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Lin J, Hou Y, Shang H. Clinical Reasoning: A Middle-aged Man With Progressive Gait Abnormalities. Neurology 2021; 97:e2423-e2428. [PMID: 34504025 DOI: 10.1212/wnl.0000000000012756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Progressive spastic paraplegia is the core symptom of hereditary spastic paraplegias (HSPs), a group of monogenic disorders characterized pathologically by degeneration of the corticospinal tract and dorsal column and leading to irreversible neurologic deficits. However, acquired causes, such as structural, vascular, inflammatory, infectious, metabolic, toxic, neurodegenerative, and iatrogenic causes, can also cause acquired spastic paraplegia. We describe the case of a middle-aged man presenting with progressive spastic paraplegia combined with ataxia and parkinsonism. No mutation of HSP genes was detected. After a comprehensive diagnostic workup, hyperintensities in the bilateral basal ganglia, mesencephalon, pons, and cerebellum on T1-weighted images were found, which demonstrated hypointensity on susceptibility-weighted imaging. Furthermore, an increased blood ammonia level and diffuse slow-wave activity in EEG were detected. The patient had a 7-year history of hypertension, alcoholic liver cirrhosis, and transjugular intrahepatic portosystemic shunt operation 2 years before the onset of spastic paraplegia symptoms. Current workup combined with patient history resulted in a diagnosis of acquired hepatocerebral degeneration and hepatic myelopathy.. This case provided a detailed diagnostic approach for progressive spastic paraplegias and exhaustive differential diagnoses of basal ganglia deposits. The take-home message from this case was that acquired causes, especially curable causes, should always be excluded first when dealing with patients with progressive spastic paraplegia.
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Affiliation(s)
- Junyu Lin
- From the Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yanbing Hou
- From the Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Huifang Shang
- From the Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
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Pigoni A, Iuculano F, Saetti C, Airaghi L, Burdick L, Spreafico S, Curioni M, Lombardi R, Valenti L, Fracanzani AL, Fargion S. Acquired hepatocerebral degeneration (AHD): a peculiar neurological impairment in advanced chronic liver disease. Metab Brain Dis 2018; 33:347-352. [PMID: 28918510 DOI: 10.1007/s11011-017-0107-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 09/06/2017] [Indexed: 12/11/2022]
Abstract
We discuss the case of a rare and often unrecognized neurologic syndrome, called Acquired Hepatocerebral Degeneration (AHD), observed in patients with advanced liver disease and portosystemic shunts. The clinical manifestations can be very heterogeneous and in our case included a combination of cerebellar and extrapyramidal signs, arisen in a period of few days. Brain Magnetic Resonance Imaging (MRI) showed, in T1-weighted images, diffuse bilateral hyper intensities in basal ganglia and biemispheric brain and cerebellar cortices, resembling paramagnetic deposits. No other neurological impairments, like stroke, infection or neoplasia, were found. It was excluded an episode of acute hepatic encephalopathy. We also ruled out Wilsonian degeneration, iron overload and autoimmune encephalitis and we lastly found high manganese levels as the possible cause of the brain paramagnetic deposits. Even though either serum Mn determination or its accumulation in the brain are not specific for AHD, however the chronic and progressively worsening of the neurological manifestations advocated a degenerative condition, possibly AHD. We finally opted for the early restoration of liver function by OLT, and we observed complete clinical symptoms' resolution and partial MRI reversal after a follow up of 6 months.
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Affiliation(s)
- A Pigoni
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - F Iuculano
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy.
| | - C Saetti
- Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Neurology Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L Airaghi
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - L Burdick
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - S Spreafico
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - M Curioni
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - R Lombardi
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - L Valenti
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - A L Fracanzani
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - S Fargion
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
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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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Torigoe M, Maeshima K, Takeshita Y. Congenital intrahepatic portosystemic venous shunt presenting with paraparesis as the initial symptom. Intern Med 2013; 52:2439-42. [PMID: 24190148 DOI: 10.2169/internalmedicine.52.0881] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
An 85-year-old woman was hospitalized with rapidly progressive paraparesis without altered consciousness, although she was not definitively diagnosed. She developed acute drowsiness and disorientation several days later. An intrahepatic portosystemic venous shunt (IPSVS) was observed on enhanced computed tomography, and hyperammonemia suggested leakage of neurotoxins from the shunt as the etiology of the patient's symptoms. Her neurological symptoms and hyperammonemia improved following transcatheter shunt embolization. We diagnosed her with hepatic myelopathy, which is a rare complication of liver cirrhosis and portosystemic venous shunts. Hepatic myelopathy resulting from a congenital IPSVS has not been previously reported. A diagnosis of hepatic myelopathy should be ruled out in diagnostically difficult cases of paraparesis.
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Ziaja M, Pyka J, Boczkus B, Plonka BK, Plonka PM. Changes in the nitric oxide level in the rat liver as a response to brain injury. Nitric Oxide 2011; 25:423-30. [DOI: 10.1016/j.niox.2011.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 06/28/2011] [Accepted: 07/23/2011] [Indexed: 12/21/2022]
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Fernández-Rodriguez R, Contreras A, De Villoria JG, Grandas F. Acquired hepatocerebral degeneration: clinical characteristics and MRI findings. Eur J Neurol 2011; 17:1463-70. [PMID: 20491897 DOI: 10.1111/j.1468-1331.2010.03076.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the prevalence of acquired hepatocerebral degeneration (AHD), its clinical and neuroimaging characteristics and response to treatments. BACKGROUND Acquired hepatocerebral degeneration is a chronic encephalopathy with predominant motor signs in the context of severe liver disease. Its clinical picture is not well defined, and its prevalence and risk factors are not well known. METHODS Review of a database of 1000 patients with cirrhosis to identify cases of AHD. Clinical and neuroimaging data, follow-up and response to treatments, including liver transplantation, were recorded. RESULTS Eight patients with AHD were identified. Its prevalence was 0.8% of patients with cirrhosis. The main risk factor for AHD was the presence of portosystemic shunts. Movement disorders, especially a combination of parkinsonism and cerebellar signs were observed in all patients. All AHD cases showed on MRI T1-weighted images hyperintensities in the globus pallidus, and 75% had extrapallidal involvement as well. Antiparkisonian drugs and treatments to prevent acute encephalopathies were ineffective. Three patients who underwent liver transplantation did not experience neurological improvement. Persistence of portosystemic shunts was demonstrated in two cases. CONCLUSIONS Acquired hepatocerebral degeneration is a chronic encephalopathy which occurs in ∼1% of patients with liver cirrhosis and seems related to portosystemic shunts. Its is characterized by a combination of parkinsonism and cerebellar signs. MRI pallidal and extrapallidal lesions are seen in most patients, probably reflecting intracerebral deposits of manganese. Liver transplant did not improve the neurological signs in our patients, perhaps because of the persistence of portosystemic shunts.
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Affiliation(s)
- R Fernández-Rodriguez
- Movement Disorders Research Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Abstract
Repeated episodes of liver failure or chronic liver cirrhosis may cause acquired (non-Wilsonian) hepatocerebral degeneration (AHCD). Patients with AHCD may show cognitive deficits, ataxia, dysarthria, movement disorders, including parkinsonism, and sometimes myelopathy. Various parenchymal and cholestatic hepatic disorders may result in AHCD. Most patients with AHCD have evidence of portosystemic shunting without necessarily having abnormal liver function. Recent evidence suggests manganese plays a crucial role in the pathogenesis of AHCD. Excess dietary manganese is rapidly cleared by the liver before reaching the systemic circulation. In patients with cirrhosis and portosystemic shunting, manganese bypasses the liver and accumulates in the internal pallidum, while serum manganese levels may be normal or increased. Magnetic resonance imaging abnormalities mainly consist of a signal hyperintensity on T1-weighted images in the internal pallidum. It may also be seen in the putamen, the caudate nucleus, the capsula interna, the mesencephalon, and the cerebellum, and is believed to reflect local manganese accumulation. No specific treatment of AHCD exists. Controlled studies are lacking, but case reports have stressed the usefulness of branched-chain amino acid therapy, trientine, and liver transplantation for the treatment of movement disorders. Levodopa may be efficacious in the treatment of AHCD parkinsonism.
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Affiliation(s)
- Wassilios Meissner
- Department of Neurology, University Hospital of Bordeaux, University of Bordeaux 2, Bordeaux, France.
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Qu B, Liu C, Guo L, Yang Y, Li JH, Yu L, Lv Y. The role of liver transplantation in the treatment of hepatic myelopathy: case report with review of the literature. Transplant Proc 2009; 41:1987-9. [PMID: 19545775 DOI: 10.1016/j.transproceed.2009.01.105] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 01/08/2009] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Hepatic myelopathy (HM) is a rare neurological complication of chronic liver disease, causing progressive spastic paraparesis. Unlike hepatic encephalopathy, the conservative treatment of HM is usually considered inefficient. Although some scattered case studies have reported that the clinical symptoms and signs of patients with HM were improved after orthotopic liver transplantation (OLT), there have also been cases of failure. The aim of this study was to identify the role of OLT in the treatment of HM. PATIENTS AND METHODS We present two patients, who underwent OLT at the early stage after progressive HM had been diagnosed, gaining definite improvement of their neurological status within a relatively short time. In addition, we review all five similar cases that have hitherto been reported in English literature. RESULTS The clinical symptoms and signs of HM improved to variable degrees after OLT in most cases except one with a long HM history. The degree of improvement correlated with the time interval between the onset of the first symptoms of HM and OLT. CONCLUSIONS OLT represents an effective therapeutic option for HM. The duration of clinical manifestations of HM before OLT may be the main factor affecting the therapeutic outcome.
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Affiliation(s)
- B Qu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Shaanxi, People's Republic of China
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Ferrara J, Jankovic J. Acquired hepatocerebral degeneration. J Neurol 2009; 256:320-32. [PMID: 19224314 DOI: 10.1007/s00415-009-0144-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2008] [Accepted: 10/20/2008] [Indexed: 12/20/2022]
Abstract
Cirrhosis and its co-morbidities may cause a variety of neurological complications, the most common being bouts of toxic metabolic encephalopathy. A proportion of patients with chronic liver disease develop acquired hepatocerebral degeneration (AHD), a chronic progressive neurological syndrome characterized by parkinsonism, ataxia and other movement disorders. This article reviews the clinical spectrum, pathophysiology, neuroimaging features and differential diagnosis of AHD along with emerging treatment options.
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Affiliation(s)
- Joseph Ferrara
- Dept. of Neurology, Baylor College of Medicine, 6550 Fannin, Suite 1801, Houston, Texas 77030, USA
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Abstract
BACKGROUND Acquired hepatocerebral degeneration (AHD) and hepatic myelopathy (HM) are rare complications of chronic liver disease and are usually resistant to medical therapy. MATERIALS AND METHODS The clinical and laboratory findings of 14 male and 2 female patients with AHD or HM were evaluated. RESULTS The prevalence of AHD and HM was 2% inpatient case series in the last 10 years. The median age of the patients (5 Child's B and 11 Child's C) was 48.7 years (28 to 66 y), and the mean known duration of the liver disease was 75 months (24 to 194 mo). The median time of onset of neurologic findings after diagnosis of the liver disease was 14.5 months. Eight patients who had marked spastic paraparesis or tetraparesis were included in the HM group and all others had AHD group. Sixty-nine percent of the patients had a spontaneous or surgical portosystemic shunts, and the remaining dense retroperitoneal collaterals. During the follow-up period of median 29 months (4 to 72 mo), 12 patients died while waiting for liver transplantation, and these patients suffered from the several complications of chronic liver disease more than the living patients. A marked improvement was observed in 2 of the patients (1 with AHD and the other with HM) at 6 and 8 months after the liver transplantation, respectively. CONCLUSIONS Our data suggest that liver transplantation had an important effect on the improvement in these patients.
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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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Servin-Abad L, Tzakis A, Schiff ER, Regev A. Acquired hepatocerebral degeneration in a patient with HCV cirrhosis: complete resolution with subsequent recurrence after liver transplantation. Liver Transpl 2006; 12:1161-5. [PMID: 16799948 DOI: 10.1002/lt.20815] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Acquired (non-Wilsonian) hepatocerebral degeneration (AHD) is a chronic brain disorder caused by liver dysfunction and long-standing portal-systemic shunting. It typically presents with dysathria, ataxia, tremor, involuntary movements and altered mental status, and often does not respond to conventional medical therapy for hepatic encephalopathy. There is scarce and conflicting information regarding the clinical course of AHD after liver transplantation (OLT). We present a case of a 47-year-old woman with hepatitis C (HCV) cirrhosis who developed severe manifestations of AHD after multiple bouts of hepatic encephalopathy. Her first OLT was complicated with primary nonfunction requiring immediate retransplantation. The second OLT led to complete clinical and radiological resolution of the AHD. However the patient developed recurrence of AHD 11 months post-transplant due to recurrent HCV and chronic rejection leading to cirrhosis of the graft. The patient developed severe neurological symptoms, despite mild synthetic graft dysfunction. A third OLT led again to disappearance of the clinical and radiological manifestations of AHD. AHD may show complete resolution after OLT; however it may rapidly recur following recurrent liver disease or graft dysfunction.
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Affiliation(s)
- Luis Servin-Abad
- Division of Hepatology, Center for Liver Diseases, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
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14
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Abstract
Neurological complications of gastrointestinal, hepatic and pancreatic disease
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Abstract
The present review is aimed at providing practical assistance to the clinical neurologist in reaching a diagnosis, understanding the pathogenic mechanisms of movement disorders associated with systemic diseases, and determining appropriate therapy. Infectious disease by direct effect or as an acquired autoimmune neurological disease, stroke, hypoxia-ischemia, paraneoplastic syndromes, collagen disorders, endocrine, liver and kidney diseases that may cause hypokinetic or hyperkinetic abnormal movement are considered separately. The type and evolution of abnormal movement caused by systemic disease vary with age and underlying pathology. Therapy for abnormal movements should include a primary treatment for the systemic disease.
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Affiliation(s)
- Fernando Alarcón
- Department of Neurology, Eugenio Espejo Hospital, P.O. Box 17-07-9515, Quito, Ecuador.
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Utku U, Asil T, Balci K, Uzunca I, Celik Y. Hepatic myelopathy with spastic paraparesis. Clin Neurol Neurosurg 2004; 107:514-6. [PMID: 16202825 DOI: 10.1016/j.clineuro.2004.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2004] [Revised: 09/27/2004] [Accepted: 10/04/2004] [Indexed: 12/30/2022]
Abstract
Progressive myelopathy is a rare neurological complication of chronic liver disease with portal hypertension and there is no special diagnostic tool for hepatic myelopathy. Neuropathological studies of the patients with hepatic myelopathy have demonstrated demyelination of the lateral corticospinal tracts with various degree of axonal loss. Transcranial magnetic stimulation (TMS) is widely utilized as an indicator of changes in excitability and conductivity of the motor pathways. TMS studies are also used for the diagnosis of hereditary spastic paraparesis in the literature. In this study, we described two patients who presented with spastic paraparesis; TMS studies suggested that they had myelopathy and diagnosed as hepatic myelopathy when all the other possible diagnoses were ruled out.
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Affiliation(s)
- Ufuk Utku
- Univercity of Trakya Faculty of Medicine, Department of Neurology, Edirne 22030, Turkey
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Lewis MB, Howdle PD. Cognitive dysfunction and health-related quality of life in long-term liver transplant survivors. Liver Transpl 2003; 9:1145-8. [PMID: 14586873 DOI: 10.1053/jlts.2003.50239] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although several studies have investigated short-term effects of liver transplantation on cognitive function and health-related quality of life, there have been no studies looking at long-term effects. Patients who received a single liver transplant at St James's University Hospital (Leeds, UK) before October 1, 1991, were invited to participate in this cross-sectional study. Cognitive function was assessed using the Mini-Mental State Examination, the Rey Auditory Verbal Learning Test, trail-making tests, the Stroop test, and the Benton Visual Retention Test. Anxiety and depression were documented using the Hospital Anxiety and Depression Scale. Health-related quality of life was assessed using the EuroQol. Twenty-five healthy volunteers acted as controls. Thirty-six patients had undergone transplantation before October 1, 1991. Thirteen patients (36%) had died, 6 patients had received more than one transplant, 2 patients did not speak English, and 3 patients did not want to participate, leaving 12 patients included in the study. Patients scored significantly lower on measures of health-related quality of life than healthy controls, but there were no differences in levels of anxiety or depression. Patients scored significantly lower than controls across a wide range of cognitive functions, suggesting global cognitive impairment. We show that patients who survive for more than 10 years after liver transplantation have significant cognitive dysfunction and poor health-related quality of life. Whether these patients never return to normal after transplantation or whether they experience an increased rate of decline in cognitive function and health-related quality of life is uncertain and requires further study.
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Abstract
Portal systemic encephalopathy, in its many guises, can be reversible after medical management or liver transplantation. It is much less certain whether patients with a longstanding neurodegenerative syndrome (known in the medical vernacular as acquired hepatocerebral degeneration) can improve. Impressive neuroimaging abnormalities have been reported in this entity.(1) However, the combination of a severe disabling neurologic deficit and widespread magnetic resonance abnormalities tempers the enthusiasm of transplant surgeons to proceed with liver transplantation. In our liver transplantation program, we were recently confronted with such a case, and present herein not only the characteristic magnetic resonance imaging findings but also some of the dilemmas of management.
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Affiliation(s)
- Eelco F m Wijdicks
- Department of Neurology and Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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