Niall Quinn. Professor of Clinical Neurology UCL IoN & NHNN Queen Square London UK

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1 Niall Quinn Professor of Clinical Neurology UCL IoN & NHNN Queen Square London UK

2 Decade of the basal ganglia 1960 Shy Drager syndrome 1961 Striatonigral degeneration 1961 Birkmeyer & Hornykiewicz; Barbeau : L-dopa 1964 Steele-Richardson-Olszewski : PSP 1967 Hoehn & Yahr 1967 Cotzias : L-dopa 1968 Rebeiz : CBD 1969 Graham & Oppenheimer : MSA

3 MSA - neuropathology Cell loss &/or gliosis in:- striatum (mainly posterior putamen) substantia nigra, locus coeruleus inferior olives pontine nuclei, middle cerebellar peduncles cerebellar Purkinje cells intermediolateral cell columns, Onuf s nucleus plus -synuclein positive oligodendroglial cytoplasmic inclusions (GCIs)

4 1989 Papp-Lantos bodies J Neurol Sci 94: GCIs stain positive for alpha-synuclein Spillantini et al Neurosci Lett 251: Is MSA primarily a glial disease?

5 First set of diagnostic criteria for MSA

6 Second consensus criteria Probable MSA Autonomic failure plus Poorly levodopa- or Cerebellar syndrome responsive parkinsonism Gilman S et al. Second consensus statement on the diagnosis of multiple system atrophy Neurology 2008; 71:

7 Second consensus criteria Possible MSA MSA-P Parkinsonism plus Autonomic dysfunction Cerebellar syndrome Rapidly progressive parkinsonism Postural instability in 3 years Dysphagia in 5 years Poor levodopa response plus one of : Stridor Pyramidal signs MRI atrophy of: Putamen/MCP/pons/brainstem/cerebellum MSA-C Cerebellar syndrome plus Autonomic dysfunction Parkinsonism Putamen/mcp/pons FDG hypometabolism in: Putamen/brainstem/cerebellum SPECT/PET Putamen igrostriatal DA denervation MCP=middle cerebellar peduncle

8 Clinical features

9 MSA Survival - median 7-9 (max 19) years Aetiology - unknown, very rarely familial, no alpha-syn genetic abnormalities found Prevalence approx 5/100,000 (versus 150/100,000 for PD) i.e. 1 for every 30 PD

10 Count Age at onset EMSA-SG MSA (n=361) : 57.4 years Missing Age ranges (years) NNIPPS PSP (n=363) : 63.5 years MSA (n=403) : 57.4 years

11 Bensimon G et al. Riluzole treatment, survival and diagnostic criteria in Parkinson plus disorders: The NNIPPS Study Brain 2009: 132 ; NNIPPS study PSP (n=363) MSA (n=403) Falls and <1 year 50% 23% instability <3 years 79% 45% Falls or <1year 59% 33% instability <3 years 82% 60%

12 Autonomic failure NHNN NAMSA-SG EMSA-SG n=100 n=87 n=412 OH % Symptomatic OH 68% - 57% Syncope 15% (x 3) 41% 30% Incontinence 71% 88% 76% Retention 27% - - Incomplete emptying - 80% 54% MED 95% 93% 86%

13 Genitourinary dysfunction in multiple system atrophy WOMEN MEN YRS BEFORE DIAGNOSIS IMPOTENCE URINARY PARKINSONISM AUTONOMIC CEREBELLAR PYRAMIDAL Beck RO et al. Genitourinary dysfunction in multiple system atrophy: clinical features and treatment in 62 cases. J Urol. 1994;151(5):

14 Parkinsonism in 100 cases of clinically diagnosed MSA Total 91% Akinesia/rigidity 91% Tremor absent in 34% present in 66% at rest 29% classical pill-rolling 9% postural 47% action 20% (more than 1 type may be present in 1 patient) Wenning at al Brain 1994; 117:

15 Levodopa response in MSA-P Initial Best Last Excellent 20% 29% 13% or good Moderate 80% 71% 87% or poor

16 2008 Second consensus criteria - a problem with probable MSA Autonomic failure plus Poorly levodopa- or Cerebellar syndrome responsive parkinsonism But - many MSA patients show reasonable response early on

17 Cerebellar signs in 100 cases of clinically diagnosed MSA Limb ataxia 47% Intention tremor 13% Gait ataxia 37% (Postural instability 93%) Nystagmus 25%

18 Pyramidal signs in 30% but : no frank pyramidal weakness no scissoring of gait

19 RBD Common in both MSA & PD (more in MSA), so unhelpful in separating MSA-P from PD, but may help separate MSA-C from other cerebellar AF (OH) Common in both MSA & PD (more in MSA), so less helpful in separating MSA-P from PD, but may help separate MSA-C from other cerebellar Olfaction Typically normal in MSA, but impaired in PD

20 Supporting features :- Orofacial dystonia Disproportionate antecollis Camptocormia +/or Pisa syndrome Contractures Inspiratory sighs Severe dysphonia Severe dysarthria New/increased snoring Cold hands/ feet / nose/ ears Pathological laughter/crying Jerky myoclonic tremor

21 EMSA-SG red flags versus PD Early instability* Rapid progression* Pisa syndrome / disproportionate antecollis Stridor / sighs Severe dysphonia / dysarthria / dysphagia* Emotional incontinence* 2 out of 6 : specificity 98.3%, sensitivity 84.5% * also features of PSP Kollensperger M et al. Red flags for Multiple System Atrophy. Movement Disorders 2008; 23:

22 Non-supporting features :- Classic pill-rolling tremor Clinically significant neuropathy Hallucinations not induced by drugs Onset after age 75 Family history of ataxia/parkinsonism Dementia (DSM) White matter lesions suggesting MS

23 Red flags Wheelchair sign

24 Courtesy of Helen Ling, QSBB Diagnostic accuracy of MSA is about 75% Queen Square Brain Bank Archival Collection (Total = 1870 cases) Clinically diagnosed MSA = 169 Path confirmed MSA = 126 (PPV: 75%) Other path Dx: PD = 23 (14%) PSP = 10 (6%) CBD = 0 VaD = 3 Others = 7 Path confirmed MSA = 165 Correct clinical diagnosis = 128 (Sensitivity: 77%) Other clinical Dx: PD = 22 (13%) PSP = 9 (5%) CBS = 1 Others = 5

25 When DLB, PD and PSP masquerade as MSA : an autopsy study of 134 patients 83 (62%) had correct MSA diagnosis at autopsy 51 (38%) had non-msa :- 19 DLB 8 PD 15 PSP 9 others (2 CBD, 2 vasc P, 5 misc) Koga S et al Neurology 2015; 85:

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27 Female, age 45, seen May yrs UTIs, urgency, nocturia, incontinence & increased RV, RBD, unsteady, falls 1 year Freezing of gait, increased snoring, inspiratory sighs, dysarthria, dysphagia, limb rigidity, finger twitching Abn DaT, normal MRI Current- Pads day & night, double micturition Falls once a week On rising, unsteady and dizzy, no vertigo, no syncope, occ blurred vision / coathanger symptom O/E - Quivering strained high-pitched hypophonic speech, saccadic pursuit, antecollis, Pisa syndrome, hand myoclonus, poor circulatory return, bilateral d/d/kinesis & dysmetria in arms, heel-shin ataxia, marked akinesia & rigidity, extensor plantars

28 45 yo woman April 2015 Admitted to hospital for autonomic tests :- Standard battery Postprandial study Plasma adrenaline and noradrenaline 24-hr ambulatory BP and HR profile Conclusion :- She has evidence of autonomic failure and at this stage, although PD with AF cannot be excluded, the clinical features and autonomic findings do not exclude MSA Ideal to review her in 3 or 4 months

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30 Investigations (1) Measure BP lying & after 3mins standing (actually part of the physical exam) Measure post-micturition residual volume MRI brain scan mainly to exclude other things These are usually the only investigations needed!

31 Normal MSA PSP

32 (Ideally do T2* and DWI if you can) Putamen: Lateral hyperintense slit Posterior hypointensity Atrophy Pons: Hot cross bun, MCP hyperintensity

33 Investigations (2) DaT scan - only in some MSA-C cases OH /AFTs alone can t separate PD+AF from MSA+AF but may help separate MSA-C from SAOA Sphincter EMG - abnormal result unhelpful in MSA-P vs PD but may be helpful in MSA-C vs other crerebellar MIBG scan - typically normal in MSA, abn. in PD (FDG-PET)

34 MSA speech Very characteristic Diagnosis over the telephone Typically croaky, quivery (partly myoclonic), strained, high-pitched & (sometimes severely) hypophonic Slurred in MSA-C

35 Management I Parkinsonism Spasticity Bladder Impotence Postural faintness Stridor Antecollis Myoclonus Depression / emotional incontinence L-D, (?agonist), amantadine STN stim*, grafts don t help Baclofen Peripheral a/cholinergics, i.s.c. Sildanefil etc High salt intake, head-up tilt at night, elastic support stockings, etc Fludrocortisone/ephedrine/midodrine /L-threo-DOPS CPAP/cord lateralization/tracheostomy Prismatic spectacles, (botulinum toxin) Clonazepam/valproate/levetiracetam Tricyclic/SSRI * Only if levodopa-responsive

36 Management II Dietician Speech & swallowing therapist Continence nurse Occupational therapist Physiotherapist Palliative care Diet Advice, amplifiers, communication aids, + n/g tube or PEG Home visit Wheelchair assessment MSA Trust helpline & nurses