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Li J, Wan S, Wen F, Li Q, Cui Y, Lu Z, Lin H. Liver Transplantation Reverses Hepatic Myelopathy in the Decompensated Phase of Cirrhosis: Case Report and Literature Review. J Clin Transl Hepatol 2024; 12:436-442. [PMID: 38638382 PMCID: PMC11022064 DOI: 10.14218/jcth.2023.00487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/14/2024] [Accepted: 02/05/2024] [Indexed: 04/20/2024] Open
Abstract
Hepatic myelopathy (HM) is a rare neurological complication in the end stage of many liver diseases and is characterized by bilateral spastic paraparesis without sensory and sphincter dysfunction. It occurs owing to metabolic disorders and central nervous system dysfunction associated with cirrhosis. Without timely and effective clinical intervention, the prognosis of these patients is devastating. Although liver transplantation (LT) is an effective treatment for HM, the prognosis of these patients remains unsatisfactory. Early recognition and diagnosis of this disease are essential for improving patient prognosis. Here, we report a case of hepatitis B virus-associated decompensated cirrhosis with HM. The patient recovered well after LT. We also summarize the clinical characteristics and post-transplant outcomes of 25 patients with HM treated by LT through 2023, including this case.
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Affiliation(s)
| | | | - Fukai Wen
- Department of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Qingyu Li
- Department of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yifeng Cui
- Department of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Zhaoyang Lu
- Department of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Han Lin
- Department of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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Holroyd KB, Berkowitz AL. Metabolic and Toxic Myelopathies. Continuum (Minneap Minn) 2024; 30:199-223. [PMID: 38330479 DOI: 10.1212/con.0000000000001376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE This article reviews the clinical presentation, diagnostic evaluation, and treatment of metabolic and toxic myelopathies resulting from nutritional deficiencies, environmental and dietary toxins, drugs of abuse, systemic medical illnesses, and oncologic treatments. LATEST DEVELOPMENTS Increased use of bariatric surgery for obesity has led to higher incidences of deficiencies in nutrients such as vitamin B12 and copper, which can cause subacute combined degeneration. Myelopathies secondary to dietary toxins including konzo and lathyrism are likely to become more prevalent in the setting of climate change leading to drought and flooding. Although modern advances in radiation therapy techniques have reduced the incidence of radiation myelopathy, patients with cancer are living longer due to improved treatments and may require reirradiation that can increase the risk of this condition. Immune checkpoint inhibitors are increasingly used for the treatment of cancer and are associated with a wide variety of immune-mediated neurologic syndromes including myelitis. ESSENTIAL POINTS Metabolic and toxic causes should be considered in the diagnosis of myelopathy in patients with particular clinical syndromes, risk factors, and neuroimaging findings. Some of these conditions may be reversible if identified and treated early, requiring careful history, examination, and laboratory and radiologic evaluation for prompt diagnosis.
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Corrêa DG, da Cruz LCH, da Rocha AJ, Pacheco FT. Imaging Aspects of Toxic and Metabolic Myelopathies. Semin Ultrasound CT MR 2023; 44:452-463. [PMID: 37555682 DOI: 10.1053/j.sult.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
Metabolic and toxic myelopathies usually occurs due to several different causes. Metabolic myelopathy usually occurs due to deficiency of a nutrient, such as vitamin B12. Toxic myelopathy occurs secondary to the exposure to an external toxic agent. Although they may have a difficult diagnosis, determination of the specific cause of myelopathy is of utmost importance, because many causes are amenable to treatment. Although they have many clinical, electrophysiologic, and neuropathologic similarities, imaging may aid in the suspicion of toxic or metabolic myelopathy. The aim of this article, is to review the imaging features of the main toxic and metabolic myelopathies.
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Affiliation(s)
- Diogo Goulart Corrêa
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Rio de Janeiro, RJ, Brazil; Department of Radiology, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil.
| | | | - Antônio José da Rocha
- Department of Neuroradiology, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Department of Radiology, DASA, São Paulo, SP, Brazil
| | - Felipe Torres Pacheco
- Department of Neuroradiology, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Department of Radiology, DASA, São Paulo, SP, Brazil
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Chang CY, Liu C, Duan FF, Zhai H, Song SS, Yang S. Spontaneous remission of hepatic myelopathy in a patient with alcoholic cirrhosis: A case report. World J Clin Cases 2022; 10:11172-11177. [PMID: 36338225 PMCID: PMC9631124 DOI: 10.12998/wjcc.v10.i30.11172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/24/2022] [Accepted: 09/19/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hepatic myelopathy (HM) is a rare neurological complication of advanced cirrhosis. Prognosis of patients with HM is generally poor without timely liver transplantation or interventional therapy. Self-resolving HM in patients with alcoholic cirrhosis has never been reported.
CASE SUMMARY A 53-year-old man with alcoholic cirrhosis and recurrent overt hepatic encephalopathy for 1 year was admitted for lower extremity weakness, slow movement, and stumbling gait. The patient was diagnosed with HM after excluding other causes of spastic paraparesis. The patient refused liver transplantation. However, the patient kept total abstinence and received a multidisciplinary treatment for complications of decompensated cirrhosis. The symptoms of HM resolved gradually after 2 years of treatment. All complications of alcoholic cirrhosis resolved after 4 years of follow-up.
CONCLUSION The case demonstrates that HM can resolve in patients without liver transplan-tation after total abstinence and systemic management of complications.
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Affiliation(s)
- Chun-Yan Chang
- Division Third Center of Hepatology, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Chen Liu
- Division Third Center of Hepatology, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Fang-Fang Duan
- Division Third Center of Hepatology, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Hang Zhai
- Division Third Center of Hepatology, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Shan-Shan Song
- Division Third Center of Hepatology, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Song Yang
- Division Third Center of Hepatology, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
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Jalan R, Rose CF. Heretical thoughts into hepatic encephalopathy. J Hepatol 2022; 77:539-548. [PMID: 35358618 DOI: 10.1016/j.jhep.2022.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/03/2022] [Accepted: 03/11/2022] [Indexed: 02/06/2023]
Abstract
Clinical progress in the development of new diagnostic modalities and therapeutic strategies for the management of patients with hepatic encephalopathy has lagged behind the vast knowledge that has been generated from basic studies. In this article, we critically assess matters that should be revisited, such as definition, classification, diagnosis and grading of hepatic encephalopathy, which are difficult to apply reproducibly using the current criteria. Many lines of investigation have confirmed that hepatic encephalopathy is irreversible in many patients and suggest the need for further studies focussing on mechanisms of neuronal injury and death, to guide future drug development for these patients. The clinical evidence behind using lactulose for all severities of hepatic encephalopathy, which is currently considered the standard of care, is poor and placebo-controlled trials for hepatic encephalopathy should be considered ethically sound. This expert opinion identifies current challenges in hepatic encephalopathy and highlights areas which require further debate and investigation in order to help advance the field both scientifically and clinically.
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Affiliation(s)
- Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom.
| | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada.
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Kaur J, Jesrani G, Gupta M, Lehl SS. Spastic paraparesis associated with advanced liver cirrhosis: a condition obscure in terms of treatment and prognosis. BMJ Case Rep 2020; 13:13/6/e235090. [PMID: 32513765 DOI: 10.1136/bcr-2020-235090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hepatic myelopathy or spastic paraparesis of liver disease is an insidious onset condition with pure motor spastic paraparesis without sensory, bladder or bowel involvement in patients with chronic liver disease, in which the neurological dysfunction cannot be explained by other causes. It is a rare, relentlessly progressive and mostly irreversible neurological complication resulting from portosystemic shunts occurring spontaneously, created surgically or due to 'functional shunting'. In some cases, no evidence of shunting is elicitable due to difficulty in locating the hidden collaterals. We report this rare case of a 33-year-old man with chronic liver disease presenting with spastic paraparesis after 11 months of resolution of an episode of hepatic encephalopathy.
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Affiliation(s)
- Jaspreet Kaur
- General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Gautam Jesrani
- General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Monica Gupta
- General Medicine, Government Medical College and Hospital, Chandigarh, India
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Ciarlariello VB, Fujino MVT, Almeida MDD, Barsottini OGP, Pedroso JL. Teaching Video NeuroImages: Hepatic myelopathy: An unusual neurologic complication of hepatic encephalopathy. Neurology 2019; 93:e320-e321. [PMID: 31308174 DOI: 10.1212/wnl.0000000000007782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Vinícius Boaratti Ciarlariello
- From the Department of Neurology (V.B.C., M.V.T.F., M.D.d.A.), Hospital Israelita Albert Einstein; and Department of Neurology (O.G.P.B., J.L.P.), Ataxia Unit, Universidade Federal de São Paulo, Brazil
| | - Marcos Vinícius Tadao Fujino
- From the Department of Neurology (V.B.C., M.V.T.F., M.D.d.A.), Hospital Israelita Albert Einstein; and Department of Neurology (O.G.P.B., J.L.P.), Ataxia Unit, Universidade Federal de São Paulo, Brazil
| | - Marcio Dias de Almeida
- From the Department of Neurology (V.B.C., M.V.T.F., M.D.d.A.), Hospital Israelita Albert Einstein; and Department of Neurology (O.G.P.B., J.L.P.), Ataxia Unit, Universidade Federal de São Paulo, Brazil
| | - Orlando G P Barsottini
- From the Department of Neurology (V.B.C., M.V.T.F., M.D.d.A.), Hospital Israelita Albert Einstein; and Department of Neurology (O.G.P.B., J.L.P.), Ataxia Unit, Universidade Federal de São Paulo, Brazil
| | - José Luiz Pedroso
- From the Department of Neurology (V.B.C., M.V.T.F., M.D.d.A.), Hospital Israelita Albert Einstein; and Department of Neurology (O.G.P.B., J.L.P.), Ataxia Unit, Universidade Federal de São Paulo, Brazil.
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Abstract
RATIONALE Hepatic myelopathy (HM), also known as portal-systemic myelopathy, is a rare neurological complication that occurs in patients with chronic liver disease. There is no easy and feasible treatment, liver transplantation is the only accepted therapy that may be effective for patients at early stage at present. The pathogenesis of the disease is not clear yet, and the prognosis is poor. Here we describe a reversible HM after fecal microbiota transplantation. PATIENT CONCERNS In this report, a middle-aged female patient with hepatitis B cirrhosis, occurred HM after transjugular intrahepatic portosystemic shunt, a progressive spastic paraparesis in both legs were the main symptoms. DIAGNOSIS The patient was diagnosed with HM. INTERVENTIONS The patient received 3 times of fecal microbiota transplantations (FMT). OUTCOMES The patient's muscle strength of both legs were increased at various degrees, the patient's condition improved from HM2 to HM1. LESSONS FMT may be another effective way to treat HM. It is cheaper, more operable, and simpler than the approved treatment and worthy of further research.
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Cui LB, Ren S, Xi YB, Zeng LL, Chen G, Liu K, Yu T, He C, Guo W, Yin Z, Wang Z, Niu J, Luo B, Hu D, Han G, Yin H. Motor Cortex Mapping in Patients With Hepatic Myelopathy After Transjugular Intrahepatic Portosystemic Shunt. Acad Radiol 2019; 26:e38-e46. [PMID: 30076082 DOI: 10.1016/j.acra.2018.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 06/15/2018] [Accepted: 06/15/2018] [Indexed: 02/07/2023]
Abstract
RATIONALE AND OBJECTIVES As a special movement disorder, hepatic myelopathy (HM) is characterized by spastic paraperesis and may be secondary to transjugular intrahepatic portosystemic shunt (TIPS). The prediction and diagnosis of HM is difficult due to largely unknown neuropathological underpinnings and a lack of specific biomarkers. We aimed to delve into the alterations in motor system of HM patients' brain and their potential clinical implication. MATERIAL AND METHODS Twenty-three patients with HM and 23 without HM after TIPS and 24 demographically matched healthy controls were enrolled. High-spatial-resolution structural imaging and functional data at rest were acquired. Motor areas were included as seed regions for functional connectivity analysis. Then, we performed brain volume analysis. RESULTS We found decreased right supplementary motor area (SMA)-seeded functional connectivity with bilateral insula, thalamus and midbrain, left cerebellum and middle temporal gyrus, and right middle cingulate gyrus in HM compared to non-HM patients (p < 0.001). The right insula revealed decreased volume (p < 0.001), and white matter volume reduced in the right corona radiata beneath the right SMA (p < 0.001) in HM relative to non-HM patients. Furthermore, the strength of right SMA-seeded connectivity with insula was positively correlated with folic acid level in HM patients (r = 0.60, p = 0.03), showing an accuracy of 0.87 to distinguish HM from non-HM. CONCLUSION Our study demonstrates the HM-specific dysconnectivity with an anatomical basis, and its correlation with laboratory findings and diagnostic value. Detecting these abnormalities might help to predict and diagnose post-TIPS HM.
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Kashala-Abotnes E, Okitundu D, Mumba D, Boivin MJ, Tylleskär T, Tshala-Katumbay D. Konzo: a distinct neurological disease associated with food (cassava) cyanogenic poisoning. Brain Res Bull 2018; 145:87-91. [PMID: 29981837 DOI: 10.1016/j.brainresbull.2018.07.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/18/2018] [Accepted: 07/04/2018] [Indexed: 10/28/2022]
Abstract
Epidemics of neurodegenerative diseases putatively caused by food toxins have been reported in the tropics with no clear understanding of their pathogenetic mechanisms. These diseases include the disease named Konzo that has been well documented in sub-Sahara Africa, mostly among children and women of childbearing age. Outbreaks of Konzo have occurred in the Democratic Republic of Congo, Mozambique, Tanzania, Central African Republic, Angola, Cameroun, and most recently in Zambia. The main clinical picture consists of a symmetrical, permanent and irreversible spastic paraparesis (motor neuron disease) with no signs of sensory or genitourinary impairments. Recently, cognitive impairments and neurodevelopmental delays have been reported among school-aged and very young children. The exact pathogenetic mechanisms of the disease remain unknown. Epidemiological studies consistently show an association between outbreaks of the disease and chronic dietary reliance on insufficiently processed cyanogenic cassava (manioc or tapioca). Biochemical and toxicological studies suggest that the metabolites of linamarin (α-Hydroxyisobutyronitrile β-D-glucopyranoside, the main cassava cyanogen), notably cyanide (mitochondrial toxin), thiocyanate (AMPA chaotropic agent), and cyanate (protein carbamoylating agent) may play an important role in the pathogenesis of Konzo. Experimental data suggest that thiol-redox and protein- folding mechanisms may also be perturbed. Factors of susceptibility including genetics, poor nutrition, poverty and dietary cyanogen exposure, or their interactions have been suggested. Serological studies have ruled out the role of retroviruses such as the human lymphotropic viruses HIV-I/II or HTLV-I/II. Because there is no cure for Konzo, prevention of the disease remains of paramount importance. Prospects for cognitive rehabilitation still need to be explored and tested.
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Affiliation(s)
| | - Daniel Okitundu
- Department of Neurology, University of Kinshasa, Democratic Republic of Congo
| | - Dieudonne Mumba
- Department of Tropical Medicine, University of Kinshasa & National Institute of Biomedical Research (INRB), Democratic Republic of Congo
| | - Michael J Boivin
- Departments of Psychiatry and Neurology & Ophthalmology, Michigan State University, East Lansing MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Thorkild Tylleskär
- Department of Global Public Health and Primary Care, University of Bergen, Norway
| | - Desire Tshala-Katumbay
- Department of Neurology, University of Kinshasa, Democratic Republic of Congo; Department of Tropical Medicine, University of Kinshasa & National Institute of Biomedical Research (INRB), Democratic Republic of Congo; Department of Neurology & School of Public Health, Oregon Health & Science University, Portland OR, USA
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11
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Brain white matter fiber tracts involved in post-transjugular intrahepatic portosystemic shunt hepatic myelopathy. Neuroreport 2017; 28:1164-1169. [DOI: 10.1097/wnr.0000000000000898] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Hepatic myelopathy (HM) is characterized by progressive weakness and spasticity of the lower extremities, which is a severe spinal cord involvement rarely occurring in patients with cirrhosis or other chronic liver diseases. The diagnosis is assigned after the exclusion of other clinical entities leading to spastic paraparesis. Liver transplantation represents a potentially treatment for HM in early stage.
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Affiliation(s)
- Li Li
- Jing- Ying Li, Xiu-Hui Li, Center for Combined TCM and Western Medicine, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Chun-Yan Gou
- Jing- Ying Li, Xiu-Hui Li, Center for Combined TCM and Western Medicine, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
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Shin HW, Park HK. Recent Updates on Acquired Hepatocerebral Degeneration. Tremor Other Hyperkinet Mov (N Y) 2017; 7:463. [PMID: 28975044 PMCID: PMC5623760 DOI: 10.7916/d8tb1k44] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 07/24/2017] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Acquired hepatocerebral degeneration (AHD) refers to a chronic neurological syndrome in patients with advanced hepatobiliary diseases. This comprehensive review focuses on the pathomechanism and neuroimaging findings in AHD. METHODS A PubMed search was performed using the terms "acquired hepatocerebral degeneration," "chronic hepatocerebral degeneration," "Non-Wilsonian hepatocerebral degeneration," "cirrhosis-related parkinsonism," and "manganese and liver disease." RESULTS Multiple mechanisms involving the accumulation of toxic substances such as ammonia or manganese and neuroinflammation may lead to widespread neurodegeneration in AHD. Clinical characteristics include movement disorders, mainly parkinsonism and ataxia-plus syndrome, as well as cognitive impairment with psychiatric features. Neuroimaging studies of AHD with parkinsonism show hyperintensity in the bilateral globus pallidus on T1-weighted magnetic resonance images, whereas molecular imaging of the presynaptic dopaminergic system shows variable findings. Ataxia-plus syndrome in AHD may demonstrate high-signal lesions in the middle cerebellar peduncles on T2-weighted images. DISCUSSION Future studies are needed to elucidate the exact pathomechanism and neuroimaging findings of this heterogeneous syndrome.
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Affiliation(s)
- Hae-Won Shin
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, Republic of Korea
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD, USA
| | - Hee Kyung Park
- Department of Neurology, Inje University Ilsan-Paik Hospital, Goyang, Republic of Korea
- Movement Disorder Center, Department of Neurosciences, University of California San Diego, San Diego, CA, USA
- *To whom correspondence should be addressed. E-mail:
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Brannelly NT, Hamilton-Shield JP, Killard AJ. The Measurement of Ammonia in Human Breath and its Potential in Clinical Diagnostics. Crit Rev Anal Chem 2016; 46:490-501. [PMID: 26907707 DOI: 10.1080/10408347.2016.1153949] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Ammonia is an important component of metabolism and is involved in many physiological processes. During normal physiology, levels of blood ammonia are between 11 and 50 µM. Elevated blood ammonia levels are associated with a variety of pathological conditions such as liver and kidney dysfunction, Reye's syndrome and a variety of inborn errors of metabolism including urea cycle disorders (UCD), organic acidaemias and hyperinsulinism/hyperammonaemia syndrome in which ammonia may reach levels in excess of 1 mM. It is highly neurotoxic and so effective measurement is critical for assessing and monitoring disease severity and treatment. Ammonia is also a potential biomarker in exercise physiology and studies of drug metabolism. Current ammonia testing is based on blood sampling, which is inconvenient and can be subject to significant analytical errors due to the quality of the sample draw, its handling and preparation for analysis. Blood ammonia is in gaseous equilibrium with the lungs. Recent research has demonstrated the potential use of breath ammonia as a non-invasive means of measuring systemic ammonia. This requires measurement of ammonia in real breath samples with associated temperature, humidity and gas characteristics at concentrations between 50 and several thousand parts per billion. This review explores the diagnostic applications of ammonia measurement and the impact that the move from blood to breath analysis could have on how these processes and diseases are studied and managed.
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Affiliation(s)
- N T Brannelly
- a Department of Biological Biomedical and Analytical Science , University of the West of England , Bristol , UK
| | | | - A J Killard
- a Department of Biological Biomedical and Analytical Science , University of the West of England , Bristol , UK
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Abstract
Minimal hepatic encephalopathy (mHE) is common among patients with cirrhotic liver disease and causes significant morbidity and mortality. It may present as cognitive impairment, behavioural changes and, less frequently, with neurological symptoms which make diagnosis of the disease challenging. A history of falls and accidents may also be suggestive of mHE. Diagnosis primarily relies on at least two positive psychometric tests of which the psychometric hepatic encephalopathy score (PHES) is essential. Alternatively, PHES and an electroencephalogram may be used to establish a diagnosis. Biochemical markers of encephalopathy currently have no role in the diagnosis of mHE. Treatment is not always advocated for a diagnosis of mHE but is dependent on the degree of impairment caused by the symptoms. After treatment of other metabolic abnormalities and co-morbidities associated with cirrhosis, more specific treatment for mHE largely relies on therapies used to lower ammonia levels. Laxatives and rifaximin are commonly used in treatment and work through decreasing ammonia absorption from the gut. Other therapies, such as BCAA, LOLA, L-carnitine and phenylbutyrate, modify responses to ammonia as well as enhancing metabolism and excretion. mHE resulting from spontaneous portosystemic shunts or transhepatic intraportal systemic shunts may require ablation or reduction of the shunt. Early detection and appropriate treatment of mHE is important to prevent significant cognitive impairments and progression to overt HE.
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Affiliation(s)
- Shamindra Direkze
- Royal Free Hospital NHS Foundation Trust, University College London, London, UK
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Zhovtis Ryerson L, Herbert J, Howard J, Kister I. Adult-onset spastic paraparesis: an approach to diagnostic work-up. J Neurol Sci 2014; 346:43-50. [PMID: 25263600 DOI: 10.1016/j.jns.2014.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/20/2014] [Accepted: 09/12/2014] [Indexed: 11/30/2022]
Abstract
Adult-onset, chronic progressive spastic paraparesis may be due to a large number of causes and poses a diagnostic challenge. There are no recent evidence-based guidelines or comprehensive reviews to help guide diagnostic work-up. We survey the literature on chronic progressive spastic paraparesis, with special emphasis on myelopathies, and propose a practical, MRI-based approach to facilitate the diagnostic process. Building on neuro-anatomic and radiographic conventions, we classify spinal MRI findings into six patterns: extradural; intradural/extramedullary; Intramedullary; Intramedullary-Tract specific; Spinal Cord Atrophy; and Normal Appearing Spinal Cord. A comprehensive differential diagnosis of chronic progressive myelopathy for each of the six patterns is generated. We highlight some of the more common and/or treatable causes of progressive spastic paraparesis and provide clinical pointers that may assist clinicians in arriving at the diagnosis. We outline a practical, comprehensive MRI-based algorithm to diagnosing adult-onset chronic progressive myelopathy.
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Affiliation(s)
| | - Joseph Herbert
- NYU Langone Multiple Sclerosis Comprehensive Care Center, New York, NY, USA
| | - Jonathan Howard
- NYU Langone Multiple Sclerosis Comprehensive Care Center, New York, NY, USA
| | - Ilya Kister
- NYU Langone Multiple Sclerosis Comprehensive Care Center, New York, NY, USA
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Abstract
PURPOSE OF REVIEW This article summarizes the most common neurologic sequelae of acute and chronic liver failure, liver transplantation, and other treatments for liver disease, and outlines the pathogenesis, neurologic manifestations, and treatment of Wilson disease. RECENT FINDINGS The neurologic manifestations of liver disease are caused by the liver's failure to detoxify active compounds that have deleterious effects on the central and peripheral nervous systems. In addition, treatments for liver disease such as liver transplantation, transjugular intrahepatic portosystemic shunt, and antiviral medications can also be neurotoxic. Wilson disease affects the liver and nervous system simultaneously and may often initially be diagnosed by a neurologist; treatment options have evolved over recent years. SUMMARY Acute and chronic liver diseases are encountered commonly in the general population. Neurologic dysfunction will eventually affect a significant number of these individuals, especially if the disease progresses to liver failure. Early recognition of these neurologic manifestations can lead to more effective management of these patients.
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Central motor and sensory conduction in patients with hepatic myelopathy. Spinal Cord 2014; 52:439-43. [PMID: 24777163 DOI: 10.1038/sc.2014.61] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 03/17/2014] [Accepted: 03/28/2014] [Indexed: 01/13/2023]
Abstract
STUDY DESIGN Experimental neurophysiological study. OBJECTIVES The hepatic myelopathy (HM) is characterized by progressive weakness and spasticity of the lower extremities, while there are only a few reports of sensory impairment. However, sensory function has been poorly explored in HM. We believe that an electrophysiological assessment of dorsal columns by somatosensory evoked potentials (SEPs) and of cortico-spinal lateral tracts by motor evoked potentials (MEPs) should be of considerable value in the functional evaluation of the spinal cord involvement in patients with HM. SETTING Salzburg (Austria) and Merano (Italy). METHODS Eight patients diagnosed with HM were studied with MEPs and SEPs. Neurological examination revealed different degrees of cortico-spinal tract involvement in all patients and sensory abnormalities in three patients. RESULTS Central motor conduction to lower limb muscles was abnormal in all patients, while central sensory conduction was abnormal in seven out of the eight patients. Both central motor and sensory conduction to upper limbs are normal in all patients. CONCLUSION The main finding is that electrophysiological evidence of central sensory involvement is present in a very high percentage of patients with HM, and that the threshold for electrophysiological abnormalities is below that for clinical manifestations. Therefore, central sensory and motor conduction studies are sensitive methods for detecting, localizing and monitoring spinal cord damage in HM.
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Central motor conduction studies in patients with spinal cord disorders: a review. Spinal Cord 2014; 52:420-7. [DOI: 10.1038/sc.2014.48] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/17/2014] [Accepted: 03/22/2014] [Indexed: 11/09/2022]
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Hirozawa D, Fukada K, Yaegaki T, Hoshi T, Sawada J, Hazama T. [Reversible hepatic myelopathy: a case report]. Rinsho Shinkeigaku 2014; 54:223-6. [PMID: 24705837 DOI: 10.5692/clinicalneurol.54.223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of reversible hepatic myelopathy. A 42-year-old female patient with 3-year history of alcoholic liver cirrhosis developed spastic gait, hyperreflexia and mild somatosensory disturbance in her lower extremities. The increased level of serum ammonia and the deficits of N30 and P38 in the tibial somatosensory evoked potentials (SEP) in conjunction with exclusion of the other known causes of myelopathy supported the diagnosis of her hepatic myelopathy. The ammonia lowering therapy by the oral administration of lactulose successfully improved the spastic gait accompanied with the emergence of N30 and P38 in the tibial SEP. Although liver transplantation was known to be the only therapy for hepatic myelopathy in the literatures, our case showed that the ammonia lowering therapy can be effective for the early stage of hepatic myelopathy.
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Nardone R, Höller Y, Storti M, Lochner P, Tezzon F, Golaszewski S, Brigo F, Trinka E. Spinal cord involvement in patients with cirrhosis. World J Gastroenterol 2014; 20:2578-85. [PMID: 24627593 PMCID: PMC3949266 DOI: 10.3748/wjg.v20.i10.2578] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 01/03/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
A severe spinal cord involvement may rarely occur in patients with cirrhosis and other chronic liver diseases; this complication is usually associated with overt liver failure and surgical or spontaneous porto-systemic shunt. Hepatic myelopathy (HM) is characterized by progressive weakness and spasticity of the lower extremities, while sensory and sphincter disturbances have rarely been described and are usually less important. The diagnosis is assigned in the appropriate clinical setting on clinical grounds after the exclusion of other clinical entities leading to spastic paraparesis. Magnetic resonance imaging is often unremarkable; however, also intracerebral corticospinal tract abnormalities have been reported recently. The study of motor evoked potentials may disclose central conduction abnormalities even before HM is clinically manifest. HM responds poorly to blood ammonia-lowering and other conservative medical therapy. Liver transplantation represents a potentially definitive treatment for HM in patients with decompensated cirrhosis of Child-Pugh B and C grades. Other surgical treatment options in HM include surgical ligation, shunt reduction, or occlusion by interventional procedures.
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Goldberg J, Daniel M, van Heuvel Y, Victor M, Beyer C, Clarner T, Kipp M. Short-term cuprizone feeding induces selective amino acid deprivation with concomitant activation of an integrated stress response in oligodendrocytes. Cell Mol Neurobiol 2013; 33:1087-98. [PMID: 23979168 DOI: 10.1007/s10571-013-9975-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 08/12/2013] [Indexed: 12/20/2022]
Abstract
Cuprizone [bis(cyclohexylidenehydrazide)]-induced toxic demyelination is an experimental approach frequently used to study de- and re-myelination in the central nervous system. In this model, mice are fed with the copper chelator cuprizone which leads to oligodendrocyte apoptosis and subsequent microgliosis, astrocytosis, and demyelination. The underlying mechanisms of cuprizone-induced oligodendrocyte death are still unknown. We analysed differences in amino acid levels after short-term cuprizone exposure (i.e., 4 days). Furthermore, an amino acid response (AAR) pathway activated in oligodendrocytes after cuprizone intoxication was evaluated. Short-term cuprizone exposure resulted in a selective decrease of alanine, glycine, and proline plasma levels, which was paralleled by an increase of apoptotic cells in the liver and a decrease of alanine aminotransferase in the serum. These parameters were paralleled by oligodendrocyte apoptosis and the induction of an AAR with increased expression of the transcription factors ATF-3 and ATF-4 (activating transcription factor-3 and -4). Immunohistochemistry revealed that ATF-3 is exclusively expressed by oligodendrocytes and localized to the nuclear compartment. Our results suggest that cuprizone-induced liver dysfunction results in amino acid starvation and in consequence to the activation of an AAR. We propose that this stress response modulates oligodendrocyte viability in the cuprizone animal model.
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Affiliation(s)
- Johannes Goldberg
- Faculty of Medicine, Institute of Neuroanatomy, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
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Ben Amor S, Saied MZ, Harzallah MS, Benammou S. Hepatic myelopathy with spastic paraparesis: report of two cases and review of the literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 23 Suppl 2:167-71. [PMID: 23728397 DOI: 10.1007/s00586-013-2828-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 12/08/2012] [Accepted: 05/08/2013] [Indexed: 12/11/2022]
Abstract
PURPOSE The present report illustrates two men aged for 59 and 43 years, respectively, who presented with slowly progressive spastic paraparesis. STUDY DESIGN Two case reports and review of literature. METHODS The patent's history, clinical examination, biology, magnetic resonance imaging (MRI) findings and treatment are reported. We also discuss the pathogenesis and various treatment options. RESULTS Neurologic examination showed spastic paraparesis without other neurological disorders. MRI of the spinal cord and brain were normal. Cytologic examination of cerebrospinal fluid from each patient was normal. Hemogram disclosed a pancytopenia. Partial thromboplastin time was prolonged. Liver function tests revealed raised serum bilirubin, normal alanine aminotransferase and aspartate aminotransferase, reduced total protein and albumin. Plasma ammonia was elevated. Blood vitamin B12 and folate values were in normal ranges. Serum antibodies to human T cell lymphotropic virus, human immunodeficiency virus, syphilis and hepatitis C virus were absent. Hepatitis B virus antibody assay was positive. The electromyographic evaluation for second motor neuron involvement was also normal. Endoscopy revealed esophageal varices and a spleno-renal shunt. CONCLUSIONS Hepatic myelopathy remains a default diagnosis assigned only after the exclusion of other causes of spastic paraparesis and partial transverse myelopathy. An accurate history, along with appropriate imaging and laboratory findings, is crucial.
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Affiliation(s)
- Sana Ben Amor
- Department of Neurology, Sahloul Hospital, Belt drive, 4054, Sahloul city, Sousse, Tunisia,
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Wang MQ, Liu FY, Duan F. Management of surgical splenorenal shunt-related hepatic myelopathy with endovascular interventional techniques. World J Gastroenterol 2012; 18:7104-8. [PMID: 23323015 PMCID: PMC3531701 DOI: 10.3748/wjg.v18.i47.7104] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 08/25/2012] [Accepted: 09/19/2012] [Indexed: 02/06/2023] Open
Abstract
We present a case with hepatic myelopathy (HM) due to a surgical splenorenal shunt that was successfully treated by endovascular interventional techniques. A 39-year-old man presented with progressive spastic paraparesis of his lower limbs 14 mo after a splenorenal shunt. A portal venogram identified a widened patent splenorenal shunt. We used an occlusion balloon catheter initially to occlude the shunt. Further monitoring of the patient revealed a decrease in his serum ammonia level and an improvement in leg strength. We then used an Amplatzer vascular plug (AVP) to enable closure of the shunt. During the follow up period of 7 mo, the patient experienced significant clinical improvement and normalization of blood ammonia, without any complications. Occlusion of a surgically created splenorenal shunt with AVP represents an alternative therapy to surgery or coil embolization that can help to relieve shunt-induced HM symptoms.
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Mladenović D, Hrnčić D, Rašić-Marković A, Puškaš N, Petrovich S, Stanojlović O. Spectral analysis of thioacetamide-induced electroencephalographic changes in rats. Hum Exp Toxicol 2012; 32:90-100. [DOI: 10.1177/0960327112456312] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Thioacetamide (TAA) is widely used as a model of hepatic encephalopathy (HE). The aim of our study was to investigate the effects of TAA on electroencephalographic (EEG) changes in rats and to compare them with human HE. Male Wistar rats were divided into groups: (1) saline-treated group and (2) TAA-treated groups: TAA300 (300 mg/kg), TAA600 (600 mg/kg), and TAA900 (900 mg/kg). Daily dose of TAA (300 mg/kg) was administered intraperitoneally once (TAA300), twice (TAA600), or thrice (TAA900) in subsequent days. EEG changes were recorded about 24 h after the last dose of TAA. Absolute and relative power density in alpha bands were significantly higher in TAA300 versus control group. In TAA300, absolute beta power density was higher and relative beta power density was lower versus control group. Absolute alpha, theta, delta, and relative theta power were significantly lower, while relative power in delta band was significantly higher in TAA900 versus control group ( p < 0.01). In conclusion, decrease in EEG voltage with an increase in delta relative power, which correspond to the EEG manifestations of severe HE in humans, was observed in TAA900 group. Electrical activity in TAA300 group correlates with mild HE in humans.
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Affiliation(s)
- D Mladenović
- Institute of Pathophysiology, Faculty of Medicine, University of Belgrade, Dr Subotica 9 Belgrade, Serbia
| | - D Hrnčić
- Institute of Medical Physiology “Richard Burian”, Faculty of Medicine, University of Belgrade, Višegradska 26/II, Belgrade, Serbia
| | - A Rašić-Marković
- Institute of Medical Physiology “Richard Burian”, Faculty of Medicine, University of Belgrade, Višegradska 26/II, Belgrade, Serbia
| | - N Puškaš
- Institute of Histology and Embryology, Faculty of Medicine, University of Belgrade, Višegradska 26, Belgrade, Serbia
| | - S Petrovich
- Laboratory of Molecular Biology and Endocrinology, Vinča Institute of Nuclear Sciences, University of Belgrade, Serbia
| | - O Stanojlović
- Institute of Medical Physiology “Richard Burian”, Faculty of Medicine, University of Belgrade, Višegradska 26/II, Belgrade, Serbia
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Caldwell C, Werdiger N, Jakab S, Schilsky M, Arvelakis A, Kulkarni S, Emre S. Use of model for end-stage liver disease exception points for early liver transplantation and successful reversal of hepatic myelopathy with a review of the literature. Liver Transpl 2010; 16:818-26. [PMID: 20583082 DOI: 10.1002/lt.22077] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hepatic myelopathy (HM) is a rarely reported disorder characterized by progressive spastic paraparesis due to impaired corticospinal tract function in the setting of cirrhosis or portosystemic shunting. HM has not to date been recognized as a Model for End-Stage Liver Disease (MELD) exception for transplantation. Outcomes for a small number of patients from Europe and Asia who have undergone liver transplantation (LT) for HM suggest a potential neurological benefit, especially with earlier transplantation. We report the first use of MELD exception points for the condition of HM to enable early LT resulting in the reversal of marked spastic paraparesis. Our patient, whose myelopathy had markedly progressed without further hepatic decompensation, underwent LT 14 months after the diagnosis of HM with an adjusted MELD score of 30, which was granted as a United Network for Organ Sharing exception. After LT, there was significant neurological improvement as the patient progressed from wheelchair dependency to full ambulation. We reviewed the literature of other HM patients who had undergone LT. With our patient, there were in all 15 reported cases of LT in individuals with HM. LT can lead to a marked improvement in HM, particularly in the earlier clinical stages of the disorder. Early LT can be accomplished, as in our case, by the submission of an appeal for a MELD upgrade.
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Affiliation(s)
- Cary Caldwell
- Department of Medicine, Section of Digestive Disease, Yale University School of Medicine, New Haven, CT, USA.
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Guerit JM, Amantini A, Fischer C, Kaplan PW, Mecarelli O, Schnitzler A, Ubiali E, Amodio P. Neurophysiological investigations of hepatic encephalopathy: ISHEN practice guidelines. Liver Int 2009; 29:789-96. [PMID: 19638107 DOI: 10.1111/j.1478-3231.2009.02030.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
By studying neuronal activity through neuronal electrogenesis, neurophysiological investigations provide a functional assessment of the nervous system and, therefore, has been used for quantitative assessment and follow-up of hepatic encephalopathy (HE). The different clinical neurophysiological approaches can be classified depending on the function to explore and their sensitivity to HE. The reliable techniques are those that reflect cortical function, i.e., cognitive-evoked potentials (EPs) (P300 paradigm), electroencephalogram (EEG), visual EPs (latency>100 ms) and somatosensory EPs (SEPs) (latency between 25 and 100 ms). Short-latency EPs (brainstem acoustic EPs, SEPs of a latency<25 ms) are in principle insensitive to HE, but can disclose brainstem conduction deficits due to oedema. SEPs and motor EPs can disclose myelopathies. Because of its parallelism to the clinical examination, clinical neurophysiology can complement the neurological examination: (i) to provide evidence of HE in patients who have normal consciousness; (ii) to rule out, at least under some conditions, disturbances of consciousness due to other causes (e.g. drug-induced disturbances, non-convulsive status epilepticus) with the reservation that the mildest degrees of encephalopathy might be associated with an EEG pattern similar to that induced by drugs; and (iii) to demonstrate the worsening or, conversely improvement, of HE in the follow-up period.
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Koo JE, Lim YS, Myung SJ, Suh KS, Kim KM, Lee HC, Chung YH, Lee YS, Suh DJ. Hepatic myelopathy as a presenting neurological complication in patients with cirrhosis and spontaneous splenorenal shunt. THE KOREAN JOURNAL OF HEPATOLOGY 2008; 14:89-96. [PMID: 18367861 DOI: 10.3350/kjhep.2008.14.1.89] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hepatic myelopathy is a rare complication of chronic liver disease that is associated with extensive portosystemic shunts. The main clinical feature of hepatic myelopathy is progressive spastic paraparesis in the absence of sensory or sphincter impairment. Early and accurate diagnosis of hepatic myelopathy is important because patients with early stages of the disease can fully recover following liver transplantation. Motor-evoked potential studies may be suitable for the early diagnosis of hepatic myelopathy, even in patients with preclinical stages of the disease. Here we describe two patients who presented with spastic paraparesis associated with a spontaneous splenorenal shunt and without any previous episode of hepatic encephalopathy. One patient experienced improved neurologic symptoms after liver transplantation, whereas the other patient only received medical treatment, which did not prevent the progression of spastic paraparesis.
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Affiliation(s)
- Ja Eun Koo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Chapter 18 Toxic disorders of the upper motor neuron system. HANDBOOK OF CLINICAL NEUROLOGY 2007; 82:353-72. [DOI: 10.1016/s0072-9752(07)80021-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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