A cross-sectional study was conducted in Suez Canal university hospital. The study included 46 patients with compensated chronic hepatitis C-positive patients who were eligible to antiviral therapy but not starting with, with high education level (final stage after completion of secondary education), age range 18–65 years, and both genders were included. We excluded patients with renal failure, decompensated liver disease, hypoxic encephalopathy, drug or alcohol intoxication, history of old cerebrovascular stroke, seizures, patient with pacemaker, or metal implant.
Patients were divided into two groups: patients with HCV with and without cognitive impairment. Both groups were matched for age, sex, and staging.
Included subjects were subjected to complete medical history and full abdominal and neurological examination. Laboratory investigations were done including liver function tests, renal function, and PCR for HCV.
Brain MRI and MRS was done for each subject, a high-resolution sagittal T1-weighted MR scan was acquired by using a 1.5 T Philips Achieva scanner, TR = 20 ms, TE = 5 ms, flip angle = 30, field of view = 220 mm, acquisition matrix 256, and slice thickness 1.3 mm. All subjects were investigated using cerebral MRI and MRS studies using single-voxel technique of short-time echo to identify metabolites of interest. The spectroscopic voxel of interest was positioned to assay metabolites in three brain regions: the basal ganglia (putamen and globuspallidus combined), posterior cingulate gyrus, and hippocampus. Metabolites of interest were choline (CHO), creatine (Cr), glutamine-glutamate (Glu), myo-inisotol (MYO), and N-acetyl aspartate (NAA). This attempt was to determine mainly the choline/creatine ratios (CHO/Cr ratio), myo-inistol to creatine ratio (MYO/Cr), N-acetyl aspartate-to-choline ratio (NAA/CHO ratio), glutamate to creatine ratio (Glu/Cr ratio), and N-acetyl aspartate-to-creatine ratios (NAA/Cr ratio).
Assessment of cognitive functions
It was assessed by mini-mental state examination as screening tool for categorization of patients before imaging and Wechsler Memory Scale - Revised, the short form for further details after imaging.
Mini-mental state examination (MMSE) [7]
The mini-mental state examination is probably the most widely used measure of cognitive decline. The MMSE has a maximum score of 30 points; patients with MMSE > 28 were recruited in chronic hepatitis C patients without cognitive impairment group, while patients with MMSE scores 25–28 [8] were recruited in chronic hepatitis C patients with cognitive impairment group, patients with MMSE of 24 or less were excluded.
Wechsler Memory Scale - Revised (WMS-R) short form [9]
The Wechsler Memory Scale - Revised short form comprises a series of brief subtests, each measuring a different facet of memory functions. Accordingly, WMS-R results are thought to measure the cognitive performance as follows: 1-verbal memory, 2-visual memory, 3-attention/concentration/psychomotor speed assessment, and 4-visuo-spatial function assessment. The test takes around 45 min. The subtests that were presented to the subjects as verbal stimuli were available as an Arabic version.
Statistical analysis
Data was managed using Statistical Package of Social Sciences (SPSS) version 16.0. Statistical significance tests were used and p value of less than or equal (0.05) was considered statistically significant (at 95% level of confidence). Descriptive statistics were presented as (mean ± standard deviation) for quantitative variables and as (%) for qualitative variables. Correlation was done using Pearson coefficient to assess relationships between quantitative variables. ANOVA test was used to compare means of metabolite ratios among different brain regions.
Ethical consideration
An informed written consent was taken from each patient. All data obtained from every patient were confidential and were not used outside the study. The patients have the rights to withdraw from the study at any time without giving any reason. All the cost of the investigations was afforded by the researcher.
The study was approved from ethical committee Faculty of Medicine, Suez Canal University on January 14, 2015 (research no. 2450).