Resident Tutorial: Ataxia

Resident Tutorial
Long case Board

Examination
Surat Tanprawate, MD, FRCPT
Northern Neuroscience Center
Chiangmai University
www.neurologycoffeecup.com
By
Dr. Surat
Present
“Fear factors in Long Case
Neuro Examination”
and
“How to approach to ataxia”
Fear Factors
• Hard to get neurological history

• Hard to do the physical
neurological exam
• Hard to conclude the results
• Hard to make neurological
diagnosis
Fear Factors
• Hard to get
Symptomatology
neurological history
• Hard to do the physical Practice the physical
exam
neurological exam
• Hard to conclude the Practice to list the
results problem
• Hard to make To know the common
neurological diagnosis diseases
Key Concept
Symptoms
approach
“Algorithm”
Key Concept
Symptoms
&Signs
“Specific
examination”
Key Concept
To diagnose
“Problem list
and Conclusion”
Symptomatology
Syndrome
Symptomatology
• Disorder of
consciousness • Visual disorder
• Level of
consciousness • Visual loss
• Content of • Ocular motility
consciousness disorder
• Mental disorder
• Diplopia
• Memory
• Intelligence • Abnormal ocular
ossilation
• Personality
• Behavioral
• Dementia
Symptomatology
Lower cranial nerve disorder
• Deafness/tinnitus
• Vertigo
• Balance/staggering
• Swallowing
• Voice change
Multiple Cranial Nerve Disorders

Symptomatology
• Sensory disorder • Sphincter
• Pain disorder disorder
• Headache and facial pain
• Others pain disorder • Episodic
• Numbness/tingling disorder
• Motor disorder – Seizure/epilepsy
• Weakness – Syncope
• Movement disorder – TIA
• Gait abnormality – Abnormal movement
• Ataxic disorder – Migraine
Syndrome
• Amnistic and Dementia syndrome
• Neuro-opthalmology syndrome
• Syndrome of Multiple cranial nerve disorder
• Stroke syndrome
• Cortical stroke syndrome
• Lacunar stroke syndrome
• Brain stem stroke syndrome
• Spinal cord syndrome

Ataxia
Algorithm
Gait abnormality
Ataxia
Specific examination
Specific examination
-confirm ataxic disorder
-for categorized ataxia
Conclusion and Diagnosis

Greek word
A=nega.ve
Taxi=order
Ataxia Algorithm
Ataxic symptoms?
-Nystagmus
-Dysarthria
-Trunkcal ataxia
-Limb and gait -ataxia
Ataxic symptoms
mimicker?
• Mild weakness True Ataxia

• Apraxia Ataxia: disease
• Abnormal movement other than cerebellum
• Gait abnormality
Cerebellar’s disease
-Where’s the lesion (cerebellum,
cerebellar peduncle, cerebellar
tract)
-What’s the lesion
Neuroanatomy
Neurophysiology
Function of
cerebellum
• Coordinating skill voluntary

movement
• Muscle activity
• Control equilibrium
• Muscle tone
Function of
cerebellum
• Lesion
• Incoordination (ataxia) of
volitional movement
• Tremor (ataxic or intention
tremor)
• Disorder of equilibrium and gait
• Diminish muscle tone
Cerebellar
pathway
To a7ributed 
sensorimotor 
network: 
• cerebral cortex
• basal motor nuclei
• thalamus
• re:cular forma:on
Func.onal Zone
Part of Cerebellum
Functional Deep Nuclei Connections Functions
divisions
Vermis Fastigial Vestibular nucleus Axial and proximal
(face, proximal Reticular formation muscle control
body) Medial descending Progressive movement
system
Intermediate zone Interposed Red nucleus Distal muscle control

(spinal cord) Motor cortex Progressive movement
Lateral descending
system
Lateral zone Dentate Red nucleus Motor planning

(cortex, pons) Thalamus Initiation
Motor, premotor Timing
cortex
Flocculonodular Vestibular nuclei, Vestibular nuclei Axial equilibrium
lobe visual system Eye movements
Vestibular reflexes
Basic Anatomy – Cerebellar peduncles
Cerebellar Tracts connect to Major pathways Connections
peduncles brain stem
Superior Brachium Afferent Rubral, thalamic,

conjunctivuum Efferent Dentate, spinal cord
Middle Brachium pontis Afferent Pontine nuclei

only
Inferior Restiform body Afferent Vestibular, olive, Spinal

Efferent cord
Receives from
Flocculonodular lobe
Blood Vessel
Ataxia Algorithm
Ataxic symptoms?
-Nystagmus
-Dysarthria
-Trunkcal ataxia
-Limb and gait -ataxia
Ataxic symptoms
mimicker?
• Mild weakness True Ataxia

• Apraxia Ataxia: disease
• Abnormal movement other than cerebellum
• Gait abnormality
Cerebellar’s disease
-Where’s the lesion (cerebellum,
cerebellar peduncle, cerebellar
tract)
-What’s the lesion
What is the cerebellar
syndrome?
What is the associated

signs?
Associated signs
With With mild

Pure
Brainstem hemiparesis
cerebellum
signs
Classified Classified Involve fronto-

Cerebellar Brainstem Ponto-
syndrome Syndrome? Cerebellar
Pathway
“Ataxic
hemiparesis”
Classiﬁed cerebellar syndrome
Cerebellar Unilateral
hemispheric intermediate,
syndrome lateral zones
Rostral Ant,
vermis sup vermis
syndrome
Caudal Flucculo
vermis nodular,
syndrome post vermis
Pan All
cerebellar regions
syndrome
Cerebellar syndrome and its disorders
Cerebellar  Regions  Distribu.ons of  Common 
syndromes involved deﬁcits causes
Cerebellar  Cerebellar Ipsilateral head &  Infarct, neoplasm, 
hemisphere  hemisphere body abscess, 
syndrome demyelina:on
Rostral vermis  Ant, sup vermis Gait, trunk Alcoholism, 

syndrome thiamine def
Caudal vermis  Flucculonodular,  Axial  Midline neoplasm

syndrome post vermis diisequilibrium
Pancerebellar  All regions Bilateral  Toxic, metabolic, 

syndrome symmetrical signs  infec:ous, 
of cerebellar  paraneoplas:c, 
dysfunc:on degenera:ve
Posterior inferior cerebellar artery (PICA)
Anterior inferior cerebellar artery (AICA)
Superior cerebellar artery (SCA)
Posterior cerebral artery (PCA)
PICA = lateral medulla & inferior cerebellum

AICA = lateral caudal pons & part of cerebellum
SCA = superior cerebellum & rostral laterodorsal pons
PCA = midbrain, thalamus, medial surface of occipital lobe, inferior and medial
surfaces of temporal lobe
Brainstem Vascular Territories
SYNDROME STRUCTURES DAMAGED CLINICAL SYMPTOM
Lateral medullary (PICA, Corticospinal tract Contralateral hemiplegia

Wallenberg’s)syndrome (pyramid)
Spinothalamic tract Contralateral hemisensory
Damage Level:
loss
Lateral medullar
Trigerminal spinal Ipsilateral facial hemisensory

nucleus loss
Vascular supply
PICA
Nucleus ambiguous Ipsilateral palatal, pharyngeal,
vocal cord paralysis
Dysarthria, dysphagia
Sympathetic fiber Ipsilateral Horner’s

syndrome
Vestibular nuclei Vertigo, N/V
Cerebellum Ipsilateral cerebellar sign

SYNDROME STRUCTURES DAMAGED CLINICAL SYMPTOM
Lateral inferior Vestibular nucleus Ipsilateral vertigo, N/V,

pontine syndrome nystagmus
(AICA stroke syndrome) Cochlear nucleus Ipsilateral deafness
Damage Level:
Lateral inferior pons
Nuclear of CN7 Ipsilateral facial palsy
Cerebellum Ipsilateral ataxia
CN 5 Ipsilateral hemisensory
loss of face
Spinothalamic tract
Contralateral hemisensory
loss
Neurological
examination in
ataxia
Patient Video
Nystagmus
Patient Video
Intention tremor
Patient Video
Finger to Nose Test

Patient Video
Ataxic gait
Patient Video
Ataxic speech
What’s lesion?
Time, Caused, Onset
Medical History
Neurological Signs
Time Caused Onset
• Subacute
• Sudden • Intoxication
• Vascular
• Chronic
• Acute • Hereditary
• Intoxication • Paraneoplastic
• Viral, Post infectious syndrome
• Hypothyroid
• Intoxication
Symmetrical ataxia
plus syndrome
• Acquired
• Wernicke’s encephalopathy
• Miller Fisher syndrome
• Hereditary
• SCA
• FA
Pt. with progressive ataxia
Imaging
• to exclude identifiable
structural lesion
• Atrophy of cerebellum or
spinal cord
Evaluate
•Accurate family history
AD • Phenotype AR
SCA1,2 Singleton patient

MJD
SCA6, 7
FA
SCA10,12 Acquired causes
-Alcohol/medication AT
DRPLA
-Hypothyroid AVED
SCA17 -Vit.B12 Abetalipoproteinemia
-Anti-HIV AOA
-Paraneoplastic study
-GAD Ab
Mitochondrial disorder
Next Episode: Neuro-opthalmology approach
Diplopia, Visual loss, Ptosis
END

Resident Tutorial: Ataxia

Uploaded by

Copyright:

Available Formats

Resident Tutorial: Ataxia

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Resident Tutorial: Ataxia

Uploaded by

Copyright:

Available Formats

What are some common neurological symptoms discussed?

What are some common neurological symptoms discussed?

What are some common vascular territories of the brainstem discussed?

What are some common vascular territories of the brainstem discussed?

Resident Tutorial

Long case Board

• Hard to get neurological history

Multiple Cranial Nerve Disorders

• Syndrome of Multiple cranial nerve disorder

• Lacunar stroke syndrome

• Brain stem stroke syndrome

• Spinal cord syndrome

Conclusion and Diagnosis

• Mild weakness True Ataxia

• Coordinating skill voluntary

Intermediate zone Interposed Red nucleus Distal muscle control

Lateral zone Dentate Red nucleus Motor planning

Superior Brachium Afferent Rubral, thalamic,

Middle Brachium pontis Afferent Pontine nuclei

Inferior Restiform body Afferent Vestibular, olive, Spinal

• Mild weakness True Ataxia

What is the associated

With With mild

Classified Classified Involve fronto-

Rostral vermis Ant, sup vermis Gait, trunk Alcoholism,

Caudal vermis Flucculonodular, Axial Midline neoplasm

Pancerebellar All regions Bilateral Toxic, metabolic,

PICA = lateral medulla & inferior cerebellum

Lateral medullary (PICA, Corticospinal tract Contralateral hemiplegia

Trigerminal spinal Ipsilateral facial hemisensory

Sympathetic fiber Ipsilateral Horner’s

Vestibular nuclei Vertigo, N/V

Cerebellum Ipsilateral cerebellar sign

Lateral inferior Vestibular nucleus Ipsilateral vertigo, N/V,

Cerebellum Ipsilateral ataxia

Finger to Nose Test

SCA1,2 Singleton patient

You might also like

• Mild weakness True Ataxia

• Mild weakness True Ataxia

Rostral vermis  Ant, sup vermis Gait, trunk Alcoholism, 

Caudal vermis  Flucculonodular,  Axial  Midline neoplasm

Pancerebellar  All regions Bilateral  Toxic, metabolic, 