Differential Diagnosis for a 70-year-old Lady with Cerebellar Signs, Episodic Ataxia, and Vertigo
Single Most Likely Diagnosis
- Degenerative Cerebellar Disease: This is the most likely diagnosis given the patient's age and the gradual onset of cerebellar signs and symptoms over 2 years. Conditions such as spinocerebellar ataxia or multiple system atrophy could be considered under this category.
Other Likely Diagnoses
- Vestibular Disorders: Conditions affecting the vestibular system, such as benign paroxysmal positional vertigo (BPPV), vestibular migraine, or Meniere's disease, could explain the episodic vertigo and ataxia.
- Cerebellar Stroke or Transient Ischemic Attack (TIA): Although less likely given the episodic nature over 2 years, small vessel disease or recurrent TIAs in the cerebellum could cause these symptoms.
- Autoimmune Cerebellar Ataxia: This includes conditions like gluten ataxia or paraneoplastic cerebellar degeneration, which could present with subacute or chronic cerebellar symptoms.
Do Not Miss Diagnoses
- Posterior Fossa Tumor: Although rare, a tumor in the posterior fossa (e.g., acoustic neuroma, meningioma) could cause these symptoms by compressing cerebellar structures or the brainstem. Missing this diagnosis could be catastrophic.
- Subclavian Steal Syndrome: This condition, caused by stenosis or occlusion of the subclavian artery, can lead to vertebral artery flow reversal and subsequent brainstem or cerebellar ischemia, presenting with vertigo and ataxia.
- Infectious or Inflammatory Causes: Conditions like cerebellitis or brainstem encephalitis could present acutely but might have a more subacute onset in some cases.
Rare Diagnoses
- Mitochondrial Disorders: Conditions such as mitochondrial myopathies, encephalopathies, lactic acidosis, and stroke-like episodes (MELAS) could present with a combination of cerebellar signs, ataxia, and vertigo, although they are more commonly associated with younger patients.
- Prion Diseases: Rare neurodegenerative disorders like Creutzfeldt-Jakob disease could present with ataxia and cerebellar signs, although the progression is typically much faster than 2 years.
- Toxic or Metabolic Causes: Certain toxins or metabolic disorders (e.g., vitamin deficiencies like vitamin B12 or E deficiency) could cause cerebellar ataxia, though these would be less common in the context provided.