1. Morning Report Acute Ataxia 8/31/09 Lorena Muñiz, MD

2. Definitions  Ataxia: From Greek ataktos: without order. Failure of muscular coordination. Pathologic abnormality of organization or modulation of movement. Disturbances in the control of body posture, motor coordination, speech control and eye movements.

3.  Dizziness: impairment in spatial perception and stability, considered imprecise.  Vertigo: sensation of spinning or having one's surroundings spin about them.

4.  Dysmetria: From English difficult to measure. Lack of coordination of movement typified by the undershoot and/or overshoot of intended position with the hand, arm, leg, or eye.

5.  Dysdiadochokinesia: From Greek dys "bad", dia "across", docho "receive", kinesia "movement“. Inability to perform rapid, alternating movements.

6.  Dysarthria: Motor speech disorder resulting from neurological injury, characterised by poor articulation  Nystagmus: form of involuntary eye movement characterized by alternating smooth pursuit in one direction and rapid movement in the other direction.

7.  Opsoclonus: Rapid, involuntary, multivectorial (horizontal and vertical), unpredictable, conjugate fast eye movements.  Myoclonus: Brief, involuntary twitching of a muscle or a group of muscles.

8.  Romberg's test: assess the dorsal columns of the spinal cord. Indication of loss of the sense of position, patient loses balance when standing erect, feet together, and eyes closed. +Romberg: ataxia is sensory in nature, depending on loss of proprioception. – Romberg: ataxia is cerebellar.

9. Types of Ataxia  Cerebellar ataxia 1.Vestibulocerebellum impaired balance and control of eye movements, postural instability. 2.Spinocerebellum wide-based "drunken sailor" gait. 3. Cerebrocerebellum disturbances in carrying out voluntary, planned movements.

10.  Sensory ataxia: Loss of proprioception (joint position sense), dysfunction of the dorsal columns of the spinal cord, spinal nerve roots or peripheral nerves.  Vestibular ataxia: Loss of balance, in acute and unilateral cases is associated with prominent vertigo, nausea and vomiting.

11. Etiology  Infectious/immune-mediated cerebellar disorders Acute cerebellar ataxia*  Post infectious cerebellitis Acute demyelinating encephalomyelitis Systemic infections Brainstem encephalitis Multiple sclerosis

12.  Toxic Alcohol Anticonvulsants (phenytoin, carbamazepine) Benzodiazepines Barbiturates Antihistamines Lithium Heavy metals (lead, mercury, thallium)

13.  Mass lesions Tumors: brain stem, cerebellum Vascular lesions (AVM) Abscesses  Hydrocephalus  Trauma Head Neck (vertebral artery dissection)

14.  Vascular events Stroke, hemorrhage  Paraneoplastic disorders Opsoclonus-myoclonus syndrome: Occult Neuroblastoma or ganglioneuroblastoma  Sensory ataxia Miller Fisher syndrome: ataxia, areflexia, ophtalmoplegia(vertical gaze)

15.  Paretic ataxia  Other neurologic disorders Basilar migraine: vertigo, hemiparesis, cranial nerve dysfunction, N/V/HA Benign paroxysmal vertigo Seizures Inborn error of metabolism  Functional

16. Work up  History: Prior or current symptoms of infection. Recent immunizations. Headaches, vomit, diplopia. ROS. Drug ingestion. Head on neck trauma. Similar episodes in past or in family.

17.  Physical exam Complete neurological exam  Mental status  Cranial nerves  Cerebellar testing  Sensation  Strength  Meningeal signs  Reflexes  Gait

18.  Initial ancillary tests Laboratory  Urine/serum drug screen/level  CBC  Electrolytes Imaging  CT brain  MRI brain

19. Thank you!