**2. Pathophysiology of ataxia**

Ataxic disease is most commonly caused by dysfunction of the cerebellum or its pathways, including impairment of vestibular or proprioceptive input to the cerebellum [6, 7]. Cerebro-cerebellar connectivity is organized into multiple circuits that function to connect devices in parallel. Depending on the location of the cerebro-cerebellar connectivity injury, the characteristic findings regarding ataxic disorders are generally the following: Lesions affecting the lateral portion of the cerebellum lead to ipsilateral symptoms, while lesions affecting diffusely can lead to generalized symptoms. Lesions affecting the cerebellar hemisphere lead to appendicular ataxia. While insults within the vermis lead to postural gait ataxia with limb preservation. Lesions in the vestibulocerebellar areas cause gait imbalance, vertigo, and ataxia [8–10].

Taking into account the clinical scenario, according to Cabaraux et al., 2021, cerebellar symptoms of cerebellar injury can be grouped into three main cerebellar syndromes:


The ataxic diseases can generally be the result of a considerable variability of causes, and there can be numerous etiologies for ataxias, which can occur isolated or simultaneously, acutely or chronically, and at any age, both in children and in adults and even common in the elderly [6–10].

Findings from the physical examination, in combination with the assessment of risk factors and presentation of the complaint, lead to a decision. Ataxia also can be seen in 30–60% of patients with posterior circulation stroke [14, 15]. Patients may present atypically and with multiple causes that may exist simultaneously. This contributes to the important clinical heterogeneity of ataxic disorders in daily practice [8].

However, studies have shown that misdiagnoses of posterior circulation strokes are frequent, with dizziness and difficulty walking more likely to be manifested than focal weakness, changes in vision, or neglect [10–15]. In emergency care, attention should be focused on treatable and reversible etiologies of ataxia.

Hereditary ataxias represent a wide clinical spectrum of disorders, and phenotypic variability is recurrent between individuals suffering from the same ataxia subtype. It may be characterized by episodic, spinocerebellar, Friedreich's, X-linked, and mitochondrial ataxia as well as sporadic conditions. Clinically, it is presented by progressive ataxia combined with extra-cerebellar and multisystemic involvements, including peripheral neuropathy, pyramidal signs, movement disorders, seizures, and cognitive dysfunction. Friedreich's ataxia is the most common cause of an autosomal recessive pattern of inheritance, appearing between the first and second decades of life. The abnormalities affecting multisystem are seen and include myocardiopathy, endocrinological diseases, vision, and hearing loss. Gait ataxia, loss of sensory and proprioception, *pes cavus*, spastic extensor plantar responses, and extremities atrophies [6, 16, 17].
