Acute Ataxia in Children: A Review of the Differential Diagnosis and Evaluation in the Emergency Department

• Published in: Pediatric neurology 2016-12, Vol.65, p.14-30
• Main Authors: Caffarelli, Mauro, MD, Kimia, Amir A., MD, Torres, Alcy R., MD
• Format: Article
• Language: English
• Subjects: acute ataxia; Acute Disease; Ataxia - chemically induced; Ataxia - diagnosis; Ataxia - therapy; cerebellar ataxia; Cerebellar Ataxia - chemically induced; Cerebellar Ataxia - diagnosis; Cerebellar Ataxia - therapy; Child; children; Diagnosis, Differential; differential diagnosis; Drug Overdose - diagnosis; Drug Overdose - therapy; Emergency Medical Services - methods; Emergency Service, Hospital; Guillain-Barré syndrome; Humans; lumbar puncture; magnetic resonance; Neurology; Pediatrics; toxic ingestion
• ISSN: 0887-8994; 1873-5150
• DOI: 10.1016/j.pediatrneurol.2016.08.025

Abstract Acute ataxia in a pediatric patient poses a diagnostic dilemma for any physician. While the most common etiologies are benign, there are occasional cases that require urgent intervention. Clinical cases of stroke, toxic ingestion, infection, and neuro-inflammatory disorders will frequently report clinical ataxia as an essential—if not the only—presenting feature. The available retrospective research utilize inconsistent definitions of acute ataxia, precluding the ability to pool data from these studies. No prospective data exist that report on patients presenting to the emergency department with ataxia. This review examines the reported causes of ataxia and attempts to group them into distinct categories: post-infectious and inflammatory central and peripheral phenomena, toxic ingestion, neurovascular, infectious and miscellaneous. From there, we synthesize the existing literature to understand which aspects of the history, physical exam, and ancillary testing might aid in narrowing the differential diagnosis. MRI is superior to CT in detecting inflammatory or vascular insults in the posterior fossa, though CT may be necessary in emergent situations. Lumbar puncture may be deferred until after admission in most cases, with suspicion for meningitis being the major exception. There is insufficient evidence to guide laboratory evaluation of serum, testing should be ordered based on clinical judgement—recommended studies include metabolic profiles and screening labs for metabolic disorders (lactate and ammonia). All patients should be reflexively screened for toxic ingestions.