Reader response: A meta-analysis of magnetic resonance spectroscopy in the diagnosis of hepatic encephalopathy
Vinod K.Gupta, Physician-Medical Director, Migraine-Headache Institution, Gupta Medical Center (New Delhi, India)
Submitted January 09, 2020
I read the article by Zeng et al.1 Magnetic resonance spectroscopy (MRS) changes—particularly in the parietal lobe related to glutamine/glutamate, choline, and myo-inositol—correlate with the severity of hepatic encephalopathy (HE), helping to distinguish between cirrhotic patients with and without minimal hepatic encephalopathy (MHE).
The clinical picture of the cirrhotic patient is generally clinically evident.2 Most commonly utilized tools to predict outcomes in patients with cirrhosis include: assessing severity of portal hypertension using hepatic venous pressure gradient measurements, using scoring systems such as the Model for End-stage Liver Disease and Child-Pugh-Turcotte scores, and recently, clinical staging systems based on cirrhosis-related clinical complications.2 Slipping of the cirrhotic patient in to MHE or HE is frequently marked by elevations of blood ammonia and the highly characteristic flapping tremor, besides constructive apraxia.3 MHE / HE in patients with cirrhosis is a clinical diagnosis of exclusion based on a high index of suspicion that should, however, not be based solely on ammonia levels.
MRS changes of MHE should be correlated with early clinical signs of hepatic decompensation to augment clinical utility. Cirrhosis and cirrhotic decompensation are not clinically subtle issues that might benefit clinically to any extent with MRS findings.
Utility of MRS with brain parietal changes in the outpatient settings would indeed be clinically valuable in the pre-decompensated non-hospitalized cirrhotic patient. Correlation of MRS findings with hepatic venous pressure gradient measurements or other clinical scores would be useful. Otherwise such studies will remain purely academic and clinically unhelpful, even in tertiary care centers.
Disclosure
The author reports no relevant disclosures. Contact journal@neurology.org for full disclosures.
References
Zeng G, Penninkilampi R. Chaganti J, et al. A meta-analysis of magnetic resonance spectroscopy in the diagnosis of hepatic encephalopathy. Neurology 2020 Epub Jan 9.
Haj M, Rockey DC. Predictors of clinical outcomes in cirrhosis patients. Curr Opin Gastroenterol 2018;34:266–271.
Ninan J, Feldman L. Ammonia levels and hepatic encephalopathy in patients with known chronic liver disease. J Hosp Med 2017;12:659–661.
I read the article by Zeng et al.1 Magnetic resonance spectroscopy (MRS) changes—particularly in the parietal lobe related to glutamine/glutamate, choline, and myo-inositol—correlate with the severity of hepatic encephalopathy (HE), helping to distinguish between cirrhotic patients with and without minimal hepatic encephalopathy (MHE).
The clinical picture of the cirrhotic patient is generally clinically evident.2 Most commonly utilized tools to predict outcomes in patients with cirrhosis include: assessing severity of portal hypertension using hepatic venous pressure gradient measurements, using scoring systems such as the Model for End-stage Liver Disease and Child-Pugh-Turcotte scores, and recently, clinical staging systems based on cirrhosis-related clinical complications.2 Slipping of the cirrhotic patient in to MHE or HE is frequently marked by elevations of blood ammonia and the highly characteristic flapping tremor, besides constructive apraxia.3 MHE / HE in patients with cirrhosis is a clinical diagnosis of exclusion based on a high index of suspicion that should, however, not be based solely on ammonia levels.
MRS changes of MHE should be correlated with early clinical signs of hepatic decompensation to augment clinical utility. Cirrhosis and cirrhotic decompensation are not clinically subtle issues that might benefit clinically to any extent with MRS findings.
Utility of MRS with brain parietal changes in the outpatient settings would indeed be clinically valuable in the pre-decompensated non-hospitalized cirrhotic patient. Correlation of MRS findings with hepatic venous pressure gradient measurements or other clinical scores would be useful. Otherwise such studies will remain purely academic and clinically unhelpful, even in tertiary care centers.
Disclosure
The author reports no relevant disclosures. Contact journal@neurology.org for full disclosures.
References