Focal neurological signs in hepatic encephalopathy in cirrhotic patients: an underestimated entity?

OBJECTIVES: Focal neurological signs have been poorly documented in the cou rse of hepatic encephalopathy in cirrhotic patients because they are not me ntioned in any textbooks of liver diseases. Having the opportunity to obser ve such cases, we underwent a prospective study to determine incidence, cha racteristics, associated factors, prognostic significance, and outcome of t his rare form of hepatic encephalopathy. METHODS: Over a 12-month period, all cirrhotic patients hospitalized in the intensive care unit of our department for hepatic encephalopathy were pros pectively studied, patients with clinical and electroencephalogram evidence s of hepatic encephalopathy were examined by a senior physician and, in cas es of focal neurological signs, underwent examination by a neurologist, CT scan, lumbar punction, and cerebral magnetic resonance imaging and echo Dop pler examination of neck and head vessels. Clinical and biological paramete rs were compared in patients during episodes with and without focal neurolo gical signs, and outcome was noted. RESULTS: Thirty-four cirrhotic patients were hospitalized for 48 episodes o f hepatic encephalopathy; two of these patients with cerebral hematoma were excluded. Twenty-four patients exhibited 38 hepatic encephalopathy episode s without focal neurological signs (82.6%), and eight patients exhibited ei ght hepatic encephalopathy episodes with focal neurological signs (17.4%) t hat were hemiplegia and hemiparesia in six patients (75%). In all patients, cerebral CT scan and cerebrospinal fluid examination disclosed no abnormal ities, as neither did cerebral magnetic resonance imaging (n = 5) and echo Doppler examination of neck and head vessels(n = 5). Except for female sex, which was mole often encountered in patients with focal neurological signs (p < 0.05), there were no differences between episodes with and without fo cal neurological signs for any of the parameters studied. In surviving pati ents who recovered from hepatic encephalopathy (7/8), focal neurological si gns disappeared without recurrences after follow up of 6 months (3-12). CONCLUSIONS: Hepatic encephalopathy with focal neurological signs when care fully searched is not uncommon. It could be more frequent in cirrhotic fema les, is reversible, and has no prognostic significance. (C) 2001 by Am. Cel l. of Gastroenterology.