Chronic, fluctuating neuropsychiatric disorder is a recognized complication of cirrhosis of the liver associated with an extensive portal collateral circulation, having been reported when portal-systemic anastomoses develop spontaneously1 or when portal-systemic shunts have been created surgically for portal hypertension.2 The clinical and electroencephalographic (EEG) changes in such patients are characteristically reversed by restriction of dietary protein and administration of antibiotics.3,4 More recently, Zieve and associates 5 described permanent paraplegia with demyelination of the pyramidal tracts of the spinal cord in a patient with cirrhosis following portacaval anastomosis. Reference was made to an earlier report of encephalopathy and paraplegia in a patient with cirrhosis and extensive portal-systemic collateral vessels.6 Subsequently, three additional instances of apparently irreversible neuropsychiatric disorder associated with cirrhosis have been reported, two following shunt operations and another developing spontaneously,7,8 thus supporting a causal relationship between the conditions. The present paper (1) describes a