Images in Clinical Neurology The Neurohospitalist 2017, Vol. 7(1) 49-50 a The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1941874416637407 journals.sagepub.com/home/nhos Wernicke-Like Encephalopathy Associated With Ifosfamide John Kent Lin, MD 1 , Daniel S. Chow, MD 2 , Leslie Sheu, MD 1 , and Bhavya Rehani, MD 2 Keywords imaging, Wernicke encephalopathy, dyskinesia, drug induced A 73-year-old female with maxillary chondroblastic sarcoma, chronic kidney disease, and undernutrition presented with ataxia, myoclonus, and confusion 1 week after ifosfamide and etoposide. Three days later, she became obtunded. Magnetic resonance imaging of the brain revealed abnorm- alities in the bilateral thalami (Figure 1) and mammillary bod- ies (Figure 2), suggestive of thiamine deficiency. Treatment dose of intravenous thiamine was administered, and her neu- rologic status normalized within 24 hours. Ifosfamide rarely causes a Wernicke-like encephalopathy, particularly in patients with sarcoma, elevated creatinine, and hypoalbuminemia. 1 Toxicity is likely mediated through its metabolite Chloroacetaldehyde, which may impair thiamine function, and is treated with methylene blue or thiamine. 2 Figure 2. Axial fluid-attenuated inversion recovery (FLAIR) magnetic resonance (MR) image demonstrates increased signal intensity in the mammillary bodies, bilaterally (arrows). Author’s Note John Kent Lin, Daniel Chow, Leslie Sheu, and Bhavya Rehnai contrib- uted to drafting or revising the manuscript for intellectual content. Bha- vya Rehani is the corresponding author, principal author, and guarantor. Department of Medicine, University of California–San Francisco, San Fran- cisco, CA, USA Department of Radiology and Biomedical Imaging, University of California– San Francisco, San Francisco, CA, USA Figure 1. Axial fluid-attenuated inversion recovery (FLAIR) magnetic resonance (MR) image demonstrates increased signal intensity involving the thalami, bilaterally (arrows). Corresponding Author: Bhavya Rehani, University of California–San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA. Email: bhavya.rehani@ucsf.edu