Hemorrhagic stroke in a patient with liver cirrhosis and a clinical picture of hepatic encephalopathy: a clinical case of interdisciplinary routing

Abstract

In patients with liver cirrhosis, impaired consciousness, behavior and coordination are often initially attributed to hepatic encephalopathy. However, a new focal neurological deficit requires urgent exclusion of acute stroke because the diagnostic pathway and management differ fundamentally. We report a 52-year-old patient with HCV-related liver cirrhosis, portal hypertension and recurrent hepatic encephalopathy. After an episode of loss of consciousness and elevated blood pressure, In patients with liver cirrhosis, impaired consciousness, behavior and coordination are often initially attributed to hepatic encephalopathy. However, a new focal neurological deficit requires urgent exclusion of acute stroke because the diagnostic pathway and management differ fundamentally. We report a 52-year-old patient with HCV-related liver cirrhosis, portal hypertension and recurrent hepatic encephalopathy. After an episode of loss of consciousness and elevated blood pressure,the patient had persistent disorientation, impaired coordination, right homonymous hemianopia, mild sensorimotor aphasia and reduced superficial sensation on the right. Because of focal neurological symptoms, the gastroenterologist referred the patient for urgent neurological assessment and neuroimaging. Brain CT revealed a parenchymal hemorrhage in the left temporoparietal region; CT angiography showed no aneurysm or arteriovenous malformation. The patient was admitted to a stroke unit. Neurosurgical intervention was not indicated due to hematoma location, absence of mass effect and absence of pathological vessels on angiography. The practical value of this case lies in an algorithm for early recognition of neurological red flags in cirrhotic patients during gastroenterological assessment. Any new focal neurological deficit in a patient with liver cirrhosis should be treated as a potential stroke and should prompt urgent neuroimaging while hepatic encephalopathy is assessed and treated in parallel.