A Head CT is Unnecessary in the Initial Evaluation of A Cirrhotic Patient with Recurrent Hepatic Encephalopathy

Abstract

In conclusion, the yield of a head CT in determining the cause of change in mental status is extremely low in patients with cirrhosis who present with recurrent hepatic encephalopathy.

Low yield of head CT in cirrhotic patients presenting with hepatic encephalopathy

“…These two patients had a 5 mm haemorrhagic metastatic lesion and an 8 mm cortical haemorrhage, both without mass effect or surrounding oedema. Similarly, Kumar et al evaluated 147 HCTs in cirrhotic patients presenting with HE, in which 4% had abnormal HCT findings 6 and only one (0.7%) patient had abnormal imaging in the setting of a normal neurological exam. However, the patient did have a history of remote fall.…”

“…However, the patient did have a history of remote fall. 6 All patients in Rahimi and Rockey’s cohort evaluating cirrhotic patients admitted to the hospital with altered mentation found to have abnormal imaging had FNDs. 7 Lastly, Donovan et al examined a cohort of patients with cirrhosis presenting with HE and reported higher rates of detecting ICH in patients presenting with trauma, FNDs or a history of ICH compared with patients presenting with AMS, headache or fever.…”

“…William Beaumont Hospital, Royal Oak (WBH-RO) is a tertiary care referral centre in Michigan, USA with an active liver transplant programme since 2010. 6 A retrospective cohort of emergency department (ED) and hospitalised adult patient encounters at WBH-RO presenting with HE between 1 January 2016 and 31 December 2018 was identified using an electronic health record (EHR) query of the following International Classification of Diseases (ICD) codes: (1) 572.2 HE (ninth edition) and (2) K72.91 Hepatic failure, unspecified with coma (10th edition). Patients were included if they had a HCT without intravenous contrast on presentation or during the hospitalisation, and a diagnosis of liver cirrhosis.…”

“…However, ICH is typically accompanied by focal neurological deficit(s) (FND) on physical examination. Despite low diagnostic yield in the absence of FND demonstrated by several studies, [5][6][7] noncontrast head CT (HCT) is still frequently used in evaluation of cirrhotic patients presenting with altered consciousness, contributing to higher healthcare costs. 5 The American Association for the Study of Liver Diseases (AASLD) and European…”

Neurologic Imaging in a Patient with Cirrhosis and Altered Mental Status: To CT or Not to CT

“…Clinicians may have concern regarding intracranial hemorrhage due to underlying coagulopathy or thrombocytopenia, even though these findings do not translate to an increased risk of bleeding [3,12]. Studies have shown that the yield of brain imaging in repeat HE admissions is low, specifically when there are no histories of falls or trauma or focal neurologic deficits on exam [5,13]. Donovan et al looked at 462 HE admissions and found that the number needed to scan (NNS) for a positive result varied by indication for the scan, showing a low yield if no indication for imaging other than altered mental status: focal neurological deficits (NNS � 9), fall/trauma (NNS � 20), and altered mental status without any other findings (NNS � 293) [14].…”