Figure 1
Figure 1
T1-weighted MR image demonstrates bilateral symmetric hyperintensity in globus pallidus.
Bilateral symmetric hyperintensity in globus pallidus on T1-weighted MR image in a patient with chronic liver disease
SectionNeuroradiology
Case TypeClinical Cases
Authors
Canyigit M1, Koksal A2, Sarisahin M2, Yucesoy C2, Erol B1, Akhan O2.
1) Ankara Ataturk Education and Research Hospital, Department of radiology, Bilkent; 2) Bayindir Hospital, Department of radiology, Sogutozu. Ankara, Turkey.
Connected authors
56 years, male
Clinical History
A 56 year old man was admitted to the hospital with disbalance, vertigo and vomiting for two hours.
Imaging Findings
His physical examination was totally normal; his laboratory findings were within normal ranges except alcaline phosphatase and gamma glutamile transferase level, which were 123 U/L (normal range 30-115) and 75 U/L (normal range 10-50), respectively. Medical history of the patient showed chronic liver disease secondary to hepatitis C. An urgent cranial MDCT showed hypodensity on right frontal lobe representing cerebral infarct without cerebral haemorrhage. Cranial MRI was obtained in order to acute cerebral infarct and demonstrated bilateral symmetric hyperintensity in globus pallidus on T1-weighted image as well as chronic right frontal infarct. No acute infarct observed.
Discussion
Bilateral symmetric hyperintensity in basal ganglia, predominantly globus pallidus, firstly described by Inoue et al [1], on T1-weighted MRI of the brain has been reported in 75-100% of cirrhotic patients, in which the reason was an increase in blood manganese and its accumulation in the brain due to liver dysfunction and portal-systemic shunting [2,3]. There is no correlation between the stage of hepatic encephalopathy and globus pallidus hyperintensity [3]. Both chronic manganese intoxication and liver failure manifest progressive extrapyramidal syndromes such as rigidity, bradykinesia, gait abnormalities, dysarthria and tremor [4]. Although neurological abnormalities improve rapidly, pallidal hyperintensity shows a slow normalization after liver transplantation. Globus pallidus hyperintensity significantly increases after placement of a transjugular intrahepatic portosystemic shunt but has no correlation with hepatic encephalopathy and neuropsychiatric deterioration. Therefore, cranial MRI is not a sufficient method for monitoring the progression of hepatic encephalopathy [4].
Bilateral symmetric hyperintensity in basal ganglia on T1-weighted MRI has been also revealed in hyperalimentation, CO poisoning, hypothyroidism, acute kernicterus, asphyxia, neurofibromatosis and metastatic melanoma. The clinical and laboratory findings help to differentiate these diseases from cirrhosis. Furthermore, in contrast to other causes, acute kernicterus and asphyxia have been showed in newborn (5, 6).
Bilateral symmetric hyperintensity in basal ganglia on T1-weighted MRI has been also revealed in hyperalimentation, CO poisoning, hypothyroidism, acute kernicterus, asphyxia, neurofibromatosis and metastatic melanoma. The clinical and laboratory findings help to differentiate these diseases from cirrhosis. Furthermore, in contrast to other causes, acute kernicterus and asphyxia have been showed in newborn (5, 6).
Differential Diagnosis List
Globus pallidus hyperintensity secondary to chronic liver disease
Final Diagnosis
Globus pallidus hyperintensity secondary to chronic liver disease
References
[1] Inoue E, Hori S, Narumi Y, et al. (1991) Portal-systemic encephalopathy: presence of basal ganglia lesions with high signal intensity on MR images. Radiology 179:551-5. (PMID: 2014310)
[2] Das K, Singh P, Chawla Y, Duseja A, Dhiman RK, Suri S (2008) Magnetic resonance imaging of brain in patients with cirrhotic and non-cirrhotic portal hypertension. Dig Dis Sci 53:2793-98. (PMID: 18688722)
[3] Cordoba J, Sanpedro F, Alonso J, Rovira A (2002) 1H Magnetic resonance in the study of hepatic encephalopathy in humans. Metab Brain Dis 17:415-29. (PMID: 12602517)
[4] Krieger S, Jauss M, Jansen O, et al. (1997) MRI findings in chronic hepatic encephalopathy depend on portosystemic shunt: results of a controlled prospective clinical investigation. J Hepatol 27:121-6. (PMID: 9252084)
[5] Coskun A, Yikilmaz A, Kumandas S, Karahan OI, Akcakus M, Manav A. Hyperintense globus pallidus on T1-weighted MR imaging in acute kernicterus: is it common or rare?. Eur Radiol 2005:15;1263-67.
[6] Govaert P, Lequin M, Swarte R, et al. Changes in globus pallidus with (pre)term kernicterus. Pediatrics 2003; 112:1256-63.
Case information
| URL: | https://eurorad.org/case/8001 |
| DOI: | 10.1594/EURORAD/CASE.8001 |
| ISSN: | 1563-4086 |
Figure 1
T1-weighted MR image demonstrates bilateral symmetric hyperintensity in globus pallidus.