his edition of "The Crucible" contains the first installment of what we hope will become an T ongoing discussion of critical care issues in liver transplantation. After considering an agenda of salient critical care topics, we chose to inaugurate the Critical Care Forum with this discussion on neurological concerns. Intensivists, transplant surgeons, and others involved in the immediate postoperative care of liver transplant recipients generally do not expect a serious neurological setback after transplantation. We expect that a functioning allograft will generally improve neurological impairment, especially in those patients with certain preexisting metabolic encephalopathies. Despite this rather naive optimism, neurological events do occur and account for a large portion of perioperative complications. Clinical series have documented neurological complications in 8.3% to 47% of all patients receiving liver tran~plantation.'-~ These neurological events, which can range from seizures to stroke to coma, are often first recognized while the patient is still in the intensive care unit. For those of us whose primary specialty is not neurology, the neurological specialist has become an important colleague and an invaluable resource in caring for these patients.
We have asked Jeffrey Frank, MD, from The Cleveland Clinic Foundation, Cleveland, OH, to address how he would evaluate and care for the patient with altered consciousness before liver transplantation. Dr Frank is Director of the Neuromedical/Neurosurgical Intensive Care Unit at The Cleveland Clinic Foundation. Dr Frank is a popular speaker on the neurological manifestations of the patient with liver disease and the clinical approach to the patient in coma.
Eelco Wijdicks, MD, provides us with his approach to the patient who experiences impaired consciousness after liver transplantation. Dr Wijdicks is a consultant in the Department of Neurology and Co-Director of the Neurology/Neurosurgical Intensive Care Unit at the Mayo Clinic in Rochester, MN. Dr Wijdicks has lectured and written extensively on brain edema, intracranial hemorrhage, central pontine myelinolysis, and the neuromuscular complications that are sometimes observed after liver transplantation.
In some clinical series, seizure is the most frequent neurological complication after liver tran~pIantation.'-~ We have asked Zbigniew Wszolek, MD, to address this frequent and sometimes troublesome issue. Dr Wszolek is Medical Director of the Clinical Neurophysiology Laboratory at the University of Nebraska in Omaha. Dr Wszolek has combined his expertise in neurophysiology with an extensive clinical experience in caring for liver transplant recipients. He is uniquely qualified to address the topic of "Seizures After Liver Transplantation.