Central nervous system alterations in liver cirrhosis: The role of portal-systemic shunt and portal hypoperfusion

The role of portal-systemic shunting and portal liver hypoperfusion in the pathophysiology of central nervous system dysfunction of cirrhosis is not yet well defined. It is well known that one of the most important collateral vessels (CV) is a patent paraumbilical vein (PUV) but there is controversy regarding its clinical significance. We have evaluated the relationships between neuropsychological and EEG alterations, ammonia plasma level (NH4), hepatic function, and portal hemodynamics (Doppler Ultrasound) in 95 cirrhotic patients. Patency, diameter, or flow of PUV or the presence of other CV were not related to an increased prevalence of neuropsychological or EEG abnormalities. Patients with effective portal flow (EPF = portal flow - PUV flow) lower than 692 mL/min (median) had a significantly higher risk of failing the neuropsychological test, or of having an altered EEG. Low EPF and prothrombin time (<50%), and high NH4 (> or = 51 micromol/L) were independent predictors of an abnormal EEG. Considering both low EPF and the numerosity of CV, only low EPF was found to explain EEG alterations. In conclusion, portal liver hypoperfusion and decreased liver function were associated with an increased risk of central nervous system dysfunction in cirrhotic patients, whereas PUV patency per se was not.