Approach to the Patient: Ataxia

Causes are best grouped by determining whether ataxia is symmetric or focal and by the time course (Table 184-1). Also important to distinguish whether ataxia is present in isolation or is part of a multisystem neurologic disorder. Acute symmetric ataxia is usually due to medications, toxins including alcohol, viral infection, or a postinfectious syndrome (especially varicella). Subacute or chronic symmetric ataxia can result from hypothyroidism, vitamin deficiencies, infections (Lyme disease, tabes dorsalis, prions), alcohol, other toxins, or an inherited condition (see below). An immune-mediated progressive ataxia is associated with antigliadin antibodies; biopsy of the small intestine may reveal villous atrophy of gluten enteropathy. Elevated serum anti-glutamic acid decarboxylase (GAD) antibodies have been associated with a progressive ataxic syndrome affecting speech and gait. Progressive nonfamilial cerebellar ataxia after age 45 suggests a paraneoplastic syndrome, either subacute cortical cerebellar degeneration (ovarian, breast, lung, Hodgkin's) or opsoclonus-myoclonus (neuroblastoma, breast, lung).

Unilateral ataxia suggests a focal lesion in the ipsilateral cerebellar hemisphere or its connections. An important cause of acute unilateral ataxia is stroke. Mass effect from cerebellar hemorrhage or swelling from cerebellar infarction can compress brainstem structures, producing altered consciousness and ipsilateral pontine signs (small pupils, sixth or seventh nerve palsies); limb ataxia may not be prominent. Other diseases producing asymmetric or unilateral ataxia include tumors, multiple sclerosis, progressive multifocal leukoencephalopathy (immunodeficiency states), and congenital malformations.