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We present the case of a 61-years-old male, diagnosed with liver cirrhosis, portal hypertension and type II diabetes mellitus, who developed bilateral signs of Parkinsonism, intention tremor and spastic paraparesis. Based on laboratory workup, brain CT, brain MRI and thoraco-lumbar MRI, a diagnosis of acquired hepato-cerebral degeneration with hepatic paraparesis was established. Although a rare entity, hepatic paraparesis needs to be considered in the right setting. As a result, we describe its key features, as well as new concepts that have emerged in recent years using advanced imaging, with emphasis on pathogenesis.