Serial Evaluation of Children With ALF With Advanced MRI, Serum Proinflammatory Cytokines, Thiamine, and Cognition Assessment

Objectives: This prospective, sequential study was done to understand changes in cerebral edema (CE) on magnetic resonance imaging and magnetic resonance spectroscopy, liver functions, and neurocognitive testing (NCT) in children with acute liver failure (ALF). Methods: A total of 11 ALF and 8 healthy controls were evaluated with advanced magnetic resonance (MR) imaging, blood proinflammatory cytokines (PCs), thiamine levels, liver functions, and NCT. Reevaluation was done at 43.5 +/- 26.9 days (first follow-up, n = 8) and 157.3 +/- 52.3 days (second follow-up, n = 6) after discharge. Results: At diagnosis, patients with ALF had vasogenic and cytotoxic CE, raised brain glutamine (23.2 +/- 3.4 vs 15.3 +/- 2.7), and serum PCs (tumor necrosis factor [TNF]-alpha 40.1 +/- 8.9 vs 7.2 +/- 2.7 pg/mL, interleukin [IL]-6 29.2 +/- 14.4 vs 4.7 +/- 1.2 pg/mL). The mammillary bodies (MBs) were smaller, and brain choline (1.9 +/- 0.36 vs 2.6 +/- 0.6) and blood thiamine (55.2 +/- 6.7 vs 81.8 +/- 10.2 nmol/L) were lower than controls. At first follow-up, the brain glutamine and CE recovered. Brain choline and MBs volume showed improvement and thiamine levels normalized. Significant reduction in TNF-alpha and IL-6 was seen. The patients performed poorly on NCT, which normalized at second follow-up. Liver biochemistry and thiamine levels were normal and TNF-alpha and IL-6 showed further reduction at second follow-up. Conclusions: Patients with ALF have CE contributed by raised brain glutamine and PCs. MBs are small because of thiamine deficiency and show recovery in follow-up. CE and brain glutamine recover earlier than normalization of NCT and liver functions. Persistence of raised cytokines up to 6 months after insult suggests possible contribution from liver regeneration.