Quantification of the Electroencephalographic Theta/Alpha Ratio for the Assessment of Portal-Systemic Encephalopathy Following Implantation of Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS)

The aim of the study was the quantification of metabolically caused electroencephalographic changes of portal-systemic encephalopathy, a prototype of hepatic encephalopathy. We examined 12 patients with liver cirrhosis before and after implantation of a transjugular intrahepatic portosystemic stent shunt (TIPSS) by means of quantitative digital electroencephalography (EEG). One month after TIPSS implantation, all patients showed an increase in the power of the theta frequency band as well as a decrease in the power of the alpha frequency band. To reduce the error variance, we formed the quotient of the relative power of the theta and alpha frequency band. Theta/alpha quotient values over 0.7 indicate a general change of the EEG with a sensitivity of 93% and a specificity of 87%. The results we have to hand indicate a correlation between the albumin concentration and the theta/alpha quotient 1 and 3 months after TIPSS. No significant correlation was revealed with regard to the Child-Pugh score or the liver function parameters cholinesterase, bilirubin, and prothrombin time. Neither the arterial ammonia concentration nor the performance in the psychometric test showed significance in relation to the theta/alpha quotient. Substances with a high albumin bond and potential neurotoxicity may—in the case of lower albumin levels—be absorbed with increased frequency in the CNS and may be responsible for the observed EEG change.     

Effects of idebenone on electroencephalograms of patients with cerebrovascular disorders

A daily dose of 90 mg of idebenone was given to nine patients with cerebrovascular disorders to investigate its effects on clinical symptoms and electroencephalograms (EEG). Changes in EEG before and after the administration were compared quantitatively by computer analysis using the wave-form recognition method. Significant increase in frequency in the alpha band (O1) and trends of increased appearance of beta waves, decreased appearance of alpha 1 bands, and lowered amplitude in the alpha 1 and alpha 2 bands were observed after administration of idebenone. The theta waves of 30 microV and over had a significantly diminished maximum amplitude (C3) and a tendency to appear less often. Mean frequency of the EEG and appearance of fast waves apparently increased in the patients showing improvement of the clinical symptoms as compared with those not showing improvement. The results suggested that idebenone improved the EEG in the patients with cerebrovascular disorders, causing changes in EEG similar to those observed with psychostimulants.     

Is waking electroencephalographic activity a predictor of daytime sleepiness in sleep-related breathing disorders?

No data are available in the literature assessing the potential use of waking electroencephalographic (EEG) activity in the detection of excessive daytime sleepiness (EDS) in patients with sleep-related breathing disorders (SRBD). The aim of this study was to evaluate whether waking EEG spectral power reflects the level of EDS in SRBD patients. The study was performed in 48 patients in whom quantitative EEG analysis, including the alpha attenuation coefficient (AAC), was performed. Sleepiness was assessed by the Epworth Sleepiness Scale, the Stanford Sleepiness Scale, the Visual Analogue Scale and the maintenance of wakefulness test. Although AAC and EEG spectral power tended to vary throughout the day, none of these variations correlated with EDS measures. Waking EEG measures were not different between snorers and apnoeic patients. Compared to nonsleepy patients, sleepy patients had greater theta and slow alpha powers, but the differences did not reach statistical significance. The EEG slowing was independent of hypoxaemia, severity of SRBD, or degree of sleep disruption. The authors conclude that waking electroencephalographic measures are not sensitive enough to predict variation in alertness or to differentiate sleepy from nonsleepy sleep-related breathing disorders patients. The degree of electroencephalographic slowing was related neither to sleep disruption nor to severity of sleep-related breathing disorders.     

心肺复苏后昏迷患者脑电图模式对预后的预测

目的探讨心肺复苏后昏迷患者脑电图评估时间和脑电图模式对预后预测的价值。方法选择64例心肺复苏后昏迷患者行脑电图评估。按首次脑电图监测时间段将患者分为1～3d、4～7d及〉7d监测组。脑电图监测包括全面抑制、爆发-抑制、α／θ昏迷和慢波增多四个模式，临床预后（格拉斯哥预后评分）以6个月为终点。分别统计四个脑电图模式在三个时间段内预测预后的敏感性、特异性、阳性预测值、假阳性率及总符合率。结果心肺复苏后脑电图全面抑制模式在7d内预测预后不良敏感性（67％～80％）、特异性（100％）较高；爆发-抑制模式在7d内预测预后不良特异性高（100％），但敏感性（6％～8％）低；α／θ昏迷模式预测预后不良敏感性为3％～40％、特异性为50％～67％；慢波增多在7d内预测预后良好敏感性（100％）、特异性（91％～94％）均高。结论心肺复苏后早期（7d内）脑电图显示全面抑制和爆发-抑制模式预测预后不良准确、可靠；慢波增多模式预测预后良好准确、可靠；α／θ昏迷模式预测预后不良的准确性和可靠性有限。     

肝硬化患者的脑电活动地形图

对２０例无临床肝性脑病的失代偿期肝硬化患者进行脑电活动地形图（ＢＥＡＭ）检查，并与３３例正常人作对照，以探讨亚临床肝性脑病（ＳＨＥ）的诊断价值。结果表明，２０例肝硬化患者中，ＢＥＡＭ正常５例，轻度异常５例，轻￣中度异常５例，中度异常５例，总异常率为７５％（１５／２０）。ＢＥＡＭ异常的分布特点以弥漫性分布为主要表现，主要为慢频域（δ．θ．δ＋θ／α＋β）活动增强，Ｚ值增高，只有３例波及α频域。提示：     

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) for variceal haemorrhage: initial results in 28 patients

Background: Endoscopic sclerotherapy is an effective form of treatment of bleeding varices in patients with cirrhosis. However, the mortality in patients who rebleed is high. Recently, trans-jugular intrahepatic portosystemic stent-shunt (TIPSS) has been developed as an alternative to surgical shunt formation in patients who have failed sclerotherapy.
Aim: To review the early experience with TIPSS at a teaching hospital.
Methods: Twenty-eight patients underwent TIPSS on 30 occasions between September 1991 and June 1993 for bleeding oesophageal or gastric varices. The majority had alcoholic liver disease.
Results: TIPSS was performed successfully in all patients. Immediate control of bleeding was achieved, but one patient rebled within 24 hours. Complications related to the procedure occurred in 30%, but no patient died from these. Thirty-day mortality was 11% (three of 28), two patients dying from progressive liver failure and one from sepsis. A further three patients died from six weeks to two months following TIPSS, due to liver failure in one, spontaneous bacterial peritonitis in the second and in the third after a fall. This represents an overall mortality of 21%. Three patients have rebled at mean follow-up of 11.3 months. One of these had repeat TIPSS while the other two had balloon dilatation of the stent with control of bleeding. Four patients developed mild chronic encephalopathy which was readily controlled with medical therapy.
Conclusions: TIPSS is an effective means for control of bleeding from oesophageal and/or gastric varices not responding to other methods. Further follow-up is required with regard to rates of rebleeding, encephalopathy and survival.     

EEG arousal and cardiovascular reactivity in professional drivers: the glare pressor test.

Patterns of electroencephalographic (EEG) and polygraphically recorded cardiovascular (CV) reactivity to the glare pressor test (GPT) were compared in 19 healthy, young male professional drivers and eight non-driver controls. After the first headlight impulse, 15 drivers showed persistent blockade of spontaneous alpha activity or complete desynchronization. This was accompanied by a significant fall in digital pulse amplitude and a significant rise in diastolic blood pressure (BP) (7.3 +/- 9.5 mmHg). Most drivers recovered baseline alpha activity and showed milder diastolic BP and digital pulse changes after the final (5th) glare impulse. However, in two drivers this last glare stimulus elicited the most pronounced changes: in one case a rapid onset of ventricular extrasystoles and in the other, maximal rise in diastolic BP, together with a persistently desynchronized EEG. No significant effects of the GPT upon central and CV indices were found in the control group. These results indicate that drivers show cardiovascular hyperreactivity to the GPT, with strong central arousal as expected during night driving when an on-coming headlight can represent impending danger and the need for accurate and timely responses to avoid a collision. Once optimal stimulus parameters for routine application are determined, the glare pressor test with EEG and polygraphic recording will offer a clinically useful, standardizable method for evaluating the connection between central mechanisms and CV reactivity in professional drivers, a cohort of patients whose occupational activity epitomizes mentally stressful work, and who are at high cardiac risk.     

Neurological and Psychological Changes in Hemodialysis Patients Before and After the Treatment

Neurological, psychological, and cognitive disorders in chronic kidney disease may contribute to poor quality of life in these patients. The aim of this study was to assess the electroencephalographic, psychological, and cognitive changes before and after hemodialysis (HD) compared with healthy controls (HC). Sixteen HD patients and 15 HC were enrolled. Electroencephalogram (EEG), Minnesota multiphasic personality inventory (MMPI‐2) Satisfaction profile (SAT‐P), and Neuropsychological test Global z‐scores (NPZ5) were performed before (T0) and after (T1) HD treatment and in HC. Renal function, inflammatory markers and mineral metabolism indexes were also evaluated. Patients did not show significant differences before and after HD in the absolute and relative power of band of EEG, except in Theta/Alpha index (P < 0.001). At T1, HD patients showed significant differences in Beta, Delta and Theta band, in addition to Theta/alpha index, with respect to HC. Moreover, HD patients showed significant differences in specific MMPI‐2 clinical and content scales, SAT‐P domains and NPZ5 tests of memory and concentration with respect to HC. We also observed significant correlations between renal function, mineral metabolism, inflammatory markers and psychocognitive alterations. In our sample EEG abnormalities tend to reduce, but not significantly, after HD treatment and differences remain present with respect to HC. In HD patients cognitive and psychological alterations were associated with reduced quality of life and correlated with mineral metabolism and inflammation. Modification in EEG and in psychological and cognitive parameters should be assessed in a larger HD population to confirm our observation.     

QPEEG analysis of the effects of sodium valproate on adult Chinese patients with generalized tonic-clonic seizures

Objectives EEG effects of the sustained-release form of sodium valproate (SR-VPA) are unknown, although it is widely used in Chinese patients with generalized tonicclonic seizures (GTCS). Methods Fourteen newly diagnosed, untreated GTCS patients were recruited and treated with SR-VPA. Waking EEG was recorded and analyzed by way of quantitative pharmaco-electroencephalogram (QPEEG) analysis during the three-month follow-up. Results There was a statistically significant decrease in the absolute power of the delta band (P?P?p?相似文献   

肝硬化患者的脑电活动地形图

目的：探讨脑电活动地形图（ＢＥＡＭ）对亚临床肝性脑病（ＳＨＥ）的诊断价值。方法：对２０例无临床肝性脑病的失代偿期肝硬化患者进行ＢＥＡＭ检查，并与３３例正常人作对照分析。结果：２０例肝硬化患者中，ＢＥＡＭ正常５例，轻度异常５例，轻一中度异常５例，中度异常５例，总异常率为７５．００％（１５／２０）。ＢＥＡＭ异常的分布特点以弥漫性分布为主要表现，主要为慢频域（δ、θ、δ＋θ／α＋β）活动增强，Ｚ值增高，只有３例波及α频域。结论ＳＨＥ患者ＢＥＡＭ检查异常率明显增高，可作为ＳＨＥ的早期诊断依据，由于该技术先进，无损伤且敏感，是诊断ＳＨＥ的一种理想方法。本文认为ＢＥＡＭ检查中度以上异常者，可考虑进行预防性肝性脑病的药物治疗。     

Cerebral metabolic change after treatment in biotinidase deficiency

Summary A 13.5-year-old boy with biotinidase deficiency was studied 8 days before and 5 months after biotin treatment by positron emission tomography (PET) and computerized electroencephalographic topography (CET). With biotin treatment there was a marked improvement in the presenting symptom of loss of visual acuity and a more modest recovery in spastic quadraparesis. By PET scanning, the relative metabolic rate for glucose was more than 2 standard deviations lower in the temporal and occipital cortices than in adult or age-matched controls. With biotin treatment, these values rose to normal limits for both control groups. By CET, normalized EEG equivalent to the relative glucose metabolic rate showed asymmetric slowing in the left temporal and frontal regions before treatment, whereas none of the 32 leads exceeded normal limits of delta, theta, alpha or beta after treatment. These results suggest a strong correlation between clinical, metabolic and electrical measures of brain function as related to biotin treatment in biotinidase deficiency.     

Transjugular intrahepatic portosystemic stent-shunt and its effects on orthotopic liver transplantation

BACKGROUND: It has been reported that preoperative transjugular intrahepatic portosystemic stent-shunt (TIPSS) reduces peri-operative transfusion requirements during orthotopic liver transplant, and may result in fewer episodes of poor, early graft function by reducing portosystemic shunting, thus improving portal blood supply to the graft. OBJECTIVE: To test the hypotheses that TIPSS improves early graft function and reduces transfusion requirements. METHODS: A retrospective review of 82 liver transplant recipients between 1993 and 1999 was performed. The subgroups comprised 29 patients who had TIPSS prior to first orthotopic liver transplant and 53 matched controls without TIPSS. RESULTS: There was no significant difference in the early graft function in the two groups. The prothrombin time before an orthotopic liver transplant was independently predictive of initial poor function. Transfusion requirements and total operating times were similar for both groups, although transfusion requirements were greater in those patients where TIPSS led to technical difficulties during the operation (n = 6). The TIPSS patients required a longer hospital stay than the non-TIPSS patients (41 +/- 8 vs 26 +/- 4 days, P < 0.05). There were significantly more patients needing dialysis in the TIPSS group (41.3% vs 9.4%, P < 0.001). Pulmonary infection was less common in the TIPSS group (P < 0.05), with a trend to reduced wound infections. The 12 month patient and graft survival were similar in both groups. Serum albumin levels assessed before orthotopic liver transplant independently predicted 12 month graft survival. CONCLUSIONS: TIPSS does not improve early graft function, nor reduce blood transfusion requirements perioperatively. The longer post-operative hospital stay in the TIPSS group is worthy of further study. TIPSS prior to transplantation, despite having the potential for technical operative complications, has no detrimental effects on patient and graft survival, and if required should be undertaken.     

Lateral asymmetries in the frontal brain: effects of depression and a family history of alcoholism in female adolescents

BACKGROUND: Subtle electroencephalographic (EEG) abnormalities have been detected among subjects with depressed affect. The present study attempted to discern whether these abnormalities reflect a main effect or an interaction between depression and either of two family history variables--a family history of alcoholism or a family history of depression. METHODS: The subjects were 151 adolescent females, aged 14 to 20 years, of whom 58 met DSM-III-R diagnostic criteria for a lifetime history of a major depressive episode. The electroencephalogram was recorded from 31 electrode sites while the subjects sat relaxed, with their eyes open, for 5 min. RESULTS: Analyses of EEG data revealed that a personal history of depression and a family history of alcoholism had opposite effects on the EEG power spectrum. Depression was associated with an increase in alpha power (7.5-12.5 Hz). In contrast, a family history of alcoholism was associated with an increase in fast beta power (19-30 Hz) and a decrease in theta power (4-7 Hz). There were no significant main or interactive effects of a family history of depression. Current source density topographic analyses of the significant group differences in alpha and fast beta power demonstrated that the effects of depression could be localized to the right frontal brain, whereas the effects of a family history of alcoholism were localized to the left frontal area. CONCLUSIONS: The laterally opposite effects of depression and a family history of alcoholism suggest a high level of functional differentiation of the frontal brain. They also suggest that the different neurophysiological substrates of depression and familial risk can be distinguished through the use of modern methods of EEG source localization.     

Effect of sodium benzoate in the treatment of atypical nonketotic hyperglycinaemia

A 6-month-old girl presented with hypotonia and mild psychomotor retardation. Subsequently, an atypical manifestation of a nonketotic hyperglycinaemia was diagnosed, confirmed by significantly reduced activity of the glycine cleavage system in the liver tissue. After the patient developed hypsarrhythmia and had a single cerebral seizure, treatment with both sodium benzoate and dextromethorphan was started. During the following year, the girl was free of seizures with improvement of the EEG activity and showed retarded but continuously progressing psychomotor development. At the age of 20 months she began to walk freely but had generalized muscular hypotonia and moderate mental retardation. Discontinuation of dextromethorphan medication after one year of treatment did not change the clinical and electroencephalographic status. However, after cessation of sodium benzoate therapy, epileptic activity in the EEG and behavioural changes occurred. These changes disappeared promptly after sodium benzoate therapy was reinstituted. Thus, this case of mild atypical nonketotic hyperglycinaemia with only moderate psychomotor retardation and without epilepsy benefited from treatment with sodium benzoate in terms of electroencephalographic and behavioural changes.     

Effect of aging on treadmill exercise induced theta power in the rat

The effects of aging on the electroencephalogram (EEG) power spectra of 8- and 60-week-old Wistar–Kyoto rats were examined during the waking baseline and treadmill exercise. Using continuous and simultaneous recordings of EEG and electromyogram signals, this study demonstrated that the alpha (10–13 Hz), theta (6–10 Hz), and delta (0.5–4 Hz) powers of the EEG were significantly lower in older rats as compared with young rats during the waking baseline. In the young rats, treadmill exercise resulted promptly in a higher alpha power, higher theta power, and higher theta power percentage as compared with the waking baseline. In the aged rats, treadmill exercise only resulted in a higher theta power and higher theta power percentage. During the treadmill exercise, however, the aged rats still showed a significantly lower exercise-evoked theta power change than the young rats. These results suggested that aging is accompanied by lower EEG activities during waking and this also is accompanied by an attenuated response of the brain to exercise in the rat.     

Management of Budd–Chiari Syndrome

Thrombotic occlusion of the hepatic veins leads to liver dysfunction and liver failure requiring liver transplantation in advanced cases. The cause for the occlusion of the hepatic veins is not completely understood. However, several underlying conditions such as polycytemia, factor V Leiden mutation, and protein C and S deficiency are found in these patients. We here report our single-center experience with 18 consecutive patients with Budd–Chiari Syndrome (BCS) who were treated at our institution between August 1992 and June 2003. Twelve patients underwent liver transplantation, three patients received stents into the hepatic veins or vena cava, another patient was treated with TIPSS (transjugular intrahepatic postosystemic stent shunt), and one patient underwent surgical mesocaval shunting. Three patients, among those the patient with TIPSS, were put on anticoagulant therapy and are scheduled for liver transplantation. We outline the indication for an approach tailored to the stage of the disease and the adaption of the procedures with the deterioration of clinical conditions. Surgical aspects and postoperative management with a focus on liver transplantation are outlined. We conclude from our observations that the management of BCS requires an approach that exhausts conservative approaches until clinical conditions deteriorate with respect to portal hypertension or liver function. Conservative management, i.e., interventional and supportive medical therapy, has been used up to 8 years in our series, until the time for liver transplantation is reached. Liver transplantation for BCS had more complications than transplantation for other liver diseases in our series. Therefore, we propose to keep liver function stable using interventional techniques to maintain venous outflow. If venous outflow cannot be interventionally restored and liver function deteriorates or cirrhosis develops during this time course, liver transplantation is the therapy of choice.     

Diagnostic tools for the detection of subclinical hepatic encephalopathy: comparison of standard and computerized psychometric tests with spectral-EEG

The prevalence of subclinical hepatic encephalopathy (SHE) varies according to the diagnostic tool used in its detection. Since a standardised approach to the diagnosis of SHE is not yet available, we compared psychometric tests and EEG spectral analysis. On the same day 32 cirrhotic patients without overt hepatic encephalopathy and 18 controls were assessed by psychometric tests, both standard and computerized (CPT), and by EEG spectral analysis (EEG-SA). The CPT, measuring reaction time (Rt) and errors (er), were Font, Choice1, Choice2 and Scan test. The standard psychometric tests were the number connection test (NCT), the Reitan-B test, the Line Tracing Test [for time: LTT(t) and for errors: LTT(er)], and the Symbol Digit test (SD). Both psychometric tests [Reitan-B test, LTT(er) and CPT but Font (Rt) and Choice2 (er)] and EEG-SA parameters [mean dominant frequency (MDF) and theta power (%)] significantly correlated (p<0.05) with albumin plasma levels. LTT(er), Scan, Font, Choice1 and Choice2 were significantly related to % and MDF. There was no control with positive EEG-SA, though one control was positive with LTT(t) and with the number of errors made during Font and Scan tests. The percentage of cirrhotics with positive EEG-SA was 34% (CI_95%=19–53), while 9–66% were positive with psychometric tests, depending on the test considered. In spite of the correlation between neuropsychological and neurophysiological parameters, the diagnostic agreement between EEG-SA and each psychometric test was not high. In conclusion: 1) neurophysiological and neuropsychological impairment in cirrhotics without overt hepatic encephalopathy were found linked to each other and to hepatic dysfunction; 2) psychometric tests were not sufficiently good predictors of EEG alterations; therefore, neuropsychological tools can not substitute neurophysiological ones to detect CNS dysfunction in liver disease.     

经颈静脉肝内门体支架分流术的并发症及其防治

目的探讨经颈静脉肝内门体支架分流术（ｔｒａｎｓｊｕｇｕｌａｒｉｎｔｒａｈｅｐａｔｉｃｐｏｒｔｏｓｙｓｔｅｍｉｃｓｔｅｎｔ－ｓｈｕｎｔ，ＴＩＰＳＳ）的并发症及其防治。方法分析３１例行ＴＩＰＳＳ术患者的情况。结果手术成功率９６７％，术后近期并发症有转氨酶升高（１００％）、术后炎性反应（３２２％）、胆道出血（６４％）、术后死亡（６４％）、腹膜炎（３２％）。术后远期并发症有胆红素升高（５４８％）、白蛋白下降（２９０％）、支架狭窄或阻塞（１９３％）、低蛋白水肿（１６１％）、肝性脑病（１６１％）、合并肝癌（６４％）。结论ＴＩＰＳＳ术应严格掌握适应证并应严密注意术后并发症的防治。     

Dextrose and vigilance: the effect of dextrose on the spectro-analytic parameters of pharmaco-EEG]

In a randomized single-blind cross-over-design the effect of 15 g dextrose was investigated against placebo with 48 healthy subjects at two different days each. The quantitative pharmaco-EEG was recorded occipitocentral at the left side (O1-Cz) under vigilance controlled conditions and then under resting conditions (three minutes each). Having measured its baseline it was repeated six times every 20 minutes starting 10 minutes after the application of the substance. After the administration of dextrose a stabilization of vigilance could be seen in the EEG by the following differences of statistical significance (p < = 0.05) between dextrose and placebo under resting recording conditions: In the first control (14.-16. minute post) there was a significant decrease of the relative power in the delta and in the theta range combined with an increase of alpha 2. In the second control (34.-36. minute post) there was a significant decrease of relative power in the theta range and significant increase in the alpha 1 range. In the third control (54.-56. minute post) and later on no effects of dextrose were left in the pharmaco-EEG. The significant differences in the first and second control have to be interpreted as follows: After the administration of dextrose the level of vigilance was increased compared to the placebo group.     

Clinical significance of the latency period of abnormal ammonia metabolism in chronic liver disease: Proposal of a new concept

The liver is a key organ in regulating metabolism, and chronic liver disease is associated with several metabolic disorders. In the later stages of liver cirrhosis, the urea cycle is impaired, which disrupts of ammonia detoxification and eventually causes hyperammonemia and hepatic encephalopathy. Although hyperammonemia is not detected during the period between the late stage of chronic hepatitis and the early stage of liver cirrhosis, hepatic albumin synthesis capacity decreases as the fibrosis progresses. Increased ammonia levels are associated with a decreased capacity of the liver to synthesize albumin as well as activation of hepatic stellate cells, which promote fibrosis. Herein, we discuss the possibility that abnormal ammonia metabolism might play an important role in the pathogenesis of liver diseases even without hyperammonemia. We consider the disease period without hyperammonemia as the latency period of abnormal ammonia metabolism and discuss its clinical significance.