Choroid plexus cyst burden is associated with glymphatic dysfunction and cognitive impairment in hepatic encephalopathy.

BACKGROUND: Choroid plexus cysts (CPCs) are often considered incidental imaging findings in adults, but their phenotype and clinical relevance in HE are unclear. Our study aims to evaluate CPCs and choroid plexus volume (CPV) in HE and examine their associations with glymphatic clearance estimated by diffusion tensor image analysis along the perivascular space (DTI-ALPS) index, brain structure, and cognition. METHODS: In this cross-sectional study, 3T MRI was performed in 3 groups: HE, cirrhosis without hepatic encephalopathy (NHE), and healthy controls (HCs). We assessed CPC burden, CPV, the DTI-ALPS index, structural brain measures and cognitive performance. Group differences were tested with ANCOVA. RESULTS: CPCs were detected in 100% of participants with HE versus 60% in NHE and 26.7% in HCs. Normalized CPC mean diameter and CPV were higher in HE than in NHE and HCs (all p values <0.05). The DTI-ALPS index decreased stepwise from HCs to NHE to HE. Cirrhosis was associated with widespread subcortical atrophy and cortical thinning, more extensive in HE. CPC burden and CPV correlated inversely with cognitive and structural metrics, whereas the DTI-ALPS index correlated positively. Mediation analyses suggested that CP phenotypes may be associated with cognitive impairment through glymphatic dysfunction accompanied by structural brain alterations. CONCLUSIONS: HE is characterized by increased CPC burden and enlarged CPV, accompanied by a lower DTI-ALPS index, structural brain alterations, and cognitive impairment. CPC burden and CPV are potential auxiliary choroid plexus-related MRI phenotypes of HE.