Cortical Ribboning as a Key MRI Finding in Wernicke's Encephalopathy With Altered Mental Status

Wernicke's encephalopathy (WE) is associated with thiamine (vitamin B1) deficiency and may lead to mental status changes, ophthalmoplegia, and ataxia. While treatment is simple, delayed diagnosis can have serious consequences, making early detection essential. However, the complete triad of symptoms is rarely seen. When mental status changes occur, physical examination may be limited, making WE harder to identify without other characteristic signs. Furthermore, measuring blood thiamine levels is not always immediately possible, adding to the challenge of diagnosis. We encountered a case of WE presenting with mental status changes, where cortical ribboning appeared as a significant MRI finding. A 77-year-old male had experienced slowness of movement for approximately one year and was diagnosed with multiple system atrophy (MSA). He had difficulty eating; thus, he preferred soft rice porridge. He developed acute mental status changes, and a brain MRI revealed prominent cortical ribboning in both frontal cortices along with subtle medial thalami. The patient received intravenous thiamine, leading to dramatic recovery of mental status, and subsequent MRI follow-up showed near-complete resolution of both cortical and thalamic lesions. Cortical ribboning, which played a key role in this patient, is recognized as an atypical MRI finding of thiamine deficiency and is suggested to be associated with altered mental status in WE. However, to the best of our knowledge, no literature clearly lists thiamine deficiency as a differential diagnosis for cortical ribboning in patients with mental status changes. Recognizing this key imaging finding is crucial in differentiating WE in patients with mental status changes. Preventing the potentially fatal outcome of WE is of paramount importance. Patients with dysphagia tend to prefer soft foods, which may result in reduced thiamine intake. Our experience reaffirms the importance of a well-balanced diet in MSA patients with dysphagia.