The importance of knowing the typical and atypical imaging findings of Wernicke encephalopathy
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LETTER TO THE EDITOR
The importance of knowing the typical and atypical imaging findings of Wernicke encephalopathy Giulio Zuccoli1 Received: 12 August 2020 / Accepted: 17 August 2020 © Belgian Neurological Society 2020
Keywords Wernicke encephalopathy · Thiamine · Wernicke–Korsakoff syndrome · MRI · Striatum · Extrapontine myelinolysis Dear Editor, I recently read the interesting paper published by Dr. Eren and Coll regarding the unique MR imaging presentation of Wernicke Encephalopathy (WE) on MR [1]. The patient described in the paper, presented with the clinical features of WE, and recovered after the administration of thiamine [1]. The case represents a success from a clinical standpoint and should be regarded as such. The medical community should always be reminded about the importance of a timely administration of thiamine to prevent the irreversible brain damage associated with untreated WE [2]. However, as a neuroradiologist, I would like to add some technical considerations. The brain MR images presented in support of the diagnosis of acute WE show remarkable bilateral symmetrical volume loss of the putamina and of the head of the caudate nucleus. The sum of these two anatomical structures is also known as the dorsal striatum. No restricted diffusion was reported [1]. Based on the described MR imaging features, there appears to be a clinical-radiological dissociation due to the lack of brain edema, and of the typical involvement of the central gray matter, that is invariably affected in acute WE [2]. The majority of acute WE patients present with edema in at least three of the “typical” neuroanatomical regions, likewise the (a) mamillary bodies, the (b) periventricular regions of the third ventricle, the (d) medial thalamic nuclei, and the (e) periaqueductal gray matter [2]. Furthermore, the * Giulio Zuccoli [email protected] 1
Program for the Study of Neurodevelopment in Rare Disorders (NDRD), University of Pittsburgh, Children Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA
MR imaging morphology of these lesions, which resemble a “butterfly” on coronal images, is pathognomonic for WE [2, 3]. These findings, based on my 20 year research experience of this disease, are better seen on fluid attenuated inversion recovery images (FLAIR). During the acute phase of the disease, “atypical” brain imaging findings, like those described at the level of the bilateral dorsal striatum by the authors [1], have been reported in the medical literature, but only and exclusively in association with the “typical” findings [2]. “Atypical” findings include bilateral alterations in the striatal nuclei, supra- and infra-tentorial cortex, cranial nerves nuclei, fornixes, and red nuclei [2]. Knowledge of these imaging findings may indeed save lives, particularly when clinical presentation is non-specific, since timely administration of thiamine may halt brain damage, thus preventing the development of Korsakoff Syndrome [3]. For these reasons and in my humble opinion, the case recently published
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