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NEUROIMAGE
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
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355186

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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)

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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.

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  References Top

1.
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
    
2.
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
    
3.
Aasheim ET. Wernicke encephalopathy after bariatric surgery – A systematic review. Ann Surg 2008;248:714-20.  Back to cited text no. 3
    
4.
Singh S, Kumar A. Wernicke encephalopathy after bariatric surgery – A systematic review. Neurology 2007;68:807-11.  Back to cited text no. 4
    
5.
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]  
6.
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]  
7.
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
    


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