The qEEG-TIPS score: development of a predictive model for recurrent overt hepatic encephalopathy after elective TIPS

Background & Aims: Overt hepatic encephalopathy (OHE) continues to be the primary complication following transjugular intrahepatic portosystemic shunt (TIPS) placement. It significantly impairs patients' health-related quality of life, particularly in its recurrent and persistent forms, and may outweigh the benefits of the procedure. This study aimed to develop and internally validate a prognostic score incorporating quantified electroencephalography (qEEG) to predict the risk of post-TIPS recurrent OHE at 3 and 6 months. Methods: We prospectively enrolled 161 consecutive patients with cirrhosis undergoing elective TIPS for refractory or recurrent ascites or secondary prophylaxis of variceal bleeding. All patients underwent qEEG assessment using validated spectral analysis criteria prior to TIPS placement. A multivariable Cox regression model was constructed to estimate the risk of recurrent OHE. Model performance was evaluated using time-dependent ROC curves, calibration plots, decision curve analysis, and internal validation via bootstrap resampling (B = 1,500). Results: Independent predictors of recurrent OHE included age, serum albumin, prior OHE history, and qEEG alterations, which were incorporated into the novel qEEG-TIPS score. The time-dependent AUCs were 0.76 (95% CI 0.70-0.82) and 0.80 (95% CI 0.76-0.85) at 3 and 6 months, respectively. The score identified high-risk patients with a significantly greater incidence of recurrent OHE at 6 months (48% vs. 8% in low-risk patients, p <0.001). Internal validation yielded an optimism-corrected C-index of 0.74 (95% CI 0.69-0.84), indicating mild overfitting but good predictive stability. Decision curve analysis supported the clinical utility of the model. Conclusions: The qEEG-TIPS score demonstrated good discrimination and calibration in predicting short-term risk of recurrent OHE after TIPS. This tool may assist in risk stratification and guide personalized management both before and after TIPS. Impact and implications: Recurrent overt hepatic encephalopathy (OHE) is the primary complication of transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis, markedly reducing quality of life, increasing healthcare burden, and complicating clinical decision-making. This study introduces and internally validates the qEEG-TIPS score, a novel, non-invasive tool integrating quantified electroencephalography with clinical variables to predict the short-term risk of recurrent OHE after elective TIPS. These findings hold particular relevance for patients, hepatologists, and transplant teams as they enable more personalized risk assessment prior to TIPS and may guide decisions on prophylaxis, patient selection, and post-procedural monitoring. If externally validated, the qEEG-TIPS score could enhance clinical pathways by identifying high-risk patients for targeted interventions, supporting more cost-effective and patient-centered TIPS management strategies.