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Alcoholic woman hospitalized for Wernicke encephalopathy, presented with left hemiparesis, and was suspected to have stroke (MRI)

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MRI in a 45-year-old alcoholic woman with a recent hospitalization for Wernicke encephalopathy who presented with left hemiparesis and was initially suspected to have had a stroke. (a) Axial T2-weighted image demonstrates high T2-signal intensity in the upper pons, resembling a pig’s snout (the so-called “piglet sign”). (b) The same axial T2-weighted image with the area of edema of the pons is highlighted in green. The transverse pontine fibers (pontocerebellar fibers and median raphe) are most affected and there is sparing of the peripheral (ventrolateral longitudinal) fibers and corticospinal tracts, producing the pig’s snout appearance. The edema involves the right corticospinal tracts (blue arrow), which explains the patient's left-sided hemiparesis. (c and d) DWI and apparent diffusion coefficient (ADC) map corresponding to the restricted diffusion in the pons. (e) Sagittal FLAIR image demonstrates increased FLAIR signal in the pons. (Source: Kusel K, Azzam O, Youssef A, Prentice D. Alcoholic pontine myelinolysis: beware the stroke mimic. BJR Case Rep 2021;7(4):20210005. Creative Commons Attribution license [CC BY], https://creativecommons.org/licenses/by/4.0.)