Episode 199: Ataxia in Children

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Aug 1, 2024

Explore the critical evaluation of pediatric ataxia through the lens of a troubling case involving an 18-month-old boy. Discover the common and rare causes of ataxia, like acute cerebellar ataxia and Guillain-Barre syndrome. Dive into the significance of history-taking and physical exams in diagnosis. Learn about essential diagnostic tests, including neuroimaging, and treatment strategies centered on identifying underlying conditions. It's a masterclass in pediatric emergency medicine and the art of thorough assessment.

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ANECDOTE

Sudden Pediatric Ataxia Case

Dr. Ellen Duncan describes her 18-month-old son who developed sudden head floppiness and inability to sit or stand.
She decided to go to the ED when vomiting began, illustrating parental urgency in acute pediatric neurologic changes.

INSIGHT

Broad Differential For Pediatric Ataxia

Acute cerebellar ataxia is the most common cause of pediatric ataxia seen in the ED.
Other important differentials include ingestion, Guillain-Barré, basilar migraine, cerebellitis, encephalitis, tumor, and labyrinthitis.

ADVICE

Use History To Narrow Causes

Obtain a clear time course, ask about prior episodes, recent illnesses, trauma, and toxic exposures when evaluating ataxia.
Also screen for signs of increased intracranial pressure, ear infections, and family history to guide workup.

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We discuss a case of ataxia in children and how to approach the evaluation of these pts.

Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD

Download Leave a Comment Tags: Neurology, Pediatrics

Show Notes

Introduction

The episode focuses on ataxia in children, which can range from self-limiting to life-threatening conditions.
Pediatric emergency medicine specialist shares insights on the topic.

The Case

An 18-month-old boy presented with ataxia, unable to keep his head up, sit, or stand, and began vomiting.
Previously healthy except for recurrent otitis media and viral-induced wheezing.
The decision to take the child to the emergency department (ED) was based on acute symptoms.

Differential Diagnosis

Common causes include acute cerebellar ataxia, drug ingestion, Guillain-Barre syndrome, and basilar migraine.
Less common causes include cerebellitis, encephalitis, brain tumors, and labyrinthitis.

Importance of History and Physical Examination

A detailed history and physical exam are essential in diagnosing ataxia.
Key factors include time course, recent infections, signs of increased intracranial pressure, and toxic exposures.
Look for signs such as bradycardia, hypertension, vomiting, and overall appearance.

Diagnostic Workup

Initial tests include point-of-care glucose and neuroimaging for concerns about trauma or increased intracranial pressure.
MRI is preferred for posterior fossa abnormalities, but non-contrast head CT is commonly used due to accessibility.
Lumbar puncture may be needed if meningismus is present.

Treatment Approach

Treatment depends on the underlying cause:
- Acute cerebellar ataxia is self-limiting and typically resolves with time.
- Antibiotics are required for meningitis or encephalitis.
- Steroids may be useful for cerebellitis and acute disseminated encephalomyelitis (ADEM).
- Specialist consultations are necessary for severe diagnoses like intracranial masses.

Outcome of the Case Study

The child had a normal fast T2 MRI and improved during the ED stay.
Diagnosed with a combination of cerebellar ataxia and labyrinthitis.
Received myringotomy tubes and experienced no further neurologic changes or otitis media episodes.

Take-Home Points

Diverse Etiologies: Ataxia in children can have various causes that range from self-limiting to life-threatening
Comprehensive Assessment: History and physical exams guide diagnosis and workup direction, focusing on symptom time course, infections, and toxic exposures.
Physical Examination Clues: Vital signs and appearance offer clues; increased ICP may present with bradycardia, hypertension, and vomiting.
Diagnostic Imaging: Point-of-care glucose testing and neuroimaging are key; MRI is preferred for posterior fossa abnormalities.
Tailored Treatment: Treatment varies by cause; acute cerebellar ataxia typically resolves over time without specific intervention.