Article Text

Download PDFPDF
Autonomic innervation in multiple system atrophy and pure autonomic failure
  1. V Donadio1,
  2. P Cortelli1,
  3. M Elam2,
  4. V Di Stasi1,
  5. P Montagna1,
  6. B Holmberg3,
  7. M P Giannoccaro1,
  8. E Bugiardini1,
  9. P Avoni1,
  10. A Baruzzi1,
  11. R Liguori1
  1. 1Department of Neurological Sciences, University of Bologna, Bologna, Italy
  2. 2Department of Clinical Neurophysiology, Sahlgrenska Hospital, Goteborg University, Goteborg, Sweden
  3. 3Department of Neurology, Sahlgrenska Hospital, Goteborg University, Goteborg, Sweden
  1. Correspondence to Dr Vincenzo Donadio, Dipartimento di Scienze Neurologiche, Università di Bologna, Via Ugo Foscolo 7, Bologna 40123, Italy; vincenzo.donadio{at}


Background Pure autonomic failure (PAF) and multiple system atrophy (MSA) are both characterised by chronic dysautonomia although presenting different disability and prognosis. Skin autonomic function evaluation by indirect tests has revealed conflicting results in these disorders. Here, the authors report the first direct analysis of skin sympathetic fibres including structure and function in PAF and MSA to ascertain different underlying autonomic lesion sites which may help differentiate between the two conditions.

Methods The authors studied eight patients with probable MSA (mean age 60±5 years) and nine patients fulfilling diagnostic criteria for PAF (64±8 years). They underwent head-up tilt test (HUTT), extensive microneurographic search for muscle and skin sympathetic nerve activities from peroneal nerve and punch skin biopsies from finger, thigh and leg to evaluate cholinergic and adrenergic autonomic dermal annexes innervation graded by a semiquantitative score presenting a high level of reliability.

Results MSA and PAF patients presented a comparable neurogenic orthostatic hypotension during HUTT and high failure rate of microneurographic trials to record sympathetic nerve activity, suggesting a similar extent of chronic dysautonomia. In contrast, they presented different skin autonomic innervation in the immunofluorescence analysis. MSA patients showed a generally preserved skin autonomic innervation with a significantly higher score than PAF patients showing a marked postganglionic sympathetic denervation. In MSA patients with a long disease duration, morphological abnormalities and/or a slightly decreased autonomic score could be found in the leg reflecting a mild postganglionic involvement.

Conclusion Autonomic innervation study of skin annexes is a reliable method which may help differentiate MSA from PAF.

  • Autonomic
  • clinical neurology
  • microneuronography
  • multisystem atrophy
  • peripheral neuropathology

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding Supported by RFO 2008 University of Bologna grant to RL. VD was supported by a fellowship grant from the European Neurological Society.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Ethics approval was provided by the Human Ethics Committee of Bologna and Göteborg University.

  • Provenance and peer review Not commissioned; externally peer reviewed.