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Encephalopathy Jounal ofNeurology, Neurosurgery, and Psychiatry 1997;62:51-60 51 Operational criteria for the classification of chronic alcoholics: identification of Wemicke's encephalopathy D Caine, G M Halliday, J J Kril, C G Harper Abstract suggest that there can be a complete resolution Objectives-To establish better opera- of the underlying brain abnormality in tional criteria for the diagnosis of Wernicke's encephalopathy, similar to the res- Wernicke's encephalopathy. Current olution of neuropathology in hepatic criteria for diagnosing Wernicke's encephalopathy. However, unlike hepatic encephalopathy require the presence of encephalopathy, in which the clinical signs are three clinical signs (oculomotor abnor- a precursor of the pathology, many patients malities, cerebellar dysfunction, and an with the neuropathology of Wernicke's altered mental state), although it has encephalopathy do not have recorded signs of often been reported that most patients do the classic triad.' 2 This raises the question of not filfil all these criteria. whether the clinical correlates of the patholog- Methods-The clinical histories of 28 ical lesions are being missed during life or alcoholics with neurological and neu- whether the pathology represents clinically ropsychological assessments and defini- silent lesions. A similar situation is seen in tive neuropathological diagnoses were Alzheimer's disease, in which many non- examined to determine clinical signs for demented aged patients show a similar type use in a screening schedule. Operational and distribution of neuropathology to their criteria were then proposed for differenti- demented counterparts. 12 Recently research ating patients with Wernicke's into the pathophysiology of aging and encephalopathy alone or in combination Alzheimer's disease has been successfully with Korsakoff's psychosis or hepatic advanced by the use of operational criteria encephalopathy. The new criteria for which can be applied across clinics and labora- Wernicke's encephalopathy require two of tories.'3 14 The aim of the present study is to the following four signs; (1) dietary defi- propose operational criteria for the diagnosis ciencies, (2) oculomotor abnormalities, of Wernicke's encephalopathy. (3) cerebellar dysfunction, and (4) either Most patients world wide with Wernicke's an altered mental state or mild memory encephalopathy are alcoholics,'5 with 30%- impairment. Reproducibility and validity 80% of chronic alcoholics having the clinical testing of these criteria were performed or biochemical signs of thiamine deficiency.'6 on 106 alcoholics screened from a large Two extensive clinicopathological studies' 2 necropsy sample. found that the incidence of oculomotor abnor- Results-Despite rater variability with malities was low and therefore reliance on the Neuropsychology Unit, regard to specific symptoms, within and classic triad would result in significant under- Royal Prince Alfred between rater reliability for diagnostic recognition of these patients during life. Hospital, classification the Camperdown, 2050, using criteria retrospec- Because an altered mental state is also a com- Australia tively on patient records was 100% for mon neurological sign associated with hepatic D Caine three independent raters. Validity testing encephalopathy,'7 the overlap between the two Prince ofWales showed that Wernicke's encephalopathy diseases poses substantial and often unrecog- Medical Research was underrecognised only when occurring nised difficulties for diagnosis. Operational Institute, High Street, cri- Randwick, 2031, with hepatic encephalopathy (50% sensi- teria for recognising and separating these Australia tivity). common conditions are needed. Therefore the G M Halliday Conclusions-By contrast with current aim of the present study was to devise and test Neuropathology criteria, the proposed operational criteria such operational criteria for classifying chronic Division, Departments show that the ofPathology, antemortem identification alcoholics for both treatment and research. We University of Sydney, of Wernicke's encephalopathy can be have assessed only alcoholics in order to 2006 and Royal Prince achieved with a high degree of specificity. analyse a large and relatively homogeneous Alfred Hospital, Camperdown, 2050, group of patients with Wemicke's encephal- Australia ( Neurol Neurosurg Psychiatry 1997;62:51-60) opathy. The criteria account for the diagnoses G M Halliday of other common medical complications asso- J J Kril ciated with this patient population.4 Key signs C G Harper Keywords: alcoholism; diagnostic criteria; neurological for operational criteria for Correspondence to: impairnent; Wernicke-Korsakoff syndrome diagnosis are pro- Dr G Halliday, Prince of posed and the reliability and predictive validity Wales Medical Research and Institute, Villa 2, High (specificity sensitivity) of using these crite- Street, Randwick. 2031, It is well known that the pathology of ria to classify chronic alcoholics tested. Australia. Wernicke's encephalopathy may not be associ- Received 25 March 1996 ated with the full clinical triad and that in the and in final revised form 30 August 1996 acute phase clinical symptoms may resolve Methods Accepted 2 September 1996 with thiamine treatment.'-" These findings To determine characteristic signs and 52 Caine, Halliday, Kril, Harper symptoms for alcoholics with and without standardised administration and scoring of the Wernicke's encephalopathy, the histories of 28 following neuropsychological tests: Wechsler patients, well known to the neuropsychology memory scale, Rey auditory verbal learning unit, Royal Prince Alfred Hospital, who had test, Rey-Osterrieth complex figure test, trail died between 1989 and 1993 and had making test, and Stroop test.2' The diagnosis necropsy confirmation of their clinical diag- of Wernicke's encephalopathy, Wernicke- noses were examined. These had a variety of Korsakoff syndrome, hepatic encephalopathy, neurological presentations, including eight or alcohol related brain dysfunction was made patients with Wernicke's encephalopathy using the history obtained, information from (classic triad but with no evidence of a perma- referring agencies, the results of the clinical nent amnesic syndrome), six patients with the and neuropsychological examinations, and Wernicke-Korsakoff syndrome (alcoholics those of any additional tests which may have with Wernicke's encephalopathy fulfilling cur- been ordered. rent criteria for Korsakoffs psychosis'8 20)), nine patients with hepatic encephalopathy PATHOLOGICAL DIAGNOSIS (neurological abnormalities associated with A full necropsy was performed for all patients decompensated liver disease'7), and eight including macroscopic and microscopical patients with alcohol related brain dysfunction examination of all organs. A detailed neu- (neurological or neuropsychological impair- ropathological examination was performed. ment, although not fulfilling the criteria for The external brain features were examined Wernicke's encephalopathy, Wernicke- before and after fixation in neutral buffered Korsakoff syndrome, or hepatic encephalopa- formalin for 14 days. The brain was then thy). Three patients had both Wernicke's embedded in 3% agar and sectioned at 3 mm encephalopathy and hepatic encephalopathy. intervals in the coronal plane with a rotary In all patients the clinical diagnosis matched slicer. The cut surfaces of each slice were the neuropathological diagnosis, patients with examined for neuropathological abnormalities. alcohol related brain dysfunction having no Standardised blocks of the superior frontal, neuropathological abnormality. superior parietal, inferior temporal, and parahippocampal cortices, hippocampus, STANDARDISED CLINICAL EXAMINATION amygdala, anterior and posterior basal ganglia Patients in the neuropsychology unit under- including the basal forebrain, thalamus, went a 90 minute clinical assessment by a con- mamillary bodies of the hypothalamus, mid- sultant neurologist or neurology registrar, brain, pons, medulla oblongata, and cerebel- comprising a detailed history following a stan- lum (vermis, lateral cortices and dentate dard protocol, a complete general medical nuclei) were sampled for paraffin embedding. examination, and a detailed neurological Sections were cut at 10 mm and stained with examination including an examination of men- haematoxylin and eosin, luxol fast blue, and tal status. They also underwent clinical neu- silver stains before microscopical examination ropsychological assessment which included and diagnosis (by CGH). Other specialised stains were performed if required to exclude cerebral infarction, head injury, or degenera- Table 1 Schedule ofclinical signs and symptoms with domains highlighted (see textfor definitions) tive conditions such as Alzheimer's disease. Serious liver disease was diagnosed if liver cir- Previous history or atfirst Developed rhosis or hepatitis was confirmed at necropsy. presentation subsequently At any time Hepatic encephalopathy was diagnosed if the Wernick's encephalopathy patient had serious liver disease and Alzheimer WE diagnosed clinically type II astrocytes in the brain (common in the Dietary deficiency Undernutrition basal ganglia, cerebral cortex, or pons). Vitamin deficiency Wernicke's encephalopathy was diagnosed Eye signs Ophthalmoplegia when mamillary body and periventricular Nystagmus lesions were evident.2223 In acute Wernicke's Gaze palsy con- Gerebellar signs encephalopathy the pathology was largely Ataxia fined to abnormalities
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