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Case

A 33-year-old man with stomach carcinoma presented with sudden-onset diplopia preceded by vomiting, anorexia, and weight loss for 3 months. He had upbeat nystagmus (UBN) and mild gait ataxia. Magnetic resonance imaging (MRI) showed bilateral medial thalami involvement suggesting Wernicke's encephalopathy (WE). UBN is an important diagnostic clue for WE and frequently results from the damage to the perihypoglossal complex (nucleus intercalatus and nucleus of Roller) in the dorsal medulla. UBN in WE may switch to downbeat nystagmus during convergence, change in the direction of gaze, or with vestibular stimuli.¹ MRI typically shows T2 hyperintensity in medial thalamus, hypothalamus, periaqueductal region, floor of the fourth ventricle and mammillary bodies with/without diffusion restriction.²

Video Legend

Upbeat nystagmus (UBN) in the primary position (straight ahead gaze), right, left, up and down gaze; suppressed by convergence. After treatment with high dose intravenous thiamine, his UBN improved.

Figure 1

MR imaging of the patient. T2W coronal (A), diffusion weighted image (DWI) coronal (B) and DWI axial (C) showing bilateral symmetric medial thalami hyperintensity with low values in apparent diffusion coefficient (ADC) maps (D) suggesting diffusion restriction.

References

1. Kattah JC, McClelland C, Zee DS. Vertical nystagmus in Wernicke's encephalopathy: pathogenesis and role of central processing of information from the otoliths. J Neurol. 2019;266(Suppl 1):139-145; doi: 10.1007/s00415-019-09326-9
2. Ota Y, Capizzano AA, Moritani T, Naganawa S, Kurokawa R, Srinivasan A. Comprehensive review of Wernicke encephalopathy: pathophysiology, clinical symptoms and imaging findings. Jpn J Radiol. 2020;38(9):809-820; doi: 10.1007/s11604-020-00989-3

Authors

Asish Vijayaraghavan, Comprehensive Neuro-Intensive Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India; Lakshmi J Nair, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India; Soumya Sundaram, Comprehensive Neuro-Intensive Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India

Disclosures

The authors report no disclosures.