HEPATIC ENCEPHALOPATHY MIMICKING STROKE IN A PATIENT WITH CHRONIC LIVER DISEASE

Abstract

Hepatic Encephalopathy is a potentially reversible life-threatening neuro-psychiatric complication of liver cirrhosis. It generally presents with sleep disturbances, drowsiness and personality changes. Focal neurological loss in form of hemiplegia is a very rare presentation of hepatic encephalopathy. A 55-year old gentleman presented with irritability, drowsiness, right sided body weakness and constipation for last 3 days. He was a diagnosed patient of Hepatitis C positive Chronic liver disease for 3 years having completed a 24-week course of oral sofosbuvir 400mg and daclatasvir 60mg. On examination, the patient was drowsy but arousable having a GCS of 12/15 (E3, V4, M5). Power of grade 4/5 was noted in both left upper and lower limb with an extensor left plantar reflex. Flapping tremors were preset and bilateral mild pitting pedal edema was noted. Abdomen was soft, non-tender, mildly distended with positive shifting dullness. A CT scan (Brain) was done to rule out intracranial bleeding and the patient was admitted on lines of ischemic stroke and hepatic encephalopathy. He had thrombocytopenia, deranged LFTs and serum ammonia level. MRI Scan (Brain) showed foci of diffusion restriction in the left periventricular region and basal ganglia and T2WI/FLAIR hyperintense signals in the periventricular region, basal ganglia and deep white matter, however MR angiography demonstrated normal cerebral vessels. He was diagnosed as having hepatic encephalopathy mimicking stroke and underlying liver cirrhosis. After initiating lactulose and Rifaximin, the patient passed stools which resulted in resolution of his symptoms. His repeat serum ammonia was within normal limits and the patient was discharged.