title: Neurologic spectrum of chronic liver failure and basal ganglia T1 hyperintensity on magnetic resonance imaging: probable manganese neurotoxicity.
abstract: BACKGROUND
  An atypical form of parkinsonism has been described in patients with chronic liver disease, associated with increased T1 signal in the basal ganglia on magnetic resonance imaging. The magnetic resonance imaging signal changes are characteristic of manganese accumulation, which has been neuropathologically confirmed. Manganese neurotoxicity may result in additional neurologic findings besides parkinsonism.
  
  
  OBJECTIVE
  To fully characterize patients with chronic central nervous system symptoms and chronic liver failure associated with basal ganglia T1 hyperintensity.
  
  
  METHODS
  Prospective and retrospective case study.
  
  
  METHODS
  Mayo Clinic, Rochester, Minn.
  
  
  METHODS
  Eight patients referred for neurologic evaluation and studied prospectively, and 7 additional retrospectively identified patients who had been examined by Mayo Clinic neurologists.
  
  
  METHODS
  Neurologic syndromes identified.
  
  
  RESULTS
  Three syndromes were recognized in these 15 patients with liver failure and basal ganglia T1 hyperintensity on magnetic resonance imaging: (1) isolated parkinsonism, (2) gait ataxia plus other neurologic findings (ataxia-plus), and (3) cognitive impairment with psychiatric features. All but 1 patient had elevated blood manganese levels. Ammonia levels were normal in most, and the neurologic syndromes did not appear to reflect the well-known toxic-metabolic encephalopathy of liver disease.
  
  
  CONCLUSIONS
  Chronic liver failure may result in heterogeneous neurologic syndromes that cut across a variety of liver diseases. We selected cases on the basis of evidence of brain manganese accumulation, and this may be a crucial component of these syndromes. Further studies are necessary to explore this issue.
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Klos
authors.forename: J Eric
authors.initials: JE
authors.lastname: Ahlskog
authors.forename: Keith A
authors.initials: KA
authors.lastname: Josephs
authors.forename: Robert D
authors.initials: RD
authors.lastname: Fealey
authors.forename: Clayton T
authors.initials: CT
authors.lastname: Cowl
authors.forename: Neeraj
authors.initials: N
authors.lastname: Kumar
mesh_terms: D000328:Adult; D000368:Aged; D000641:Ammonia / Q000097:blood; D001480:Basal Ganglia Diseases / Q000209:etiology* / Q000378:metabolism / Q000473:pathology; D001923:Brain Chemistry; D003072:Cognition Disorders / Q000209:etiology / Q000378:metabolism / Q000473:pathology; D005260:Female; D020234:Gait Ataxia / Q000150:complications / Q000378:metabolism / Q000473:pathology; D006801:Humans; D017093:Liver Failure / Q000209:etiology* / Q000378:metabolism / Q000473:pathology; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D020149:Manganese Poisoning / Q000097:blood / Q000150:complications*; D008875:Middle Aged; D020734:Parkinsonian Disorders / Q000150:complications / Q000378:metabolism / Q000473:pathology; D011446:Prospective Studies; D012189:Retrospective Studies
chemical_list: D000641:Ammonia