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Thread: Multiple system atrophy (MSA) case pictures - NEURORADIOLOGY ATLAS

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    Default Multiple system atrophy (MSA) case pictures - NEURORADIOLOGY ATLAS

    Etiology and Pathophysiology
    MSA is characterized by progressive loss of neuronal and oligodendroglial cells in numerous sites in the central nervous system (CNS). The cause of MSA remains unclear, although a history of trauma has been suggested. Pesticide exposure as a causative factor in MSA has been suggested but has not been confirmed statistically. Autoimmune mechanisms have also been suggested as potential causes of MSA, but evidence for these is weak.

    There is some evidence of genetic predispositions in Japanese cohorts. Autosomal recessive inheritance and genetic alterations with abnormal expansion of 1 allele of the SCA type 3 gene has been reported. Single nucleotide polymorphisms (SNPs) at the SNCA locus coding for alpha-synuclide have been identified. G51D mutation in the SNCA locus has been described, but a connection between SCNA locus and MSA disease could not be confirmed. Associations with COQ2 and C9orf72 have been reported.

    Researchers initially assumed that gray-matter damage caused MSA. However, the discovery of oligodendroglial glial cytoplasmic inclusions (GCIs) (see Table 8) indicated that damage primarily affects the white matter. The chronic alterations in glial cells may impair trophic function between oligodendrocytes and axons and cause secondary neuronal damage. Whether the inclusions represent primary lesions or nonspecific secondary markers of cellular injury remains unknown. In addition to the GCIs, extensive myelin degeneration occurs in the brain. Changes in myelin may play an important role in the pathogenesis of MSA. The clinical symptoms of MSA correlate with cell loss in different CNS sites. (See Table 5, below.)

    Occurrence in the United States
    The prevalence of MSA is reported to be between 3.4-4.9 cases per 100,000 population. The estimated mean incidence is 0.6-0.7 cases per 100,000 person-years. MSA meets orphan disease status

    Many patients do not receive the correct diagnosis during their lifetime because of the difficulty in differentiating MSA from other disorders (eg, Parkinson disease, pure autonomic failure [PAF], other rare movement disorders). About 29-33% of patients with isolated late-onset cerebellar ataxia and 8-10% of patients with parkinsonism will develop MSA. Therefore, a higher prevalence than that estimated can be assumed.
    Multiple system atrophy (MSA) case attachment.php?s=db44e0f34e2491a50430a7e4bda9e50a&attachmentid=1530&d=1440347490

    Patients with MSA have a poor prognosis. The disease progresses rapidly. Median survivals of 6.2-9.5 years from the onset of first symptoms have been reported since the late 20th century. No current therapeutic modality reverses or halts the progress of this disease. MSA-P and MSA-C have the same survival times, but MSA-P shows more rapid dysfunctional progression.
    An older age at onset has been associated with shorter duration of survival in MSA. The overall striatonigral cell loss is correlated with the severity of disease at the time of death.
    Bronchopneumonia (48%) and sudden death (21%) are common terminal conditions in MSA. Urinary dysfunction in MSA often leads to lower urinary tract infections (UTIs); more than 50% of patients with MSA suffer from recurrent lower UTIs and a significant number die of related complications.

    History and Physical Examination
    Most patients with multiple system atrophy (MSA) develop the disease when they are older than 40 years (average 52-55y), and they experience fast progression. Usually autonomic and/or urinary dysfunction develops first. Patients with MSA may have parkinsonian symptoms with poor or nonsustained response to levodopa therapy. Only 30% of MSA-P patients have an initial transient improvement. About 90% of patients are nonresponsive to long-term levodopa therapy.

    Typically, 60% of patients experience objective decline in motor function within 1 year. Motor impairment can be caused by cerebellar dysfunction. Corticospinal tract dysfunction also can occur but is not often a major symptomatic feature of MSA. Table 2a provides an overview of the clinical domains and their main features. More details are described in subsequent sections

    Autonomic and/or urinary dysfunction
    Autonomic symptoms are the initial feature in 41-74% of patients with MSA; these symptoms ultimately develop in 97% of patients. Genitourinary dysfunction is the most frequent initial complaint in women, and erectile dysfunction is the most frequent initial complaint in men.

    Severe orthostatic hypotension
    Severe orthostatic hypotension is defined as a reduction in systolic blood pressure (BP) of at least 30mm Hg or in diastolic BP of at least 15mm Hg, within 3 minutes of standing from a previous 3-minute interval in the recumbent position. This form of hypotension is common in MSA, being present in at least 68% of patients. Most patients do not respond with an adequate heart rate increase. The definition of severe orthostatic BP fall as a diagnostic criterion for MSA is stricter than the definition of orthostatic hypotension as a physical finding as defined by the American Autonomic Society

    Postprandial hypotension
    Patients are also susceptible to postprandial hypotension. Altered venous capacitance and baroreflex dysfunction have been reported as a cause.

    Supine hypertension
    Approximately 60% of patients with MSA have orthostatic hypotension and supine hypertension. The supine hypertension is sometimes severe (>190/110mm Hg) and complicates the treatment of orthostatic hypotension.


    Last edited by Medical Photos; 08-23-2015 at 04:32 PM.

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