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The vestibulo-ocular reflexes during head impulse in Wernicke’s encephalopathy
  1. Kwang-Dong Choi,
  2. Sun-Young Oh,
  3. Hyo-Jung Kim,
  4. Ji Soo Kim
  1. Department of Neurology, College of Medicine, Seoul National University, Seoul National University Bundang Hospital, Korea
  1. Dr Ji Soo Kim, Department of Neurology, College of Medicine, Seoul National University, Department of Neurology, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea; jisookim{at}snu.ac.kr

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Ocular motor findings in Wernicke’s encephalopathy (WE) include gaze evoked nystagmus (GEN), central positional nystagmus, weakness of abduction, internuclear ophthalmoplegia and horizontal or vertical gaze palsy to total ophthalmoplegia. Another feature of WE is vestibular paresis.1 2 Previous studies documented hypoactive vestibular responses to both caloric and rotational stimuli, and a short vestibulo-ocular reflex (VOR) time constant. To address differential susceptibility of individual semicircular canals (SCC) according to stimulation frequency, we measured high acceleration VOR of the individual SCC using head impulse manoeuvres, and the low frequency VOR using bithermal caloric and rotatory chair tests in two patients with WE.

Figure 1 (A) T2 weighted MRIs of patient No 1. Symmetrical hyperintense lesions are shown at dorsal portions of both the medulla, periaqueductal gray matter and medial portions of both thalami. (B) Bithermal caloric tests in patient No 1 show minimal responses in both ears initially (B-1), which markedly improved 6 months after thiamine replacement (B-2). (C) Head impulses in the plane of each semicircular canal (SCC) reveal severely impaired vestibulo-ocular reflexes (VOR) from both lateral SCCs while the VORs from the vertical SCCs are normal or minimally impaired. Normal data were obtained from 10 healthy subjects (seven men and three women, aged 29–70 years, mean 52.1 (SD 13.6) years) without a history of vestibular or neurological disorders.

Case reports

Patient No 1

A 63-year-old woman had undergone Whipple’s operation because of carcinoma of the ampulla of Vater 1 month previously and had received total parenteral nutrition (TPN). Two weeks after initiation of TPN, she began to suffer from anorexia, vomiting and vertigo which progressed to psychomotor slowing, apathy, forgetfulness and ataxia. On examination, she was awake but not attentive. She was fluent, but comprehension was impaired. The pupils were normal. Horizontal saccades were slowed and limited, and the limited ocular motor range did not improve with oculocephalic stimulation of the VOR. Other findings included horizontal GEN, limb dysmetria and severe truncal ataxia. T2 weighted …

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