Central nervous system lesions in liver transplant recipients - Prospective assessment of indications for biopsy and implications for management
Central nervous system lesions in liver transplant recipients - Prospective assessment of indications for biopsy and implications for management
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DOI：
10.1097/00007890-199812270-00005
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发表时间：
1998-12-27
期刊：
影响因子：
6.2
通讯作者：
Singh, N
中科院分区：
文献类型：
--
作者：
Bonham, CA;Dominguez, EA;Singh, N
背景肝移植受者中枢神经系统（CNS）病变的准确诊断仍然是个问题。由于凝血障碍，脑活检通常不可行。我们试图确定选择的临床或放射学特征是否可以预测肝移植受者中枢神经系统病变的可能病因，从而确定诊断性脑活检的必要性。在四个地理位置不同的医疗机构的肝移植中心进行了一项为期4年的前瞻性、观察性、队列研究。共有1730例连续肝移植受者接受了CNS病变的评估; 60例放射学记录的CNS病变患者组成了研究样本。血管事件（52%，31/60）、感染（18%，11/60）、免疫抑制相关白质脑病（12%，7/60）、脑桥中央髓鞘溶解（8%，5/60）和恶性肿瘤（3%，2/60）是CNS病变的主要病因。CNS病变最有可能发生在移植后30天内（43%，26/60）;脑桥中央髓鞘溶解、硬膜下血肿、急性梗死和曲霉菌脑脓肿是这段时间内的主要病因。所有脑脓肿均为真菌性;这些患者中有73%（8/11）同时记录了由相同真菌病原体引起的神经（肺部）感染。因此，诊断性脑活检是不必要的，在这些患者。接受透析的患者更有可能出现缺血性或感染性CNS病变（P=0.03）。重复移植受者更容易发生血管事件（P=0.03）。25%（15/60）的CNS病变发生在移植后1年以上;小血管缺血性病变、恶性肿瘤或非曲霉菌性脑脓肿占所有此类病变。根据可识别的表现，包括发病时间、独特的风险因素和神经影像学特征，可以在肝移植受者的绝大多数CNS病变中建立推定的病因学诊断。肝移植受者脑脓肿的经验性治疗应包括抗真菌药而非抗菌药物。
Background. Precise diagnosis of central nervous system (CNS) lesions in liver transplant recipients remains problematic. Brain biopsies are often not feasible as a result of coagulopathy. We sought to determine whether selected clinical or radiologic characteristics can predict the likely etiology of CNS lesions in liver transplant recipients and thus obviate the need for diagnostic brain biopsies.Methods. A 4-year prospective, observational, cohort study was conducted at liver transplant centers at four geographically diverse medical institutions. A total of 1730 consecutive liver transplant recipients were evaluated for CNS lesions; 60 patients with radiologically documented CNS lesions comprised the study sample.Results. Vascular events (52%, 31/60), infections (18%, 11/60), immunosuppressive associated leukoencephalopathy (12%, 7/60), central pontine myelinolysis (8%, 5/60), and malignancy (3%, 2/60) were the predominant etiologies of CNS lesions. CNS lesions were most likely to occur within 30 days of transplantation (43%, 26/60); central pontine myelinolysis, subdural hematoma, acute infarcts, and Aspergillus brain abscesses were the predominant etiologies during this Lime. All brain abscesses were fungal; 73% (8/11) of these patients concurrently had documented extraneural (pulmonary) infection as a result of the same fungal pathogen. Thus, a diagnostic brain biopsy is not warranted in these patients. Patients on dialysis were more likely to have ischemic or infectious CNS lesions (P=0.03). Vascular events were more likely to occur in repeat transplant recipients (P=0.03). Twenty-five percent (15/60) of the CNS lesions occurred more than 1 year after transplantation; small vessel ischemic lesions, malignancy, or non-Aspergillus fungal brain abscesses accounted for all such lesions.Conclusions. A presumptive etiologic diagnosis can be established in a vast majority of CNS lesions in liver transplant recipients based on identifiable presentation that includes time of onset, unique risk factors, and neuroimaging characteristics. Empiric therapy of brain abscesses in liver transplant recipients should include antifungal and not antibacterial agents.