Ataxia: Difference between revisions

Latest revision as of 02:32, 23 September 2021

This page is for adult patients. For pediatric patients, see: ataxia (peds).

Background

Sign of a variety of disease processes; not a diagnosis in itself
Isolated lesion of cerebellum is NOT the most common cause
Must distinguish between motor (cerebellar) and sensory (cord, peripheral nerves) ataxia
- Sensory ataxia may be compensated to a degree with visual sensory information

Clinical Features

Sensory (failure to transmit proprioception) versus motor (cerebellar) ataxia
- Romberg test
  - Comparison of posture stability when eyes are open versus eyes closed
  - If ataxia worsens with loss of visual input suggestive of sensory ataxia
  - If ataxia does not significantly change with eyes closed suggests motor ataxia
- Finger-to-nose, heel-to-shin, rapid alternating movements
  - If abnormal with eyes open, suggests motor ataxia
  - If abnormal with eyes closed, suggests sensory ataxia
Systemic versus isolated nervous system disease
CNS versus PNS

Differential Diagnosis

Systemic conditions
- Intoxications with diminished alertness
- Intoxications with relatively preserved alertness
- Other metabolic disorders
Disorders predominantly of the nervous system
- Conditions affecting predominantly one region of the CNS
  - Hemorrhage, vertebral and carotid artery dissection
  - Infarction
  - Lateral medullary syndrome
    - Degenerative changes
  - Abscess
  - Brain tumor
  - Head trauma
  - Hydrocephalus, normal pressure hydrocephalus, VP shunt malfunction
  - Parkinson's disease
  - Prion disease
  - Heat stroke
  - Leukostasis and hyperleukocytosis
  - Cervical spondylosis
  - Posterior column disorders
- Conditions affecting predominantly the peripheral nervous system
  - Peripheral neuropathy
  - Vestibulopathy (e.g. vestibular neuritis, labyrinthitis)
  - Guillain-Barre
- Miscellaneous
  - Acute mountain sickness
  - Syphilis
  - Tick paralysis
  - Ciguatera, neurotoxic shellfish poisoning
  - African trypanosomiasis
  - Tympanic membrane rupture
  - Legionella
  - Paraneoplastic syndromes
    - Postinfectious cerebellitis (acute cerebellar ataxia)
  - Post vaccination (varicella)
  - Vasculitis
  - Epilepsy

Evaluation

Depends on rapidity of symptoms and additional features
If acute consider CT, MRI, LP

Management

Treat underlying pathology

Disposition

Admission

Patients with acute or subacute cases of ataxia should be admitted if benign etiology cannot be established
Admit patient if they cannot ambulate safely on their own

Discharge

Discharge patients with mild or reversible symptoms as long as they are AAOX4 and can ambulate safely.
Consider follow-up with neurology or primary care

References

Authors:

@@ Line 1: / Line 1: @@
+{{Adult top}} [[ataxia (peds)]].''
 ==Background==
 *Sign of a variety of disease processes; not a diagnosis in itself
@@ Line 6: / Line 7: @@
 ==Clinical Features==
-*Sensory versus motor ataxia
+*Sensory (failure to transmit proprioception) versus motor (cerebellar) ataxia
 **Romberg test
 ***Comparison of posture stability when eyes are open versus eyes closed
 ***If ataxia worsens with loss of visual input suggestive of sensory ataxia
 ***If ataxia does not significantly change with eyes closed suggests motor ataxia
+**Finger-to-nose, heel-to-shin, rapid alternating movements
+***If abnormal with eyes open, suggests motor ataxia
+***If abnormal with eyes closed, suggests sensory ataxia
 *Systemic versus isolated nervous system disease
 *CNS versus PNS
-*Cerebellar versus posterior column (proprioceptive)
-**Finger to nose
-***Performing test with eyes closed tests proprioception
-**Heel-to-shin test
-***Posterior column disease: Difficult locating knee
-***Cerebellar disease: Action completed with series of jerky movements
 ==Differential Diagnosis==
 *Systemic conditions
 **Intoxications with diminished alertness
-***Ethanol
+***[[Ethanol]]
-***Sedative-hypnotics
+***[[Sedative/hypnotic toxicity]]
+***[[Toxic alcohols]]
+***[[GHB]]
+***[[Benzodiazepine toxicity]]
+***[[TCA toxicity]]
+***[[Antipsychotic toxicity]]
+***[[Inhalant abuse]], [[hydrocarbon toxicity]]
+***[[Pentobarbital]]
+***[[Chloral hydrate toxicity]]
+***[[Marijuana toxicity]]
+***[[Phencyclidine toxicity]]
 **Intoxications with relatively preserved alertness
-***Phenytoin
+***[[phenytoin toxicity|Phenytoin]], [[fosphenytoin]], [[Keppra]]
-***Carbamazepine
+***[[Carbamazepine toxicity|Carbamazepine]], [[oxcarbazepine]]
-***Valproic acid
+***[[Valproic acid toxicity|Valproic acid]]
-***Lead, organic mercurials
+***[[Heavy metal toxicity|Lead, organic mercurials]]
+***[[Carbon monoxide]]
+***[[Acute radiation syndrome]]
+***[[Lithium toxicity]]
+***[[Mushroom toxicity]]
+***[[Lacosamide]]
+***[[Arsenic toxicity]]
+***[[Gabapentin]]
+***[[Marijuana toxicity]]
+***[[Phencyclidine toxicity]]
+***[[Lindane]]
+***[[Vitamin A toxicity]]
 **Other metabolic disorders
 ***[[Hyponatremia]]
-***Inborn errors of metabolism
+***[[Hypernatremia]]
-***Wernicke's disease
+***[[Hypomagnesemia]]
+***[[Inborn errors of metabolism]]
+***[[Wernicke disease]]
+***[[Vitamin B7 deficiency]]
+***[[Vitamin E deficiency]]
 *Disorders predominantly of the nervous system
 **Conditions affecting predominantly one region of the CNS
-***Cerebellum
+***[[ICH|Hemorrhage]], [[vertebral and carotid artery dissection]]
-****Hemorrhage
+***[[Stroke|Infarction]]
-****Infarction
+***[[Lateral medullary syndrome]]
 ****Degenerative changes
-****Abscess
+***[[Brain abscess|Abscess]]
-***Cortex
+***[[Brain tumor]]
-****Frontal tumor, hemorrhage, or trauma
+***[[Head trauma]]
-****Hydrocephalus
+***[[Hydrocephalus]], [[normal pressure hydrocephalus]], [[VP shunt malfunction]]
-***Subcortical
+***[[Parkinson's disease]]
-****Thalamic infarction or hemorrhage
+***[[Prion disease]]
-****Parkinson's disease
+***[[Heat stroke]]
-****Normal pressure hydrocephalus
+***[[Leukostasis and hyperleukocytosis]]
-***Spinal cord
+***Cervical spondylosis
-****Cervical spondylosis
+***[[spinal cord injury|Posterior column disorders]]
-****Posterior column disorders
 **Conditions affecting predominantly the peripheral nervous system
 ***Peripheral neuropathy
-***Vestibulopathy
+***Vestibulopathy (e.g. [[vestibular neuritis]], [[labyrinthitis]])
+***[[Guillain-Barre]]
+**Miscellaneous
+***[[Acute mountain sickness]]
+***[[Syphilis]]
+***[[Tick paralysis]]
+***[[Ciguatera]], [[neurotoxic shellfish poisoning]]
+***[[African trypanosomiasis]]
+***[[Tympanic membrane rupture]]
+***[[Legionella]]
+***[[Paraneoplastic syndromes]]
+****Postinfectious cerebellitis (acute cerebellar ataxia)
+***Post vaccination ([[varicella]])
+***[[Vasculitis]]
+***[[Epilepsy]]
 ==Evaluation==
-*Depends on rapidity of symptoms
+*Depends on rapidity of symptoms and additional features
-*If acute consider CT, MRI, LP
+*If acute consider [[head CT|CT]], [[brain MRI|MRI]], [[LP]]
 ==Management==
+*Treat underlying pathology
 ==Disposition==
+===Admission===
+*Patients with acute or subacute cases of ataxia should be admitted if benign etiology cannot be established
+*Admit patient if they cannot ambulate safely on their own
+===Discharge===
+*Discharge patients with mild or reversible symptoms as long as they are AAOX4 and can ambulate safely.
+*Consider follow-up with neurology or primary care
 ==See Also==
@@ Line 68: / Line 112: @@
 *[[Weakness]]
 *[[Cerebellar Stroke]]
+*[[Focal neuro deficits]]
 ==References==
 <references/>
 [[Category:Neurology]]
+[[Category:Symptoms]]