due to different metabolic disturbances including medications or illicit-drugs. It can lead to altered consciousness, going from delirium to coma, which may require intensive care and invasive mechanical ventilation. Even if it is a life-threatening condition, TME might have an excellent prognosis if its etiology is rapidly identified and treated adequately. This review summarizes the main etiologies, their differential diagnosis, and diagnostic strategy and management of TME with a critical discussion on the definition of TME.

Diagnosis and Management of Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a severe complication of cirrhosis. The prevalence of overt HE (OHE) ranges from 30% to 45%, whereas the prevalence of minimal HE (MHE) is as high as 85% in some case series. Widespread use of transjugular intrahepatic portosystemic shunt to control complications related to portal hypertension is associated with an increase in HE incidence. If the diagnosis of OHE remains simple in most cases, then the diagnosis of MHE is less codified because of many differential diagnoses with different therapeutic implications. This review analyzes current knowledge about the pathophysiology, diagnosis, and different therapeutic options of HE.

Propofol pump controls nonconvulsive status epilepticus in a hepatic encephalopathy patient: A case report

BACKGROUND

Status epilepticus is an emergent and critical condition which needs management without hesitation. Nonconvulsive status epilepticus (NCSE) tends to be less recognized, and its diagnosis is delayed in comparison with overt status epilepticus because of the absence of specific clinical signs. It is often difficult to make a diagnosis, particularly in patients with hepatic encephalopathy.

CASE SUMMARY

A 38-year-old man with a history of alcoholic liver cirrhosis presented with altered mental status; the initial diagnosis was hepatic encephalopathy. Although optimal treatment for hepatic encephalopathy was administered, the patient's mental status did not improve. A final diagnosis of NCSE was made by continuous electroencephalogram (EEG) monitoring. Treatment with levetiracetam and propofol pump was immediately started. The patient’s consciousness gradually improved after discontinuation of propofol therapy, and no further epileptic discharge was observed by EEG monitoring. After 1 wk, the patient returned to full consciousness, and he was able to walk in the hospital ward without assistance. He was discharged with minimal sequela of bilateral conjunctivitis.

CONCLUSION

In cases of persistent altered mental status without reasonable diagnosis, NCSE should be considered in hepatic encephalopathy patients with persistently altered levels of consciousness, and EEG monitoring is very important. We also recommend propofol as a safe and efficient therapy for NCSE in liver cirrhosis patients.

Neuroimaging Correlates of Periodic Discharges

Despite being first described over 50 years ago, periodic discharges continue to generate controversy as to whether they are always, sometimes, or never "ictal." Investigators and clinicians have proposed adjunctive markers to help clarify this distinction-in particular measures of perfusion and metabolism. Here, we review the growing number of neuroimaging studies using Fluorodeoxyglucose-PET, MRI diffusion, Magnetic resonance perfusion, Single Photon Emission Computed Tomography, and Magnetoencepgalography to gain further insight into the physiology and clinical significance of periodic discharges. To date, however, no definitive consensus exists regarding the features of periodic discharges that warrant treatment intensification. However, an emerging consilience among neuroimaging modalities suggests that periodic discharges can induce a hyperexcitatory state with associated hypermetabolism and hyperperfusion, which may result in local metabolic failure.