Skip to main content
Advertisement

Main menu

  • Home
  • Content
    • Current Issue
    • Publication Preview--Ahead of Print
    • Past Issue Archive
    • Case of the Week Archive
    • Classic Case Archive
    • Case of the Month Archive
  • For Authors
  • About Us
    • About AJNR
    • Editors
    • American Society of Neuroradiology
  • Submit a Manuscript
  • Podcasts
    • Subscribe on iTunes
    • Subscribe on Stitcher
  • More
    • Subscribers
    • Permissions
    • Advertisers
    • Alerts
    • Feedback
  • Other Publications
    • ajnr

User menu

  • Subscribe
  • Alerts
  • Log in

Search

  • Advanced search
American Journal of Neuroradiology
American Journal of Neuroradiology

American Journal of Neuroradiology

  • Subscribe
  • Alerts
  • Log in

Advanced Search

  • Home
  • Content
    • Current Issue
    • Publication Preview--Ahead of Print
    • Past Issue Archive
    • Case of the Week Archive
    • Classic Case Archive
    • Case of the Month Archive
  • For Authors
  • About Us
    • About AJNR
    • Editors
    • American Society of Neuroradiology
  • Submit a Manuscript
  • Podcasts
    • Subscribe on iTunes
    • Subscribe on Stitcher
  • More
    • Subscribers
    • Permissions
    • Advertisers
    • Alerts
    • Feedback
  • Follow AJNR on Twitter
  • Visit AJNR on Facebook
  • Follow AJNR on Instagram
  • Join AJNR on LinkedIn
  • RSS Feeds
LetterLETTER

MR Imaging: An Increasingly Important Tool in the Early Diagnosis of Wernicke Encephalopathy

G. Zuccoli and N. Pipitone
American Journal of Neuroradiology June 2012, 33 (6) E92; DOI: https://doi.org/10.3174/ajnr.A3152
G. Zuccoli
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
N. Pipitone
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • References
  • PDF
Loading

The recent article by Ha et al published in the American Journal of Neuroradiology1 has rekindled the debate sparked by previous studies2⇓–4 that had linked atypical brain MR imaging findings to the nonalcoholic (NA) variant of Wernicke encephalopathy (WE). In unselected patients with WE, the anatomic regions most frequently involved by MR imaging are the medial thalami and the periventricular regions of the third ventricle.3 However, atypical MR imaging findings may also be observed, including symmetric alterations of the cerebellum, cerebral cortex, and cranial nerve nuclei (CNN).3,4 Atypical MR imaging findings usually occur in association with the typical MR imaging findings of WE.5 In the largest case series published to date encompassing 56 patients with WE, we detected atypical MR imaging changes more commonly in NA compared with patients with alcoholism (AL).4 In particular, involvement of CNN was seen in 32% of NA versus none of the AL patients.

In contrast to our findings, Ha et al1 found no significant differences in the distribution of typical and atypical MR imaging findings in AL and NA patients with WE. Both their1 and our studies are retrospective in design, and thus prone to incurring a selection bias due to the lack of predefined entry criteria. Therefore, the study populations may differ in some characteristics that cannot be determined a posteriori.

There are, however, some differences in the studies that may help to explain, at least in part, their different conclusions. First, our study included more than twice as many patients as the study by Ha et al.1 Sample size is invariably a critical issue because all other things being equal, studies with larger numbers of patients are more likely to arrive at significant results than those with fewer patients. In particular, if we consider only NA patients, our study included 3 times as many patients (n = 30) as the study by Ha et al (n = 11). Second, in our patients, MR imaging was performed in the acute stage of WE, whereas in the study by Ha et al, the mean interval between the onset of manifestations and performance of MR imaging was 4.5 days. This delay may have potentially resulted in some differences in the brain changes depicted by MR imaging. Third, 43% of our patients fulfilled the classic diagnostic triad of WE compared with 17% of the patients investigated by Ha et al, suggesting that our patients may have had, on average, more severe disease and thus a higher likelihood of having abnormal MR imaging findings. Fourth, Ha et al did not specifically identify CNN lesions except in 1 NA patient with involvement of CNN IX. However, they did show that 14 NA patients and 10 AL patients had active lesions in the dorsal medulla or in the periventricular gray matter of the fourth ventricle, which are sites where many CNN are located.1 Therefore, although CNN were not formally identified in the study by Ha et al,1 the findings of their study may, nevertheless, support the concept that CNN involvement is more common in NA patients, in agreement with our own3,4,6 and the findings of others.2,7 The involvement of CNN IX reported by Han et al is a particularly intriguing finding, both because this specific CNN has not previously been shown to be involved in WE4,8 and because CNN IX is notoriously difficult to distinguish from neighboring nuclei. It would be interesting to have a chance to review the images on the basis of which CNN IX involvement was diagnosed.

We concur with Ha et al1 that thiamine deficiency is a crucial component in the pathogenesis of WE and that prompt treatment with thiamine can avert a dismal prognosis. At risk patients should thus receive thiamine regardless of whether they are hospitalized. However, we would also like to suggest that other factors, including alcohol intake, may modulate the expression of WE.5 Until data from prospective studies become available, we think that the current body of evidence still supports the notion that MR imaging findings in NA patients differ, at least in part, from those of AL patients with WE. Most important, both our study4 and the one by Ha et al1 clearly demonstrate that the spectrum of radiographic alterations is broader than that of “classic” changes. Therefore, radiologists should be aware that WE may present with both typical and atypical findings. At least equally important, despite the partial discrepancies in the results published, the role of MR imaging in clinching an early diagnosis of WE is fully confirmed.

References

  1. 1.↵
    1. Ha ND,
    2. Weon YC,
    3. Jang JC,
    4. et al
    . Spectrum of MR imaging findings in Wernicke encephalopathy: are atypical areas of involvement only present in nonalcoholic patients? AJNR Am J Neuroradiol 2012 Mar 1. [Epub ahead of print]
  2. 2.↵
    1. Bae SJ,
    2. Lee HK,
    3. Lee JH,
    4. et al
    . Wernicke's encephalopathy: atypical manifestation at MR imaging. AJNR Am J Neuroradiol 2001; 22: 1480– 82
    Abstract/FREE Full Text
  3. 3.↵
    1. Zuccoli G,
    2. Gallucci M,
    3. Capellades J,
    4. et al
    . Wernicke encephalopathy: MR findings at clinical presentation in 26 alcoholic and nonalcoholic patients. AJNR Am J Neuroradiol 2007; 28: 1328– 31
    Abstract/FREE Full Text
  4. 4.↵
    1. Zuccoli G,
    2. Santa CD,
    3. Bertolini M,
    4. et al
    . MR imaging findings in 56 patients with Wernicke encephalopathy: nonalcoholics may differ from alcoholics. AJNR Am J Neuroradiol 2009; 30: 171– 76
    Abstract/FREE Full Text
  5. 5.↵
    1. Zuccoli G,
    2. Pipitone N
    . Neuroimaging findings in acute Wernicke's encephalopathy: review of the literature. AJR Am J Roentgenol 2009; 192: 501– 08
    CrossRefPubMed
  6. 6.↵
    1. Zuccoli G,
    2. Motti L
    . Atypical Wernicke's encephalopathy showing lesions in the cranial nerve nuclei and cerebellum. J Neuroimaging 2008; 18: 194– 97
    PubMed
  7. 7.↵
    1. Hygino da Cruz LC Jr.,
    2. Domingues RC,
    3. Vilanova I,
    4. et al
    . MR imaging findings in Wernicke encephalopathy: nonalcoholics may be similar to alcoholics. AJNR Am J Neuroradiol 2010; 31: E54– 55
    FREE Full Text
  8. 8.↵
    1. Santos AC,
    2. Tavares LL,
    3. da Graca Morais MM,
    4. et al
    . Non-alcoholic Wernicke's encephalopathy: broadening the clinicoradiological spectrum. Br J Radiol 2010; 83: 437– 46
    Abstract/FREE Full Text
  • © 2012 by American Journal of Neuroradiology
PreviousNext
Back to top

In this issue

American Journal of Neuroradiology: 33 (6)
American Journal of Neuroradiology
Vol. 33, Issue 6
1 Jun 2012
  • Table of Contents
  • Index by author
Advertisement
Print
Download PDF
Email Article

Thank you for your interest in spreading the word on American Journal of Neuroradiology.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
MR Imaging: An Increasingly Important Tool in the Early Diagnosis of Wernicke Encephalopathy
(Your Name) has sent you a message from American Journal of Neuroradiology
(Your Name) thought you would like to see the American Journal of Neuroradiology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
MR Imaging: An Increasingly Important Tool in the Early Diagnosis of Wernicke Encephalopathy
G. Zuccoli, N. Pipitone
American Journal of Neuroradiology Jun 2012, 33 (6) E92; DOI: 10.3174/ajnr.A3152

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
MR Imaging: An Increasingly Important Tool in the Early Diagnosis of Wernicke Encephalopathy
G. Zuccoli, N. Pipitone
American Journal of Neuroradiology Jun 2012, 33 (6) E92; DOI: 10.3174/ajnr.A3152
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
Purchase

Jump to section

  • Article
    • References
  • Info & Metrics
  • References
  • PDF

Related Articles

  • Reply:
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Crossref
  • Google Scholar

This article has not yet been cited by articles in journals that are participating in Crossref Cited-by Linking.

More in this TOC Section

  • Pattern Recognition in Mitochondrial Leukodystrophies is Hampered by the Peculiarities of Mitochondrial Genetics
  • Callosal Angle Narrowing in Research Data Bases of the Cognitively Impaired
  • Reply:
Show more Letters

Similar Articles

Advertisement

News and Updates

  • Lucien Levy Best Research Article Award
  • Thanks to our 2021 Distinguished Reviewers
  • Press Releases

Resources

  • Evidence-Based Medicine Level Guide
  • How to Participate in a Tweet Chat
  • AJNR Podcast Archive
  • Ideas for Publicizing Your Research
  • Librarian Resources
  • Terms and Conditions

Opportunities

  • Share Your Art in Perspectives
  • Get Peer Review Credit from Publons
  • Moderate a Tweet Chat

American Society of Neuroradiology

  • Neurographics
  • ASNR Annual Meeting
  • Fellowship Portal
  • Position Statements

© 2022 by the American Society of Neuroradiology | Print ISSN: 0195-6108 Online ISSN: 1936-959X

Powered by HighWire