Cerebral changes in hepatic encephalopathy.

Hepatic encephalopathy (HE) accompanied by an impairment of consciousness from orientation disorder (grade II) to coma (grade IV) is considered to be overt HE and is treated as an emergency. However, subclinical hepatic encephalopathy (SHE) can be detected by sensitive and quantitative neuropsychological examinations in cirrhotic patients without overt HE. The introduction of the SHE concept is clinically important for preventing the deterioration of SHE (grades 0 and I) to overt HE (grade II and more severe), prolonging the compensated state of cirrhosis without its deterioration to hepatic failure, and the continuation of patient treatment at home. We developed a new diagnostic method for SHE using a quantitative neuropsychological test, with the computerization of all operations. Evaluations of cerebral function and morphology are useful for the determination of the pathophysiology of HE, and assist the diagnosis of SHE. The latencies of the P3 wave in the visually evoked potential and the P300 wave in the event-related potential are prolonged in cirrhotic patients with SHE and are well expressed in three-dimensional coloured topograms (brain mapping). Automated polysomnographic analysis is useful for continuous-monitoring electroencephalograms (EEG) and for the detection of the sleep disturbance observed in cirrhotic patients with SHE. Brain atrophy in computed tomography (CT), magnetic resonance imaging (MRI) and high signals in the basal ganglia in the MR-T1-weighted images have frequently been observed in patients with SHE. The reduction of regional cerebral blood flow (rCBF) by 99mtechnetium-1, 1-ethylcysteinate dimer (99mTc-ECD)-single photon emission computed tomography (SPECT) and the choline/N-acetylaspartic acid ratio by proton-magnetic resonance spectroscopy (1H-MRS) were observed in the hippocampus in patients with SHE. These approaches (cerebral function tests and imaging diagnoses of the brain) can also be used to evaluate the effectiveness of treatments for HE; for example, branched-chain amino acid (BCAA) was shown by automated continuous polysomnographic analysis to be a psychotropic drug which acts directly on the central nervous system and the clinical significance of choline administration to HE patients is now being evaluated by 1H-MRS and neuropsychological tests.