Cerebral Edema in Acute Liver Failure: Insights From Autopsy

Acute liver failure (ALF) is a rare critical illness with a high mortality, characterised by the abrupt loss of hepatic function associated with altered consciousness from hepatic encephalopathy. In some patients, the further development of cerebral edema (CE) and intracranial hypertension (ICH) with cerebral herniation (CH) can be fatal. The current prevalence of CE and CH is unknown, and the utility of clinical physical signs and cerebral computed tomography (CT) imaging to assess the presence of CE and ICH has had limited evaluation. We investigated these issues in a large ALF patient series, evaluating cerebral findings at autopsy. The prevalence of CE and CH was markedly lower than previously reported, present in only a minority of cases studied. Younger age, more severe HE, and vasopressor requirement were closely associated with CE and CH, and manifestations were present early after transfer to a transplantation centre. External clinical signs were specific for CE but lacked sensitivity, failing to identify the majority of autopsy-proven cases. Cerebral CT showed high specificity, sensitivity, and accuracy.