Intracranial Pressure Monitoring in Acute Liver Failure

Institutional Case Series

Patrick R. Maloney, Grant W. Mallory, John L.D. Atkinson, Eelco F. Wijdicks, Alejandro Rabinstein, Jamie Van Gompel

Research output: Contribution to journalArticle

9 Citations (Scopus)

Abstract

Acute liver failure (ALF) has been associated with cerebral edema and elevated intracranial pressure (ICP), which may be managed utilizing an ICP monitor. The most feared complication of placement is catastrophic intracranial hemorrhage in the setting of severe coagulopathy. Previous studies reported hemorrhage rates between 3.8–22 % among various devices, with epidural catheters having lower hemorrhage rates and precision relative to subdural bolts and intraparenchymal catheters. We sought to identify institutional hemorrhagic rates of ICP monitoring in ALF and its associated factors in a modern series guided by protocol implantation. Patient records treated for ALF with ICP monitoring at Mayo Clinic in Rochester, MN from 1995 to 2014 were reviewed. Protocalized since 1995, epidural (EP) ICP monitors were first used followed by intraparenchymal (IP) for stage III–IV hepatic encephalopathy. The following variables and outcomes were collected: patient demographics, ICPs and treatment methods, laboratory data, imaging studies, number of days for ICP monitoring, radiographic and symptomatic hemorrhage rates, orthotopic liver transplantation rates, and death. A total of 20 ICP monitors were placed for ALF, 7 EP, and 13 IP. International normalized ratio (INR) at placement of an EP monitor was 2.4 (1.7–3.2) with maximum of 2.7 (2.0–3.6) over the following 2.3 (1–3) days. Mean EP ICP at placement was 36.3 (11–55) and maximum of 43.1 (20–70) mm Hg. INR at placement of an IP monitor was 1.3 (<0.8–3.0) with maximum value of 2.9 (1.6–5.4) over the following 4.2 (2–6) days. Mean IP ICP at placement was 9.9 (2–19) and maximum was 39.8 (11–100) mm Hg. There was one asymptomatic hemorrhage in the EP group (14.3 % hemorrhage rate) and two hemorrhages in the IP group (hemorrhage rate was 15.4 %), both of which were fatal. Overall mortality rate in the EP group was 71.4 % (5/7) with two patients receiving transplantation, and one death in the transplant group. Overall mortality in the IP group was 38.5 % (5/13) with nine liver transplantations; three of the transplanted patients died, including one of the fatal hemorrhages due to monitor placement. Intracranial hypertension is common in patients with ALF with severe hepatic encephalopathy. Monitored patients in both groups experienced elevations of ICP in the setting of intermittent coagulopathy. Severity of coagulopathy did not influence hemorrhage rate. Yet, hemorrhages related to IP monitoring can be catastrophic and may add to the overall mortality.

Original languageEnglish (US)
Pages (from-to)86-93
Number of pages8
JournalNeurocritical Care
Volume25
Issue number1
DOIs
StatePublished - Aug 1 2016

Fingerprint

Acute Liver Failure
Intracranial Pressure
Hemorrhage
Intracranial Hypertension
International Normalized Ratio
Hepatic Encephalopathy
Mortality
Liver Transplantation
Catheters
Intracranial Hemorrhages
Brain Edema
Transplantation
Demography
Transplants
Equipment and Supplies

Keywords

  • Acute liver failure
  • Cerebral edema
  • Fulminant hepatic failure
  • Intracranial pressure monitoring

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Clinical Neurology

Cite this

Intracranial Pressure Monitoring in Acute Liver Failure : Institutional Case Series. / Maloney, Patrick R.; Mallory, Grant W.; Atkinson, John L.D.; Wijdicks, Eelco F.; Rabinstein, Alejandro; Van Gompel, Jamie.

In: Neurocritical Care, Vol. 25, No. 1, 01.08.2016, p. 86-93.

Research output: Contribution to journalArticle

Maloney, Patrick R. ; Mallory, Grant W. ; Atkinson, John L.D. ; Wijdicks, Eelco F. ; Rabinstein, Alejandro ; Van Gompel, Jamie. / Intracranial Pressure Monitoring in Acute Liver Failure : Institutional Case Series. In: Neurocritical Care. 2016 ; Vol. 25, No. 1. pp. 86-93.
@article{0d44bd5d547f4823922648855a8ca654,
title = "Intracranial Pressure Monitoring in Acute Liver Failure: Institutional Case Series",
abstract = "Acute liver failure (ALF) has been associated with cerebral edema and elevated intracranial pressure (ICP), which may be managed utilizing an ICP monitor. The most feared complication of placement is catastrophic intracranial hemorrhage in the setting of severe coagulopathy. Previous studies reported hemorrhage rates between 3.8–22 {\%} among various devices, with epidural catheters having lower hemorrhage rates and precision relative to subdural bolts and intraparenchymal catheters. We sought to identify institutional hemorrhagic rates of ICP monitoring in ALF and its associated factors in a modern series guided by protocol implantation. Patient records treated for ALF with ICP monitoring at Mayo Clinic in Rochester, MN from 1995 to 2014 were reviewed. Protocalized since 1995, epidural (EP) ICP monitors were first used followed by intraparenchymal (IP) for stage III–IV hepatic encephalopathy. The following variables and outcomes were collected: patient demographics, ICPs and treatment methods, laboratory data, imaging studies, number of days for ICP monitoring, radiographic and symptomatic hemorrhage rates, orthotopic liver transplantation rates, and death. A total of 20 ICP monitors were placed for ALF, 7 EP, and 13 IP. International normalized ratio (INR) at placement of an EP monitor was 2.4 (1.7–3.2) with maximum of 2.7 (2.0–3.6) over the following 2.3 (1–3) days. Mean EP ICP at placement was 36.3 (11–55) and maximum of 43.1 (20–70) mm Hg. INR at placement of an IP monitor was 1.3 (<0.8–3.0) with maximum value of 2.9 (1.6–5.4) over the following 4.2 (2–6) days. Mean IP ICP at placement was 9.9 (2–19) and maximum was 39.8 (11–100) mm Hg. There was one asymptomatic hemorrhage in the EP group (14.3 {\%} hemorrhage rate) and two hemorrhages in the IP group (hemorrhage rate was 15.4 {\%}), both of which were fatal. Overall mortality rate in the EP group was 71.4 {\%} (5/7) with two patients receiving transplantation, and one death in the transplant group. Overall mortality in the IP group was 38.5 {\%} (5/13) with nine liver transplantations; three of the transplanted patients died, including one of the fatal hemorrhages due to monitor placement. Intracranial hypertension is common in patients with ALF with severe hepatic encephalopathy. Monitored patients in both groups experienced elevations of ICP in the setting of intermittent coagulopathy. Severity of coagulopathy did not influence hemorrhage rate. Yet, hemorrhages related to IP monitoring can be catastrophic and may add to the overall mortality.",
keywords = "Acute liver failure, Cerebral edema, Fulminant hepatic failure, Intracranial pressure monitoring",
author = "Maloney, {Patrick R.} and Mallory, {Grant W.} and Atkinson, {John L.D.} and Wijdicks, {Eelco F.} and Alejandro Rabinstein and {Van Gompel}, Jamie",
year = "2016",
month = "8",
day = "1",
doi = "10.1007/s12028-016-0261-y",
language = "English (US)",
volume = "25",
pages = "86--93",
journal = "Neurocritical Care",
issn = "1541-6933",
publisher = "Humana Press",
number = "1",

}

TY - JOUR

T1 - Intracranial Pressure Monitoring in Acute Liver Failure

T2 - Institutional Case Series

AU - Maloney, Patrick R.

AU - Mallory, Grant W.

AU - Atkinson, John L.D.

AU - Wijdicks, Eelco F.

AU - Rabinstein, Alejandro

AU - Van Gompel, Jamie

PY - 2016/8/1

Y1 - 2016/8/1

N2 - Acute liver failure (ALF) has been associated with cerebral edema and elevated intracranial pressure (ICP), which may be managed utilizing an ICP monitor. The most feared complication of placement is catastrophic intracranial hemorrhage in the setting of severe coagulopathy. Previous studies reported hemorrhage rates between 3.8–22 % among various devices, with epidural catheters having lower hemorrhage rates and precision relative to subdural bolts and intraparenchymal catheters. We sought to identify institutional hemorrhagic rates of ICP monitoring in ALF and its associated factors in a modern series guided by protocol implantation. Patient records treated for ALF with ICP monitoring at Mayo Clinic in Rochester, MN from 1995 to 2014 were reviewed. Protocalized since 1995, epidural (EP) ICP monitors were first used followed by intraparenchymal (IP) for stage III–IV hepatic encephalopathy. The following variables and outcomes were collected: patient demographics, ICPs and treatment methods, laboratory data, imaging studies, number of days for ICP monitoring, radiographic and symptomatic hemorrhage rates, orthotopic liver transplantation rates, and death. A total of 20 ICP monitors were placed for ALF, 7 EP, and 13 IP. International normalized ratio (INR) at placement of an EP monitor was 2.4 (1.7–3.2) with maximum of 2.7 (2.0–3.6) over the following 2.3 (1–3) days. Mean EP ICP at placement was 36.3 (11–55) and maximum of 43.1 (20–70) mm Hg. INR at placement of an IP monitor was 1.3 (<0.8–3.0) with maximum value of 2.9 (1.6–5.4) over the following 4.2 (2–6) days. Mean IP ICP at placement was 9.9 (2–19) and maximum was 39.8 (11–100) mm Hg. There was one asymptomatic hemorrhage in the EP group (14.3 % hemorrhage rate) and two hemorrhages in the IP group (hemorrhage rate was 15.4 %), both of which were fatal. Overall mortality rate in the EP group was 71.4 % (5/7) with two patients receiving transplantation, and one death in the transplant group. Overall mortality in the IP group was 38.5 % (5/13) with nine liver transplantations; three of the transplanted patients died, including one of the fatal hemorrhages due to monitor placement. Intracranial hypertension is common in patients with ALF with severe hepatic encephalopathy. Monitored patients in both groups experienced elevations of ICP in the setting of intermittent coagulopathy. Severity of coagulopathy did not influence hemorrhage rate. Yet, hemorrhages related to IP monitoring can be catastrophic and may add to the overall mortality.

AB - Acute liver failure (ALF) has been associated with cerebral edema and elevated intracranial pressure (ICP), which may be managed utilizing an ICP monitor. The most feared complication of placement is catastrophic intracranial hemorrhage in the setting of severe coagulopathy. Previous studies reported hemorrhage rates between 3.8–22 % among various devices, with epidural catheters having lower hemorrhage rates and precision relative to subdural bolts and intraparenchymal catheters. We sought to identify institutional hemorrhagic rates of ICP monitoring in ALF and its associated factors in a modern series guided by protocol implantation. Patient records treated for ALF with ICP monitoring at Mayo Clinic in Rochester, MN from 1995 to 2014 were reviewed. Protocalized since 1995, epidural (EP) ICP monitors were first used followed by intraparenchymal (IP) for stage III–IV hepatic encephalopathy. The following variables and outcomes were collected: patient demographics, ICPs and treatment methods, laboratory data, imaging studies, number of days for ICP monitoring, radiographic and symptomatic hemorrhage rates, orthotopic liver transplantation rates, and death. A total of 20 ICP monitors were placed for ALF, 7 EP, and 13 IP. International normalized ratio (INR) at placement of an EP monitor was 2.4 (1.7–3.2) with maximum of 2.7 (2.0–3.6) over the following 2.3 (1–3) days. Mean EP ICP at placement was 36.3 (11–55) and maximum of 43.1 (20–70) mm Hg. INR at placement of an IP monitor was 1.3 (<0.8–3.0) with maximum value of 2.9 (1.6–5.4) over the following 4.2 (2–6) days. Mean IP ICP at placement was 9.9 (2–19) and maximum was 39.8 (11–100) mm Hg. There was one asymptomatic hemorrhage in the EP group (14.3 % hemorrhage rate) and two hemorrhages in the IP group (hemorrhage rate was 15.4 %), both of which were fatal. Overall mortality rate in the EP group was 71.4 % (5/7) with two patients receiving transplantation, and one death in the transplant group. Overall mortality in the IP group was 38.5 % (5/13) with nine liver transplantations; three of the transplanted patients died, including one of the fatal hemorrhages due to monitor placement. Intracranial hypertension is common in patients with ALF with severe hepatic encephalopathy. Monitored patients in both groups experienced elevations of ICP in the setting of intermittent coagulopathy. Severity of coagulopathy did not influence hemorrhage rate. Yet, hemorrhages related to IP monitoring can be catastrophic and may add to the overall mortality.

KW - Acute liver failure

KW - Cerebral edema

KW - Fulminant hepatic failure

KW - Intracranial pressure monitoring

UR - http://www.scopus.com/inward/record.url?scp=84960365538&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84960365538&partnerID=8YFLogxK

U2 - 10.1007/s12028-016-0261-y

DO - 10.1007/s12028-016-0261-y

M3 - Article

VL - 25

SP - 86

EP - 93

JO - Neurocritical Care

JF - Neurocritical Care

SN - 1541-6933

IS - 1

ER -