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Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1402-1404

Isolated Enhancement Effect is the Only MRI Finding for Wernicke's encephalopathy


1 Department of Neurology, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
2 Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China

Date of Submission07-Nov-2018
Date of Decision20-Jul-2019
Date of Acceptance20-Jan-2020
Date of Web Publication30-Oct-2021

Correspondence Address:
Jie-Wen Zhang
Department of Neurology, Zhengzhou University People's Hospital, Zhengzhou, Henan - 450003
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329531

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 » Abstract 


Wernicke's encephalopathy (WE) is an acute neuropsychiatric disorder that results from thiamine (vitamin B1) deficiency. The typical clinical manifestations, which occur as triads in 20% of patients with the disorder, are acute mental status changes, ophthalmoplegia, and ataxia. Brain magnetic resonance imaging (MRI) has important value in diagnosis as it can reveal abnormalities in the thalamus, mammillary body, third and fourth ventricles, and periaqueductal area. Here we describe a 44-year-old female patient with WE, in the context of fasting following bowel surgery. The unique neuroimaging findings were symmetrical mammillary body and dorsal midbrain abnormalities, only evident on contrast-enhanced brain MRI.


Keywords: Cognitive disorders, mammillary body, MRI, Wernicke's encephalopathy
Key Message: Isolated Enhancement Effect could be the Only MRI Finding for Wernicke's encephalopathy.


How to cite this article:
He S, Xu YY, Chen S, Chen XL, Zhang JW. Isolated Enhancement Effect is the Only MRI Finding for Wernicke's encephalopathy. Neurol India 2021;69:1402-4

How to cite this URL:
He S, Xu YY, Chen S, Chen XL, Zhang JW. Isolated Enhancement Effect is the Only MRI Finding for Wernicke's encephalopathy. Neurol India [serial online] 2021 [cited 2021 Nov 28];69:1402-4. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1402/329531




Wernicke's encephalopathy (WE) is an acute neuropsychiatric disorder that results from thiamine (vitamin B1) deficiency. The typical clinical manifestations, which occur as triads in 20% of patients with the disorder, are acute mental status changes, ophthalmoplegia, and ataxia.[1] Brain magnetic resonance imaging (MRI) has important value in diagnosis as it can reveal abnormalities in the thalamus, mammillary body, peri-third and fourth ventricle areas, and peri-aqueductal area. Here we describe a 44-year-old female patient with WE, in the context of fasting following bowel surgery. The unique neuroimaging findings were symmetrical mammillary body and dorsal midbrain abnormalities, only evident on contrast-enhanced brain MRI. This case added further evidence that the isolated enhancement effect could be the only imaging finding for WE. In total, five reports of WE have shown abnormal enhancement of the mammillary bodies as the only abnormal finding on the MRI.


 » Case History Top


A 44-year-old female patient was admitted to the Department of Gastrointestinal Surgery due to intestinal obstruction. Four days later, she underwent laparoscopic, ileocecal resection, with jejunostomy, under general anesthesia. Postoperative pathology revealed endometriosis of the small intestine. The patient fasted after surgery and received parenteral nutrition and anti-infective treatment. Eight days post-surgery she developed dizziness, blurred vision, nausea, and vomiting. Neurological examination revealed that she was conscious with normal cognitive function (orientation, memory, and calculation). Her eye movements were voluntary and full; however, unsustained nystagmus could be observed when she looked to either side. Although muscle strength and tone were normal, the patient's bilateral tendon reflex was weak and neither the finger-to-nose test nor the heel-knee-tibia test yielded the positive result.

The patient underwent conventional, and gadolinium-enhanced MRI scanning. No obvious abnormalities were detected on the conventional, unenhanced MRI except mild, white matter hyperintensity. However, the gadolinium-enhanced scan showed prominent enhancement in the mammillary body and dorsal midbrain [Figure 1]. The patient's mental status was observed to deteriorate rapidly. Hallucinations occurred on the tenth postoperative day, followed by reduced speech and stupor, and limited horizontal eye movements. Wernicke's encephalopathy was considered in the context of fasting, following bowel surgery, with apparent mental and cognitive changes, eye movement abnormalities, and ataxia. Hence, vitamin B1 was administered and nutritional support provided. One week later, improvements in the patient's consciousness and mental state were observed and she was able to communicate properly. However, bilateral eye abduction movements were still insufficient. After discharge, the oral vitamin B1 supplement was continued. One month later at the clinical follow-up, the patient could walk independently and showed normal mental state with poor short-term memory.
Figure 1: Patient's brain MRI. Unenhanced brain MRI images (a-f) showed no obvious abnormalities (a and b: T2-weighted image; c and d: Flair sequence; e and f: DWI sequence). Sagittal and coronal gadolinium-enhanced brain MRI showed mallillary body enhancement (g and h; White arrow). Sagittal enhanced brain MRI showed enhancement of the dorsal midbrain (i)

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 » Discussion Top


WE is an acute-phase manifestation of vitamin B1 deficiency, causing central nervous system damage. Vitamin B1 deficiency can cause brain cell energy metabolism disorders, local lactic acidosis, and N-methyl-D-aspartate receptor-mediated, excitatory amino acid toxicity. Additionally, it can induce destruction of the blood-brain barrier and cause oxidative damage. WE can occur regardless of the means by which the absorption or transport of vitamin B1 is inhibited. At present, the diagnosis of WE is largely clinical, with MRI of the head being the most valuable auxiliary examination.

In the literature, the sensitivity of MRI in the diagnosis of WE was reported as 53%, and the specificity, 93%.[2] Typical brain MRI abnormalities include T2-weighted imaging (T2WI) or fluid-attenuated inversion recovery (FLAIR) hyperintensities. These are found specifically in the medial thalamus, mammillary body, peri-third and fourth ventricles areas, and periaqueductal area. Atypical manifestations include abnormal signals in the cerebellum, medulla, caudate nucleus, red nucleus, corpus callosum, and cerebral cortex. In this case, there were no obvious abnormalities on plain MRI scans, but enhanced MRI showed symmetrical enhancement of the mammillary body and dorsal midbrain. Studies have shown that nearly half of WE patients presented with an enhancement effect, which reflected the destruction of the blood-brain barrier.[3],[4] Most commonly, the mammillary body is enhanced, followed by the thalamus and tectal plate. According to Zuccoli et al. (2009),[5] WE that occurs as a result of excessive drinking, more commonly involves the thalamus and mammillary body. Conversely, WE in those with moderate drinking habits is more likely to involve the cranial nerve nucleus. Reports that isolated enhancement, especially mammillary body enhancement, could be the only MRI finding for WE are rare;[6],[7] however, the reason was unclear. It is possible that the mammillary body could not be observed using axial T2WI or FLAIR sequences owing to its small size. Anatomically, the mammillary body is best observed on coronal and sagittal T2WI sequences, neither of which was routinely performed. In addition, partial volume effect due to the adjacent suprasellar cistern may have also affected the visibility of the mammillary body on T2WI.[6]

This case added further evidence that isolated enhancement effect is the only imaging finding for WE. Contrast-enhanced brain MRI should therefore be considered for patients in whom the plain brain MRI is normal.

Ethical approval

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Declaration of patient consent

Informed consent was obtained from the patient included in the study.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Harper CG, Giles M, Finlayjones R. Clinical signs in the Wernicke-Korsakoff complex: A retrospective analysis of 131 cases diagnosed at necropsy. J Neurol Neurosurg Psychiatry 1986;49:341-5.  Back to cited text no. 1
    
2.
Antunez E, Estruch R, Cardenal C. Usefulness of CT and MR imaging in the diagnosis of acute Wernicke's encephalopathy. AJR Am J Roentgenol 1998;171:1131-7.  Back to cited text no. 2
    
3.
Mascalchi M, Simonelli P, Tessa C. Do acute lesions of Wernicke's encephalopathy show contrast enhancement? Report of three cases and review of literature. Neuroradiology 1999;41:249-54.  Back to cited text no. 3
    
4.
Lyu Y, Jiang T. Pathophysiological evaluation in a case of Wernicke's encephalopathy by multimodal MRI. Neurol India 2019;67:1112-5.  Back to cited text no. 4
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5.
Zuccoli G, Santa Cruz D, Bertolini M, Rovira A, Gallucci M, Carollo C, et al. MR imaging findings in 56 patients with Wernicke encephalopathy: Nonalcoholics may differ from alcoholics. AJNR Am J Neuroradiol 2009;30:171-6.  Back to cited text no. 5
    
6.
Konno Y, Kanoto M, Hosoya T. Clinical significance of mammillary body enhancement in Wernicke encephalopathy: Report of 2 cases and review of the literature. Magn Reson Med Sci 2014;13:123-6.  Back to cited text no. 6
    
7.
Shogry ME, Curnes JT. Mamillary body enhancement on MR as the only sign of acute Wernicke encephalopathy. AJNR AM J Neuroradiol 1994;15:172-4.  Back to cited text no. 7
    


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