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|LETTER TO EDITOR
|Year : 2017 | Volume
| Issue : 4 | Page : 872-873
Under recognized cause of reversible cognitive decline: A radiological aid
Amith S Kumar, Ritu Shree, Julie Sachdeva, Anuja Patil, Manoj K Goyal, Vivek Lal
Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||5-Jul-2017|
Manoj K Goyal
Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar AS, Shree R, Sachdeva J, Patil A, Goyal MK, Lal V. Under recognized cause of reversible cognitive decline: A radiological aid. Neurol India 2017;65:872-3
A 55-year old businessman-politician, presented with complaints of memory disturbances with changes in behavior of 6-month duration. Detailed neurological examination revealed a mini-mental state examination of 18/30 with significant impairment of frontal and temporal lobe functions. He was noted to have multiple spider naevi and asterixis. Gadolinium-enhanced magnetic resonance imaging of the brain revealed bilateral, symmetric high signal intensity of the globus pallidi on T1-weighted sequence; diffuse white matter high signal intensities predominantly involving the hemispheric corticospinal tract; and, focal high-signal T2 lesions in the subcortical hemispheric white matter. Diffusion-weighted images showed increased mean diffusivity in hemispheric white matter [Figure 1]. Magnetic resonance (MR) angiogram of intra- and extracranial vessels was normal. Serum ammonia levels were raised. Fibroscan revealed liver stiffness measurement (LSM) of 54.2 kPa, indicating cirrhosis. He was treated with antihepatic coma measures and had significant improvement in symptoms.
|Figure 1: (a) T1-weighted MR image showing bilateral, symmetric high signal intensity of the globus pallidi, (b) diffusion-weighted image showing increased mean diffusivity of high-signal T2 lesions in subcortical white matter, (c) zoom images showing high-signal T2 lesions along the corticospinal tracts in bilateral cerebral peduncles|
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Portosystemic encephalopathy is an under recognized cause of subacute cognitive decline. Bilateral, symmetric high signal intensities of the globus pallidi (particularly medial) on T1-weighted sequences have been reported to be due to increased concentration of manganese deposition. High-signal T2 lesions in subcortical white matter along with increase in mean diffusivity are the result of interstitial brain edema. Early recognition of brain imaging suggestive of portosystemic shunt can lead to a prompt diagnosis of a reversible cause of cognitive decline.
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