La radiologia medica

, Volume 116, Issue 2, pp 319–333 | Cite as

CT and MRI of Wernicke’s encephalopathy

  • A. Cerase
  • E. Rubenni
  • A. Rufa
  • I. Vallone
  • P. Galluzzi
  • G. Coratti
  • F. Franchi
  • F. Giannini
  • C. Venturi
Neuroradiology / Neuroradiologia

Abstract

The purpose of this pictorial essay is to present the computed tomography (CT) and magnetic resonance imaging (MRI) findings of Wernicke’s encephalopathy, a rare, severe, acute neurological syndrome due to thiamine (vitamin B1) deficiency, associated with high morbidity and mortality. The classical clinical triad, which includes ocular signs, altered consciousness and ataxia, can be found in only one-third of patients. Although chronic alcoholic patients are the most commonly affected, Wernicke’s encephalopathy may complicate malnutrition conditions in nonalcoholic patients, in whom it is greatly underestimated. CT and above all MRI of the brain play a fundamental role in diagnosing the condition and ruling out other diseases. MRI is the most sensitive technique and is required in all patients with a clinical suspicion of Wernicke’s encephalopathy. Medial thalami, mamillary bodies, tegmentum, periaqueductal region, and tectal plate are typical sites of abnormal MRI signal. The dorsal medulla, red nuclei, cranial nerve nuclei, cerebellum, corpus callosum, frontal and parietal cerebral cortex are less common sites of involvement although they are more frequently affected in nonalcoholic patients. Paramagnetic contrast material may help to identify lesions not otherwise visible.

Keywords

Wernicke’s encephalopathy Computed tomography Magnetic resonance 

TC e RM dell’encefalopatia di Wernicke

Riassunto

Lo scopo di questa rassegna iconografica è presentare i possibili reperti alla tomografia computerizzata (TC) e alla risonanza magnetica (RM) dell’encefalopatia di Wernicke, una rara grave sindrome neurologica acuta da deficit di tiamina (vitamina B1), con elevate morbilità e mortalità. La triade sintomatologica classica comprende disturbi oculari, alterazioni della coscienza e atassia, ma si presenta soltanto in un terzo dei pazienti. L’encefalopatia di Wernicke colpisce più frequentemente soggetti etilisti cronici, ma può complicare molte condizioni di malnutrizione in soggetti non-etilisti cronici, nei quali è spesso sottostimata. Lo studio dell’encefalo mediante TC e, soprattutto, RM riveste un ruolo fondamentale nell’orientamento diagnostico e nell’esclusione di altra patologia. La RM presenta elevata sensibilità e deve quindi essere eseguita in tutti i pazienti con sospetto clinico di encefalopatia di Wernicke. Le sedi tipiche di alterazione del segnale RM sono nuclei mediali del talamo, corpi mammillari, tegmento, sostanza grigia periacqueduttale e lamina quadrigemina. Sedi meno tipiche di interessamento, e più frequentemente coinvolte nei pazienti non-etilisti, sono la porzione dorsale del bulbo, il nucleo rosso e i nuclei dei nervi cranici, il cervelletto, il corpo calloso e la corteccia fronto-parietale. Il mezzo di contrasto paramagnetico può mostrare la presenza di lesioni non altrimenti evidenti.

Parole chiave

Encefalopatia di Wernicke Tomografia computerizzata Risonanza magnetica 

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References/Bibliografia

  1. 1.
    Gayet CJA (1875) Affection encéphalique (encéphalite diffuse probable). Localisée aux étages superieurs des pédoncles cérébraux et aux couches optiques, ainsi qu’ou plancher due quatrième ventricule et aux parois laterales du troisième. Observation recueillie. Archives de physiologie normale et pathologique 2:341–351Google Scholar
  2. 2.
    Wernicke K (1881) Die acute, hämorrhagische polioencephalitis superior. In: Lehrbuch der gehirnkrankheiten fur aetzrzte und studirende. Kassel, Fischer, and Berlin 22:229–242Google Scholar
  3. 3.
    Korsakoff SS (1887) Disturbance of psychic function in alcoholic paralysis and its relationship to disturbance in the psychic sphere in multiple neuritis of non alcoholic origin. Vestnik Psichiatrii 1:V fascicleGoogle Scholar
  4. 4.
    Thomson AD, Cook CC, Guerrini I et al (2008) Wernicke’s encephalopathy revisited. Translation of the case history section of the original manuscript by Carl Wernicke ‘Lehrbuch der Gehirnkrankheiten fur Aerzte and Studirende’ (1881) with a commentary. Alcohol Alcohol 43:174–179PubMedGoogle Scholar
  5. 5.
    Thomson AD, Cook CC, Guerrini I et al (2008) Wernicke’s encephalopathy: ‘Plus ça change, plus c’est la mème chose’. Alcohol Alcohol 43:180–186PubMedGoogle Scholar
  6. 6.
    Caine D, Halliday GM, Kril JJ et al (1997) Operational criteria for the classification of chronic alcoholics: identification of Wernicke’s encephalopathy. J Neurol Neurosurg Psychiatry 62:51–60PubMedCrossRefGoogle Scholar
  7. 7.
    Thomson AD, Marshall EJ (2006) The natural history and pathophysiology of Wernicke’s encephalopathy and Korsakoff’s psychosis. Alcohol Alcohol 41:151–158PubMedGoogle Scholar
  8. 8.
    Donnino MW, Vega J, Miller J et al (2007) Myths and misconceptions of Wernicke’s encephalopathy: what every emergency physician should know. Ann Emerg Med 50:715–721PubMedCrossRefGoogle Scholar
  9. 9.
    Sechi G, Serra A (2007) Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol 6:442–455PubMedCrossRefGoogle Scholar
  10. 10.
    Gallucci M, Bozzao A, Splendiani A et al (1990) Wernicke encephalopathy: MR findings in five patients. AJNR Am J Neuroradiol 11:887–892/10bis. Gallucci M, Bozzao A, Splendiani A et al (1990) Wernicke encephalopathy: MR findings in five patients. AJR Am J Roentgenol 155:1309–1314PubMedGoogle Scholar
  11. 11.
    Tessa C, Simonelli P, Mascalchi M et al (1997) Esiste impregnazione contrastografica nell’encefalopatia di Wernicke in fase acuta? Descrizione di 3 casi e revisione della letteratura. Rivista di Neuroradiologia 10(Suppl. 2):52Google Scholar
  12. 12.
    Antunez E, Estruch R, Cardenal C et al (1998) Usefulness of CT and MR imaging in the diagnosis of acute Wernicke’s encephalopathy. AJR Am J Roentgenol 171:1131–1137PubMedGoogle Scholar
  13. 13.
    Pagnan L, Berlot G, Pozzi-Mucelli RS (1998) Magnetic resonance imaging in a case of Wernicke’s encephalopathy. Eur Radiol 8:977–980PubMedCrossRefGoogle Scholar
  14. 14.
    D’Aprile P, Tarantino A, Santoro N et al (2000) Wernicke’s encephalopathy induced by total parenteral nutrition in patient with acute leukaemia: unusual involvement of caudate nuclei and cerebral cortex on MRI. Neuroradiology 42:781–783PubMedCrossRefGoogle Scholar
  15. 15.
    Chu K, Kang DW, Kim HJ et al (2002). Diffusion-weighted imaging abnormalities in Wernicke encephalopathy. Reversible cytotoxic edema? Arch Neurol 59:123–127PubMedCrossRefGoogle Scholar
  16. 16.
    Mascalchi M, Belli G, Guerrini L et al (2002) Proton MR spectroscopy of Wernicke encephalopathy. AJNR Am J Neuroradiol 23:1803–1806PubMedGoogle Scholar
  17. 17.
    Rugilo CA, Uribe Roca MC, Zurru MC et al (2003) Proton MR spectroscopy in Wernicke Encephalopathy. AJNR Am J Neuroradiol 24:952–955PubMedGoogle Scholar
  18. 18.
    Tartaglione T, Monteforte MG, Gaudino S et al (2003) Encefalopatia di Wernicke in pazienti non alcoolisti. Valutazione retrospettiva della nostra casistica. Rivista di Neuroradiologia 16(Suppl. 1):47Google Scholar
  19. 19.
    Weidauer S, Nichtweiss M, Lanfermann H et al (2003) Wernicke encephalopathy: MR findings and clinical presentation. Eur Radiol 13:1001–1009PubMedGoogle Scholar
  20. 20.
    Lee ST, Jung YM, Na DL et al (2005) Corpus callosum atrophy in Wernicke’s encephalopathy. J Neuroimaging 15:367–372PubMedGoogle Scholar
  21. 21.
    Kornreich L, Bron-Harlev E, Hoffmann C et al (2005) Thiamine deficiency in infants: MR findings in the brain. AJNR Am J Neuroradiol 26:1668–1674PubMedGoogle Scholar
  22. 22.
    Loh Y, Watson WD, Verma A et al (2005) Restricted diffusion of the splenium in acute Wernicke’s encephalopathy. J Neuroimaging 15:373–375PubMedGoogle Scholar
  23. 23.
    Moritani T, Smoker RK, Sato Y et al (2005) Diffusion-weighted imaging of acute excitotoxic brain injury. AJNR Am J Neuroradiol 26:216–228PubMedGoogle Scholar
  24. 24.
    White ML, Zhang Y, Andrew LG et al (2005) MR Imaging with diffusionweighted imaging in acute and chronic Wernicke encephalopathy. AJNR Am J Neuroradiol 26:2306–2310PubMedGoogle Scholar
  25. 25.
    Lapergue B, Klein I, Olivot JM et al (2006) Diffusion-weighted imaging of cerebellar lesions in Wernicke’s encephalopathy. J Neuroradiol 33:126–128PubMedCrossRefGoogle Scholar
  26. 26.
    Fei G, Zhong C, Jin L et al (2008) Clinical characteristics and MR imaging features of nonalcoholic Wernicke encephalopathy. AJNR Am J Neuroradiol 29:164–169PubMedCrossRefGoogle Scholar
  27. 27.
    Helbok R, Beer R, Engelhardt K et al (2008) Intracerebral haemorrhage in a malnourished patient, related to Wernicke’s encephalopathy. Eur J Neurol 15:e99–e100PubMedCrossRefGoogle Scholar
  28. 28.
    Ohira M, Suzuki S, Takahashi S (2008) MR imaging can predict the development of nonalcoholic Wernicke encephalopathy. AJNR Am J Neuroradiol 29:E81–E82PubMedCrossRefGoogle Scholar
  29. 29.
    Roh JH, Kim JH, Koo Y et al (2008) Teaching NeuroImage: diverse MRI signal intensities with Wernicke encephalopathy. Neurology 70:e48PubMedCrossRefGoogle Scholar
  30. 30.
    Luigetti M, De Paulis S, Spinelli P et al (2009) Teaching NeuroImages: the full-blown neuroimaging of Wernicke encephalopathy. Neurology 72:e115PubMedCrossRefGoogle Scholar
  31. 31.
    Sullivan EV, Pfefferbaum A (2009) Neuroimaging of the Wernicke-Korsakoff syndrome. Alcohol Alcohol 44:155–165PubMedGoogle Scholar
  32. 32.
    Zuccoli G, Santa Cruz D, Bertolini M et al (2009) MR imaging findings in 56 patients with Wernicke encephalopathy: nonalcoholics may differ from alcoholics. AJNR Am J Neuroradiol 30:171–176PubMedCrossRefGoogle Scholar
  33. 33.
    Zuccoli G, Pipitone N (2009) Neuroimaging findings in acute Wernicke’s encephalopathy: review of the literature. AJR Am J Roentgenol 192:501–508PubMedCrossRefGoogle Scholar
  34. 34.
    Zuccoli G, Siddiqui N, Bailey A, Bartoletti SC (2010) Neuroimaging findings in pediatric Wernicke encephalopathy: a review. Neuroradiology 52:523–529PubMedCrossRefGoogle Scholar
  35. 35.
    Guerrini I, Thomson AD, Gurling HM (2009) Molecular genetics of alcoholrelated brain damage. Alcohol Alcohol 44:166–170PubMedGoogle Scholar
  36. 36.
    Suzuki S, Ichijo M, Fujii H et al (1996) Acute Wernicke’s encephalopathy: comparison of magnetic resonance images and autopsy findings. Internal Medicine 35:831–834PubMedCrossRefGoogle Scholar
  37. 37.
    Gui QP, Zhao WQ, Wang LN (2006) Wernicke’s encephalopathy in nonalcoholic patients: clinical and pathologic features of three cases and literature reviewed. Neuropathology 26:231–235PubMedCrossRefGoogle Scholar
  38. 38.
    Tallaksen CM, Bell H, Bøhmer T (1993) Thiamin and thiamin phosphate ester deficiency assessed by high performance liquid chromatography in four clinical cases of Wernicke encephalopathy. Alcohol Clin Exp Res 17:712–716PubMedCrossRefGoogle Scholar
  39. 39.
    Sorimachi T, Ito Y, Morita K et al (2008) Thin-section diffusion-weighted imaging of the infratentorium in patients with acute cerebral ischemia without apparent lesion on conventional diffusion-weighted imaging. Neurol Med Chir (Tokyo) 48:108–113CrossRefGoogle Scholar
  40. 40.
    Weon YC, Kim JH, Lee JS et al (2008) Optimal diffusion-weighted imaging protocol for lesion detection in transient global amnesia. AJNR Am J Neuroradiol 29:1324–1328PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2011

Authors and Affiliations

  • A. Cerase
    • 1
  • E. Rubenni
    • 2
  • A. Rufa
    • 3
  • I. Vallone
    • 1
  • P. Galluzzi
    • 1
  • G. Coratti
    • 4
  • F. Franchi
    • 4
  • F. Giannini
    • 5
  • C. Venturi
    • 1
  1. 1.UOC NINT Neuroimmagini e Neurointerventistica, Dipartimento di NeuroscienzeAzienda Ospedaliera Universitaria Senese, Policlinico “Santa Maria alle Scotte”SienaItaly
  2. 2.Dipartimento di Patologia Umana ed Oncologica, Sezione di Radiologia UniversitariaUniversità di Siena, Policlinico “Santa Maria alle Scotte”SienaItaly
  3. 3.UOC Neurologia Malattie Neurometaboliche, Dipartimento di Scienze Neurologiche, Neurochirurgiche e del ComportamentoUniversità di Siena, Policlinico “Santa Maria alle Scotte”SienaItaly
  4. 4.UOC Rianimazione Generale, Dipartimento di Terapia Intensiva e AnestesiaAzienda Ospedaliera Universitaria Senese, Policlinico “Santa Maria alle Scotte”SienaItaly
  5. 5.Dipartimento di Neuroscienze, Sezione di Neurologia, Università di SienaPoliclinico “Santa Maria alle Scotte”SienaItaly

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