A 55-year-old female patient with a history of hypercholesterolemia and anxiety was referred for progressive imbalance while walking and intense fear of falling for the past 14 years. The patient had become progressively disabled and had been using a wheelchair for 4 years prior to presentation. Neurological examination showed gaze-evoked horizontal nystagmus in both directions along with slow saccades and gaze restriction in both vertical and horizontal planes. There was ataxic dysarthria. Tone was normal in all 4 limbs but stretch reflexes were absent and plantar fascia were mute. Limb power was normal. Ataxia was seen on finger-to-nose and heel-knee-shin tests. Chorea was present in both legs. Ankle inversion with bilateral hammertoes was noted. Electromyography revealed sensory neu-ronopathy. On brain magnetic resonance imaging (MRI), diffuse cerebellar atrophy was noted along with T2 hyperintensities in bilateral middle cerebellar peduncles, cerebellar white matter, pons, and bilateral thalamus (Figure). Psychiatric treatment was commenced for her severe anxiety but did not relieve the fear of falling.
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