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Denk CH, Kunzmann J, Maieron A, Wöhrer A, Quinot V, Oberndorfer S. Histopathological examination of characteristic brain MRI findings in acute hyperammonemic encephalopathy: A case report and review of the literature. Neuroradiol J 2024; 37:630-635. [PMID: 37915221 PMCID: PMC11444322 DOI: 10.1177/19714009231212370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Acute hyperammonemic encephalopathy is associated with distinct brain MRI findings, namely, hyperintensity in T2-weighted sequences as well as restricted diffusion in diffusion-weighted imaging with accentuation in the insular cortex and cingulate gyrus. The pathophysiology and the histopathological correlates of these characteristic MRI findings are largely unknown. CASE REPORT We present a 57-year-old male with a history of chronic alcohol abuse, liver cirrhosis and portal hypertension, and a clinical syndrome (variceal bleeding, depression of consciousness, seizures), elevated plasma ammonia levels, and characteristic brain MRI abnormalities suggestive of acute hyperammonemic encephalopathy. A postmortem histopathological examination revealed extensive hypoxic ischemic encephalopathy without evidence for metabolic encephalopathy. No episodes of prolonged cerebral hypoxemia were documented throughout the course of the disease. We conducted a review of the literature, which exhibited no reports of hyperammonemic encephalopathy in association with characteristic brain MRI findings and a consecutive histopathological examination. CONCLUSION This is the first report of a patient with acute hyperammonemic encephalopathy together with characteristic brain MRI findings and a histopathological correlation. Although characteristic MRI findings of acute hyperammonemic encephalopathy were present, a histopathological examination revealed only hypoxic pathology without signs of metabolic encephalopathy.
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Affiliation(s)
- CH Denk
- Department of Neurology, University Hospital St. Pölten, Karl Landsteiner Private University of Health Sciences (KLPU), Austria
| | - J Kunzmann
- Department of Radiology, University Hospital St. Pölten, Karl Landsteiner Private University of Health Sciences (KLPU), Austria
| | - A Maieron
- Department of Gastroenterology, University Hospital St. Pölten, Karl Landsteiner Private University of Health Sciences (KLPU), Austria
| | - A Wöhrer
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Austria
| | - V Quinot
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Austria
| | - S Oberndorfer
- Department of Neurology, University Hospital St. Pölten, Karl Landsteiner Private University of Health Sciences (KLPU), Austria
- Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, Austria
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Huang NX, Huang HW, Dong QY, Wen YL, Li D, Li JQ, Chen HJ. Metabolic alterations in the right anterior insula among patients with cirrhosis without overt hepatic encephalopathy: a magnetic resonance spectroscopy study. Front Neurol 2024; 14:1291478. [PMID: 38283679 PMCID: PMC10811796 DOI: 10.3389/fneur.2023.1291478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Purpose We investigated metabolic alterations in the right anterior insula (rAI) in cirrhotic patients and determined its association with patients' cognitive dysfunction. Methods In this study, 31 healthy controls (HCs) and 32 cirrhotic patients without overt hepatic encephalopathy participated. Both blood ammonia level and Child-Pugh score were measured. The psychometric hepatic encephalopathy score (PHES) was used to evaluate cognitive function. 1H-magnetic resonance spectroscopy (MRS) data located in the rAI were recorded on a commercially available 3T magnetic resonance imaging scanner. The ratios of metabolites were measured, including N-acetylaspartate (NAA)/total creatine (tCr), glutamate plus glutamine (Glx)/tCr, myo-inositol (mI)/tCr, and total choline (tCho)/tCr. We adopted the non-parametric Mann-Whitney U-test for intergroup comparison of metabolic ratios. To determine the association between metabolite concentration and clinical parameters, we performed Spearman correlation analyses. Results Patients with cirrhosis performed worse on PHES in comparison with HCs (P < 0.001). Patients with cirrhosis had significantly decreased mI/tCr (0.87 ± 0.07 vs. 0.74 ± 0.19, P = 0.025) and increased Glx/tCr (1.79 ± 0.17 vs. 2.07 ± 0.29, P < 0.001) in the rAI. We did not observe any significant between-group differences in tCho/tCr and NAA/tCr. The blood ammonia level was correlated with Glx/tCr (r = 0.405, P = 0.022) and mI/tCr (r = -0.398, P = 0.024) of the rAI. In addition, PHES was negatively correlated with Glx/tCr of the rAI (r = -0.379, P = 0.033). Conclusion Metabolic disturbance of the rAI, which is associated with ammonia intoxication, might account for the neural substrate of cirrhosis-related cognitive dysfunction to some extent.
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Affiliation(s)
- Nao-Xin Huang
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hui-Wei Huang
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qiu-Yi Dong
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yu-Lin Wen
- Shanghai Key Laboratory of Magnetic Resonance, School of Physics and Electronic Science, East China Normal University, Shanghai, China
| | - Dan Li
- Department of Gastroenterology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jian-Qi Li
- Shanghai Key Laboratory of Magnetic Resonance, School of Physics and Electronic Science, East China Normal University, Shanghai, China
| | - Hua-Jun Chen
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
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Aristizábal-Ortiz S, Márquez-Zuchini S, Guarnizo A. Hyperammonemic encephalopathy. Neurol Sci 2023; 44:3361-3362. [PMID: 37310579 DOI: 10.1007/s10072-023-06901-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Affiliation(s)
- Santiago Aristizábal-Ortiz
- Department of Radiology, Hospital Universitario Fundación Santa Fe de Bogotá, Carrera 7 No. 117-15, 110111, Bogotá, Colombia
| | - Silvia Márquez-Zuchini
- Department of Radiology, Hospital Universitario Fundación Santa Fe de Bogotá, Carrera 7 No. 117-15, 110111, Bogotá, Colombia
| | - Angela Guarnizo
- Department of Radiology, Division of Neuroradiology, Hospital Universitario Fundación Santa Fe de Bogotá, Carrera 7 No. 117-15, 110111, Bogotá, Colombia.
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Guo RM, Li QL, Zhong LR, Guo Y, Jiao J, Chen SQ, Wang J, Zhang Y. Brain MRI findings in acute hepatic encephalopathy in liver transplant recipients. Acta Neurol Belg 2018; 118:251-258. [PMID: 29275444 DOI: 10.1007/s13760-017-0875-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/15/2017] [Indexed: 12/24/2022]
Abstract
Acute hepatic encephalopathy has significant morbidity and mortality in liver transplant recipients unless it is promptly treated. We evaluated the brain magnetic resonance (MR) imaging findings associated with acute hepatic encephalopathy in transplant recipients. We retrospectively reviewed the clinical and imaging data and outcomes of twenty-five liver transplant patients (16 male; mean age, 49.3 years) with clinically diagnosed acute hepatic encephalopathy and forty liver transplant patients (20 males; mean age, 45.5 years) without neurological symptoms suggestive of hepatic encephalopathy at our institution. Bilateral symmetric hyperintensities of the insular cortex and cingulate gyrus were observed in twenty-one patients (84.00%), bilateral symmetric extensive increased cortical signal intensity (involving two or more regions) was observed in 72.00% of the patients, leptomeningeal enhancement in 73.68%, and visualization of prominent venules in 52.00%. The most common symptom at diagnosis was rigidity (n = 14), and the plasma ammonia levels ranged from 68.63 to 192.16 μmol/L. After active treatment, 17 patients gradually recovered, four patients suffered from mild or moderate neurologic deficits, and four patients with widespread brain edema died. The specific brain MR imaging features were bilateral symmetric increased cortical signal intensity, especially in the insular cortex and cingulate gyrus, leptomeningeal enhancement, visualization of the prominent venules, and widespread brain edema. These features may indicate poor prognosis and should alert radiologists to the possibility of acute hepatic encephalopathy in liver transplant recipients and encourage clinicians to prepare appropriate treatment in advance.
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Affiliation(s)
- Ruo-Mi Guo
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Nuclear Medicine, The Third Affiliated Hospital, Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, 510630, China
| | - Qing-Ling Li
- Department of VIP Medical Center, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Li-Ru Zhong
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yu Guo
- Department of VIP Medical Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Ju Jiao
- Department of Nuclear Medicine, The Third Affiliated Hospital, Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, 510630, China
| | - Shao-Qiong Chen
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jin Wang
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yong Zhang
- Department of Nuclear Medicine, The Third Affiliated Hospital, Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, 510630, China.
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Imaging spectrum of central nervous system complications of hematopoietic stem cell and solid organ transplantation. Neuroradiology 2017; 59:105-126. [PMID: 28255902 DOI: 10.1007/s00234-017-1804-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
Neurologic complications are common after hematopoietic stem cell transplantation (HSCT) and solid organ transplantation (SOT) and affect 30-60% of transplant recipients. The aim of this article is to provide a practical imaging approach based on the timeline and etiology of CNS abnormalities, and neurologic complications related to transplantation of specific organs. The lesions will be classified based upon the interval from HSCT procedure: pre-engraftment period <30 days, early post-engraftment period 30-100 days, late post-engraftment period >100 days, and the interval from SOT procedure: postoperative phase 1-4 weeks, early posttransplant syndromes 1-6 months, late posttransplant syndromes >6 months. Further differentiation will be based on etiology: infections, drug toxicity, metabolic derangements, cerebrovascular complications, and posttransplantation malignancies. In addition, differentiation will be based on complications specific to the type of transplantation: allogeneic and autologous hematopoietic stem cells (HSC), heart, lung, kidney, pancreas, and liver. Thus, in this article we emphasize the strategic role of neuroradiology in the diagnosis and response to treatment by utilizing a methodical approach in the work up of patients with neurologic complications after transplantation.
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Pulivarthi S, Gurram MK. Magnetic resonance imaging of brain findings in hyperammonemic encephalopathy. J Neurosci Rural Pract 2016; 7:469-71. [PMID: 27365975 PMCID: PMC4898126 DOI: 10.4103/0976-3147.181487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Yoon SJ, Choi SY, Kim JG. Hyperammonemic Encephalopathy with Diffuse Cortical and Thalamic Signal Changes on Diffusion-Weighted Brain MRI. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.2016.9.1.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Rosario M, McMahon K, Finelli PF. Diffusion-weighted imaging in acute hyperammonemic encephalopathy. Neurohospitalist 2013; 3:125-30. [PMID: 24167645 DOI: 10.1177/1941874412467806] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Magnetic resonance imaging (MRI) findings associated with chronic liver disease are characterized by cerebral atrophy and bilateral, symmetric hyperintensities of the globus pallidus on T1-weighted images without corresponding signal intensities in T2-weighted images. Recently, distinct MRI changes of acute hepatic encephalopathy have been described which may be misinterpreted given their resemblance to hypoxic-ischemic injury imaging changes as well as their limited description in the neurologic literature. We describe 3 cases of acute hyperammonemic encephalopathy primarily characterized by restricted diffusion involving the insular and cingulate cortices and thalamus bilaterally.
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Affiliation(s)
- Michael Rosario
- Department of Neurology, University of Connecticut, Hartford Hospital, Hartford, Connecticut, CT, USA
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