This 63-year-old man was evaluated for a 3-year history of progressive unsteadiness when walking and clumsiness with fine motor tasks. A year prior to that, he had an episode of sudden-onset vertigo associated with nausea and vomiting, which resolved without recurrence. After 2 years of unsteadiness, he started to fall, with increasing frequency of at least once per month, mostly sideways, especially when steps were “not landing evenly on the ground.” He resorted to using a cane to minimize the frequency of falls. His speech had become somewhat slurred, and he was choking to liquids, especially hot ones, but not to solids. He had some urinary urgency and increasing episodes of urinary incontinence. He noted some light-headedness upon standing up or bending forward. Hepatitis C was recently diagnosed. His brother, maternal cousin, and one of his sister’s daughters had childhood-onset mental retardation.