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==
-*Failure to produce smooth intentional movements
+*Sign of a variety of disease processes; not a diagnosis in itself
-*Sign of a variety of disease processes; not a diagnosis in its self
+*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
-==DDX==
+==Differential Diagnosis==
-#Systemic conditions
+*Systemic conditions
-##Intoxications with diminished alertness
+**Intoxications with diminished alertness
-###Ethanol
+***[[Ethanol]]
-###Sedative-hypnotics
+***[[Sedative/hypnotic toxicity]]
-##Intoxications with relatively preserved alertness
+***[[Toxic alcohols]]
-###Phenytoin
+***[[GHB]]
-###Carbamazepine
+***[[Benzodiazepine toxicity]]
-###Valproic acid
+***[[TCA toxicity]]
-###Lead, organic mercurials
+***[[Antipsychotic toxicity]]
-##Other metabolic disorders
+***[[Inhalant abuse]], [[hydrocarbon toxicity]]
-###Hyponatremia
+***[[Pentobarbital]]
-###Inborn errors of metabolism
+***[[Chloral hydrate toxicity]]
-###Wernicke's disease
+***[[Marijuana toxicity]]
-#Disorders predominantly of the nervous system
+***[[Phencyclidine toxicity]]
-##Conditions affecting predominantly one region of the CNS
+**Intoxications with relatively preserved alertness
-###Cerebellum
+***[[phenytoin toxicity|Phenytoin]], [[fosphenytoin]], [[Keppra]]
-####Hemorrhage
+***[[Carbamazepine toxicity|Carbamazepine]], [[oxcarbazepine]]
-####Infarction
+***[[Valproic acid toxicity|Valproic acid]]
-####Degenerative changes
+***[[Heavy metal toxicity|Lead, organic mercurials]]
-####Abscess
+***[[Carbon monoxide]]
-###Cortex
+***[[Acute radiation syndrome]]
-####Frontal tumor, hemorrhage, or trauma
+***[[Lithium toxicity]]
-####Hydrocephalus
+***[[Mushroom toxicity]]
-###Subcortical
+***[[Lacosamide]]
-####Thalamic infarction or hemorrhage
+***[[Arsenic toxicity]]
-####Parkinson's disease
+***[[Gabapentin]]
-####Normal pressure hydrocephalus
+***[[Marijuana toxicity]]
-###Spinal cord
+***[[Phencyclidine toxicity]]
-####Cervical spondylosis
+***[[Lindane]]
-####Posterior column disorders
+***[[Vitamin A toxicity]]
-##Conditions affecting predominantly the peripheral nervous system
+**Other metabolic disorders
-###Peripheral neuropathy
+***[[Hyponatremia]]
-###Vestibulopathy
+***[[Hypernatremia]]
+***[[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
+***[[ICH|Hemorrhage]], [[vertebral and carotid artery dissection]]
+***[[Stroke|Infarction]]
+***[[Lateral medullary syndrome]]
+****Degenerative changes
+***[[Brain abscess|Abscess]]
+***[[Brain tumor]]
+***[[Head trauma]]
+***[[Hydrocephalus]], [[normal pressure hydrocephalus]], [[VP shunt malfunction]]
+***[[Parkinson's disease]]
+***[[Prion disease]]
+***[[Heat stroke]]
+***[[Leukostasis and hyperleukocytosis]]
+***Cervical spondylosis
+***[[spinal cord injury|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 [[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
-==Source==
+===Discharge===
-Tintinalli
+*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==
+*[[Altered Mental Status]]
+*[[Ataxia (Peds)]]
+*[[Weakness]]
+*[[Cerebellar Stroke]]
+*[[Focal neuro deficits]]
-[[Category:Neuro]]
+==References==
+<references/>
+[[Category:Neurology]]
+[[Category:Symptoms]]