A discussion of new-onset extrapyramidal syndrome without tremor and neuroimaging signs of encephalopathy following hepatic cirrhosis

Abstract

Liver cirrhosis can cause neurological, extrapyramidal-type disorders, such as stiffness, bradykinesia, tremor, confusion, depression. Cirrhotic extrapyramidal syndrome can worsen clinically, leading to encephalopathy, which in the most severe cases leads to coma. Brain MRI is able to highlight the extrapyramidal signs, through the presence of hyperintensity areas at the basal ganglia. In addition, extrapyramidal symptoms appear already in the metabolic compensation phase. We describe the case of a 50-year-old male, suffering from new-onset extrapyramidal syndrome, secondary to alcoholic hepatic cirrhosis, diagnosed seven years before. The case is singular for some features: the late-onset of the extrapyramidal syndrome, the absence of tremor, and especially the lack of neuroimaging findings such as MRI hyperintense areas along the basal ganglia.We hypothesize a mechanism of metabolic compensation, which would be responsible for the late appearance of the extrapyramidal syndrome and the lack of signs of encephalopathy in brain MRI.The lack of tremor is less clear, because it is a constant symptom of extrapyramidal pathology, and it is unusual that it is lacking as a symptom, after so many years.