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AJNR - American Journal of Neuroradiology

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Reversal of Parkinsonism and Portosystemic Encephalopathy Following Embolization of a Congenital Intrahepatic Venous Shunt: Brain MR Imaging and ¹H Spectroscopic Findings

Antônio J. da Rocha^a, Flávio T. Braga^a, Carlos J. da Silva^a, Antônio C. M. Maia, Jr^a, Guilherme S. Mourão^b and Rubens J. Gagliardi^c

^a Centro de Medicina Diagnóstica, Setor de Imagem, Laboratório Fleury, São Paulo Brazil
^b Medimagem, Hospital Beneficiência Portuguesa de São Paulo, São Paulo Brazil
^c Department of Neurology, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo Brazil

View larger version (75K): [in a new window]   FIG 1. Initial examination. T1-weighted MR images show bilateral and symmetrical hyperintensities in the substantia nigra and cerebral peduncle (A), subthalamic region and hemispheric white matter (B), and the globus pallidus and putamen (C).

View larger version (15K): [in a new window]   FIG 2. Initial examination. 1H spectroscopy shows decreased mI/Cr and Cho/Cr ratios and an elevated alpha- and beta-, gamma-Glx/Cr peak areas ratios (arrows).

View larger version (75K): [in a new window]   FIG 3. Angio-MR examination (A) shows the right branch of portal vein (arrow), the intrahepatic aneurysm (arrowhead), and the right hepatic vein (smaller arrow). Portogram (B) shows the aneurysm (arrow) at the posterior division of the right branch of portal vein. Portogram after embolization (C) shows successful occlusion of the shunt and associated aneurysm.

View larger version (75K): [in a new window]   FIG 4. Follow-up examinations after 6 (A, B) and 9 (C, D) months. T1-weighted MR images on the left show a progressive decrease of the symmetrical bilateral high signal intensity in the globus pallidus and putamen, and 1H spectroscopic measurements on the right show normalization of the mI/Cr and Cho/Cr ratios and a progressive decrease of the alpha- and beta, gamma-Glx/Cr peak areas ratios after 6 and 9 months (arrows).