title: Liver transplantation results in complete neurologic recovery from malignant hypertension secondary to fulminant hepatic failure: a case report.
abstract: BACKGROUND
  Uncontrolled intracranial hypertension can lead to cerebral herniation and death in patients with acute liver failure.
  
  
  METHODS
  A 26-year-old female was admitted for acute liver failure following inadvertent acetaminophen overdose. The pH on admission was 6.9. Her neurologic status precipitously deteriorated and she was listed for liver transplantation. An intracranial pressure (ICP) monitoring catheter was inserted, which revealed a pressure >60 mmHg. After neurointensive care treatment, ICP was lowered and an emergency left lobe living donor liver transplant was performed. Intraoperative management of the ICP, which rose to 80 mmHg during the explant phase, was achieved by therapy with barbiturates and hypothermia. After surgery, hepatic function improved initially, but 7 days post transplantation the graft showed signs of acute failure. The pathology report of a liver biopsy suggested acute rejection and liver retransplantation using a deceased donor liver was then carried out. The postoperative course was uneventful and the patient recovered completely without any residual neurologic deficits.
  
  
  CONCLUSIONS
  This case states that favourable outcomes can result from sub-optimal starting points, and that the human brain has the ability to overcome extremely adverse conditions. Critical in this effort is the role of proper neuromonitoring which helps implement the appropriate treatment measures.
authors.affiliation: Department of Surgery, Transplant Unit, MGH, Boston, MA, USA. tsoulfasg@gmail.com
authors.forename: Georgios
authors.initials: G
authors.lastname: Tsoulfas
authors.forename: Nahel
authors.initials: N
authors.lastname: Elias
authors.forename: Warren S
authors.initials: WS
authors.lastname: Sandberg
authors.forename: Dicken S C
authors.initials: DS
authors.lastname: Ko
authors.forename: Tatsuo
authors.initials: T
authors.lastname: Kawai
authors.forename: A Benedict
authors.initials: AB
authors.lastname: Cosimi
authors.forename: Parmenion P
authors.initials: PP
authors.lastname: Tsitsopoulos
authors.forename: Polyxeni
authors.initials: P
authors.lastname: Agorastou
authors.forename: Martin
authors.initials: M
authors.lastname: Hertl
mesh_terms: D000328:Adult; D005260:Female; D006501:Hepatic Encephalopathy / Q000150:complications / Q000601:surgery; D006801:Humans; D006974:Hypertension, Malignant / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery*; D019586:Intracranial Hypertension / Q000150:complications / Q000601:surgery; D007427:Intracranial Pressure; D017114:Liver Failure, Acute / Q000150:complications* / Q000503:physiopathology / Q000601:surgery*; D016031:Liver Transplantation / Q000502:physiology; D016343:Monitoring, Intraoperative / Q000379:methods; D012086:Reoperation