I read with interest the article by Yoshikawa and colleagues.¹ The authors reported the case of a 44 year old woman with hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber disease) involving the liver, who had raised serum concentrations of manganese, hyperintense areas in the basal ganglia on T1 weighted magnetic resonance images, and levodopa unresponsive parkinsonism. Naturally, I agree that the parkinsonism in this case is most probably related to portal-systemic (portal-venous) shunts. There are, however, two points that deserve clarification.

First, it is not entirely clear whether their fig 2 (left panel) shows portal-systemic or arteriovenous shunts. The authors say that the figure shows a selective angiogram of the superior mesenteric artery. If that were the case, there should not be a “feeding artery” involved in the intrahepatic shunts (as they state in the legend to fig 2). Instead, the figure would show the portal vein and portal-systemic shunts (that …