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

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.