Hospital Outcomes in Medical Patients With Alcohol-Related and Non-Alcohol-Related Wernicke Encephalopathy

OBJECTIVE

To conduct a nationwide retrospective cohort study to assess trends and hospitalization-associated outcomes in patients with Wernicke encephalopathy.

PATIENTS AND METHODS

In this nationwide retrospective cohort study, we used in-hospital claims data of patients hospitalized with Wernicke encephalopathy in Switzerland from January 1, 2012, to December 31, 2020. We estimated incidence rates per 100,000 person-years among the overall Swiss population stratified by alcohol and non-alcohol-induced Wernicke encephalopathy. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included progression to Korsakoff syndrome and 1-year hospital readmission. We estimated odds ratios (ORs) for binary outcomes.

RESULTS

It was found that 4098 of 4393 hospitalizations (93.3%) for Wernicke encephalopathy during the 8-year study were alcohol-related. Incidence rates for hospitalizations were 14-fold higher in alcohol-related compared with non-alcohol-related Wernicke encephalopathy (5.43 vs 0.39 per 100,000 person-years). The risk for in-hospital mortality was significantly lower in patients with alcohol-related vs non-alcohol-related Wernicke encephalopathy (3.2% vs 8.5%; adjusted OR, 0.38; 95% CI, 0.23 to 0.62). Patients with alcohol-related Wernicke encephalopathy had higher risk for development of Korsakoff syndrome (16.9% vs 1.7%; adjusted OR, 10.64; 95% CI, 4.37 to 25.92) and 1-year hospital readmission (31.6% vs 18.7%; adjusted OR, 1.4; 95% CI, 1.04 to 1.88).

CONCLUSION

In this Swiss nationwide cohort study, Wernicke encephalopathy was a rare but serious cause for hospitalization and mainly alcohol-related. Patients with alcohol-related Wernicke encephalopathy had lower risks of in-hospital mortality but were more likely to develop Korsakoff syndrome and be readmitted to the hospital.

Wernicke encephalopathy: limitations in a laboratory and radiological diagnosis

Wernicke encephalopathy is an emergent neurological disorder caused by vitamin B1 (thiamine) deficiency. Here, we present a case of Wernicke encephalopathy in a male patient in his 70s with normal serum thiamine levels and MRI findings on admission. He had a history of heavy alcohol consumption and a gradual decrease in food intake. On arrival at the hospital, his consciousness was impaired which persisted even after glucose replacement. Moreover, horizontal nystagmus and cerebellar ataxia were observed. Head CT scan and MRI revealed no abnormal findings. Further, his serum thiamine level was within the normal range. The patient was clinically diagnosed with Wernicke encephalopathy, and high-dose thiamine therapy was started. Then, his symptoms improved immediately. Thus, in case of clinical suspicion, treatment for Wernicke encephalopathy must be initiated promptly even in patients with normal serum thiamine levels.

Wernicke-Korsakoff syndrome and other diseases associated with thyamine deficiency

Wernicke-Korsakoff syndrome is the best known consequence of thiamine deficiency, frequently associated with patients with chronic and excessive alcohol consumption, but it can be produced by any cause that produces thiamine deficiency. The disease is underdiagnosed so it is essential to have a high clinical suspicion, mainly in patients who do not have alcohol consumption as a risk factor. For this, the diagnosis continues to be eminently clinical, with the difficulty of high clinical variability. Complementary tests are used to support the diagnosis and rule out other causes that can produce similar symptoms, with magnetic resonance imaging being the most cost-effective imaging test. Treatment is based on the administration of thiamine, which should be started early, and parenterally at the appropriate doses, in all patients with compatible symptoms, without waiting to confirm the diagnosis.

Nonalcoholic Wernicke-Korsakoff Syndrome Resulting From Psychosis

ABSTRACT

Wernicke encephalopathy (WE) results from thiamine deficiency. If undiagnosed or inadequately treated, WE evolves into Korsakoff syndrome (KS). We herein report a case of nonalcoholic Wernicke-Korsakoff syndrome (WKS) that resulted from malnutrition due to psychosis in a 42-years-old male patient. Thiamine deficiency was secondary to severe malnourishment due to poisoning delusions and daily life disorganization in a patient with previously unrecognized schizophrenia. Besides the presence of WE's classic triad of signs, brain magnetic resonance imaging showed also typical thalamic lesions. Furthermore, the patient also presented anterograde and retrograde amnesia, executive dysfunction, and confabulations, compatible with KS being already present. Intravenous treatment with thiamine was given for 37 days. Improvement in cognitive functions and brain imaging alterations was evident. Nevertheless, persistent WKS deficits were present. This case highlights the multiplicity of etiologies of WKS, namely, psychiatric, and its debilitating consequences if not promptly recognized and treated.

[The knowledge of resident doctors on diagnostics, etiology and treatment of Wernicke encephalopathy]

Wernicke encephalopathy (we) is a severe, acute neuropsychiatric disorder caused by a deficiency in thiamine. There have been indications that we is undertreated, which can lead to the Korsakoff syndrome, delirium or death. Treatment according to protocol is simple and effective. The knowledge of physicians about we has not been researched before.<br/> AIM: To test the knowledge of resident doctors on diagnosis, etiology and treatment of we. <br/> METHOD: The knowledge of 70 resident doctors in different medical specialties was examined through two clinical cases: the first with we due to hyperemesis gravidarum and the second due to alcohol abuse. Both open and multiple-choice questions were asked. Cues of the classical triad of we (cognitive disorder, eye movement disorder and gait disorder) were given accumulatively.<br/> RESULTS: The classical triad of we was not recognized by 73% of the resident doctors in the case of hyperemesis gravidarum and they missed we in the case of alcohol abuse. Many of the resident doctors were not able to name the thiamin deficiency, the triad of we, more than three causes of we or the correct treatment with thiamine sufficiently. 67% of resident doctors indicated that their knowledge of we was insufficient and 76% expressed a need for more information about we.<br/> CONCLUSION: The knowledge of resident doctors about the diagnostics, etiology and management of we is insufficient. Moreover, the resident doctors evaluate their knowledge about we to be insufficient. Medical school and postgraduate specialization have to focus more on this common and severe syndrome, which can appear in different medical areas.

[Not Available]

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.

Refeeding Syndrome: An Important Complication Following Obesity Surgery

BACKGROUND

Refeeding syndrome (RFS) is an important and well-known complication in malnourished patients, but the incidence of RFS after obesity surgery is unknown and the awareness of RFS in obese patients as a postsurgical complication must be raised. We present a case of RFS subsequent to biliopancreatic diversion in a morbidly obese patient.

CASE REPORT

A 48-year-old female patient with a BMI of 41.5 kg/m2 was transferred to our hospital due to Wernicke's Encephalopathy in a global malabsorptive syndrome after biliopancreatic diversion. Parenteral nutrition, vitamin supplementation and high-dosed intravenous thiamine supplementation were initiated. After 14 days, the patient started to develop acute respiratory failure, and neurological functions were impaired. Blood values showed significant electrolyte disturbances. RFS was diagnosed and managed according to the NICE guidelines. After 14 days, phosphate levels had returned to normal range, and neurological symptoms were improved.

CONCLUSION

Extreme weight loss following obesity surgery has been shown to be associated with undernutrition. These patients are at high risk for evolving RFS, even though they may still be obese. Awareness of RFS as a postsurgical complication, the identification of patients at risk as well as prevention and correct management should be routinely performed at every bariatric center.

Beriberi, a severe complication after metabolic surgery - review of the literature

BACKGROUND

The epidemic growth of morbid obesity has led to an increase in the number of bariatric interventions. During the distribution process of bariatric surgical interventions, the risk for severe nutritious complications such as bariatric beriberi can rise.

METHODS

By means of systematic literature review, epidemiological data, clinical characteristics and diagnostic as well as therapeutic recommendations for bariatric beriberi were elicited. Databases and registries such as PubMed, Cochrane and Ovid were searched for a defined time period with the key words 'lack of thiamine' / 'Wernicke-Korsakoff syndrome' / 'encephalopathy' after bariatric surgical interventions.

RESULTS

Up to December 2013, overall 255 patients had been found as published cases, indicating that the risk for the postoperative occurrence of thiamine deficiency and Wernicke-Korsakoff syndrome is increased in women. In addition, the risk correlates with patient's age. The majority of patients developed symptoms of a dry beriberi with peripheral neuritis, ataxia and paraplegia, indicating an advanced stage of disease approximately 4-12 weeks postoperatively. Laboratory analysis in case of a suspicious clinical finding is the appropriate diagnostics. As treatment, prompt initiation of parenteral thiamine substitution under clinical monitoring is required.

CONCLUSION

Bariatric beriberi can occur within the first 1-3 postoperative months. To minimize the risk of severe consequences, immediate substitution of thiamine in clinical suspicion or prolonged parenteral nutrition is necessary. A delayed diagnosis or missing the correct diagnosis can lead to irreversible damages of the CNS with coma and fatal outcome. Knowledge on the subject, including development of thiamine deficiency, symptomatology and emergency treatment, are considered essential for bariatric surgeons but also for further medical disciplines involved in treatment.

[Diagnostics and treatment of Wernicke-Korsakoff syndrome patients with an alcohol abuse]

Wernicke-Korsakoff syndrome is a condition with high morbidity and mortality and occurs as a consequence of thiamine deficiency. Clinical symptoms are often ambiguous and post-mortem examinations show that the syndrome is underdiagnosed and probably undertreated. There is sparse clinical evidence concerning optimal dosage and duration of treatment. This article reviews the current literature and concludes that all patients with a history of alcohol abuse should be treated with high dosage IV thiamine for an extended period of time, albeit further research is needed.

[Wernicke encephalopathy and Korsakoff's psychosis: clinical-pathophysiological correlation, diagnostics and treatment]

Wernicke's encephalopathy and Korsakoff's psychosis are severe unfavorable forms of alcoholic brain damage with poor prognosis. Thiamine deficiency represents a common cause of both diseases. In many cases, Korsakoff's psychosis develops in the outcome of Wernicke's encephalopathy, which, along with the general etiology, lets talk about a single disease - Wernicke-Korsakoff syndrome, acute (usually reversible) stage of which is Wernicke's encephalopathy and a chronic one (often irreversible) is Korsakoff psychosis. The dramatic paradox of Wernicke's encephalopathy is that in most cases it is difficult to detect, but early diagnosed cases are quite easy to cure. Unrecognized and therefore go untreated Wernicke's encephalopathy is a serious threat to the health and lives of patients, worsens the processes of brain aging and increases the risk of Alzheimer's disease in later life. The basic approach to the treatment of Wernicke-Korsakoff syndrome is long-term parenteral administration of thiamine, often in high doses. As an adjuvant means of therapy memantine is considered.

Wernicke's encephalopathy that developed during the introduction period of peritoneal dialysis

A 43-year-old man was admitted with end-stage renal disease caused by IgA nephropathy, and was treated with maintenance peritoneal dialysis. The patient developed general fatigue and appetite loss, and his symptoms were gradually aggravated by depression. After approximately 2 months on dialysis, the patient presented with altered consciousness and ophthalmoplegia. Wernicke's encephalopathy was diagnosed based on the presence of classic symptoms and the findings on magnetic resonance imaging. Thiamine replacement therapy was immediately initiated. The patient recovered from most of his neurological symptoms; however, the sequela of Korsakoff syndrome remained. A marginal thiamine deficiency in combination with predisposing factors must be considered when treating dialysis patients.

Anterograde episodic memory in Korsakoff syndrome

A profound anterograde memory deficit for information, regardless of the nature of the material, is the hallmark of Korsakoff syndrome, an amnesic condition resulting from severe thiamine (vitamin B1) deficiency. Since the late nineteenth century when the Russian physician, S. S. Korsakoff, initially described this syndrome associated with "polyneuropathy," the observed global amnesia has been a primary focus of neuroscience and neuropsychology. In this review we highlight the historical studies that examined anterograde episodic memory processes in KS, present a timeline and evidence supporting the myriad theories proffered to account for this memory dysfunction, and summarize what is known about the neuroanatomical correlates and neural systems presumed affected in KS. Rigorous study of KS amnesia and associated memory disorders of other etiologies provide evidence for distinct mnemonic component processes and neural networks imperative for normal declarative and nondeclarative memory abilities and for mnemonic processes spared in KS, from whence emerged the appreciation that memory is not a unitary function. Debate continues regarding the qualitative and quantitative differences between KS and other amnesias and what brain regions and neural pathways are necessary and sufficient to produce KS amnesia.

[Clinical application of neuroimaging to alcohol-related dementia]

Alcohol-related dementia (ARD) is one of the most common dementing disorders in middle-aged people and occurs in heavy drinkers who are estimated to be 10 - 15 % of the adult men in a community. While the concept of ARD is multifactorial and includes all cognitive deficits in alcoholics, the central clinical manifestations are exemplified by Korsakoff's syndrome (KS), a persistent neuropsychiatric syndrome, characterized by amnesia and disorientation that is caused by thiamine deficiency along with excessive alcohol consumption. Antemortem detection of intracranial changes has been made possible by MRI and many studies have revealed that alcoholics have atrophic changes in frontal lobe, cerebellum, medial temporal lobe and hippocampus. However, these brain regions are vulnerable to excessive alcohol and seem to be independent of cognitive deficits in alcoholics. This review shows the regional differences in gray matter volumes between cognitively normal alcoholics and patients with KS. By employing a 3-dimensional MRI method for voxel-based morphometry that enables an automated, unbiased, comprehensive assessment, we demonstrate that parahippocampal/hippocampal atrophy is specific to KS and thalamic atrophy and the third ventricle enlargement are more severe in patients with KS than in cognitively normal alcoholics.

The evolution and treatment of Korsakoff's syndrome: out of sight, out of mind?

Wernicke's Encephalopathy is an acute neuro-psychiatric condition caused by an insufficient supply of thiamine (Vitamin B1) to the brain. If undiagnosed or inadequately treated, it is likely to proceed to Korsakoff's Syndrome. Wernicke's Encephalopathy can result from dietary deficiency alone and this form is usually successfully treated, with little chance of Korsakoff's Syndrome supervening. On the other hand, thiamine deficiency associated with alcohol misuse/dependence may require up to 1 gram of thiamine IV in the first 24 hours to be treated successfully. The reasons for this difference in treatment will be discussed. Thiamine diphosphate acts as a co-factor for a number of thiamine-dependent enzymes. Thiamine deficiency leads to a reduction in the activity of these enzymes, and this leads to alterations in mitochondrial activity, impairment of oxidative metabolism, decreased energy status and eventually selective neuronal death. The damage caused by the combination of thiamine deficiency and alcohol metabolism probably interferes with adequate thiamine transport at a number of sites in the body, including the blood-brain barrier, as well as causing damage to the apoenzymes which then require higher concentrations of thiamine to work normally. The accumulated damage is likely to render the use of oral thiamine therapeutically inadequate since the body is unable to produce high enough concentrations of thiamine in the blood to traverse the blood-brain barrier. Some individuals are probably genetically predisposed to develop Wernicke's. Long before individuals with alcohol misuse or dependence develop Wernicke's Encephalopathy the neurons and other cells of the body are functioning sub-optimally because of the inadequate supply of thiamine and the neurotoxic effect of alcohol. This relative deficiency initiates a series of pathological changes which accumulate and further interfere with the supply of thiamine and its utilisation at a time when the requirements are increased. The best treatment for Korsakoff's Syndrome is timely recognition of Wernicke's Encephalopathy and appropriate intervention and prevention.

[Beriberi after bariatric surgery]

Bariatric surgery is in general the only effective treatment for morbid obesity. Bariatric surgery is frequently associated with vitamin and mineral deficiencies which may lead to neurological and other symptoms. We describe a case of severe vitamin B1 (thiamine) deficiency.

CASE DESCRIPTION

A 49-year-old man visited the emergency department with acute confusion, muscle weakness in arms and legs and visual impairment after a period of dysphagia and recurrent vomiting. Four months earlier, he had had bariatric gastric sleeve surgery for morbid obesity. Laboratory tests demonstrated that he had vitamin B1 deficiency, in view of which the diagnosis of beriberi and Wernicke encephalopathy was made. Despite normalisation of the vitamin B1 concentration following intravenous supplementation, the muscle strength hardly recovered and the patient developed Korsakov syndrome.

CONCLUSION

For this deficiency there is no other treatment than vitamin B1 supplementation. Timely recognition of vitamin deficiencies and pro-active supplementation are essential in order to prevent serious complications following bariatric surgery.

Wernicke-Korsakoff syndrome in the course of thyrotoxicosis - a case report

Wernicke-Korsakoff syndrome (also called Wernicke's encephalopathy) is a potentially fatal, neuropsychiatric syndrome caused most frequently by thiamine deficiency. The three classic symptoms found together are confusion, ataxia and eyeball manifestations. Memory disturbances can also be symptoms. Wernicke's encephalopathy mainly results from alcohol abuse, but also from malnutrition, cancer, chronic dialysis, thyrotoxicosis and, in well-founded cases, encephalopathy associated with autoimmune thyroid disease (EAATD). The coexistence of many factors makes a proper diagnosis difficult, delays appropriate treatment and consequently reduces the chance of complete recovery. We present the case of a 53 year-old female with Wernicke's encephalopathy caused by chronic malnutrition, surgical operation, as well as thyrotoxicosis. She received treatment with intravenous thiamine administration and also anti-thyroid treatment which caused satisfactory regression of her neurological symptoms.

Complete recovery from undertreated Wernicke-Korsakoff syndrome following aggressive thiamine treatment

BACKGROUND

Wernicke-Korsakoff syndrome (WKS) is a neuropsychiatric condition which results from thiamine deficiency, most commonly due to alcohol abuse. The prognosis of WKS is poor and its outcome depends mainly on prompt treatment.

CASE REPORT

A 52-year-old male with a ten-year history of heavy alcohol abuse was admitted in hospital and treated for WKS. Ataxic and oculomotor symptoms promptly reversed following standard treatment but no change was observed in higher mental functioning. Although the protracted WK symptoms made the patient's improvement unlikely, aggressive treatment with thiamine (600 mg/day orally and 300 mg/day intramuscularly) fully reversed the condition within two months.

CONCLUSION

Even though prolongation of undertreatment of WKS typically precludes significant improvement of symptoms due to irreversible damage of the brain, at least in some cases, higher thiamine doses (over 500 mg/day) for a longer period (at least three months) than usually recommended should be tried.

Reversible alcohol-related dementia: a five-year follow-up study using FDG-PET and neuropsychological tests

OBJECTIVE

As the pathophysiology of alcohol-related dementia (ARD) is unclear, we examined a patient with reversible ARD using neuropsychological tests and (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET).

DESIGN

A five-year follow-up case study with neuropsychological tests and FDG-PET.

SETTING

Kyoto University Hospital. Patients A 42-year-old patient who was unable to perform his office duties because of slowly progressive amnesia with executive dysfunction.

RESULTS

The initial evaluation with neuropsychological tests showed severe verbal memory disturbance. The patient did not discuss his excessive alcohol consumption in the initial history-taking session and thiamine deficiency was absent; therefore, early-stage Alzheimer's disease was suspected. Later, the patient revealed prior excessive alcohol intake and his cognitive function improved markedly after a period of abstinence. Retrospective analysis of initial FDG-PET images using a voxel-wise statistical method revealed glucose hypometabolism in the diencephalon and basal forebrain. Follow-up for 5 years after the initial evaluation showed improved cognitive function and recovery of glucose metabolism in the two brain regions.

CONCLUSION

Hypofunction in the diencephalon and basal forebrain was associated with cognitive decline in our patient. This case may provide evidence for the etiopathic brain regions in reversible type ARD.

[The use of stabilo-training with feedback in the rehabilitation of patients with posttraumatic Korsakov's syndrome]

The complex research, including clinical scales (FIM, Mayo-Portland) and data on stabilography and electroencephalography (EEG) studies, was conducted in 10 patients with posttraumatic Korsakov's syndrome (KS) before and after the rehabilitation course using stabilo-training (ST) with feedback (7-12 sessions). A control group consisted of 18 healthy people. In patients with KS, more severe cognitive (memory) disorders were noted before ST that was correlated with the maximal reduction of coherence in all frequency bands in frontal and parietal-occipital areas as well as in the long diagonal pairs between the left frontal and the right parietal-occipital areas which was most distinct for the alpha-band. A trend to the normalization of stabilography parameters and step-by step increasing of EEG coherence parameters, especially the alpha-band, was found after the rehabilitation ST course, which was accompanied with the KS regress. It increased initially in parietal-occipital-central areas of the right hemisphere with the following increase in central-frontal areas and then in frontal areas, mostly in the left hemisphere, that was in compliance with the tendency to the normalization of spatial-temporary EEG organization.

Nursing assessment and management of alcohol-related brain damage in young people

The long term consequences of chronic alcohol misuse are increasingly affecting young people. This one part unit outlines the main signs and symptoms of Wernicke's encephalopathy and Korsakoff's syndrome. It details nursing assessment and management of these conditions, as well as regimens for safe detoxification.

Dementia in a retired world boxing champion: case report and literature review

OBJECTIVE

Dementia in retired boxers, also referred to as "dementia pugilistica" (DP), is usually attributed to repeated concussive and subconcussive blows to the head. We report the case of a former world boxing champion whose progressive cognitive decline could be ascribed to DP, cerebral infarcts and Wernicke-Korsakoff syndrome. This case demonstrates that dementia in retired boxers may be caused and/or exacerbated by etiologic factors other than DP.

MATERIALS AND METHODS

We correlated the clinical features with the histochemical and immunohistochemical changes observed on autopsy brain material from a retired boxer, reviewed the literature on boxing-related dementia, and compared our findings with previous reports on DP.

RESULTS

Neuropathologic examination revealed numerous neurofibrillary tangles (NFTs), rare neuritic plaques (NPs), multiple cerebral infarcts, fenestrated septum pellucidum, atrophic and gliotic mamillary bodies, and pale substantia nigra and locus ceruleus.

CONCLUSIONS

Our neuropathologic data confirmed the notion that dementia in retired boxers could be due to several factors such as DP, multiple cerebral infarcts and Wernicke-Korsakoff syndrome. Our findings illustrate the need to comprehensively examine former boxers with dementia as well as carefully evaluate the neuropathologic changes that may cause or contribute to the patient's cognitive and behavioral symptoms. Such an approach is crucial in order to provide prompt and more definitive therapies.

Paul Yakovlev remembered: an interview with Maurice Victor. Interviewed by Robert Laureno

Maurice Victor, the great Canadian neurologist, was an expert on the neurology of alcoholism including the Wernicke-Korsakoff syndrome. In Boston, Massachusetts he encountered the leading neuroanatomist, Paul Yakovlev, an immigrant from Russia. Together Victor and Yakovlev collaborated on translating the work of S.S. Korsakoff from Russian to English. This interview of Victor about Yakovlev is informative about both of these great figures in North American Neurology.

The impact of prolonged hunger strike: clinical and laboratory aspects of twenty-five hunger strikers

BACKGROUND

Hunger strike is a very serious entity which may lead to severe diseases and death.

AIMS

The aim of this study is to document the clinical, neurophysiological, neuroradiological, and neuropsychological aspects of prolonged hunger strike.

MATERIAL AND METHOD

We investigated the clinical and laboratory characteristics of 25 hungerstrikers hospitalized during refeeding process. One sample t-test, independent samples t-test, Mann-Whitney and Pearson correlation tests were used for statistical analyses.

RESULTS

Twelve of them had a continuous hunger strike ranging between 190-366 days. The other 13 had quitting intervals for various reasons with a continuous hunger ranging between 65-265 days with a total hunger duration of 153-382 days. The mean loss of body mass index (BMI) was 40.98 +/- 9.3%. Imbalance, sleep disorders, somatosensory disturbances, and adynamia were the most common complaints. At admission, one third experienced ophthalmoparesis, about half of them had paresis, one quarter had truncal ataxia. At discharge 16% had persistent ophthalmoparesis and 36% nystagmus. Only four patients (16%) could walk independently. There was no serious MRI, EEG findings. Most prominent EMG findings were the decrease in median and sural nerve cnap, median and fibular cmap, and fibular ncv values. They showed mild impairment in MMTS and most of them had attention deficit and frontal type memory impairment.

CONCLUSION

It can be concluded that vitamin B intake, independent of the quantity and timing, lowers the morbidity and mortality of hunger strikers.

[Thiamine deficiency caused by malnutrition: a rare cause?]

A 50-year-old man was admitted to our psychiatric clinic with symptoms of depression, comorbid neurological disturbances and cardiomyopathy. The condition was diagnosed as beriberi and Korsakov's syndrome, on the basis of thiamine deficiency. The patient's diet was unbalanced and restricted, but he was not an alcohol abuser. Thiamine suppletion led to a partial remission of symptoms. If a patient presents with depressive symptoms combined with neurological disturbances or heart irregularities, the Wernicke-Korsakov syndrome should be ruled out, even if the patient does not abuse alcohol. If in doubt, always opt for thiamine suppletion.

Acute Korsakoff-like amnestic syndrome resulting from left thalamic infarction following a right hippocampal hemorrhage

Korsakoff-like amnestic syndromes have been rarely described following structural lesions of the central nervous system. In this report, we describe a case of acute Korsakoff-like syndrome resulting from the combination of a left anteromedian thalamic infarct and a right hippocampal hemorrhage. We also review the literature relevant to the neuropathology and pathophysiology of Korsakoff syndrome and anterograde amnesia.

[Amnesic syndrome following lesion of the fornix or does reversible Korsakow's syndrome exist?]

The 53-year-old female patient had suffered massive subarachnoid bleeding due to rupture of left-localized aneurysm of the anterior communicant artery. Following the neurosurgical intervention, deterioration of consciousness related to strong vasospasm occurred. Cerebral CT examination was performed, showing a 0.5 cm ischaemic lesion of the left hippocampal fornix. Due to intensive therapy, the patient recovered gradually, however considerable short-time memory deficit and severe anterograde amnesia remained. Admission of the patient in psychiatric care 5 weeks after the operation was necessary since acute deterioration had been added to memory disturbance and anterograde amnesia. Clinical features included severe short-time memory deficit, continuous and severe anterograde amnesia, disorientation, alterations of verbal fluency and abstraction. The amnesic syndrome was probably related to the hippocampal damage, but considering the development of cognitive deficits, cerebral CT was performed again, which verified internal hydrocephalus. A ventriculo-peritoneal shunt has been implanted and the patient was re-admitted in psychiatry care because of her memory deficit, anterograde amnesia and disorientation. Thereafter, low doses of citalopram and donepezil therapy was started together with temporarily used antipsychotic medication (risperidone). Gradual, but continuous improvement of memory and cognitive function could be detected, with total recovery after one year. The deficits in long- and short-term memory, orientation and cognition were totally restored.

[Korsakoff's syndrome secondary to left thalamic bleeding]

Korsakoff's syndrome is characterised by an important impairment in memory in comparison to other cognitive functions. Presence of confabulations is frequent but they are not characteristic of this syndrome. Alcohol abuse is the main cause of this syndrome but it also has been associated to other causes, like malnutrition or structural lesions. Although the role of thalamus in memory processing is well established, the development of confabulations in the setting of a thalamic lesion is poorly described in the literature. We present a 61 year-old hypertensive man, with an important impairment in anterograde memory, confabulations and acalculia after a left thalamic haemorrhage. Other cognitive functions were intact except a partial temporal disorientation. Thalamic dementia is generally caused by bilateral thalamic damage. Usually, all cognitive functions are impaired. As thalamus takes part in Papez's circuit, either thalamic nuclei or their connections lesions may originate memory impairment. However, although a relation between the presence of confabulations and connections from thalamus to frontal lobe lesions has been described, there is almost no evidence in the literature.

Neurologic complications after surgery for obesity

Bariatric surgical procedures are increasingly common. In this review, we characterize the neurologic complications of such procedures, including their mechanisms, frequency, and prognosis. Literature review yielded 50 case reports of 96 patients with neurologic symptoms after bariatric procedures. The most common presentations were peripheral neuropathy in 60 (62%) and encephalopathy in 30 (31%). Among the 60 patients with peripheral neuropathy, 40 (67%) had a polyneuropathy and 18 (30%) had mononeuropathies, which included 17 (94%) with meralgia paresthetica and 1 with foot drop. Neurologic emergencies including Wernicke's encephalopathy, rhabdomyolysis, and Guillain-Barré syndrome were also reported. In 18 surgical series reported between 1976 and 2004, 133 of 9996 patients (1.3%) were recognized to have neurologic complications (range: 0.08-16%). The only prospective study reported a neurologic complication rate of 4.6%, and a controlled retrospective study identified 16% of patients with peripheral neuropathy. There is evidence to suggest a role for inflammation or an immunologic mechanism in neuropathy after gastric bypass. Micronutrient deficiencies following gastric bypass were evaluated in 957 patients in 8 reports. A total of 236 (25%) had vitamin B(12) deficiency and 11 (1%) had thiamine deficiency. Routine monitoring of micronutrient levels and prompt recognition of neurological complications can reduce morbidity associated with these procedures.

Eating Avoidance Disorder and Wernicke-Korsakoff Syndrome Following Gastric Bypass: An Under-Diagnosed Association

Wernicke-Korsakoff syndrome (WKS) and disordered eating behavior have been reported separately after bariatric surgery. We report a patient who following a bariatric operation developed WKS associated with a disturbed eating behavior without vomiting. This morbidly obese man developed an intense fear of gaining weight in the postoperative period and engaged in an extreme form of "food avoidance behavior". 2 months postoperatively after severe weight loss, he was hospitalized with disorientation and an amnesic syndrome. He was discharged 2 months later with stable weight and regular eating habits. Despite this, at the last follow-up visit 2 years postoperatively, he still had a residual partial amnesic syndrome. The surgical team must be aware of peculiar forms of pathological eating that may appear after bariatric surgery; the emergence of an eating avoidance disorder may be associated with the development of WKS.

Wernicke-Korsakoff Syndrome Associated with Hyperemesis Gravidarum

PURPOSE

The authors hereby describe a case of Wernicke-Korsakoff syndrome with accompanying ocular findings that is caused by hyperernesis gravidarum.

METHODS

We experienced a 27-year-old female at 12 weeks of pregnancy, who visited our clinic because of weight loss, gait disturbance, decreased mentality and dizziness after prolonged vomiting for 2 months. Neurological examination demonstrated ataxia of gait and loss of orientation. Ophthalmologic examination showed decreased visual acuity, upbeat nystagmus, diplopia and retinal hemorrhage.

RESULTS

We report a relatively rare case of Wernicke-Korsakoff syndrome with ophthalmic symptoms induced by hyperemesis gravidarum.

CONCLUSIONS

If a pregnant women has symptoms of severe vomiting along with other ocular findings such as retinal hemorrhage or restricted extraocular movement, one must suspect the diagnosis of Wernicke-Korsakoff syndrome, and should start appropriate treatment immediately.

The cost of living in purgatory's shadow

A 40-year-old alcoholic man developed Wernicke-Korsakoff syndrome. His examination showed ophthalmoplegia, ataxia and memory difficulties. His cranial magnetic resonance imaging scan showed increased signal in the paraventricular regions of the thalamus on T-2 weighted, diffusion and axial fluid-attenuated inversion recovery sequences consistent with the syndrome. The ophthalmoplegia resolved with thiamine administration; however, his memory did not improve.

Acute Korsakoff syndrome following mammillothalamic tract infarction

There are limited case reports of structural lesions causing Korsakoff syndrome. This report describes acute Korsakoff syndrome following localized, bilateral infarction of the mammillothalamic tracts (MTTs). Axial T2-weighted imaging revealed the lesions at the lateral wall level of the third ventricle and diffusion-weighted imaging confirmed that the left lesion was new and the right old. Korsakoff syndrome persisted 6 months after the onset. This case suggests that bilateral MTT dysfunction can lead to Korsakoff syndrome.

[Dysfunction of serotonergic systems in thiamine-deficient diet fed mice: effects of SSRI on abnormality induced by thiamine deficiency]

Mice fed a thiamine deficient (TD) diet, showed some abnormal behaviors such as amnesia and mood abnormality. It is known that several neurons, especially marked in serotonergic neuron, are damaged in humans and rodents in the earlier phase of TD. The symptoms derived from dysfunction of serotonergic neurons are observed in Wernicke-Korsakoff patients (WKS)-derived TD, and it is known that fluvoxamine is effective for WKS. However, the mechanism of this dysfunction is still unclear. For that reason, we studied the relative mechanism between abnormal behaviors and selective dysfunction of serotonergic neurons in TD animals. As a result, this dysfunction by TD is much affected by the brainstem region. But the effect of fluvoxamine on depressive symptoms in WKS patients is not reported; therefore we also studied the effects of fluvoxamine on the depressive behaviors in TD mice as a model of WKS. The increase of immobility time in a forced swimming test as depressive behavior in TD mice was significantly inhibited by fluvoxamine, suggesting an improvable effect on depressive symptoms. With those results of ours, the possible mechanisms between the abnormal behaviors derived from the dysfunction of serotonergic neurons and the role of serotonin in TD and WKS are reviewed here.

Korsakoff syndrome following chronic subdural hematoma

We describe a patient who developed Korsakoff syndrome following a spontaneous chronic subdural hematoma. The present case demonstrates persistence of both amnesia and confabulation long after recovery from the acute phase of spontaneous chronic subdural hematoma. There are few reports describing persistent amnesia with confabulation following brain damage. We considered that chronic subdural hematoma in the bilateral frontal and temporal lobes caused amnesia and confabulations, and these conditions persisted as a result of organic atrophic changes of both the frontal and temporal lobes due to long-term compression by chronic subdural hematoma.

Reversible acute axonal polyneuropathy associated with Wernicke-Korsakoff syndrome: impaired physiological nerve conduction due to thiamine deficiency?

Acute axonal polyneuropathy and Wernicke-Korsakoff encephalopathy developed simultaneously in three patients. Nerve conduction studies (NCS) detected markedly decreased compound muscle action potentials (CMAPs) and sensory nerve action potentials (SNAPs) with minimal conduction slowing; sympathetic skin responses (SSRs) were also notably decreased. Sural nerve biopsies showed only mild axonal degeneration with scattered myelin ovoid formation. The symptoms of neuropathy lessened within two weeks after an intravenous thiamine infusion. CMAPs, SNAPs, and SSRs also increased considerably. We suggest that this is a new type of peripheral nerve impairment: physiological conduction failure with minimal conduction delay due to thiamine deficiency.

[Particular aspects of bioelectric brain activity in post-traumatic Korsakoff syndrome]

Thirty two patients, 21 with recurrent and 11 with chronic Korsakoff's syndrome of traumatic genesis, and 20 healthy subjects were studied, using visual and spectral coherent EEG analysis and investigation of three-dimensional localization of dipolar beta 1-activity sources (13-20 Hz EEG bands). In Korsakoff's syndrome, negative prognostic significance of a stable increase of EEG beta 1-activity coherence generated by a limited number of sources, preferably of frontal basal and stem localization, was found. In the context of clinical data, this EEG phenomenon may be related to inhibited state of corresponding cortical areas.

[Pharmacological treatment of Korsakoff's psychosis: a review of the literature and experience in two cases]

INTRODUCTION

Korsakoff s psychosis (KP) is a relatively frequent pathological condition in our community that has been infradiagnosed. The most common cause is chronic alcohol consumption, although it can be brought about by other aetiologies accompanied by vitamin deficiencies. The lack of thiamine entails an alteration in the synthesis of neurotransmitters, which provides the neurochemical foundation for the specific cognitive impairment that defines the syndrome.

AIMS

To evaluate the application of pharmacological treatments, in accordance with the neurochemical disorders described in the literature, and report our experience in two cases treated with anticholinesterases.

CASE REPORTS

1) Female aged 47, with a history of addiction to alcohol. Following Wernicke s encephalopathy, which improved with parenteral thiamine, she presented a memory disorder compatible with KP. After two months treatment with donepezil, a cognitive improvement was observed in the neuropsychological tests. 2) Male aged 77, who presented KP a month after being diagnosed and treated for a post encephalitic vasculitis caused be varicella zoster virus. His cognitive and functional condition improved after 3 months treatment with donepezil.

DISCUSSION AND CONCLUSIONS

There are not enough studies in the literature with representative samples that consider the effects of thiamine or of other forms of treatment on cognitive impairment in KP. Noradrenaline, serotonin, glutamate and acetylcholine have been proposed in the pathogeny of the syndrome. Based on experiences gained in cholinergic disorders, two cases responded to treatment with donepezil. Effective treatment must be based on a combination of aetiological and pharmacological treatment, and cognitive rehabilitation.