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Relationship Between Cerebral Perfusion in Frontal-Limbic-Basal Ganglia Circuits and Neuropsychologic Impairment in Patients with Subclinical Hepatic Encephalopathy

Departments of Nuclear Medicine, Neurology, and Gastroenterology, Hospital de Sant Pau, Barcelona
Magnetic Resonance Center of Pedralbes, Barcelona, Spain

Correspondence: For correspondence or reprints contact: Ana M. Catafau, MD, Servicio de Medicina Nuclear, Hospital de Sant Pau, Sant Antoni M. Claret, 167, 08025 Barcelona, Spain.

ABSTRACT

Early detection of neuropsychologic impairment in drrhotic patients with subclinical hepatic encephalopathy (SHE) is important for their prognosis and quality of life. Abnormal MRI and MR spectroscopy (MRS) findings have been proposed as early markers of brain damage in these patients, but the role of functional neuroimaging in this field still has to be defined. In this study, the SPECT perfusion pattern in patients with SHE was investigated, and the relationship between regional cerebral blood flow (rCBF) and the MRI, MRS, neuropsychologic evaluation and biochemical data of these patients was assessed. Methods: Data were obtained from 13 cirrhotic patients with SHE and 13 age-matched healthy volunteers. Fasting venous blood ammonia and manganese sampling and a battery of standardized neuropsychologic tests related to basal ganglia function and sensitive to the effects of liver disease were all performed on the same day. MRI and ^99mTc-hexamethyl propyteneamine oxime SPECT were performed within 2 wk. Results: A pattern of decreased prefrontal rCBF was found in patients with SHE compared with healthy volunteers. Basal ganglia and mesial temporal rCBF correlated inversely with performance on motor tasks involving speed (Purdue pegboard test) and frontal premotor function (Luria graphic altemances and Stroop tests). Thalamic rCBF correlated positively with T1-weighted MRI signal hyperintensity in the globus pallidus and with abnormal MRS findings. Neither the MRI signal intensity of the globus pallidus nor MRS correlated with neuropsychologic test results. Conclusion: Cirrhotic patients with SHE show a SPECT pattern of impaired prefrontal perfusion that does not seem to account for their neuropsychologic deficits. On the other hand, perfusion in some parts of the limbic system and limbic-connected brain regions, such as the striatum and the mesial temporal regions, increased with neuropsychologic impairment. These findings suggest that brain SPECT may be more sensitive than MRI in delineating cirrhotic patients requiring in-depth clinical testing to reveal basal ganglia-related neuropsychologic alterations.

Key Words: brain SPECT • subclinical hepatic encephalopathy • neuropsychology • MRI • MR spectroscopy

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