Teaching Video NeuroImages: Hepatic myelopathy: An unusual neurologic complication of hepatic encephalopathy

A 57-year-old man with alcoholic cirrhosis presented with a 4-year history of hepatic encephalopathy (HE) and progressive gait impairment that worsened during HE (video 1). Examination disclosed spasticity and weakness in lower limbs. Brain MRI showed hyperintense signal in basal ganglia and spectroscopy disclosed increased glutamine/glutamate and decreased myo-inositol (figure). Spine MRI was normal, and other causes were ruled out. Hepatic myelopathy was diagnosed.

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