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01-12-2016 | Original Article

Qualifying and quantifying minimal hepatic encephalopathy

Authors: Marsha Y. Morgan, Piero Amodio, Nicola A. Cook, Clive D. Jackson, Gerald Kircheis, Mette M. Lauridsen, Sara Montagnese, Sami Schiff, Karin Weissenborn

Published in: Metabolic Brain Disease | Issue 6/2016

Abstract

Minimal hepatic encephalopathy is the term applied to the neuropsychiatric status of patients with cirrhosis who are unimpaired on clinical examination but show alterations in neuropsychological tests exploring psychomotor speed/executive function and/or in neurophysiological variables. There is no gold standard for the diagnosis of this syndrome. As these patients have, by definition, no recognizable clinical features of brain dysfunction, the primary prerequisite for the diagnosis is careful exclusion of clinical symptoms and signs. A large number of psychometric tests/test systems have been evaluated in this patient group. Of these the best known and validated is the Portal Systemic Hepatic Encephalopathy Score (PHES) derived from a test battery of five paper and pencil tests; normative reference data are available in several countries. The electroencephalogram (EEG) has been used to diagnose hepatic encephalopathy since the 1950s but, once popular, the technology is not as accessible now as it once was. The performance characteristics of the EEG are critically dependent on the type of analysis undertaken; spectral analysis has better performance characteristics than visual analysis; evolving analytical techniques may provide better diagnostic information while the advent of portable wireless headsets may facilitate more widespread use. A large number of other diagnostic tools have been validated for the diagnosis of minimal hepatic encephalopathy including Critical Flicker Frequency, the Inhibitory Control Test, the Stroop test, the Scan package and the Continuous Reaction Time; each has its pros and cons; strengths and weaknesses; protagonists and detractors. Recent AASLD/EASL Practice Guidelines suggest that the diagnosis of minimal hepatic encephalopathy should be based on the PHES test together with one of the validated alternative techniques or the EEG. Minimal hepatic encephalopathy has a detrimental effect on the well-being of patients and their care-givers. It responds well to treatment with resolution of test abnormalities and the associated detrimental effects on quality of life, liver-related mortality and morbidity. Patients will only benefit in this way if they can be effectively diagnosed. Corporate efforts and consensus agreements are needed to develop effective diagnostic algorithms.

Amodio P, Quero JC, Del Piccolo F, Gatta A, Schalm SW (1996) Diagnostic tools for the detection of subclinical hepatic encephalopathy: comparison of standard and computerized psychometric tests with spectral-EEG. Metab Brain Dis 11(4):315–327CrossRefPubMed

Amodio P, Marchetti P, Del Piccolo F, de Tourtchaninoff M, Varghese P, Zuliani C (1999a) Spectral versus visual EEG analysis in mild hepatic encephalopathy. Clin Neurophysiol 110(8):1334–1344CrossRefPubMed

Amodio P, Del Piccolo F, Marchetti P, Angeli P, Iemmolo R, Caregaro L, Merkel C, Gerunda G, Gatta A (1999b) Clinical features and survival of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests. Hepatology 29(6):1662–1667CrossRefPubMed

Amodio P, Del Piccolo F, Petteno E, Mapelli D, Angeli P, Iemmolo R, Muraca M, Musto C, Gerunda G, Rizzo C, Merkel C, Gatta A (2001) Prevalence and prognostic value of quantified electroencephalogram (EEG) alterations in cirrhotic patients. J Hepatol 35(1):37–45CrossRefPubMed

Amodio P, Schiff S, Del Piccolo F, Mapelli D, Gatta A, Umilta C (2005) Attention dysfunction in cirrhotic patients: an inquiry on the role of executive control, attention orienting and focusing. Metab Brain Dis 20(2):115–127CrossRefPubMed

Amodio P, Pellegrini A, Ubiali E, Mathy I, Piccolo FD, Orsato R, Gatta A, Guerit JM (2006) The EEG assessment of low-grade hepatic encephalopathy: comparison of an artificial neural network-expert system (ANNES) based evaluation with visual EEG readings and EEG spectral analysis. Clin Neurophysiol 117(10):2243–2251CrossRefPubMed

Amodio P, Campagna F, Olianas S, Iannizzi P, Mapelli D, Penzo M, Angeli P, Gatta A (2008) Detection of minimal hepatic encephalopathy: normalization and optimization of the psychometric hepatic encephalopathy score. A neuropsychological and quantified EEG study. J Hepatol 49(3):346–353CrossRefPubMed

Amodio P, Ridola L, Schiff S, Montagnese S, Pasquale C, Nardelli S, Pentassuglio I, Trezza M, Marzano C, Flaiban C, Angeli P, Cona G Bisiacchi P., Gatta A, Riggio O (2010) Improving detection of minimal hepatic encephalopathy using the inhibitory control task. Gastroenterology 139(2): 510–518CrossRefPubMed

Bajaj JS, Saeian K, Verber MD, Hischke D, Hoffmann RG, Franco J, Varma RR, Rao SM (2007a) Inhibitory control test is a simple method to diagnose minimal hepatic encephalopathy and predict development of overt hepatic encephalopathy. Am J Gastroenterol 102(4):754–760CrossRefPubMed

Bajaj JS, Hafeezullah M, Hoffmann RG, Saeian K (2007b) Minimal hepatic encephalopathy: a vehicle for accidents and traffic violations. Am J Gastroenterol 102(9):1903–1909CrossRefPubMed

Bajaj JS, Hafeezullah M, Franco J, Varma RR, Hoffmann RG, Knox JF, Hischke D, Hammeke TA, Pinkerton SD, Saeian K (2008) Inhibitory control test for the diagnosis of minimal hepatic encephalopathy. Gastroenterology 135(5):1591–1600CrossRefPubMed

Bajaj JS, Cordoba J, Mullen KD, Amodio P, Shawcross DL, Butterworth RF, Morgan MY; International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) (2011a) The design of clinical trials in hepatic encephalopathy–an international society for hepatic encephalopathy and nitrogen metabolism (ISHEN) consensus statement.. Aliment Pharmacol Ther 33(7): 739–747

Bajaj JS, Wade JB, Gibson DP, Heuman DM, Thacker LR, Sterling RK, Stravitz RT, Luketic V, Fuchs M, White MB, Bell DE, Gilles H, Morton K, Noble N, Puri P, Sanyal AJ (2011b) The multi-dimentional burden of cirrhosis and hepatic encephalopathy on patients and caregivers. Am J Gastroenterol 106(9):1646–1653CrossRefPubMedPubMedCentral

Bajaj JS, Thacker LR, Heuman DM, Fuchs M, Sterling RK, Sanyal AJ, Puri P, Siddiqui MS, Stravitz RT, Bouneva I, Luketic V, Noble N, White MB, Monteith P, Unser A, Wade JB (2013) The stroop smartphone application is a short and valid method to screen for minimal hepatic encephalopathy. Hepatology 58(3):1122–1132CrossRefPubMedPubMedCentral

Bajaj JS, Heuman DM, Sterling RK, Sanyal AJ, Siddiqui M, Matherly S, Luketic V, Stravitz RT, Fuchs M, Thacker LR, Gilles H, White MB, Unser A, Hovermale J, Gavis E, Noble NA, Wade JB (2015) Validation of EncephalApp, smartphone-based stroop test, for the diagnosis of covert hepatic encephalopathy. Clin Gastroenterol Hepatol 13(10):1828–1835

Berlioux P, Robic MA, Poirson H, Métivier S, Otal P, Barret C, Lopez F, Péron JM, Vinel JP, Bureau C (2014) Pre-transjugular intrahepatic portosystemic shunts (TIPS) prediction of post-TIPS overt hepatic encephalopathy: the critical flicker frequency is more accurate than psychometric tests. Hepatology 59(2):622–629CrossRefPubMed

Campagna F, Montagnese S, Schiff S, Ruzzoli M, Biancardi A, Iannizzi P, Pujatti PL, Angeli P, Gatta A, Merkel C, Leandro G, Mapelli D, Amodio P (2015) Confounders in the detection of minimal hepatic encephalopathy: a neuropsychological and quantified EEG study. Liver Int 35(5):1524–15320CrossRefPubMed

Cona G, Montagnese S, Bisiacchi PS, Gatta A, Cillo U, Angeli P, Amodio P, Schiff S (2014) Early markers of neural dysfunction and compensation: a model from minimal hepatic encephalopathy. Clin Neurophysiol 125(6):1138–1144CrossRefPubMed

Dhiman RK, Kurmi R, Thumburu KK, Venkataramarao SH, Agarwal R, Duseja A, Chawla Y (2010) Diagnosis and prognostic significance of minimal hepatic encephalopathy in patients with cirrhosis of liver. Dig Dis Sci 55(8):2381–2390CrossRefPubMed

Duarte-Rojo A, Estradas J, Hernández-Ramos R, Ponce-de-León S, Córdoba J, Torre A (2011) Validation of the psychometric hepatic encephalopathy score (PHES) for identifying patients with minimal hepatic encephalopathy. Dig Dis Sci 56(10):3014–3023CrossRefPubMed

Felipo V, Ordono JF, Urios A, El Mlili N, Gimenez-Garzo C, Aguado C, Gonzalez-Lopez O, Giner-Duran R, Serra MA, Wassel A, Rodrigo JM, Salazar J, Montoliu C (2012) Patients with minimal hepatic encephalopathy show impaired mismatch negativity correlating with reduced performance in attention tests. Hepatology 55(2):530–539CrossRefPubMed

Ferenci P, Lockwood AH, Mullen K, Tarter R, Weissenborn K, Blei AT (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(3):716–721CrossRefPubMed

Foley JM, Watson CW, Adams RD (1950) Significance of electroencephalographic changes in hepatic coma. Trans Am Neurol Assoc 51:161–165PubMed

Folstein MF, Folstein SE, McHugh PR (1975) “Mini-mental state”. a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12(3):189–198CrossRefPubMed

Gitlin N, Lewis DC, Hinkley L (1986) The diagnosis and prevalence of subclinical hepatic encephalopathy in apparently healthy, ambulant, non-shunted patients with cirrhosis. J Hepatol 3(1):75–82CrossRefPubMed

Gluud LL, Vilstrup H, Morgan MY (2015) Nonabsorbable disaccharides for hepatic encephalopathy in people with cirrhosis. Cochrane Database of Systematic Reviews (in press)

Goldbecker A, Weissenborn K, Hamidi Shahrezaei G, Afshar K, Rümke S, Barg-Hock H, Strassburg CP, Hecker H, Tryc AB (2013) Comparison of the most favoured methods for the diagnosis of hepatic encephalopathy in liver transplantation candidates. Gut 62(10):1497–1504CrossRefPubMed

Groeneweg M, Quero JC, De BI, Hartmann IJ, Essink-bot ML, Hop WC, Schalm SW (1998) Subclinical hepatic encephalopathy impairs daily functioning. Hepatology 28(1):45–49CrossRefPubMed

Jackson C, Sherratt M (2004) A novel spatio-temporal decomposition of the EEG: derivation, validation and clinical application. Clin Neurophysiol 115(1):227–237CrossRefPubMed

Kircheis G, Wettstein M, Timmermann L, Schnitzler A, Häussinger D (2002) Critical flicker frequency for quantification of low-grade hepatic encephalopathy. Hepatology 35(2):357–366CrossRefPubMed

Kircheis G, Bode JG, Hilger N, Kramer T, Schnitzler A, Häussinger D (2009) Diagnostic and prognostic values of critical flicker frequency determination as new diagnostic tool for objective HE evaluation in patients undergoing TIPS implantation. Eur J Gastroenterol Hepatol 21(12):1383–1394CrossRefPubMed

Kircheis G, Hilger N, Häussinger D (2014) Value of critical flicker frequency and psychometric hepatic encephalopathy score in diagnosis of low-grade hepatic encephalopathy. Gastroenterology 146(4):961–969CrossRefPubMed

Kurmi R, Dhiman RK, Reddy K, et al (2008) Psychometric hepatic encephalopathy score, critical flicker frequency and p300 event related potentials for the diagnosis of minimal hepatic encephalopathy: evidence that psychometric hepatic encephalopathy score is enough. Indian J Gastroenterol 27(Suppl 1):S1

Lauridsen MM, Jepsen P, Vilstrup H (2011) Critical flicker frequency and continuous reaction times for the diagnosis of minimal hepatic encephalopathy. A comparative study of 154 patients with liver disease. Metab Brain Dis 26(2):135–139CrossRefPubMed

Lauridsen MM, Grønbæk H, Næser EB, Leth ST, Vilstrup H (2012) Gender and age effects on the continuous reaction times method in volunteers and patients with Cirrhosis. Metab Brain Dis 27(4):559–565CrossRefPubMed

Lauridsen MM, Frøjk J, de Muckadell OB, Vilstrup H (2014) Opposite effects of sleep deprivation on the continuous reaction times in patients with liver cirrhosis and normal Persons. Metab Brain Dis 29(3):655–660CrossRefPubMed

Lauridsen MM, Schaffalitzky de Muckadell OB, Vilstrup H (2015) Minimal hepatic encephalopathy characterized by parallel use of the continuous reaction time and portosystemic encephalopathy tests. Metab Brain Dis 30(5):1187–1192

Llinàs-Reglà J, Vilalta-Franch J, López-Pousa S, Calvó-Perxas L, Garre-Olmo J (2013) Demographically adjusted norms for Catalan older adults on the stroop color and word test. Arch Clin Neuropsychol 28(3):282–296CrossRefPubMed

Luo M, Li L, Lu C-Z, W-K C (2011) Clinical efficacy and safety of lactulose for minimal hepatic encephalopathy: a meta-analysis. Euro L Gastroenterol Hepatol 23(12):1250–1257CrossRef

Mardini H, Saxby BK, Record CO (2008) Computerized psychometric testing in minimal encephalopathy and modulation by nitrogen challenge and liver transplant. Gastroenterology 135(5):1582–1590CrossRefPubMed

Marks M, Jackson CD, Montagnese S, Jenkins CW, Head IM, Morris RW, Morgan MY (2008) Derivation of a normative UK database for the psychometric hepatic encephalopathy score (PHES): confounding effect of ethnicity and test scoring. J Hepatol 48(Suppl 2):S119–S300CrossRef

Miese F, Kircheis G, Wittsack HJ, Wenserski F, Hemker J, Mödder U, Häussinger D, Cohnen M (2006) 1 H-MR spectroscopy, magnetization transfer, and diffusion-weighted imaging in alcoholic and nonalcoholic patients with cirrhosis with hepatic encephalopathy. AJNR Am J Neuroradiol 27(5):1019–1026PubMed

Moering RG, Schinka JA, Mortimer JA, Graves AB (2004) Normative data for elderly African Americans for the stroop color and word test. Arch Clin Neuropsychol 19(1):61–71CrossRefPubMed

Montagnese S, Amodio P, Morgan MY (2004) Methods for diagnosing hepatic encephalopathy in patients with cirrhosis: a multidimensional approach. Metab Brain Dis 19(3–4):281–312CrossRefPubMed

Montagnese S, Jackson C, Morgan MY (2007) Spatio-temporal decomposition of the electroencephalogram in patients with cirrhosis. J Hepatol 46(3):447–458CrossRefPubMed

Montagnese S, Cona G, Schiff S, Maresio G, Gatta A, Merkel C, Amodio P (2010) The hunter and the pianist: two hepatic encephalopathy tales. J Clin Gastroenterol 45(6):563–566CrossRef

Montagnese S, Amato E, Schiff S, Facchini S, Angeli P, Gatta A, Amodio P (2012a) A patients' and caregivers' perspective on hepatic encephalopathy. Metab Brain Dis 27(4):567–572CrossRefPubMed

Montagnese S, Schiff S, Turco M, Bonato CA, Ridola L, Gatta A, Nousbaum JB, Riggio O, Merkel C, Amodio P (2012b) Simple tools for complex syndromes: a three-level difficulty test for hepatic encephalopathy. Dig Liver Dis 44(11):957–960CrossRefPubMed

Montagnese S, Schiff S, Amodio P (2015) Quick diagnosis of hepatic encephalopathy: fact or fiction? Hepatology 61(1):405–406CrossRefPubMed

Nardelli S, Pentassuglio I, Pasquale C, Ridola L, Moscucci F, Merli M, Mina C, Marianetti M, Fratino M, Izzo C, Merkel C, Riggio O (2013) Depression, anxiety and alexithymia symptoms are major determinants of health related quality of life (HRQoL) in cirrhotic patients. Metab Brain Dis 28(2):239–243CrossRefPubMed

Niedermeyer E (1999) Metabolic Central Nervous System Disorders. In: Niedermeyer E, Lopes Da Silva F (eds) Electroencephalography. Basic principles, clinical applications, and related fields, 4th edn. Williams & Wilkins, Baltimore, pp. 416–431

Norman MA, Moore DJ, Taylor M, Franklin D Jr, Cysique L, Ake C, Lazarretto D, Vaida F, Heaton RK; HNRC Group (2011) Demographically corrected norms for African Americans and Caucasians on the Hopkins verbal learning test-revised, brief visuospatial memory test-revised, stroop color and word test, and Wisconsin card sorting test 64-card version. J Clin Exp Neuropsychol 33(7): 793–804

Parsons-Smith BG, Summerskill WHJ, Dawson AM, Sherlock S (1957) The electroencephalograph in liver disease. Lancet 273(7001):867–871CrossRefPubMed

Patidar KR, Thacker LR, Wade JB, Sterling RK, Sanyal AJ, Siddiqui MS, Matherly SC, Stravitz RT, Puri P, Luketic VA, Fuchs M, White MB, Noble NA, Unser AB, Gilles H, Heuman DM, Bajaj JS (2014) Covert hepatic encephalopathy is independently associated with poor survival and increased risk of hospitalization. Am J Gastroenterol 109(11):1757–1763CrossRefPubMedPubMedCentral

Poordad FF (2007) Review of the burden of hepatic encephalopathy. Aliment Pharmacol Ther 25(Suppl 1):3–9CrossRefPubMed

Quero JC, Hartmann IJ, Meulstee J, Hop WC, Schalm SW (1996) The diagnosis of subclinical hepatic encephalopathy in patients with cirrhosis using neuropsychological tests and automated electroencephalogram analysis. Hepatology 24(3):556–560CrossRefPubMed

Randolph C, Hilsabeck R, Kato A (2009) International society for hepatic encephalopathy and nitrogen metabolism (ISHEN). neuropsychological assessment of hepatic encephalopathy: ISHEN practice guidelines. Liver Int 29(5):629–635CrossRefPubMed

Reitan RM (1955) The relation of the trail making test to organic brain damage. J Consult Psychol 19(5):393–394CrossRefPubMed

Riggio O, Ridola L, Pasquale C, Pentassuglio I, Nardelli S, Moscucci F, Merli M, Montagnese S, Amodio P, Merkel C (2011) A simplified psychometric evaluation for the diagnosis of minimal hepatic encephalopathy. Clin Gastroenterol Hepatol 9(7):613–616CrossRefPubMed

Roman E, Córdoba J, Torrens M, Torras X, Villanueva C, Vargas V, Guarner C, Soriano G (2011) Minimal hepatic encephalopathy is associated with falls. Am J Gastroenterol 106(3):476–482CrossRefPubMed

Romero Gómez M, Córdoba J, Jover R, del Olmo J, Fernández A, Flavià M, Compañy L, Poveda MJ, Felipo V; Red Nacional de Investigación en Encefalopatía Hepática (2006) Normality tables in the Spanish population for psychometric tests used in the diagnosis of minimal hepatic encephalopathy. Med Clin 127 (7): 246–249.

Romero-Gómez M, Córdoba J, Jover R, del Olmo JA, Ramírez M, Rey R, de Madaria E, Montoliu C, Nuñez D, Flavia M, Compañy L, Rodrigo JM, Felipo V (2007) Value of the critical flicker frequency in patients with minimal hepatic encephalopathy. Hepatology 45(4):879–885CrossRefPubMed

Schiff S, Vallesi A, Mapelli D, Pellegrini A, Orsato R, Umiltà CA, Amodio P (2005) Response inhibition impairment precede motor alteration in the early stage of liver cirrhosis. A behavioural and electrophysiological study. Metab Brain Dis 20(4):381–392CrossRefPubMed

Schomerus H, Hamster W (2001) Quality of life in cirrhotics with minimal hepatic encephalopathy. Metab Brain Dis 16(1–2):37–41CrossRefPubMed

Schomerus H, Hamster W, Blunck H, Reinhard U, Mayer K, Dolle W (1981) Latent portasystemic encephalopathy. I Nature of cerebral functional defects and their effect on fitness to drive. Dig Dis Sci 26(7):622–630CrossRefPubMed

Schomerus H, Weissenborn K, Hamster W, Rückert N, Hecker H (1999) PSE-Syndrom-Test. Psychodiagnostisches Verfahren zur quantitativen Erfassung der (minimalen) portosystemischen Encephalopathie (PSE). Frankfurt: Swets & Zeitlinger BV, Swets Test Services

Schomerus H, Hamster W (1998) Neuropsychological aspects of portal-systemic encephalopathy. Metab Brain Dis 13(4):361–377CrossRefPubMed

Seo YS, Yim SY, Jung JY, Kim CH, Kim JD, Keum B, An H, Yim HJ, Lee HS, Kim CD, Ryu HS, Um SH (2012) Psychometric hepatic encephalopathy score for the detection of minimal hepatic encephalopathy in Korean patients with liver cirrhosis. J Gastroenterol Hepatol 27(11):1695–1704CrossRefPubMed

Shah NJ, Neeb H, Kircheis G, Engels P, Häussinger D, Zilles K (2008) Quantitative cerebral water content mapping in hepatic encephalopathy. NeuroImage 41(3):706–717CrossRefPubMed

Sharma P, Kumar A, Singh S, Tyagi P, Kumar A (2013) Inhibitory control test, critical flicker frequency, and psychometric tests in the diagnosis of minimal hepatic encephalopathy in cirrhosis. Saudi J Gastroenterol 19(1):40–44CrossRefPubMedPubMedCentral

Timmermann L, Butz M, Gross J, Ploner M, Südmeyer M, Kircheis G, Häussinger D, Schnitzler A (2008) Impaired cerebral oscillatory processing in hepatic encephalopathy. Clin Neurophysiol 119(2):265–272CrossRefPubMed

Van de Rijt CC, Schalm SW, De Groot GH, De VM (1984) Objective measurement of hepatic encephalopathy by means of automated EEG analysis. Electroencephalogr Clin Neurophysiol 57(5):423–426CrossRefPubMed

Van der Elst W, Van Boxtel MP, Van Breukelen GJ, Jolles J (2006) The stroop color-word test: influence of age, sex, and education; and normative data for a large sample across the adult age range. Assessment 13(1):62–79CrossRefPubMed

Vienna test system (WINWTS), version 4.50. Mödling, Austria: Dr G. Schuhfried GmbH, (1999)

Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, Weissenborn K, Wong P (2014) Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the American association for the study of liver diseases and the European association for the study of the liver. Hepatology 60(2):715–735CrossRefPubMed

Wechsler D (1981) Wechsler adult intelligence scale-revised. Psychological Corporation, New York

Wein C, Koch H, Popp B, Oeher G, Schauder P (2004) Minimal hepatic encephalopathy impairs fitness to drive. Hepatology 39(3):739–745CrossRefPubMed

Weissenborn K (2015a) Challenges in diagnosing hepatic encephalopathy. Neurochem Res 40(2):265–273CrossRefPubMed

Weissenborn K (2015b) Diagnosis of minimal hepatic encephalopathy. J Clin Exp Hepatol 5(Suppl 1):S54–S59CrossRefPubMed

Weissenborn K, Ennen JC, Schomerus H, Rückert N, Hecker H (2001) Neuropsychological characterization of hepatic encephalopathy. J Hepatol 34(5):768–773CrossRefPubMed

Weissenborn K, Hecker H, Rückert N (2015) Pitfalls in psychometric testing. Gastroenterology 148(3):664–665CrossRefPubMed

Wunsch E, Koziarska D, Kotarska K, Nowacki P, Milkiewicz P (2013) Normalization of the psychometric hepatic encephalopathy score in Polish population. A prospective, quantified electroencephalography study. Liver Int 33(9):1332–1340CrossRefPubMed

Zafiris O, Kircheis G, Rood HA, Boers F, Häussinger D, Zilles K (2004) Impaired visuo-spatial decision making in hepatic encephalopathy relates to attenuated BOLD-signal in the right inferior parietal cortex. NeuroImage 22(2):541–552CrossRefPubMed

Title: Qualifying and quantifying minimal hepatic encephalopathy
Authors: Marsha Y. Morgan
Piero Amodio
Nicola A. Cook
Clive D. Jackson
Gerald Kircheis
Mette M. Lauridsen
Sara Montagnese
Sami Schiff
Karin Weissenborn
Publication date: 01-12-2016
Publisher: Springer US
Published in: Metabolic Brain Disease / Issue 6/2016
Print ISSN: 0885-7490
Electronic ISSN: 1573-7365
DOI: https://doi.org/10.1007/s11011-015-9726-5

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