From the Guidelines
For patients presenting with gait instability, MRI of the brain is the most appropriate initial neuroimaging modality. This recommendation is based on the most recent and highest quality evidence available, including the American College of Radiology's Appropriateness Criteria for movement disorders and neurodegenerative diseases 1. MRI provides detailed visualization of brain structures, including the cerebellum, brainstem, and subcortical regions that control balance and coordination.
Key Considerations for Neuroimaging in Gait Instability
- A standard brain MRI protocol with T1, T2, FLAIR, and diffusion-weighted sequences can identify structural abnormalities like strokes, tumors, normal pressure hydrocephalus, or neurodegenerative changes that may cause gait problems.
- In some cases, cervical spine MRI should be added to evaluate for spinal cord compression or myelopathy.
- Functional MRI or DTI (diffusion tensor imaging) may provide additional information about neural pathway integrity in complex cases, as suggested by the use of advanced MRI techniques for evaluating the microstructural makeup of the brain parenchyma 1.
- CT scans are less preferred for initial evaluation due to their limited soft tissue contrast, although they may be useful in acute settings to rule out conditions like hemorrhage.
- PET scans may be considered as a secondary test in cases where neurodegenerative disorders are suspected, given their ability to evaluate for abnormal patterns of glucose metabolism or buildup of abnormal particles or proteins within neurons 1.
Clinical Guidance
The choice of imaging should be guided by the patient's clinical presentation, with MRI remaining the gold standard for comprehensive evaluation of neurological causes of gait instability. This approach aligns with the principle of prioritizing morbidity, mortality, and quality of life outcomes by ensuring that patients receive the most accurate diagnosis possible to inform treatment decisions.
From the Research
Neuroimaging Options for Gait Instability
- There are various neuroimaging techniques that can be used to assess gait instability, but the best option is not explicitly stated in the provided studies 2, 3, 4, 5, 6.
- The studies suggest that a thorough clinical observation of gait, taking a focused patient history, and physical, neurological, and orthopedic examinations are basic steps in the categorization of gait disorders and serve as a guide for ancillary investigations and therapeutic interventions 2, 3, 4.
- MRI protocols, including T1- and T2-weighted sequences, diffusion-weighted imaging, and enhanced T1-weighted sequencing, can be used to assess patients with multiple sclerosis and other conditions that may cause gait instability 5.
- A novel method for simultaneous T1-weighted and T2-weighted 3D MRI using RF phase-modulated gradient echo imaging has been proposed, which may provide an alternative approach for assessing gait instability 6.
Key Considerations
- The choice of neuroimaging technique may depend on the underlying cause of gait instability and the patient's specific condition 2, 3, 4.
- A combination of clinical evaluation and neuroimaging may be necessary to accurately diagnose and manage gait instability 2, 3, 4.
- Further research is needed to determine the most effective neuroimaging technique for assessing gait instability in different patient populations 5, 6.