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Multiple system atrophy (MSA) is a neurodegenerative disorder characterised by autonomic failure in the form of orthostatic hypotension, neurogenic bladder and impotence, in association with a variable combination of parkinsonism, cerebellar ataxia and pyramidal signs.1 MSA is divided into predominant parkinsonism (MSA-P) and cerebellar (MSA-C) forms. Current clinical diagnostic criteria for ‘probable MSA’ require prominent autonomic failure. However, it is widely recognised that these symptoms may develop long after motor features.2 In the case of MSA-P, early parkinsonism in the absence of significant autonomic failure may be impossible to differentiate from Parkinson's disease. Establishing a correct diagnosis early in the course of MSA has direct implications for prognosis and counselling of patients and family. The clinical research implications are broad, including exclusion of such patients from studies of Parkinson's disease and inclusion in studies on MSA, particularly those that would benefit from early diagnosis, such as trials of experimental disease-modifying therapies. The potential of brain MRI as a diagnostic tool for MSA has been studied3 and it has been incorporated in the current diagnostic criteria, though only as supportive criteria of ‘possible MSA’.4 It is unclear how brain MRI signs of MSA can predate its clinical diagnosis and …
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