A case report published on Jul. 28 describes a novel interventional approach that successfully treated a patient with hepatic myelopathy, a rare neurological complication of decompensated chronic liver disease. The patient, who had previously undergone transjugular intrahepatic portosystemic shunt (TIPS) placement for cirrhosis-related variceal bleeding, experienced marked improvement in severe spastic paraparesis following embolization of an unrecognized paraspinal vein shunt.
Hepatic myelopathy is characterized by progressive spastic weakness of the lower limbs without significant sensory loss and is typically considered incurable except through early liver transplantation. The condition has been linked to spontaneous or iatrogenic portosystemic shunting, but the specific vessels involved have not been clearly identified. This case highlights the potential role of a paraspinal vein shunt in its pathogenesis.
The patient, a 42-year-old man with alcoholic and hepatitis B-related cirrhosis, developed progressive lower limb weakness and recurrent hepatic encephalopathy four years after TIPS placement. Laboratory tests showed pancytopenia, hypoalbuminaemia, hyperbilirubinaemia, elevated INR and ammonia levels; imaging revealed patent TIPS and multiple collateral veins including a gastro-renal shunt (GRS). Despite normalization of ammonia levels with lactulose and rifaximin therapy, gait did not improve.
During an attempted GRS embolization to address recurrent encephalopathy, clinicians incidentally discovered a paraspinal vein shunt connecting the left renal vein to the ascending lumbar vein. Embolization of the GRS alone did not improve symptoms; however, subsequent embolization of the PVS resulted in significant reduction in venous varicosities as seen on angiography.
One month after PVS embolization, lower limb strength improved noticeably. Sustained recovery was observed at two-, three-, six-, and twelve-month follow-ups: independent ambulation returned with increased muscle strength scores and reduced spasticity ratings.
The authors note that this single-case report limits generalizability, but suggest that interruption of venous compression via PVS embolization may represent an important therapeutic alternative for patients who are not candidates for liver transplantation.
