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Ataxia / Vertigo / Dizziness


  • ATAXIA:
    • Symptoms: gait impairment, unclear (scanning) speech, visual blurring due to nystagmus, hand incoordination, and tremor with movement
    • Pathways:
      • Spinocerebellar Pathway 
      • Frontopontocerebellar pathway
    • DDx
      • True Cerebellar Ataxia: (ABSENCE OF VERTIGO)
        • Symmetric and Progressive
          • Acute
          • Subacute
          • Chronic
        • Focal and Ipislateral
          • Acute
          • Subacute
          • Chronic
      • Ataxia due to Vestibular Nerve or Labyrinthine Disease: (PRESENCE OF VERTIGO)
      • Sensory Ataxia: Ataxia dramatically worsens when visual input is removed (Romberg Sign)
      • Proximal Muscle Weakness (Mimics Ataxia):

References 
Harrison's Principles of Internal Medicine, 18e
Related Physical Examination Videos
Gait and Balance Disorders Video (Access Medicine) 
Additional References
    • Cerebellar Signs:(Video e43-7) and Standford 25 (Video)
      • Axial 
        • Scanning Speech
      • Nystagmus : fast phase toward side of cerebellar lesion
      • Appendicular: 
        • Upper Extremity: 
          • Eyes closed and Rapidly touching the nose with alternating finger 
          • Finger-to-Nose Test: Side to side tremor, which gets worse nearer and nearer to the target
          • Mirror Test for dysmetria (inability to measure distances)
          • Rebound Phenomenon 
          • Finger Tapping Test or Miller-Fischer Test (3 different findings and interpretation)
            • Accurate but slow due to weakness: Pyramidal Tract Disorder 
            • First movement is good, but then it sticks and gets glued, and cannot move it further: Extrapyramidal Disorder like PD 
            • Fast but inaccurate : Cerebellar ataxia 
          • Rapid Alternating movement: Dysdidekokinesia
            • Slap on the knees fast
            • Turn the lights in the ceilings 
        • Lower Extremity: 
          • Heel-knee-shin test 
      • Test for Tone (Decreased tone in cerebellar disease) 
        • Externally rotated legs 
        • Arm swing 
        • Pendular knee jerks (>4)
      • Gait and Stance 
        • Look for arm movement
          • Stress gait; Will bring out the movement disorder of arm if any 
            • on heels
            • on toes
            • Tandel Walk: Ultimate Stress gait 
          • Wide based unbalanced gait 
  • VERTIGO Acute vs Recurrent vs. Positional - Central vs. Peripheral
    • History: Acute or Recurrent, Positional, Hx of migraine, loss of hearing, other focal neuro deficit
    • PE: Key is to differentiate peripheral from central vertigo (HINTS + degree of imbalance + Neuro deficit)
      • Head Impulse Test
      • Nystagmus Characteristics
      • Test of Skew Deviation
      • Degree of imbalance
      • Neuro Deficit including Hearing Test 
      • If peripheral suspected: DxHallpike Test
        (Peripheral (if ALL): Positive HI, Fast Phase N Contra laterally, TS No Skew
        (Central: INFARCT if any: Impulse Negative, Fast acting Alternating, Refixation on CoverTest)
Diagnosis and initial management of cerebellar infarction Lancet Neurology 2008

Dizziness: A Diagnostic Approach AAFP 2010
Upbeating Nystagmus with left sided torsional movement during Dx HallpikeYou Tube Video
Positive Head Impulse test in Peripheral Vertigo You Tube Video
Abnormal Cover Uncover Test to detect Skew Deviation You Tube Video
Skew Deviation Revisited Survey of Opthalmology

HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging Stroke 2009

Case 34-2013: A 69-Year-Old Man with Dizziness and Vomiting (Vertigo : Central vs. Peripheral ; Stroke - Vascular Anatomy)

Am Fam Physician. 2010;82(4):361-368 

N Engl J Med 2013;369:1736-48.

N Engl J Med 2013;369:1253-61.



N Engl J Med 2013;369:1253-61.


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