A 55-year-old man with cirrhosis presented with hyperammonemic encephalopathy, subsequently fatal (plasma ammonia level ϭ 410 M/L). Three-Tesla MRI initially showed restricted diffusion (figure 1A) in the cerebral cortex, suggesting poor prognosis, 1 thalami, and striatum. Apparent diffusion coefficient pseudonormalized 8 days after admission (figure 1B), comparable to the evolution of hypoxic encephalopathy.2 T2 hyperintensity of the gray matter progressively increased ( figure 2A). High glutamate plus glutamine without lactate was detected on day 2 in the right thalamus, while N-acetylaspartate progressively declined ( figure 2B). These imaging findings illustrate the time course of hyperammonemic encephalopathy.

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Splenorenal shunts are a rare cause of hyperammonemia and hepatic encephalopathy in the absence of cirrhosis. We report the case of a woman, who presented hepatic encephalopathy, with a normal functioning graft, after 14 years of liver transplantation, confirmed by liver biopsy.

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