Brain CT Scan Diagnostic and Prognostic Value in Patients With Acute Liver Failure and Cerebral Edema: A Multicenter Cohort Study

Abstract

Objective: Patients with acute liver failure (ALF) may develop cerebral edema. We aimed to study the CT scan diagnostic and prognostic value among patients with ALF and cerebral edema.

Design: International multicenter retrospective cohort.

Setting: U.S. Acute Liver Failure Study Group prospective registry.

Patients: Consecutive patients with ALF within the registry from January 1998 to August 2016.

Interventions: The primary exposure was cerebral edema on CT scan. The primary endpoint was 21-day post-inclusion transplant-free survival (TFS).

Measurements and main results: Among 2108 patients with ALF, 243 (11.5%) had a brain CT scan. Among those 243 patients, 105 (43.2%) had cerebral edema and 11 (4.5%) later developed tonsillar herniation. Patients with cerebral edema on CT scan were younger (36 vs. 46 yr; p < 0.001) and more often females (81.0% vs. 63.8%; p = 0.003), had more acetaminophen-related ALF (61.0% vs. 39.4%; p < 0.001), required more frequently invasive mechanical ventilation on day 1 (73.3% vs. 55.8%; p = 0.005), and had higher maximum days 1-7 model for end-stage liver disease (MELD) score (39 vs. 35; p = 0.002) than others. Following adjustment for confounders (age, acetaminophen toxicity, and severity of disease by MELD), cerebral edema was associated with lower odds of 21-day TFS (adjusted odds ratio = 0.36 [95% CI, 0.18-0.72]; C-statistic = 0.81 [95% CI, 0.75-0.86]; p = 0.003). However, cerebral edema was not associated with selection for liver transplant (22.9% vs. 16.1%; p = 0.18).

Conclusions: In our cohort of patients with ALF, brain CT scan use increased overtime. Among those with a brain CT scan, about two in five had cerebral edema. Cerebral edema on CT scan was independently associated with worse 21-day TFS but did not preclude transplant. Brain CT scan may provide additional diagnostic and prognostic information in selected patients with ALF.

Keywords: cerebral edema; death; intracranial hypertension; liver failure; transplant.