Nine of 48 adult patients who underwent orthotopic liver transplantation developed significant clinical neurological abnormalities recognized shortly after operation. Decrease in consciousness occurred with resultant coma, focal and generalized seizures and the occasional appearance of a state of akinetic mutism. Neuropathological abnormalities consisted of multifocal areas of infarction in cerebral cortex and basal ganglia in 5 patients, central pontine myelinolysis in 5 (often more extensive than usually reported), Wernicke's encephalopathy in 3, glial nodules in 2, and fungal abscesses in one. Alzheimer II astrocytosis was found in all brains available for retrospective study. There was direct evidence in 2 of the patients that air embolization from the homografts had occurred. Correlation of this with the brain infarcts in these and other cases seems reasonable. The ease with which air passed to the systemic circulation is explicable by the right to left venous-arterial shunts that are common in chronic liver disease. With the delineation of this cause for the neurologic complications, measures to prevent it in future cases have been described.
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