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 after Bariatric Surgery with Atypical Magnetic Resonance Imaging: A Case Report

Wernicke's encephalopathy (WE) is a disease caused by thiamine deficiency related to alcoholism, hyperemesis, or thiamine malabsorption. The clinical manifestations of WE are mental change, ataxia, and ophthalmoplegia. The typical magnetic resonance imaging (MRI) findings of WE are symmetrical involvement of medial thalamus, periventricular region of the third ventricle, periaqueductal area, and mammillary body. The atypical MRI findings are more common in nonalcoholic WE. Since the increasing population of obesity and the preference of weight loss surgery, the risk of developing thiamine deficiencies associated with weight loss surgery has become a considerable etiology of WE. We herein reported a case reminds clinicians that WE can be a possible diagnosis in patient who developed acute altered mental status with atypical MRI lesion involving bilateral centrum semiovale and corona radiata after receiving bariatric surgery.

[From thiamine deficiency to Wernicke encephalopathy, unknown pathology]

The thiamine deficiency and its clinical consequences, especially the Wernicke encephalopathy, are still often not diagnosed. The etiologies are numerous, but the most frequent is the alcohol dependence. The diagnostic is mainly clinical and the treatment must be started as soon as possible by substituting the thiamine with intravenous injection.

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Zusammenfassung. Erwachsene in der Schweiz trinken durchschnittlich zwei Gläser Wein pro Tag. Alkoholmissbrauch und kognitive Störungen sind eng verknüpft, vor allem bei älteren Personen. Die klinische Untersuchung muss nach Anzeichen von Unterernährung suchen und eine neuropsychologische Untersuchung einschliessen, wenn der Mini-Mental-Status pathologisch ist. Bei Anzeichen einer Gayet-Wernicke-Krankheit muss eine intravenöse B1-Vitamin-Therapie zur prophylaktischen oder therapeutischen Behandlung eingeleitet werden. Kognitive Beeinträchtigung ist eine schlechte Prognose für die Behandlung von Alkoholabhängigkeit, sollte aber nicht dazu führen, die Behandlungsbemühungen aufzugeben.

[Wernicke encephalopathy and dry beriberi; late complications after bariatric surgery performed on a patient with a psychiatric history]

A 38-year-old woman was admitted in a psychiatric hospital because of memory disorders. Dry beriberi and Korsakoff's syndrome, as a late neuropsychiatric manifestation of Wernicke's encephalopathy, were established. The beriberi symptoms decreased slowly, but the patient's memory impairments persisted. These clinical features were caused by a thiamine deficiency. Gastric bypass surgery is associated with an increased risk of thiamine deficiency. Excessive alcohol consumption and poor compliance with vitamin deficiency treatment both contributed to the rapid onset of these disorders. The case we describe demonstrates how important it is that patients who have undergone bariatric surgery are prescribed the correct vitamin supplements and that the treatment is continued for an appropriate period of time; this treatment is particularly important in the case of patients who are also suffering from an comorbid alcohol-related disorder.

Wernicke's encephalopathy following Roux en Y gastric bypass surgery

Wernicke’s encephalopathy (WE) is a serious neurological disorder characterized by a classical triad of acute mental confusion, ataxia, and opthalmoplegia due to thiamine deficiency. It was initially described in chronic alcoholics; however, any condition resulting in poor nutritional status places the patient at risk of WE. Bariatric surgery is now considered as an emergent cause of WE. The number of bariatric surgery is increasing for morbid obesity. We present a case of a 40-year-old male who presented with confusion and difficulty in maintaining the balance while walking 3 months after Roux en Y gastric bypass surgery. Diagnosis of WE was made on clinical ground and confirmed by magnetic resonance imaging of the brain, which showed bilateral hyperintense signals in paramedian thalami. Parenteral thiamine replacement was started, and patient showed complete recovery.

Wernicke Encephalopathy: a Future Problem Even After Sleeve Gastrectomy? A Systematic Literature Review

Wernicke encephalopathy (WE) is a serious complication of bariatric surgery with significant morbidity and mortality. A few cases have been reported in the literature, mainly in patients after a Roux-en-Y gastric bypass. Since sleeve gastrectomy (SG) has become a more established and popular bariatric procedure, WE is expected to appear more frequently after SG. We performed a literature review on WE after SG, and 13 cases have been found to be sufficiently documented. The risk of WE needs to be considered in patients with a prolonged vomiting episode and any type of neurological symptoms, independent of the presence of any surgical complications.

Wernicke encephalopathy in a patient with liver failure: Clinical case report

Early recognition and diagnosis of Wernicke encephalopathy is pivotal for the prognosis of this medical emergency, especially in patients with liver failure which predisposes individuals to develop hepatic encephalopathy. For these patients, distinguishing between hepatic encephalopathy and Wernicke encephalopathy is a challenge in real-world clinical practice.A male patient with 21-year medical history of liver cirrhosis presented diarrhea and ascites. One month before this visit, he was noted to have poor appetite and progressive fatigue. After admission, although several major symptoms, including diarrhea, ascites, hyponatremia, and hypoproteinemia, were greatly improved through appropriate treatments, his laboratory indicators were not changed much. His appetite was not reversed at discharge. On the 5th day after discharge, the patient suddenly became reluctant to speak and did not remember the recent happenings. Simultaneously, unsteady gait and strabismus occurred. On the basis of clinical manifestations and brain magnetic resonance imaging scan results, the patient was diagnosed as Wernicke encephalopathy and these relative symptoms were resolved after intravenous vitamin B1.To our knowledge, this is the second case report of Wernicke encephalopathy developing in a critically ill cirrhotic patient without hepatocellular carcinoma or operative intervention. Wernicke encephalopathy may be underdiagnosed in these patients and this case raises physicians' awareness of its possible onset.

The Long-Term Cost to the UK NHS and Social Services of Different Durations of IV Thiamine (Vitamin B1) for Chronic Alcohol Misusers with Symptoms of Wernicke's Encephalopathy Presenting at the Emergency Department

BACKGROUND

Wernicke's encephalopathy (WE) is an acute neuropsychiatric condition caused by depleted intracellular thiamine, most commonly arising in chronic alcohol misusers, who may present to emergency departments (EDs) for a variety of reasons. Guidelines recommend a minimum 5-day course of intravenous (IV) thiamine in at-risk patients unless WE can be excluded.

OBJECTIVE

To estimate the cost impact on the UK public sector (NHS and social services) of a 5-day course of IV thiamine, vs a 2- and 10-day course, in harmful or dependent drinkers presenting to EDs.

METHODS

A Markov chain model compared expected prognosis of patients under alternative admission strategies over 35 years. Model inputs were derived from a prospective cohort study, expert opinion via structured elicitation and NHS costing databases. Costs (2012/2013 price year) were discounted at 3.5 %.

RESULTS

Increasing treatment from 2 to 5 days increased acute care costs but reduced the probability of disease progression and thus reduced the expected net costs by GBP87,000 per patient (95 % confidence interval GBP19,300 to GBP172,300) over 35 years.

CONCLUSIONS

Increasing length of stay to optimize IV thiamine replacement will place additional strain on acute care but has potential UK public sector cost savings. Social services and the NHS should explore collaborations to realise both the health benefits to patients and savings to the public purse.

MRI Findings In Acute Wernicke's Encephalopathy, Caused By Hyperemesis Gravidarum

A 25-year old pregnant female with history of confusion and drowsiness for 02 days was referred by neurophysician for MRI brain. MRI demonstrated T2W/FLAIR hyper intensities in medial thalami, periaqueductal areas with variable diffusion restriction, apparent as hyper intense signal on DWI and no signal change on ADC mapping that was typically consistent with Wernicke's encephalopathy. A high index of suspicion is necessary, as delayed or lack of treatment can lead to high morbidity and mortality.

Spine surgery under general anaesthesia complicated by Wernicke’s encephalopathy in previously asymptomatic patient

Wernicke’s encephalopathy (WE) is a very rare complication of surgical intervention, especially among patients with no liver dysfunction and no history of alcohol abuse. In a surgical setting, Wernicke’s syndrome was mostly associated with abdominal surgery (bariatric, e.g. gastric bypass, splenectomy) but there are no papers in the literature dealing with such a complication among spine patients.

[A Case of Wernicke's Encephalopathy Presenting with Acute Deterioration of Consciousness Caused by Peripheral Parenteral Nutrition]

We report the case of a 67-year-old woman with Wernicke's encephalopathy(WE), who had been suffering from repeated vomiting and poor oral intake due to both reflux esophagitis and atrophic gastritis. She presented with altered of consciousness, horizontal nystagmus, and gait disturbance, and acute deterioration of consciousness was observed after starting peripheral parenteral nutrition (PPN). Brain MRI showed bilateral high intensity lesions in the medial thalamus and the dorsal midbrain on FLAIR and T2-weighted images. Although brain MRI characteristics are useful for diagnosing WE, it is possible that there are no abnormal MRI findings in its early stages. In addition, only 10-20% of WE cases present with the classical clinical triad of confusion, ophthalmoplegia, and ataxia. Therefore, confirming the diagnosis can be challenging. In general, rapid improvement of symptoms is observed with prompt vitamin B1 supplementation. However, delays in treatment can result in irreversible amnesia and ataxia. Furthermore, in the state of vitamin B1 deficiency, even PPN, not just total parenteral nutrition, can worsen symptoms, and this deterioration is attributed to the glucose load.

[Laparoscopic Gastrostomy for a Patient with Wernicke's Encephalopathy after Gastrectomy--A Case Report with a Literature Review]

Wernicke's encephalopathy is usually related to alcoholism, malnutrition, or hyperemesis gravidarum. We report a case of Wernicke's encephalopathy after distal gastrectomy for gastric cancer. A 58-year-old man underwent distal gastrectomy with Billroth Ⅰreconstruction for early gastric cancer. Nine months later, he developed anorexia and vomiting for a few days. Brain MRI showed no significant findings, and he resumed ingestion 5 days after admission. On the 8th day of hospitalization, dysphagia suddenly developed and brain MRI indicated Wernicke's encephalopathy. Vitamin B1 was immediately injected, and neurological symptoms gradually improved. However, dysphagia did not adequately improve, leading to severe aspiration pneumonitis. Laparoscopic gastrostomy was performed for aspiration of the stomach contents and initiation of enteral nutrition. After gastrostomy, the patient made good progress and was transferred to a rehabilitation hospital. We should recognize that gastrectomy can cause Wernicke's encephalopathy.

[Wernicke encephalopathy]

Wernicke encephalopathy is an acute neuropsychiatric disease with heterogeneous symptoms, including changes in mental status, ataxia and ocular abnormalities; if left untreated, these symptoms can lead to morbidity and even to mortality. The treatment is thiamine suppletion. Because of the heterogeneity of the symptoms and the high risk of morbidity and mortality if the symptoms are not treated, it is vitally important that on observing a patient's early symptoms the clinician immediately suspects that the symptoms could point to Wernicke encephalopathy.

Role of astrocytes in thiamine deficiency

Thiamine deficiency (TD) is the underlying cause of Wernicke's encephalopathy (WE), an acute neurological disorder characterized by structural damage to key periventricular structures in the brain. Increasing evidence suggests these focal histological lesions may be representative of a gliopathy in which astrocyte-related changes are a major feature of the disorder. These changes include a loss of the glutamate transporters GLT-1 and GLAST concomitant with elevated interstitial glutamate levels, lowered brain pH associated with increased lactate production, decreased levels of GFAP, reduction in the levels of glutamine synthetase, swelling, alterations in levels of aquaporin-4, and disruption of the blood-brain barrier. This review focusses on how these manifestations contribute to the pathophysiology of TD and possibly WE.