Acute Neurological Assessment and Urgent Imaging Required
This elderly man with new-onset staggering and inability to walk straight—particularly without dizziness—requires immediate neurological examination and urgent brain MRI to rule out posterior fossa stroke or cerebellar pathology. 1
Critical Red Flags Present
This presentation is concerning for central nervous system pathology rather than benign causes:
- Ataxia without vertigo is a red flag for brainstem or cerebellar stroke that mandates immediate hospital transfer for neuroimaging 1
- The absence of dizziness actually increases concern for cerebellar pathology, as peripheral vestibular causes typically present with prominent vertigo 2
- Staggering gait with lateral deviation suggests cerebellar or posterior circulation involvement requiring time-sensitive evaluation 1
Immediate Bedside Examination
Perform these specific tests immediately to localize the lesion:
- Finger-to-nose and heel-to-shin tests to assess for dysmetria, which localizes to cerebellar pathways 1
- Check for nystagmus, internuclear ophthalmoplegia, or vertical gaze abnormalities suggesting brainstem or cerebellar pathology 1
- Evaluate for new cranial nerve palsies, Horner's syndrome, or hearing loss 1
- Assess for hemiparesis, sensory loss, or limb incoordination 1
- Perform upright-supine test to evaluate for vertical eye misalignment suggesting brainstem pathology 1
Urgent Diagnostic Imaging
MRI brain with diffusion-weighted imaging is the preferred modality to evaluate for acute ischemic stroke in posterior circulation, as CT has limited sensitivity for posterior fossa pathology 1
- Imaging should be performed within hours given the red flag features present 1
- This could represent acute stroke requiring time-sensitive intervention 1
Critical Pitfall to Avoid
Do not assume this is simply age-related gait instability or a fall risk issue. While the Mayo Clinic guidelines appropriately emphasize fall assessment in elderly patients 3, those recommendations apply to chronic gait problems or multifactorial fall risk—not acute-onset ataxic gait without dizziness, which is a stroke mimic requiring urgent evaluation 1.
Additional Considerations While Arranging Transfer
- Measure orthostatic blood pressure to exclude orthostatic hypotension as a contributing factor 1
- Review all medications for centrally acting agents that could impair balance 3, 1
- Ensure supervised ambulation until diagnosis is established to prevent falls 1
- Assess vision for impairment contributing to gait instability 1
If Stroke is Ruled Out
Only after excluding acute stroke should you consider:
- Physical therapy referral for gait and balance training 1
- Home safety assessment to identify trip hazards 1
- Ensure consistent walker use if prescribed 1
- Timed Up and Go test (>12 seconds indicates increased fall risk) and 4-Stage Balance Test (tandem stand <10 seconds indicates fall risk) for ongoing monitoring 3
The key distinction here is that new-onset ataxic gait without dizziness in an elderly patient is a neurological emergency until proven otherwise, not a geriatric fall risk assessment scenario.