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Changes in Brain Size in Hepatic Encephalopathy: A Coregistered MRI Study

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Abstract

Magnetic resonance imaging (MRI) coregistration techniques can be used to track changes in brain volume. We aimed to determine whether treatment in chronic liver disease altered brain size. The study group comprised nine patients with cirrhosis (7 Child's grade B and 2 Child's grade C). Six had minimal and three had overt hepatic encephalopathy on clinical, psychometric, and electrophysiological testing. Cerebral MRI was performed in seven patients before and 6 weeks after starting lactulose. A further two patients underwent transjugular intrahepatic portosystemic stent shunting with MRI performed before and 24 h afterwards. One patient had a further scan 3 months after TIPSS. Brain size was measured using a semiautomated contour/thresholding technique. Measurable changes were found after treatment intervention, but there was no correlation with severity of encephalopathy (West Haven criteria) or liver dysfunction (Child's score). Three patients improved on lactulose, the brain size decreased with an increase in ventricular volume. Two patients deteriorated; the brain size increased with a concomitant decrease in ventricular volume. Two stable patients had small changes, one with an increase in brain size and a decrease in ventricular volume and the other showing the converse. Following TIPSS, there was an increase in brain size in both patients, evident within 24 h in one patient and at 3 months in the other. Coregistered MRI demonstrates easily detectable changes in brain size following treatment intervention. Our results support the hypothesis that low-grade brain swelling is present, even in minimal hepatic encephalopathy.

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REFERENCES

  • Barbiroli, B., Gaiani, S., Lodi, R., Iotti, S., Tonon, C., Clementi, V., Donati, G., and Bolondi, L. (2002). Abnormal brain energy metabolism shown by in vivo phosphorus magnetic resonance spectroscopy in patients with chronic liver disease. Brain Res. Bull. 15:75–82.

    Google Scholar 

  • Butterworth, R.F., Gigu´ ere, J.F., Michaud, J., Lavoie, J., and Layrargues, G.P. (1987). Ammonia: Key factor in the pathogenesis of hepatic encephalopathy. Neurochem. Pathol. 6:1–12.

    Google Scholar 

  • Chamuleau, R.A., Bosman, D.K., Bov´ ee, W.M.M.J., Luyten, P.R., and den Hollander, J.A. (1991). What the clinician can learn from MR glutamine/glutamate assays. NMR Biomed. 4:103–108.

    Google Scholar 

  • Charness, E. (1993). Brain lesions in alcoholics. Alcohol. Clin. Exp. Res. 17:2–11.

    PubMed  Google Scholar 

  • Conn, H.O. (1997). Trail making and number-connection tests in the assessment of mental state in portal systemic encephalopathy. Am.J.Dig.Dis. 22:541–550.

    Google Scholar 

  • Conn, H.O., Leevy, C.M., Vlahcevic, Z.R., Rodgers, J.B., Maddrey, W.C., Seeff, L., and Leevy, L.L. (1997). Comparison of lactulose and neomycin in the treatment of chronic portal–systemic encephalopathy: A double blind trial. Gastroenterology 72:573–583.

    Google Scholar 

  • Cordoba, J., Alonso, J., Rovira, A., Jacas, C., Sanpedro, F., Castells, L., Vargas, V., Margarit, C., Kulisewsky, J., Estaban, R., and Guardia, J. (2001). The development of low-grade cerebral edema in cirrhosis is supported by the evolution of 1 H-magnetic resonance abnormalities after liver transplantation. J. Hepatol. 35:598–604.

    PubMed  Google Scholar 

  • Cordoba, J., Sanpedro, F., Alonso, J., and Rovira, A. (2002). 1 H magnetic resonance in the study of hepatic encephalopathy in humans. Metab. Brain. Dis. 17:415–429.

    PubMed  Google Scholar 

  • Forton, D.M., Thomas, H.C., Murphy, C.A., Allsop, J.M., Foster, G.R., Main, J., Wesnes, K.A., and Taylor-Robinson, S.D. (2002). Hepatitis C and cognitive impairment in a cohort of patients with mild liver disease. Hepatology 35:433–439.

    PubMed  Google Scholar 

  • Hajnal, J.V., Saeed, N., Soar, E., Oatridge, A., Young, I.R., and Bydder, G.M. (1995). A registration and in-terpolation procedure for subvoxel matching of serially acquired MR images. J. Comput. Assist. Tomogr. 19:677–691.

    PubMed  Google Scholar 

  • Harper, C., and Kril, J. (1985). Brain atrophy in chronic alcoholic patients: A quantitative pathological study. J.Neurol. Neurosurg. Psychiatry 48:211–217.

    PubMed  Google Scholar 

  • Harper, C., and Kril, J. (1991). If you drink your brain will shrink. Neuropathological considerations. Alcohol Alcohol. Suppl. 1:375–380.

    PubMed  Google Scholar 

  • Harris, D.N., Bailey, S.M., Smith, P.L., Taylor, K.M., Oatridge, A., and Bydder, G.M. (1993). Brain swelling in the first hour after coronary artery bypass surgery. Lancet 342:586–587.

    Article  PubMed  Google Scholar 

  • Häussinger, D. (1996). Role of cellular hydration in the regulation of cell function. Biochem. J. 313:697–710.

    PubMed  Google Scholar 

  • Häussinger, D., Kircheis, G., Fischer, R., Shliess, F., and vom Dahl, S. (2000). Hepatic encephalopathy in chronic liver disease: A clinical manifestation of astrocytic swelling and low-grade cerebral edema. J. Hepatol. 32:1035–1038.

    PubMed  Google Scholar 

  • Häussinger, D., Laubenberger, J., vom Dahl, S., Ernst, T., Bayer, S., Langer, M., Gerok, W., and Hennig, J. (1994). Proton magnetic resonance spectroscopy studies on human brain myoinositol osmolarity and hepatic encephalopathy. Gastroenterology 107:1475–1480

    PubMed  Google Scholar 

  • Jalan, R., Newby, D.E., Olde Damink, S.W., Redhead, D.N., Hayes, P.C., and Lee, A. (2001). Acute changes in cerebral blood flow and metabolism during portosystemic shunting. Liver Transpl. 7:274–278.

    PubMed  Google Scholar 

  • Jalan, R., Seery, J.P., and Taylor-Robinson, S.D. (1996). Pathogenesis and treatment of chronic hepatic en-cephalopathy. Aliment. Pharmacol. Ther. 1(10):681–697.

    Google Scholar 

  • Kendrick, D.C., Gibson, A.J., and Moyes, I.G.A. (1979). The revised Kendrick battery: Clinical studies. Br. J. Soc. Clin. Psychol. 18:329–339.

    PubMed  Google Scholar 

  • Kreis, R., Farrow, N., and Ross, B.D. (1991). Localised 1 H NMR spectroscopy in patients with chronic hepatic encephalopathy. Analysis of changes in cerebral glutamine, choline and inositols. NMR Biomed. 4:109–116.

    PubMed  Google Scholar 

  • Larsen, F.S., and Wendon, J. (2002). Brain edema in liver failure: Basic physiologic principles and management. Liver Transpl. 8:983–989.

    PubMed  Google Scholar 

  • Laubenberger, J., H¨ aussinger, D., Bayer, S., Gufler, H., Hennig, J., and Langer, M. (1997). Proton magnetic resonance spectroscopy of the brain in symptomatic and asymptomatic patients with liver cirrhosis. Gas-troenterology 112:1758–1761.

    Google Scholar 

  • Lee, K., Moller, L., Hardt, F., Haubek, A., and Jensen, E. (1979). Alcohol-induced brain damage and liver damage in young males. Lancet 2:759–761.

    PubMed  Google Scholar 

  • Morgan, M.Y., Alonso, M., and Stanger, L.C. (1989). Lactitol and lactulose for the treatment of subclinical hepatic encephalopathy in cirrhotic patients. J. Hepatol. 8:208–217.

    PubMed  Google Scholar 

  • Munoz, S.J., and Maddrey, W.C. (1988). Major complications of acute and chronic liver disease. Gastroenterol. Clin. North. Am. 17:265–287.

    PubMed  Google Scholar 

  • Nolte, W., Wiltfang, J., Schindler, C., Munke, H., Unterberg, K., Zumhasch, U., Figulla, H.R., Werner, G., Hartmann, H., and Ramadori, G. (1998). Portosystemic hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with cirrhosis: Clinical, laboratory, psychometric and electroencephalographic investigations. Hepatology 28:1215–1225.

    PubMed  Google Scholar 

  • Oatridge, A. (1999). The Use of Subvoxel Image Registration and Subtraction of Serial Magnetic Resonance Imaging for Detecting Small Changes to the Brain, Leeds Metropolitan University, Leeds.

    Google Scholar 

  • Oatridge, A., Barnard, M.L., Puri, B.K., Taylor-Robinson, S.D., Hajnal, J.V., Saeed, N., and Bydder, G.M. (2002a). Changes in brain size with treatment in patients with hyper-or hypothyroidism. Am. J. Neuroradiol. 23:1539–1544.

    PubMed  Google Scholar 

  • Oatridge, A., Holdcroft, A., Saeed, N., Hajnal, J.V., Puri, B.K., Fusi, L., and Bydder, G.M. (2002b). Changes in brain size during and after pregnancy: Study in healthy women and women with preeclampsia. Am. J. Neuroradiol. 23:19–26.

    PubMed  Google Scholar 

  • Patel, N., Forton, D.M., Coutts, G.A., Thomas, H.C., and Taylor-Robinson, S.D. (2000). Intracellular pH measure-ments of the whole head and the basal ganglia in chronic liver disease: A phosphorus-31 MR spectroscopy study. Metab. Brain Dis. 15:223–240.

    PubMed  Google Scholar 

  • Pugh, R.N.H., Murray-Lyon, I.M., Dawson, J.L., Pietroni, M.C., and Williams, R. (1972). Transection of the oesophagus for bleeding oesophageal varices. Br.J.Surg. 60:646–649.

    Google Scholar 

  • Quero, J.C., Huizenga, J.R., Chamuleau, R.A.F.M., Blijenberg, B.G., Gips, C.H., and Schalm, S.W. (1993). Determination of ammonia in capillary and arterial blood simultaneously using the BAC II. Hepato-Gastroenterology 40:81.

    PubMed  Google Scholar 

  • Ross, B.D., Kreis, R., and Ernst, T. (1992). Clinical tools for the 90s: Magnetic resonance spectroscopy and metabolite imaging. Eur. J. Rad. 14:128–140.

    Google Scholar 

  • Rovira, A., Cordoba, J., Sanpedro, F., Grive, E., Rovira-Gols, A., and Alonso, J. (2002). Normalization of T2 signal abnormalities in hemispheric white matter with liver transplant. Neurology 59:335–341.

    PubMed  Google Scholar 

  • Rovira, A., Grive, E., Pedraza, S., Rovira, A., and Alonso, J. (2001). Magnetization transfer ratio values and proton MR spectroscopy of normal-appearing cerebral white matter in patients with liver cirrhosis. Am. J. Neuroradiol. 22:1137–1142.

    PubMed  Google Scholar 

  • Saeed, N. (1998). Magnetic resonance image segmentation using pattern recognition and applied to registration and quantitation. NMR Biomed. 11:157–167.

    PubMed  Google Scholar 

  • Saeed, N., Puri, B.K., Oatridge, A., Hajnal, J.V., and Young, I.R. (1998). Two methods for semi-automated quantification of changes in ventricular volume and their use in schizophrenia. Magn. Reson. Imag. 16:1237–1247.

    Google Scholar 

  • Schenker, S., and Brady, C.E., III (1994). Pathogenesis of hepatic encephalopathy. In (H.O. Conn and J. Bircher, eds.), Hepatic Encephalopathy: Syndromes and Therapies. Bloomington. Medi-Ed Press, Bloomington, USA, 43–61.

    Google Scholar 

  • Strange, K. (1993). Maintenance of cell volume in the central nervous system. Pediatr. Nephrol. 7:689–697.

    PubMed  Google Scholar 

  • Taylor-Robinson, S.D., Buckley, C., Changani, K.K., Hodgson, H.J.F., and Bell, J.D. (1999). Cerebral phosphorus-31 and proton magnetic resonance spectroscopy in patients with subclinical hepatic encephalopathy. Liver 19:389–398.

    PubMed  Google Scholar 

  • Taylor-Robinson, S.D., Oatridge, A., Hajnal, J.V., Burroughs, A.K., McIntyre, N., and deSouza, N.M. (1995).MR imaging of the basal ganglia in chronic liver disease: Correlation of T1-weighted and magnetization transfer contrast measurements with liver dysfunction and neuropsychiatric status. Metab. Brain Dis. 10:175–188.

    PubMed  Google Scholar 

  • Taylor-Robinson, S.D., Sargentoni, J., Mallalieu, R.J., Bell, J., Bryant, D.J., Coutts, G.A., and Morgan, M.Y. (1994a). Cerebral phosphorus-31 magnetic resonance spectroscopy in patients with chronic hepatic en-cephalopathy. Hepatology 20:1173–1178.

    PubMed  Google Scholar 

  • Taylor-Robinson, S.D., Sargentoni, J., Marcus, C.D., Morgan, M.Y., and Bryant, D.J. (1994b). Regional variations in cerebral proton spectroscopy in patients with chronic hepatic encephalopathy. Metab. Brain Dis. 9:347–359.

    PubMed  Google Scholar 

  • Taylor-Robinson, S.D., Sargentoni, J., Oatridge, A., Bryant, D.J., Hajnal, J.V., Marcus, C.D., Seery, J.P., Hodgson, H.J., and deSouza, N.M. (1996). MR imaging and spectroscopy of the basal ganglia in chronic liver disease: Correlation of T1-weighted contrast measurements with abnormalities in proton and phosphorus-31 MR spectra. Metab. Brain Dis. 11:249–268.

    PubMed  Google Scholar 

  • Wechsler, D. (1955). Adult Intelligence Scale Manual, Psychological Corporation, New York.

    Google Scholar 

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Authors and Affiliations

  1. Robert Steiner MR Unit, Imaging Sciences Department, MRC Clinical Sciences Centre, Imperial College London, London, United Kingdom

    Nayna Patel, Susan White, Angela Oatridge & Simon D. Taylor-Robinson

  2. Division of Medicine A, Imperial College London, London, United Kingdom

    Nayna Patel, Novraj S. Dhanjal & Simon D. Taylor-Robinson

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  1. Nayna Patel
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  4. Angela Oatridge
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  5. Simon D. Taylor-Robinson
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Patel, N., White, S., Dhanjal, N.S. et al. Changes in Brain Size in Hepatic Encephalopathy: A Coregistered MRI Study. Metab Brain Dis 19, 431–445 (2004). https://doi.org/10.1023/B:MEBR.0000043987.09022.e3

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