Metabolic Brain Disease

, Volume 20, Issue 2, pp 115–127 | Cite as

Attention Dysfunction in Cirrhotic Patients: An Inquiry on the Role of Executive Control, Attention Orienting and Focusing

  • Piero Amodio
  • Sami Schiff
  • Franco Del Piccolo
  • Daniela Mapelli
  • Angelo Gatta
  • Carlo Umiltà


Attention alterations are reported in cirrhotics. Aiming at clarifying attention functioning in cirrhotics, an inquiry on the functioning of the anterior (AAS) and the posterior (PAS) attention system was performed. Thirty-six cirrhotics without overt hepatic encephalopathy (24 with EEG or TMT-A alterations) and 16 matched control subjects were enrolled. The AAS was studied by the Stroop task measuring selective attention control, the PAS was studied by the Posner task and the Focus task measuring automatic covert orienting and visual focusing of attention respectively.

Cirrhotics presented a task-dependent psychomotor slowing (Stroop > Posner > Focus) with an increased percentage of errors in the incongruent condition of the Stroop task [F(1, 57) = 4.9, p < 0.03]. Class C patients had both a selective slowing [F(1, 33) = 4.3, p < 0.05] and an increased percentage of errors in the incongruent condition [F(1, 34) = 5.1, p < 0.05] compared to Class A–B patients and controls. The patients with an altered EEG performed the Stroop test significantly slowly than those without EEG alterations [F(1, 41) = 8.9, p < 0.01] and with a clear trend for a higher number of errors in the incongruent condition [F(1, 39) = 3.8, p < 0.06]. In contrast, attention orienting and focusing were maintained. In conclusion, the AAS is more sensitive than the PAS to the early stages of hepatic encephalopathy.

Key words

Attention liver cirrhosis TMT-A EEG attention focusing attention orienting divided attention 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Amodio, P., Marchetti, P., Del Piccolo, F., Sartori, G., Prior, M., Merkel, C., and Gatta, A. (1995). Visual attention orienting in liver cirrhosis without overt hepatic encephalopathy. Metab. Brain Dis. 10:335–345.PubMedGoogle Scholar
  2. Amodio, P., Marchetti, P., Del Piccolo, F., Campo, G., Rizzo, C., Iemmolo, R.M., Gerunda, G., Caregaro, L., Merkel, C., and Gatta, A. (1998). Visual attention in cirrhotic patients: A study on covert visual attention orienting. Hepatology 27:1517–1523.CrossRefPubMedGoogle Scholar
  3. Amodio, P., Del Piccolo, F., Marchetti, P., Angeli, P., Iemmolo, R., Caregaro, L., Merkel, C., Gerunda, G., and Gatta, A. (1999a). Clinical features and survivial of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests. Hepatology 29:1662–1667.CrossRefGoogle Scholar
  4. Amodio, P., Marchetti, P., Del Piccolo, F., de Tourtchaninoff, M., Varghese, P., Zuliani, C., Campo, G., Gatta, A., and Guerit, J.M. (1999b). Spectral versus visual EEG analysis in mild hepatic encephalopathy. Clin. Neurophysiol. 110:1334–1344.CrossRefGoogle Scholar
  5. Amodio, P., Wenin, H., Del Piccolo, F., Mapelli, D., Montagnese, S., Pellegrini, A., Musto, C., Gatta, A., and Umilta, C. (2002). Variability of trail making test, symbol digit test and line trait test in normal people. A normative study taking into account age-dependent decline and sociobiological variables. Aging Clin. Exp. Res. 14:117–131.PubMedGoogle Scholar
  6. Benso, F., Turatto, M., Mascetti, G.G., and Umiltà, C. (1998). The time course of attentional focusing. Eur. J. Cogn. Psychol. 10:373–388.Google Scholar
  7. Caregaro, L., Alberino, F., Amodio, P., Merkel, C., Bolognesi, M., Angeli, P., and Gatta, A. (1996). Malnutrition in alcoholic and virus-related cirrhosis. Am. J. Clin. Nutr. 63:602–609.PubMedGoogle Scholar
  8. Corbetta, M. (1998). Frontoparietal cortical networks for directing attention and the eye to visual locations: identical, independent, or overlapping neural systems? Proc. Natl. Acad. Sci. U.S.A. 95:831–838.CrossRefPubMedGoogle Scholar
  9. Elsass, P., Lund, Y., and Ranek, L. (1978). Encephalopathy in patients with cirrhosis of the liver. A neuropsychological study. Scand. J. Gastroenterol. 13:241–247.PubMedGoogle Scholar
  10. Ferenci, P., Lockwood, A., Mullen, K., Tarter, R., Weissenborn, K., and Blei, A.T. (2002). Hepatic encephalopathy—definition, nomenclature, diagnosis, and quantification: Final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology 35:716–721.CrossRefPubMedGoogle Scholar
  11. Glaser, M.O., and Glaser, W.R. (1982). Time course analysis of the Stroop phenomenon. J. Exp. Psychol. Hum. Percept. Perform. 8:875–894.CrossRefPubMedGoogle Scholar
  12. Joebges, E.M., Heidemann, M., Schimke, N., Hecker, H., Ennen, J.C., and Weissenborn, K. (2003). Bradykinesia in minimal hepatic encephalopathy is due to disturbances in movement initiation. J. Hepatol. 38:273–280.CrossRefPubMedGoogle Scholar
  13. Jonides, J. (1980). Towards a model of the mind’s eye’s movement. Can. J. Psychol. 34:103–112.PubMedGoogle Scholar
  14. Jover, R., Company, L., Gutierrez, A., Zapater, P., Perez-Serra, J., Girona, E., Aparicio, J.R., and Perez-Mateo, M. (2003). Minimal hepatic encephalopathy and extrapyramidal signs in patients with cirrhosis. Am. J. Gastroenterol. 98:1599–1604.CrossRefPubMedGoogle Scholar
  15. Klem, G.H., Lüders, H.O., Jasper, H.H., and Elger, C. (1999). The ten-twenty electrode system of the International Federation. In (G. Deuschal and A. Eisen, eds.), Recommandations for the Practice of Clinical Neurophysiology: Guidlines of the International Federation of Clinical Neurophysiology, Elsevier, Amsterdam, pp. 3–6.Google Scholar
  16. Krieger, S., Jauss, M., Jansen, O., Theilmann, L., Geissler, M., and Krieger, D. (1996). Neuropsychiatric profile and hyperintense globus pallidus on Tl-weighted magnetic resonance images in liver cirrhosis [see comments]. Gastroenterology 111:147–155.PubMedGoogle Scholar
  17. Lockwood, A.H., Murphy, B.W., Donnelly, K.Z., Mahl, T.C., and Perini, S. (1993). Positron-emission tomographic localization of abnormalities of brain metabolism in patients with minimal hepatic encephalopathy. Hepalology 18:1061–1068.CrossRefGoogle Scholar
  18. Lockwood, A.H., Weissenborn, K., Burchert, W., Bokemeyer, M., and Wack, D.S. (1998). Neuropsychological test deficit correlate with alterated cerebral glucose metabolism in patients with non-alcoholic cirrhosis. Neurology 50:A253.Google Scholar
  19. McCrea, M., Cordoba, J., Vessey, G., Blei, A.T., and Randolph, C. (1996). Neuropsychological characterization and detection of subclinical hepatic encephalopathy. Arch. Neurol. 53:758–763.PubMedGoogle Scholar
  20. Mesulam, M.M. (1981). A cortical network for directed attention and unilateral neglect. Ann. Neurol. 10:309–325.CrossRefPubMedGoogle Scholar
  21. Pardo, J.V., Pardo, P.J., Janer, K.W., and Raichle, M.E. (1990). The anterior cingulate cortex mediates processing selection in the Stroop attentional conflict paradigm. Proc. Natl. Acad. Sci. U.S.A. 87:256–259.PubMedGoogle Scholar
  22. Posner, M.I., and Petersen, S.E. (1990). The attention system of the human brain. Annu. Rev. Neurosci. 13:25–42.CrossRefPubMedGoogle Scholar
  23. Rikkers, L., Jenko, P., Rudman, D., and Freides, D. (1978). Subclinical hepatic encephalopathy: Detection, prevalence, and relationship to nitrogen metabolism. Gastroenterology 75:462–469.PubMedGoogle Scholar
  24. Schomerus, H., Hamster, W. (1998). Neuropsychological aspects of portal-systemic encephalopathy. Metab. Brain Dis. 13:361–377.CrossRefPubMedGoogle Scholar
  25. Schomerus, H., Hamster, W., Blunck, H., Reinhard, U., Mayer, K., and Dolle, W. (1981). Latent portasystemic encephalopathy. I. Nature of cerebral functional defects and their effect on fitness to drive. Dig. Dis. Sci. 26:622–630.CrossRefPubMedGoogle Scholar
  26. Shallice, T. (1988). From Neuropsychology to mental structure, Cambridge University Press, Cambridge.Google Scholar
  27. Stuss, D.T., Floden, D., Alexander, M.P., Levine, B., and Katz, D. (2001). Stroop performance in focal lesion patients: Dissociation of processes and frontal lobe lesion location Neuropsychologia 39:771–786.CrossRefPubMedGoogle Scholar
  28. Tarter, R.E., Hegedus, A.M., Van Thiel, D.H., Schade, R.R., Gavaler, J.S., and Starzl, T.E. (1984). Nonalcoholic cirrhosis associated with neuropsychological dysfunction in the absence of overt evidence of hepatic encephalopathy. Gastroenterology 86:1421–1427.PubMedGoogle Scholar
  29. Tarter, R.E., Panzak, G., Switala, J., Lu, S., Simkevitz, H., and Van Thiel, D. (1997). Isokinetic muscle strength and its association with neuropsychological capacity in cirrhotic alcoholics. Alcohol Clin. Exp. Res. 21:191–196.PubMedGoogle Scholar
  30. Weissenborn, K., Scholz, M., Hinrichs, H., Wiltfang, J., Schmidt, F.W., Kunkel, H. (1990). Neurophysiological assessment of early encephalopathy. Electroencephalogr. Clin. Neurophysiol. 75:289–295.Google Scholar
  31. Weissenborn, K., Heidenreich, S., Ennen, J., and Ruckert, N. (2001). Attention deficit in minimal hepatic encephalopathy. Metab. Brain Dis. 16:13–19.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media, Inc. 2005

Authors and Affiliations

  • Piero Amodio
    • 1
    • 4
  • Sami Schiff
    • 1
    • 2
  • Franco Del Piccolo
    • 1
  • Daniela Mapelli
    • 1
    • 3
  • Angelo Gatta
    • 1
  • Carlo Umiltà
    • 3
  1. 1.Department of Clinical and Experimental MedicineCirmanmec University of PadovaItaly
  2. 2.Department of Neurological and Vision ScienceUniversity of VeronaItaly
  3. 3.Department of General PsychologyCirmanmec University of PadovaItaly
  4. 4.PadovaItaly

Personalised recommendations