SlideShare a Scribd company logo
1 of 81
ATAXIA
BY-Dr. Shyam Kartikey Dwivedi
Guide-Dr. Meenakshi Girish
DEFINING ATAXIA
• Ataxia is a symptom, not a specific disease or
diagnosis.
• Ataxia means poor coordination of movement.
• The term ataxia is most often used to describe
walking that is uncoordinated and unsteady.
Ataxia can affect coordination of fingers, hands,
arms, speech (dysarthria) and eye movements
(nystagmus).
MECHANISM OF DEVELOPING ATAXIA
• ANATOMY OF CEREBELLUM
- LOBES
- AFFERENTS
- EFFERENTS
- FUNCTIONS
External features
• Two cerebellar hemispheres .
• Median vermis.
• Two surfaces ----superior and
inferior
• 3 fissures:
– fissura prima,
– horizontal fissure and
– posterolateral fissure
• 3 lobes in each hemisphere
– anterior ,
– posterior and
– flocculonodular.
Schematic representation of the major anatomical
subdivisions of the cerebellum.
ANATOMICAL FUNCTIONAL AREAS OF
THE CEREBELLUM
There are 3 lobe:-
Anterior lobe
Posterior lobe
Flocculonodular lobe
Longitudinal functional division of anterior &
posterior lobes
Vermis – control axial body, neck ,shoulder &
hip
Intermediate zone- controls the contraction of
the distal portion of upper & lower limb
especially hand, finger, feet & toes
Lateral zone- controls the overall planning of
sequential motor movement
• Abnormality in vermis of cerebellum, then child
cannot sit still but constantly move the body to
& fro & bob the head.
• abnormality in cerebellar hemisphere causes
tendency to veer in the direction of affected side
with dysmetria & hypotonia in the ipsilateral
limbs.
Cardinal features - Cerebellar pathology
– Stance and gait
– Poor regulation and coordination of skilled
movements (Dysmetria and dysdiadokinesia)
– Eye movement disturbances
– Altered Muscle tone (Hypotonia)
– Speech (Dysarthria)
Core Symptoms
• Difficulty with balance of gait
• Clumsiness of hands
• Dysarthria
• Gaze problems
Manifestations- Stance and gait
–Wide based stance & Gait
–Gait- staggering, irregular steps, lateral
veering.
–Cerebellar gait -visible or more prominent
–Sudden turn, Abrupt stops , Tandem
walking
• Impairment of joint position sense resulting
from interruption of afferent nerve fibers in
the peripheral nerves, posterior roots, or
posterior columns of the spinal cord. The
effect of these lesions is to deprive the
patients of the knowledge of the position of
their limbs
–Ataxic sensory gait
• brisk leg movements
• legs placed far apart to correct instability
• steps of variable length
• need for carefully watching the ground.
• +ve Romberg's sign .
• Most of the autosomal recessive and
dominant ataxias and with a known genetic
defect are characterized by the coexistence of
cerebellar and sensory ataxia
Limb coordination
• Asynergia- movements are broken into isolated
subsequent steps , lack easiness/ smoothness
• Dysdiadochokinesia- impaired rapidly
alterating movement
• Dysmetria. there is an abnormal excursion in
movements and errors in reaching a precise
target
• Tests
–finger-to nose,the finger-chase
tests for the upper limbs
–heel-to-knee and heel-to-tibia
tests for the lower limbs.
Muscle tone
• Hypotonia is a typical cerebellar sign.
• Wider excursion of hands on shaking the
arms.
In ataxic patient, the hypotonia is
not a constant clinical sign.
Speech- Dysarthria
• Altered articulation of words
• Abnormal fluency of speech.
• Scanning Dysarthria
• Slurring
• Disorder may be a simple slowing of speech or
may manifest as a slurring and scanning
Dysarthria called because the words are
broken into syllables.
• As the disease progresses, both slurring and
slowness may occur and words might become
difficult to understand
Scenario
• 2 yr girl
• Acute onset of not able to walk since morning
• No fever
• No erythema, no pain with palpation of
extremities
• H/o normal development, walking for 8
months.
• Awake and alert, but fussy
Refusal to Walk (or abnormal
gait/limp)
• Infections – septic arthritis, osteomyelitis,
discitis, myositis
• Inflammatory – transient synovitis
• H/o Trauma
• Bony deformity/problem – slipped
epiphysis, hip dysplasia, asceptic necrosis
(legg-calve-perthes), vaso-occlusive crisis,
osteochondrosis, tumors.
• Abdominal pain – appendicitis, PID, abscess
• Neurologic – weakness (muscular dystrophy,
NMJ, GBS, TM), ataxia, infections – meningitis,
spinal abscess.
• Psychogenic - conversion
History
• When was walking last normal; onset of
symptoms?
• Any trauma?
• Vitals? Fever?
• Any LOC or abnormal movements?
• nausea/vertigo/posterior fossa symptoms?
• Why is walking altered? - pain, weakness,
numbness, imbalance, can't say?
Neurologic Exam – walk
refusal/abnormal walk
• CN – pupils, eye movements (abnormal
movements, opsoclonus), CN 8 (ear exam,
tinnitus, hearing loss) – peripheral vestibular
neuropathy/labrynthitis
• Motor – strength – weakness –>
myopathy/NMJ/peripheral nerve/UMN
• Reflexes – absent? -->GBS, increased?->UMN
• Sensory – uncommon reason in kids – B12,
tabes dorsalis, diabetic peripheral neuropathy
• Cerebellar – Rapid alternating movements ,
Finger-nose-finger, heel-knee-shin, other
rhythmic movements-clapping, also listen to
speech.
• Gait – romberg, tandem – think of different
abnormal gait types.
ACUTE EPISODIC CHRONIC
ATAXIA
Causes of ataxia:ACUTE
Drug ingestion(antiepileptic,antihistamine)
acute postinfectious cerebellitis(varicella)
Brain tumor
Neuroblastoma
Head-trauma
Vertebrobasilar dissection/stroke
ADEM
Opsoclonus-Myoclonus-Ataxia
Acute Cerebellar Ataxia
– GBS
– Miller Fisher
syndrome(ataxia,ophthalmoplegia,areflexia)
– Tick paralysis
– Infections – encephalitis, cerebellar abscess,
acute labrynthitis
– Toxicities – alcohol, lead
– Conversion reaction
Causes of Ataxia : EPISODIC
• Basilar artery migraine (benign paroxysmal
vertigo)
• Epileptic ataxia(pseudoataxia)
• Dominant paroxysmal ataxia( episodic ataxia
type-1 & type-2
Causes of Ataxia : EPISODIC
• Metabolic:
– Hypoglycemia
– Hyperammonemia
– Organic acid disorders , Maple syrup
– Hartnup ,hyperpyruvic acidemia
– Refsum’s
– Porphyria
• Chronic
– Congenital anomaly of posterior fossa
• Dandy-walker, chiari, cerebellar
dysplasias, Basilar impression
– Hereditary ataxias
• Freidrich ataxia, ataxia-telangectasia,
spinocerebellar ataxia,
– Neurodegenerative
• abetaliproteinemia, vitamin E deficiency,
Refsum, Niemann-Pick,
tumors
Posterior fossa tumor -cerebellar astrocytoma,
brain stem glioma, ependymoma,
medulloblastoma
Cerebellar Hemangioblastoma (VHL)
DEPENDING ON AGE OF
PRESENTATION
• Ataxia in children before 1 year of age:-
Congenital malformation
Mild arrested hydrocephalus
Cerebral palsy
Marinesco- Sjogren syndrome(cerebellar
ataxia,MR,congenital cataract)
• Ataxia in children between 1-5 years of age:-
Drug ingestion
Acute cerebellar ataxia
Myoclonic encephalopathy & neuroblastoma
Inborn errors of metabolism
Brain tumors
Ataxia telangiectasia
refsum’s disease
• Ataxia in children between 5-10 years:-
Drug ingestion
Acute cerebellar ataxia
Brain tumors
Wilson’s disease
Adrenoleukodystrophy
Hereditary ataxias
• Ataxia in children above 10 years:-
Friedreich’s ataxia
Miller Fisher syndrome
Cerebellar hemorrhage
Multiple sclerosis
Olivopontocerebellar degeneration
Hereditary ataxias
INVESTIGATIONS:
 CBC, electrolytes, glucose, BUN,
creatinine
 ANA
 Thyroid function tests
 Alpha-FP
 Immunoglobulins (IgE, IgA)
 Drug screen
 Vitamins B12 and E
 MRI
 Electrodiagnostic
• Nerve conduction velocities
• ECG
• ECHO
EMG
Imaging
 CT
 MRI
 PET
 Cerebellum, brainstem atrophy, enlarged IV
ventricle
 Above +  T2 signal putamen, substantia nigra,
inferior olive, pontine & dentate nuclei
 Glucose utilization in cerebellar hemisphere,
frontal, prefrontal area,brainstem
Treatment
Identify treatable causes of ataxia
No proven therapy for SCAs
Some patients with paraneoplastic cerebellar
syndrome improve following removal of
tumour and immunotherapy
Genetic counselling can reduce risk in future
generations
Treatable causes of ataxia
Hypothyroidism
Vitamin B12 deficiency
Refsum’s disease
Wilson’s Disease
Ataxia with anti-gliadin antibodies and gluten
senstive enteropathy
Ataxia due to malabsorption syndromes
Lyme’s disease
Mitochondrial encephalomyopathies,
aminoacidopathies, Leukodystrophies and
urea cycle abnormalities
Phytanic acid -hydroxylase deficiency
• Clinical features:
– Retinitis pigmentosa
– cardiomyopathy
– hypertrophic neuropathy
– Ichythiosis
• Treatment:
– Dietary restriction of Phytanic acid
Treatable causes of inherited ataxia
Refsum’s disease
Abetalipoproteinemia
• Clinical features:
– Acanthocytosis
– Retinitis pigment
– Fat malabsorption
• Treatment:
– Vitamin E
Treatable causes of inherited ataxia
Copper accumulation
• Clinical features:
– Kayser-Fleischer ring
– Liver involvement
• Treatment:
– Chelators: Penicillamine, BAL , EDTA
Treatable causes of inherited ataxia
Wilson’s Disease
Tryptophan malabsorption
• Clinical features:
– Pellagra rash
– intermittent ataxia
• Treatment:
– Niacin
Treatable causes of inherited ataxia
Hartnup’s disease
Dominant Recurrent Ataxia:
• Types -EA1 & EA2
• Age-5-7 years
• Episodic attacks of ataxia
• t/t-acetazolamide & antiepileptic
TYPES OF ATAXIA
1. CEREBELLAR
2. SENSORY
3. VESTIBULAR
4. FRONTAL LOBE ATAXIA
5. MIXED
6. PSYCHOGENIC
7. PSEUDO ATAXIA
8. MISCELLANEOUS
ACUTE CEREBELLAR ATAXIA
• Age -2 to 7 years
• Ataxia maximal at onset,sudden
• Ataxia varies from mild unsteadiness while
walking to complete inability to stand or walk.
• Tendon reflex, nystagmus +/-
• Diagnosis-drug screening, brain imaging & LP if
encephalitis
• t/t-self limited disease
Cerebellar
Ataxia
Ataxic gait and
position:
Left cerebellar tumor
a. Sways to the right in
standing position
b. Steady on the
right leg
c. Unsteady on the
left leg
d. ataxic gait
a b c
d
• SENSORY- Sensory disturbances can also on
occasion simulate the imbalance of cerebellar
disease; with sensory ataxia, imbalance
dramatically worsens when visual input is removed
(Romberg sign).
• VESTIBULAR – ataxia associated with vestibular
nerve or labyrinthine disease results in a disorder
of gait associated with a significant degree of
dizziness, light-headedness, or the perception of
movement
• PSEUDO ATAXIA- Mild Pyramidal weakness &
Extrapyramidal disorders, weakness of
proximal leg muscles mimics cerebellar
disease
• PSYCHOGENIC – Extremely anxious patients
Differentiation of sensory and cerebellar ataxia
Cerebellar ataxia Sensory ataxia
Scanning speech Normal speech
Nystagmus and other ocular signs Absent
Sensory exam normal, Romberg
test -ve /+ve
Sensory loss, Romberg’s test postive
Pendular reflexes Hypo to areflexia
Reeling, ataxic gait Stamping gait
Differentiation of vestibular and cerebellar
ataxia
Cerebellar ataxia Vestibular disorders
Sense of imbalance Vertigo and associated tinnitus and
hearing loss
Past pointing is in the ipsilateral limb
and in the direction of the lesion
Present in both the limbs and in the
direction of the lesion
Gaze evoked nystagmus Direction of the nystagmus in away from
the lesion
Scanning speech, intention tremors,
dysdiadochokinesia, rebound
phenomena, hypotonia and pendular
reflexes
Absent
 Vestibular ataxia is due to lesion of vestibular pathways resulting
in impairment & imbalance of vestibular inputs. e.g. vestibular,
neuronitis, streptomycin toxicity.
Differentiation between cerebellar and frontal
lobe disorder
Cerebellar Frontal Lobes
Base of support Wide based Wide based
Velocity Variable Very slow
Stride Irregular, lurching Short, shuffling
Heal to shin Abnormal Normal
Initiation Normal Hesitant
Turns Unsteady Hesitant, Multistep
Postural instability * ****
Falls Late events Frequent
 Frontal lobe ataxia (Brun’s ataxia) is due to involvement of
subcortical small vessels, Binswanger’s disease, multi infarct
state
Important points in history
Age at onset
Mode of onset
Precipitating factors
Rate of progression
Symptoms of raised ICP
Presence of systemic symptoms
Drug history and toxin exposure
Family history
Examination
Neck tilt and titubation
Nystagmus and other ocular movement
abnormalities
Dysarthria
Intention tremor
Hypotonia
Past pointing
Rebound phenomenon
Macrographia
Stance
Ataxic Gait
Pendular knee jerk
A 4 year old boy presents to the emergency department with
balance problems. He had been previously healthy, but his walking
has worsened progressively for the past 2 days, with staggering and
lurching.
On PE, the boy is cooperative and alert. His muscles are not tender,
and his joints are not red, swollen or tender. His vision seems
functionally normal, but there is end-gaze nystagmus in all
directions. When sitting independently, his head and trunk bob. His
strength appears normal, and his reflexes are normal. When asked
to stand with his hands outstretched, a symmetric tremor is evident,
and worsens as he approaches this target on finger-to-nose testing.
His gait is broad-based. A urine toxicology screen reveals normal
results. Brain magnetic resonance imaging shows no tumors or other
gray or white matter lesions. Lumbar puncture shows 3 WBCs, 2
RBCs, protein 20, glucose 50.
Of the following, you are MOST likely to advise the
child's mother that:
A. Intravenous steroids significantly reduce
recurrence risk
B. Neuroblastoma is a common cause of these
symptoms
C. Repeat lumbar puncture is needed in 2 days
D. Symptoms may resolve in weeks to months
E. Symptoms usually resolve after antibiotic
treatment
D. Symptoms may resolve in
weeks to months
-Cerebellar ataxia
-Cerebellar findings on exam: Lateral end gaze
nystagmus, dysmetria, ataxia, titubation.
-Subacute onset with normal mental status
suggests acute cerebellar ataxia
-Usually acquired after infection or immunization
-MRI shows lesion
-
Regarding other choices:
A. Intravenous steroids significantly reduce
recurrence risk: They don't
B. Neuroblastoma is a common cause of these
symptoms: not as common
C. Repeat lumbar puncture is needed in 2 days: no
new information
E. Symptoms usually resolve after antibiotic
treatment: Not a primary infectious process
1. A horizontal gaze evoked nystagmus in which the direction of the
fast phase reverses with sustained lateral gaze or beats transiently in
the opposite direction when the eyes return to primary position is
called
A. Periodic alternating nystagmus
B. Seesaw nystagmus
C. Rebound nystagmus
D. Dysconjugate nystagmus
1. A horizontal gaze evoked nystagmus in which the direction of the
fast phase reverses with sustained lateral gaze or beats transiently in
the opposite direction when the eyes return to primary position is
called
A. Periodic alternating nystagmus
B. Seesaw nystagmus
C. Rebound nystagmus
D. Dysconjugate nystagmus
2. The typical signs of cerebellar herniation include the following
EXCEPT
A. Stiff neck
B. Alteration of consciousness
C. Ptosis and pupillary abnormality
D. Cardiac and respiratory abnormalities
2. The typical signs of cerebellar herniation include the following
EXCEPT
A. Stiff neck
B. Alteration of consciousness
C. Ptosis and pupillary abnormality
D. Cardiac and respiratory abnormalities
3. Romberg’s sign is positive in which type of lesion :
A. Cerebellar
B. Posterior column
C. Hysterical
D. Vestibular
3. Romberg’s sign is positive in which type of lesion :
A. Cerebellar
B. Posterior column
C. Hysterical
D. Vestibular
5. Which statement is not true of Friedreich’s ataxia?
A. Recessive inheritance
B.Dysarthria
C. Flexor plantar response
D. Absent ankle jerk
5. Which statement is not true of Friedreich’s ataxia?
A. Recessive inheritance
B.Dysarthria
C. Flexor plantar response
D. Absent ankle jerk
6. Alcoholic cerebellar degeneration is characterized by :
A. Gaze evoked nystagmus
B. Limb ataxia
C. Gait ataxia
D. Action myoclonus
6. Alcoholic cerebellar degeneration is characterized by :
A. Gaze evoked nystagmus
B. Limb ataxia
C. Gait ataxia
D. Action myoclonus
7. Cerebellar ataxia can result from intoxication with :
A. Lead
B. Mercury
C. Manganese
D. Gold
7. Cerebellar ataxia can result from intoxication with :
A. Lead
B. Mercury
C. Manganese
D. Gold
References
• Fenichel
• Forfar
• Swaimann
• Nelson
`

More Related Content

What's hot

Cerebellar ataxia
Cerebellar ataxiaCerebellar ataxia
Cerebellar ataxiaHanaa Nooh
 
Cerebellum & ataxia
Cerebellum & ataxiaCerebellum & ataxia
Cerebellum & ataxiaAmr Hassan
 
Movement disorders
Movement disordersMovement disorders
Movement disordersHelao Silas
 
Motor Neuron Disease
Motor Neuron DiseaseMotor Neuron Disease
Motor Neuron DiseaseNeurologyKota
 
Sensory ataxia
Sensory ataxiaSensory ataxia
Sensory ataxiaSusanth Mj
 
Hereditary neuropathies
Hereditary neuropathies  Hereditary neuropathies
Hereditary neuropathies NeurologyKota
 
Parkinson's plus syndromes
Parkinson's  plus syndromesParkinson's  plus syndromes
Parkinson's plus syndromesNeurologyKota
 
Athetosis and dystonia
Athetosis and dystoniaAthetosis and dystonia
Athetosis and dystoniaPS Deb
 
Nutritional and toxic myelopathies
Nutritional and toxic myelopathiesNutritional and toxic myelopathies
Nutritional and toxic myelopathiesNeurologyKota
 
Hereditary motor and sensory neuropathy
Hereditary motor and sensory neuropathyHereditary motor and sensory neuropathy
Hereditary motor and sensory neuropathyHazel Panabe
 
Psp - Progressive Supranuclear Palsy
Psp - Progressive Supranuclear PalsyPsp - Progressive Supranuclear Palsy
Psp - Progressive Supranuclear PalsyJaber Samer
 
Demyelinating diseases
Demyelinating diseasesDemyelinating diseases
Demyelinating diseasesPraveen Nagula
 

What's hot (20)

Cerebellar ataxia
Cerebellar ataxiaCerebellar ataxia
Cerebellar ataxia
 
Cerebellum & ataxia
Cerebellum & ataxiaCerebellum & ataxia
Cerebellum & ataxia
 
Movement disorders
Movement disordersMovement disorders
Movement disorders
 
Motor Neuron Disease
Motor Neuron DiseaseMotor Neuron Disease
Motor Neuron Disease
 
Hereditary Ataxia
Hereditary AtaxiaHereditary Ataxia
Hereditary Ataxia
 
Sensory ataxia
Sensory ataxiaSensory ataxia
Sensory ataxia
 
Spinocerbellar Ataxia
Spinocerbellar AtaxiaSpinocerbellar Ataxia
Spinocerbellar Ataxia
 
Hereditary neuropathies
Hereditary neuropathies  Hereditary neuropathies
Hereditary neuropathies
 
Parkinson's plus syndromes
Parkinson's  plus syndromesParkinson's  plus syndromes
Parkinson's plus syndromes
 
Dystonia: Causes, Types, Symptoms, and Treatments
Dystonia: Causes, Types, Symptoms, and TreatmentsDystonia: Causes, Types, Symptoms, and Treatments
Dystonia: Causes, Types, Symptoms, and Treatments
 
Spinocerebellar ataxia
Spinocerebellar ataxiaSpinocerebellar ataxia
Spinocerebellar ataxia
 
Motor Neuron Disease
Motor Neuron DiseaseMotor Neuron Disease
Motor Neuron Disease
 
Transverse myelitis
Transverse myelitisTransverse myelitis
Transverse myelitis
 
Cerebellar Ataxia
 Cerebellar Ataxia Cerebellar Ataxia
Cerebellar Ataxia
 
Athetosis and dystonia
Athetosis and dystoniaAthetosis and dystonia
Athetosis and dystonia
 
Nutritional and toxic myelopathies
Nutritional and toxic myelopathiesNutritional and toxic myelopathies
Nutritional and toxic myelopathies
 
Hereditary motor and sensory neuropathy
Hereditary motor and sensory neuropathyHereditary motor and sensory neuropathy
Hereditary motor and sensory neuropathy
 
Psp - Progressive Supranuclear Palsy
Psp - Progressive Supranuclear PalsyPsp - Progressive Supranuclear Palsy
Psp - Progressive Supranuclear Palsy
 
Demyelinating diseases
Demyelinating diseasesDemyelinating diseases
Demyelinating diseases
 
Movement disorders
Movement disordersMovement disorders
Movement disorders
 

Similar to Ataxia seminar

03 01-06 approach to ataxia
03 01-06 approach to ataxia03 01-06 approach to ataxia
03 01-06 approach to ataxiaAndrea Pardo
 
Ataxia 130514030409-phpapp01
Ataxia 130514030409-phpapp01Ataxia 130514030409-phpapp01
Ataxia 130514030409-phpapp01Indhu Reddy
 
Uremic Encephalopathy- A Neurologist's Point of View
Uremic Encephalopathy- A Neurologist's Point of ViewUremic Encephalopathy- A Neurologist's Point of View
Uremic Encephalopathy- A Neurologist's Point of Viewsm171181
 
Approach to a patient with peripheral neuropathy
Approach to a patient with peripheral neuropathyApproach to a patient with peripheral neuropathy
Approach to a patient with peripheral neuropathyTikal Kansara
 
Hypokinetic Movement Disorders - Parkinson disease
Hypokinetic Movement Disorders - Parkinson diseaseHypokinetic Movement Disorders - Parkinson disease
Hypokinetic Movement Disorders - Parkinson diseaseChetan Ganteppanavar
 
ppt on peripheral neuropathy.pptx
ppt on peripheral neuropathy.pptxppt on peripheral neuropathy.pptx
ppt on peripheral neuropathy.pptxAnurag Ghotkar
 
Approach to Milestone Regression
Approach to Milestone RegressionApproach to Milestone Regression
Approach to Milestone RegressionNeurologyKota
 
Approach to Peripheral Neuropathy
Approach to Peripheral NeuropathyApproach to Peripheral Neuropathy
Approach to Peripheral NeuropathyAnand Nambirajan
 
Stroke [uncensored] - by MHR Corporation
Stroke [uncensored] - by MHR CorporationStroke [uncensored] - by MHR Corporation
Stroke [uncensored] - by MHR CorporationMohd Hanafi
 
Approach to a case of paraparesis .pptx
Approach to a case of  paraparesis .pptxApproach to a case of  paraparesis .pptx
Approach to a case of paraparesis .pptxShyamjithLakshmanan1
 
An approach to a child with abnormal movement
An approach to a child with abnormal movementAn approach to a child with abnormal movement
An approach to a child with abnormal movementSunil Agrawal
 
Conus medullaris and cauda equina syndromes
Conus medullaris and cauda equina syndromesConus medullaris and cauda equina syndromes
Conus medullaris and cauda equina syndromesshaishav_bhagat
 
Differential diagnosis balance issues
Differential diagnosis balance issuesDifferential diagnosis balance issues
Differential diagnosis balance issuesadr397
 

Similar to Ataxia seminar (20)

Gait disorders
Gait disordersGait disorders
Gait disorders
 
03 01-06 approach to ataxia
03 01-06 approach to ataxia03 01-06 approach to ataxia
03 01-06 approach to ataxia
 
Approach to Ataxia
Approach to AtaxiaApproach to Ataxia
Approach to Ataxia
 
Ataxia
AtaxiaAtaxia
Ataxia
 
Ataxia 130514030409-phpapp01
Ataxia 130514030409-phpapp01Ataxia 130514030409-phpapp01
Ataxia 130514030409-phpapp01
 
Uremic Encephalopathy- A Neurologist's Point of View
Uremic Encephalopathy- A Neurologist's Point of ViewUremic Encephalopathy- A Neurologist's Point of View
Uremic Encephalopathy- A Neurologist's Point of View
 
Approach to a patient with peripheral neuropathy
Approach to a patient with peripheral neuropathyApproach to a patient with peripheral neuropathy
Approach to a patient with peripheral neuropathy
 
Hypokinetic Movement Disorders - Parkinson disease
Hypokinetic Movement Disorders - Parkinson diseaseHypokinetic Movement Disorders - Parkinson disease
Hypokinetic Movement Disorders - Parkinson disease
 
ppt on peripheral neuropathy.pptx
ppt on peripheral neuropathy.pptxppt on peripheral neuropathy.pptx
ppt on peripheral neuropathy.pptx
 
Ataxia yash final
Ataxia yash finalAtaxia yash final
Ataxia yash final
 
Ataxia
AtaxiaAtaxia
Ataxia
 
Approach to Milestone Regression
Approach to Milestone RegressionApproach to Milestone Regression
Approach to Milestone Regression
 
Approach to ataxia
Approach to ataxiaApproach to ataxia
Approach to ataxia
 
Approach to Peripheral Neuropathy
Approach to Peripheral NeuropathyApproach to Peripheral Neuropathy
Approach to Peripheral Neuropathy
 
Stroke [uncensored] - by MHR Corporation
Stroke [uncensored] - by MHR CorporationStroke [uncensored] - by MHR Corporation
Stroke [uncensored] - by MHR Corporation
 
Approach to a case of paraparesis .pptx
Approach to a case of  paraparesis .pptxApproach to a case of  paraparesis .pptx
Approach to a case of paraparesis .pptx
 
An approach to a child with abnormal movement
An approach to a child with abnormal movementAn approach to a child with abnormal movement
An approach to a child with abnormal movement
 
Conus medullaris and cauda equina syndromes
Conus medullaris and cauda equina syndromesConus medullaris and cauda equina syndromes
Conus medullaris and cauda equina syndromes
 
Backache
Backache Backache
Backache
 
Differential diagnosis balance issues
Differential diagnosis balance issuesDifferential diagnosis balance issues
Differential diagnosis balance issues
 

More from Dr Praman Kushwah

Antibiotic stewardship by dr praman
Antibiotic stewardship by dr pramanAntibiotic stewardship by dr praman
Antibiotic stewardship by dr pramanDr Praman Kushwah
 
Total parenteral nutrition in the nicu Total parenteral nutrition in the nicu
Total parenteral nutrition in the nicu Total parenteral nutrition in the nicuTotal parenteral nutrition in the nicu Total parenteral nutrition in the nicu
Total parenteral nutrition in the nicu Total parenteral nutrition in the nicuDr Praman Kushwah
 
Cytogenetics dr majaz Cytogenetics
Cytogenetics dr majaz CytogeneticsCytogenetics dr majaz Cytogenetics
Cytogenetics dr majaz CytogeneticsDr Praman Kushwah
 
Steroids in neonatology Steroids in neonatology
Steroids in neonatology  Steroids in neonatology Steroids in neonatology  Steroids in neonatology
Steroids in neonatology Steroids in neonatology Dr Praman Kushwah
 
Intrauterine growth restriction Intrauterine growth restriction
Intrauterine growth restriction Intrauterine growth restrictionIntrauterine growth restriction Intrauterine growth restriction
Intrauterine growth restriction Intrauterine growth restrictionDr Praman Kushwah
 
Intrapartum assessment of fetal well being (1)
Intrapartum assessment of fetal well being (1)Intrapartum assessment of fetal well being (1)
Intrapartum assessment of fetal well being (1)Dr Praman Kushwah
 
Aneuploidy screening Aneuploidy screening
Aneuploidy screening  Aneuploidy screening Aneuploidy screening  Aneuploidy screening
Aneuploidy screening Aneuploidy screening Dr Praman Kushwah
 
Thyroid disorders in neonate radha
Thyroid disorders in neonate  radhaThyroid disorders in neonate  radha
Thyroid disorders in neonate radhaDr Praman Kushwah
 
Fluid homeostasis Fluid homeostasis
Fluid homeostasis Fluid homeostasisFluid homeostasis Fluid homeostasis
Fluid homeostasis Fluid homeostasisDr Praman Kushwah
 
Understanding mri in neonate
Understanding mri in neonateUnderstanding mri in neonate
Understanding mri in neonateDr Praman Kushwah
 
Neurodevelopmental follow up
Neurodevelopmental follow upNeurodevelopmental follow up
Neurodevelopmental follow upDr Praman Kushwah
 
Pathophysiology of preterm labor
Pathophysiology of preterm laborPathophysiology of preterm labor
Pathophysiology of preterm laborDr Praman Kushwah
 
Developmental supportive care in nicu
Developmental supportive care in nicuDevelopmental supportive care in nicu
Developmental supportive care in nicuDr Praman Kushwah
 
approach to infant with Hydrops fetalis
approach to infant with Hydrops fetalisapproach to infant with Hydrops fetalis
approach to infant with Hydrops fetalisDr Praman Kushwah
 

More from Dr Praman Kushwah (20)

Antibiotic stewardship by dr praman
Antibiotic stewardship by dr pramanAntibiotic stewardship by dr praman
Antibiotic stewardship by dr praman
 
Total parenteral nutrition in the nicu Total parenteral nutrition in the nicu
Total parenteral nutrition in the nicu Total parenteral nutrition in the nicuTotal parenteral nutrition in the nicu Total parenteral nutrition in the nicu
Total parenteral nutrition in the nicu Total parenteral nutrition in the nicu
 
Cytogenetics dr majaz Cytogenetics
Cytogenetics dr majaz CytogeneticsCytogenetics dr majaz Cytogenetics
Cytogenetics dr majaz Cytogenetics
 
Infant of diabetic mother
Infant of diabetic motherInfant of diabetic mother
Infant of diabetic mother
 
Steroids in neonatology Steroids in neonatology
Steroids in neonatology  Steroids in neonatology Steroids in neonatology  Steroids in neonatology
Steroids in neonatology Steroids in neonatology
 
Intrauterine growth restriction Intrauterine growth restriction
Intrauterine growth restriction Intrauterine growth restrictionIntrauterine growth restriction Intrauterine growth restriction
Intrauterine growth restriction Intrauterine growth restriction
 
Intrapartum assessment of fetal well being (1)
Intrapartum assessment of fetal well being (1)Intrapartum assessment of fetal well being (1)
Intrapartum assessment of fetal well being (1)
 
Aneuploidy screening Aneuploidy screening
Aneuploidy screening  Aneuploidy screening Aneuploidy screening  Aneuploidy screening
Aneuploidy screening Aneuploidy screening
 
Thyroid disorders in neonate radha
Thyroid disorders in neonate  radhaThyroid disorders in neonate  radha
Thyroid disorders in neonate radha
 
Pulmonary graphics radha
Pulmonary graphics radhaPulmonary graphics radha
Pulmonary graphics radha
 
Fluid homeostasis Fluid homeostasis
Fluid homeostasis Fluid homeostasisFluid homeostasis Fluid homeostasis
Fluid homeostasis Fluid homeostasis
 
Rop hearing
Rop hearingRop hearing
Rop hearing
 
Understanding mri in neonate
Understanding mri in neonateUnderstanding mri in neonate
Understanding mri in neonate
 
Growh charts by praman
Growh charts by pramanGrowh charts by praman
Growh charts by praman
 
Neurodevelopmental follow up
Neurodevelopmental follow upNeurodevelopmental follow up
Neurodevelopmental follow up
 
Pain scales
Pain scalesPain scales
Pain scales
 
Pathophysiology of preterm labor
Pathophysiology of preterm laborPathophysiology of preterm labor
Pathophysiology of preterm labor
 
Developmental supportive care in nicu
Developmental supportive care in nicuDevelopmental supportive care in nicu
Developmental supportive care in nicu
 
approach to infant with Hydrops fetalis
approach to infant with Hydrops fetalisapproach to infant with Hydrops fetalis
approach to infant with Hydrops fetalis
 
Rh isoimmunisation
Rh isoimmunisationRh isoimmunisation
Rh isoimmunisation
 

Recently uploaded

Russian Call Girls Kota * 8250192130 Service starts from just ₹9999 ✅
Russian Call Girls Kota * 8250192130 Service starts from just ₹9999 ✅Russian Call Girls Kota * 8250192130 Service starts from just ₹9999 ✅
Russian Call Girls Kota * 8250192130 Service starts from just ₹9999 ✅gragmanisha42
 
(Deeksha) 💓 9920725232 💓High Profile Call Girls Navi Mumbai You Can Get The S...
(Deeksha) 💓 9920725232 💓High Profile Call Girls Navi Mumbai You Can Get The S...(Deeksha) 💓 9920725232 💓High Profile Call Girls Navi Mumbai You Can Get The S...
(Deeksha) 💓 9920725232 💓High Profile Call Girls Navi Mumbai You Can Get The S...Ahmedabad Call Girls
 
VIP Call Girl DLF Phase 2 Gurgaon (Noida) Just Meet Me@ 9711199012
VIP Call Girl DLF Phase 2 Gurgaon (Noida) Just Meet Me@ 9711199012VIP Call Girl DLF Phase 2 Gurgaon (Noida) Just Meet Me@ 9711199012
VIP Call Girl DLF Phase 2 Gurgaon (Noida) Just Meet Me@ 9711199012adityaroy0215
 
Call Girl Gorakhpur * 8250192130 Service starts from just ₹9999 ✅
Call Girl Gorakhpur * 8250192130 Service starts from just ₹9999 ✅Call Girl Gorakhpur * 8250192130 Service starts from just ₹9999 ✅
Call Girl Gorakhpur * 8250192130 Service starts from just ₹9999 ✅gragmanisha42
 
nagpur Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
nagpur Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meetnagpur Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
nagpur Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real MeetCall Girls Service
 
(Sonam Bajaj) Call Girl in Jaipur- 09257276172 Escorts Service 50% Off with C...
(Sonam Bajaj) Call Girl in Jaipur- 09257276172 Escorts Service 50% Off with C...(Sonam Bajaj) Call Girl in Jaipur- 09257276172 Escorts Service 50% Off with C...
(Sonam Bajaj) Call Girl in Jaipur- 09257276172 Escorts Service 50% Off with C...indiancallgirl4rent
 
Krishnagiri call girls Tamil aunty 7877702510
Krishnagiri call girls Tamil aunty 7877702510Krishnagiri call girls Tamil aunty 7877702510
Krishnagiri call girls Tamil aunty 7877702510Vipesco
 
ooty Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
ooty Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meetooty Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
ooty Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real MeetCall Girls Service
 
Mangalore Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
Mangalore Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real MeetMangalore Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
Mangalore Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real MeetCall Girls Service
 
Call Now ☎ 9999965857 !! Call Girls in Hauz Khas Escort Service Delhi N.C.R.
Call Now ☎ 9999965857 !! Call Girls in Hauz Khas Escort Service Delhi N.C.R.Call Now ☎ 9999965857 !! Call Girls in Hauz Khas Escort Service Delhi N.C.R.
Call Now ☎ 9999965857 !! Call Girls in Hauz Khas Escort Service Delhi N.C.R.ktanvi103
 
VIP Call Girl Sector 32 Noida Just Book Me 9711199171
VIP Call Girl Sector 32 Noida Just Book Me 9711199171VIP Call Girl Sector 32 Noida Just Book Me 9711199171
VIP Call Girl Sector 32 Noida Just Book Me 9711199171Call Girls Service Gurgaon
 
Call Girl In Zirakpur ❤️♀️@ 9988299661 Zirakpur Call Girls Near Me ❤️♀️@ Sexy...
Call Girl In Zirakpur ❤️♀️@ 9988299661 Zirakpur Call Girls Near Me ❤️♀️@ Sexy...Call Girl In Zirakpur ❤️♀️@ 9988299661 Zirakpur Call Girls Near Me ❤️♀️@ Sexy...
Call Girl In Zirakpur ❤️♀️@ 9988299661 Zirakpur Call Girls Near Me ❤️♀️@ Sexy...Sheetaleventcompany
 
Call Girls Service Faridabad 📲 9999965857 ヅ10k NiGhT Call Girls In Faridabad
Call Girls Service Faridabad 📲 9999965857 ヅ10k NiGhT Call Girls In FaridabadCall Girls Service Faridabad 📲 9999965857 ヅ10k NiGhT Call Girls In Faridabad
Call Girls Service Faridabad 📲 9999965857 ヅ10k NiGhT Call Girls In Faridabadgragmanisha42
 
Enjoyment ★ 8854095900 Indian Call Girls In Dehradun 🍆🍌 By Dehradun Call Girl ★
Enjoyment ★ 8854095900 Indian Call Girls In Dehradun 🍆🍌 By Dehradun Call Girl ★Enjoyment ★ 8854095900 Indian Call Girls In Dehradun 🍆🍌 By Dehradun Call Girl ★
Enjoyment ★ 8854095900 Indian Call Girls In Dehradun 🍆🍌 By Dehradun Call Girl ★indiancallgirl4rent
 
Call Girl Raipur 📲 9999965857 ヅ10k NiGhT Call Girls In Raipur
Call Girl Raipur 📲 9999965857 ヅ10k NiGhT Call Girls In RaipurCall Girl Raipur 📲 9999965857 ヅ10k NiGhT Call Girls In Raipur
Call Girl Raipur 📲 9999965857 ヅ10k NiGhT Call Girls In Raipurgragmanisha42
 
❤️♀️@ Jaipur Call Girl Agency ❤️♀️@ Manjeet Russian Call Girls Service in Jai...
❤️♀️@ Jaipur Call Girl Agency ❤️♀️@ Manjeet Russian Call Girls Service in Jai...❤️♀️@ Jaipur Call Girl Agency ❤️♀️@ Manjeet Russian Call Girls Service in Jai...
❤️♀️@ Jaipur Call Girl Agency ❤️♀️@ Manjeet Russian Call Girls Service in Jai...Gfnyt.com
 
Call Girl Raipur 📲 9999965857 whatsapp live cam sex service available
Call Girl Raipur 📲 9999965857 whatsapp live cam sex service availableCall Girl Raipur 📲 9999965857 whatsapp live cam sex service available
Call Girl Raipur 📲 9999965857 whatsapp live cam sex service availablegragmanisha42
 
VIP Call Girl Sector 88 Gurgaon Delhi Just Call Me 9899900591
VIP Call Girl Sector 88 Gurgaon Delhi Just Call Me 9899900591VIP Call Girl Sector 88 Gurgaon Delhi Just Call Me 9899900591
VIP Call Girl Sector 88 Gurgaon Delhi Just Call Me 9899900591adityaroy0215
 
❤️♀️@ Jaipur Call Girls ❤️♀️@ Meghna Jaipur Call Girls Number CRTHNR Call G...
❤️♀️@ Jaipur Call Girls ❤️♀️@ Meghna Jaipur Call Girls Number CRTHNR   Call G...❤️♀️@ Jaipur Call Girls ❤️♀️@ Meghna Jaipur Call Girls Number CRTHNR   Call G...
❤️♀️@ Jaipur Call Girls ❤️♀️@ Meghna Jaipur Call Girls Number CRTHNR Call G...Gfnyt.com
 
Call Girls Hyderabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Hyderabad Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Hyderabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Hyderabad Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 

Recently uploaded (20)

Russian Call Girls Kota * 8250192130 Service starts from just ₹9999 ✅
Russian Call Girls Kota * 8250192130 Service starts from just ₹9999 ✅Russian Call Girls Kota * 8250192130 Service starts from just ₹9999 ✅
Russian Call Girls Kota * 8250192130 Service starts from just ₹9999 ✅
 
(Deeksha) 💓 9920725232 💓High Profile Call Girls Navi Mumbai You Can Get The S...
(Deeksha) 💓 9920725232 💓High Profile Call Girls Navi Mumbai You Can Get The S...(Deeksha) 💓 9920725232 💓High Profile Call Girls Navi Mumbai You Can Get The S...
(Deeksha) 💓 9920725232 💓High Profile Call Girls Navi Mumbai You Can Get The S...
 
VIP Call Girl DLF Phase 2 Gurgaon (Noida) Just Meet Me@ 9711199012
VIP Call Girl DLF Phase 2 Gurgaon (Noida) Just Meet Me@ 9711199012VIP Call Girl DLF Phase 2 Gurgaon (Noida) Just Meet Me@ 9711199012
VIP Call Girl DLF Phase 2 Gurgaon (Noida) Just Meet Me@ 9711199012
 
Call Girl Gorakhpur * 8250192130 Service starts from just ₹9999 ✅
Call Girl Gorakhpur * 8250192130 Service starts from just ₹9999 ✅Call Girl Gorakhpur * 8250192130 Service starts from just ₹9999 ✅
Call Girl Gorakhpur * 8250192130 Service starts from just ₹9999 ✅
 
nagpur Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
nagpur Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meetnagpur Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
nagpur Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
 
(Sonam Bajaj) Call Girl in Jaipur- 09257276172 Escorts Service 50% Off with C...
(Sonam Bajaj) Call Girl in Jaipur- 09257276172 Escorts Service 50% Off with C...(Sonam Bajaj) Call Girl in Jaipur- 09257276172 Escorts Service 50% Off with C...
(Sonam Bajaj) Call Girl in Jaipur- 09257276172 Escorts Service 50% Off with C...
 
Krishnagiri call girls Tamil aunty 7877702510
Krishnagiri call girls Tamil aunty 7877702510Krishnagiri call girls Tamil aunty 7877702510
Krishnagiri call girls Tamil aunty 7877702510
 
ooty Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
ooty Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meetooty Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
ooty Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
 
Mangalore Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
Mangalore Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real MeetMangalore Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
Mangalore Call Girls 👙 6297143586 👙 Genuine WhatsApp Number for Real Meet
 
Call Now ☎ 9999965857 !! Call Girls in Hauz Khas Escort Service Delhi N.C.R.
Call Now ☎ 9999965857 !! Call Girls in Hauz Khas Escort Service Delhi N.C.R.Call Now ☎ 9999965857 !! Call Girls in Hauz Khas Escort Service Delhi N.C.R.
Call Now ☎ 9999965857 !! Call Girls in Hauz Khas Escort Service Delhi N.C.R.
 
VIP Call Girl Sector 32 Noida Just Book Me 9711199171
VIP Call Girl Sector 32 Noida Just Book Me 9711199171VIP Call Girl Sector 32 Noida Just Book Me 9711199171
VIP Call Girl Sector 32 Noida Just Book Me 9711199171
 
Call Girl In Zirakpur ❤️♀️@ 9988299661 Zirakpur Call Girls Near Me ❤️♀️@ Sexy...
Call Girl In Zirakpur ❤️♀️@ 9988299661 Zirakpur Call Girls Near Me ❤️♀️@ Sexy...Call Girl In Zirakpur ❤️♀️@ 9988299661 Zirakpur Call Girls Near Me ❤️♀️@ Sexy...
Call Girl In Zirakpur ❤️♀️@ 9988299661 Zirakpur Call Girls Near Me ❤️♀️@ Sexy...
 
Call Girls Service Faridabad 📲 9999965857 ヅ10k NiGhT Call Girls In Faridabad
Call Girls Service Faridabad 📲 9999965857 ヅ10k NiGhT Call Girls In FaridabadCall Girls Service Faridabad 📲 9999965857 ヅ10k NiGhT Call Girls In Faridabad
Call Girls Service Faridabad 📲 9999965857 ヅ10k NiGhT Call Girls In Faridabad
 
Enjoyment ★ 8854095900 Indian Call Girls In Dehradun 🍆🍌 By Dehradun Call Girl ★
Enjoyment ★ 8854095900 Indian Call Girls In Dehradun 🍆🍌 By Dehradun Call Girl ★Enjoyment ★ 8854095900 Indian Call Girls In Dehradun 🍆🍌 By Dehradun Call Girl ★
Enjoyment ★ 8854095900 Indian Call Girls In Dehradun 🍆🍌 By Dehradun Call Girl ★
 
Call Girl Raipur 📲 9999965857 ヅ10k NiGhT Call Girls In Raipur
Call Girl Raipur 📲 9999965857 ヅ10k NiGhT Call Girls In RaipurCall Girl Raipur 📲 9999965857 ヅ10k NiGhT Call Girls In Raipur
Call Girl Raipur 📲 9999965857 ヅ10k NiGhT Call Girls In Raipur
 
❤️♀️@ Jaipur Call Girl Agency ❤️♀️@ Manjeet Russian Call Girls Service in Jai...
❤️♀️@ Jaipur Call Girl Agency ❤️♀️@ Manjeet Russian Call Girls Service in Jai...❤️♀️@ Jaipur Call Girl Agency ❤️♀️@ Manjeet Russian Call Girls Service in Jai...
❤️♀️@ Jaipur Call Girl Agency ❤️♀️@ Manjeet Russian Call Girls Service in Jai...
 
Call Girl Raipur 📲 9999965857 whatsapp live cam sex service available
Call Girl Raipur 📲 9999965857 whatsapp live cam sex service availableCall Girl Raipur 📲 9999965857 whatsapp live cam sex service available
Call Girl Raipur 📲 9999965857 whatsapp live cam sex service available
 
VIP Call Girl Sector 88 Gurgaon Delhi Just Call Me 9899900591
VIP Call Girl Sector 88 Gurgaon Delhi Just Call Me 9899900591VIP Call Girl Sector 88 Gurgaon Delhi Just Call Me 9899900591
VIP Call Girl Sector 88 Gurgaon Delhi Just Call Me 9899900591
 
❤️♀️@ Jaipur Call Girls ❤️♀️@ Meghna Jaipur Call Girls Number CRTHNR Call G...
❤️♀️@ Jaipur Call Girls ❤️♀️@ Meghna Jaipur Call Girls Number CRTHNR   Call G...❤️♀️@ Jaipur Call Girls ❤️♀️@ Meghna Jaipur Call Girls Number CRTHNR   Call G...
❤️♀️@ Jaipur Call Girls ❤️♀️@ Meghna Jaipur Call Girls Number CRTHNR Call G...
 
Call Girls Hyderabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Hyderabad Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Hyderabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Hyderabad Just Call 9907093804 Top Class Call Girl Service Available
 

Ataxia seminar

  • 1. ATAXIA BY-Dr. Shyam Kartikey Dwivedi Guide-Dr. Meenakshi Girish
  • 2.
  • 3. DEFINING ATAXIA • Ataxia is a symptom, not a specific disease or diagnosis. • Ataxia means poor coordination of movement. • The term ataxia is most often used to describe walking that is uncoordinated and unsteady. Ataxia can affect coordination of fingers, hands, arms, speech (dysarthria) and eye movements (nystagmus).
  • 4. MECHANISM OF DEVELOPING ATAXIA • ANATOMY OF CEREBELLUM - LOBES - AFFERENTS - EFFERENTS - FUNCTIONS
  • 5. External features • Two cerebellar hemispheres . • Median vermis. • Two surfaces ----superior and inferior • 3 fissures: – fissura prima, – horizontal fissure and – posterolateral fissure • 3 lobes in each hemisphere – anterior , – posterior and – flocculonodular.
  • 6. Schematic representation of the major anatomical subdivisions of the cerebellum.
  • 7. ANATOMICAL FUNCTIONAL AREAS OF THE CEREBELLUM There are 3 lobe:- Anterior lobe Posterior lobe Flocculonodular lobe
  • 8. Longitudinal functional division of anterior & posterior lobes Vermis – control axial body, neck ,shoulder & hip Intermediate zone- controls the contraction of the distal portion of upper & lower limb especially hand, finger, feet & toes Lateral zone- controls the overall planning of sequential motor movement
  • 9. • Abnormality in vermis of cerebellum, then child cannot sit still but constantly move the body to & fro & bob the head. • abnormality in cerebellar hemisphere causes tendency to veer in the direction of affected side with dysmetria & hypotonia in the ipsilateral limbs.
  • 10. Cardinal features - Cerebellar pathology – Stance and gait – Poor regulation and coordination of skilled movements (Dysmetria and dysdiadokinesia) – Eye movement disturbances – Altered Muscle tone (Hypotonia) – Speech (Dysarthria)
  • 11. Core Symptoms • Difficulty with balance of gait • Clumsiness of hands • Dysarthria • Gaze problems
  • 12. Manifestations- Stance and gait –Wide based stance & Gait –Gait- staggering, irregular steps, lateral veering. –Cerebellar gait -visible or more prominent –Sudden turn, Abrupt stops , Tandem walking
  • 13. • Impairment of joint position sense resulting from interruption of afferent nerve fibers in the peripheral nerves, posterior roots, or posterior columns of the spinal cord. The effect of these lesions is to deprive the patients of the knowledge of the position of their limbs
  • 14. –Ataxic sensory gait • brisk leg movements • legs placed far apart to correct instability • steps of variable length • need for carefully watching the ground. • +ve Romberg's sign .
  • 15. • Most of the autosomal recessive and dominant ataxias and with a known genetic defect are characterized by the coexistence of cerebellar and sensory ataxia
  • 16. Limb coordination • Asynergia- movements are broken into isolated subsequent steps , lack easiness/ smoothness • Dysdiadochokinesia- impaired rapidly alterating movement • Dysmetria. there is an abnormal excursion in movements and errors in reaching a precise target
  • 17. • Tests –finger-to nose,the finger-chase tests for the upper limbs –heel-to-knee and heel-to-tibia tests for the lower limbs.
  • 18. Muscle tone • Hypotonia is a typical cerebellar sign. • Wider excursion of hands on shaking the arms. In ataxic patient, the hypotonia is not a constant clinical sign.
  • 19. Speech- Dysarthria • Altered articulation of words • Abnormal fluency of speech. • Scanning Dysarthria • Slurring
  • 20. • Disorder may be a simple slowing of speech or may manifest as a slurring and scanning Dysarthria called because the words are broken into syllables. • As the disease progresses, both slurring and slowness may occur and words might become difficult to understand
  • 21. Scenario • 2 yr girl • Acute onset of not able to walk since morning • No fever • No erythema, no pain with palpation of extremities • H/o normal development, walking for 8 months. • Awake and alert, but fussy
  • 22. Refusal to Walk (or abnormal gait/limp) • Infections – septic arthritis, osteomyelitis, discitis, myositis • Inflammatory – transient synovitis • H/o Trauma • Bony deformity/problem – slipped epiphysis, hip dysplasia, asceptic necrosis (legg-calve-perthes), vaso-occlusive crisis, osteochondrosis, tumors.
  • 23. • Abdominal pain – appendicitis, PID, abscess • Neurologic – weakness (muscular dystrophy, NMJ, GBS, TM), ataxia, infections – meningitis, spinal abscess. • Psychogenic - conversion
  • 24. History • When was walking last normal; onset of symptoms? • Any trauma? • Vitals? Fever? • Any LOC or abnormal movements? • nausea/vertigo/posterior fossa symptoms? • Why is walking altered? - pain, weakness, numbness, imbalance, can't say?
  • 25. Neurologic Exam – walk refusal/abnormal walk • CN – pupils, eye movements (abnormal movements, opsoclonus), CN 8 (ear exam, tinnitus, hearing loss) – peripheral vestibular neuropathy/labrynthitis • Motor – strength – weakness –> myopathy/NMJ/peripheral nerve/UMN • Reflexes – absent? -->GBS, increased?->UMN
  • 26. • Sensory – uncommon reason in kids – B12, tabes dorsalis, diabetic peripheral neuropathy • Cerebellar – Rapid alternating movements , Finger-nose-finger, heel-knee-shin, other rhythmic movements-clapping, also listen to speech. • Gait – romberg, tandem – think of different abnormal gait types.
  • 28. Causes of ataxia:ACUTE Drug ingestion(antiepileptic,antihistamine) acute postinfectious cerebellitis(varicella) Brain tumor Neuroblastoma Head-trauma Vertebrobasilar dissection/stroke ADEM Opsoclonus-Myoclonus-Ataxia Acute Cerebellar Ataxia
  • 29. – GBS – Miller Fisher syndrome(ataxia,ophthalmoplegia,areflexia) – Tick paralysis – Infections – encephalitis, cerebellar abscess, acute labrynthitis – Toxicities – alcohol, lead – Conversion reaction
  • 30. Causes of Ataxia : EPISODIC • Basilar artery migraine (benign paroxysmal vertigo) • Epileptic ataxia(pseudoataxia) • Dominant paroxysmal ataxia( episodic ataxia type-1 & type-2
  • 31. Causes of Ataxia : EPISODIC • Metabolic: – Hypoglycemia – Hyperammonemia – Organic acid disorders , Maple syrup – Hartnup ,hyperpyruvic acidemia – Refsum’s – Porphyria
  • 32. • Chronic – Congenital anomaly of posterior fossa • Dandy-walker, chiari, cerebellar dysplasias, Basilar impression – Hereditary ataxias • Freidrich ataxia, ataxia-telangectasia, spinocerebellar ataxia, – Neurodegenerative • abetaliproteinemia, vitamin E deficiency, Refsum, Niemann-Pick,
  • 33. tumors Posterior fossa tumor -cerebellar astrocytoma, brain stem glioma, ependymoma, medulloblastoma Cerebellar Hemangioblastoma (VHL)
  • 34. DEPENDING ON AGE OF PRESENTATION • Ataxia in children before 1 year of age:- Congenital malformation Mild arrested hydrocephalus Cerebral palsy Marinesco- Sjogren syndrome(cerebellar ataxia,MR,congenital cataract)
  • 35. • Ataxia in children between 1-5 years of age:- Drug ingestion Acute cerebellar ataxia Myoclonic encephalopathy & neuroblastoma Inborn errors of metabolism Brain tumors Ataxia telangiectasia refsum’s disease
  • 36. • Ataxia in children between 5-10 years:- Drug ingestion Acute cerebellar ataxia Brain tumors Wilson’s disease Adrenoleukodystrophy Hereditary ataxias
  • 37. • Ataxia in children above 10 years:- Friedreich’s ataxia Miller Fisher syndrome Cerebellar hemorrhage Multiple sclerosis Olivopontocerebellar degeneration Hereditary ataxias
  • 38.
  • 39.
  • 40. INVESTIGATIONS:  CBC, electrolytes, glucose, BUN, creatinine  ANA  Thyroid function tests  Alpha-FP  Immunoglobulins (IgE, IgA)  Drug screen  Vitamins B12 and E
  • 41.  MRI  Electrodiagnostic • Nerve conduction velocities • ECG • ECHO EMG
  • 42. Imaging  CT  MRI  PET  Cerebellum, brainstem atrophy, enlarged IV ventricle  Above +  T2 signal putamen, substantia nigra, inferior olive, pontine & dentate nuclei  Glucose utilization in cerebellar hemisphere, frontal, prefrontal area,brainstem
  • 43. Treatment Identify treatable causes of ataxia No proven therapy for SCAs Some patients with paraneoplastic cerebellar syndrome improve following removal of tumour and immunotherapy
  • 44. Genetic counselling can reduce risk in future generations
  • 45. Treatable causes of ataxia Hypothyroidism Vitamin B12 deficiency Refsum’s disease Wilson’s Disease Ataxia with anti-gliadin antibodies and gluten senstive enteropathy Ataxia due to malabsorption syndromes Lyme’s disease Mitochondrial encephalomyopathies, aminoacidopathies, Leukodystrophies and urea cycle abnormalities
  • 46. Phytanic acid -hydroxylase deficiency • Clinical features: – Retinitis pigmentosa – cardiomyopathy – hypertrophic neuropathy – Ichythiosis • Treatment: – Dietary restriction of Phytanic acid Treatable causes of inherited ataxia Refsum’s disease
  • 47. Abetalipoproteinemia • Clinical features: – Acanthocytosis – Retinitis pigment – Fat malabsorption • Treatment: – Vitamin E Treatable causes of inherited ataxia
  • 48. Copper accumulation • Clinical features: – Kayser-Fleischer ring – Liver involvement • Treatment: – Chelators: Penicillamine, BAL , EDTA Treatable causes of inherited ataxia Wilson’s Disease
  • 49. Tryptophan malabsorption • Clinical features: – Pellagra rash – intermittent ataxia • Treatment: – Niacin Treatable causes of inherited ataxia Hartnup’s disease
  • 50. Dominant Recurrent Ataxia: • Types -EA1 & EA2 • Age-5-7 years • Episodic attacks of ataxia • t/t-acetazolamide & antiepileptic
  • 51. TYPES OF ATAXIA 1. CEREBELLAR 2. SENSORY 3. VESTIBULAR 4. FRONTAL LOBE ATAXIA 5. MIXED 6. PSYCHOGENIC 7. PSEUDO ATAXIA 8. MISCELLANEOUS
  • 52. ACUTE CEREBELLAR ATAXIA • Age -2 to 7 years • Ataxia maximal at onset,sudden • Ataxia varies from mild unsteadiness while walking to complete inability to stand or walk. • Tendon reflex, nystagmus +/- • Diagnosis-drug screening, brain imaging & LP if encephalitis • t/t-self limited disease
  • 53. Cerebellar Ataxia Ataxic gait and position: Left cerebellar tumor a. Sways to the right in standing position b. Steady on the right leg c. Unsteady on the left leg d. ataxic gait a b c d
  • 54. • SENSORY- Sensory disturbances can also on occasion simulate the imbalance of cerebellar disease; with sensory ataxia, imbalance dramatically worsens when visual input is removed (Romberg sign). • VESTIBULAR – ataxia associated with vestibular nerve or labyrinthine disease results in a disorder of gait associated with a significant degree of dizziness, light-headedness, or the perception of movement
  • 55. • PSEUDO ATAXIA- Mild Pyramidal weakness & Extrapyramidal disorders, weakness of proximal leg muscles mimics cerebellar disease • PSYCHOGENIC – Extremely anxious patients
  • 56. Differentiation of sensory and cerebellar ataxia Cerebellar ataxia Sensory ataxia Scanning speech Normal speech Nystagmus and other ocular signs Absent Sensory exam normal, Romberg test -ve /+ve Sensory loss, Romberg’s test postive Pendular reflexes Hypo to areflexia Reeling, ataxic gait Stamping gait
  • 57. Differentiation of vestibular and cerebellar ataxia Cerebellar ataxia Vestibular disorders Sense of imbalance Vertigo and associated tinnitus and hearing loss Past pointing is in the ipsilateral limb and in the direction of the lesion Present in both the limbs and in the direction of the lesion Gaze evoked nystagmus Direction of the nystagmus in away from the lesion Scanning speech, intention tremors, dysdiadochokinesia, rebound phenomena, hypotonia and pendular reflexes Absent  Vestibular ataxia is due to lesion of vestibular pathways resulting in impairment & imbalance of vestibular inputs. e.g. vestibular, neuronitis, streptomycin toxicity.
  • 58. Differentiation between cerebellar and frontal lobe disorder Cerebellar Frontal Lobes Base of support Wide based Wide based Velocity Variable Very slow Stride Irregular, lurching Short, shuffling Heal to shin Abnormal Normal Initiation Normal Hesitant Turns Unsteady Hesitant, Multistep Postural instability * **** Falls Late events Frequent  Frontal lobe ataxia (Brun’s ataxia) is due to involvement of subcortical small vessels, Binswanger’s disease, multi infarct state
  • 59. Important points in history Age at onset Mode of onset Precipitating factors Rate of progression
  • 60. Symptoms of raised ICP Presence of systemic symptoms Drug history and toxin exposure Family history
  • 61. Examination Neck tilt and titubation Nystagmus and other ocular movement abnormalities Dysarthria Intention tremor Hypotonia
  • 63.
  • 64. A 4 year old boy presents to the emergency department with balance problems. He had been previously healthy, but his walking has worsened progressively for the past 2 days, with staggering and lurching. On PE, the boy is cooperative and alert. His muscles are not tender, and his joints are not red, swollen or tender. His vision seems functionally normal, but there is end-gaze nystagmus in all directions. When sitting independently, his head and trunk bob. His strength appears normal, and his reflexes are normal. When asked to stand with his hands outstretched, a symmetric tremor is evident, and worsens as he approaches this target on finger-to-nose testing. His gait is broad-based. A urine toxicology screen reveals normal results. Brain magnetic resonance imaging shows no tumors or other gray or white matter lesions. Lumbar puncture shows 3 WBCs, 2 RBCs, protein 20, glucose 50.
  • 65. Of the following, you are MOST likely to advise the child's mother that: A. Intravenous steroids significantly reduce recurrence risk B. Neuroblastoma is a common cause of these symptoms C. Repeat lumbar puncture is needed in 2 days D. Symptoms may resolve in weeks to months E. Symptoms usually resolve after antibiotic treatment
  • 66. D. Symptoms may resolve in weeks to months -Cerebellar ataxia -Cerebellar findings on exam: Lateral end gaze nystagmus, dysmetria, ataxia, titubation. -Subacute onset with normal mental status suggests acute cerebellar ataxia -Usually acquired after infection or immunization -MRI shows lesion -
  • 67. Regarding other choices: A. Intravenous steroids significantly reduce recurrence risk: They don't B. Neuroblastoma is a common cause of these symptoms: not as common C. Repeat lumbar puncture is needed in 2 days: no new information E. Symptoms usually resolve after antibiotic treatment: Not a primary infectious process
  • 68. 1. A horizontal gaze evoked nystagmus in which the direction of the fast phase reverses with sustained lateral gaze or beats transiently in the opposite direction when the eyes return to primary position is called A. Periodic alternating nystagmus B. Seesaw nystagmus C. Rebound nystagmus D. Dysconjugate nystagmus
  • 69. 1. A horizontal gaze evoked nystagmus in which the direction of the fast phase reverses with sustained lateral gaze or beats transiently in the opposite direction when the eyes return to primary position is called A. Periodic alternating nystagmus B. Seesaw nystagmus C. Rebound nystagmus D. Dysconjugate nystagmus
  • 70. 2. The typical signs of cerebellar herniation include the following EXCEPT A. Stiff neck B. Alteration of consciousness C. Ptosis and pupillary abnormality D. Cardiac and respiratory abnormalities
  • 71. 2. The typical signs of cerebellar herniation include the following EXCEPT A. Stiff neck B. Alteration of consciousness C. Ptosis and pupillary abnormality D. Cardiac and respiratory abnormalities
  • 72. 3. Romberg’s sign is positive in which type of lesion : A. Cerebellar B. Posterior column C. Hysterical D. Vestibular
  • 73. 3. Romberg’s sign is positive in which type of lesion : A. Cerebellar B. Posterior column C. Hysterical D. Vestibular
  • 74. 5. Which statement is not true of Friedreich’s ataxia? A. Recessive inheritance B.Dysarthria C. Flexor plantar response D. Absent ankle jerk
  • 75. 5. Which statement is not true of Friedreich’s ataxia? A. Recessive inheritance B.Dysarthria C. Flexor plantar response D. Absent ankle jerk
  • 76. 6. Alcoholic cerebellar degeneration is characterized by : A. Gaze evoked nystagmus B. Limb ataxia C. Gait ataxia D. Action myoclonus
  • 77. 6. Alcoholic cerebellar degeneration is characterized by : A. Gaze evoked nystagmus B. Limb ataxia C. Gait ataxia D. Action myoclonus
  • 78. 7. Cerebellar ataxia can result from intoxication with : A. Lead B. Mercury C. Manganese D. Gold
  • 79. 7. Cerebellar ataxia can result from intoxication with : A. Lead B. Mercury C. Manganese D. Gold
  • 81. `