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Cirosis Es Neuro Tunetek PDF
Cirosis Es Neuro Tunetek PDF
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Page 1 of 110
Learning objectives
That there is a relationship between the brain and the liver has been known for many
years, and patients with chronic liver disease frequently experience a wide spectrum of
neurological problems that can adversely affect patient's neurocognitive functioning [1-3].
Page 2 of 110
The present exhibit aims:
1. To appraise the wide array of neurological syndromes and disorderes that can
be associated with liver cirrhosis, highlighting their most pertinent neuroimaging
manifestations and providing an up-to-date information on these relatively understudied
entities.
Background
LIVER-BRAIN AXIS
Normal brain functioning depends on several aspects of normal liver functioning. For
example, the liver supplies certain nutrients to the brain that the brain itself cannot
produce. The liver also cleanses the blood of substances that could damage brain cells
(i.e., neurotoxins, for e.g. ammonia, manganese, and other chemicals).
In chronic liver disease and cirrhosis, the liver loses its capacity to remove toxic
substances from the blood due to loss of functional liver cells (i.e., hepatocytes).
Moreover, some of the blood that normally flows through the portal vein into the liver for
cleansing is diverted directly into the general circulation without first passing through the
liver, a phenomenon known as portal-systemic shunting. As a result, the shunted blood is
not detoxified and blood levels of toxic substances rise. Persistently elevated neurotoxin
levels can damage brain cells and cause a wide spectrum of neurocognitive decline.
A neurological syndrome associated with a liver disease may affect the CNS, the
peripheral nervous system, or both; and, could represent a direct complication of the
disease, or part of spectrum of pathologies that affect the brain and liver concurrently
[1-6].
Page 3 of 110
(A) Direct effects of cirrhosis on the nervous system:
Wilson disease
Hepatitis C virus infection
Among solid organ transplant recipients, recipients of liver transplantation have the
highest incidence of neurological complications. Neurological complications following
liver transplantation have an overall incidence of 13 - 47%.
Page 4 of 110
(3) Osmotic demyelination
(7) Seizures
Hyperintense signals in the basal ganglia, namely the globus pallidus, can
be seen in as many as 70-100% of patients with liver cirrhosis (Fig 2) [1, 7].
Page 5 of 110
Fig. 2: Symmetrical T1-hyperintensity involving the bilateral globus pallidus (arrows) in
an asymptomatic 54-year old male with hepatitis-B related liver cirrhosis.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 6 of 110
Fig. 3: Axial T1-weighted MR images showing hyperintense signal of the caudate
nucleus (black arrows) in addition to the involvement of the globos pallidi (white
arrows).
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
The exact causes and mechanisms of the increased signal intensity remain
indefinite, however several hypotheses have been proposed. Deposition of
paramagnetic substances, particularly manganese (Mn), is speculated to be
responsible for the signal alteration [1, 7, 8].
Page 7 of 110
Fig. 4: (A) Axial T2-WI and (B) FLAIR sequence delineating subtle symmetrical
hyperintensity involving the bilateral lentiform nuclei in a young 26-year old lady with
liver cirrhosis.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 8 of 110
Fig. 5: A 40-year old male with alcoholic liver cirrhosis and grade-I hepatic
encephalopathy. Fast-FLAIR MR images reveal diffuse high-signal intensity in the
hemispheric white matter on either sides.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
DWI (and ADC maps) has also identified abnormalities within the
periventricular white, thalami, and basal ganglia in studies of patients with
cirrhosis with hepatic encephalopathy [9, 10].
Page 9 of 110
Fig. 6: Cerebral atrophy accompanying typical intracranial signal intensity changes
in a 36-year old patient with long standing cryptogenic cirrhosis. Axial T1-WI shows
symmetrical T1-prolongation of the basal ganglia (asterisk) representing manganese
deposition. Attendant widening of the sylvian fissures (thick arrows) and ventricular
enlargement (thin arrows) suggest cerebral parenchymal atrophy.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 10 of 110
Fig. 7: Ventricular enlargement (white arrow) and subarachnoid CSF-space (sylvian
fissure) widening represent cerebral involutional changes in a 30-year old male with
alcohol induced liver cirrhosis.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
HEPATIC ENCEPHALOPATHY
Page 11 of 110
to manganese, but this only variably correlates with the plasma ammonia
levels and acute HE symptoms.
Fig. 8: Typical imaging manifestations of HE. Fast FLAIR images exhibit symmetrical
cortical edema involving the insular cortex (arrow) and cingulate gyrus (arrowhead).
Note that the occipital cortex (asterisk) is characteristically spared.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 12 of 110
Thus, the cingulate gyrus and insular cortex appear to be particularly
vulnerable to hyperammonemic-hyperglutaminergic encephalopathy, while
the perirolandic and occipital cortex seem relatively resistant. These MR
manifestations therefore should alert the radiologist to the possibility of acute
hyperammonemic encephalopathy in appropriate clinical settings (Fig 9) [19,
20].
Fig. 9: Acute HE. DWI displaying extensive symmetrical gyral edema which
characteristically involves the insular cortex (arrow) and cingulate gyrus (arrowhead);
and, typically spares the perirolandic and occipital cortex (dotted arrow).
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 13 of 110
Diffuse cortical involvement although can be reversible; often has a higher
potential for neurologic sequelae [21]. Concomitant subcortical white matter,
basal ganglia, thalami, and brain stem involvement suggests more severe
injury [19].
The MRI extent of cortical involvement on FLAIR and DWI has been shown
to strongly correlate with the maximal plasma ammonia level, and plasma
ammonia level correlates well with the clinical outcome. However MRI
severity correlates only moderately with the clinical outcome [21, 22].
Fig. 10: Chronic HE. Axial T1-WI showing cortical atrophy with gyriform T1-
hyperintensity representing cortical laminar necrosis in a follow-up case of liver
cirrhosis with recurrent episodes of grade-3 HE in the past.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 14 of 110
zones or the parieto-occipital regions (as opposed to the temporal lobe
cortices) [19].
Page 15 of 110
Fig. 11: A 50-year old liver cirrhosis patient developed cognitive deficits, ataxia,
dysarthria, movement disorders, and features of parkinsonism. MR images reveal
symmetrical T1-hyperintensity of the basal ganglia (A) with attendant T2-hyperintense
changes involving the bilateral middle cerebellar peduncles (B). Imaging findings in the
light of the clinical details are in keeping with acquired hepatocerebral degeneration.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
CIRRHOSIS-RELATED PARKINSONISM
Page 16 of 110
Rapidly progressing parkinsonian symptoms, which are unresponsive to
treatment of hepatic encephalopathy, indicate cirrhosis-related Parkinsonism
[28].
Page 17 of 110
Fig. 12: Symmetrical T1-hyperintensity can be seen involving the basal ganglia (A, B),
cerebral peduncles (C), and the dorsal aspect of pons (D) in a patient of liver cirrhosis
presenting with features of parkinsonism.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 18 of 110
Hepatic or cirrhotic myelopathy is a rare complication of chronic liver disease
that is associated with extensive portosystemic shunts [34, 35].
Page 19 of 110
Fig. 13: A 50-year old male patient with hepatic myelopathy. MR spine failed to
depict any overt intramedullary signal alteration; however, screening of brain revealed
symmetrical hyperintensity along the bilateral corticospinal tracts.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Motor-evoked potential studies thus play a pivotal role for diagnosing and
monitoring disease progression and response to treatment [38].
Page 20 of 110
The risk for development of ICH in patients with liver cirrhosis is debatable;
nonetheless, various studies have proposed that liver cirrhosis is a risk
factor for ICH [39-44].
Chronic liver disease is a risk factor for ICH primarily due to impaired
coagulation. Coagulopathy in patients with liver disease results from
impairments in the clotting and fibrinolytic systems, as well as from reduced
number and function of platelets (Fig 14, 15) [41].
Fig. 14: Unenhanced CT in a liver disease patient with deranged coagulation profile
shows a large intraparenchymal hematoma (thick white arrow) in right frontal lobe with
contiguous extension into the ipsialteral ventricle (dotted arrow). In addition, there is
synchronous contralateral intracerebral bleed seen in the left frontal region (thick black
arrow). Furthermore, there is evidence of extra-axial bleed that can be seen along the
interhemispheric fissure (thin black arrow).
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 21 of 110
Fig. 15: Infratentorial bleed in a delirious patient with decompensated liver cirrhosis.
Axial CT sections reveal a large hematoma involving the cerebellar vermis (arrow)
causing compression and effacement of the fourth ventricle with upstream obstructive
ventriculomegaly (arrowhead). The cerebral sulci are effaced and the cortico-medullary
junction indistinct (asterisk) suggesting raised intracranial pressure.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
The relation between high alcohol intake and ICH may involve several
mechanisms among which alcohol-induced hypertension and coagulation
disorders are speculated to be the most likely etiological factors [41].
Page 22 of 110
Bacterial infections have been acknowledged as an important factor in
disease mortality and are estimated to cause up to 25% of deaths in cirrhotic
patients [45, 46].
The specific risk factors for infection in cirrhotic patients are low serum
albumin, gastrointestinal bleeding, repeated intensive care unit admissions
for any cause, and therapeutic endoscopy [45].
Certain infectious agents that are more virulent and more common in
patients with liver disease include Vibrio, Campylobacter, Yersinia,
Plesiomonas, Enterococcus, Aeromonas, Capnocytophaga, and Listeria
species, as well as organisms from other species [45].
Liver cirrhosis patients are at increased risk of bacterial meningitis and often
have a poor prognosis (Fig 16) [49, 50].
Page 23 of 110
Fig. 16: Pyogenic meningitis and ventriculitis in a 42-year old patient with NASH
related liver cirrhosis. Post gadolinium T1-WI reveals inflammation, thickening and
abnormal enhancement of the right lateral ventricle ependyma (A, B) and choroid
plexus (C) in keeping with ventriculitis and choroid plexitis. In addition, abnormal
leptomeningeal enhancement can be seen along the right mesial temporal lobe (D) in
keeping with leptomeningitis.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Often, nuchal rigidity may be a delayed or even absent clinical sign. Also,
the initial presentation of brain abscess may not be fever or leukocytosis, but
focal neurologic deficits [49-51].
Page 24 of 110
Mortality may reach 80% in patients with Child-Pugh stage C cirrhosis [49,
50].
Fig. 17: Miliary tuberculosis in a middle aged liver cirrhosis patient with history of
longstanding alcohol abuse. Contrast enhanced T1-WI shows multiple pinhead sized
enhancing granulomas randomly scattered in the bilateral cerebral hemispheres.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 25 of 110
Cerebral edema is very common in patients with fulminant or acute liver
failure. In severe cases, this can lead to potentially fatal herniation [53].
Whilst the primary cause of death in patients with acute liver failure (ALF) is
multi-organ failure; cerebral edema and ensuing brain herniation constitute a
major cause of mortality [54].
Page 26 of 110
Fig. 18: Diffuse cerebral edema in a patient with acute on chronic (Hepatitis-B and C
related)liver failure. Noncontrast CT shows effaced sulci with loss of cortico-medullary
differentiation and indistinct margins of the lenticular nuclei suggesting diffuse cerebral
edema and raised intracranial tension.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 27 of 110
Fig. 19: Fulminant hepatic failure. T2W MR imaging reveals effaced cerebral
sulci with slit-like ventricles (A, B) and diffuse gyral swelling (C, D) in keeping with
diffuse ceerbral edema. The cisternal spaces are also effaced suggesting impending
herniation (C, D).
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 28 of 110
Fig. 20: (A, B) Sagittal and axial T2-WI show bilateral medial part of the temporal
lobes protruding over the tentorial edge in keeping with uncal herniation (black arrows).
In addition, there is downward cerebellar herniation (tonsillar herniation or coning) seen
in this patient of fulminant hepatic failure. The patient was subsequently declared brain
dead and succumbed to the disease.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 29 of 110
Adams and colleagues in 1959 described central pontine myelinolysis
(CPM) as a disease affecting alcoholics and the malnourished [63].
The concept was extended from 1962 with the recognition that lesions
can occur outside the pons, so-called extrapontine myelinolysis (EPM). In
1976 a link between these disorders and the rapid correction of sodium
in hyponatraemic patients was suggested, and by 1982 substantially
established [64].
The association with alcoholism was the first to be noted and continues
to be particularly frequent (in up to 40% of cases). It has been suggested
that alcohol itself interferes with sodium/water regulation by suppression of
antidiuretic hormone, and inadequate nutrition of alcoholics is an obvious
accompaniment [64-66].
In acute CPM, MRI shows signal alteration in the central pons with sparing
of the tegmentum, ventrolateral pons and corticospinal tracts (Fig 21, 22).
Page 30 of 110
Fig. 21: Central pontine myelinolysis. Sagittal T2-WI shows relatively bulky appearing
pons with attendant signal intensity changes (black arrow) in a 48-year old patient with
alcoholic liver cirrhosis.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 31 of 110
Fig. 22: (A, B) Axial Fast FLAIR and T2-WI of the aforementioned patient shows
hyperintensity involving the central pons with characteristic sparing of the periphery.
Careful evaluation suggests that there is predominant involvement of the transverse
pontine fibres - finding which is quite characteristic of CPM.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 32 of 110
Fig. 23: Extra-pontine myelinolysis. Axial FLAIR images showing extra-pontine areas
of signal alteration (demyelination) involving the left thalamus (white arrow) and the
right cerebellar hemisphere (black arrow) in a malnourished chronic alcoholic male
patient with decompensated liver cirrhosis.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
About 25-50% of patients with CPM also have EPM; this usually affects
the cerebellum but may also affect parts of the cerebrum. In up to 25% of
patients the demyelination is exclusively extrapontine [67].
WERNICKE ENCEPHALOPATHY
If untreated, irreversible brain damage may ensue and could even lead to
coma, death, or Korsakoff syndrome, a permanent brain injury that results
in antegrade amnesia and confabulation. The classic triad of WE includes
ataxia, global confusion, and opthalmoplegia.
CT has been shown to have a low sensitivity for the detection of WE, and
when findings are present, they are often nonspecific areas of low density
[66].
Page 33 of 110
Fig. 24: Wernicke encephalopathy. Axial T2-WI showing confluent areas of increased
intensity surrounding the aqueduct and the third ventricle in a debilitated and
malnourished patient of alcohol induced liver cirrhosis complaining of ataxia and
opthalmoplegia.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 34 of 110
Fig. 25: Coronal T2-WI showing bilateral areas of increased intensity surrounding the
aqueduct and the third ventricle contiguously extending into the mamillary bodies.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 35 of 110
Fig. 26: Fast FLAIR images of the same patient showing symmetrical signal
alterations at characteristic sites including periventricular region of the third ventricle,
periaqueductal area, thalamus, and mamillary bodies.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 36 of 110
The disease may present in two major clinical forms: acute and chronic.
In the acute form, which often results in death, patients present with
severe impairment of consciousness, seizures, and muscle rigidity. The
chronic form of the disease may last for several months or years and is
characterized by variable degrees of mental confusion, dementia, and
impairment of gait.
CT shows diffuse periventricular low density and focal areas of low density
in the genu and splenium of the corpus callosum. On MRI, there is high
T2-and FLAIR signal intensity changes involving the body of the corpus
callosum, genu, splenium, and adjacent white matter. These appear
hypointense on T1-WI and during the acute phase, may show peripheral
contrast enhancement [66].
Page 37 of 110
Fig. 27: Sagittal T2-WI in a chronic alcoholic male showing relatively atrophic posterior
body of the corpus callosum (white arrow) with focal area of signal alteration within the
splenium (black arrow). In addition, note is made of disproportionate cerebellar atrophy
(arrowhead) - likely representing alcoholic cerebellar degeneration.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 38 of 110
Fig. 28: Axial FAST FLAIR image in a liver cirrhosis patient with auditory hallucinations
following alcohol withdrawal showing subtle symmetrical bi-temporal hyperintensity
(arrows).
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 39 of 110
in the clinical setting of posterior reversible encephalopathy syndrome
complicating alcohol withdrawal [66].
CT and MRI show enlargement of the cerebral ventricles and sulci in the
majority of alcohol abusers. There is evidence for regional vulnerability
in the brains of alcohol abusers with frontal lobe changes being the most
pronounced (Fig 29).
Page 40 of 110
Fig. 29: Axial FLAIR and T2WI showing selective bi-frontal cerebral atrophy in a 36-
year old chronic alcoholic male patient with underlying liver cirrhosis.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
The loss of cerebral white matter is evident across a wide range of ages,
and is of sufficient magnitude to account for the associated ventricular
enlargement. Diffusion-tensor imaging detects microstructural abnormalities
in the white matter tracts of alcohol abusers even in the absence of
macroscopic lesions.
Midline cerebellar structures, especially the anterior and superior vermis are
predominantly affected [71, 72].
Page 41 of 110
Fig. 30: Alcoholic cerebellar degeneration. DIffuse cerebellar atrophy is seen in the
form of cerebellar foliar prominence, ventricular enlargement and prominence of the
infratentorial subarachnoid CSF spaces in a 44-year old male cirrhotic with history of
chronic alcohol abuse.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 42 of 110
be difficult to distinguish on clinical grounds alone and require corroboratory
imaging studies.
Despite the ubiquitous presence of toxic copper within the brain, pathologic
findings are limited primarily to the basal ganglia, thalamus, and brain
stem. The initial neurological presentations frequently include dysarthria
and tremors, with later manifestations of neuropsychiatric problems, and
Parkinsonian tremors, ataxia, dystonia, and chorea.
Page 43 of 110
Fig. 31: Axial T2-WI in a patient with Wilson disease depicting symmetrical increased
signal intensity of the bilateral lentiform nuclei (ahite arrow), thalami (black arrow) and
caudate nuclei (arrowhead).
References: Image reproduced from: Arora A et al. Intracranial MR manifestations
of Wilson disease. Poster no. C-1518 on EPOS (ECR 2011). DOI: 10.1594/ecr2011/
C-1518
Page 44 of 110
Fig. 32: DWI in a patient with Wilson disease depicting diffusion restriction involving
the lentiform and caudate nuclei (hepatolenticular degeneration) during the acute
phase of the disease.
References: Image reproduced from: Arora A et al. Intracranial MR manifestations
of Wilson disease. Poster no. C-1518 on EPOS (ECR 2011). DOI: 10.1594/ecr2011/
C-1518
Page 45 of 110
Fig. 33: Axial T2WI (A) and T2*GRE (B) showing hypointense signal and blooming
reflecting heavy metal deposition in the lentiform nuclei in a patient of Wilson disease.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Fig. 34: Symmetrical increased T1-signal intensity involving the lentiform nuclei in a
patient of Wilson disease.
References: Image reproduced from: Arora A et al. Intracranial MR manifestations
of Wilson disease. Poster no. C-1518 on EPOS (ECR 2011). DOI: 10.1594/ecr2011/
C-1518
Page 46 of 110
Fig. 35: (A, B) Giant panda sign in a young patient of Wilson disease. (C) The sign
is due to a combination of high signal intensity in the tegmentum (black arrow) with
sparing of the red nuclei (dotted arrow), pars reticulate (white arrow) and the superior
colliculi (arrowhead).
References: Image reproduced from: Arora A et al. Intracranial MR manifestations
of Wilson disease. Poster no. C-1518 on EPOS (ECR 2011). DOI: 10.1594/ecr2011/
C-1518
Page 47 of 110
Fig. 36: Giant panda cub. Axial T2WI in a patient of Wilson disease depicting signal
alteration in the dorsal pons simulating the face of a giant panda - popularly referred to
as 'giant panda cub' sign.
References: Image reproduced from: Arora A et al. Intracranial MR manifestations
of Wilson disease. Poster no. C-1518 on EPOS (ECR 2011). DOI: 10.1594/ecr2011/
C-1518
The exact pathogenesis of this SIGN is not known, but it is postulated that
the paramagnetic effects of the deposition of heavy metals, such as iron
and copper, may be responsible. It is believed that iron is assumed to play
a more important role than copper in reducing the signal intensity of the
superior colliculi on the T2-weighted scan. At times, signal alteration may
also be encountered within the dorsal pons which has been popularly called
as 'Giant Panda Cubs' (Fig 36) [74].
Page 48 of 110
hemorrhages (secondary to occlusive vasculopathy and vasculitis), have
been reported, being the initial manifestation of HCV infection in some cases
[75, 76].
Fig. 37: Transient ischemic attacks in a 39-year old patient with chronic (hepatitis-
C related) liver disease. DWI reveals multiple acute lacunar infarcts involving the left
pareito-temporal and right cerebellar hemisphere - possibly secondary to occlusive
vasculopathy or vasculitis.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 49 of 110
dysarthria, dysphagia, and incontinence, have been associated with diffuse
involvement of the white matter in HCV chronically infected patients. An
ischemic pathogenesis of these rapidly evolving syndromes is supported by
MRI findings showing small lesions in subcortical regions and periventricular
white matter (Fig 38). Moreover, severe and diffuse infra- and supratentorial
white matter alterations, highly suggestive of vasculitis, are observed in
subjects with coincidental systemic vasculitis [75].
Fig. 38: A young 36-year old patient of hepatitis-C related liver cirrhosis and
progressive neurocognitive decline. Axial FAST FLAIR imaging reveals bilateral
multifocal patchy and confluent areas of subcortical white matter hyperintensities.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 50 of 110
Fig. 39: A 45-year old male with (hepatitis-C) liver cirrhosis and rapidly progressive
dementia and neurocognitive decline. FAST FLAIR images reveal patchy and confluent
areas of signal alteration involving the periventricular as well as hemispheric white
matter.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Neurologic complications are more common after liver transplantation than other
solid-organ transplants primarily due to the poorer clinical condition of liver disease
patients due to malnutrition, coagulopathy, electrolyte imbalance, and pre-transplant
encephalopathy. In addition, the highly complex and lengthy surgical procedure with
Page 51 of 110
major hemodynamic changes and blood/fluid shifts also predisposes these patients to
develop diverse neurological problems [80, 81].
Patients with a pre-liver transplant history of alcoholic liver disease are more
likely to develop PRES. Chronic alcohol presumably creates alterations in
cerebral blood flow and induce morphologic and biomechanical changes
in cerebral vessels resulting in more friability and less elasticity of blood
vessels which may influence cerebral blood flow distribution possibly
contributing to the development of PRES [82, 83].
Page 52 of 110
Fig. 40: PRES in a post liver-transplant patient. Axial FAST FLAIR sequence
exhibiting cortico-subcortical areas of T2-hyperintensity in the parieto-occipital region.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 53 of 110
Fig. 41: Axial T2*GRE image of the hitherto discussed patient with PRES showing
punctate areas of blooming in keeping with petechial hemorrhages in the left occipital
lobe.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
IMMUNOSUPPRESSANT-RELATED LEUKOENCEPHALOPATHY
Page 54 of 110
A wide variety of neurologic side effects has been described with the use of
immunosuppressant drugs - most of them being minor (for e.g. headache,
tremor, paresthesia). However, immunosuppression-associated major
neurotoxicity such as leukoencephalopathy may develop in some post
transplant recipients [84-86].
Page 55 of 110
Fig. 42: Immunosupressive leukoencephalopathy. A 56-year old post liver transplant
patient on tacrolimus complaining of unrelenting headaches and visual disturbances.
MR images show multifocal areas of white matter signal alteration involving the parieto-
occipital lobes and right fronto-parietal region appearing bright on T2WI (A) and dark
on T1WI (B).
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 56 of 110
In late stages of disease, patients can develop cortical blindness,
quadriparesis, severe dementia and even coma. Death usually occurs within
6 months of diagnosis [90].
Fig. 43: Suspected PML in a 44 year old post liver transplant patient with
neurocognitive decline. Axial FLAIR images showing patchy and conflueent scattered
hyperintensities in bilateral parieto-temporal and frontal white matter.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
The gold standard for the diagnosis of PML is a brain biopsy, although the
combination of a recent onset of neurological disease with white matter
lesions on MRI and a positive PCR for the JC virus in the CSF can confirm
the diagnosis in the absence of a brain biopsy [89].
Page 57 of 110
There is no direct antiviral therapy available against the JC polyomavirus.
Restoration of the immune response achieved by tapering or terminating
the immunosuppressive regimen is the mainstay of treatment. However, the
prognosis remains extremely poor regardless of treatment [89].
CEREBROVASCULAR COMPLICATIONS
Fig. 44: Multifocal areas of bilateral intracerebral hemorrhage in a 56-year old post
liver-transplant patient.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 58 of 110
In addition, hypercholesterolaemia, diabetes, and hypertension secondary to
long term use of immunosuppressive therapy may also compound the risk of
cerebral bleeds.
Fig. 45: Right middle cerebral artery (MCA) infarct. Axial T2WI (A) and DWI (B)
showing acute infarct with diffusion restriction involving the right temporal lobe in the
MCA territory.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Page 59 of 110
Fig. 46: Anoxic-hypoxic ischemic encephalopathy following liver transplant (day-3).
DWI showing diffusion restriction and extensive gyral swelling involving the bilateral
cerebral hemispheres in a contiguous fashion.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Diffuse cortical (laminar) necrosis in the setting of acute anoxic insult (global
hypoperfusion) has a universally poor prognosis with most patients either
progressing to brain death or remaining in a persistent vegetative state [92].
POST-TRANSPLANT ENCEPHALOPATHY
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Fig. 47: Severe hyperammonemic encephalopathy in a 35 year old post liver
transplant patient (post operative day 6). Axial FLAIR images showing extensive
cortical swelling and T2 prolongation especially along the insular cortices and cingulate
gyrus.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
OPPORTUNISTIC INFECTIONS
Fungal and viral infections are the most common in post transplant
recipients, while bacterial and protozoic infections are less common.
Page 61 of 110
Exposure to infectious agents may stem from donor-related infections,
recipient-related infections, nosocomial infections and community infections.
Fig. 48: Post-transplant invasive fungal sinusitis, orbital cellulitis & meningitis in a 26
year old female. Axial CT section showing destruction of the lamina papyracea (white
arrow) with extension of the fungal elements into the right orbit with attendant orbital
cellulitis (asterisk).
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Candida is the most common fungal infection after liver transplantation, but
CNS infections caused by Candida species are rare.
Page 62 of 110
Fig. 49: Invasive mucormycosis. Post liver-transplant patient with invasive fungal
sinusitis (asterisk) invading the left orbit (star) and ipsilateral cavernous sinus (white
arrow) with contiguous extension into the left peri-mesencephalic cistern (arrowhead).
References: Dr Rajiv Gupta, Radiology, Medanta, The Medicity, Gurgaon, India
Opportunistic bacterial CNS infections are relatively less common after liver
transplantation but the risk may be increased with environmental exposure.
OSMOTIC DEMYELINATION
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Fig. 50: Central pontine myelinolysis in a post liver transplant patient. Axial FLAIR
image showing predominant involvement of the transverse pontine fibres (white arrow)
with characteristic sparing of the descending corticospinal tracts (asterisk). Note
the peripheral pontine fibers (black arrow) are also spared - hence the term 'central'
pontine myelinolysis.
References: RADIODIAGNOSIS, INSTITUTE OF LIVER & BILIARY SCIENCES,
INSTITUTE OF LIVER & BILIARY SCIENCES - New Delhi/IN
Due to massive fluid shifts in early posttransplant period, the risk of CPM/
EPM is also higher in first 48 h after transplantation (Fig 49).
Majority of the PTLD cases are associated with Epstein-Barr virus (EBV)
infection and occur a few years following solid organ transplantation.
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Intracranial involvement is more often parenchymal than leptomeningeal
[94].
Page 65 of 110
Fig. 3: Axial T1-weighted MR images showing hyperintense signal of the caudate nucleus
(black arrows) in addition to the involvement of the globos pallidi (white arrows).
Fig. 4: (A) Axial T2-WI and (B) FLAIR sequence delineating subtle symmetrical
hyperintensity involving the bilateral lentiform nuclei in a young 26-year old lady with liver
cirrhosis.
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Fig. 5: A 40-year old male with alcoholic liver cirrhosis and grade-I hepatic
encephalopathy. Fast-FLAIR MR images reveal diffuse high-signal intensity in the
hemispheric white matter on either sides.
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Fig. 7: Ventricular enlargement (white arrow) and subarachnoid CSF-space (sylvian
fissure) widening represent cerebral involutional changes in a 30-year old male with
alcohol induced liver cirrhosis.
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Fig. 8: Typical imaging manifestations of HE. Fast FLAIR images exhibit symmetrical
cortical edema involving the insular cortex (arrow) and cingulate gyrus (arrowhead). Note
that the occipital cortex (asterisk) is characteristically spared.
Fig. 9: Acute HE. DWI displaying extensive symmetrical gyral edema which
characteristically involves the insular cortex (arrow) and cingulate gyrus (arrowhead);
and, typically spares the perirolandic and occipital cortex (dotted arrow).
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Fig. 10: Chronic HE. Axial T1-WI showing cortical atrophy with gyriform T1-hyperintensity
representing cortical laminar necrosis in a follow-up case of liver cirrhosis with recurrent
episodes of grade-3 HE in the past.
Fig. 11: A 50-year old liver cirrhosis patient developed cognitive deficits, ataxia,
dysarthria, movement disorders, and features of parkinsonism. MR images reveal
symmetrical T1-hyperintensity of the basal ganglia (A) with attendant T2-hyperintense
changes involving the bilateral middle cerebellar peduncles (B). Imaging findings in the
light of the clinical details are in keeping with acquired hepatocerebral degeneration.
Page 70 of 110
Fig. 12: Symmetrical T1-hyperintensity can be seen involving the basal ganglia (A, B),
cerebral peduncles (C), and the dorsal aspect of pons (D) in a patient of liver cirrhosis
presenting with features of parkinsonism.
Page 71 of 110
Fig. 13: A 50-year old male patient with hepatic myelopathy. MR spine failed to depict any
overt intramedullary signal alteration; however, screening of brain revealed symmetrical
hyperintensity along the bilateral corticospinal tracts.
Page 72 of 110
Fig. 14: Unenhanced CT in a liver disease patient with deranged coagulation profile
shows a large intraparenchymal hematoma (thick white arrow) in right frontal lobe with
contiguous extension into the ipsialteral ventricle (dotted arrow). In addition, there is
synchronous contralateral intracerebral bleed seen in the left frontal region (thick black
arrow). Furthermore, there is evidence of extra-axial bleed that can be seen along the
interhemispheric fissure (thin black arrow).
Page 73 of 110
Fig. 15: Infratentorial bleed in a delirious patient with decompensated liver cirrhosis.
Axial CT sections reveal a large hematoma involving the cerebellar vermis (arrow)
causing compression and effacement of the fourth ventricle with upstream obstructive
ventriculomegaly (arrowhead). The cerebral sulci are effaced and the cortico-medullary
junction indistinct (asterisk) suggesting raised intracranial pressure.
Fig. 16: Pyogenic meningitis and ventriculitis in a 42-year old patient with NASH related
liver cirrhosis. Post gadolinium T1-WI reveals inflammation, thickening and abnormal
enhancement of the right lateral ventricle ependyma (A, B) and choroid plexus (C)
in keeping with ventriculitis and choroid plexitis. In addition, abnormal leptomeningeal
enhancement can be seen along the right mesial temporal lobe (D) in keeping with
leptomeningitis.
Page 74 of 110
Fig. 17: Miliary tuberculosis in a middle aged liver cirrhosis patient with history of
longstanding alcohol abuse. Contrast enhanced T1-WI shows multiple pinhead sized
enhancing granulomas randomly scattered in the bilateral cerebral hemispheres.
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Fig. 18: Diffuse cerebral edema in a patient with acute on chronic (Hepatitis-B and C
related)liver failure. Noncontrast CT shows effaced sulci with loss of cortico-medullary
differentiation and indistinct margins of the lenticular nuclei suggesting diffuse cerebral
edema and raised intracranial tension.
Page 76 of 110
Fig. 19: Fulminant hepatic failure. T2W MR imaging reveals effaced cerebral sulci with
slit-like ventricles (A, B) and diffuse gyral swelling (C, D) in keeping with diffuse ceerbral
edema. The cisternal spaces are also effaced suggesting impending herniation (C, D).
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Fig. 20: (A, B) Sagittal and axial T2-WI show bilateral medial part of the temporal lobes
protruding over the tentorial edge in keeping with uncal herniation (black arrows). In
addition, there is downward cerebellar herniation (tonsillar herniation or coning) seen
in this patient of fulminant hepatic failure. The patient was subsequently declared brain
dead and succumbed to the disease.
Page 78 of 110
Fig. 21: Central pontine myelinolysis. Sagittal T2-WI shows relatively bulky appearing
pons with attendant signal intensity changes (black arrow) in a 48-year old patient with
alcoholic liver cirrhosis.
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Fig. 22: (A, B) Axial Fast FLAIR and T2-WI of the aforementioned patient shows
hyperintensity involving the central pons with characteristic sparing of the periphery.
Careful evaluation suggests that there is predominant involvement of the transverse
pontine fibres - finding which is quite characteristic of CPM.
Fig. 23: Extra-pontine myelinolysis. Axial FLAIR images showing extra-pontine areas of
signal alteration (demyelination) involving the left thalamus (white arrow) and the right
cerebellar hemisphere (black arrow) in a malnourished chronic alcoholic male patient
with decompensated liver cirrhosis.
Page 80 of 110
Fig. 24: Wernicke encephalopathy. Axial T2-WI showing confluent areas of increased
intensity surrounding the aqueduct and the third ventricle in a debilitated and
malnourished patient of alcohol induced liver cirrhosis complaining of ataxia and
opthalmoplegia.
Page 81 of 110
Fig. 25: Coronal T2-WI showing bilateral areas of increased intensity surrounding the
aqueduct and the third ventricle contiguously extending into the mamillary bodies.
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Fig. 26: Fast FLAIR images of the same patient showing symmetrical signal alterations
at characteristic sites including periventricular region of the third ventricle, periaqueductal
area, thalamus, and mamillary bodies.
Page 83 of 110
Fig. 27: Sagittal T2-WI in a chronic alcoholic male showing relatively atrophic posterior
body of the corpus callosum (white arrow) with focal area of signal alteration within the
splenium (black arrow). In addition, note is made of disproportionate cerebellar atrophy
(arrowhead) - likely representing alcoholic cerebellar degeneration.
Page 84 of 110
Fig. 28: Axial FAST FLAIR image in a liver cirrhosis patient with auditory hallucinations
following alcohol withdrawal showing subtle symmetrical bi-temporal hyperintensity
(arrows).
Page 85 of 110
Fig. 29: Axial FLAIR and T2WI showing selective bi-frontal cerebral atrophy in a 36-year
old chronic alcoholic male patient with underlying liver cirrhosis.
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Fig. 30: Alcoholic cerebellar degeneration. DIffuse cerebellar atrophy is seen in the
form of cerebellar foliar prominence, ventricular enlargement and prominence of the
infratentorial subarachnoid CSF spaces in a 44-year old male cirrhotic with history of
chronic alcohol abuse.
Page 87 of 110
Fig. 31: Axial T2-WI in a patient with Wilson disease depicting symmetrical increased
signal intensity of the bilateral lentiform nuclei (ahite arrow), thalami (black arrow) and
caudate nuclei (arrowhead).
Page 88 of 110
Fig. 32: DWI in a patient with Wilson disease depicting diffusion restriction involving the
lentiform and caudate nuclei (hepatolenticular degeneration) during the acute phase of
the disease.
Fig. 33: Axial T2WI (A) and T2*GRE (B) showing hypointense signal and blooming
reflecting heavy metal deposition in the lentiform nuclei in a patient of Wilson disease.
Page 89 of 110
Fig. 34: Symmetrical increased T1-signal intensity involving the lentiform nuclei in a
patient of Wilson disease.
Page 90 of 110
Fig. 35: (A, B) Giant panda sign in a young patient of Wilson disease. (C) The sign is
due to a combination of high signal intensity in the tegmentum (black arrow) with sparing
of the red nuclei (dotted arrow), pars reticulate (white arrow) and the superior colliculi
(arrowhead).
Page 91 of 110
Fig. 36: Giant panda cub. Axial T2WI in a patient of Wilson disease depicting signal
alteration in the dorsal pons simulating the face of a giant panda - popularly referred to
as 'giant panda cub' sign.
Page 92 of 110
Fig. 37: Transient ischemic attacks in a 39-year old patient with chronic (hepatitis-
C related) liver disease. DWI reveals multiple acute lacunar infarcts involving the left
pareito-temporal and right cerebellar hemisphere - possibly secondary to occlusive
vasculopathy or vasculitis.
Page 93 of 110
Fig. 38: A young 36-year old patient of hepatitis-C related liver cirrhosis and progressive
neurocognitive decline. Axial FAST FLAIR imaging reveals bilateral multifocal patchy and
confluent areas of subcortical white matter hyperintensities.
Fig. 39: A 45-year old male with (hepatitis-C) liver cirrhosis and rapidly progressive
dementia and neurocognitive decline. FAST FLAIR images reveal patchy and confluent
areas of signal alteration involving the periventricular as well as hemispheric white matter.
Page 94 of 110
Fig. 40: PRES in a post liver-transplant patient. Axial FAST FLAIR sequence exhibiting
cortico-subcortical areas of T2-hyperintensity in the parieto-occipital region.
Page 95 of 110
Fig. 41: Axial T2*GRE image of the hitherto discussed patient with PRES showing
punctate areas of blooming in keeping with petechial hemorrhages in the left occipital
lobe.
Page 96 of 110
Fig. 42: Immunosupressive leukoencephalopathy. A 56-year old post liver transplant
patient on tacrolimus complaining of unrelenting headaches and visual disturbances.
MR images show multifocal areas of white matter signal alteration involving the parieto-
occipital lobes and right fronto-parietal region appearing bright on T2WI (A) and dark on
T1WI (B).
Fig. 43: Suspected PML in a 44 year old post liver transplant patient with neurocognitive
decline. Axial FLAIR images showing patchy and conflueent scattered hyperintensities
in bilateral parieto-temporal and frontal white matter.
Page 97 of 110
Fig. 44: Multifocal areas of bilateral intracerebral hemorrhage in a 56-year old post liver-
transplant patient.
Fig. 45: Right middle cerebral artery (MCA) infarct. Axial T2WI (A) and DWI (B) showing
acute infarct with diffusion restriction involving the right temporal lobe in the MCA territory.
Page 98 of 110
Fig. 46: Anoxic-hypoxic ischemic encephalopathy following liver transplant (day-3). DWI
showing diffusion restriction and extensive gyral swelling involving the bilateral cerebral
hemispheres in a contiguous fashion.
Fig. 47: Severe hyperammonemic encephalopathy in a 35 year old post liver transplant
patient (post operative day 6). Axial FLAIR images showing extensive cortical swelling
and T2 prolongation especially along the insular cortices and cingulate gyrus.
Page 99 of 110
Fig. 48: Post-transplant invasive fungal sinusitis, orbital cellulitis & meningitis in a 26 year
old female. Axial CT section showing destruction of the lamina papyracea (white arrow)
with extension of the fungal elements into the right orbit with attendant orbital cellulitis
(asterisk).
Fig. 50: Central pontine myelinolysis in a post liver transplant patient. Axial FLAIR
image showing predominant involvement of the transverse pontine fibres (white arrow)
with characteristic sparing of the descending corticospinal tracts (asterisk). Note the
peripheral pontine fibers (black arrow) are also spared - hence the term 'central' pontine
myelinolysis.
Only with better understanding of the prevalence, clinical features and imaging
manifestations of different neurological complications associated with liver cirrhosis
and liver transplanatation, can we hope to aptly & promptly diagnose them and offer
appropriate therapeutic options.
Personal information
Assistant Professor
Email: aroradrankur@yahoo.com
References