Combined diffusion tensor imaging and magnetic resonance spectroscopy to predict neurological outcome before transjugular intrahepatic portosystemic shunt Marika Rudler 1,2 | Nicolas Weiss 1,3 | Vincent Perlbarg 4 | Maxime Mallet 1,3 | Simona Tripon 1,3 | Romain Valabregue 5 | Małgorzata Marjańska 6 | Philippe Cluzel 7 | Damien Galanaud 1,7,8 | Dominique Thabut 1,2 1 Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France 2 Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France 3 Intensive Care Unit, Department of Neurology, Pitié-Salpêtrière Charles Foix Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Pierre et Marie Curie University, Paris, France 4 Bioinformatics and Biostatistics Platform, IHU-A-ICM, Brain and Spine Institute, Paris, France 5 CENIR, ICM, Inserm U 1127, CNRS, UMR 7225, Sorbonne University, Pierre et Marie Curie University, UMR S 1127F, Paris,France 6 Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota, Minneapolis, Minnesota 7 AP-HP, UPMC, Department of Radiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France 8 Institut-Hospitalo-Universitaire-A-Institut du Cerveau et de la Moelle (IHU-A-ICM), Paris, France Correspondence Marika Rudler, Unité de Soins Intensifs d'Hépatologie, Groupe Hospitalier Pitié- Salpêtrière Charles Foix, Paris, France. Email: marika.rudler@aphp.fr Funding information FARE (Fonds d'Aide à la Recherche et à l'Evaluation en hépato-gastroentérologie); le club francophone pour l’étude de l'hypertension portale Summary Background: Hepatic encephalopathy (HE) may occur after transjugular intrahepatic portosystemic shunt (TIPSS) placement. Multimodal magnetic resonance imaging (MRI), combining anatomical sequences, diffusion tensor imaging (DTI) and 1 H mag- netic resonance spectroscopy, is modified in cirrhotic patients. Aims: To describe multimodal MRI images before TIPSS, to assess if TIPSS induces changes in multimodal MRI, and to find predictors of HE after TIPSS in patients with cirrhosis. Methods: Consecutive cirrhotic patients with an indication for TIPSS were prospec- tively screened. Diagnosis of minimal HE was performed using psychometric HE test score. Multimodal MRI was performed before and 3 months after TIPSS placement. Results: Twenty‐five consecutive patients were analysed (median age = 59, male gender 76%, median Child‐Pugh score = 8 [5‐8], MELD score = 12 [9‐17], indication for TIPSS placement: ascites/secondary prophylaxis of variceal bleeding/other 20/3/ 2), no HE/minimal HE/overt HE: 21/4/0. 8/25 patients developed HE after TIPSS. Before TIPSS placement, metabolite concentrations were different in patients with or without minimal HE (lower myo‐inositol, mI, higher glutamate/glutamine), but there were no differences in DTI data. TIPSS placement induced changes in metabo- lite concentrations even in asymptomatic patients, but not in DTI metrics. Baseline fractional anisotropy was significantly lower in patients who developed HE after TIPSS in five regions of interest. Conclusions: TIPSS placement induced significant changes in cerebral metabolites, even in asymptomatic patients. Patients who developed HE after TIPSS displayed lower fractional anisotropy before TIPSS. Brain MRI with DTI acquisition may help selecting patients at risk of HE. The Handling Editor for this article was Professor Peter Hayes, and it was accepted for publication after full peer-review. Received: 11 April 2018 | First decision: 14 May 2018 | Accepted: 18 July 2018 DOI: 10.1111/apt.14938 Aliment Pharmacol Ther. 2018;48:863–874. wileyonlinelibrary.com/journal/apt © 2018 John Wiley & Sons Ltd | 863