Sanad Esmail BSc (Hons), MBBCh (Hons), MPhil, MRCP (UK)
Background: Cerebellar ataxia is characterised by loss of fine coordination of muscle groups during volitional movements and can affect cranial, trunk or limb musculature. CT/MRI brain imaging often represents a core investigative modality but can be normal or reveal minor changes that may not fully explain the degree of clinical ataxia evident at the bedside.
Aim: To provide general physicians and neurologists with a practical guide on how to approach the ataxic patient with negative neuroimaging and to discuss important differential diagnoses that should be considered in such circumstances.
Methods: A selection of relevant original research and review articles was obtained from the author’s personal archive and by searching PubMed, EMBASE and Medline using a combination of the terms cerebellar ataxia, cerebellar syndrome and normal neuroimaging or CT/MRI.
Results: Cerebellar ataxia represents an important neurological presentation in the emergency and outpatient clinic settings. Causes of cerebellar ataxia with unremarkable neuroimaging are vast and include stroke, toxic, nutritional/metabolic, neurodegenerative, autoimmune, paraneoplastic, genetic and post-traumatic. Although neuroimaging forms a key part of the workup of new-onset cerebellar ataxia, sensitivity may be limited, but this is dependent on aetiology. In progressive ataxic syndromes, cerebellar atrophy is frequently a common endpoint but may not be apparent early in disease.
Conclusions: New-onset cerebellar ataxia with negative or soft neuroimaging findings may still require an extensive diagnostic workup, but this must be guided by the clinical history and examination findings.View pdf