Ataxia DDx

Overview

Ataxia is impaired coordination in the absence of weakness. Acute ataxia is a neurological emergency, and vascular lesions of the cerebellum (infarction, hemorrhage) must be considered/ excluded.

Causes

Acute onset (minutes/ hours)

• cerebellar hemorrhage or infarction (particularly suspect this if hemiataxia or other brainstem signs)
• Intoxication with alcohol or drugs is perhaps the most common etiology (truncal/ gait, bilateral, altered mental state) e.g. alcohol, antiepileptics
• Migraine (basilar migraine variant can present with cerebellar ataxia and brainstem signs; headache may not be prominent)
• Post-traumatic/post-concussive

Subacute ataxia (hours/days)

•  Infectious causes: most common in children
  — viral cerebellitis, especially 2–10 years old (pyrexia, limb/gait ataxia, and dysarthria, with recovery over a period of weeks)
  — Postinfectious encephalomyelitis, especially varicella.
• Intoxication (see acute)
• Multiple sclerosis, consider this especially in young adults (history of relapse, other brainstem signs)
• Paraneoplastic syndromes (especially neuroblastoma in children and lung carcinoma in adults)
• Others
  — Foramen magnum compression
  — Hydrocephalus
  — Labyrinthitis/vestibular neuritis ( vertigo, nausea, and vomiting are more prominent)
  — Miller-Fisher variant of Guillain-Barré syndrome (ophthalmoplegia, ataxia, areflexia)
  — Posterior fossa lesions (features of  increased intracranial pressure)
  — Post-concussion

Hereditary

• Autosomal dominant spinocerebellar ataxia (SCA)
• Recessively inherited and X-linked ataxia
  — ataxia telangiectasia
  — Friedreich ataxia
  — other rare causes

CCC Differential Diagnosis Series
NEURO	Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision
RESP	Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement
CVS	Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction
GIT	Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage
GUT	Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency,
MSK	Arthritis, Shoulder pain, Wasting of the small muscles of the hand
DERM	Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans
ENDO	Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss
HAEM	Splenomegaly
PAEDS	Floppy infant
MISC	Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest
IMAGING	CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR, ABDO: Gas on abdominal X-ray, Kidney mass, BRAIN: Intracranial calcification, Intracranial structures with contrast, Ventriculomegaly, OTHER: Pseudofracture on X-Ray,
LABS	LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia,  HIGH: Bilirubin and Jaundice, Hyperammonaemia, Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia,  ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes

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