FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Movement & neurodegeneration

Wernicke-Korsakoff syndrome

Thiamine (B1) deficiency (alcohol excess, hyperemesis, malnutrition)

Overview

A thiamine-deficiency neuropsychiatric emergency. Wernicke encephalopathy is the acute, REVERSIBLE triad (confusion, ophthalmoplegia, ataxia); if untreated it progresses to Korsakoff syndrome — irreversible anterograde amnesia with confabulation. Give IV thiamine BEFORE glucose.

Recognise

  • Wernicke triad: CONFUSION + OPHTHALMOPLEGIA/nystagmus + ATAXIA (often incomplete)
  • Context: chronic alcohol, hyperemesis gravidarum, bariatric surgery, severe malnutrition
  • Korsakoff: profound anterograde (and some retrograde) amnesia with CONFABULATION

Red flags

  • Wernicke is a medical emergency — untreated it becomes irreversible Korsakoff; giving glucose before thiamine can precipitate it

Differentials & how to tell them apart

Alcohol intoxication/withdrawalcoexists, but the triad/eye signs point to Wernicke — treat empirically
Delirium of other causesepsis, metabolic — but the ophthalmoplegia + ataxia is specific
Hepatic encephalopathyasterixis, deranged LFTs, raised ammonia
Strokefocal deficit, imaging

Investigations

Clinical diagnosis — do not delay treatment. Thiamine level/MRI (mammillary body changes) are supportive but not required.

Management

IV high-dose thiamine immediately — and before any glucose

  1. 1Give IV high-dose thiamine (Pabrinex) immediately on suspicion of Wernicke.Gate: Give thiamine BEFORE any glucose/dextrose — a glucose load in a thiamine-deficient patient can precipitate or worsen Wernicke encephalopathy
  2. 2Treat the cause (alcohol, hyperemesis, nutrition); ongoing thiamine; if Korsakoff develops, long-term cognitive support.
IV thiamine (Pabrinex) — high-dose, BEFORE any glucose
Glucose only AFTER thiamine — glucose before thiamine can precipitate/worsen Wernicke

Key points

Wernicke (reversible triad) → Korsakoff (irreversible amnesia + confabulation). Thiamine before glucose is the classic exam gate. Suspect it in any confused alcoholic or hyperemesis.

Monitor & prognosis

Neuro/eye signs, cognition, nutritional state.

Wernicke reverses with prompt thiamine; Korsakoff amnesia is largely permanent.

Source: NICE CKS (alcohol); BNF (thiamine)