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Images in Neurology
May 2004

Wernicke Encephalopathy

Arch Neurol. 2004;61(5):775-776. doi:10.1001/archneur.61.5.775

A 50-year-old woman was admitted to the hospital with dyspnea and pancytopenia after autologous stem cell transplantation for multiple myeloma. Her hospitalization was complicated by poor oral intake and nausea and vomiting from a previously diagnosed villous adenoma with gastrointestinal bleeding. Over 2 weeks, she became lethargic, inattentive, and disoriented. She could not count fingers at 1 foot, had pale optic discs, poor abduction of the left eye, horizontal end-gaze nystagmus, and postural tremor. She could not register 3 words at 10 seconds. One day after receiving intravenous thiamine, she was alert, attentive, registered 3 words, had full extraocular movements, and visual acuity of 20/50 OD and 20/40 OS. Within 72 hours, she was oriented to person and place but was unable to recall 3 words at 1 minute. Magnetic resonance imaging of the brain showed increased signal in the optic chiasm and mamillary bodies on fluid-attenuated inversion recovery images (Figure 1, A [arrow]). The mamillary bodies were enhanced following contrast injection on T1-weighted images (Figure 1, C [arrow]), typical of Wernicke encephalopathy (WE). Noncontrasted T1-weighted images (Figure 1, B) were normal. Other areas that may be involved in WE include the periaqueductal gray matter, medial thalamus, hypothalamus, and the floor of the fourth ventricle. Some authors suggest that if contrast is not given, the diagnosis of WE may be missed on magnetic resonance imaging.1