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Clinical Atlas Prestige · Evidence-first

Psych VivasAddiction psychiatry

Psych Vivas · Addiction psychiatry

Alcohol-related brain injury and Korsakoff — structured clinical viva

Fellowship viva on Caine criteria, parenteral thiamine EFNS/UK teaching, MRI limits, KS amnesia, capacity, ARBD rehabilitation.

clinical
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Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar called to the medical ward. A 49-year-old with severe alcohol dependence day two of admission has nystagmus, ataxia, fluctuating orientation, and confabulates about working in the hospital kitchen. Junior staff gave oral thiamine 100 mg once and want MRI before 'stronger vitamins'. His partner asks whether he has early Alzheimer disease and whether he can sign a tenancy agreement tomorrow. Defend diagnosis, emergency thiamine strategy with doses, imaging role, Korsakoff versus ARBI language, capacity, and long-term care.

Interpretation

Reveal interpretation

Working diagnosis. Probable Wernicke encephalopathy (malnutrition risk + oculomotor + cerebellar + altered mental state — Caine met) with evolving or concurrent Korsakoff-range amnestic features (confabulation, orientation failure). May coexist with alcohol withdrawal. This is not first-label Alzheimer disease.[1][4][5]

Immediate action. Stop under-treatment with low-dose oral-only thiamine for suspected WE. Start high-dose parenteral thiamine multi-day now (EFNS-style 200 mg IV TDS teaching; many protocols use higher ~500 mg IV TDS for established WE), replete Mg, manage withdrawal if present. Do not wait for MRI.[2][3]

Imaging. MRI can support (mammillary bodies, medial thalami, periaqueductal grey) but is adjunctive; normal imaging does not exclude early WE.[2][6]

Capacity. Dense amnesia/confabulation likely impairs retention and use of information for a tenancy agreement — formal capacity assessment, collateral, least-restrictive supports; delay binding decisions until stable and supported.[4][7]

Long-term. Abstinence, step-down oral thiamine while risk persists, neuropsychology, cognitive rehab, ARBD/supported living pathway, family education.[4][5][7]

Escalating viva probes

ProbeModel point
Caine criteriaAny 2 of 4 → treat as WE
Classic triad frequencyMinority of cases — trap
EFNS thiamine figure200 mg preferably IV TDS cited
UK high-dose teachingOften ~500 mg IV TDS / Pabrinex pairs for WE
KS definitionDisproportionate memory impairment
ConfabulationNeither necessary nor sufficient
MRI before thiamine?No — treat first
Alzheimer default?No — ARBI/KS pathway first

Key points

Treat on Caine

Two features in an at-risk patient = parenteral thiamine now.

Oral is not enough for WE

Suspected WE needs multi-day high-dose parenteral therapy.

KS is amnesia-first

Disproportionate memory deficit; confabulation optional; capacity often impaired.
[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]Arts NJ, Walvoort SJ, Kessels RP Korsakoff's syndrome: a critical review. Neuropsychiatr Dis Treat, 2017.PMID 29225466
  6. [6]Sullivan EV, Pfefferbaum A Neuroimaging of the Wernicke-Korsakoff syndrome. Alcohol Alcohol, 2009.PMID 19066199
  7. [7]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