Wernicke encephalopathy with cerebellar involvement
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Two-week history of weakness, ataxia and dysarthria. On examination, there was bilateral nystagmus (vertical and horizontal). Background of heavy alcohol intake.
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There is increased FLAIR signal in the superior cerebellum bilaterally including the vermis. This is associated with high signal on the B=1000 imaging and mild associated low signal on the ADC map. Additionally, there is high signal on the B value imaging in the medial thalami.
Given the clinical presentation, alcohol history and low thiamine levels, the patient was diagnosed with Wernicke encephalopathy with atypical imaging features. The patient was treated with thiamine and improved clinically and radiologically. MRI 10 days after the initial study showed no progression, with some mild improvement.
Wernicke encephalopathy affecting the cerebellum is an atypical presentation 1. Typically, Wernicke encephalopathy affects the medial thalami, mammillary bodies, tectal plate and periaqueductal areas.
The distribution would be unusual for infarction, involving both superior cerebellar arteries but not the posterior cerebral artery territory or brainstem.