Wernicke’s encephalopathy after emergency cholecystectomy and hepatic arterial embolization: A radiological and critical care challenge

Wernicke's encephalopathy (WE) is an acute neuro-metabolic disorder caused by thiamine deficiency. In postoperative and critically ill patients, subtle neurological signs are often masked by sedation, delaying diagnosis. A 59-year-old woman underwent emergent cholecystectomy for acute cholecystitis complicated by multiple bilomas. Postoperative hemorrhage required superselective hepatic artery embolization. After initial stabilization and discharge, she was readmitted with respiratory failure and reduced consciousness, requiring intubation and mechanical ventilation. Despite cessation of sedation, she remained in prolonged coma. MRI revealed symmetrical thalamic, mammillary body, and periaqueductal lesions consistent with WE. Low serum thiamine levels confirmed the diagnosis. High-dose intravenous thiamine led to progressive neurological improvement. WE in nonalcoholic postoperative ICU patients is frequently underrecognized due to overlapping metabolic disturbances, insufficient nutritional intake, and sedation masking neurological signs. MRI is crucial for early diagnosis. Multidisciplinary coordination between intensivists, radiologists, anesthesiologists, and nutritionists is essential for timely recognition and treatment. This case highlights the importance of vigilant nutritional assessment, early neuroimaging, and empiric thiamine administration in postoperative ICU patients with unexplained persistent coma to prevent irreversible neurological damage.