Red flags 🚩^(1-3)

New-onset, hyperacute ataxia (minutes to hours) is a medical emergency → urgent neuroimaging for suspected vascular event.

Other features that point to “Can’t Miss” 🚩etiologies include

• Head trauma
• Meningismus (h/a, fever, photophobia)
• Altered mental status
• Symptoms of elevated ICP (headache, n/v, limb weakness or sensory deficits)

Definition ^(1-3)

• Irregular timing, precision, amplitude of movements
  • Sensory ataxia = proprioception deficits, which could be unrelated to cerebellum (e.g., dorsal column lesions).
  • Motor ataxia = distinctly refers to cerebellar deficit.

For acute ataxia in children, see Acute Ataxia in Children (Diagnosis)

Presentation is varied and may only present with one symptom. The commonest ataxic presentations include

• Uncoordinated intentional movements
• Balance issues
• Gait abnormalities (e.g., wide-based gait)

History ^(1-3)

• Timeline and evolution of symptoms (hyperacute 🚩 vs. acute (<7d) vs. subacute vs. chronic).
• Is this a new problem?
• History of head trauma? 🚩
• Review of systems (e.g., fever, pain, headache, numbness or tingling, peripheral weakness; any changes in vision, hearing, gait, coordination, balance).
• Recent infection.
• Complete medication, drug, ingestion history.
• Family history of movement disorders.
• Past and current medical conditions.
• If balance is the only complaint, ask about vertigo, tinnitus, hearing issues and consider other diagnosis.
• Elevated ICP symptoms (headache, n/v, limb weakness or sensory deficits). 🚩

Physical Exam ^(1-4)

• Vitals
• Full neurological exam
  • Focused cerebellar exam 
    • Key to look for uncoordinated intentional movements
    • Finger/nose test (dysmetria)
    • Heel/shin test
    • Rapid alternating hand slapping (dysdiadochokinesia)
    • Heel tapping
    • Hold full glass of water without spilling
    • Gait analysis (essential) and tandem walking
  • Proprioceptive testing (e.g., Romberg, if positive result B12 deficient)
  • Eye movement (nystagmus, opsoclonus) 🚩
  • Fundoscopy (papilledema)  🚩
  • Reflexes (areflexic)  🚩
  • Speech (scanning speech – breaking words/phrases into many syllables)
• Other 
  • Asterixis (metabolic issues)
  • Oscillation of trunk or head
  • Neck stiffness (meningismus)  🚩
  • Rashes

Differential ^(1-3)

Labs (1,2)

Imaging (1,2)

Management ^(1-3)

• Stabilize patient.
• Treatment depends on the underlying etiology.
• Many patients with ataxia do not need treatment.
• Refer subacute and chronic cases to neurology.

• Admit patients with red flag features 🚩
  • New, rapid onset ataxia.
  • Head trauma.
  • Meningismus (h/a, fever, photophobia).
  • Altered mental status.
  • Symptoms of elevated ICP (headache, n/v, limb weakness or sensory deficits).
• Refer to neurology.

Stabilized patient.
Comorbidities managed.

• Considerations for discharge
  • Patient is stable, not deteriorating. 
  • Ruled out “can’t miss” etiology with history, physical, labs, neuroimaging.
  • Diagnosis identified and/or patient has minimal risk of acutely worsening.
• Consult neurology for unclear presentations and for further investigation of subacute or chronic ataxia.

1. Neurology – Ataxia (Gait) – By Wendy Stewart M.D. – overview of ataxic gait patterns and CNS localization.

   Gaits Examination (Stanford Medicine 25) – discusses cerebellar/ataxic gait and Romberg test for proprioceptive deficits.

   
   

1. Todd P, Shakkottai V. Overview of cerebellar ataxia in adults. Hurtig H, Eichler A, editors. [Internet]. 2023 [cited 2024 Jan 4]. Available from: https://www.uptodate.com/contents/overview-of-cerebellar-ataxia-in-adults?search=ataxia&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

   
   

2. Shakkottai V. Assessment of Ataxia [Internet]. Klockgether T, Perlman S, editors. BMJ Best Practice. BMJ; 2022 [cited 2024 Jan 4]. Available from: https://bestpractice-bmj-com.eu1.proxy.openathens.net/topics/en-gb/1097

   
   

3. Tintinalli JE, O. John Ma, Yealy D, Meckler GD, J. Stephan Stapczynski, Cline DM, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th edition. McGraw Hill Professional; 2019.

   
   

4. Cerebellum Examination (Stanford Medicine 25) [Internet]. www.youtube.com. [cited 2024 Jan 4]. Available from: https://www.youtube.com/watch?v=Imu1kk_gOKA&ab_channel=StanfordMedicine25