Hepatic encephalopathy: a neurologist's perspective

Liver disease is increasingly common, estimated to affect over 25% of the world's population. Failure of the liver to maintain a normal metabolic milieu leads to impaired brain function (hepatic encephalopathy), and conditions that cause liver disease can themselves predispose to neurological disease. As neurologists' involvement with the acute take increases, it is important that we are familiar with the neurological complications of liver disease, their investigation and management, and to know which other neurological diseases occur in this patient population. In this article, we review the causes, presentation and treatment of hepatic encephalopathy, and discuss important differential diagnoses in patients with liver disease who present with neurological disturbance.

Electroencephalography in encephalopathy and encephalitis

Electroencephalography (EEG) is a useful adjunct to clinical neurological examination, particularly as it may detect subtle or subclinical disturbance of cerebral function and it allows monitoring of cerebral activity over time. Continuous EEG combined with quantitative analysis and machine learning may help identify changes in real time, before the emergence of clinical signs and response to interventions. EEG is rarely pathognomonic in encephalopathy/encephalitis but when interpreted correctly and within the clinical context, certain phenotypes may indicate a specific pathophysiology (eg, lateralised periodic discharges in HSV-1, generalised periodic discharges in sporadic Creutzfeldt-Jakob disease, and extreme delta brushes in anti-n-methyl-D-aspartate receptor autoimmune encephalitis). EEG is included in some specialist guidelines for disease assessment, monitoring and prognostication (ie, hepatic, cancer immunotherapy, viral, prion, autoimmune encephalitis and hypoxic ischaemic encephalopathy). EEG is invaluable for confirming or excluding non-convulsive seizures or status epilepticus, particularly in critically ill patients, and in understanding new concepts such as epileptic encephalopathy and the ictal-interictal continuum.

Detecting signatures of consciousness in acute brain injury after stimulation with apomorphine and methylphenidate: protocol for a placebo-controlled, randomized, cross-over study

Introduction

Acute brain injury can lead to states of decreased consciousness, that is, disorder of consciousness (DoC). Detecting signs of consciousness early is vital for DoC management in the intensive care unit (ICU), neurorehabilitation and long-term prognosis. Our primary objective is to investigate the potential of pharmacological stimulant therapies in eliciting signs of consciousness among unresponsive or low-responsive acute DoC patients.

Methods

In a placebo-controlled, randomised, cross-over setting, we evaluate the effect of methylphenidate and apomorphine in 50 DoC patients with acute traumatic or non-traumatic brain injury admitted to the ICU. Patients are examined before and after administration of the trial drugs using (1) neurobehavioural scales to determine the clinical level of consciousness, (2) automated pupillometry to record pupillary responses as a signature for awareness and (3) near-infrared spectroscopy combined with electroencephalography to record neurovascular coupling as a measure for cortical activity. Primary outcomes include pupillary dilations and increase in cortical activity during passive and active paradigms.

Ethics

The study has been approved by the ethics committee (Journal-nr: H-21022096) and follows the principles of the Declaration of Helsinki. It is deemed to pose minimal risks and to hold a significant potential to improve treatment options for DoC patients. If the stimulants are shown to enhance cortical modulation of pupillary function and neurovascular coupling, this would warrant a large multicentre trial to evaluate their clinical impact.

Dissemination

Results will be available on EudraCT, clinicaltrialsregister.eu and published in an international peer-reviewed journal.

Trial registration number

EudraCT Number: 2021-001453-31.

Electroencephalography Attenuations in Adults: Clinical Correlates

Spontaneous intermittent generalized attenuations (SIGAs) are defined as a transient decrease in amplitude of electroencephalography (EEG) activity in response to a physiologic process, external stimuli, or as a result of a pathologic condition. We seek to investigate their relationship to clinical outcomes. Demographic information, modified Rankin Scale (mRS), and clinical information were noted on 22 consecutive patients with SIGAs on their EEG. 12 of the 22 patients (54.5%) died, and 12 patients (54.5%) were admitted to the intensive care unit or coronary care unit. Future studies should attempt to prospectively compare outcomes among patients with SIGAs against a control group.

Heterozygous truncating variants in SUFU cause congenital ocular motor apraxia

Purpose

This study aimed to delineate the genetic basis of congenital ocular motor apraxia (COMA) in patients not otherwise classifiable.

Methods

We compiled clinical and neuroimaging data of individuals from six unrelated families with distinct clinical features of COMA who do not share common diagnostic characteristics of Joubert syndrome or other known genetic conditions associated with COMA. We used exome sequencing to identify pathogenic variants and functional studies in patient-derived fibroblasts.

Results

In 15 individuals, we detected familial as well as de novo heterozygous truncating causative variants in the Suppressor of Fused (SUFU) gene, a negative regulator of the Hedgehog (HH) signaling pathway. Functional studies showed no differences in cilia occurrence, morphology, or localization of ciliary proteins, such as smoothened. However, analysis of expression of HH signaling target genes detected a significant increase in the general signaling activity in COMA patient–derived fibroblasts compared with control cells. We observed higher basal HH signaling activity resulting in increased basal expression levels of GLI1, GLI2, GLI3, and Patched1. Neuroimaging revealed subtle cerebellar changes, but no full-blown molar tooth sign.

Conclusion

Taken together, our data imply that the clinical phenotype associated with heterozygous truncating germline variants in SUFU is a forme fruste of Joubert syndrome.

Charcot in the ICU: functional tetraplegia after surgery

Functional neurological disorder is a condition in which a patient has physical findings that are not compatible with anatomical boundaries, have no structural substrate and are not representable of an established disease. General anaesthesia and surgery have been previously reported as precipitating factors for functional disorders and mostly involve dissociative (non-epileptic) seizures. We report a patient with no psychiatric history or prior abnormal examination who developed sudden onset functional tetraplegia and sensory disturbances immediately after elective surgery, and who was subsequently discharged home several days later after nearly complete resolution of neurologic deficits. We highlight the features of this syndrome, including its unique postoperative presentation, unusual resolution and absence of any identifiable psycho-dynamic mechanism. We also introduce the tripod sign as a useful clinical tool in identifying functional tetraplegia.

Predicting the outcome of a comatose patient at the bedside

The call to the bedside and the prognostication of a comatose patient-telling family members what to expect-commonly falls to neurologists. The assessment is often confounded by the treatment paradigms of modern intensive care (ie, drugs, drug interactions and targeted temperature management). Patients may be too unstable to leave the intensive care unit for neuroimaging; thus, repeated clinical examinations are decisive. Despite diverse causes, certain principles do apply: (1) Many patients can improve, although with significant abnormalities; (2) Neuroimaging and electrodiagnostic tests can help but are rarely definitive; (3) Secondary involvement of the upper brainstem marks a tipping point with much lower probability for an independent outcome; (4) We rarely predict mortality or diagnose brain death; usually the major concern is anticipated neurological deficits; and (5) Prior comorbidity and permanent organ dysfunction are critical factors in making decisions about de-escalation or escalation of care. This review provides a practical approach to evaluating outcome of a comatose patient. Prognostication is difficult, and we should only attempt it when the diagnosis is confirmed and appropriate (often aggressive) medical or surgical treatment has been tried.

Aurora B-INCENP Localization at Centromeres/Inner Kinetochores Is Required for Chromosome Bi-orientation in Budding Yeast

For proper chromosome segregation in mitosis, sister kinetochores must interact with microtubules from opposite spindle poles (chromosome bi-orientation) [1, 2]. To promote bi-orientation, Aurora B kinase disrupts aberrant kinetochore-microtubule interactions [3, 4, 5, 6]. It has long been debated how Aurora B halts this action when bi-orientation is established and tension is applied across sister kinetochores. A popular explanation for it is that, upon bi-orientation, sister kinetochores are pulled in opposite directions, stretching the outer kinetochores [7, 8] and moving Aurora B substrates away from Aurora-B-localizing sites at centromeres (spatial separation model) [3, 5, 9]. This model predicts that Aurora B localization at centromeres is required for bi-orientation. However, this notion was challenged by the observation that Bir1 (yeast survivin), which recruits Ipl1-Sli15 (yeast Aurora B-INCENP) to centromeres, can become dispensable for bi-orientation [10]. This raised the possibility that Aurora B localization at centromeres is dispensable for bi-orientation. Alternatively, there might be a Bir1-independent mechanism for recruiting Ipl1-Sli15 to centromeres or inner kinetochores [5, 9]. Here, we show that the COMA inner kinetochore sub-complex physically interacts with Sli15, recruits Ipl1-Sli15 to the inner kinetochore, and promotes chromosome bi-orientation, independently of Bir1, in budding yeast. Moreover, using an engineered recruitment of Ipl1-Sli15 to the inner kinetochore when both Bir1 and COMA are defective, we show that localization of Ipl1-Sli15 at centromeres or inner kinetochores is required for bi-orientation. Our results give important insight into how Aurora B disrupts kinetochore-microtubule interaction in a tension-dependent manner to promote chromosome bi-orientation.

•

The COMA inner kinetochore sub-complex facilitates chromosome bi-orientation

•

COMA physically interacts with Sli15 and recruits Ipl1-Sli15 to the inner kinetochore

•

This function of COMA is independent of Bir1 and its role supporting robust cohesion

•

Localizing Ipl1-Sli15 at centromeres/inner kinetochores is crucial for bi-orientation

Fork pausing allows centromere DNA loop formation and kinetochore assembly

De novo kinetochore assembly, but not template-directed assembly, is dependent on COMA, the kinetochore complex engaged in cohesin recruitment. The slowing of replication fork progression by treatment with phleomycin (PHL), hydroxyurea, or deletion of the replication fork protection protein Csm3 can activate de novo kinetochore assembly in COMA mutants. Centromere DNA looping at the site of de novo kinetochore assembly can be detected shortly after exposure to PHL. Using simulations to explore the thermodynamics of DNA loops, we propose that loop formation is disfavored during bidirectional replication fork migration. One function of replication fork stalling upon encounters with DNA damage or other blockades may be to allow time for thermal fluctuations of the DNA chain to explore numerous configurations. Biasing thermodynamics provides a mechanism to facilitate macromolecular assembly, DNA repair, and other nucleic acid transactions at the replication fork. These loop configurations are essential for sister centromere separation and kinetochore assembly in the absence of the COMA complex.

Molecular basis for inner kinetochore configuration through RWD domain-peptide interactions

Kinetochores are dynamic cellular structures that connect chromosomes to microtubules. They form from multi‐protein assemblies that are evolutionarily conserved between yeasts and humans. One of these assemblies—COMA—consists of subunits Ame1^CENP‐U, Ctf19^CENP‐P, Mcm21^CENP‐O and Okp1^CENP‐Q. A description of COMA molecular organization has so far been missing. We defined the subunit topology of COMA, bound with inner kinetochore proteins Nkp1 and Nkp2, from the yeast Kluyveromyces lactis, with nanoflow electrospray ionization mass spectrometry, and mapped intermolecular contacts with hydrogen‐deuterium exchange coupled to mass spectrometry. Our data suggest that the essential Okp1 subunit is a multi‐segmented nexus with distinct binding sites for Ame1, Nkp1‐Nkp2 and Ctf19‐Mcm21. Our crystal structure of the Ctf19‐Mcm21 RWD domains bound with Okp1 shows the molecular contacts of this important inner kinetochore joint. The Ctf19‐Mcm21 binding motif in Okp1 configures a branch of mitotic inner kinetochores, by tethering Ctf19‐Mcm21 and Chl4^CENP‐N‐Iml3^CENP‐L. Absence of this motif results in dependence on the mitotic checkpoint for viability.

Preserved consciousness in vegetative and minimal conscious states: systematic review and meta-analysis

Active, passive and resting state paradigms using functional MRI (fMRI) or EEG may reveal consciousness in the vegetative (VS) and the minimal conscious state (MCS). A meta-analysis was performed to assess the prevalence of preserved consciousness in VS and MCS as revealed by fMRI and EEG, including command following (active paradigms), cortical functional connectivity elicited by external stimuli (passive paradigms) and default mode networks (resting state). Studies were selected from multiple indexing databases until February 2015 and evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2. 37 studies were identified, including 1041 patients (mean age 43 years, range 16-89; male/female 2.1:1; 39.5% traumatic brain injuries). MCS patients were more likely than VS patients to follow commands during active paradigms (32% vs 14%; OR 2.85 (95% CI 1.90 to 4.27; p<0.0001)) and to show preserved functional cortical connectivity during passive paradigms (55% vs 26%; OR 3.53 (95% CI 2.49 to 4.99; p<0.0001)). Passive paradigms suggested preserved consciousness more often than active paradigms (38% vs 24%; OR 1.98 (95% CI 1.54 to 2.54; p<0.0001)). Data on resting state paradigms were insufficient for statistical evaluation. In conclusion, active paradigms may underestimate the degree of consciousness as compared to passive paradigms. While MCS patients show signs of preserved consciousness more frequently in both paradigms, roughly 15% of patients with a clinical diagnosis of VS are able to follow commands by modifying their brain activity. However, there remain important limitations at the single-subject level; for example, patients from both categories may show command following despite negative passive paradigms.

UNUSUAL MANIFESTATIONS OF MYXEDEMA

Eight cases of myxedema with interesting features are presented. Hypertension is common in myxedema and usually persists when the myxedema is treated. Two patients are reported in whom the hypertension improved with the treatment of the myxedema. Other cases presented with ascites, psychosis, recurrent coma with marked hyponatremia and hypochloremia, ataxia, muscular hypertrophy and myotonia. In each patient the abnormalities were corrected by administration of thyroid hormone. In most instances the mechanism whereby symptoms are produced is poorly understood.