title: Cerebral oedema is rare in acute-on-chronic liver failure patients presenting with high-grade hepatic encephalopathy.
abstract: OBJECTIVE
  Acute-on-chronic liver failure (ACLF) has a rapidly progressive disease course associated with significant mortality. The prevalence of clinically significant cerebral oedema in ACLF is unknown.
  
  
  METHODS
  We aimed to describe the prevalence of cerebral oedema in a cohort of ACLF adult (>18 years). We identified patients admitted to a single, specialist intensive care unit between January 2005 and January 2011 with high-grade hepatic encephalopathy (≥3) and a clinical picture of either ACLF or chronic liver disease (CLD). Patients who had undergone cranial CT imaging were identified and their imaging reviewed. The ACLF and CLD groups were compared.
  
  
  RESULTS
  One thousand and eight patients with CLD were admitted. One hundred and seventy-three patients (110 male) underwent neuroimaging. Eighty-one (48 male) fulfilled criteria for ACLF. Variceal bleeding (30%) and sepsis (31%) were the most frequent precipitants of ACLF. Of those with neuroimaging from the total cohort, 30% of CT scans were normal, 30% demonstrated increased cerebral atrophy for age, 17% small vessel disease and 16% intracranial haemorrhage (ICH). Cerebral oedema was seen in three patients with ACLF only. An increased prevalence of ICH was observed in the ACLF group (23% vs. 9%, P = 0.008).
  
  
  CONCLUSIONS
  The prevalence of clinically relevant cerebral oedema was low (4%) but fatal. Death was attributable to tonsillar herniation. An increased prevalence of ICH was seen in ACLF patients and remains an important differential.
authors.affiliation: Institute of Liver Studies, King's College Hospital, London, UK.
authors.forename: Deepak
authors.initials: D
authors.lastname: Joshi
authors.forename: John
authors.initials: J
authors.lastname: O'Grady
authors.forename: Amit
authors.initials: A
authors.lastname: Patel
authors.forename: Debbie
authors.initials: D
authors.lastname: Shawcross
authors.forename: Steven
authors.initials: S
authors.lastname: Connor
authors.forename: Neil
authors.initials: N
authors.lastname: Deasy
authors.forename: Chris
authors.initials: C
authors.lastname: Willars
authors.forename: William
authors.initials: W
authors.lastname: Bernal
authors.forename: Julia
authors.initials: J
authors.lastname: Wendon
authors.forename: Georg
authors.initials: G
authors.lastname: Auzinger
mesh_terms: D065290:Acute-On-Chronic Liver Failure / Q000401:mortality*; D000328:Adult; D000368:Aged; D001929:Brain Edema / Q000175:diagnosis*; D015331:Cohort Studies; D058625:End Stage Liver Disease; D004932:Esophageal and Gastric Varices / Q000150:complications; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000150:complications; D006501:Hepatic Encephalopathy / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D055815:Young Adult
keywords: acute-on-chronic liver failure; cerebral oedema; hepatic encephalopathy; hyponatraemia; intracranial haemorrhage