How should I approach the investigation of a patient with new-onset ataxia, including necessary imaging and laboratory tests?

The approach to investigating new-onset ataxia depends on its presentation and progression:

• Sudden-onset unsteady gait: For adults experiencing sudden-onset unsteady gait, refer to the NICE guideline on stroke and transient ischaemic attack in over 16s for assessment ¹. This pathway typically involves urgent neuroimaging.
• Rapidly progressive unsteady gait (within days to weeks): Adults with rapidly progressive unsteady gait (gait ataxia) should be referred for neurological assessment using a suspected cancer pathway referral ¹. This referral will lead to urgent investigation, including appropriate imaging.
• Gradually progressive unsteady gait: Adults with gradually progressive unsteady gait (gait ataxia) should be referred for neurological assessment ¹. As part of the initial investigation, the following laboratory tests should be considered:
  • Taking an alcohol history and following recommendations in the NICE guideline on alcohol-use disorders ¹.
  • Checking thyroid function ¹.
  • Checking for vitamin B12 and folate deficiency ¹.
  • Considering serological testing for gluten sensitivity, as recommended in the NICE guideline on coeliac disease ¹.
  The neurological assessment will guide further imaging requirements.