Noninvasive Monitoring of Cerebral Perfusion by Transcranial Doppler During Fulminant Hepatic Failure and Liver Transplantation

Abstract

Survival in patients with fulminant hepatic failure (FHF) treated medically, rather than surgically, ranges from 12%-67% (mean 39%), depending on the cause of the disease (1). The major cause of mortality is increased intracranial pressure (ICI’) from brain edema (2). For patients with a poor prognosis (3), orthotopic liver transplantation may be the definitive treatment (41, even though, only a few years ago, some considered this treatment ineffective by the time patients reached Grade 4 encephalopathy (5). ICI’ monitoring allows physicians to use specific therapy to control intracranial hypertension. Continuous measurement of ICI’ perioperatively in the management of FHF has been associated with a survival rate of 54%74% in a series of six to 23 patients (6-9), which is generally higher than with medical means (l), and was as high as 92% for the selected group who had undergone liver transplantation (6). Such invasive monitoring, however, is especially risky in FHF patients with coagulopathy, in whom the incidence of bleeding from ICI’ monitoring ranges from 5%-22% (6,8) with a mortality rate of 60% (6). Although the use of ICI’ monitoring for FHF has become more routine (8), not all centers support the use of this invasive monitoring. We describe a patient with FHF and brain edema who underwent liver transplantation and whose cerebral perfusion was monitored noninvasively by transcranial Doppler (TCD) imaging, as well as invasively by ICI’. The noninvasive technique provided adequate information when cerebral perfusion was low, comparable with the invasive technique, and allowed intracranial hypertension to be diagnosed and treated effectively.