Teaching Neuro Images : Bilateral anterior thalami and fornix macrohemorrhage in Wernicke-Korsakoff syndrome

Abstract

A 55-year-old man with alcoholism required sigmoid resection for complicated diverticulitis. A few weeks after starting parenteral nutrition, he developed multidirectional gaze nystagmus, gait ataxia, and confusion, leading to the diagnosis of Wernicke encephalopathy. Thiamine treatment was started and his symptoms improved, helping to confirm the diagnosis. However, the patient developed memory loss consistent with Korsakoff syndrome due to hemorrhage involving the fornix and the bilateral anterior thalami (figure). More typical fluid-attenuated inversion recovery lesions (mamillary bodies, tectal plate, and periaqueductal area), which may be reversible, 1 were not seen. Macroscopic hemorrhage is rarely observed in Wernicke-Korsakoff syndrome 2,3 and is associated with poor prognosis. 3

Human alcohol-related neuropathology

“…KS is characteristically associated with deficits in forming memory and in the implementation of executive functions due to disruption of neuronal circuits in the thalamus, mammillary bodies, hippocampus, frontal lobes and cerebellum [72]. WKS neuroimaging reveals bilateral macro-hemorrhages in the anterior thalami and fornix [101]. However, with chronicity, KS may be more accurately diagnosed with 3-D MRI with voxel-based morphometry to demonstrate parahippocampal, hippocampal, and thalamic atrophy with enlargement of the third ventricle [94].…”

The Neurological Complications of Nutritional Deficiency following Bariatric Surgery

“…MRI patterns in these patients have been described and often include T2 prolongation in dorsomedial thalami and periaqueductal gray matter, enhancement of the mammillary bodies, and occasional diffusion restriction [ 39 ]. Hemorrhage involving the fornix and anterior thalami has also been seen on MRI imaging of a patient with Wernicke's encephalopathy [ 40 ]. Patients with Wernicke's encephalopathy have been shown to respond to intravenous thiamine administration [ 41 ].…”