Brain edema in liver failure: Basic physiologic principles and management

  title={Brain edema in liver failure: Basic physiologic principles and management},
  author={Fin Stolze Larsen and Julia A. Wendon},
  journal={Liver Transplantation},
In patients with severe liver failure, brain edema is a frequent and serious complication that may result in high intracranial pressure and brain damage. This short article focuses on basic physiologic principles that determine water flux across the blood‐brain barrier. Using the Starling equation, it is evident that both the osmotic and hydrostatic pressure gradients are imbalanced across the blood‐brain barrier in patients with acute liver failure. This combination will tend to favor cerebral… 
Treatment of Brain Edema in Acute Liver Failure
Management of intracranial pressure in patients with acute liver failure should be guided by well-defined treatment protocols, and the most promising novel therapeutic alternative is the induction of moderate hypothermia for brain swelling caused by liver failure.
Prevention and management of brain edema in patients with acute liver failure
  • F. Larsen, J. Wendon
  • Medicine
    Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society
  • 2008
If intracranial hypertension evolves despite these first‐tier interventions, increased sedation, induction of hypothermia, and the use of anti‐inflammatory drugs may help secure brain viability.
Therapeutic hypothermia for acute liver failure
Although an ample body of experimental and human data provides a rationale for the use of therapeutic Hypothermia in patients with acute liver failure, multicenter, randomized, controlled clinical trials are needed to confirm that hypothermia secures brain viability and improves survival without causing harm.
Encephalopathy and Cerebral Edema in the Setting of Acute Liver Failure: Pathogenesis and Management
Treatment should be focused at optimizing liver function and regenerative capacity and minimizing the inflammatory milieu, and the use of cooling in the management of patients with acute liver failure and raised intracranial pressure is developed.
Mild hypothermia for acute liver failure: a review of mechanisms of action.
At a time when mild hypothermia is increasingly used in several specialized centers, performance of a randomized controlled trial seems critical to confirm the benefits of mild hypotherapy in acute liver failure and to provide adequate guidelines for its use.
Mechanisms of brain edema in acute liver failure and impact of novel therapeutic interventions
Continued elucidation of the mechanisms of brain edema in acute liver failure has established ammonia and the astrocyte as major players in its pathogenesis and are reflected in the various clinical trials of novel therapeutic interventions.
Cerebral Blood Flow in Acute Liver Failure: A Finding in Search of a Mechanism
Several mediators potentially involved in the development of cerebral hyperemia in ALF are examined in this review, but further work is needed to assess the role, if any, of each of them.
Management of Cerebral Edema in Acute Liver Failure
This review particularly provides a practical focus on general management of the patient with established cerebral edema as well as specific intracranial pressure‐lowering strategies, and a brief summary into the pathophysiology and risk factors for developing cerebralEdema in the context of acute liver failure.


Cerebral blood flow and metabolism in fulminant liver failure
The depressed cerebral metabolic rate for oxygen in patients with fulminant liver failure is inappropriate to metabolic requirements, as demonstrated by both cerebral lactate production and the increase in cerebral oxygen consumption after improvement in cerebral blood flow.
Mild Hypothermia Prevents Cerebral Edema and CSF Lactate Accumulation in Acute Liver Failure
It is suggested that mild hypothermia could be beneficial in the prevention of severe encephalopathy and brain edema in patients with ALF awaiting liver transplantation and open the way for magnetic resonance spectroscopic monitoring of cerebral function in ALF.
Cerebral herniation in patients with acute E liver failure is correlated with arterial ammonia concentration
In ALF in humans, vast amounts of ammonia escape hepatic metabolism, leading to high arterial ammonia concentrations, which in turn is associated with increased cerebral ammonia uptake and CH.
Indomethacin prevents the development of experimental ammonia‐induced brain edema in rats after portacaval anastomosis
Avoiding cerebral vasodilatation with indomethacin will prevent the development of brain edema in this hyperammonemic model, and cerebral vasoconstriction reduces cerebral ammonia uptake and, if selective to the brain, may be of benefit in FHF.
Regional Cerebral Blood Flow and CO2 Reactivity in Fulminant Hepatic Failure
The relatively “normal” CBF values obtained in FHF patients in severe hepatic encephalopathy coupled with the lack of vasodilatation to hypoventilation suggest a state of uncoupled CBF and metabolism or “luxury perfusion” that could theoretically contribute to vasogenic edema, brain swelling, and cerebral herniation.
Cerebral blood flow and the development of ammonia‐induced brain edema in rats after portacaval anastomosis
In this model, the rise of CBF reflects intracranial events that occur after glutamine synthesis, and Activation of nitric oxide synthase in the brain could account for these findings.