Abstract
PurposeThe majority of cirrhotic patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) experienced the first post-TIPS hepatic encephalopathy (HE) episode within the first three months after TIPS insertion. However, so far, little is known about the exact neuro-pathophysiological mechanism of TIPS's effects on brain function. We aimed to investigate the dynamics of brain function alteration of post-TIPS patients using resting-state functional MRI (rs-fMRI).Materials and MethodsSixteen cirrhotic patients who were scheduled for TIPS and 16 healthy controls were included in the rs-fMRI scans. Ten patients repeated the MRI study in a median 8-day follow-up interval following TIPS and seven in a median 3-month follow-up. The amplitude of low frequency fluctuation (ALFF), an index reflecting the spontaneous brain activity, was compared between patients before TIPS and healthy controls as well as patients pre- and post- TIPS.ResultsCompared with healthy controls, patients showed decreased ALFF in frontal and parietal regions and increased ALFF in insula. Patients who underwent the median 8-day follow-up fMRI examinations showed decreased ALFF in posterior cingulate cortex (PCC)/precuneus and increased ALFF in anterior cingulate cortex (ACC). Of 10 patients in this group, 9 had moderate to large increase rate of ALFF value (>20%, mean 49.19%) in ACC, while only one patient with the smallest increase rate of ALFF value (<10%) in ACC, who experienced three episodes of overt HE during the 3-month follow-up. In the median 3-month follow up observation, patients displayed persistently decreased ALFF in PCC, ACC and medial prefrontal cortex (MPFC), while no increased regional ALFF was observed.ConclusionTIPS insertion alters cirrhotic patients' ALFF patterns in the resting state, which may imply different short-term and moderate-term effects on cirrhotic patients, i.e., both impairment and compensatory mechanism of brain functions in peri-TIPS and continuous impairment of brain function 3 months following TIPS.
Highlights
Transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneously created shunt through the liver parenchyma connecting the right or left portal vein to one of the three main hepatic veins [1], which is used increasingly in patients with variceal hemorrhage and refractory ascites
In the median 3-month follow up observation, patients displayed persistently decreased Amplitude of low frequency fluctuation (ALFF) in posterior cingulate cortex (PCC), anterior cingulate cortex (ACC) and medial prefrontal cortex (MPFC), while no increased regional ALFF was observed
TIPS insertion is more effective than other alternative treatments such as endoscopic sclerotherapy in prevention of recurrent variceal bleeding [2,3], the majority of controlled trials [2,3,4] and two meta-analyses [5,6] demonstrated that it increased the risk of portosystemic hepatic encephalopathy (HE) and had no survival benefit
Summary
Transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneously created shunt through the liver parenchyma connecting the right or left portal vein to one of the three main hepatic veins [1], which is used increasingly in patients with variceal hemorrhage and refractory ascites. TIPS insertion is more effective than other alternative treatments such as endoscopic sclerotherapy in prevention of recurrent variceal bleeding [2,3], the majority of controlled trials [2,3,4] and two meta-analyses [5,6] demonstrated that it increased the risk of portosystemic hepatic encephalopathy (HE) and had no survival benefit. Some authors considered TIPS as a doubleedged sword and did not recommend it as a first-line treatment for the prevention of variceal rebleeding [7]. Many authors reported that the majority of post-TIPS HE happened within the first three months [8,9]. Kramer et al [10] first demonstrated TIPS can aggravate the cognitive impairment in patients without HE in a 6-month follow up observation using several neurophysiological tests e.g., event-
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