Subacute tremor and ataxia: Diligence in pursuit of a diagnosis: Expert commentary

      Cerebellar syndromes often present a lengthy, complicated and daunting differential diagnosis [
      • Kuo S.H.
      ]. Too often in medicine, when faced with an unknown diagnosis, an indiscriminant “shotgun” approach is employed, working the patient up for ‘everything’. What is much more appropriate, cost-effective and patient-focused is to start off using the tried-and-true history and physical examination to construct the differential diagnosis of a cerebellar syndrome. The first step in narrowing down the possibilities is the temporal profile: slowly progressive cerebellar symptoms and signs, over years, usually point toward a degenerative etiology, such as one of the spinocerebellar ataxias or multiple system atrophy-cerebellar (MSA-C), with some exceptions. Yet, it is important to appreciate that not all slowly progressive cerebellar syndromes are degenerative or untreatable and among others, considerations here include ataxia with vitamin E deficiency and cerebrotendinous xanthomatosis [
      • Stezin A.
      • Pal P.K.
      Treatable ataxias: how to find the needle in the haystack?.
      ]. Cerebellar syndromes that develop sub-acutely (weeks to months) are much less likely degenerative and usually point instead toward inflammatory, toxic, autoimmune and paraneoplastic etiologies. Other features that help further narrow the differential include the age of the patient, family history, a review of medications and toxins including alcohol, as well as accompanying neurological and systemic symptoms and signs. The first round of testing also needs consideration of treatable cerebellar syndromes, described by Stezin and Pal as important needles to find in the haystack of cerebellar disorders [
      • Stezin A.
      • Pal P.K.
      Treatable ataxias: how to find the needle in the haystack?.


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