Letter to the Editor: Beyond the liver - integrating emerging predictors in hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

Abstract

We read with great interest the prospective study by Zhuang et al published in the recent issue of the World Journal of Radiology, regarding the cerebral blood flow changes following transjugular intrahepatic portosystemic shunt creation provides a vital hemodynamic correlate to the pathogenesis of hepatic encephalopathy. However, this letter argues that cerebrovascular alterations should not be interpreted in isolation but rather as the downstream consequence of broader systemic dysregulation. We highlight the critical role of emerging predictors such as sarcopenia, shunt magnitude, and portal vein anatomy, in modulating the neurotoxic burden within the gut-liver-brain axis. By integrating these systemic variables with cerebral hemodynamic metrics, we propose a multidimensional approach to improve risk stratification. This perspective is essential for developing personalized transjugular intrahepatic portosystemic shunt planning strategies that minimize hepatic encephalopathy risk while maintaining shunt efficacy.

Keywords: Hepatic encephalopathy; Transjugular intrahepatic portosystemic shunt; Cerebral blood flow; Sarcopenia; Portal hypertension

Core Tip: While Zhuang et al identify cerebral hypoperfusion as a hallmark of post-transjugular intrahepatic portosystemic shunt encephalopathy, this letter argues that these changes represent the final downstream consequence of a systemic multi-hit failure. We integrate emerging evidence on the gut-liver-muscle axis, emphasizing that sarcopenia, the AMMON-OHE model, and shunt magnitude are critical upstream determinants of neurotoxicity. We propose that to prevent cognitive decline, specialists must move beyond isolated hemodynamic targets and adopt a precision medicine approach, tailoring stent expansion to the patient's individual metabolic and muscular reserve.