What you need to know about acute ataxias in adults

O que você precisa saber sobre ataxias agudas em adultos

The concept of movement disorders emergencies (MDE) was coined to address distinct situations that combine specific features: a neurological condition evolving acutely where the predominant manifestation is a movement disorder in which failure to accurately diagnose and manage may result in significant morbidity or even mortality¹. The sparse older literature related to this entity was only organized and gained visibility as a distinct theme in neurology at the begining of the past decade. As such, recognition of MDE is a relatively recent development in a field in which the stereotypic clinical scenarios are dominated by disorders with chronic, degenerative backgrounds followed at outpatient clinics on elective appointments. On a casual consideration, this sketchy view became inescapable, forging the impression that movement disorders specialists are generally unfamiliar and gauche in a hospital emergency department environment.

As mentioned above, the MDE bureau only recently became visible in the medical literature. A search on Pubmed using the keywords “movement disorders” and either “emergencies” or “acute” found 41 entries, only 16 of which in fact discuss the topic per se, including some related to subtopics, such as MDE in the elderly or acute chorea, for instance. The literature on MDE is not only exiguous, but also new, fragmented and not fully matured. The first dedicated review on MDE was published in 2005², while virtually all earlier publications related to aspects of this topic dealt with drug-induced MDE. As another example, the first time the most prestigious world congress in the field, the Movement Disorders Society meeting, held a session on MDE was in 2011, while the pioneers in this topic first discussed it at the American Academy of Neurology annual meeting in 2002³.

In this issue of the Arquivos de Neuropsiquiatria, Pedroso et al.⁴ present a review of another form of MDE: acute ataxias in adults. This is thus far a unique addition to the literature as previously published reviews on acute ataxias were either focused on children or described specific acute ataxic syndromes (i.e., paraneoplastic, infectious, etc.). The content of this manuscript is broad and detailed, convering topics that are familiar to most general neurologists, such as acute ataxias due to vascular lesions, infections (both viral and bacterial) and toxins (alcohol, antibiotics, anticonvulsants, non therapeutic chemicals, etc.), as well as a variety of other less common etiologies that should invariably be part of the differential diagnosis, such as immune-mediated (anti-GAD, celiac disease, steroid responsive encephalopathy, etc.), paraneoplastic, vitamin deficiencies, structural lesions, metabolic diseases and also psychogenic ataxia.

This review has several additional strengths: first, the authors used a reasonable definition for acute ataxia: “…a syndrome that occurs in less than 72 hours in previously healthy subjects”⁴, almost a rule of thumb, quite useful to delineate the clinical scenario and guide specific parameters for initial investigation. Second, the review covers with the adequate amount of detail most of the important facets of these syndromes, such as a broad description of the clinical and paraclinical diagnostic process, most important differentials, as well as treatment approaches and prognosis. Finally, the authors are experienced, internationally recognized authorities in the field.

Amid the difficult assessment and critical management of such acute, disabling and life-threatening syndromes, the information provided by the review call attention to important but often overlooked opportunities in the field of movement disorders, starting with the recognition that this is a dynamic and exciting subspecialty in which accurate investigations and interventions may uncover potentially treatable/curable conditions.

References

• ¹
  Munhoz RP, Moscovich M, Araujo PD, Teive HA. Movement disorders emergencies: a review. Arq Neuropsiquiatr. 2012 Jun;70(6):453-61. https://doi.org/10.1590/S0004-282X2012000600013
  » https://doi.org/10.1590/S0004-282X2012000600013
• ²
  Kipps CM, Fung VS, Grattan-Smith P, Moore GM, Morris JG. Movement disorder emergencies. Mov Disord. 2005;20(3):322-34. https://doi.org/10.1002/mds.20325
  » https://doi.org/10.1002/mds.20325
• ³
  Fahn S, Frucht S. Movement disorder emergencies. In 54th Annual Meeting American Academy of Neurology, 2002, Dever. Philadelphia: Lippincott Willians & Wilkins; 2002. p. 454.
• ⁴
  Pedroso JL, Vale TC, Braga-Neto P, Dutra LA, França Jr MC, Teive HAG, Barsottini OGP. Acute cerebellar ataxia: differential diagnosis and clinical approach. Arq Neuropsiquiatr. 2019;77(3):184-93. https://doi.org/10.1590/0004-282X20190020
  » https://doi.org/10.1590/0004-282X20190020

Publication Dates

• Publication in this collection
  Mar 2019

History

• Received
  19 Feb 2019
• Accepted
  26 Feb 2019