Low Likelihood of Intracranial Hemorrhage in Patients With Cirrhosis and Altered Mental Status

Abstract

Given the myriad causes of altered mental status (AMS), patients with cirrhosis and hepatic encephalopathy often present a diagnostic dilemma. In light of the perceived bleeding tendency of patients with cirrhosis, intracranial hemorrhage (ICH) is often feared, so these patients frequently undergo non-contrast computed tomography (CT) of the head. However, little is known about the diagnostic yield of CT for patients with cirrhosis presenting with AMS. We analyzed all unique admissions of patients with cirrhosis who underwent head CT from 2003 through 2013 (N= 462) at the Beth Israel Deaconess Medical Center in Boston. By using blinded reviewers, we coded the indications and results of the CT scans separately and evaluated patient characteristics associated with acute findings. A higher proportion of patients who presented with falls or trauma, focal neurologic signs, or history of ICH were found to have ICH (13 of 146, 8.9%) than of patients who presented with AMS, headache, or fever (1 of 316, 0.3%; P < .0001). The odds ratio of ICH in patients with low-risk indications was 0.02 (95% confidence interval, 0.001-0.14). The number needed to scan (NNS) for each positive result from CT varied by indication: focal neurologic deficits (NNS= 9), fall/trauma (NNS= 20), and AMS (NNS= 293). There was no association between presence of new, acute ICH and platelet count, international normalized ratio, level of creatinine, or Model for End-Stage Liver Disease score. Despite abnormal hemostatic indices, patients with cirrhosis presenting with AMS in the absence of focal neurologic deficits or trauma have a low likelihood of ICH.