Hepatopulmonary syndrome and venous emboli causing intracerebral hemorrhages after liver transplantation

Increasing experience has fostered the acceptance of liver transplantation as a treatment for patients with hepatopulmonary syndrome. Morbidity and mo rtality is most commonly attributed to progressive arterial hypoxemia posto peratively. A cerebral hemorrhage has been reported in one patient with hep atopulmonary syndrome after transplantation. However, a postmortem examinat ion of the brain was not performed and the pathogenesis or type of cerebral hemorrhage was undefined. We report on a patient with severe hepatopulmona ry syndrome who developed multiple intracranial hemorrhages after transplan tation. The intracerebral hemorrhages were most consistent with an embolic etiology on postmortem examination. We postulate that venous embolization, caused by the manipulation of a Swan Ganz catheter in a thrombosed central vein, resulted in pulmonary emboli that passed through dilated intrapulmona ry vessels into the cerebral microcirculation. Special attention to central venous catheters and avoidance of manipulation may be warranted in subject s with severe hepatopulmonary syndrome after liver transplantation.