Critical Care Explorations (Apr 2025)

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

  • Filipe S. Cardoso, MD, MSc,
  • William M. Lee, MD,
  • Constantine J. Karvellas, MD, MSc,
  • U.S. Acute Liver Failure Study Group,
  • W.M. Lee, MD,
  • Anne M. Larson, MD,
  • Iris Liou, MD,
  • Oren Fix, MD,
  • Michael Schilsky, MD,
  • Timothy McCashland, MD,
  • J. Eileen Hay, MBBS,
  • Natalie Murray, MD,
  • A. Obaid S. Shaikh, MD,
  • Andres Blei, MD,
  • Daniel Ganger, MD,
  • Atif Zaman, MD,
  • Steven H.B. Han, MD,
  • Robert Fontana, MD,
  • Brendan McGuire, MD,
  • Raymond T. Chung, MD,
  • Alastair Smith, MB, ChB,
  • Robert Brown, MD,
  • Jeffrey Crippin, MD,
  • Adrian Reuben, MBBS,
  • Santiago Munoz, MD,
  • Rajender Reddy, MD,
  • R. Todd Stravitz, MD,
  • Lorenzo Rossaro, MD,
  • Raj Satyanarayana, MD,
  • Tarek Hassanein, MD,
  • Constantine J. Karvellas, MD,
  • Jodi Olson, MD,
  • Ram Subramanian, MD,
  • James Hanje, MD,
  • Bilal Hameed, MD,
  • Grace Samuel,
  • Ezmina Lalani,
  • Carla Pezzia,
  • Corron Sanders, PhD,
  • Nahid Attar,
  • Linda S. Hynan, PhD,
  • Valerie Durkalski, PhD,
  • Wenle Zhao, PhD,
  • Jaime Speiser,
  • Catherine Dillon,
  • Holly Battenhouse,
  • Michelle Gottfried

DOI
https://doi.org/10.1097/cce.0000000000001251
Journal volume & issue
Vol. 7, no. 4
p. e1251

Abstract

Read online

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.