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Hepatic encephalopathy and tremors
Vet Record 2024
Theofanis Liatis, Sofie F. M. Bhatti, Barbara Glanemann, Steven De Decker
Background
Tremors have been sporadically reported in cats with hepatic encephalopathy caused by congenital portosystemic shunts (HE-CPSS) or postattenuation neurological syndrome (PANS). These conditions involve hyperammonaemia and hypermanganesaemia, which may contribute to neurological signs. The study aimed to describe the clinical features of tremors in such cats.
Methods
This was a single-centre retrospective study analyzing clinical records from 2003 to 2023. Cats diagnosed with HE-CPSS and presenting tremors were included. Data such as clinical findings, serum ammonia levels, imaging results, and follow-up outcomes were reviewed. Tremor onset and localization were assessed alongside treatment outcomes. Descriptive statistics were used for analysis.
Results
-Population: 19 cats met the inclusion criteria, with a median age of 7 months. Domestic shorthair was the predominant breed.
-Tremor Characteristics: Tremors were generalised (52.6%) or focal (47.4%), occurring primarily at rest. Episodic, non-intentional tremors were common in 15 cats; 4 showed intentional features.
-Treatment and Outcomes:
-Tremors resolved in 9 of 14 cats after surgical or medical management.
-12 cats underwent surgical treatment, with partial or complete ligation of shunts.
-4 cats were treated medically, 3 of whom experienced tremor resolution.
-Other Observations: Hyperammonaemia was identified in 80% of tested cases. MRI findings were available for two cats, showing abnormalities in one. Residual tremors were noted in some cases post-treatment.
Limitations
The retrospective design limited control over data collection. Only a few cases had video documentation, advanced imaging, or electrophysiological evaluation of tremors. These gaps restrict the understanding of pathophysiological mechanisms.
Conclusions
Tremors are a notable neurological sign in cats with HE-CPSS or PANS, potentially serving as a differential diagnosis. Successful treatment typically resolves tremors, though residual symptoms may persist in some cases. Further studies using video and advanced diagnostics are needed to elucidate underlying mechanisms.
Magnetic resonance imaging of a cat with hepatic encephalopathy due to congenital extrahepatic portosystemic shunts revealed bilateral symmetrical T2-weighted (T2W) hyperintense and T1-weighted (T1W) hypointense non-contrast-enhancing lesions in the thalamus, lateral geniculate nuclei, red nuclei, caudal colliculi, vestibular nuclei, olivary nuclei and dentate nuclei, and T1W hyperintensity in the lentiform nuclei. (a) Sagittal T2W sequence showing diffuse T2W hyperintensity in the brainstem. Transverse T2W sequences showing bilateral symmetric T2W hyperintensities in the (b) thalami (asterisk) and lateral geniculate nuclei (arrowhead), (c) red nuclei (arrowhead), (d) rostral colliculi (arrowhead), (e) caudal colliculi (asterisk) and reticular formation, (f) white matter (asterisk) and (g) vestibular nuclei (arrowhead). Transverse (h and i), dorsal (j) and transverse (k) T1W precontrast sequences showing T1W bilateral hypointensity of the red nuclei (arrowhead; h), white matter (arrowhead; i) and T1W hyperintensity of the lentiform nuclei (arrowhead; k and l).
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