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Stankovic I, Fanciulli A, Sidoroff V, Wenning GK. A Review on the Clinical Diagnosis of Multiple System Atrophy. CEREBELLUM (LONDON, ENGLAND) 2023; 22:825-839. [PMID: 35986227 PMCID: PMC10485100 DOI: 10.1007/s12311-022-01453-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 06/15/2023]
Abstract
Multiple system atrophy (MSA) is a rare, adult-onset, progressive neurodegenerative disorder with major diagnostic challenges. Aiming for a better diagnostic accuracy particularly at early disease stages, novel Movement Disorder Society criteria for the diagnosis of MSA (MDS MSA criteria) have been recently developed. They introduce a neuropathologically established MSA category and three levels of clinical diagnostic certainty including clinically established MSA, clinically probable MSA, and the research category of possible prodromal MSA. The diagnosis of clinically established and clinically probable MSA is based on the presence of cardiovascular or urological autonomic failure, parkinsonism (poorly L-Dopa-responsive for the diagnosis of clinically established MSA), and cerebellar syndrome. These core clinical features need to be associated with supportive motor and non-motor features (MSA red flags) and absence of any exclusion criteria. Characteristic brain MRI markers are required for a diagnosis of clinically established MSA. A research category of possible prodromal MSA is devised to capture patients manifesting with autonomic failure or REM sleep behavior disorder and only mild motor signs at the earliest disease stage. There is a number of promising laboratory markers for MSA that may help increase the overall clinical diagnostic accuracy. In this review, we will discuss the core and supportive clinical features for a diagnosis of MSA in light of the new MDS MSA criteria, which laboratory tools may assist in the clinical diagnosis and which major differential diagnostic challenges should be borne in mind.
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Affiliation(s)
- Iva Stankovic
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Victoria Sidoroff
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gregor K Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Goh YY, Saunders E, Pavey S, Rushton E, Quinn N, Houlden H, Chelban V. Multiple system atrophy. Pract Neurol 2023; 23:208-221. [PMID: 36927875 DOI: 10.1136/pn-2020-002797] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 03/18/2023]
Abstract
This is a practical guide to diagnosing and managing multiple system atrophy (MSA). We explain the newly published Movement Disorders Society Consensus Diagnostic Criteria, which include new 'Clinically Established MSA' and 'Possible Prodromal MSA' categories, hopefully reducing time to diagnosis. We then highlight the key clinical features of MSA to aid diagnosis. We include a list of MSA mimics with suggested methods of differentiation from MSA. Lastly, we discuss practical symptom management in people living with MSA, including balancing side effects, with the ultimate aim of improving quality of life.
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Affiliation(s)
- Yee Yen Goh
- Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | | | | | | | - Niall Quinn
- Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Henry Houlden
- Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Viorica Chelban
- Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK .,Neurobiology and Medical Genetics Laboratory, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Moldova
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Leahy CB, Robinson AC, Jabbari E, Morris HR, Lally I, Djoukhadar I, Roncaroli F, Kobylecki C. A case of Lewy body disease and anaplastic astrocytoma presenting with atypical parkinsonism. Neuropathology 2022; 42:540-547. [PMID: 35822248 PMCID: PMC10084019 DOI: 10.1111/neup.12848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 12/15/2022]
Abstract
We report on a patient with atypical parkinsonism due to coexistent Lewy body disease (LBD) and diffuse anaplastic astrocytoma. The patient presented with a mixed cerebellar and parkinsonian syndrome, incomplete levodopa response, and autonomic failure. The clinical diagnosis was multiple system atrophy (MSA). Supportive features of MSA according to the consensus diagnostic criteria included postural instability and early falls, early dysphagia, pyramidal signs, and orofacial dystonia. Multiple exclusion criteria for a diagnosis of idiopathic Parkinson's disease (iPD) were present. Neuropathological examination of the left hemisphere and the whole midbrain and brainstem revealed LBD, neocortical-type consistent with iPD, hippocampal sclerosis, and widespread neoplastic infiltration by an anaplastic astrocytoma without evidence of a space occupying lesion. There were no pathological features of MSA. The classification of atypical parkinsonism was difficult in this patient. The clinical features and disease course were confounded by the coexistent tumor, leading to atypical presentation and a diagnosis of MSA. We suggest that the initial features were due to Lewy body pathology, while progression and ataxia, pyramidal signs, and falls were accelerated by the occurrence of the astrocytoma. Our case reflects the challenges of an accurate diagnosis of atypical parkinsonism, the potential for confounding co-pathology and the need for autopsy examination to reach a definitive diagnosis.
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Affiliation(s)
- Christopher B Leahy
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
| | - Andrew C Robinson
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, School of Biological SciencesUniversity of Manchester, Salford Royal HospitalSalfordUK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science CentreManchesterUK
| | - Edwin Jabbari
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of NeurologyLondonUK
| | - Huw R Morris
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of NeurologyLondonUK
| | - Imogen Lally
- Department of Cellular PathologyNorthern Care Alliance NHS Foundation TrustManchesterUK
| | - Ibrahim Djoukhadar
- Department of Neuroradiology, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
| | - Federico Roncaroli
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, School of Biological SciencesUniversity of Manchester, Salford Royal HospitalSalfordUK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science CentreManchesterUK
| | - Christopher Kobylecki
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
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Wenning GK, Stankovic I, Vignatelli L, Fanciulli A, Calandra-Buonaura G, Seppi K, Palma JA, Meissner WG, Krismer F, Berg D, Cortelli P, Freeman R, Halliday G, Höglinger G, Lang A, Ling H, Litvan I, Low P, Miki Y, Panicker J, Pellecchia MT, Quinn N, Sakakibara R, Stamelou M, Tolosa E, Tsuji S, Warner T, Poewe W, Kaufmann H. The Movement Disorder Society Criteria for the Diagnosis of Multiple System Atrophy. Mov Disord 2022; 37:1131-1148. [PMID: 35445419 PMCID: PMC9321158 DOI: 10.1002/mds.29005] [Citation(s) in RCA: 216] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/25/2022] [Accepted: 02/28/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The second consensus criteria for the diagnosis of multiple system atrophy (MSA) are widely recognized as the reference standard for clinical research, but lack sensitivity to diagnose the disease at early stages. OBJECTIVE To develop novel Movement Disorder Society (MDS) criteria for MSA diagnosis using an evidence-based and consensus-based methodology. METHODS We identified shortcomings of the second consensus criteria for MSA diagnosis and conducted a systematic literature review to answer predefined questions on clinical presentation and diagnostic tools relevant for MSA diagnosis. The criteria were developed and later optimized using two Delphi rounds within the MSA Criteria Revision Task Force, a survey for MDS membership, and a virtual Consensus Conference. RESULTS The criteria for neuropathologically established MSA remain unchanged. For a clinical MSA diagnosis a new category of clinically established MSA is introduced, aiming for maximum specificity with acceptable sensitivity. A category of clinically probable MSA is defined to enhance sensitivity while maintaining specificity. A research category of possible prodromal MSA is designed to capture patients in the earliest stages when symptoms and signs are present, but do not meet the threshold for clinically established or clinically probable MSA. Brain magnetic resonance imaging markers suggestive of MSA are required for the diagnosis of clinically established MSA. The number of research biomarkers that support all clinical diagnostic categories will likely grow. CONCLUSIONS This set of MDS MSA diagnostic criteria aims at improving the diagnostic accuracy, particularly in early disease stages. It requires validation in a prospective clinical and a clinicopathological study. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Gregor K Wenning
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Iva Stankovic
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Luca Vignatelli
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Giovanna Calandra-Buonaura
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Klaus Seppi
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Wassilios G Meissner
- French Reference Center for MSA, Department of Neurology for Neurodegenerative Diseases, University Hospital Bordeaux, 33076 Bordeaux and Institute of Neurodegenerative Diseases, University Bordeaux, CNRS, Bordeaux, France.,Department of Medicine, University of Otago, Christchurch, and New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Florian Krismer
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Daniela Berg
- Department of Neurodegeneration and Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,Department of Neurology, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Pietro Cortelli
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Glenda Halliday
- Brain and Mind Centre, Faculty of Medicine and Health, School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Günter Höglinger
- Department of Neurology, Hanover Medical School, Hanover, Germany.,German Center for Neurodegenerative Diseases, Munich, Germany
| | - Anthony Lang
- Edmond J. Safra Program in Parkinson's Disease, University Health Network and the Division of Neurology, University of Toronto, Toronto, Canada
| | - Helen Ling
- Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, United Kingdom.,Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Irene Litvan
- Department of Neurosciences, Parkinson and Other Movement Disorders Center, University of California, San Diego, California, USA
| | - Phillip Low
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yasuo Miki
- Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, United Kingdom.,Department of Neuropathology, Institute of Brain Science, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Jalesh Panicker
- UCL Queen Square Institute of Neurology, London, United Kingdom.,Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Maria Teresa Pellecchia
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Salerno, Italy
| | - Niall Quinn
- UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Ryuji Sakakibara
- Neurology, Internal Medicine, Sakura Medical Center, Toho University, Sakura, Japan
| | - Maria Stamelou
- Parkinson's Disease and Movement Disorders Department, HYGEIA Hospital, and Aiginiteion Hospital, University of Athens, Athens, Greece.,Philipps University Marburg, Germany and European University of Cyprus, Nicosia, Cyprus
| | - Eduardo Tolosa
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED) Hospital Clínic, IDIBAPS, Universitat de Barcelona, Catalonia, Spain.,Movement Disorders Unit, Neurology Service, Hospital Clínic de Barcelona, Catalonia, Spain
| | - Shoji Tsuji
- Department of Molecular Neurology, The University of Tokyo, Graduate School of Medicine, Tokyo, Japan.,International University of Health and Welfare, Chiba, Japan
| | - Tom Warner
- Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Werner Poewe
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, Langone Medical Center, New York University School of Medicine, New York, New York, USA
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Goldstein DS, Isonaka R, Lamotte G, Kaufmann H. Different phenoconversion pathways in pure autonomic failure with versus without Lewy bodies. Clin Auton Res 2021; 31:677-684. [PMID: 34669076 PMCID: PMC10680053 DOI: 10.1007/s10286-021-00829-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/05/2021] [Indexed: 12/30/2022]
Abstract
Pure autonomic failure (PAF) is a rare disease in which chronic neurogenic orthostatic hypotension (nOH) dominates the clinical picture. Longitudinal studies have reported that PAF can phenoconvert to a central synucleinopathy with motor or cognitive involvement-i.e., to Parkinson disease (PD), dementia with Lewy bodies (DLB), or multiple system atrophy (MSA). These studies have classified patients clinically as having PAF based on nOH without an identified secondary cause or clinical evidence of motor or cognitive impairment due to central neurodegeneration. This approach lumps together two nOH syndromes that are pathologically and neurochemically distinct. One is characterized by intraneuronal cytoplasmic alpha-synuclein aggregates (i.e., Lewy bodies) and degeneration of postganglionic sympathetic neurons, as in PD and DLB; the other is not, as in MSA. Clinical and postmortem data show that the form of PAF that involves sympathetic intraneuronal synucleinopathy and noradrenergic deficiency can phenoconvert to PD or DLB-but not to MSA. Conversely, PAF without these features leaves open the possibility of premotor MSA.
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Affiliation(s)
- David S Goldstein
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, 9000 Rockville Pike MSC-1620, Bethesda, MD, 20892, USA.
| | - Risa Isonaka
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, 9000 Rockville Pike MSC-1620, Bethesda, MD, 20892, USA
| | - Guillaume Lamotte
- Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA
| | - Horacio Kaufmann
- Division of Autonomic Disorders, Department of Neurology, NYU Langone Health, NYU Dysautonomia Center, New York University Grossman School of Medicine, 530 First Avenue, Suite 9Q, New York, NY, 10016, USA.
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Gandor F, Gruber D, Dziewas R, Ebersbach G, Warnecke T. Reply to: "Laryngeal Movement Disorders in Multiple System Atrophy: A Diagnostic Biomarker?". Mov Disord 2021; 36:2000-2001. [PMID: 34409689 DOI: 10.1002/mds.28694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Florin Gandor
- Movement Disorders Hospital, Kliniken Beelitz GmbH, Beelitz-Heilstätten, Germany.,Department of Neurology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Doreen Gruber
- Movement Disorders Hospital, Kliniken Beelitz GmbH, Beelitz-Heilstätten, Germany.,Department of Neurology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Rainer Dziewas
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Georg Ebersbach
- Movement Disorders Hospital, Kliniken Beelitz GmbH, Beelitz-Heilstätten, Germany
| | - Tobias Warnecke
- Department of Neurology, University Hospital Münster, Münster, Germany
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