Nonalcoholic Wernicke encephalopathy with extensive cortical involvement: cortical laminar necrosis and hemorrhage demonstrated with susceptibility-weighted MR phase images

Wernicke encephalopathy with atypical imaging findings in a depressed patient: A case report

This case report highlights the rare occurrence of Wernicke encephalopathy caused by malnutrition in a depressed patient with atypical imaging findings. A 60-year-old female with depression developed a disturbance of consciousness owing to Wernicke encephalopathy. Magnetic resonance imaging showed abnormal signals in the thalamus and mammillary bodies around the third ventricle, cerebral aqueduct, and fourth ventricle. Abnormal signals were also present in the cerebral cortex around the central sulcus, and an intracranial hemorrhage from the thalamus was observed. Therefore, clinicians should consider Wernicke encephalopathy in the differential diagnosis of altered consciousness in depressed patients. Early assessment of nutritional status and prompt intervention are crucial in cases of prolonged depression-related malnutrition.

Wernicke's encephalopathy in Crohn's disease and ulcerative colitis

Crohn's disease (CD) and ulcerative colitis (UC) are chronic and debilitating inflammatory conditions of the gastrointestinal tract. Thiamine can deplete rapidly in CD and UC, which can lead to Wernicke's encephalopathy (WE), is an acute neurologic disorder. Our objective was to systematically review the presentation of WE in CD and UC. We conducted our search from inception using the MeSH terms "Crohn's disease," "ulcerative colitis," and "Wernicke's encephalopathy." Our search yielded 28 case studies reporting on 31 cases. CD was diagnosed in 21 cases, and UC in 10. The first signs of WE were nausea and vomiting (13 cases), double vision (10), blurred vision (10), and hearing loss (4). In 12 cases, partial or complete bowel resection was one of the etiologies of thiamine depletion. In nine cases, thiamine was not supplemented intramuscularly or intravenously while parenteral nutrition or glucose was given to the patient. In 10 cases, detailed descriptions of thiamine treatment were given. Thiamine treatment at suboptimal levels (7 of 10 cases) turned out to lead to residual cognitive deficits in three cases. In three cases with optimal treatment (1500 mg/d intravenously), complete remission of WE symptoms was achieved. Rapid treatment with high doses (500 mg, 3 times/d) of thiamine saves lives, and treats WE in its core symptomatology.

Gayet Wernicke's encephalopathy with cortical damage following a subtotal gastrectomy: An uncommon association

Wernicke's encephalopathy is a pathological entity caused by Vitamin B1 (Thiamine) deficiency in malnourished individuals, especially alcoholics, patients operated for digestive surgery or suffering from gastrointestinal tract's diseases or incoercible vomiting. Classically it manifests by confusion with oculomotor disorders and ataxia. However, other neurological manifestations are possible. Magnetic resonance imaging is the gold standard imaging technique for diagnosis. It shows signal abnormality on periventricular area around the third and fourth ventricles and on mammillary bodies in the most common cases, however other localizations are possible, in particular the cerebral cortex, which can explain the occurrence of epileptic seizures in some patients. Early administration of Thiamine, intravenously or intramuscularly, allows ad-integrum recovery, while delayed treatment is associated with serious consequences in terms of mortality and morbidity with debilitating neurological sequelae. The presence of cortical lesions is of poor prognosis despite a well-managed treatment. In this article, we report a nonalcoholic Wernicke's encephalopathy case, following a subtotal gastrectomy. Epileptic seizures were the major clinical manifestation, related to the associated cortical lesions. Despite early and well-managed treatment, the patient had a poor prognosis, with progression, after one month, to a persistent chronic vegetative state.

Epileptic seizures in nonalcoholic Wernicke's encephalopathy: a case report and literature review

Wernicke encephalopathy (WE) is characterized by eye signs, cerebellar dysfunction, and confusion. Epileptic seizures are rare in nonalcoholic WE. We reviewed the clinical, laboratory, radiological, and prognostic characteristics of nonalcoholic WE accompanied by epileptic seizures. We reported 1 case and searched similar cases using PubMed, WoK, Ovid, and Embase. WE was diagnosed according to dietary deficiencies, clinical symptoms and brain magnetic resonance imaging (MRI). We reviewed 13 patients (median age, 27 years; 5 men) with clear histories of thiamine deficiency and symptoms of typical WE. The type of epileptic seizures reported in the 13 cases reviewed was generically reported as seizures or convulsions in 4 patients; 7 patients had generalized tonic-clonic seizures, 1 partial seizure, and 1 generalized convulsive status epileptics. Two patients had epileptic seizures as the first symptom of WE. Laboratory tests mainly indicated metabolic acidosis and electrolyte disturbances. Electroencephalography may present as normal patterns, increased slow waves or epileptic discharge. Six patients had cortical lesions on brain MRI. These lesions were usually diffuse and band-like, and sometimes involved all lobes either symmetrically or asymmetrically, with the frontal lobe as the most susceptible area. All cortical lesions were accompanied by non-cortical lesions typical of WE. Brain MRI abnormalities, after thiamine treatment, mostly disappeared on follow-up MRIs. The patients had good prognoses. Only 1 patient had repeated seizures, and there were no comas or deaths. Patients with nonalcoholic WE accompanied by seizures are young and generally have good prognoses. Most patients experienced generalized convulsive seizures, which may have been related to abnormal cerebral cortical metabolism due to subacute thiamine deficiency.

Non-alcoholic Wernicke's encephalopathy with cortical involvement and polyneuropathy following gastrectomy

In this study, we present the clinical manifestations, brain magnetic resonance imaging (MRI) and concurrent polyneuropathies in two patients with non-alcoholic Wernicke's encephalopathy (WE) after gastrojejunostomy (Billroth II) anastomosis procedures. These patients developed sub-acute onset of disorientation and disturbance of consciousness following several weeks of poor intake. Peripheral neuropathy of varying severity was noted before and after the onset of WE. Brain MRI of the patients showed cerebellar vermis and symmetric cortical abnormalities in addition to typical WE changes. Electrophysiological studies demonstrated axonal sensorimotor polyneuropathy. Prompt thiamine supplement therapy was initiated and both patients gradually recovered, however mild amnesia was still noted 6 months later. We reviewed non- alcoholic WE with atypical cortical abnormalities in English language literatures and identified 29 more cases. Eight out of 31 (25.8%) patients died during follow-up. Nine patients with gait disturbance or motor paresis had showed hyporeflexia in neurological examinations. In addition to classic triad, seizure was recorded in seven patients. Dietary deprivation is a risk factor for non-alcoholic WE among elderly patients receiving gastrointestinal surgery. The prognosis is good after thiamine supplement therapy. Recognizing the MRI features and predisposing factors in patients who have undergone gastrectomy can aid in the diagnosis and management.

Cortical damage in Wernicke's encephalopathy with good prognosis: a report of two cases and literature review

Wernicke's encephalopathy (WE) is a thiamine deficiency-related condition, in which lesions are usually present in the periventricular and subcortical areas of the brain. However, lesions have also been found in atypical areas, such as the cerebral cortex. The present study summarizes the clinical outcomes and radiological features of WE with cortical impairment. We report two cases of cortical involvement in patients with WE, and review 22 similar cases from other reports. Among all 24 cases, 4 patients had a confirmed history of chronic daily alcohol abuse, and 19 of them had an identified causes of thiamine deficiency. 17 cases reported specific clinical information, among which 11 patients had symptoms of cortical impairment. 23 cases reported prognostic information at the end of treatment or at follow-up. The mortality rate was 26.1 % in our review. All patients had abnormal magnetic resonance imaging (MRI) signals or pathological findings in the bilateral cortex. Among patients with available MRI, 89.0 % had banding-like signs along the para-central sulcus. 13 cases underwent follow-up MRI examinations and 76.9 % displayed normal images. We suggest that WE with bilateral cortical involvement may have an acceptable prognosis, but that the mortality rate is higher than that among typical cases, especially if patients are not treated promptly and correctly. We identified the frontal and parietal lobes, especially around the central sulcus, to be the most susceptible areas, and suggest that the banding signs may be characteristic of WE. Persistent hyper-intensity on T2-weighted-fluid-attenuated inversion recovery, or gadolinium enhancement, may predict poor outcome.

Wernicke's encephalopathy in a malnourished surgical patient: a difficult diagnosis

Background

Wernicke’s encephalopathy is an acute neurological disorder resulting from thiamine deficiency mainly related to alcohol abuse. Severe thiamine deficiency is an emerging problem in non-alcoholic patients and it may develop in postoperative surgical patients with risk factors.

Case presentation

We reported a case of a 46 years old woman who underwent, one year before, to cephalic duodenopancreatectomy complicated with prolonged recurrent vomiting. She underwent to a second surgical operation for intestinal sub-occlusion and postoperatively she developed septic shock and hemorrhagic Wernicke’s disease. After ICU admission, because of neurological deterioration, she underwent CT scan and MRI that highlighted a strong suspicion for Wernicke’s disease. We treated her with an initially wrong low dose of thiamine, then after MRI we increased the dosage with a neurological status improvement. Despite therapeutic efforts used to control septic shock and thrombocytopenia, she died on the 21^st day after surgery because of massive cerebral bleeding and unresponsive cerebral edema.

Conclusion

Early detection of subclinical thiamine deficiency is a difficult task, as symptoms may be nonspecific. Wernicke’s disease remains a clinical diagnosis because there are no specific diagnostic abnormalities revealed in cerebrospinal fluid, electroencephalogram or evoked potentials. About this, the best aid for a correct diagnosis is the clinical suspicion and clinicians should consider the disorder in any patients with unbalanced nutrition, increased metabolism or impaired food absorption. A hallmark of our case was the brain hemorrhage in the typical areas of the Wernicke’s disease, maybe triggered by the thrombocytopenia secondary to sepsis. It might be a good clinical practice administer thiamine to all patients presenting with coma or stupor and risk factors related with thiamine deficiency. Any therapeutic delay may result in permanent neurological damage or death.

MR imaging findings in alcoholic and nonalcoholic acute Wernicke’s encephalopathy: a review. Biomed Res Int. 2014;2014:503596. [PMID: 25050351 PMCID: PMC4094710 DOI: 10.1155/2014/503596]

Wernicke's encephalopathy (WE) is a severe neurological syndrome caused by thiamine (vitamin B1) deficiency and clinically characterized by the sudden onset of mental status changes, ocular abnormalities, and ataxia. Apart from chronic alcoholism, the most common cause of WE, a lot of other conditions causing malnutrition and decreasing thiamine absorption such as gastrointestinal surgical procedures and hyperemesis gravidarum must be considered as predisposing factors. Due to its low prevalence and clinical heterogeneity, WE is often misdiagnosed, leading to persistent dysfunctions and, in some cases, to death. Nowadays, MR imaging of the brain, showing T2 and FLAIR hyperintensities in typical (thalami, mammillary bodies, tectal plate, and periaqueductal area) and atypical areas (cerebellum, cranial nerve nuclei, and cerebral cortex), is surely the most important and effective tool in the diagnostic assessment of WE. The aim of this paper is to propose a state of the art of the role of MR imaging in the early diagnosis of this complex disease.