Acute severe hepatic encephalopathy

Case contributed by Andrew Dixon
Diagnosis almost certain


Alcoholic patient presenting with confusion and reduced conscious state.

Patient Data

Age: 60 years
Gender: Male

Diffuse cortical T2 and DWI hyperintensity with sparing of the perirolandic and occipital regions. Edema within the thalami and posterior limbs of the internal capsules. Basal ganglia T1 hyperintensity. 

Case Discussion

An example of acute severe hepatic encephalopathy showing the classic pattern of diffuse cortical edema with sparing of the perirolandic and occipital regions. The typical T1 hyperintense basal ganglia changes of chronic hepatic encephalopathy are also demonstrated. 

Creutzfeldt-Jakob disease would be an important differential to consider for cortical and thalamic signal changes like this in the absence of any known liver disease, although in this case the perirolandic and occipital lobe sparing is relatively pathognomonic of hepatic encephalopathy.  

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