How should I approach the investigation of a patient with new-onset at

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

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 . 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 . 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 . 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 .
- Checking thyroid function .
- Checking for vitamin B12 and folate deficiency .
- Considering serological testing for gluten sensitivity, as recommended in the NICE guideline on coeliac disease .
The neurological assessment will guide further imaging requirements.

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