Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 27525  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Resource Links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (644 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this Article
   Article Figures

 Article Access Statistics
    PDF Downloaded6    
    Comments [Add]    

Recommend this journal


Table of Contents    
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1752-1753

Nonalcoholic Wernicke Encephalopathy Post-Bariatric Surgery—“Bariatric Beriberi”

Department of Neurology; Neurological Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates

Date of Submission29-Nov-2019
Date of Decision30-Nov-2019
Date of Acceptance07-Feb-2020
Date of Web Publication30-Aug-2022

Correspondence Address:
Seby John
Department of Neurology, Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi
United Arab Emirates
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.355186

Rights and Permissions

How to cite this article:
Kesav P, Soni H, Hussain SI, John S. Nonalcoholic Wernicke Encephalopathy Post-Bariatric Surgery—“Bariatric Beriberi”. Neurol India 2022;70:1752-3

How to cite this URL:
Kesav P, Soni H, Hussain SI, John S. Nonalcoholic Wernicke Encephalopathy Post-Bariatric Surgery—“Bariatric Beriberi”. Neurol India [serial online] 2022 [cited 2022 Sep 30];70:1752-3. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1752/355186

A 22-year old male, teetotaller, four months post-sleeve gastrectomy for morbid obesity, presented with sub-acute-onset painless diplopia, gait unsteadiness, and dysphagia of 3 weeks duration. On neurological examination he had an inward deviation of both eyeballs, bilateral lateral rectus palsy with binocular horizontal diplopia, and gaze-evoked horizontal nystagmus. He had normal motor power and sensory exam with intact deep tendon reflexes, however, he was ataxic with cerebellar signs. Hematology investigations revealed low vitamin B1 (46.4 [range: 66.5–200] nmol/L). MRI of the brain showed bilateral symmetric T2 fluid-attenuated inversion recovery (FLAIR) hyperintensities involving periventricular third ventricle and brainstem with T1 post-contrast enhancement [Figure 1]a and [Figure 1]b. A diagnosis of nonalcoholic post-bariatric surgery Wernicke encephalopathy (NAWE) was made as per the operational criteria for WE (Presence of two out of the following four signs—dietary deficiencies, oculomotor abnormalities, cerebellar dysfunction, and either altered mental state or mild memory impairment).[1] He improved significantly with 3 days of parenteral thiamine, followed by oral maintenance doses.
Figure 1: (a) T2 fluid-attenuated inversion recovery (FLAIR) sequences of MRI brain showing hyperintensities along the periventricular region of the third ventricle (short white arrow), tectal midbrain (thick white arrow) and nucleus prepositus hypoglossi in the dorsal medulla (long white arrow). (b) Post-contrast T1 sequences showing punctate contrast enhancement in the periventricular region of the third ventricle (thick white arrow) and patchy enhancement at the level of tectal plate of the midbrain (long white arrow)

Click here to view

Post-bariatric surgery NAWE (“bariatric beriberi”),[2] being less common with restrictive procedures like sleeve gastrectomy,[2],[3],[4],[5] usually manifests 4–12 weeks postoperatively, even though it can occur as late as 18–24 months.[4] NAWE is distinct from classic WE, both clinically and from a neuroimaging standpoint. The triad of mental status changes, ocular and cerebellar dysfunctions are seen in 38–65% of NAWE as against 16–38% with WE.[2],[3],[4],[5],[6] Atypical MRI neuroimaging findings involving cranial nerve nuclei and infratentorial lesions are more characteristic of NAWE, occurring along with typical sites of involvement in WE (thalamus, mamillary body, tectal plate, periaqueductal area).[6],[7] Being a medical emergency, a high index of suspicion should be exercised in order to promptly diagnose NAWE with atypical imaging findings.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Caine D, Halliday GM, Kril JJ, Harper CG. Operational criteria for the classification of chronic alcoholics: Identification of Wernicke's encephalopathy. J Neurol Neurosurg Psychiatry 1997;62:51-60.  Back to cited text no. 1
Oudman E, Wijnia JW, Dam M, Biter LU, Postma A. Preventing Wernicke encephalopathy after bariatric surgery. Obes Surg 2018;28:2060-8.  Back to cited text no. 2
Aasheim ET. Wernicke encephalopathy after bariatric surgery – A systematic review. Ann Surg 2008;248:714-20.  Back to cited text no. 3
Singh S, Kumar A. Wernicke encephalopathy after bariatric surgery – A systematic review. Neurology 2007;68:807-11.  Back to cited text no. 4
Renna R, Plantone F, Plantone D. A case of hemorrhagic Wernicke's encephalopathy following gastric surgery. Neurol India 2012;60:453-4.  Back to cited text no. 5
  [Full text]  
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. 6
[PUBMED]  [Full text]  
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. 7


  [Figure 1]


Print this article  Email this article
Online since 20th March '04
Published by Wolters Kluwer - Medknow