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To the Editor:
We read the Teaching NeuroImage by Luigetti et al.1 with interest. They provided magnetic resonance images demonstrating typical Wernicke encephalopathy (WE) lesions. In Image A, there is distinct hyperintensity of the facial nerve nuclei bilaterally in addition to the described alteration of the deep gray matter.
Selective involvement of the cranial nerve nuclei is an established characteristic of nonalcoholic (NA) WE, which helps to differentiate alcoholic (AL) from NA etiologies.2 In the patient described by the authors,1 involvement of the periventricular gray matter located anterior to the fourth ventricle does not differentiate between AL and NA etiologies because this is also evident in AL patients.2 However, the presence of facial nerve nuclei involvement does discriminate between these etiologies. Cortical involvement has only been described in NA patients, likely representing an indicator of poor prognosis even when thiamine is promptly administered.
We found that 18% of NA patients showed symmetric lesions of cranial nerve nuclei including abducens, facial, vestibular, and hypoglossal. …
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