Wernicke-Korsakoff Syndrome Workup

  • Author: Glen L Xiong, MD; Chief Editor: David Bienenfeld, MD   more...
 
Updated: Sep 15, 2011
 

Approach Considerations

Initial laboratory studies are directed at the differential diagnostic possibilities that can be identified and corrected rapidly.

Maintain a high level of suspicion for thiamine deficiency to avoid iatrogenic precipitation of Wernicke-Korsakoff syndrome. Heightened awareness should lead to prophylactic supplementation in at-risk patients.

This syndrome is most commonly observed in patients with alcoholism. Consequently, when these patients present to an emergency department, they are routinely administered thiamine prior to glucose infusion.

Several other categories of patients are at increased risk for thiamine deficiency, including inpatients receiving total parental nutrition, which necessitates vigilant monitoring for indicative signs and symptoms to ensure prompt treatment.

Coding

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) does not consider Wernicke-Korsakoff syndrome as a distinct entity. However, if dementia is prominent, for Axis I purposes, dementia due to [General Medical Condition] (294.1) may be used for coding purposes. If acute confusion is prominent, then the code for delirium [due to medical condition] (293.0) may be considered.

The International Statistical Classification of Diseases and Related Health Problems (ICD-9) code includes (291.1) Alcohol-induced persisting amnestic disorder; Wernicke-Korsakoff Syndrome (alcohol). Since the ICD-9 codes link the diagnosis to alcohol-related conditions, non-alcohol associated Wernicke-Korsakoff syndrome would require other nonspecific codes, eg, (265.1) Other and unspecified manifestations of thiamine deficiency; Other vitamin B-1 deficiency states.

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Laboratory Tests

Laboratory studies to detect various morbidities in the diagnosis of Wernicke-Korsakoff syndrome include the following:

  • Electrolytes - To rule out an acute metabolic derangement causing mental confusion
  • Complete blood count (CBC) - To rule out an acute infectious process, thrombocytosis, or erythrocytosis predisposing to thrombosis and infarction
  • Coagulation panel - To evaluate for a potential bleeding diathesis
  • Arterial blood gas - To evaluate for hypoxemia, hypercarbia, acidosis, or alkalosis
  • Serum/urine toxic drug screen - To rule out acute toxic ingestion; this is most helpful if results are available rapidly
  • Liver-associated enzymes - May provide evidence of alcohol abuse or liver dysfunction

Serum thiamine levels

Serum thiamine levels have been used in case reports to confirm Wernicke-Korsakoff syndrome. However, studies have not directly examined the correlation between a critical serum thiamine level and the development of neurologic symptoms and Wernicke-Korsakoff syndrome itself. One small study did show that the serum thiamine level correlated well with cerebellar vermal atrophy.[12] For now, the role of serum thiamine levels remains uncertain, although it may eventually play a part in confirming the diagnosis of Wernicke-Korsakoff syndrome and/or monitoring adequacy of treatment.

Lumbar puncture/CSF analysis

Seriously consider this procedure for any confused patient with fever and/or headache, particularly elderly patients, to rule out an infectious etiology. Patients with Wernicke-Korsakoff syndrome have a protein content that is within the reference range or mildly elevated without pleocytosis on CSF analysis.

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Imaging Studies

CT brain scan (noncontrast)

Computed tomography (CT) scanning can help in the rapid assessment for hemorrhage, mass effect, edema, and large, subacute stroke.

MRI of the brain with contrast

Magnetic resonance imaging (MRI) demonstrates acute lesions of Wernicke-Korsakoff syndrome in the dorsal medial thalamic, periventricular region of the third ventricle, periaqueductal area, mamillary bodies, and dorsal medulla. Contrast enhancement of the mamillary bodies were correlated with alcohol[13] and nonalcoholic causes,[14] so whether MRI findings may be specific to the etiology of Wernicke-Korsakoff Syndrome remains uncertain.

MRI can be a useful diagnostic procedure in patients presenting with a suggestive history and stupor or coma, in whom ataxia and ophthalmoplegia are not detectable.

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Contributor Information and Disclosures
Author

Glen L Xiong, MD  Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California Davis School of Medicine; Attending Psychiatrist, Sacramento Mental Health Treatment Center; Attending Physician, Sacramento County Primary Care Clinic

Glen L Xiong, MD is a member of the following medical societies: American College of Physicians, American Psychiatric Association, and Sierra Sacramento Valley Medical Society

Disclosure: Lippincott Williams & Wilkins Royalty Book Editor; PGxHealth Consulting fee Consulting; National Alliance for Research in Schizophrenia and Depression Grant/research funds Independent contractor

Coauthor(s)

G Patrick Daubert, MD  Assistant Professor, Assistant Medical Director, Sacramento Division, California Poison Control System; Director of Clinical and Medical Toxicology Education, Department of Emergency Medicine, University of California, Davis Medical Center

G Patrick Daubert, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Alan DeAngelo, MD, and Alan Halliday, MD, to the development and writing of the source article.

References

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  13. Zuccoli G, Gallucci M, Capellades J, Regnicolo L, Tumiati B, Giadas TC, et al. Wernicke encephalopathy: MR findings at clinical presentation in twenty-six alcoholic and nonalcoholic patients. AJNR Am J Neuroradiol. Aug 2007;28(7):1328-31. [Medline].

  14. Fei GQ, Zhong C, Jin L, Wang J, Zhang Y, Zheng X, et al. Clinical characteristics and MR imaging features of nonalcoholic Wernicke encephalopathy. AJNR Am J Neuroradiol. Jan 2008;29(1):164-9. [Medline].

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