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Unsteadiness

Medicine > Neurosciences

Differential Diagnosis Schema 🧠

Cerebellar Causes

  • Cerebellar stroke: Sudden onset unsteadiness, often with dysarthria, nystagmus, and limb ataxia.
  • Cerebellar tumor: Gradual onset, with progressive unsteadiness, often accompanied by headaches and signs of raised intracranial pressure.
  • Multiple sclerosis: May present with cerebellar signs such as unsteadiness, dysmetria, and intention tremor.
  • Alcohol-related cerebellar degeneration: Chronic alcohol use leading to ataxia, unsteadiness, and cognitive impairment.
  • Friedreich’s ataxia: A hereditary ataxia presenting with progressive unsteadiness, dysarthria, and scoliosis.
  • Cerebellar ataxia: Can result from paraneoplastic syndromes, infections, or toxins, presenting with broad-based gait and difficulty with coordination.

Vestibular Causes

  • Benign paroxysmal positional vertigo (BPPV): Episodes of vertigo triggered by head movements, often accompanied by unsteadiness.
  • Meniere’s disease: Vertigo, tinnitus, and hearing loss, often with associated unsteadiness during attacks.
  • Vestibular neuritis: Acute onset of severe vertigo and unsteadiness without hearing loss, often following a viral infection.
  • Acoustic neuroma: Progressive unilateral hearing loss, tinnitus, and unsteadiness due to a tumor affecting the vestibulocochlear nerve.
  • Labyrinthitis: Vertigo, hearing loss, and unsteadiness, usually following an ear infection.
  • Central vertigo: Causes such as stroke, multiple sclerosis, or brainstem lesions presenting with vertigo, unsteadiness, and other neurological deficits.

Proprioceptive Causes

  • Peripheral neuropathy: Loss of proprioception leading to unsteadiness, often worse in the dark; commonly associated with diabetes, B12 deficiency, or alcohol abuse.
  • Tabes dorsalis: A late manifestation of syphilis, causing loss of proprioception, ataxia, and a high-stepping gait.
  • Subacute combined degeneration of the cord: Due to B12 deficiency, presenting with unsteadiness, spasticity, and sensory loss.
  • Sensory ataxia: Resulting from conditions like Guillain-Barré syndrome or chronic inflammatory demyelinating polyneuropathy (CIDP), leading to unsteadiness and poor coordination.
  • Spinal cord compression: Causing ataxia and unsteadiness due to loss of proprioceptive pathways; may be due to tumors, trauma, or degenerative disease.

Other Neurological Causes

  • Parkinson’s disease: Resting tremor, bradykinesia, and rigidity with postural instability leading to unsteadiness.
  • Normal pressure hydrocephalus: Triad of gait disturbance, urinary incontinence, and cognitive impairment; gait is often described as magnetic.
  • Multiple system atrophy: Parkinsonism with autonomic dysfunction and cerebellar signs; presents with unsteadiness and falls.
  • Progressive supranuclear palsy: Parkinsonism with vertical gaze palsy, leading to frequent falls and unsteadiness.
  • Vascular parkinsonism: Unsteadiness and falls in the context of cerebrovascular disease, often affecting the lower limbs more than upper limbs.
  • Cervical myelopathy: Compression of the spinal cord in the neck leading to gait disturbance, hand clumsiness, and unsteadiness.
  • Frontal lobe lesions: Gait apraxia and unsteadiness due to dysfunction of the frontal lobes; often associated with cognitive impairment.
  • Motor neuron disease: Progressive weakness and muscle wasting leading to unsteadiness, often with a combination of upper and lower motor neuron signs.

Key Points in History 🥼

Onset and Duration

  • Sudden onset: Suggests acute causes like stroke, vestibular neuritis, or trauma.
  • Gradual onset: More indicative of degenerative conditions like Parkinson’s disease, cerebellar ataxia, or peripheral neuropathy.
  • Intermittent episodes: May suggest conditions like BPPV, Meniere’s disease, or transient ischemic attacks.
  • Progression: Assess if symptoms are worsening, which could indicate a progressive neurological disorder.
  • Exacerbating factors: Consider if symptoms worsen with certain movements, in the dark, or with fatigue.
  • Temporal pattern: Determine if symptoms are constant or vary throughout the day.
  • Previous episodes: Ask about any similar past events that might provide clues to the diagnosis.
  • Impact on daily life: Assess how unsteadiness affects activities of daily living, which can guide the urgency of intervention.

Associated Symptoms

  • Vertigo: Suggests vestibular causes like BPPV, Meniere’s disease, or vestibular neuritis.
  • Headache: May indicate a cerebellar lesion, migraine, or raised intracranial pressure.
  • Hearing loss or tinnitus: Associated with Meniere’s disease, labyrinthitis, or acoustic neuroma.
  • Visual disturbances: May suggest multiple sclerosis, stroke, or vestibular migraine.
  • Numbness or weakness: Could indicate peripheral neuropathy, spinal cord disease, or stroke.
  • Tremor: Commonly seen in Parkinson’s disease, essential tremor, or cerebellar disorders.
  • Cognitive changes: Suggests normal pressure hydrocephalus, frontal lobe lesions, or dementia.
  • Autonomic symptoms: Consider multiple system atrophy if there are symptoms like orthostatic hypotension or urinary incontinence.
  • Seizures: Could point to a structural brain lesion or epilepsy as a cause of unsteadiness.
  • Mood changes: Depression or anxiety can sometimes present with or exacerbate unsteadiness.
  • Fatigue: Common in multiple sclerosis, chronic fatigue syndrome, or metabolic disturbances.
  • Joint pain or swelling: Suggests an inflammatory or arthritic cause contributing to unsteadiness.

Background

  • Past medical history: Document any history of neurological, cardiovascular, or metabolic disorders.
  • Medication history: Review for drugs that may cause or exacerbate unsteadiness, such as sedatives, anticonvulsants, or antihypertensives.
  • Family history: Consider hereditary conditions like Friedreich’s ataxia or familial tremor syndromes.
  • Social history: Assess alcohol use, smoking, and occupational risks that could contribute to neurological or cardiovascular issues.
  • Surgical history: Previous surgeries, especially neurosurgery, or orthopedic procedures that may impact balance.
  • Travel history: Recent travel to areas with risk of infections like malaria or viral encephalitis, which may present with neurological symptoms.
  • Immunization status: Particularly for conditions like influenza or meningitis, which could indirectly impact neurological health.
  • Dietary history: Consider malnutrition or vitamin deficiencies, particularly B12, as potential contributors to unsteadiness.
  • Psychological history: Anxiety, depression, or other mental health issues that may contribute to or result from unsteadiness.
  • Functional status: Determine the patient’s baseline mobility and any recent changes in function.
  • Falls history: Document any recent falls, their frequency, and any injuries sustained.

Possible Investigations 🌡️

Laboratory Tests

  • Full blood count (FBC): To assess for anemia, infection, or other hematological abnormalities that may cause fatigue or weakness.
  • Thyroid function tests: To rule out hyperthyroidism or hypothyroidism, which can contribute to unsteadiness.
  • Serum electrolytes: Including calcium and magnesium levels, which can influence neuromuscular function.
  • Vitamin B12 and folate levels: To assess for deficiencies that may cause peripheral neuropathy or myelopathy.
  • Liver function tests: To screen for hepatic causes of encephalopathy, which may present with unsteadiness.
  • Blood glucose levels: To assess for hypoglycemia or poorly controlled diabetes as potential causes.
  • Renal function tests: To assess for uremia, which can cause neurological symptoms.
  • Coagulation profile: To assess bleeding risk in patients presenting with potential vascular causes of unsteadiness.
  • Toxicology screen: To identify any substance misuse that may contribute to unsteadiness.
  • Autoimmune screen: Including ANA and ESR, to assess for autoimmune conditions that may cause neurological symptoms.
  • Paraneoplastic panel: To screen for paraneoplastic syndromes associated with neurological presentations.
  • CSF analysis: If central nervous system infection or inflammation is suspected.
  • Infectious disease screening: Particularly for conditions like syphilis, HIV, or viral encephalitis.
  • Serum copper and ceruloplasmin: To assess for Wilson’s disease in younger patients with unexplained neurological symptoms.
  • Lactate and pyruvate levels: To assess for mitochondrial disorders.
  • Genetic testing: If hereditary conditions like Friedreich’s ataxia are suspected.
  • ABG (arterial blood gas): To assess for hypoxemia or hypercapnia in patients with respiratory disease that may contribute to unsteadiness.
  • Hormonal assays: To investigate endocrine causes of unsteadiness, such as adrenal insufficiency.

Imaging Studies

  • MRI brain and spine: Essential for identifying structural causes of unsteadiness, such as stroke, tumors, multiple sclerosis, or cervical myelopathy.
  • CT brain: Useful in acute settings to rule out hemorrhage, large masses, or hydrocephalus.
  • CT angiography or MR angiography: To assess for vascular causes such as vertebrobasilar insufficiency or carotid artery disease.
  • DaTSCAN: A specialized imaging study used to differentiate Parkinsonian syndromes from other causes of unsteadiness.
  • EEG: Useful in patients with suspected seizures or other paroxysmal neurological events.
  • Ultrasound of carotid arteries: To assess for carotid artery stenosis, which could lead to TIAs and contribute to unsteadiness.
  • Vestibular testing (e.g., VNG, caloric testing): To assess for vestibular causes of unsteadiness such as BPPV or vestibular neuritis.
  • Electromyography (EMG) and nerve conduction studies: To evaluate for peripheral neuropathy or myopathy.
  • X-rays of spine: To assess for degenerative changes or fractures contributing to myelopathy or radiculopathy.
  • Bone scan: To assess for metastatic disease or osteomyelitis that could affect balance.
  • Tilt table testing: To evaluate autonomic function in patients with suspected autonomic instability.
  • SPECT or PET scan: May be used in research settings or for specific cases to assess brain function.
  • Holter monitor or cardiac event monitor: To assess for arrhythmias that may cause syncope or near-syncope, leading to unsteadiness.
  • Vestibular evoked myogenic potentials (VEMP): To assess for vestibular disorders like superior canal dehiscence syndrome.
  • Cervical spine MRI: To assess for cervical myelopathy, which can cause gait disturbance and unsteadiness.

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Neurosciences