Korean J Radiol.  2013 Apr;14(2):324-328. 10.3348/kjr.2013.14.2.324.

Acute Hepatic Encephalopathy Presenting as Cortical Laminar Necrosis: Case Report

• Choi JM
• Kim YH
• Roh SY

• KMID: 1482795
• DOI: http://doi.org/10.3348/kjr.2013.14.2.324

Abstract

We report on a 55-year-old man with alcoholic liver cirrhosis who presented with status epilepticus. Laboratory analysis showed markedly elevated blood ammonia. Brain magnetic resonance imaging (MRI) showed widespread cortical signal changes with restricted diffusion, involving both temporo-fronto-parietal cortex, while the perirolandic regions and occipital cortex were uniquely spared. A follow-up brain MRI demonstrated diffuse cortical atrophy with increased signals on T1-weighted images in both the basal ganglia and temporal lobe cortex, representing cortical laminar necrosis. We suggest that the brain lesions, in our case, represent a consequence of toxic effect of ammonia.

Keyword

Acute hepatic encephalopathy; Cortical laminar necrosis; Cirrhosis; Magnetic resonance imaging

MeSH Terms

Ammonia/blood
Atrophy/pathology
Brain Diseases/blood/*diagnosis/*etiology
Hepatic Encephalopathy/*complications
Humans
Liver Cirrhosis, Alcoholic/*complications
Magnetic Resonance Imaging/*methods
Male
Middle Aged
Necrosis/pathology
Status Epilepticus/pathology
Ammonia

Figure

• 

  Fig. 1 Serial MRI on 5 hours, 4th and 37th days. A. Diffusion-weighted imaging (DWI) 5 hours after onset of seizures in 55-year-old man. DWI (b = 1000) obtained 5 hours after onset of seizures showed bilateral relatively symmetric high signals in both temporo-fronto-parietal cortex, including insular and cingulate cortex, with restricted diffusion on apparent diffusion coefficient map. B. MRI on fourth day after onset of seizures. fluid-attenuated inversion recovery images shows interval increase in extent of brain cortical edema in both cerebral hemispheres, while showing unique sparing of occipital cortex and perirolandic regions. It also shows symmetric high signals in both medial thalami, basal ganglia, periventricular and cerebellar white matter. Basal ganglia shows subtle high signal on T1-weighted image in both globus pallidus. C. Follow-up MRI 37 days after onset of seizures. T1-weighted images show diffuse cortical atrophy in both temporo-fronto-parietal lobe and curvilinear form high signals on T1-weighted image, particularly temporal lobes (obvious on sagittal T1-weighted image). In addition, obvious T1 high signals appear in lower portion of both basal ganglia. These findings were considered cortical laminar necrosis, presumably consequence of extreme toxic effect of ammonia.

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