Prognostic implications of quantified electroencephalogram (EEG) in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS) for portal hypertension complications

Background: Hepatic encephalopathy (HE) is one of the most frequent complications following transjugular intrahepatic portosystemic shunt (TIPS) placement. However, pre-procedural risk stratification remains insufficiently defined. This study aimed to identify independent risk factors for post-TIPS overt HE (OHE), with a particular focus on the predictive value of pre-TIPS quantitative electroencephalography (EEG) in patients with cirrhosis. Methods: In this prospective, single-center cohort study, 257 patients were screened between February 2015 and September 2024. Eligible participants had cirrhosis and underwent TIPS for refractory ascites or secondary prophylaxis of variceal bleeding. Clinical history, laboratory data, and baseline EEG recordings were collected. Spectral EEG analysis was performed on P3–P4 derivations. The primary endpoint was the 1-year cumulative incidence of post-TIPS OHE (episodic, recurrent, and persistent), analyzed using a competing-risk model accounting for death and liver transplantation as competing events. Independent risk factors were identified through multivariable competing-risk regression analysis. Results: Of the 183 patients who met the inclusion criteria, 163 were included in the final analysis. Baseline EEG abnormalities were observed in 40% of patients (grade 1: 32%, grade 2: 5%, grade 3: 3%). Patients with abnormal EEGs were generally older, had more advanced liver disease, and showed higher levels of C-reactive protein and ammonia. During a median follow-up of 12 months (IQR 5.5), the cumulative incidence of episodic OHE reached 43% (95% CI: 35–51%), with a median onset of 21 days post-TIPS. Recurrent and persistent OHE occurred in 24% (95% CI: 18–31%) and 9% (95% CI: 5–14%) of patients, respectively. Patients with abnormal EEGs and those with a prior history of OHE had significantly higher rates of episodic OHE (55% vs. 35%, p = 0.028; 63% vs. 40%, p = 0.028). However, only age (subdistribution hazard ratio [sHR] 1.05, p < 0.001) and Child-Pugh score (sHR 1.20, p = 0.026) emerged as independent predictors in multivariable analysis. In contrast, abnormal baseline EEG (sHR 2.24, p = 0.026), prior history of OHE (sHR 2.12, p = 0.044), age (sHR 1.04, p = 0.002), and Child-Pugh score (sHR 1.37, p < 0.001) were all independent predictors of recurrent OHE. Conclusions: Quantitative EEG revealed a high prevalence of abnormalities among patients with cirrhosis undergoing elective TIPS. Notably, an abnormal baseline EEG was an independent predictor of recurrent post-TIPS OHE. These findings support the integration of quantitative EEG into the pre-TIPS evaluation to enhance risk stratification and inform patient selection.