Cerebral pulsatility index by transcranial Doppler sonography predicts the prognosis of patients with fulminant hepatic failure
Introduction
Acute liver failure rapidly develops cerebral dysfunction including hepatic encephalopathy and cerebral edema. Cerebral edema is reported to occur in more than 80% of patients with hepatic fulminant failure, which is associated with a high mortality rate [1]. However, to evaluate intracranial pressure (ICP), the direct implanting of ICP monitoring devices is involved, which carries a risk of hemorrhage [2]. Recently, transcranial Doppler sonography (TCD) as one of the neuromonitoring systems has become available to help evaluate intracranial disease. TCD is a noninvasive and bedside procedure, which was validated for the measurement of cerebral blood flow [3], [4], [5], [6]. We have reported that patients with liver cirrhosis have a higher vascular resistance according to the severity of liver diseases and hepatic encephalopathy [7]. Furthermore, patients with fulminant hepatic failure have been reported to have a cerebral hypoperfusion pattern and an increased pulsatility index [8], [9]. TCD monitoring is less invasive and safer than direct ICP monitoring. In this paper, we have reported that TCD is useful to assess the severity and predict the prognosis of patients with fulminant hepatic failure.
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Patients
The present study included four consecutive patients with fulminant hepatic failure, one patient with acute hepatitis and one patient with acute exacerbation of chronic hepatitis, who were admitted to our hospital. Severe acute hepatitis and severe acute exacerbation of chronic hepatitis were defined as having a prothrombin time <40% and no distinct hepatic encephalopathy. None of the patients in this study were hypoglycemic or treated with sedatives before the appearance of hepatic
Results
The clinical courses of the six patients (Cases 1–4: fulminant hepatic failure; Cases 5 and 6: severe acute hepatitis) are shown in Fig. 2, Fig. 3, Fig. 4. Among the four patients with fulminant hepatic failure, two patients (Cases 1 and 2) died (Fig. 2) and two were successfully treated (Fig. 3). Among the recovered patients, one patient (Case 3) underwent transplant on the third day after admission. The standard value (mean±2 S.D.) of the pulsatility index from 25 healthy controls was
Discussion
Cerebral autoregulation is due to the reactive dilatation or constriction of cerebral resistance vessels as a response to alterations in cerebral perfusion pressure. Within a wide range of arterial blood pressure values, cerebral blood flow is kept constant. But in fulminant hepatic failure, cerebral autoregulation is upset by neurotoxins, resulting in cerebral edema and intracranial hypertension. Straus et al. [9] and Larsen et al. [10] showed that cerebral autoregulation was absent in
References (13)
Brain dysfunction in fulminant hepatic failure
J Hepatol
(1994)- et al.
Complications of intracranial pressure monitoring in fulminant hepatic failure
Lancet
(1993) - et al.
Evaluation of cerebral arterial flow with transcranial Doppler ultrasound: theoretical development and phantom studied
Ultrasound Med Biol.
(1997) - et al.
Transcranial Doppler sonography in fulminant hepatic failure
Transpl Proc
(2003) - et al.
Function loss of cerebral autoregulation in patients with fulminant hepatic failure
J Hepatol
(1995) - et al.
Transcranial Doppler measurement of middle cerebral artery blood flow velocity
A validation study. Stroke
(1986)
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Neurological Monitoring in Acute Liver Failure
2018, Journal of Clinical and Experimental HepatologyCitation Excerpt :The pulsatility Index (PI) [(systolic velocity − diastolic velocity)/mean velocity] demonstrates good correlation with ICP, with a correlation coefficient of 0.938 (P < 0.0001) in a study of 81 patients who had intraventricular catheters for a range of neurosurgical conditions.53 In 4 ALF patients a PI > 1.0 was predictive of a poor outcome.54 Given the complex interplay of physiological parameters influencing cerebral regulation in ALF, attempts have been made at more sophisticated interpretations of ICP.
Cerebral Hemodynamics Patterns by Transcranial Doppler in Patients with Acute Liver Failure
2015, Transplantation ProceedingsCitation Excerpt :Perhaps the difference between MV and PI in patients who died while waiting for a transplant and those who could receive it was in the degree of intracranial hypertension (greater in the deceased). This result could indicate a prognostic significance and be of help as a criterion of priority as shown by other authors in cases reports [9,10]. In patients diagnosed with ALF admitted to the ICU there predominates a cerebral hemodynamic pattern of low-flow and resistance increase.
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