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Isen DR, Kline LB. Neuro-ophthalmic Manifestations of Wernicke Encephalopathy. Eye Brain 2020; 12:49-60. [PMID: 32636690 PMCID: PMC7335288 DOI: 10.2147/eb.s234078] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/09/2020] [Indexed: 12/18/2022] Open
Abstract
Wernicke encephalopathy (WE) is a life-threatening but reversible syndrome resulting from acute thiamine deficiency that is frequently overlooked and underdiagnosed. It is classically characterized by a triad of ocular dysfunction, ataxia, and altered mental status. However, less than 1/3 patients have the complete triad, so it is crucial to have a high index of suspicion. Awareness of the early signs of WE is essential to prevent clinical progression, as patients with the full triad already have a profoundly thiamine-deficient state. This review highlights the neuro-ophthalmic manifestations of WE to guide the clinician in identifying the condition. In addition, we provide an update regarding the clinical characteristics, pathophysiology, neuroimaging and laboratory findings, treatment options, and prognosis of WE.
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Affiliation(s)
- Danielle R Isen
- Department of Neurology, University of South Alabama School of Medicine, Mobile, AL, USA
| | - Lanning B Kline
- Department of Ophthalmology, University of Alabama School of Medicine, Birmingham, AL, USA
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Jensen K, Beylergil SB, Shaikh AG. Slow saccades in cerebellar disease. CEREBELLUM & ATAXIAS 2019; 6:1. [PMID: 30680221 PMCID: PMC6337813 DOI: 10.1186/s40673-018-0095-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/28/2018] [Indexed: 12/24/2022]
Abstract
Eye movements are frequently considered diagnostic markers indicating involvement of the cerebellum. Impaired amplitude of saccades (saccade dysmetria), impaired gaze holding function (horizontal or downbeat nystagmus), and interrupted (choppy) pursuit are typically considered hallmarks of cerebellar disorders. While saccade dysmetria is a frequently considered abnormality, the velocity of saccades are rarely considered part of the constellation of cerebellar involvement. Reduced saccade velocity, frequently called “slow saccades” are typically seen in a classic disorder of the midbrain called progressive supranuclear palsy. It is also traditionally diagnostic of spinocerebellar ataxia type 2. In addition to its common causes, the slowness of vertical saccades is not rare in cerebellar disorders. Frequently this phenomenology is seen in multisystem involvement that substantially involves the cerebellum. In this review we will first discuss the physiological basis and the biological need for high saccade velocities. In subsequent sections we will discuss disorders of cerebellum that are known to cause slowing of saccades. We will then discuss possible pathology and novel therapeutic strategies.
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Affiliation(s)
- Kelsey Jensen
- 1Neurological Institute, University Hospitals, Cleveland, OH USA.,2Department of Neurology, Case Western Reserve University, Cleveland, OH 44022 USA.,3Neurology Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH USA
| | - Sinem Balta Beylergil
- 1Neurological Institute, University Hospitals, Cleveland, OH USA.,2Department of Neurology, Case Western Reserve University, Cleveland, OH 44022 USA.,3Neurology Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH USA
| | - Aasef G Shaikh
- 1Neurological Institute, University Hospitals, Cleveland, OH USA.,2Department of Neurology, Case Western Reserve University, Cleveland, OH 44022 USA.,3Neurology Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH USA
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Prakash S, Joshi H, Patel J. Progressive supranuclear palsy responding to intravenous thiamine: superimposed Wernicke's encephalopathy? BMJ Case Rep 2018; 2018:bcr-2018-226170. [PMID: 30131406 DOI: 10.1136/bcr-2018-226170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Progressive supranuclear palsy (PSP) may be a risk factor for thiamine deficiency. The classic symptoms of PSP (postural instability, supranuclear vertical gaze palsy and dementia) overlap with the clinical triad of Wernicke's encephalopathy (cognitive impairment, gait problems and ocular abnormality). Therefore, superimposed thiamine deficiency in patients with PSP may aggravate the pre-existing symptoms of PSP. Here, we are reporting a 64-year-old woman having supranuclear ocular palsy, gait instability and dementia for the past 2-3 years. The patient fulfilled the diagnostic criteria of PSP. In parallel, she fulfilled the Caine's criteria of Wernicke's encephalopathy. Her serum thiamine level was low. Supplementation of thiamine led to marked improvement in the symptoms which had been present for many years. These symptoms were originally presumed to be due to PSP. This case highlights the needs to identify superimposed thiamine deficiency in patients with PSP.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt BK Shah Medical Institute and Research Centre, Vadodara, Gujarat, India
| | - Hemant Joshi
- Department of Neurology, Smt BK Shah Medical Institute and Research Centre, Vadodara, Gujarat, India
| | - Jay Patel
- Department of Neurology, Smt BK Shah Medical Institute and Research Centre, Vadodara, Gujarat, India
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Kim WJ, Kim MM. Wernicke's Encephalopathy Presenting with Bilateral Complete Horizontal and Downward Gaze Palsy in a Malnourished Patient. KOREAN JOURNAL OF OPHTHALMOLOGY 2017; 31:372-374. [PMID: 28682019 PMCID: PMC5540996 DOI: 10.3341/kjo.2017.0014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Won Jae Kim
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea
| | - Myung Mi Kim
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea.
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The Spectrum of Vestibular and Ocular Motor Abnormalities in Thiamine Deficiency. Curr Neurol Neurosci Rep 2017; 17:40. [DOI: 10.1007/s11910-017-0747-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hokazono K, Geminiani F, Bertholdo D. Acute up-beating nystagmus in a pregnant woman with hyperemesis gravidarum. Am J Ophthalmol Case Rep 2017; 6:81-83. [PMID: 29260066 PMCID: PMC5722145 DOI: 10.1016/j.ajoc.2017.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 01/13/2017] [Indexed: 12/02/2022] Open
Abstract
Purpose To describe a case of sudden onset of nystagmus in a pregnant patient with hyperemesis gravidarum. Observations Sixteen days after onset of persistent nausea and uncontrollable vomiting, a 12 week pregnant woman presented up-beating nystagmus, mild memory impairment and reduced sensitivity in the lower limbs. Laboratory tests presented thiamine deficiency and magnetic resonance imaging showed bilateral medial thalami and midbrain lesions. Because of suspected Wernicke's encephalopathy, the patient was treated with thiamine replacement and significant improvement of symptoms took place. Conclusions and importance Uncontrollable vomiting can lead to malabsorption of vitamin B1 causing acute onset of nystagmus.
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Affiliation(s)
- Kenzo Hokazono
- Department of Ophthalmology, Federal University of Paraná, Rua General Carneiro, 181, Curitiba, Brazil
- Corresponding author. Rua da Paz, 195, sala 213, Curitiba, PR 80050-210, Brazil.Rua da Paz, 195sala 213CuritibaPR80050-210Brazil
| | - Francisco Geminiani
- Department of Neurology, Federal University of Paraná, Rua General Carneiro, 181, Curitiba, Brazil
| | - Debora Bertholdo
- Department of Radiology, Federal University of Paraná, Rua General Carneiro, 181 Curitiba, Brazil
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Puri S, Shaikh AG. Basic and translational neuro-ophthalmology of visually guided saccades: disorders of velocity. EXPERT REVIEW OF OPHTHALMOLOGY 2017; 12:457-473. [PMID: 30774705 DOI: 10.1080/17469899.2017.1395695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction Saccades are rapid, yoked eye movements in an effort to direct a target over fovea. The complex circuitry of saccadic eye movements has been exhaustively described. As a result clinicians can elegantly localize the pathology if it falls on the neuraxis responsible for saccades. Traditionally saccades are studied with their quantitative characteristics such as amplitude, velocity, duration, direction, latency and accuracy. Areas covered Amongst all subtypes, the physiology of the visually guided saccades is most extensively studied. Here we will review the basic and pertinent neuro-anatomy and physiology of visually guided saccade and then discuss common or classic disorders affecting the velocity of visually guided saccades. We will then discuss the basic mechanism for saccade slowing in these disorders. Expert commentary Prompt appreciation of disorders of saccade velocity is critical to reach appropriate diagnosis. Disorders of midbrain, cerebellum, or basal ganglia can lead to prolonged transition time during gaze shift and decreased saccade velocity.
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Affiliation(s)
- Sushant Puri
- Dept. of Neurology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio, United States
| | - Aasef G Shaikh
- Dept. of Neurology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio, United States.,Daroff-DelOsso Ocular Motility Laboratory, Cleveland VA Medical Center, Cleveland, Ohio, United States
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Choi SY, Kim HJ, Kim JS. Chasing dizzy chimera: Diagnosis of combined peripheral and central vestibulopathy. J Neurol Sci 2016; 371:69-78. [DOI: 10.1016/j.jns.2016.09.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 09/21/2016] [Accepted: 09/30/2016] [Indexed: 12/26/2022]
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Psychiatric Emergencies for Clinicians: Emergency Department Management of Wernicke-Korsakoff Syndrome. J Emerg Med 2016; 51:401-404. [PMID: 27553920 DOI: 10.1016/j.jemermed.2016.05.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 04/15/2016] [Accepted: 05/17/2016] [Indexed: 12/27/2022]
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Chang YP, Chiu PY, Lin CT, Liu IH, Liu CH. Outbreak of thiamine deficiency in cats associated with the feeding of defective dry food. J Feline Med Surg 2016; 19:336-343. [DOI: 10.1177/1098612x15625353] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objectives The objective of this study was to determine disease progression, association between neurological signs and magnetic resonance imaging (MRI) findings, and long-term outcome in feline thiamine deficiency associated with defective dry food. Methods The clinical records of 17 cats diagnosed with thiamine deficiency related to a defective dry food were examined and data collected. The thiamine level in the food was analysed by liquid chromatography–tandem mass spectrometry. Results The thiamine level in the food was below the recommendation of the National Research Council. Fifteen cats were fed the food exclusively. Prior to the acute development of neurological signs, most cats displayed non-specific signs such as anorexia, lethargy or vomiting. Vestibular signs of varying severity were observed in 94% of the cats, and all but one of these presented with bilateral dysfunction. Other main neurological signs included altered mentation (76%), blindness (59%) and seizures (59%). Moreover, 80% of the cats with seizures presented with cluster seizures or status epilepticus. MRI abnormalities consistent with findings reported in the previous literature were detected in five cases. MRI was unremarkable in one cat with ongoing severe neurological signs even though thiamine had been administered. Most surviving cats recovered rapidly within 2 weeks of treatment and had either returned to normal or had minimal neurological signs at the 2 month follow-up. One cat recovered slowly over 6 months. Most cats with seizures in the initial stage of the disease remained seizure free at the 24 month follow-up. Conclusions and relevance This study documented the association between feline thiamine deficiency and defective dry food. MRI examination provided valuable information in the diagnosis. However, normal MRI findings do not exclude the diagnosis of feline thiamine deficiency, especially once thiamine has been supplemented. MRI findings also may not always reflect the neurological status or severity. If treated promptly, most cats will recover rapidly with a good outcome. Occasionally, recovery may be slow and take several months.
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Affiliation(s)
- Ya-Pei Chang
- Graduate Institute of Veterinary Medicine, School of Veterinary Medicine, National Taiwan University, Taipei, Taiwan
- Graduate Institute of Veterinary Clinical Science, School of Veterinary Medicine, National Taiwan University, Taipei, Taiwan
- Section of Small Animal Surgery, National Taiwan University Veterinary Hospital, Taipei, Taiwan
| | - Po-Yu Chiu
- Graduate Institute of Veterinary Clinical Science, School of Veterinary Medicine, National Taiwan University, Taipei, Taiwan
- Section of Small Animal Surgery, National Taiwan University Veterinary Hospital, Taipei, Taiwan
| | - Chung-Tien Lin
- Graduate Institute of Veterinary Clinical Science, School of Veterinary Medicine, National Taiwan University, Taipei, Taiwan
- Section of Small Animal Surgery, National Taiwan University Veterinary Hospital, Taipei, Taiwan
| | - I-Hsuan Liu
- Department of Animal Science and Technology, National Taiwan University, Taipei, Taiwan
- Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan
| | - Chen-Hsuan Liu
- Graduate Institute of Veterinary Medicine, School of Veterinary Medicine, National Taiwan University, Taipei, Taiwan
- Graduate Institute of Molecular and Comparative Pathobiology, School of Veterinary Medicine, National Taiwan University, Taipei, Taiwan
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Abstract
The differential diagnosis of patients with vestibular symptoms usually begins with the question: is the lesion central or is it peripheral? The answer commonly emerges from a careful examination of eye movements, especially when the lesion is located in otherwise clinically silent areas of the brain such as the vestibular portions of the cerebellum (flocculus, paraflocculus which is called the tonsils in humans, nodulus, and uvula) and the vestibular nuclei as well as immediately adjacent areas (the perihypoglossal nuclei and the paramedian nuclei and tracts). The neural circuitry that controls vestibular eye movements is intertwined with a larger network within the brainstem and cerebellum that also controls other types of conjugate eye movements. These include saccades and pursuit as well as the mechanisms that enable steady fixation, both straight ahead and in eccentric gaze positions. Navigating through this complex network requires a thorough knowledge about all classes of eye movements to help localize lesions causing a vestibular disorder. Here we review the different classes of eye movements and how to examine them, and then describe common ocular motor findings associated with central vestibular lesions from both a topographic and functional perspective.
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Affiliation(s)
- A Kheradmand
- Departments of Neurology and Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - A I Colpak
- Hacettepe University School of Medicine, Ankara, Turkey
| | - D S Zee
- Departments of Neurology, Otolaryngology-Head and Neck Surgery, Ophthalmology and Neuroscience, Johns Hopkins Hospital, Baltimore, MD, USA.
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Adam MK, Krespan K, Moster ML, Sergott RC. Simultaneous, Bilateral Ophthalmoplegia as the Presenting Sign of Paediatric Multiple Sclerosis: Case Report and Discussion of the Differential Diagnosis. Neuroophthalmology 2014; 38:230-237. [DOI: 10.3109/01658107.2014.902972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 02/25/2014] [Accepted: 02/25/2014] [Indexed: 12/18/2022] Open
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Palau AEB, Morgan ML, Yalamanchili S, Lee AG. Neuro-Ophthalmology Annual Review. Asia Pac J Ophthalmol (Phila) 2014; 3:104-25. [PMID: 26107493 DOI: 10.1097/apo.0000000000000052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to update the practicing ophthalmologist on the English-language neuro-ophthalmology literature from the prior year. This study is a review of English-language literature from August 1, 2012, to August 1, 2013. The authors searched PubMed articles published from August 1, 2012, to August 1, 2013, limited to English-language publications including original articles, review articles, and case reports and excluding letters to the editor, unpublished work, and abstracts. We researched the following topics: pupillary abnormalities, eye movement dysfunction, neuromuscular diseases, optic neuropathies, optic neuritis and demyelinating disease including multiple sclerosis, lesions of the chiasm and posterior primary visual pathways, elevated intracranial pressure, tumors and aneurysms affecting the visual pathways, vascular diseases, higher visual functions, and neuroimaging advances. We intend to share clinically relevant literature of the past year with the practicing ophthalmologist. We aimed to highlight remarkable and interesting literature rather than exhaustively including all new neuro-ophthalmological publications of the year. We reviewed literature in the past year with a focus on relevance and novelty. This review updates the comprehensive ophthalmologist on neuro-ophthalmic topics.
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Affiliation(s)
- Angelina Espino Barros Palau
- From the *Department of Ophthalmology, Houston Methodist Hospital, Houston, TX; †Baylor College of Medicine, Houston, TX; ‡Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medical College, Houston, TX; §University of Texas Medical Branch, Galveston, TX; ¶University of Texas M.D. Anderson Cancer Center, Houston, TX; and ∥The University of Iowa Hospitals and Clinics, Iowa City, IA
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Oguro H, Kadota K, Yamaguchi S. [How does the physician interpret the patient's narrative as it relates to the physical exam?: Consideration of differential diagnosis based on double vision and vertigo]. ACTA ACUST UNITED AC 2014; 103:486-91. [PMID: 24724391 DOI: 10.2169/naika.103.486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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