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Neurosurgical Procedures in Patients with Cirrhosis and Acute Liver Failure: Indications, Safety, and Feasibility of Intracranial Pressure Monitor Devices

  • Jeffrey P. Mullin
  • Connor Wathen
  • Alvin Chan
  • Edward C. Benzel
Chapter

Abstract

Hepatic encephalopathy (HE) is highly associated with elevated intracranial pressure (ICP), as well as hemorrhagic complications associated with liver failure related coagulopathy. To date, invasively ICP monitoring in affected patients has been somewhat controversial because of potential complications, specifically the risk of hemorrhage associated with implantation of the monitoring device, and the paucity of evidence showing the benefit of ICP monitoring. The true risk of hemorrhage remains unknown, as the literature has shown that the risk may be high or low, depending on the study. Therefore, the risk is likely contingent on the protocol and management strategies. Despite this controversy, invasive ICP monitoring remains the most accurate means of tracking a patient’s ICP and could potentially provide benefit in some patients, though the profile of such patients is yet to be elucidated.

Keywords

Hepatic encephalopathy Intracranial hypertension Intracranial monitoring Cirrhosis of the liver Acute liver failure 

References

  1. 1.
    Tapper EB, Jiang ZG, Patwardhan VR. Refining the ammonia hypothesis. Mayo Clin Proc. 2015;90:646–58.CrossRefPubMedGoogle Scholar
  2. 2.
    Norenberg MD, Rao KVR, Jayakumar AR. Mechanisms of ammonia-induced astrocyte swelling. Metab Brain Dis. 2005;20:303–18.CrossRefPubMedGoogle Scholar
  3. 3.
    Rose C. Effect of ammonia on astrocytic glutamate uptake/release mechanisms. J Neurochem. 2006;97(Suppl 1):11–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Laubenberger J, et al. Proton magnetic resonance spectroscopy of the brain in symptomatic and asymptomatic patients with liver cirrhosis. Gastroenterology. 1997;112:1610–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Skowrońska M, Albrecht J. Oxidative and nitrosative stress in ammonia neurotoxicity. Neurochem Int. 2013;62:731–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Panickar KS, Jayakumar AR, Rama Rao KV, Norenberg MD. Downregulation of the 18-kDa translocator protein: effects on the ammonia-induced mitochondrial permeability transition and cell swelling in cultured astrocytes. Glia. 2007;55:1720–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Butterworth RF. The astrocytic (‘peripheral-type’) benzodiazepine receptor: role in the pathogenesis of portal-systemic encephalopathy. Neurochem Int. 2000;36:411–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Ahboucha S, et al. Reduced brain levels of DHEAS in hepatic coma patients: significance for increased GABAergic tone in hepatic encephalopathy. Neurochem Int. 2012;61:48–53.CrossRefPubMedGoogle Scholar
  9. 9.
    Norenberg MD. Astrocytic-ammonia interactions in hepatic encephalopathy. Semin Liver Dis. 1996;16:245–53.CrossRefPubMedGoogle Scholar
  10. 10.
    Moroni F, Lombardi G, Moneti G, Cortesini C. The release and neosynthesis of glutamic acid are increased in experimental models of hepatic encephalopathy. J Neurochem. 1983;40:850–4.CrossRefPubMedGoogle Scholar
  11. 11.
    de Knegt RJ, et al. Extracellular brain glutamate during acute liver failure and during acute hyperammonemia simulating acute liver failure: an experimental study based on in vivo brain dialysis. J Hepatol. 1994;20:19–26.CrossRefPubMedGoogle Scholar
  12. 12.
    Michalak A, Rose C, Butterworth J, Butterworth RF. Neuroactive amino acids and glutamate (NMDA) receptors in frontal cortex of rats with experimental acute liver failure. Hepatology (Baltimore, MD). 1996;24:908–13.CrossRefGoogle Scholar
  13. 13.
    Oppong KN, Bartlett K, Record CO, al Mardini H. Synaptosomal glutamate transport in thioacetamide-induced hepatic encephalopathy in the rat. Hepatology (Baltimore, MD). 1995;22:553–8.Google Scholar
  14. 14.
    Llansola M, et al. NMDA receptors in hyperammonemia and hepatic encephalopathy. Metab Brain Dis. 2007;22:321–35.CrossRefPubMedGoogle Scholar
  15. 15.
    Butterworth RF. The liver-brain axis in liver failure: neuroinflammation and encephalopathy. Nat Rev Gastroenterol Hepatol. 2013;10:522–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Odeh M, Sabo E, Srugo I, Oliven A. Relationship between tumor necrosis factor-alpha and ammonia in patients with hepatic encephalopathy due to chronic liver failure. Ann Med. 2005;37:603–12.CrossRefPubMedGoogle Scholar
  17. 17.
    Bernal W, Donaldson P, Underhill J, Wendon J, Williams R. Tumor necrosis factor genomic polymorphism and outcome of acetaminophen (paracetamol)-induced acute liver failure. J Hepatol. 1998;29:53–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Dennis CV, et al. Microglial proliferation in the brain of chronic alcoholics with hepatic encephalopathy. Metab Brain Dis. 2014;29:1027–39.CrossRefPubMedGoogle Scholar
  19. 19.
    Bémeur C, Qu H, Desjardins P, Butterworth RF. IL-1 or TNF receptor gene deletion delays onset of encephalopathy and attenuates brain edema in experimental acute liver failure. Neurochem Int. 2010;56:213–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Skowrońska M, Albrecht J. Alterations of blood brain barrier function in hyperammonemia: an overview. Neurotox Res. 2011;21:236–44.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Kofke WA. In Textbook of critical care. Philadelphia, PA: Saunders/Elsevier. 2011. p. 134–45.Google Scholar
  22. 22.
    Rangel-Castillo L, Gopinath S, Robertson CS. Management of intracranial hypertension. Neurol Clin. 2008;26:521–41.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Scott TR, Kronsten VT, Hughes RD, Shawcross DL. Pathophysiology of cerebral oedema in acute liver failure. World J Gastroenterol (WJG). 2013;19:9240–55.CrossRefGoogle Scholar
  24. 24.
    Rama Rao KV, Jayakumar AR, Tong X, Alvarez VM, Norenberg MD. Marked potentiation of cell swelling by cytokines in ammonia-sensitized cultured astrocytes. J Neuroinflammation. 2010;7:66.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Rama Rao KV, Jayakumar AR, Tong X, Curtis KM, Norenberg MD. Brain aquaporin-4 in experimental acute liver failure. J Neuropathol Exp Neurol. 2010;69:869–79.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Rama Rao KV, Jayakumar AR, Norenberg MD. Brain edema in acute liver failure: mechanisms and concepts. Metab Brain Dis. 2014;29:927–36.CrossRefPubMedGoogle Scholar
  27. 27.
    Larsen FS, Wendon J. Prevention and management of brain edema in patients with acute liver failure. Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc. 2008;14(Suppl 2):S90–6.Google Scholar
  28. 28.
    Dharel N, Bajaj JS. Definition and nomenclature of hepatic encephalopathy. J Clin Exp Hepatol. 2015;5(Supplement 1):S37–41.CrossRefPubMedGoogle Scholar
  29. 29.
    Shawcross DL, Wendon JA. The neurological manifestations of acute liver failure. Neurochem Int. 2012;60:662–71.CrossRefPubMedGoogle Scholar
  30. 30.
    Wang J-Y, et al. Prevalence of minimal hepatic encephalopathy and quality of life evaluations in hospitalized cirrhotic patients in China. World J Gastroenterol. 2013;19:4984–91.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Samanta J, et al. Correlation between degree and quality of sleep disturbance and the level of neuropsychiatric impairment in patients with liver cirrhosis. Metab Brain Dis. 2013;28:249–59.CrossRefPubMedGoogle Scholar
  32. 32.
    Rui MD, et al. Excessive daytime sleepiness and hepatic encephalopathy: it is worth asking. Metab Brain Dis. 2012;28:245–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Gill RQ, Sterling RK. Acute liver failure. J Clin Gastroenterol. 2001;33:191–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Jones EA, Weissenborn K. Neurology and the liver. J Neurol Neurosurg Psychiatry. 1997;63:279–93.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Martinez-Camacho A, Fortune BE, Everson G. In Textbook of critical care. Philadelphia, PA: Saunders/Elsevier. 2011. p. 760–70.Google Scholar
  36. 36.
    Cadranel JF, et al. Focal neurological signs in hepatic encephalopathy in cirrhotic patients: an underestimated entity? Am J Gastroenterol. 2001;96:515–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Hassanein TI, Hilsabeck RC, Perry W. Introduction to the Hepatic Encephalopathy Scoring Algorithm (HESA). Dig Dis Sci. 2008;53:529–38.CrossRefPubMedGoogle Scholar
  38. 38.
    Ortiz M, et al. Development of a clinical hepatic encephalopathy staging scale. Aliment Pharmacol Ther. 2007;26:859–67.CrossRefPubMedGoogle Scholar
  39. 39.
    Salam M, et al. Modified-orientation log to assess hepatic encephalopathy. Aliment Pharmacol Ther. 2012;35:913–20.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Ong JP, et al. Correlation between ammonia levels and the severity of hepatic encephalopathy. Am J Med. 2003;114:188–93.CrossRefPubMedGoogle Scholar
  41. 41.
    Kramer L, et al. Partial pressure of ammonia versus ammonia in hepatic encephalopathy. Hepatology (Baltimore, MD). 2000;31:30–4.CrossRefGoogle Scholar
  42. 42.
    Montoliu C, et al. 3-nitro-tyrosine as a peripheral biomarker of minimal hepatic encephalopathy in patients with liver cirrhosis. Am J Gastroenterol. 2011;106:1629–37.CrossRefPubMedGoogle Scholar
  43. 43.
    Waghray A, Waghray N, Kanna S, Mullen K. Optimal treatment of hepatic encephalopathy. Minerva Gastroenterol Dietol. 2014;60:55–70.PubMedGoogle Scholar
  44. 44.
    Patidar KR, Bajaj JS. Covert and overt hepatic encephalopathy: diagnosis and management. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2015;13:2048–61.Google Scholar
  45. 45.
    Kimer N, Krag A, Møller S, Bendtsen F, Gluud LL. Systematic review with meta-analysis: the effects of rifaximin in hepatic encephalopathy. Aliment Pharmacol Ther. 2014;40:123–32.CrossRefPubMedGoogle Scholar
  46. 46.
    Iadevaia MD, et al. Rifaximin in the treatment of hepatic encephalopathy. Hepatic Med Evid Res. 2011;3:109–17.CrossRefGoogle Scholar
  47. 47.
    Sharma BC, et al. A randomized, double-blind, controlled trial comparing rifaximin plus lactulose with lactulose alone in treatment of overt hepatic encephalopathy. Am J Gastroenterol. 2013;108:1458–63.CrossRefPubMedGoogle Scholar
  48. 48.
    Cabral CM, Burns DL. Low-protein diets for hepatic encephalopathy debunked: let them eat steak. Nutr Clin Pract Off Publ Am Soc Parenter Enter Nutr. 2011;26:155–9.CrossRefGoogle Scholar
  49. 49.
    Eghtesad S, Poustchi H, Malekzadeh R. Malnutrition in Liver Cirrhosis:The Influence of Protein and Sodium. Middle East J Dig Dis. 2013;5:65–75.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Rahimi RS, Rockey DC. Hepatic encephalopathy: how to test and treat. Curr Opin Gastroenterol. 2014;30:265–71.CrossRefPubMedGoogle Scholar
  51. 51.
    Chavez-Tapia NC, et al. A systematic review and meta-analysis of the use of oral zinc in the treatment of hepatic encephalopathy. Nutr J. 2013;12:74.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Bai M, Yang Z, Qi X, Fan D, Han G. l-ornithine-l-aspartate for hepatic encephalopathy in patients with cirrhosis: a meta-analysis of randomized controlled trials. J Gastroenterol Hepatol. 2013;28:783–92.CrossRefPubMedGoogle Scholar
  53. 53.
    Dam G, Ott P, Aagaard NK, Vilstrup H. Branched-chain amino acids and muscle ammonia detoxification in cirrhosis. Metab Brain Dis. 2013;28:217–20.CrossRefPubMedGoogle Scholar
  54. 54.
    Gluud LL, et al. Branched-chain amino acids for people with hepatic encephalopathy. Cochrane Database Syst Rev. 2015;2:CD001939.Google Scholar
  55. 55.
    Chen C-C, et al. Brain surgery in patients with liver cirrhosis. J Neurosurg. 2012;117:348–53.CrossRefPubMedGoogle Scholar
  56. 56.
    Liao J-C, et al. Complications associated with instrumented lumbar surgery in patients with liver cirrhosis: a matched cohort analysis. Spine J Off J North Am Spine Soc. 2013;13:908–13.CrossRefGoogle Scholar
  57. 57.
    Keshavarzi S, MacDougall M, Lulic D, Kasasbeh A, Levy M. Clinical experience with the surgicel family of absorbable hemostats (oxidized regenerated cellulose) in neurosurgical applications: a review. Wounds Compend Clin Res Pract. 2013;25:160–7.Google Scholar
  58. 58.
    Yao HHI, Hong MKH, Drummond KJ. Haemostasis in neurosurgery: what is the evidence for gelatin-thrombin matrix sealant? J Clin Neurosci. 2013;20:349–56.CrossRefPubMedGoogle Scholar
  59. 59.
    Shimamura N, Ogasawara Y, Naraoka M, Ohnkuma H. Irrigation with thrombin solution reduces recurrence of chronic subdural hematoma in high-risk patients: preliminary report. J Neurotrauma. 2009;26:1929–33.CrossRefPubMedGoogle Scholar
  60. 60.
    Grasso G, Giambartino F, Iacopino DG. Hemostasis in brain tumor surgery using the Aquamantys system. Med Sci Monit Int Med J Exp Clin Res. 2014;20:538–43.Google Scholar
  61. 61.
    Sasbón JS, Centeno M, Ciocca M, et al. Fulminant hepatic failure. Results with liver transplantation. World Federation J Crit Care Med. 2004;1:17–22.Google Scholar
  62. 62.
    Mohsenin V. Assessment and management of cerebral edema and intracranial hypertension in acute liver failure. J Crit Care. 2013;28:783–91.CrossRefPubMedGoogle Scholar
  63. 63.
    Bernuau J, Durand F. Intracranial pressure monitoring in patients with acute liver failure: a questionable invasive surveillance. Hepatology. 2006;44(2):502–4. PubMed PMID: 16871566.CrossRefPubMedGoogle Scholar
  64. 64.
    Wendon JA, Larsen FS. Intracranial pressure monitoring in acute liver failure. A procedure with clear indications. Hepatology. 2006;44(2):504–6. PubMed PMID: 16871578.CrossRefPubMedGoogle Scholar
  65. 65.
    Vaquero J, Fontana RJ, Larson AM, Bass NM, Davern TJ, Shakil AO, Han S, Harrison ME, Stravitz TR, Muñoz S, Brown R, Lee WM, Blei AT. Complications and use of intracranial pressure monitoring in patients with acute liver failure and severe encephalopathy. Liver Transpl. 2005;11(12):1581–9. PubMed PMID:16315300.CrossRefPubMedGoogle Scholar
  66. 66.
    Bernuau J, Durand F. Intracranial pressure monitoring in patients with acute liver failure: a questionable invasive surveillance. Hepatology. 2006;44(2):502–4. PubMed PMID: 16871566.CrossRefPubMedGoogle Scholar
  67. 67.
    Tofteng F, Hauerberg J, Hansen BA, et al. Persistent arterial hyperammonemia increases the concentration of glutamine and alanine in the brain and correlates with intracranial pressure in patients with fulminant hepatic failure. J Cereb Blood Flow Metab. 2006;26:21–7.CrossRefPubMedGoogle Scholar
  68. 68.
    Bernal W, Hall C, Karvellas CJ, et al. Arterial ammonia and clinical risk factors for encephalopathy and intracranial hypertension in acute liver failure. Hepatology. 2007;46:1844–52.CrossRefPubMedGoogle Scholar
  69. 69.
    Munoz SJ. Difficult management problems in fulminant hepatic failure. Semin Liver Dis. 1993;13:395–413.CrossRefPubMedGoogle Scholar
  70. 70.
    Munoz SJ, Robinson M, Northrup B, et al. Elevated intracranial pressure and computed tomography of the brain in fulminanthepatocellular failure. Hepatology. 1991;13:209–12.CrossRefPubMedGoogle Scholar
  71. 71.
    Wijdicks EF, Plevak DJ, Rakela J, et al. Clinical and radiologic features of cerebral edema in fulminant hepatic failure. Mayo Clin Proc. 1995;70:119–24.CrossRefPubMedGoogle Scholar
  72. 72.
    Rabinstein AA. Treatment of brain edema in acute liver failure. Curr Treat Options Neurol. 2010;12:129–41.CrossRefPubMedGoogle Scholar
  73. 73.
    Fortea JI, Bañares R, Vaquero J. Intracranial pressure in acute liver failure: to bolt or not to bolt-that is the question. Crit Care Med. 2014;42(5):1304–5. doi: 10.1097/CCM.0000000000000242. PubMed PMID: 24736348.CrossRefPubMedGoogle Scholar
  74. 74.
    Stravitz RT, Kramer AH, Davern T, Shaikh AO, Caldwell SH, Mehta RL, Blei AT, Fontana RJ, BM MG, Rossaro L, Smith AD, Lee WM, Acute Liver Failure Study Group. Intensive care of patients with acute liver failure: recommendations of the U.S. Acute Liver Failure Study Group. Crit Care Med. 2007;35(11):2498–508. PubMed PMID: 17901832.110.CrossRefPubMedGoogle Scholar
  75. 75.
    Blei AT, Olafsson S, Webster S, et al. Complications of intracranial pressure monitoring in fulminant hepatic failure. Lancet. 1993;341:157–8.CrossRefPubMedGoogle Scholar
  76. 76.
    Schmidt L, Larsen FS. Prognostic implications of hyperlactatemia, multiple organ failure, and systemic inflammatory response syndrome in patients with acetaminophen-induced acute liver failure. Crit Care Med. 2006;34:337–43.CrossRefPubMedGoogle Scholar
  77. 77.
    Karvellas CJ, Fix OK, Battenhouse H, Durkalski V, Sanders C, Lee WM. Outcomes and complications of intracranial pressure monitoring in acute liver failure: a retrospective cohort study. Crit Care Med. 2014;42:1157–67.CrossRefPubMedPubMedCentralGoogle Scholar
  78. 78.
    Kamat P, Kunde S, Vos M, Vats A, Heffron T, Romero R, Fortenberry JD. Invasive intracranial pressure monitoring is a useful adjunct in the management of severe hepatic encephalopathy associated with pediatric acute liver failure. Pediatr Crit Care Med. 2012;13:e33–8.CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    Gasco J, Rangel-Castilla L, Franklin B, Thomas PG, Patterson JT. State-of-the-art management and monitoring of brain edema and intracranial hypertension in fulminant hepatic failure. A proposed algorithm. Acta Neurochir Suppl. 2010;106:311–4. doi: 10.1007/978-3-211-98811-4_58. PubMed PMID: 19812970.CrossRefPubMedGoogle Scholar
  80. 80.
    Datar S, Wijdicks EF. Neurologic manifestations of acute liver failure. Handb Clin Neurol. 2014;120:645–59. doi: 10.1016/B978-0-7020-4087-0.00044-9. Review. PubMed PMID: 24365344.CrossRefPubMedGoogle Scholar
  81. 81.
    Krisl JC, Meadows HE, Greenberg CS, Mazur JE. Clinical usefulness of recombinant activated factor VII in patients with liver failure undergoing invasive procedures. Ann Pharmacother. 2011;45:1433–8.CrossRefPubMedGoogle Scholar
  82. 82.
    Le TV, Rumbak MJ, Liu SS, et al. Insertion of intracranial pressure monitors in fulminant hepatic failure patients: early experience using recombinant factor VII. Neurosurgery. 2010;66:455–8. [discussion 458].CrossRefPubMedGoogle Scholar
  83. 83.
    Shami VM, Caldwell SH, Hespenheide EE, et al. Recombinant activated factor VII for coagulopathy in fulminate hepatic failure compared with conventional therapy. Liver Transpl. 2003;9:138–43. doi: 10.1053/jlts.2003.50017.CrossRefPubMedGoogle Scholar
  84. 84.
    Tofteng F, Larsen FS. The effect of indomethacin on intracranial pressure, cerebral perfusion and extracellular lactate and glutamate concentrations in patients with fulminant hepatic failure. J Cereb Blood Flow Metab. 2004;24:798–804.CrossRefPubMedGoogle Scholar
  85. 85.
    Canalese J, Gimson AE, Davis C, et al. Controlled trial of dexamethasone and mannitol for the cerebral oedema of fulminant hepatic failure. Gut. 1982;23:625–9.CrossRefPubMedPubMedCentralGoogle Scholar
  86. 86.
    Wijdicks EFM, Nyberg SL. Propofol to control intracranial pressure in fulminant hepatic failure. Transplant Proc. 2002;34:1220–2.CrossRefPubMedGoogle Scholar
  87. 87.
    Murphy N, Auzinger G, Bernel W, et al. The effect of hypertonic sodium chloride on intracranial pressure in patients with acute liver failure. Hepatology. 2004;39:464–70.CrossRefPubMedGoogle Scholar
  88. 88.
    Jalan R, Damink O, Steven SW, Deutz NE, et al. Moderate hypothermia for uncontrolled intracranial hypertension in acute liver failure. Lancet. 1999;354:1164–8.CrossRefPubMedGoogle Scholar
  89. 89.
    Stravitz RT, Larsen FS. Therapeutic hypothermia for acute liver failure. Crit Care Med. 2009;37(7 Suppl):S258–64. doi: 10.1097/CCM.0b013e3181aa5fb8. Review. PubMed PMID: 19535956.CrossRefPubMedGoogle Scholar
  90. 90.
    Aaslid R, Markwalder TM, Nomes H. Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg. 1982;57:769–74.CrossRefPubMedGoogle Scholar
  91. 91.
    Bellner J, Romner B, Reinstrup P, Kristiansson K-A, Ryding E, Brandt L. Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). Surg Neurol. 2004;62:45–51.CrossRefPubMedGoogle Scholar
  92. 92.
    Geeraerts T, Launey Y, Martin L, et al. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med. 2007;33:1704–11.CrossRefPubMedGoogle Scholar
  93. 93.
    Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med. 2008;15:201–4.CrossRefPubMedGoogle Scholar
  94. 94.
    Soldatos T, Karakitsos D, Chatzimichail K, Papathana M, Gouliamos A, Karabinis A. Optic nerve sonography in the diagnostic evaluation of adult brain injury. Crit Care. 2008;12:R67.CrossRefPubMedPubMedCentralGoogle Scholar
  95. 95.
    Weissenborn K, Heidenreich S, Giewekemeyer K, Rückert N, Hecker H. Memory function in early hepatic encephalopathy. J Hepatol. 2003;39:320–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Jeffrey P. Mullin
    • 1
  • Connor Wathen
    • 2
  • Alvin Chan
    • 3
  • Edward C. Benzel
    • 1
  1. 1.Department of NeurosurgeryCleveland Clinic, Neurological InstituteClevelandUSA
  2. 2.Cleveland Clinic Lerner College of MedicineClevelandUSA
  3. 3.Medical College of WisconsinMilwaukeeUSA

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