Skip to main content

Advertisement

SpringerLink
Log in

Analysis of cerebral blood flow and intracranial hypertension in critical patients with non-hepatic hyperammonemia

  • Original Article
  • Published:
Metabolic Brain Disease Aims and scope Submit manuscript

Abstract

Hyperammonemia in adults is generally associated with cerebral edema, decreased cerebral metabolism, and increased cerebral blood flow. The aim of this study was to evaluate the association between non-hepatic hyperammonemia and intracranial hypertension assessed by Doppler flowmetry and measurement of the optic nerve sheath. A prospective cohort study in critically ill patients hospitalized in intensive care units of a University Hospital between March 2015 and February 2016. Clinical data and severity scores were collected and the Glasgow coma scale was recorded. Serial serum ammonia dosages were performed in all study patients. Transcranial Doppler evaluation was carried out for the first 50 consecutive results of each stratum of ammonemia: normal (<35 μmol/L), mild hyperammonemia (≥35 μmol/L and < 50 μmol/L), moderate hyperammonemia (≥50 μmol/L and < 100 μmol/L), and severe hyperammonemia (≥100 μmol/L). The measurement of the optic nerve sheath was performed at the same time as the Doppler examination if the patient scored less than 8 on the Glasgow coma scale. There was no difference in flow velocity in the cerebral arteries between patients with and without hyperammonemia. Patients with hyperammonemia presented longer ICU stay. Optic nerve sheath thickness was higher in the group with severe hyperammonemia and this group presented an association with intracranial hypertension. Higher mortality was observed in the severe hyperammonemia group. There was an association between severe hyperammonemia and signs of intracranial hypertension. No correlation was found between ammonia levels and cerebral blood flow velocity through the Doppler examination.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  • Aaslid R, Markwalder TM, Nornes H (1982) Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 57(6):769–774

    Article  PubMed  CAS  Google Scholar 

  • Aggarwal S, Obrist W, Yonas H, Kramer D, Kang Y, Scott V, Planinsic R (2005) Cerebral hemodynamic and metabolic profiles in fulminant hepatic failure: relationship to outcome. Liver Transpl 11(11):1353–1360

    Article  PubMed  Google Scholar 

  • ATLS Subcommittee, American College of Surgeons´ Committee on Trauma, International ATLS working group (2013) Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg 74(5):1363–1366.

  • Barbosa MF, Abdala N, Carrete H et al (2006) Doppler transcraniano convencional em voluntários assintomáticos: Variabilidade e valores de referência para parâmetros de fluxo sanguíneo. Arq Neuropsiquiatr 64(3 B):829–838

    Article  PubMed  Google Scholar 

  • Bellner J, Romner B, Reinstrup P, Kristiansson KA, Ryding E, Brandt L (2004) Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). Surg Neurol 62(1):45–51

    Article  PubMed  Google Scholar 

  • Blaivas M, Theodoro D, Sierzenski PR (2003) Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Acad Emerg Med 10(4):376–381

    Article  PubMed  Google Scholar 

  • Blei AT, Olafsson S, Webster S, Levy R (1993) Complications of intracranial pressure monitoring in fulminant hepatic failure. Lancet 341(8838):157–158 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8093756

    Article  PubMed  CAS  Google Scholar 

  • Butterworth RF (2015) Pathogenesis of hepatic encephalopathy and brain edema in acute liver failure. J Clin Exp Hepatol 5(S1):S96–S103. https://doi.org/10.1016/j.jceh.2014.02.004

  • Clay AS, Hainline BE (2007) Hyperammonemia in the ICU. Chest 132(4):1368–1378

    Article  PubMed  CAS  Google Scholar 

  • Czosnyka M, Matta BF, Smielewski P, Kirkpatrick PJ, Pickard JD (1998) Cerebral perfusion pressure in head-injured patients: a noninvasive assessment using transcranial Doppler ultrasonography. J Neurosurg 88(5):802–808

    Article  PubMed  CAS  Google Scholar 

  • Geeraerts T, Merceron S, Benhamou D, Vigué B, Duranteau J (2008) Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med 34(11):2062–2067

    Article  PubMed  Google Scholar 

  • Gosling RG, King DH (1974) Arterial assessment by Doppler-shift ultrasound. Proc R Soc Med 67:447–449

    PubMed  PubMed Central  CAS  Google Scholar 

  • Gupta S, Fenves AZ, Hootkins R (2016) The role of RRT in hyperammonemic patients. Clin J Am Soc Nephrol:1–7

  • Hawkes ND, Thomas GA, Jurewicz A, Williams OM, Hillier CE, McQueen I, Shortland G (2001) Non-hepatic hyperammonaemia: an important, potentially reversible cause of encephalopathy. Postgrad Med J 77(913):717–722 Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1742166&tool=pmcentrez&rendertype=abstract

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  • Jalan R (2003) Intracranial hypertension in acute liver failure: pathophysiological basis of rational management. Semin Liver Dis 23(3):271–282

    Article  PubMed  Google Scholar 

  • Karakitsos D, Soldatos T, Gouliamos A, Armaganidis A, Poularas J, Kalogeromitros A, Boletis J, Kostakis A, Karabinis A (2006) Transorbital sonographic monitoring of optic nerve diameter in patients with severe brain injury. Transplant Proc 38(10):3700–3706

    Article  PubMed  CAS  Google Scholar 

  • Kimberly HH, Shah S, Marill K, Noble V (2008) Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 15(2):201–204

    Article  PubMed  Google Scholar 

  • Knaus W, Draper E, Wagner D, Zimmerman J (1985) APACHE II: a severity of disease classification system. Crit Care Med 13(10):818–829

    Article  PubMed  CAS  Google Scholar 

  • Laish I, Ben Ari Z (2011) Noncirrhotic hyperammonaemic encephalopathy. Liver Int 31(9):1259–1270

    Article  PubMed  Google Scholar 

  • Lee WM, Stravitz RT, Larson AM (2012) Introduction to the revised American Association for the Study of Liver Diseases position paper on acute liver failure 2011. Hepatology 55(3):965–967

    Article  PubMed  PubMed Central  Google Scholar 

  • Levey AS, Coresh J, Greene T, Stevens L (2006) Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med 145(4):247–254

    Article  PubMed  CAS  Google Scholar 

  • Prado FA, Delfino VDA, Grion CMC, De Oliveira JA (2015) Hyperammonemia in ICU patients: a frequent finding associated with high mortality. J Hepatol 62(5):1216–1218

    Article  PubMed  CAS  Google Scholar 

  • Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, Tesoro EP, Elswick RK (2002) The Richmond agitation-sedation scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 166(10):1338–1344

    Article  PubMed  Google Scholar 

  • Soldatos T, Karakitsos D, Chatzimichail K, Papathanasiou M, Gouliamos A, Karabinis A (2008) Optic nerve sonography in the diagnostic evaluation of adult brain injury. Crit Care 12(3):R67 Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2481450&tool=pmcentrez&rendertype=abstract

    Article  PubMed  PubMed Central  Google Scholar 

  • Splavski B, Radanović B, Muzević D et al (2006) Assessment of intra-cranial pressure after severe traumatic brain injury by transcranial Doppler ultrasonography. Brain Inj 20(12):1265–1270. https://doi.org/10.1080/02699050601082099

  • Strauss GI, Møller K, Holm S, Sperling B, Knudsen GM, Larsen FS (2001) Transcranial doppler sonography and internal jugular bulb saturation during hyperventilation in patients with fulminant hepatic failure. Liver Transpl 7(4):352–358

    Article  PubMed  CAS  Google Scholar 

  • Tayal VS, Neulander M, Norton HJ, Foster T, Saunders T, Blaivas M (2007) Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med 49(4):508–514

    Article  PubMed  Google Scholar 

  • Vaquero J, Chung C, Cahill ME, Blei AT (2003) Pathogenesis of hepatic encephalopathy in acute liver failure. Semin Liver Dis 23(3):259–269

    Article  PubMed  CAS  Google Scholar 

  • Vincent JL, De Mendonça A, Cantraine F et al (1998) Use of the SOFA score to asses the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine. Crit Care Med 26(11):1793–1800

  • Walker V. Severe hyperammonaemia in adults not explained by liver disease. Ann Clin Biochem. 2012;49:214–228. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22349554

  • Wartenberg KE, Schmidt JM, Mayer SA (2007) Multimodality monitoring in Neurocritical care. Crit Care Clin 23(3):507–538

    Article  PubMed  CAS  Google Scholar 

  • Wright G, Noiret L, Olde D, Steven WM, Jalan R (2011) Interorgan ammonia metabolism in liver failure: the basis of current and future therapies. Liver Int 31(2):163–175

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Universidade Estadual de Londrina, Londrina, Brazil

    Alexandre Sanches Larangeira & Marcos Toshiyuki Tanita

  2. Hospital Evangélico de Londrina, Londrina, Brazil

    Marcos Antonio Dias

  3. Hospital Universitário-Universidade Estadual de Londrina, Rua Robert Koch 60, Vila Operária, Londrina, Paraná, 86038-440, Brazil

    Olavo Franco Ferreira Filho, Vinicius Daher Alvares Delfino, Lucienne Tibery Queiroz Cardoso & Cintia Magalhães Carvalho Grion

  4. Divisão de Terapia Intensiva, Rua Robert Koch 60, Vila Operária, Londrina, Paraná, 86038-440, Brazil

    Cintia Magalhães Carvalho Grion

Authors
  1. Alexandre Sanches Larangeira
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marcos Toshiyuki Tanita
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marcos Antonio Dias
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Olavo Franco Ferreira Filho
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Vinicius Daher Alvares Delfino
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Lucienne Tibery Queiroz Cardoso
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Cintia Magalhães Carvalho Grion
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Cintia Magalhães Carvalho Grion.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Larangeira, A.S., Tanita, M.T., Dias, M.A. et al. Analysis of cerebral blood flow and intracranial hypertension in critical patients with non-hepatic hyperammonemia. Metab Brain Dis 33, 1335–1342 (2018). https://doi.org/10.1007/s11011-018-0245-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11011-018-0245-z

Keywords

Search

Navigation