title: Brain metal concentrations in chronic liver failure patients with pallidal T1 MRI hyperintensity.
abstract: BACKGROUND
  Chronic liver failure may be associated with pallidal MRI T1 hyperintensity and heterogeneous neurologic syndromes, including parkinsonism, cognitive impairment, and others. Manganese accumulation may be responsible for the imaging and clinical findings.
  
  
  OBJECTIVE
  To measure manganese plus other metal concentrations in pallidum and additional brain regions and to examine the corresponding neuropathology in cases of chronic liver failure.
  
  
  METHODS
  Regional brain metal concentrations were measured in seven chronic liver failure cases, four with pallidal T1 hyperintensity and three with normal MRI, plus five controls. Neuropathologic examination employed alpha-synuclein and tau immunohistochemistry.
  
  
  RESULTS
  In patients with pallidal T1 hyperintensity, pallidal manganese concentrations were increased sevenfold over controls and over fourfold vs liver patients with normal MRI; manganese concentrations were also significantly elevated in all other brain regions. Copper was additionally increased in all brain regions, whereas other metal concentrations were similar to control values. Neuropathology revealed mild to moderate Alzheimer type II gliosis in the liver failure groups and negative alpha-synuclein and tau immunostaining except for one case (intermediate Alzheimer disease pathology).
  
  
  CONCLUSIONS
  In chronic liver failure, manganese accumulation is responsible for the pallidal MRI T1 hyperintensity. Pallidal copper was also elevated in affected cases, but copper does not have the paramagnetic properties to generate isolated T1 hyperintensity. Basal ganglia manganese or copper accumulation may be responsible for the parkinsonism sometimes seen in chronic liver failure. Pallidal MRI T1 hyperintensity is a biomarker of manganese overload.
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, MN, USA. kklos@tulsacoxmail.com
authors.forename: K J
authors.initials: KJ
authors.lastname: Klos
authors.forename: J E
authors.initials: JE
authors.lastname: Ahlskog
authors.forename: N
authors.initials: N
authors.lastname: Kumar
authors.forename: S
authors.initials: S
authors.lastname: Cambern
authors.forename: J
authors.initials: J
authors.lastname: Butz
authors.forename: M
authors.initials: M
authors.lastname: Burritt
authors.forename: R D
authors.initials: RD
authors.lastname: Fealey
authors.forename: C T
authors.initials: CT
authors.lastname: Cowl
authors.forename: J E
authors.initials: JE
authors.lastname: Parisi
authors.forename: K A
authors.initials: KA
authors.lastname: Josephs
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease; D003300:Copper / Q000032:analysis / Q000378:metabolism; D005260:Female; D005917:Globus Pallidus / Q000737:chemistry* / Q000378:metabolism / Q000473:pathology; D006801:Humans; D017093:Liver Failure / Q000378:metabolism* / Q000473:pathology; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008345:Manganese / Q000032:analysis / Q000378:metabolism; D019216:Metals, Heavy / Q000032:analysis / Q000378:metabolism*; D008875:Middle Aged; D012042:Registries
chemical_list: D019216:Metals, Heavy; D008345:Manganese; D003300:Copper