
































J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  202292

Case Series Sri Lankan patientS with mucopoLySaccharidoSiS type iVa

Sridhar Shobana, Krishnakumar Revathi, Thirunavukkarasu Bharath Kumar

1Department of Paediatrics, Sri Manakula Vinayagar Medical College and Hospital (SMVMCH), Madagadipet, Kalitheerthalkuppam, 
Puducherry 605107, India 

Post Traumatic Cerebellar Ataxia – A Least Pondered Diagnosis: A 
Case Report

Ataxia means impaired co-ordination of voluntary muscle movement. It is a 
physical finding, not a disease and the underlying etiology needs to be 
investigated. It can be the patient’s presenting complaint or a component among 
other presenting symptoms. Cerebellar dysfunction or impaired vestibular or 
proprioceptive input to cerebellum can cause ataxia. Though there are several 
etiologies post infectious ataxia is the most common one in children. But other 
rare etiologies of ataxia should also be considered based on the clinical 
presentation. We try to emphasise on this point by presenting a case of post 
traumatic cerebellar ataxia – a rare entity in children.

Abstract

*Corresponding Author
Thirunavukkarasu Bharath Kumar
Professor,
Department of Paediatrics, 
Sri Manakula Vinayagar Medical College 
and Hospital (SMVMCH), 
Madagadipet, Kalitheerthalkuppam, 
Puducherry 605107, India
Email: shobanasrikrish95@gmail.com

Article History 
Received On : 04 Feb, 2022
Accepted On : 12 Jan, 2023

Funding sources: None 

Conflict of Interest: None

Keywords: Ataxia, Cerebellar, Diagnosis, 
Dysfunction, Pondered 

Online Access

DOI:
https://doi.org/10.3126/jnps.v42i2.42915

Introduction
Ataxia means impaired co-ordination of voluntary muscle movement. The onset is 
either acute, subacute or insidious and chronic. It can be either inherited or acquired. 
Acute cerebellar ataxia in children is most commonly post infectious etiology, and 
the most common infectious etiology is varicella.1 The MRI Brain findings in case of 
post infectious cerebellar ataxia is a homogenous mass due to cerebellar swelling. It 
is usually caused by cerebellar dysfunction or impaired vestibular or proprioceptive 
afferent input to the cerebellum.2 It can be the patient’s presenting complaint or a 
component of the presenting symptom but not a disease and the underlying etiology 
needs to be investigated. 

Case report
A one year old boy born to non consanguineous parents was brought with complaints of 
unable to stand, walk and difficulty in sitting without support. The child was apparently 
normal a day ago after which he had an accidental fall from staircase of ten steps high 
following which there was loss of consciousness for ten minutes with history of two to 
three episodes of vomiting which was non- bilious and non- projectile. Then the mother 
noticed that the child was not able to walk but stand with support. The child was taken 
to a nearby hospital where initial assessments were done, the child was stabilised and 
sent home. The child had lassitude for two days. The ataxia episode was increasing 
over these two days and the child was not able to sit or stand or walk without support. 
Then the child was brought to our hospital in view of worsening of symptoms and got 
admitted for further evaluation. The past history was of no significance. Antenatal 
and birth history was uneventful. He was a developmentally normal child and his 
anthropometry was appropriate for age. On examination GCS was 15 / 15, vitals 
were stable. On CNS examination, higher mental function, bulk, tone, reflexes were 
normal. Power was 3 / 5 in all four limbs. The child could neither sit without support nor 
stand on his own and gait was ataxic. Language domain couldn’t be assessed. Other 
systemic examinations were normal. Based on the gross motor findings and trauma 
history we suspected traumatic brain haemorrhage or injury especially affecting the 
cerebellum causing ataxia. Baseline investigations like complete blood count, serum 

Case Report

DOI: 103126/JNPS.V4113

Copyrights & Licensing © 2022 by author(s). This is an Open Access article distribut-
ed under Creative Commons Attribution License (CC BY NC )



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  2022 93

Case ReportPost traumatic ataxia

electrolytes, renal function test, serum calcium were done which 
were normal. MRI brain was done which revealed the presence 
of traumatic non- haemorrhagic contusion of left middle cerebellar 
peduncle with laminar cortical necrosis of left cerebellum and 
bilateral tonsils [Figure – 1]. So, the child was finally diagnosed 
to have post traumatic cerebellar ataxia. Neurosurgeon opinion 
was sought and advised to continue conservative management. 
The child improved clinically, vitals were stable; hemodynamically 
stable hence discharged after four days of admission with advice 
to review in OPD after two weeks but the child came for follow 
up only after one month and he was able to walk, sit and stand 
without support. Power improved to 5 / 5. Thus, the ataxia was 
confirmed to be of post - traumatic in nature.  

Figure 1. MRI Brain – green coloured arrow mark shows 
contusion of left middle cerebellar peduncle.

Discussion
Ataxia is a term for a group of disorders that affect co-ordination, 
balance and speech.  In cerebellar ataxia, dysarthria, dystonia, 
titubation, tandem gait, rebound phenomenon, intentional tremor, 
inability to stand, dysdiadochokinesia, positive Romberg sign will 
be seen.

In our case the child was one year and presented with complaints 
of unable to stand, walk and difficulty in sitting without support 
along with a history of trauma. Based on these histories post 
traumatic cerebellar ataxia was suspected and an MRI brain 
imaging was done which revealed features suggestive of the 
same. Thus, based on the history and MRI findings the provisional 
diagnosis of post traumatic cerebellar ataxia was confirmed. 

Post infectious cerebellar ataxia was the most common cause of 
ataxia. It shows a complete recovery within two weeks without 
any neurologic sequelae. Imaging studies are required only in 
atypical presentation or if there is no improvement after one to 
two weeks.1 Jayendra RG has reported a post concussion ataxia 
in a two year old girl following a fall from a two feet high bed 
who presented with unsteadiness of gait, shaking of head and 
neck, became bedridden seven days later due to severe ataxia. 

The child had intentional tremor of hand, hypotonia, vision and 
speech were normal. MRI brain showed oedema at C1- C2 
junction. Cervical traction and steroids were started, the child 
improved clinically and hence discharged after twenty days. On 
follow up after six months, the gait had improved; tone, power 
and reflexes were normal but the child had shaking of head 
with no other clinical sequel.3 Fenichel has described a post-
concussion syndrome which presents as ataxia or only unsteady 
gait that resolves within one to six months in children.4 Lalitha 
S has briefly mentioned about the potential etiology for ataxia 
based on history, age wise common etiologies and also algorithm 
for workup of ataxia. The most common etiology in pre – school 
age group is acute post infectious ataxia – varicella being the 
most common infective agent.5

Conclusions
Post traumatic ataxia is not very common in children; most common 
cause is post infectious type. So, considering the least common 
cause of ataxia as a differential diagnosis is very important to 
narrow down to the proper diagnosis from all the differential 
diagnosis and also pivotal in the timely management.

References
1. Nussinovitch M, Prais D, Volovitz B, Shapiro R, Amir J. Post- 

infectious acute cerebellar ataxia in children. Clin pediatr 
(Phila). 2003 Sep;42(7):581-4.     
DOI: 10.1177/000992280304200702.

2. Kliegman, Robert. Nelson Textbook of Paediatrics. Edition 
21. Philadelphia, PA: Elsevier, 2020.

3. Gohil JR, Munshi SS. Post concussion ataxia following minor 
head injury. Indian Pediatr. 2006 Sep;43(9):829.   
PMID: 17033127.

4. Fenichel GM. Ataxia: Post concussion syndrome. In: Clinical 
Pediatric Neurology. 4th ed. Philadlphia: WB Saunders: 
2001; p. 231.

5. Sivaswamy L. Approach to acute ataxia in childhood: 
Diagnosis and evaluation. Pediatr Ann. 2014; 43:153-9. 
DOI: 10.3928/00904481-20140325-13.


