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Alcoholic Encephalopathy


KEY FACTS

Terminology

  • Acute/subacute/chronic toxic effects of EtOH on CNS

    • Wernicke encephalopathy (WE)

    • Marchifava-Bignami disease (MBD)

Imaging

  • EtOH: Disproportionate superior vermian atrophy, enlargement of lateral ventricles, sulci with chronic EtOH

  • WE: Mammillary body, medial thalamus, hypothalamus, periaqueductal gray abnormal signal/enhancement/diffusion restriction

  • MBD: Abnormal signal and later necrosis in corpus callosum

Top Differential Diagnoses

  • Nonalcoholic atrophy

  • Demyelination (toxic, acquired/inherited metabolic)

  • Corpus callosal hyperintensity

    • Status epilepticus

    • Drug toxicity

    • Encephalitis

    • Hypoglycemia

Pathology

  • EtOH: Causes both direct/indirect neurotoxicity

  • WE: Thiamine (vitamin B1) deficiency

  • WE can be alcoholic or nonalcoholic

  • MBD: Chronic EtOH abuse, anecdotal association with red wine

Clinical Issues

  • WE: Triad of ataxia, oculomotor abnormalities, confusion

  • Classic clinical triad present in only minority of patients

  • EtOH: Cessation, establishment of adequate nutrition

  • WE: Immediate administration of IV thiamine → quick response

Diagnostic Checklist

  • 50% of WE cases occur in nonalcoholics, including children!

    • Nutritional deficiency, after gastric bypass, etc.

Sagittal graphic shows generalized and superior vermian atrophy
, as well as necrosis in the mid-corpus callosum
related to alcoholic toxicity. Mammillary body
, periaqueductal gray necrosis
is seen with Wernicke encephalopathy.

Coronal T2WI MR demonstrates pronounced cerebellar atrophy with enlarged 4th ventricle
, markedly enlarged cerebellar fissures
.

Sagittal T1WI MR shows a classic finding for Marchiafava-Bignami disease with a thinned corpus callosum and hypointensity in the middle layers
. Note that the genu, body, and splenium are all involved.

(Courtesy A. Datir, MD.)

Axial DWI MR shows restricted diffusion in the mammillary bodies
in this patient with acute Wernicke encephalopathy.

TERMINOLOGY

Abbreviations

  • Alcoholic (EtOH) encephalopathy

  • Wernicke encephalopathy (WE)

  • Marchiafava-Bignami disease (MBD)

Definitions

  • Acute, subacute, or chronic toxic effects of EtOH on CNS

  • Can be primary (direct) or secondary (indirect)

    • Primary (direct) effects of EtOH = neurotoxicity

      • –

        Cortical/cerebellar degeneration, peripheral polyneuropathy

    • Secondary (indirect) effects

      • –

        Trauma, malnutrition, coagulopathy

  • Rare treatable complication = WE

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