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Clinical Atlas Prestige · Evidence-first

Psych MEQs / SAQsAddiction psychiatry

Psych MEQs / SAQs · Addiction psychiatry

Alcohol-related brain injury and Korsakoff — Wernicke emergency to long-term care (MEQ)

FRANZCP-style MEQ on ARBI spectrum, Caine/Wernicke, parenteral thiamine EFNS vs UK high-dose teaching, MRI, Korsakoff neuropsychology, long-term ARBD care.

20 marks20 min
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
A 54-year-old man with twenty-five years of heavy drinking is brought from a hostel. He is thin, has horizontal nystagmus and gait ataxia, and is intermittently disoriented. Last drink was about 30 hours ago; he is tremulous and sweaty. CT head is reported normal. Nursing staff ask whether oral thiamine tablets are enough and whether he has Alzheimer disease because he invents answers about breakfast. (i) Define ARBI, Wernicke encephalopathy, and Korsakoff syndrome and state how they relate. (ii) Apply Caine criteria to this case and list key differentials including coexistent withdrawal. (iii) Detail acute thiamine and supportive management with named doses/routes and regional teaching points. (iv) Outline investigation strategy including MRI role and limitations. (v) Plan long-term care, capacity, and disposition once medically stable. (20 marks)

Model answer

Reveal model answer

(i) Definitions. ARBI/ARBD is the umbrella for lasting cognitive, behavioural, and structural brain sequelae of heavy alcohol use. Wernicke encephalopathy is the acute thiamine-deficiency emergency. Korsakoff syndrome is residual disproportionate amnesia (often after WE), not a synonym for all ARBI. Confabulation may occur but is not required for KS.[4][5]

(ii) Caine and differentials. Features: malnutrition, oculomotor (nystagmus), cerebellar (ataxia), altered mental state — at least two (here more) → treat as WE now.[1] Differentials/coexistents: alcohol withdrawal/DT (tremor, diaphoresis, ~30 h), head injury (normal CT lowers but does not exclude subtle injury), hypoglycaemia, infection, hepatic encephalopathy, primary dementia (less likely as first label in this acute nutritional–alcohol context).[2][5]

(iii) Acute management. Immediate high-dose parenteral thiamine multi-day: EFNS teaching 200 mg IV TDS (preferably IV, before carbohydrate); many UK/hospital protocols use higher intensity (often taught ~500 mg IV TDS / high-dose Pabrinex pairs for established WE) then step-down to oral (e.g. 100 mg TDS) while risk persists. Oral tablets alone are inadequate for suspected WE.[2][3] Replete Mg/K/phosphate; give glucose with thiamine cover if hypoglycaemic; benzodiazepines for withdrawal physiology; falls/aspiration precautions; continuous monitoring.[2][3]

(iv) Investigations. Do not delay thiamine for labs/MRI. Bloods including Mg; consider thiamine level before first dose if it will not delay treatment. MRI may support (mammillary bodies, medial thalami, periaqueductal grey); normal CT does not exclude WE.[2][6] Formal neuropsychology later if KS/ARBI residual.

(v) Long-term care. Complete thiamine course; abstinence and addiction pathway; cognitive rehab (errorless learning, external aids); nutrition; capacity assessment for finances/discharge; ARBD community/supported housing services; carer education; safeguard against exploitation. Do not default to Alzheimer pharmacology for KS amnesia.[4][7][8]

Common errors

  • Waiting for the full classic triad
  • Accepting oral thiamine only because CT is normal
  • Equating confabulation with malingering or with Alzheimer disease
  • No named parenteral dose/route or no withdrawal co-management
  • No capacity or supported living plan for dense amnesia
[1] [2] [4]

References

  1. [1]Caine D, Halliday GM, Kril JJ, et al. Operational criteria for the classification of chronic alcoholics: identification of Wernicke's encephalopathy. J Neurol Neurosurg Psychiatry, 1997.PMID 9010400
  2. [2]Galvin R, Bråthen G, Ivashynka A, et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. Eur J Neurol, 2010.PMID 20642790
  3. [3]Thomson AD, Cook CC, Touquet R, et al. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke's encephalopathy in the accident and Emergency Department. Alcohol Alcohol, 2002.PMID 12414541
  4. [4]Kopelman MD, Thomson AD, Guerrini I, et al. The Korsakoff syndrome: clinical aspects, psychology and treatment. Alcohol Alcohol, 2009.PMID 19151162
  5. [5]Zahr NM, Kaufman KL, Harper CG Clinical and pathological features of alcohol-related brain damage. Nat Rev Neurol, 2011.PMID 21487421
  6. [6]Sullivan EV, Pfefferbaum A Neuroimaging of the Wernicke-Korsakoff syndrome. Alcohol Alcohol, 2009.PMID 19066199
  7. [7]Svanberg J, Evans JJ Neuropsychological rehabilitation in alcohol-related brain damage: a systematic review. Alcohol Alcohol, 2013.PMID 23955833
  8. [8]Wilson K, Halsey A, Macpherson H, et al. The psycho-social rehabilitation of patients with alcohol-related brain damage in the community. Alcohol Alcohol, 2012.PMID 22278316