Cerebral pulsatility index by transcranial Doppler sonography predicts the prognosis of patients with fulminant hepatic failure  Manri Kawakami, Masahiko Koda, Yoshikazu Murawaki  Clinical Imaging  Volume 34, Issue 5, Pages 327-331 (September 2010) DOI: 10.1016/j.clinimag.2009.09.006 Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 1 The image on the right shows the sampling volume positioned within the middle cerebral artery for color Doppler ultrasonography. That on the left shows the time–velocity waveform. Clinical Imaging 2010 34, 327-331DOI: (10.1016/j.clinimag.2009.09.006) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 2 The clinical courses of two deceased patients with fulminant hepatitis. Case 1: A 41-year-old man with acute fulminant hepatitis related to the hepatitis B virus. Plasma exchange and CHDF were performed and PSL was administered. But hepatic encephalopathy progressed to a more severe stage and the pulsatility index was elevated to >1.00. The patient died on the 10th day. Case 2: A 47-year-old woman with subacute fulminant hepatitis due to unknown etiology. Her condition was accompanied by encephalopathy 1 month after liver dysfunction. She received plasma exchange but liver function gradually deteriorated and ascites developed. The pulsatility index was elevated to >1.00, and she died 2 months later. HE, Hepatic encephalopathy; PSL, predonisolone; CHDF, continuous hemodiafiltration. Clinical Imaging 2010 34, 327-331DOI: (10.1016/j.clinimag.2009.09.006) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 3 The clinical courses of surviving patients with fulminant hepatitis. Case 3: A 22-year-old woman with acute fulminant hepatitis related to the hepatitis B virus. Plasma exchange and CHDF were performed for acute liver failure. In spite of the progression of HE, the pulsatility index was under 1.00 and she recovered. Case 4: A 56-year-old man with acute fulminant hepatitis related to the hepatitis B virus. In spite of plasma exchange, hepatic encephalopathy progressed. The pulsatility index was <1.00 on the third day. Liver transplantation was successfully performed. IFN-β: Interferon β. Clinical Imaging 2010 34, 327-331DOI: (10.1016/j.clinimag.2009.09.006) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 4 The clinical courses of nonencephalopathic patients with prothrombin time <40%. Case 5: A 41-year-old man with acute crisis on chronic hepatitis B. Plasma exchange was performed and he recovered. The pulsatility index was kept under 1.00. Case 6: A 31-year-old woman with acute hepatitis B. Total bilirubin gradually declined without any aggressive therapy. The pulsatility index was within 1.00 and she recovered. Clinical Imaging 2010 34, 327-331DOI: (10.1016/j.clinimag.2009.09.006) Copyright © 2010 Elsevier Inc. Terms and Conditions