Neurological complications are common after liver transplantation, as they affect up to one-third of the transplanted patients and\nare associated with significant morbidity. The introduction of calcineurin inhibitors, cyclosporine A and tacrolimus, in immunosuppressive\nregimens significantly improved the outcome of solid-organ transplantation even though immunosuppressionassociated\nneurotoxicity remains a significant complication, particularly occurring in about 25% of cases after liver transplantation.\nThe immunosuppressant cyclosporine A and tacrolimus have been associated with the occurrence of major neurological\ncomplications, diffuse encephalopathy being the most common. The biochemical and pathogenetic basis of calcineurin\ninhibitors-induced neurotoxicity are still unclear although several mechanisms have been suggested. Early recognition of\nsymptoms could help reduce neurotoxic event. The aim of the study was to evaluate cerebral changes through MRI, in particular\nwith diffusion-weighted images (DWI) and apparent diffusion coefficient (ADC) maps, in two patients undergoing liver\ntransplantation after immunosuppressive therapy. We describe two patients in which clinical pictures, presenting as a severe\nneurological condition, early after orthotopic liver transplantation during immunosuppression therapy, showed a different\nevolution in keeping with evidence of focal-multifocal lesions at DWI and ADC maps. At clinical onset, DWI showed\nhyperintensity of the temporo-parieto-occipital cortex with normal ADC values in the patient with following good clinical\nrecovery and decreased values in the other one; in the latter case, MRI abnormalities were still present after ten days, until the\npatientâ??s exitus. The changes in DWI with normal ADC may be linked to brain edema with a predominant vasogenic component\nand therefore reversible, while the reduction in ADC is due to cytotoxic edema and linked to more severe, nonreversible, clinical\npicture. Brain MRI and particularly DWI and ADC maps provide not only a good and early representation of neurological\ncomplications during immunosuppressant therapy but can also provide a useful prognostic tool on clinical outcome of the patient.
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