• Christopher R Newey, Pravin George, Aarti Sarwal, Norman So, and Stephen Hantus.
• Department of Neurology, University of Missouri, 1 Hospital Drive, Columbia, MO, 65211, USA. neweyc@health.missouri.edu.
• Neurocrit Care. 2018 Feb 1; 28 (1): 97-103.

BackgroundNeurological complications in liver failure are common. Often under-recognized neurological complications are seizures and status epilepticus. These may go unrecognized without continuous electroencephalography (CEEG). We highlight the observed electro-radiological changes in patients with grade III/IV hepatic encephalopathy (HE) found to have seizures and/or status epilepticus on CEEG and the associated neuroimaging.MethodsThis study was a retrospective review of patients with West Haven grade III/IV HE and seizures/status epilepticus on CEEG.ResultsEleven patients were included. Alcohol was the most common cause of HE (54.5%). All patients were either stuporous/comatose. The most common CEEG pattern was diffuse slowing (100%) followed by generalized periodic discharges (GPDs; 36.4%) and lateralized periodic discharges (LPDs, 36.4%). The subtype of GPDs with triphasic morphology was only seen in 27.3%. All seizures and/or status epilepticus were without clinical signs. Magnetic resonance imaging (MRI) was available in six patients. Cortical hyperintensities on diffusion weighted imaging sequence were seen in all six patients. One patient had CEEG seizure concomitantly with the MRI. Seven patients died prior to discharge.ConclusionSeizures or status epilepticus in the setting of HE were without clinical findings and could go unrecognized without CEEG. The finding of cortical hyperintensity on MRI should lead to further evaluation for unrecognized seizure or status epilepticus.

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