The Banana Bag: Small Potatoes against

1
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The Banana Bag Small Potatoes against
Wernickes Encephalopathy
Neha Patel MD, Devika Das MD, Selena Stuart MD,
Analia Castiglioni MD The University of Alabama
at Birmingham


Case Description
Objectives
Take Home Points
Hospitalization 1
Hospitalization 2

• To recognize that Wernickes encephalopathy can
  present with encephalopathy alone
• To understand the utility of neuroimaging in the
  diagnosis of Wernickes encephalopathy
• To review thiamine repletion guidelines for
  suspected cases of Wernickes encephalopathy

• Wernickes encephalopathy often manifests as
  encephalopathy alone, without cerebellar ataxia
  or ophthalmoplegia
• Although MRI neuroimaging may support a diagnosis
  of WE, it should not be used to exclude a
  diagnosis of WE given its low sensitivity
• Patients at high-risk for WE warrant high-dose
  thiamine repletion when presenting with
  encephalopathy banana bags do not suffice

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
55 year old man with alcoholism admitted with
encephalopathy and ataxia no neurological
deficits
Discharged in usual state of health after 7 days
Readmitted within 48 hrs with encephalopathy and
ataxia new findings of lateral gaze palsy,
confabulation, and nystagmus
() EtOH, (-) UDS
CBC/CMP wnl Head CT wnl
MRI findings of Wernickes encephalopathy
() EtOH, (-) UDS
CBC/CMP wnl Head CT wnl
Treated for alcohol intoxication with
benzodiazepines prn and banana bags with 100mg
IV thiamine daily x 7 days
Treated for WE with 500mg IV thiamine daily with
rapid resolution of symptoms in 8 days




Overview of Wernickes Encephalopathy
References
Treatment
Diagnosis
The Classic Triad of Wernickes

• Kopelman M, Thomson A, Guerrini I. The
  Korsakoff Syndrome Clinical Aspects, Psychology
  and Treatment. Alcohol Alcoholism. Vol. 44,
  No.2, pp. 148-154, 2009.
• G, Pipitone N. Neuroimaging Findings in Acute
  Wernickes Encephalopathy Review of the
  Literature. American Journal of Roentgenology.
  Vol. 192, Feb 2009.
• Thomson A, Guerrini I, Marshall E. Wernickes
  Encephalopathy Role of Thiamine. Practical
  Gastroenterology. Series 75, pp. 21-30, 2009.
• Martin PR, Singleton CK, Hiller-Sturmhöfel S.
  The role of thiamine deficiency in alcoholic
  brain disease. Alcohol Res Health. 2003
  27134.
• Heap LC, Pratt OE, Ward RJ, et al. Individual
  susceptibility to Wernicke-Korsakoff syndrome and
  alcoholism-induced cognitive deficit impaired
  thiamine utilization found in alcoholics and
  alcohol abusers. Psychiatr Genet. 2002
  12217.

• For high-risk patients (i.e. alcoholics)
  presenting with encephalopathy
• Thiamine 250mg IM/IV daily for 3-5 days (banana
  bags do not suffice)
• If a definitive diagnosis of WE is established
• Thiamine 500mg IM/IV daily for 2-3 days, then
  250mg daily for 3-5 days, then daily
  supplementation

• Usually a clinical diagnosis
• Neuroimaging has a limited role
• Head CT offers negligible detection
• MRI only 53 sensitive
• Findings suggestive of WE include increased
  signaling in mamillary bodies, periaqueductal
  area, and thalamus

• Wernickes encephalopathy (WE) is a serious yet
  reversible sequelae of alcoholism resulting from
  profound thiamine depletion
• Untreated, up to 20 of cases result in fatality,
  and 85 of survivors develop irreparable brain
  damage, i.e. the Korsakoff syndrome

• Only 20 of cases manifest with the classic
  triad
• Majority of cases present only with
  encephalopathy (i.e. hospitalization 1)

ophthalmoplegia
cerebellar ataxia
encephalopathy