The following substance is most often incriminated in the pathogenesis of Hepatic encephalopathy

It is theorized that neurotoxic substances, including ammonia and manganese, may gain entry into the brain in the setting of liver failure. These neurotoxic substances may then contribute to morphologic changes in astrocytes. In cirrhosis, astrocytes may undergo Alzheimer type II astrocytosis. Here, astrocytes become swollen. They may develop a large pale nucleus, a prominent nucleolus, and margination of chromatin. In ALF, astrocytes may also become swollen. The changes of Alzheimer type II astrocytosis are not seen in ALF. But, in contrast to cirrhosis, astrocyte swelling in ALF may be so marked as to produce brain edema. This may lead to increased intracranial pressure and, potentially, brain herniation. REFERENCES Meds cap.com HARSH MOHAN SIXTH EDITION.PAGE-606 IMAGE REF: