Unsteadiness

Year 2 Michaelmas Term 2006

The case..

• A 56 year old man presented to his GP with a persistent right-sided headache in the occipital-parietal region, requiring analgesia

• GP thought headache might be due to neck problem and referred him for physiotherapy

Then…• 2 weeks later GP asked to do a home visit

as patient become unsteady and unable to walk

• Headache more severe and associated with nausea and vomiting

• He now felt very unsteady and found sitting up in bed distressing

• The GP arranged hospital admission

Other features of the history:• Headache worse in the mornings

• Headache worse if coughs or strains

• Patient unsteady on walking with tendency to fall to the right

• No previous history

• No medication

• Minimal alcohol

• Ex-smoker 30 years

On examination:• Cardiovascular, respiratory, abdominal

systems unremarkable• Power, tone, reflexes normal• Eyeballs jerk to right side when looks to

right• Right-sided finger-nose test abnormal with

past pointing and intention tremor• Heal-shin test on right side abnormal• Unsteady when standing with tendency to

fall to right

What causes unsteadiness? (Ataxia)

Causes of ataxia• Cerebellar ataxia

• Sensory ataxia (vestibular, visual and proprioceptive defects)

• Disorders of locomotion:

central disorders e.g MS, stroke

peripheral disorders e.g. nerve damage,

peripheral neuropathy

Which is the area of the brain involved in this case?

The right side of the cerebellum, because:

• Abnormal finger-nose test with intention tremor and past-pointing (dysmetria) on R

• Abnormal heel-shin test on right

• May also have dysdiadochokinesis on R

• Could also test for Romberg’s sign- stand with eyes open and closed. Positive Romberg’s= unsteady when close eyes (not specific for cerebellar lesion)

What is the medical term for jerky eyeballs?

Nystagmus• Tends to be worse towards the affected

side

• May also be congenital- can be linked with albinism and Down syndrome

• May be linked with other eye conditions or a number of neurological disorders, e.g MS, stroke

• Seen in alcoholic poisoning

What processes could be causig the symptoms in this patient?

A right-sided cerebellar lesion, due to…

• Space-occupying lesion: primary or secondary tumour

• Cerebellar abscess

• Cerebellar haemorrhage or haematoma

• Inner ear disease?

• Demyelination?

• Long-standing excess alcohol intake?

n.b. in cerebellar lesions the symptoms and signs usually

involve the same (ipsilateral) side

Why has he got a headache and what further examination might

help?

Headache a sign of raised intracranial pressure

• Worse in mornings

• Suggestive of space-occupying lesion

• Examination of the fundi would demonstrate papilledema

Any further investigation required?

Further investigation:

• CT/MRI

• CXR

• ?tumour markers

• ?bronchoscopy

• ?Biopsy

Other results:• CXR normal

• Bronchoscopic washings: small cell carcinoma

The patient’s progress

• Transferred to neurosurgical unit

• High-dose steroids

• Lesion excised

• Commenced radiotherapy

• Died after 6 weeks