Alcohol-related brain injury and Korsakoff — Wernicke emergency to long-term care (MEQ)

(i) Definitions. ARBI/ARBD is the umbrella for lasting cognitive, behavioural, and structural brain sequelae of heavy alcohol use. Wernicke encephalopathy is the acute thiamine-deficiency emergency. Korsakoff syndrome is residual disproportionate amnesia (often after WE), not a synonym for all ARBI. Confabulation may occur but is not required for KS.[4][5]

(ii) Caine and differentials. Features: malnutrition, oculomotor (nystagmus), cerebellar (ataxia), altered mental state — at least two (here more) → treat as WE now.[1] Differentials/coexistents: alcohol withdrawal/DT (tremor, diaphoresis, ~30 h), head injury (normal CT lowers but does not exclude subtle injury), hypoglycaemia, infection, hepatic encephalopathy, primary dementia (less likely as first label in this acute nutritional–alcohol context).[2][5]

(iii) Acute management. Immediate high-dose parenteral thiamine multi-day: EFNS teaching 200 mg IV TDS (preferably IV, before carbohydrate); many UK/hospital protocols use higher intensity (often taught ~500 mg IV TDS / high-dose Pabrinex pairs for established WE) then step-down to oral (e.g. 100 mg TDS) while risk persists. Oral tablets alone are inadequate for suspected WE.[2][3] Replete Mg/K/phosphate; give glucose with thiamine cover if hypoglycaemic; benzodiazepines for withdrawal physiology; falls/aspiration precautions; continuous monitoring.[2][3]

(iv) Investigations. Do not delay thiamine for labs/MRI. Bloods including Mg; consider thiamine level before first dose if it will not delay treatment. MRI may support (mammillary bodies, medial thalami, periaqueductal grey); normal CT does not exclude WE.[2][6] Formal neuropsychology later if KS/ARBI residual.

(v) Long-term care. Complete thiamine course; abstinence and addiction pathway; cognitive rehab (errorless learning, external aids); nutrition; capacity assessment for finances/discharge; ARBD community/supported housing services; carer education; safeguard against exploitation. Do not default to Alzheimer pharmacology for KS amnesia.[4][7][8]