Mental status changes postchemoembolization: the role of inflammatory response.

A 72-year-oldwomanwith a history of end-stage liver disease (Child class A) secondary to cryptogenic cirrhosis presented for elective transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC). Recent imaging demonstrated increased size of a hypervascular 1.3-cm nodule in the left lobe consistent with recurrence at the margin of a previous radiofrequency ablation site. She reported episodic right upper quadrant pain and infrequent encephalopathy. Chemoembolization was completed from a right transfemoral approach. A left hepatic arteriogram demonstrated segmental branches to segments 2 and 3 with marked tortuosity and a hypervascular mass with conspicuous contrast staining. An attempt to catheterize segmental arterial branches subselectively to hepatic segment 2 and 3 was unsuccessful. LC bead chemoembolization was then performed to near stasis from the level of the undivided left hepatic artery; a total of 60 mg of doxorubicin loaded onto 100to 300-μm beads was delivered to the left hepatic artery distribution. Following the procedure, the patient was admitted for overnight observation while receiving intravenous fluids, antiemetics, and pain relievers in addition to her home medications. That evening she developed signs of increasing confusion. She awoke not knowing who family members were, was making nonsensical statements, and exhibited tangential thinking. On examination there was no focal neurologic deficit or asterixis. Her overnight temperature reached a maximum of 98.8°F, and other vital signs were normal. The admitting hospitalist discontinued her fentanyl patient-controlled analgesia and scopolamine patch in addition to scheduling lactulose and administering Haldol as needed. Although the patient’s mental status was clearing by the following morning, her discharge was deferred for further observation. The following night was generally uneventful, and she was discharged in the morning on a new lactulose and rifaximin regimen for presumed hepatic encephalopathy. The patient returned 11 weeks later for repeat chemoembolization of the left hepatic lobe; her overnight hospital course during this admission was uncomplicated, without evidence of delirium or significant manifestations of postembolization syndrome (PES).