Binswanger's Disease: A Diagnostic Challenge in a Middle-aged Male

Binswanger's disease, a rare form of subcortical vascular dementia, presents with a progressive decline in cognitive and motor functions due to chronic small vessel ischemic changes in the brain. Its clinical presentation often overlaps with other neurological conditions, particularly Wernicke's encephalopathy, leading to potential diagnostic delays. We report the case of a 45-year-old male who presented with altered mental status, gait abnormalities, memory impairment and ocular pain. Given his significant history of alcohol consumption, an imperial diagnosis of Wernicke's encephalopathy was made, and treatment was commenced with thiamine supplementation. However, the persistence of behavioural changes, right-sided pyramidal signs, extrapyramidal features and cognitive deficits prompted further evaluation. The clinical findings, combined with the patient's history of hypertension, diabetes and prior stroke, led to the diagnosis of Binswanger's disease. This case highlights the importance of considering vascular dementia in differential diagnoses of subacute encephalopathy and emphasises early recognition to initiate appropriate management.