Multiple system atrophy

Atypical Parkinsonian Disorders

Atypical parkinsonian disorders (APD) include progressive supranuclear palsy, corticobasal degeneration, and multiple system atrophy. Identifying APD is important because they have different pathogenesis, disease course, and prognosis than Parkinson's disease (PD), and require different treatments. Therefore, when encountering patients with parkinsonism, it is of crucial importance to look for "red flags" or signs, such as impairments in higher cortical function, visuomotor system, cerebellar and other motor abnormalities including dystonia, myoclonus, and apraxia that help differentiate them from PD. Although disease-modifying therapies are not yet available, treatments targeting specific symptoms may improve the quality of life in these patients.

Rehabilitation of Women with Neurodegenerative Diseases

Parkinson's disease, multiple sclerosis, and Alzheimer's disease are 3 prevalent neurodegenerative diseases. Beyond disparate disease incidences between men and women, additional sex-related differences exist. Disease presentation, natural course, treatment considerations, genetic factors, hormonal factors, health care utilization patterns, and outcomes can vary between men and women in general. These disease processes represent examples of well-defined discrepancies between men and women afflicted. Other neurodegenerative conditions, such as motor neuron disorders, progressive supranuclear palsy, and multisystem atrophy, have shown to have a slight predilection toward men compared to women, yet have not been as extensively studied.

A strategic approach of the management of sleep-disordered breathing in multiple system atrophy

STUDY OBJECTIVES

Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterized by autonomic dysfunction associated with a combination of cerebellar, parkinsonian, or pyramidal signs. Sleep-disordered breathing such as stridor, obstructive sleep apnea, and central sleep apnea is common in MSA and can impact survival. Several studies have evaluated treatment modalities. However, the optimal strategy often remains unclear in these patients. This review aims to provide an overview of the current evidence on treatment of sleep-disordered breathing in MSA.

METHODS

Systematic review of the current literature through combined keyword search in PubMed, Embase, the Cochrane Library, and cited references: "multiple system atrophy," "stridor," "sleep apnea syndrome," "sleep-disordered breathing," "Shy Drager syndrome."

RESULTS

Twenty-nine papers were included, with a total of 681 patients with MSA and sleep-disordered breathing. Treatment modalities are: continuous positive airway pressure, tracheostomy, tracheostomy-invasive ventilation, noninvasive positive pressure ventilation, adaptive servoventilation, vocal cord surgery, botulinum toxin injections, oral appliance therapy, cervical spinal cord stimulation, selective serotonin reuptake inhibitors.

CONCLUSIONS

Conflicting results on survival are found for continuous positive airway pressure therapy. Tracheostomy has a proven survival benefit. Most beneficial outcomes are seen with tracheostomy-invasive ventilation. Continuous positive airway pressure, other types of positive airway pressure therapy and tracheostomy can adequately control symptoms of obstructive sleep apnea. However, continuous positive airway pressure may exacerbate central sleep apnea. There was a lack of sufficient data regarding servoventilation or noninvasive positive pressure ventilation. Some patients exhibit a floppy epiglottis and require a different approach. In conclusion, due to the complex characteristics of sleep-disordered breathing in MSA, an individualized and multidisciplinary approach is mandatory.

CITATION

Laga A, Bauters F, Hertegonne K, Tomassen P, Santens P, Kastoer C. A strategic approach of the management of sleep-disordered breathing in multiple system atrophy. J Clin Sleep Med. 2025;21(4):703-711.

Investigation of the significance of quantitative MRI parameters in differentiating PSP from MSA patients

OBJECTIVE

To investigate the utility of quantitative MRI parkinsonism indices in discriminating between progressive supranuclear palsy (PSP) and multiple system atrophy (MSA) patients.

METHODS

In our study including PSP and MSA patients, we calculated the radiological measures including superior cerebellar peduncle width, middle cerebellar peduncle width, third ventricle width, 3rdV/bifrontal width, pons/mesencephalon (P/M) ratio, P/M ratio 2.0, magnetic resonance parkinsonism index (MRPI), and MRPI 2.0 values. We also constituted a PMS scale to increase the discrimination power.

RESULTS

Comparisons between PSP and MSA patients revealed significant differences in the mesencephalon area, third ventricle width, 3rdV/bifrontal width, P/M ratio, P/M ratio 2.0, MRPI, and MRPI 2.0 values (p < 0.01 for all). The AUC values were acceptable for the third ventricle width, the 3rdV/bifrontal width ratio, the P/M ratio, the P/M 2 ratio, the MRPI and the MRPI-2. In distinguishing PSP, 0 points on the PMS scale had a negative predictive value (NPV) of 91%, whereas 3 points had a positive predictive value (PPV) of 85.7%.

CONCLUSION

None of the MRI parameters reached a good diagnostic AUC in distinguishing PSP from MSA. However, the PMS scale we propose in this study may provide high PPVs and NPVs for differential diagnosis during desk-based evaluation.

Sleep disturbance is associated with worsening quality of life in patients with multiple system atrophy

BACKGROUND

Multiple system atrophy (MSA) is a progressive neurodegenerative disorder characterized by parkinsonism, cerebellar ataxia, autonomic dysfunction, and sleep disturbances, such as rapid eye movement sleep behavior disorder (RBD). The association between sleep disturbances, including RBD, and decreased quality of life (QOL) in patients with MSA has not been elucidated. We aimed, therefore, to evaluate this association in individuals with MSA.

METHODS

We assessed a total of 34 patients with MSA (44.1 % male; 61.8 % MSA with predominant cerebellar ataxia) for sleep disturbances, RBD, and QOL using the Parkinson's Disease Sleep Scale-2 (PDSS-2), RBD Screening Questionnaire (RBDSQ), and Parkinson's Disease Questionnaire-39 (PDQ-39). Multiple regression analyses were conducted with the Summary Index (SI) of PDQ-39 total and each domain as dependent variable and age, sex, urinary dysfunction, and the PDSS-2 total, sleep, motor, parkinsonism, and the RBDSQ scores as independent variables.

RESULTS

The rate of PDSS-2 scores ≥ 15 was 41.2 %, while that of RBDSQ scores ≥ 5 was 17.6 %. Multiple regression analyses revealed that the PDSS-2 total score significantly contributed to increase in the SI of PDQ-39 total (β = 0.646, P < 0.001), mobility (β = 0.663, P < 0.001), activities of daily living (β = 0.650, P < 0.001), emotional well-being (β = 0.426, P = 0.019), and bodily discomfort (β = 0.566, P < 0.001).

CONCLUSION

We demonstrated a strong relationship between the sleep disturbances and worsening QOL in patients with MSA. Healthcare providers should also focus on sleep disturbances when managing patients with MSA.

Neurofilament Light Chain in Cerebrospinal Fluid and Blood in Multiple System Atrophy: A Systematic Review and Meta-Analysis

Background/Objectives: Multiple system atrophy (MSA) presents a challenging diagnosis due to its clinical overlap with other neurodegenerative disorders, especially other α-synucleinopathies. The main purpose of this systematic review and meta-analysis was to assess neurofilament light chain (NfL) differences in the CSF and blood of patients with MSA versus the healthy control group (HC), patients with Parkinson's disease (PD) and patients with Lewy body dementia (LBD). Secondarily, the diagnostic metrics of CSF and circulating NfL in MSA versus HC, PD, LBD, progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD) were discussed. Methods: MEDLINE and EMBASE were thoroughly searched for relevant case-control studies. Standardized mean differences (SMDs) were calculated separately for CSF and blood NfL per comparison. Statistical heterogeneity was assessed based on the Q and I^2 statistics. Results: Twenty-five relevant studies were retrieved. Quantitative syntheses revealed elevated CSF and circulating NfL levels in individuals with MSA versus HC [SMD = 1.80 (95%CI = 1.66, 1.94) and SMD = 2.00 (95%CI = 1.36, 2.63), respectively] versus PD [SMD = 1.65 (95%CI = 1.26, 2.03) and SMD = 1.63 (95%CI = 0.84, 2.43), respectively] as well as versus LBD [SMD = 1.17, (95%CI = 0.71, 1.63) and SMD = 0.65 (95%CI = 0.30, 1.00), respectively]. Diagnostic accuracy was outstanding for CSF and blood NfL in MSA versus HC and PD, and it was moderate in MSA versus LBD. On the other hand, it was suboptimal in MSA vs. PSP and CBD. Conclusions: Both CSF and circulating NfL levels are elevated in MSA compared to HC, PD and LBD. To achieve optimal diagnostic properties, further work is required in the standardization of processes and the establishment of reference NfL intervals and/or thresholds.

Blood pressure targets, medication considerations and special concerns in elderly hypertension III: Focus on stroke and neurodegenerative disorders

Controlling hypertension has become an important issue in the elderly population in whom neurological comorbidities are highly prevalent. Most of the large-scale trials focusing on hypertension management in older populations have excluded patients with comorbid neurological disorders. However, this population requires special considerations, as the benefits of antihypertensive agents are mostly uncertain and there is a higher risk of adverse events. In this review article, we discuss current evidence regarding the management of elderly patients with hypertension and common neurological disorders, including stroke and neurodegenerative diseases. In elderly patient with a history of stroke, the blood pressure management strategy is generally similar to that for young patients, however the benefits of stroke prevention from blood pressure control are less significant. For patients with neurodegenerative disorders such as cognitive dysfunction and Parkinson's disease, achieving adequate blood pressure control may be beneficial in reducing cardiovascular risks, although the higher risk of adverse events from antihypertensive treatment may offset some of these benefits. Special considerations for factors such as orthostatic hypotension, risk of falls, polypharmacy, and significant drug-drug interactions are required but frequently neglected in clinical practice. More efforts are warranted to determine the optimal treatment strategy for elderly populations with neurological disorders.

Velopharyngeal Insufficiency and Impaired Tongue Movement Indicate Neuromuscular Disorders: A 10-Year Statistical Study in a Single Tertiary Institution

Objectives: This study aimed to determine the positive predictive value of our NMD Suspicion Criteria in the diagnosis of NMDs. Other clinical factors routinely examined in our voice and swallowing examinations were also investigated to see if they had a significant association with the diagnosis of NMDs. Methods: This study retrospectively investigated the medical charts of patients who visited our Voice and Swallowing outpatient clinic between 2013 and 2022. Patients with previously diagnosed NMDs were excluded from the analysis. Among the remaining patients, we included those that were referred to neurologists for further evaluation due to suspicion of having an NMD based on the NMD Suspicion Criteria. The patients were then divided into groups according to the status of their diagnosis within 2 years of referral as "diagnosed", "denied", or "observed". These three groups of patients were then compared according to the following clinical findings; velopharyngeal insufficiency (VPI), tongue atrophy, impaired tongue movement, dysarthria, vocal fold mobility impairment, dysphagia, involuntary movement, gait disturbances, weight loss, and a sense of fatigue in order to see if they were significantly associated with the diagnosis of NMDs. Results: Of 3769 outpatients without a confirmed diagnosis of NMDs, 37 were referred to neurologists for suspected NMDs, and 19 (51%) were diagnosed with NMDs. VPI and impaired tongue movement were significant diagnostic factors for NMDs (p = 0.014, 0.033). VPI during speech (p = 0.045) was more strongly associated with the diagnosis of NMDs than VPI during swallowing (p = 0.076). Fatigue was a significant related factor for other diseases (non-NMDs) causing Voice and Swallowing problems (p = 0.049). Conclusions: In the outpatient clinic setting, suspicion of NMD should be raised, particularly when VPI and impaired tongue movement are observed, prompting a thorough assessment of velopharyngeal closure during both speech and swallowing.

Decoding TDP-43: the molecular chameleon of neurodegenerative diseases

TAR DNA-binding protein 43 (TDP-43) has emerged as a critical player in neurodegenerative disorders, with its dysfunction implicated in a wide spectrum of diseases including amyotrophic lateral sclerosis (ALS), frontotemporal lobar degeneration (FTLD), and Alzheimer's disease (AD). This comprehensive review explores the multifaceted roles of TDP-43 in both physiological and pathological contexts. We delve into TDP-43's crucial functions in RNA metabolism, including splicing regulation, mRNA stability, and miRNA biogenesis. Particular emphasis is placed on recent discoveries regarding TDP-43's involvement in DNA interactions and chromatin dynamics, highlighting its broader impact on gene expression and genome stability. The review also examines the complex pathogenesis of TDP-43-related disorders, discussing the protein's propensity for aggregation, its effects on mitochondrial function, and its non-cell autonomous impacts on glial cells. We provide an in-depth analysis of TDP-43 pathology across various neurodegenerative conditions, from well-established associations in ALS and FTLD to emerging roles in diseases such as Huntington's disease and Niemann-Pick C disease. The potential of TDP-43 as a therapeutic target is explored, with a focus on recent developments in targeting cryptic exon inclusion and other TDP-43-mediated processes. This review synthesizes current knowledge on TDP-43 biology and pathology, offering insights into the protein's central role in neurodegeneration and highlighting promising avenues for future research and therapeutic interventions.

End-of-life care in multiple system atrophy: UK survey of patients and families

OBJECTIVES

People with multiple system atrophy (MSA) and their carers may have many concerns about their disease and the future. This survey of people with MSA and their carers aimed to increase understanding of end-of-life care and palliative care for this group.

METHODS

A survey was undertaken by the MSA Trust of people living with MSA and carers of those with the condition between August and October 2022.

RESULTS

520 people responded: 215 people with MSA, 214 carers and 91 former carers. The modal class for age in people with MSA was 65-74 years, with 52% male. 76% of people living with MSA had thought to some extent about what they wanted to happen towards the end of their lives. 38% of respondents had discussed end-of-life care options with a healthcare professional and of those who had, over 81% found the conversation helpful. Nevertheless, for 37% of former carers, the death had been unexpected. Only a minority of people living with MSA had been referred for specialist palliative care. 65% of the former carers reported that they were satisfied with the quality of end-of-life care.

CONCLUSION

People with MSA and their carers continue to face many complex physical and emotional issues that would benefit from palliative care. Discussions about care at the end of life were generally perceived as helpful, but although the deterioration was often discussed, many families seemed unprepared for the death. Palliative care services were involved but this appeared limited.

Effectiveness of Lee Silverman Voice Treatment (LSVT-LOUD) in Parkinsonian-Type Multiple System Atrophy (MSA-P): A Case Report

We describe a case of Parkinsonian-type multiple system atrophy (MSA-P) treated with Lee Silverman Voice Treatment (LSVT-LOUD; LSVT Global, Inc., Phoenix, AZ, USA). At age 73, the patient developed motor symptoms, including gait disturbances with a tendency to fall, as well as swallowing difficulties and impaired dexterity in his right hand, prompting a visit to our hospital. Brain magnetic resonance imaging (MRI) revealed atrophy in the cerebellum and brainstem, particularly in the pons, along with enlargement of the fourth ventricle; however, the "cross sign" on the pons was not clearly visible. Dopamine transporter single-photon emission computed tomography (DAT-SPECT) showed decreased nuclide accumulation in the striatum. Additionally, 123I-MIBG cardiac scintigraphy demonstrated preserved nuclide accumulation in the heart. L-dopa challenge tests were conducted, but no significant improvement in motor symptoms was observed. Based on these findings, he was diagnosed with MSA-P. Over the following years, his condition progressively worsened, with increasing orthostatic hypotension, dysphagia, and falls. Various treatments, including anti-Parkinson's medications and vasopressors, provided little relief. At age 75, due to severe dysphagia and hoarseness, he was admitted for LSVT-LOUD therapy. After LSVT-LOUD treatment, the patient improved voice volume, tongue pressures, alternating motion rates of "pa," "ta," and "ka," and the Frontal Assessment Battery (FAB) score. These results suggest that LSVT-LOUD may positively impact both speech and swallowing functions, as well as frontal lobe function. Larger studies are needed to validate these results.

Asymmetry in Atypical Parkinsonian Syndromes-A Review

Background/Objectives: Atypical parkinsonian syndromes (APSs) are a group of neurodegenerative disorders that differ from idiopathic Parkinson's disease (IPD) in their clinical presentation, underlying pathology, and response to treatment. APSs include conditions such as multiple system atrophy (MSA), progressive supranuclear palsy (PSP), corticobasal syndrome (CBS), and dementia with Lewy bodies (DLB). These disorders are characterized by a combination of parkinsonian features and additional symptoms, such as autonomic dysfunction, supranuclear gaze palsy, and asymmetric motor symptoms. Many hypotheses attempt to explain the causes of neurodegeneration in APSs, including interactions between environmental toxins, tau or α-synuclein pathology, oxidative stress, microglial activation, and vascular factors. While extensive research has been conducted on APSs, there is a limited understanding of the symmetry in these diseases, particularly in MSA. Neuroimaging studies have revealed metabolic, structural, and functional abnormalities that contribute to the asymmetry in APSs. The asymmetry in CBS is possibly caused by a variable reduction in striatal D2 receptor binding, as demonstrated in single-photon emission computed tomography (SPECT) examinations, which may explain the disease's asymmetric manifestation and poor response to dopaminergic therapy. In PSP, clinical dysfunction correlates with white matter tract degeneration in the superior cerebellar peduncles and corpus callosum. MSA often involves atrophy in the pons, putamen, and cerebellum, with clinical symmetry potentially depending on the symmetry of the atrophy. The aim of this review is to present the study findings on potential symmetry as a tool for determining potential neuropsychological disturbances and properly diagnosing APSs to lessen the misdiagnosis rate. Methods: A comprehensive review of the academic literature was conducted using the medical literature available in PubMed. Appropriate studies were evaluated and examined based on patient characteristics and clinical and imaging examination outcomes in the context of potential asymmetry. Results: Among over 1000 patients whose data were collected, PSP-RS was symmetrical in approximately 84% ± 3% of cases, with S-CBD showing similar results. PSP-P was symmetrical in about 53-55% of cases, while PSP-CBS was symmetrical in fewer than half of the cases. MSA-C was symmetrical in around 40% of cases. It appears that MSA-P exhibits symmetry in about 15-35% of cases. CBS, according to the criteria, is a disease with an asymmetrical clinical presentation in 90-99% of cases. Similar results were obtained via imaging methods, but transcranial sonography produced different results. Conclusions: Determining neurodegeneration symmetry may help identify functional deficits and improve diagnostic accuracy. Patients with significant asymmetry in neurodegeneration may exhibit different neuropsychological symptoms based on their individual brain lateralization, impacting their cognitive functioning and quality of life.

Automated brain segmentation and volumetry in dementia diagnostics: a narrative review with emphasis on FreeSurfer

Background

Dementia can be caused by numerous different diseases that present variable clinical courses and reveal multiple patterns of brain atrophy, making its accurate early diagnosis by conventional examinative means challenging. Although highly accurate and powerful, magnetic resonance imaging (MRI) currently plays only a supportive role in dementia diagnosis, largely due to the enormous volume and diversity of data it generates. AI-based software solutions/algorithms that can perform automated segmentation and volumetry analyses of MRI data are being increasingly used to address this issue. Numerous commercial and non-commercial software solutions for automated brain segmentation and volumetry exist, with FreeSurfer being the most frequently used.

Objectives

This Review is an account of the current situation regarding the application of automated brain segmentation and volumetry to dementia diagnosis.

Methods

We performed a PubMed search for “FreeSurfer AND Dementia” and obtained 493 results. Based on these search results, we conducted an in-depth source analysis to identify additional publications, software tools, and methods. Studies were analyzed for design, patient collective, and for statistical evaluation (mathematical methods, correlations).

Results

In the studies identified, the main diseases and cohorts represented were Alzheimer’s disease (n = 276), mild cognitive impairment (n = 157), frontotemporal dementia (n = 34), Parkinson’s disease (n = 29), dementia with Lewy bodies (n = 20), and healthy controls (n = 356). The findings and methods of a selection of the studies identified were summarized and discussed.

Conclusion

Our evaluation showed that, while a large number of studies and software solutions are available, many diseases are underrepresented in terms of their incidence. There is therefore plenty of scope for targeted research.

The potential of phosphorylated α-synuclein as a biomarker for the diagnosis and monitoring of multiple system atrophy

INTRODUCTION

Multiple system atrophy (MSA) is a rapidly progressive neurodegenerative disorder characterized by the presence of glial cytoplasmic inclusions (GCIs) containing aggregated α-synuclein (α-Syn). Accurate diagnosis and monitoring of MSA present significant challenges, which can lead to potential misdiagnosis and inappropriate treatment. Biomarkers play a crucial role in improving the accuracy of MSA diagnosis, and phosphorylated α-synuclein (p-syn) has emerged as a promising biomarker for aiding in diagnosis and disease monitoring.

METHODS

A literature search was conducted on PubMed, Scopus, and Google Scholar using specific keywords and MeSH terms without imposing a time limit. Inclusion criteria comprised various study designs including experimental studies, case-control studies, and cohort studies published only in English, while conference abstracts and unpublished sources were excluded.

RESULTS

Increased levels of p-syn have been observed in various samples from MSA patients, such as red blood cells, cerebrospinal fluid, oral mucosal cells, skin, and colon biopsies, highlighting their diagnostic potential. The α-Syn RT-QuIC assay has shown sensitivity in diagnosing MSA and tracking its progression. Meta-analyses and multicenter investigations have confirmed the diagnostic value of p-syn in cerebrospinal fluid, demonstrating high specificity and sensitivity in distinguishing MSA from other neurodegenerative diseases. Moreover, combining p-syn with other biomarkers has further improved the diagnostic accuracy of MSA.

CONCLUSION

The p-syn stands out as a promising biomarker for MSA. It is found in oligodendrocytes and shows a correlation with disease severity and progression. However, further research and validation studies are necessary to establish p-syn as a reliable biomarker for MSA. If proven, p-syn could significantly contribute to early diagnosis, disease monitoring, and assessing treatment response.