# Hepatic myelopathy neurological complication of chronic liver disease: two case reports

## TL;DR

Hepatic myelopathy is a rare neurological complication of chronic liver disease, characterized by progressive motor issues and linked to cirrhosis and portal hypertension.

## Contribution

The paper presents two new case reports of hepatic myelopathy in Tunisian patients, highlighting diagnostic and therapeutic challenges.

## Key findings

- MRI of the spinal cord was normal, but brain MRI showed T2 hyperintensities in the pallidums, suggesting hepatic encephalopathy.
- Conservative treatments showed limited effectiveness, while early liver transplantation may prevent progression and enable recovery.

## Abstract

Hepatic myelopathy is a very rare neurological complication of chronic liver disease. Patients habitually present with progressive pure motor spastic paraparesis. This neurological dysfunction is almost always due to cirrhosis and portocaval shunt, either surgical or spontaneous.

We report two cases of a 57-year-old man and a 37-year-old woman with progressive spastic paraparesis linked to cirrhosis and portal hypertension. The two patients are of Tunisian origin (north Africa). Magnetic resonance imaging of the spinal cord of two patients was normal, while brain magnetic resonance imaging showed a T2 hypersignals of the pallidums. These signs, in favor of hepatic encephalopathy in the two patients with cirrhosis with isolated progressive spastic paraparesis without bladder or sensory disorders, help to retain the diagnosis of hepatic myelopathy.

Hepatic myelopathy is a severe and debilitating neurological complication of chronic liver disease. The pathogenesis is misunderstood and seems to be multifactorial, including the selective neurotoxic role both of ammonia and other pathogenic neurotoxins. Usually a pathological brain magnetic resonance imaging showing a hepatic encephalopathy was documented, contrasting with a normal spinal cord magnetic resonance imaging that contributed to diagnosis of hepatic myelopathy. Conservative therapies such as ammonia-lowering measures, diet supplementation, antispastic drugs, and endovascular shunt occlusion show little benefit in improving disease symptoms. Liver transplantation performed at early stage can prevent disease progression and could probably allow for recovery.