This document discusses minimal hepatic encephalopathy (MHE), which can cause subtle cognitive changes. Several neuropsychological tests are mentioned that can detect selective attention, visuospatial abilities, fine motor skills, and memory impairments in MHE patients. Ammonia is identified as the most important central nervous system neurotransmitter involved in MHE, affecting the GABA and benzodiazepine systems among others. MHE is graded on a scale from 0-4 based on severity of symptoms from normal to stupor and coma. Magnetic resonance spectroscopy can show brain metabolic changes in MHE patients that improve after liver transplantation.

2.  Mininal hepatic encephalopathy
 Episodic
 Persistent

3.  Selective attention
 Visuospatial abilities
 Fine motor skills
 Memory

4. For visuo constructive
abilities

5. Number connection test for mhe

6. Block design test -
visuospatial and motor skill

7. Line drawing
test – motor
speed and
accuracy

8. Pure motor speed

9. Cognitive assessment
by STOOP test

10.  AMMONIA – MOST IMPORTANT
 CNS NEUROTRANSMITTER EXPRESSION ,
RECEPTOR EXPRESSION and function –
 GABA- BZD system
 Neurosteroid ( allopregnenolone , tetra
hydrodeoxycorticosterone )
 Astrocyte swelling and increased glutamine
 Brain edema
 Altered brain glucose metabolism
 Serotonin ,NO ,manganese , opioid peptides

11. GRADE INTELLECTUAL NEUROMUSCULAR
0 NORMAL normal
MINIMAL Subtle changes in work or driving Psychometrric analysis
1 Personality , attention , deprresed .
Irritability
Tremor , incordination
2 Sleep cycle altered , mood &
behaviour change ,cognitive
dysfunction
Asterixis , ataxic gait ,
slow ,slurred speech
3 Somnolence , confusion ,
disorientation ,amnesia
Mnuscular rigidity ,
nystagmus , babinski ,
clonus , hyporeflexia
4 Stupor & coma Oculocephalic reflex ,
unrenponse to noxious
stimuli

12. MR SPECTROSCOPY – SHOWING DECRESED
GLUTAMATE PEAK AND INCREASED
MYOINOSITOL AND CHOLINE PEAK AFTER
LIVER TRANSPLATATION

13.  For quantitative measurement of brain changes
particularly in globus pallidus , posterior limb
of internal capsule , caudate nucleus
Critical flicker frequency test