Ann Rehabil Med.  2015 Feb;39(1):138-141. 10.5535/arm.2015.39.1.138.

Hepatic Encephalopathy With Corticospinal Tract Involvement Demonstrated by Diffusion Tensor Tractography

• Bang H
• Lee HY
• Kim BR
• Lee IS
• Jung H
• Koh SE
• Lee J

• KMID: 2273031
• DOI: http://doi.org/10.5535/arm.2015.39.1.138

Abstract

A 50-year-old man with liver cirrhosis and esophageal varix for 3 years was diagnosed with hematemesis and treated for a bleeding varix. However, bleeding recurred 11 days later, and he developed drowsiness with left hemiparesis. His left upper and lower extremity muscle strengths based on the manual muscle test at the onset were grade 2/5 and 1/5, respectively. The Babinski sign was positive. His serum ammonia level was elevated to 129.9 microg/dL (normal, 20-80 microg/dL). Magnetic resonance imaging revealed restriction on diffusion and T2-hyperintensities with decreased apparent diffusion coefficient values in the bilateral frontoparietooccipital cortex. The effect was more severe in the right hemisphere and right parietooccipital cortices, which were compatible with hepatic encephalopathy. Although the patient's mental status recovered, significant left-sided weakness and sensory deficit persisted even after 6 months. Diffusion tensor tractography (DTT) performed 3 months post-onset showed decreased volume of the right corticospinal tract. We reported a patient with hepatic encephalopathy involving the corticospinal tract by DTT.

Keyword

Hepatic encephalopathy; Diffusion tensor imaging; Rehabilitation

MeSH Terms

Ammonia
Diffusion Tensor Imaging
Diffusion*
Esophageal and Gastric Varices
Hematemesis
Hemorrhage
Hepatic Encephalopathy*
Humans
Liver Cirrhosis
Lower Extremity
Magnetic Resonance Imaging
Middle Aged
Muscle Strength
Paresis
Pyramidal Tracts*
Reflex, Babinski
Rehabilitation
Sleep Stages
Varicose Veins
Ammonia

Figure

• 

  Fig. 1 1. (A) Absence of focal lesions in the brain parenchyma and cerebrospinal fluid spaces and other vascular abnormalities at the onset, on brain computed tomography (axial view). (B) Diffusionweighted imaging (DWI) at the onset showed suspicious hyperintensity and a decreased apparent diffusion coefficient (ADC) along the bilateral frontoparietoocipital cortices. (C) Brain magnetic resonance imaging scans 3 days after the onset showed increased intensity and a decreased ADC in the bilateral frontoparietooccipital (right>left) and right parietooccital cortex with subcortical vasogenic edema on the DWI. (D) Brain diffusion tensor tractography 2 months post-onset showed a relatively smaller volume of the right corticospinal tract.

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