1307 - Sudden Onset Spastic Paraparesis After Transjugular Intrahepatic Portosystemic Shunt Procedure: A Case Report

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

SH

Silas Helbig, BS

Medical Student
Florida International University Herbert Wertheim College of Medicine
Coral Gables, Florida, United States
AL

Andrew Liepshutz, BS

Medical Student
Florida International University Herbert Wertheim College of Medicine
Miami, Florida, United States

Co-Author(s)

MF

Michelle Fernandez, BS

Adjunct Lecturer
Florida International University
Miami, Florida, United States
RT

Ronald Tolchin, DO

Medical Director of Spine Center
Baptist Hospital of Miami
Miami, Florida, United States

Case Diagnosis: Hepatic myelopathy following a transjugular intrahepatic portosystemic shunt (TIPS) procedure.

Case Description: A 64 year-old male presented with three months of back pain and trouble walking. He underwent a TIPS procedure for Hepatitis B-induced cirrhosis with esophageal varices. Three days after, he developed sudden onset burning back pain and bilateral leg tightness leading to unsteady gait. On examination, the patient was hyperreflexic and hypertonic with ankle clonus in the lower extremities with preserved sensation and normal upper extremities. His gait was characterized as slow and waddling. Laboratory data showed evidence of hepatic dysfunction, bilateral abnormal enhancement of the globi palladi and corticospinal tract on brain MRI, and unremarkable complete spine MRI. With the clinical history and other causes of myelopathy ruled out, it was concluded his symptoms were due to hepatic myelopathy.

Discussions: Neurologic complications are frequently seen in patients with liver disease, most commonly hepatic encephalopathy. Hepatic myelopathy is a rare condition associated with portosystemic shunts in those with chronic liver disease. Cases described in the literature have insidious onsets from 5 weeks to 20 years after a portosystemic shunt. While unclear, the pathogenesis is attributed to nutrient abnormalities and toxin accumulation within the corticospinal tract. Typical presentation involves lower extremity spastic paraparesis without bowel, bladder, or sensory involvement. Unlike hepatic encephalopathy, hepatic myelopathy is not responsive to ammonia lowering therapy. Early detection of hepatic myelopathy is crucial, as liver transplantation, shunt reversal, and TIPS reduction have demonstrated symptom improvement.

Conclusions: This patient presented with back pain and trouble walking after a TIPS procedure. Physicians should have high clinical suspicion for hepatic myelopathy in patients presenting with lower extremity spastic paraparesis, liver disease, and unremarkable spine MRI. The typical presentation has an insidious onset after shunt creation, yet we report this case of sudden onset hepatic myelopathy within days of the TIPS procedure.