Transcript Ataxia and Gait Disturbances

Ataxia and Gait
Disturbances
Presented by A. Hillier, D.O.
EM Resident
St. John West Shore Hospital
Ataxia and Gait Disturbances
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Generally symptoms of another disease
Ataxia
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Gait Disturbance
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Failure to produce smooth intentional
movements
Inability to perform smooth coordinated gait
May be described by patient as
-Weakness
-Stroke
-Dizziness
-Falling
Ataxia and Gait Disturbances
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Pathophysiology
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Result from any condition that affects the central
and peripheral nervous systems
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Ataxia: Types
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Motor ataxia
Sensory ataxia
Ataxia and Gait Disturbances
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Motor Ataxia
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Caused by cerebellar disorders
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Intact sensory receptors and afferent pathways
Integration of proprioception is faulty
Midline cerebellar lesions cause truncal ataxia
Lateral cerebellar lesions cause limb ataxia
Thalamic infarcts may cause contralateral ataxia
with sensory loss
Ataxia and Gait Disturbances
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Sensory Ataxia
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Failure of proprioceptive information to the CNS
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May be due to disorders of spinal cord or
peripheral nerves
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Can be compensated for by visual inputs
Ataxia and Gait Disturbances
Differential Diagnoses
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Intoxication
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Ethanol
Sedative-hypnotics
Anticonvulsants
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Hyponatremia
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Cerebellar disorders
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Tumor
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Hydrocephalus
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Cerebral vascular accidents
Inborn errors of metabolism
Multiple Sclerosis
Thalamic disorders
Parkinson’s Disease
Cervical spondylosis
Posterior column disorders
Peripheral neuropathy
Vestibulopathy
Disequilibrium of aging
Ataxia and Gait Disturbances
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Definitions
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Best to use descriptive terms for gait
disturbances
Motor ataxia: wide-based with irregular, unsteady
steps
Sensory ataxia: abrupt leg movement and
slapping impact of feet
Festinating gait: narrow-based miniature shuffling
steps. Commonly seen in PD
Ataxia and Gait Disturbances
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Apraxic gait: difficult initiating gait. May be seen in
NPH and PD
Equine gait: high stepping gait due to peroneal
weakness
Functional gait disorder: unable to walk normally
despite intact motor, sensory and cerebellar
function. Often a conversion disorder called
astasia-abasia
Ataxia and Gait Disturbances
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History
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Onset
Rapidity
Previous symptoms
PMH
Medications
Social
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Alcohol intake
Illicit drug use
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Associated Symptoms
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Headache
Drowsiness
Dizziness
Vertigo
Tinnitus
Fever
Nausea/vomiting
Weakness
Paresthesia
Ataxia and Gait Disturbances
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Physical Exam
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Gait testing
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Full neurologic exam
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Tandem gait
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Orthostatic VS
Cerebellar function
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Dysmetira
Dysdiadochokinesia
Dyssynergia
Stewart-Holmes
rebound sign
 Rhomberg
Ataxia and Gait Disturbances
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Specific Populations
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Geriatric Patient
Gait normally changes with age
Shortened stride
Slow gait
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Widened base
Senile gait may represent neuronal loss, reduced
proprioception, slowing of corrective responses and weakness
Can also be present in other neurodegenerative diseases
Occurs in ~25% of elderly population
Treatment
 Symptomatic
Usually admitted to rule out other life-threatening entities
Ataxia and Gait Disturbances
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The Alcoholic Patient
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Any gait abnormality in an alcoholic patient should raise
concern about nutritional deficiencies
If acute ataxia is associated with confusion and eye movement
abnormalities Wernicke encephalopathy needs to be
considered
Still other intracranial pathology needs to be ruled out
Treatment
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IV hydration, Vit B1 and dextrose
Most often need to be admitted
Ataxia and Gait Disturbances
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Children
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Differential diagnoses
 Drug Intoxication
May appear well, but
 Infection or inflammation
wobbly when sitting
 Neoplasm
Intoxications are most
 Trauma
common, followed by
 Inborn errors of metabolism
infection/inflammation
Ask about family member  Hydrocephalus
 Idiopathic
home medications
PMH
 Disposition
 Rule out life threatening processes
PFH
 Most are admitted
 Pediatric neurology consult
Questions?
1. Which of the following are the most frequently
encountered causes of gait disturbances?
a.
b.
c.
d.
e.
Intoxication
Parkinson Disease
Multiple sclerosis
Disequilibrium of aging
All of the above
1. Which of the following are the most common
causes of gait disturbances?
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E
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All of the above are true. These are the most
commonly seen etiologies for gait disturbances.
2. It is best when describing a patients’ gait to a
colleague, that you use terms such as apraxic,
festinating and equine. T or F?
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False.
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It is better to use descriptive terms when
describing gait, because different terms may
mean different things to different people. Similar
to the use of lethargy, obtundation and stupor.
3. A 42 year old alcoholic patient develops an
ataxic gait in association with confusion and
ocular changes. What is this syndrome called?
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Wernicke encephalopathy.
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It is the syndrome of ophthalmoplegia, confusion
and ataxia.
Due to thiamine deficiency from chronic
malnutrition
Treatment is hydration, thiamine and glucose.
4. The most common cause of childhood
ataxia is inflammatory. T or F?
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False
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Inflammatory is the 2nd leading cause of
childhood ataxia due to infection or
immunizations
Unfortunately intoxication is the most common.
5. Which of the following are probably not
necessary to help determine the etiology of
ataxia in a child?
a.
b.
c.
d.
e.
Urine drug screen and ethanol level
Head CT
Neurologic exam with emphasis on cerebellar
testing
VDRL/RPR
Gait testing
5. Which of the following are probably not
necessary to help determine the etiology of
ataxia in a child?
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D
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All of the above are important in trying to
determine the etiology of ataxia in an adult.
However, testing for neurosyphilis in a child is
probably unnecessary.