23.4% saline decreases brain tissue volume in severe hepatic encephalopathy as assessed by a quantitative CT marker

Eric Michael Liotta, Bryan D. Lizza, Anna L. Romanova, James C. Guth, Michael D. Berman, Timothy J. Carroll, Brandon Francis, Daniel R Ganger, Daniela P Ladner, Matthew Brandon Maas, Andrew M Naidech

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Objective: Cerebral edema is common in severe hepatic encephalopathy and may be life threatening. Bolus 23.4% hypertonic saline improves surveillance neuromonitoring scores, although its mechanism of action is not clearly established. We investigated the hypothesis that bolus hypertonic saline decreases cerebral edema in severe hepatic encephalopathy utilizing a quantitative technique to measure brain and cerebrospinal fluid volume changes. Design: Retrospective analysis of serial CT scans, and clinical data for a case-control series were performed. Setting: ICUs of a tertiary care hospital. Patients: Patients with severe hepatic encephalopathy treated with 23.4% hypertonic saline and control patients who did not receive 23.4% hypertonic saline. Interventions: 23.4% hypertonic saline bolus administration. Measurements and Main Results: We used clinically obtained CT scans to measure volumes of the ventricles, intracranial cerebrospinal fluid, and brain using a previously validated semiautomated technique (Analyze Direct, Overland Park, KS). Volumes before and after 23.4% hypertonic saline were compared with Wilcoxon signed rank test. Associations among total cerebrospinal fluid volume, ventricular volume, serum sodium, and Glasgow Coma Scale scores were assessed using Spearman rank correlation test. Eleven patients with 18 administrations of 23.4% hypertonic saline met inclusion criteria. Total cerebrospinal fluid (median, 47.6 mL [35.1-69.4 mL] to 61.9 mL [47.7-87.0 mL]; p < 0.001) and ventricular volumes (median, 8.0 mL [6.9-9.5 mL] to 9.2 mL [7.8-11.9 mL]; p = 0.002) increased and Glasgow Coma Scale scores improved (median, 4 [3-6] to 7 [6-9]; p = 0.008) after 23.4% hypertonic saline. In contrast, total cerebrospinal fluid and ventricular volumes decreased in untreated control patients. Serum sodium increase was associated with increase in total cerebrospinal fluid volume (r = 0.83, p < 0.001), and change in total cerebrospinal fluid volume was associated with ventricular volume change (r = 0.86; p < 0.001). Conclusions: Total cerebrospinal fluid and ventricular volumes increased after 23.4% hypertonic saline, consistent with a reduction in brain tissue volume. Total cerebrospinal fluid and ventricular volume change may be useful quantitative measures to assess cerebral edema in severe hepatic encephalopathy.

Original languageEnglish (US)
Pages (from-to)171-179
Number of pages9
JournalCritical care medicine
Volume44
Issue number1
DOIs
StatePublished - Jan 1 2016

Fingerprint

Hepatic Encephalopathy
Cerebrospinal Fluid
Brain
Brain Edema
Glasgow Coma Scale
Sodium
Tertiary Healthcare
Nonparametric Statistics
Serum
Tertiary Care Centers

Keywords

  • cerebral edema
  • coma
  • critical care
  • gastrointestinal disease
  • hepatic encephalopathy
  • hyperosmolar therapy
  • hypertonic saline
  • liver failure

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Liotta, Eric Michael ; Lizza, Bryan D. ; Romanova, Anna L. ; Guth, James C. ; Berman, Michael D. ; Carroll, Timothy J. ; Francis, Brandon ; Ganger, Daniel R ; Ladner, Daniela P ; Maas, Matthew Brandon ; Naidech, Andrew M. / 23.4% saline decreases brain tissue volume in severe hepatic encephalopathy as assessed by a quantitative CT marker. In: Critical care medicine. 2016 ; Vol. 44, No. 1. pp. 171-179.
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title = "23.4{\%} saline decreases brain tissue volume in severe hepatic encephalopathy as assessed by a quantitative CT marker",
abstract = "Objective: Cerebral edema is common in severe hepatic encephalopathy and may be life threatening. Bolus 23.4{\%} hypertonic saline improves surveillance neuromonitoring scores, although its mechanism of action is not clearly established. We investigated the hypothesis that bolus hypertonic saline decreases cerebral edema in severe hepatic encephalopathy utilizing a quantitative technique to measure brain and cerebrospinal fluid volume changes. Design: Retrospective analysis of serial CT scans, and clinical data for a case-control series were performed. Setting: ICUs of a tertiary care hospital. Patients: Patients with severe hepatic encephalopathy treated with 23.4{\%} hypertonic saline and control patients who did not receive 23.4{\%} hypertonic saline. Interventions: 23.4{\%} hypertonic saline bolus administration. Measurements and Main Results: We used clinically obtained CT scans to measure volumes of the ventricles, intracranial cerebrospinal fluid, and brain using a previously validated semiautomated technique (Analyze Direct, Overland Park, KS). Volumes before and after 23.4{\%} hypertonic saline were compared with Wilcoxon signed rank test. Associations among total cerebrospinal fluid volume, ventricular volume, serum sodium, and Glasgow Coma Scale scores were assessed using Spearman rank correlation test. Eleven patients with 18 administrations of 23.4{\%} hypertonic saline met inclusion criteria. Total cerebrospinal fluid (median, 47.6 mL [35.1-69.4 mL] to 61.9 mL [47.7-87.0 mL]; p < 0.001) and ventricular volumes (median, 8.0 mL [6.9-9.5 mL] to 9.2 mL [7.8-11.9 mL]; p = 0.002) increased and Glasgow Coma Scale scores improved (median, 4 [3-6] to 7 [6-9]; p = 0.008) after 23.4{\%} hypertonic saline. In contrast, total cerebrospinal fluid and ventricular volumes decreased in untreated control patients. Serum sodium increase was associated with increase in total cerebrospinal fluid volume (r = 0.83, p < 0.001), and change in total cerebrospinal fluid volume was associated with ventricular volume change (r = 0.86; p < 0.001). Conclusions: Total cerebrospinal fluid and ventricular volumes increased after 23.4{\%} hypertonic saline, consistent with a reduction in brain tissue volume. Total cerebrospinal fluid and ventricular volume change may be useful quantitative measures to assess cerebral edema in severe hepatic encephalopathy.",
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23.4% saline decreases brain tissue volume in severe hepatic encephalopathy as assessed by a quantitative CT marker. / Liotta, Eric Michael; Lizza, Bryan D.; Romanova, Anna L.; Guth, James C.; Berman, Michael D.; Carroll, Timothy J.; Francis, Brandon; Ganger, Daniel R; Ladner, Daniela P; Maas, Matthew Brandon; Naidech, Andrew M.

In: Critical care medicine, Vol. 44, No. 1, 01.01.2016, p. 171-179.

Research output: Contribution to journalArticle

TY - JOUR

T1 - 23.4% saline decreases brain tissue volume in severe hepatic encephalopathy as assessed by a quantitative CT marker

AU - Liotta, Eric Michael

AU - Lizza, Bryan D.

AU - Romanova, Anna L.

AU - Guth, James C.

AU - Berman, Michael D.

AU - Carroll, Timothy J.

AU - Francis, Brandon

AU - Ganger, Daniel R

AU - Ladner, Daniela P

AU - Maas, Matthew Brandon

AU - Naidech, Andrew M

PY - 2016/1/1

Y1 - 2016/1/1

N2 - Objective: Cerebral edema is common in severe hepatic encephalopathy and may be life threatening. Bolus 23.4% hypertonic saline improves surveillance neuromonitoring scores, although its mechanism of action is not clearly established. We investigated the hypothesis that bolus hypertonic saline decreases cerebral edema in severe hepatic encephalopathy utilizing a quantitative technique to measure brain and cerebrospinal fluid volume changes. Design: Retrospective analysis of serial CT scans, and clinical data for a case-control series were performed. Setting: ICUs of a tertiary care hospital. Patients: Patients with severe hepatic encephalopathy treated with 23.4% hypertonic saline and control patients who did not receive 23.4% hypertonic saline. Interventions: 23.4% hypertonic saline bolus administration. Measurements and Main Results: We used clinically obtained CT scans to measure volumes of the ventricles, intracranial cerebrospinal fluid, and brain using a previously validated semiautomated technique (Analyze Direct, Overland Park, KS). Volumes before and after 23.4% hypertonic saline were compared with Wilcoxon signed rank test. Associations among total cerebrospinal fluid volume, ventricular volume, serum sodium, and Glasgow Coma Scale scores were assessed using Spearman rank correlation test. Eleven patients with 18 administrations of 23.4% hypertonic saline met inclusion criteria. Total cerebrospinal fluid (median, 47.6 mL [35.1-69.4 mL] to 61.9 mL [47.7-87.0 mL]; p < 0.001) and ventricular volumes (median, 8.0 mL [6.9-9.5 mL] to 9.2 mL [7.8-11.9 mL]; p = 0.002) increased and Glasgow Coma Scale scores improved (median, 4 [3-6] to 7 [6-9]; p = 0.008) after 23.4% hypertonic saline. In contrast, total cerebrospinal fluid and ventricular volumes decreased in untreated control patients. Serum sodium increase was associated with increase in total cerebrospinal fluid volume (r = 0.83, p < 0.001), and change in total cerebrospinal fluid volume was associated with ventricular volume change (r = 0.86; p < 0.001). Conclusions: Total cerebrospinal fluid and ventricular volumes increased after 23.4% hypertonic saline, consistent with a reduction in brain tissue volume. Total cerebrospinal fluid and ventricular volume change may be useful quantitative measures to assess cerebral edema in severe hepatic encephalopathy.

AB - Objective: Cerebral edema is common in severe hepatic encephalopathy and may be life threatening. Bolus 23.4% hypertonic saline improves surveillance neuromonitoring scores, although its mechanism of action is not clearly established. We investigated the hypothesis that bolus hypertonic saline decreases cerebral edema in severe hepatic encephalopathy utilizing a quantitative technique to measure brain and cerebrospinal fluid volume changes. Design: Retrospective analysis of serial CT scans, and clinical data for a case-control series were performed. Setting: ICUs of a tertiary care hospital. Patients: Patients with severe hepatic encephalopathy treated with 23.4% hypertonic saline and control patients who did not receive 23.4% hypertonic saline. Interventions: 23.4% hypertonic saline bolus administration. Measurements and Main Results: We used clinically obtained CT scans to measure volumes of the ventricles, intracranial cerebrospinal fluid, and brain using a previously validated semiautomated technique (Analyze Direct, Overland Park, KS). Volumes before and after 23.4% hypertonic saline were compared with Wilcoxon signed rank test. Associations among total cerebrospinal fluid volume, ventricular volume, serum sodium, and Glasgow Coma Scale scores were assessed using Spearman rank correlation test. Eleven patients with 18 administrations of 23.4% hypertonic saline met inclusion criteria. Total cerebrospinal fluid (median, 47.6 mL [35.1-69.4 mL] to 61.9 mL [47.7-87.0 mL]; p < 0.001) and ventricular volumes (median, 8.0 mL [6.9-9.5 mL] to 9.2 mL [7.8-11.9 mL]; p = 0.002) increased and Glasgow Coma Scale scores improved (median, 4 [3-6] to 7 [6-9]; p = 0.008) after 23.4% hypertonic saline. In contrast, total cerebrospinal fluid and ventricular volumes decreased in untreated control patients. Serum sodium increase was associated with increase in total cerebrospinal fluid volume (r = 0.83, p < 0.001), and change in total cerebrospinal fluid volume was associated with ventricular volume change (r = 0.86; p < 0.001). Conclusions: Total cerebrospinal fluid and ventricular volumes increased after 23.4% hypertonic saline, consistent with a reduction in brain tissue volume. Total cerebrospinal fluid and ventricular volume change may be useful quantitative measures to assess cerebral edema in severe hepatic encephalopathy.

KW - cerebral edema

KW - coma

KW - critical care

KW - gastrointestinal disease

KW - hepatic encephalopathy

KW - hyperosmolar therapy

KW - hypertonic saline

KW - liver failure

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DO - 10.1097/CCM.0000000000001276

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