Hepatic encephalopathy with reversible focal neurologic signs resembling acute stroke: case report. J Stroke Cerebrovasc Dis. 2011;20:377-380. [PMID: 20634097 DOI: 10.1016/j.jstrokecerebrovasdis.2010.01.011]

Aphasia Associated With Acute on Chronic Kidney Failure in an Adolescent

Acute and chronic kidney disease (CKD) have known neurological associations resulting from uremia, electrolyte disturbances, comorbidities such as hypertension, or other toxin accumulation. Reversible focal neurological deficits are relatively uncommon and poorly understood sequelae of kidney disease. Herein, we describe an unusual case of an adolescent male who developed acute aphasia during his initial presentation for acute kidney injury (AKI) superimposed on progressive CKD stage 5 associated with uremia and multiple electrolyte derangements. Symptoms resolved within one day of initiating continuous renal replacement therapy (CRRT) and gradual electrolyte and uremia correction. Such transient focal neurological deficits in AKI superimposed on progressive CKD in the pediatric population has not been widely reported.

Hepatic Encephalopathy Mimicking Acute Dominant Middle Cerebral Artery Ischemic Stroke: A Case Report

Hepatic encephalopathy and hyperammonemia are common in the setting of liver disease and have been associated with both generalized and focal neurological deficits. We report a case of hepatic encephalopathy with transaminitis in the setting of hyperammonemia clinically mimicking acute dominant middle cerebral artery (MCA) syndrome. A 59-year-old right-handed woman had new-onset expressive aphasia, left gaze deviation, and right hemiparesis consistent with MCA stroke. Her symptoms began 12 h after transarterial chemoembolization, a procedure to embolize blood supply and provide cytotoxic agents to a hepatocellular carcinoma tumor. Thrombocytopenia and age-indeterminate hypodensities on brain CT precluded intravenous thrombolytic administration. MRI revealed predominantly dominant hemisphere subcortical restricted diffusion with no cortical involvement. Due to a mismatch between the MRI findings and the neurological symptoms, she underwent digital subtraction cerebral angiography to assess candidacy for intra-arterial thrombectomy, which revealed completely patent MCAs with intact filling of the distal branches. Liver enzymes and ammonia were elevated. The patient was treated with lactulose and intravenous fluids. After normalization of liver enzymes, the patient's neurological deficits resolved. Reversal of this patient's focal symptoms with medical management could potentially be explained by the recovery of blood flow-metabolic demand mismatch caused by worsening liver dysfunction and hyperammonemia. As acute stroke therapies and interventions increase in utility for large artery acute ischemic stroke, it is vital to recognize hepatic encephalopathy and liver failure as part of the differential diagnosis for patients presenting with MCA syndrome.

Understanding the impact of neurologic complications in patients with cirrhosis

Patients with cirrhosis may experience neurologic complications, including hepatic encephalopathy. Hepatic encephalopathy may be classified as covert (mild symptoms (e.g. lack of awareness)) or overt (moderate to severe symptoms (e.g. confusion or coma)), and symptoms may overlap with other neurologic conditions (e.g. epilepsy, stroke). Managing hepatic encephalopathy includes identifying and treating precipitating factors (e.g. dehydration). First-line treatment for patients with overt hepatic encephalopathy is typically lactulose; to reduce the risk of overt hepatic encephalopathy recurrence, lactulose plus the nonsystemic antibiotic rifaximin is recommended. Rifaximin reduced the risk of breakthrough overt hepatic encephalopathy by 58% versus placebo over 6 months (p < 0.001; 91% of patients in each group were on concomitant lactulose). However, neither pharmacologic hepatic encephalopathy treatment nor liver transplantation may completely reverse neurologic impairment in patients with hepatic encephalopathy. Additional neurologic considerations for patients with cirrhosis include preventing falls, as well as managing sleep-related issues, hyponatremia, and cerebral edema. Thus, monitoring neurologic impairment is an important component in the management of patients with cirrhosis.

Management of Neurologic Manifestations in Patients with Liver Disease

OPINION STATEMENT

Liver disease, both in its acute and chronic forms, can be associated with a wide spectrum of neurologic manifestations, both central and peripheral, ranging in severity from subclinical changes to neurocritical conditions. Neurologists are frequently consulted to participate in their management. In this review, we present an overview of management strategies for patients with hepatic disease whose clinical course is complicated by neurologic manifestations. Type A hepatic encephalopathy (HE), which occurs in acute liver failure, is a neurologic emergency, and multiple measures should be taken to prevent and treat cerebral edema. In Type C HE, which occurs in chronic liver disease, management should be aimed at correcting precipitant factors and hyperammonemia. There is an increasing spectrum of drug treatments available to minimize ammonia toxicity. Acquired hepatocerebral degeneration is a rare complication of the chronic form of HE, with typical clinical and brain MRI findings, whose most effective treatment is liver transplantation. Epilepsy is frequent and of multifactorial cause in patients with hepatic disease, and careful considerations should be made regarding choice of the appropriate anti-epileptic drugs. Several mechanisms increase the risk of stroke in hepatic disease, but many of the drugs used to treat and prevent stroke are contraindicated in severe hepatic failure. Hepatitis C infection increases the risk of ischemic stroke. Hemorrhagic stroke is more frequent in patients with liver disease of alcoholic etiology. Viral hepatitis is associated with a wide range of immune-mediated complications, mostly in the peripheral nervous system, which respond to different types of immunomodulatory treatment. Several drugs used to treat hepatic disease, such as the classical and the new direct-acting antivirals, may have neurologic complications which in some cases preclude its continued use.

Hepatic Encephalopathy With Corticospinal Tract Involvement Demonstrated by Diffusion Tensor Tractography

A 50-year-old man with liver cirrhosis and esophageal varix for 3 years was diagnosed with hematemesis and treated for a bleeding varix. However, bleeding recurred 11 days later, and he developed drowsiness with left hemiparesis. His left upper and lower extremity muscle strengths based on the manual muscle test at the onset were grade 2/5 and 1/5, respectively. The Babinski sign was positive. His serum ammonia level was elevated to 129.9 µg/dL (normal, 20-80 µg/dL). Magnetic resonance imaging revealed restriction on diffusion and T2-hyperintensities with decreased apparent diffusion coefficient values in the bilateral frontoparietooccipital cortex. The effect was more severe in the right hemisphere and right parietooccipital cortices, which were compatible with hepatic encephalopathy. Although the patient's mental status recovered, significant left-sided weakness and sensory deficit persisted even after 6 months. Diffusion tensor tractography (DTT) performed 3 months post-onset showed decreased volume of the right corticospinal tract. We reported a patient with hepatic encephalopathy involving the corticospinal tract by DTT.

Hepatic cirrhosis and hepatic encephalopathy with acute cerebral infarction: A case report and review of the literature

Neurological complications often occur in patient with hepatic cirrhosis and advanced liver failure. However, hepatic cirrhosis combined with cerebral infarction is a rare clinical condition. Thus, patients' mental changes, especially those associated with hepatic encephalopathy, bring great difficulties to the diagnosis and treatment. Here we report a case of hepatic cirrhosis and hepatic encephalopathy with acute cerebral infarction. We also performed a literature review to raise the awareness of this condition.

Ornithine aspartate combined with naloxone improves cognitive function, prognosis, and neuropeptide levels in patients with hepatic encephalopathy

AIM: To investigate the effect of combination therapy with ornithine aspartate plus naloxone on cognitive function, prognosis, and neuropeptide levels in patients with hepatic encephalopathy.

METHODS: One hundred and two patients diagnosed with hepatic encephalopathy were randomly divided into two equal groups: a control group (n = 51) and a study group (n = 51). The control group received traditional medical treatment, and the research group was additionally given combination therapy with ornithine aspartate plus naloxone on the basis of traditional medical treatment. The cognitive function of the patients was assessed. The response rate and time duration from coma to consciousness were recorded. Changes in blood ammonia level, markers of liver function, and neuropeptide levels were measured by standard biochemical assays.

RESULTS: The response rate was significantly higher in the study group than in the control group (86.27% vs 68.63%, P < 0.05). After treatment, the level of blood ammonia in both groups was decreased (P < 0.05). The level of blood ammonia in the study group was significantly lower than that in the control group (52.01 μmol/L ± 7.49 μmol/L vs 75.44 μmol/L ± 5.86 μmol/L, P < 0.01). The liver function markers in the two groups were also significantly improved after treatment (P < 0.05). The levels of alanine aminotransferase, gamma glutamine transferase and total bilirubin in the study group were significantly lower than those in the control group (38.5 U/L ± 5.8 U/L vs 55.3 U/L ± 4.4 U/L, 149.3 U/L ± 19.2 U/L vs 174.2 U/L ± 23.6 U/L, 65.6 μmol/L ± 10.8 μmol/L vs 81.3 μmol/L ± 12.9 μmol/L, P < 0.01). After treatment, the time duration from coma to consciousness in the study group was significantly lower than in the control group (7.53 h ± 2.68 h vs 21.02 h ± 9.83 h, P < 0.05). The MMSE and HDS-R scores in the study group were significantly higher than those in the control group (22.09 ± 2.41 vs 17.76 ± 2.02, 24.11 ± 4.12 vs 16.18 ± 3.19, P < 0.05). After treatment, the levels of arginine vasopressin and beta-endorphin in both groups were decreased (P < 0.05). The levels of arginine vasopressin and beta-endorphin in the study group were significantly lower than those in the control group (11.28 pg/mL ± 2.08 pg/mL vs 15.35 pg/mL ± 1.65 pg/mL, 42.02 pg/mL ± 7.66 pg/mL vs 53.66 pg/mL ± 6.81 pg/mL, P < 0.01).

CONCLUSION: Ornithine aspartate combined with naloxone can improve cognitive function in patients with hepatic encephalopathy, and the treatment effect is superior compared to conventional treatment.