MRI findings in chronic hepatic encephalopathy depend on portosystemic shunt: results of a controlled prospective clinical investigation

Background/Aims: Deterioration of hepatic encephalopathy is a major concern with the transjugular intrahepatic portosystemic shunt procedure. Symmetric hyperintense globus pallidus on T1-weighted cranial magnetic resonance imaging in patients with liver cirrhosis anticipates hepatocerebral disease. It is hypothesized that hepatic encephalopathy and basal ganglia signal intensity progress in patients with cirrhosis of the liver undergoing transjugular intrahepatic portosystemic shunt. Methods: Twenty-four patients were randomized to undergo either transjugular intrahepatic portosystemic shunt or elective sclerotherapy. At study entry and 6 months after randomization, neurologic assessment, psychometric tests, standard EEG, and magnetic resonance imaging were performed. The severity of liver failure was graded using Child-Pughʹs classification. The signal intensity of the globus pallidus was determined on sagittal T1-weighted magnetic resonance imaging. Results: The T1-weighted signal intensity of the globus pallidus on magnetic resonance imaging significantly increased after transjugular intrahepatic portosystemic shunt placement (p<0.01), but not with elective sclerotherapy. At follow-up, neurological symptoms indicating decline of mental status and motor performance were somewhat more prevalent in transjugular intrahepatic portosystemic shunt patients. Significant deterioration of EEG abnormalities occurred in patients treated with transjugular intrahepatic portosystemic shunt as opposed to elective sclerotherapy (p<0.01). Conclusions: Transjugular intrahepatic portosystemic shunt procedure increases hyperresonant globus pallidus on magnetic resonance imaging. Neuropsychiatric evaluation shows advancing hepatic encephalopathy, in particular with transjugular intrahepatic portosystemic shunt; however, it does not parallel the augmentation of pallidal signal intensity on magnetic resonance imaging.