Multiple System Atrophy

Multiple System Atrophy

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Multiple system atrophy (MSA) is defined as an adult-onset, sporadic, rapidly progressive, multisystem, neurodegenerative fatal disease of undetermined etiology, characterized clinically by varying severity of parkinsonian features; cerebellar, autonomic, and urogenital dysfunction; and corticospinal disorders. Neuropathological hallmarks of MSA are cell loss in the striatonigral and olivopontocerebellar structures of the brain and spinal cord accompanied by profuse, distinctive glia cytoplasmic inclusions (GCIs) formed by fibrillized alpha-synuclein proteins (defined as primary alpha-synucleinopathy). (See Etiology and Pathophysiology, History and Physical Examination, and Workup.) [1]

A consensus statement by the American Autonomic Society and American Academy of Neurology in 2007 [2] categorized MSA in MSA-P with predominant parkinsonism and MSA-P with dominant cerebellar features (MSA-C). (See Categories of MSA below.)

The concept of MSA as a unitary diagnosis encompassing several clinical syndromes has a long history. The first cases of MSA were presented as olivopontocerebellar atrophy (OPCA) about a century ago. The Shy-Drager syndrome with features of parkinsonism and autonomic failure with OH was described in 1960. The term MSA was introduced to unify different forms of MSA in 1996. The discovery of GCIs and alpha-synuclein immunostaining as a sensitive marker of MSA were major milestones in the definition of MSA as a clinicopathologic entity. (See Table 1, below). [3]

Table 1. Historical Milestones in the Definition of Terms for MSA (Open Table in a new window)

Term

Period

Authors

Comments

Olivopontocerebellar atrophy (OPCA)

1900

Dejerine and Thomas

Introduction of the term olivopontocerebellar atrophy

Orthostatic hypotension (OH)

1925

Bradbury and Eggleston

Introduction of autonomic failure as a clinical syndrome

Shy-Drager syndrome (SDS)

1960

Shy and Drager

Origin of this term as a neuropathologic entity with parkinsonism and autonomic failure with OH

Striatonigral degeneration (SND)

1960

Van der Eecken et al

Description of SND

Multiple system atrophy (MSA)

1969

Graham and Oppenheimer

Introduction of the term MSA, which represents SDS, SND, and OPCA as 1 entity

Glial cytoplasmic inclusions (GCIs)

1989

Papp et al, Matsuo et al

Discovery of GCIs as hallmark of MSA

Alpha-synuclein inclusion

1998

Spillantini et al, Wakabayashi et al

Alpha-synuclein immunostaining as a sensitive marker of MSA

MSA classification

1996-1999

Consensus Committee

Classification of MSA based on clinical domains and features and neuropathology

Unified MSA Rating Scale (UMSARS)

2003

European MSA Study Group

Unified MSA Rating Scale as a standard to define MSA symptoms [4, 5]

Second consensus for MSA

2007

Consensus Committee

New definition of MSA with simplified criteria

A consensus conference in 2007 [6] simplified the older definition of MSA—as determined by the Consensus Committee representing the American Autonomic Society and the American Academy of Neurology in 1996 and 1998 [2] —and incorporated current knowledge for a better assessment of the disease. [7]

The 2 categories of MSA are as follows:

MSA with predominant parkinsonism (MSA-P) – Extrapyramidal features predominate; the term striatonigral degeneration, parkinsonian variant is sometimes used

MSA with cerebellar features (MSA-C) – Cerebellar ataxia predominates; it is sometimes termed sporadic olivopontocerebellar atrophy

The designation of MSA-P or MSA-C depends on the dominant feature at the time of evaluation, which can change with time.

Shy-Drager syndrome

When autonomic failure predominates, MSA was sometimes termed Shy-Drager syndrome (not defined in the present consensus anymore).

Features indicating the presence of MSA (tables 2a and 2b) or of another disorder (Table 3) are described below. (Corticospinal tract dysfunction with extensor plantar response with hyperreflexia [pyramidal sign] is not used to categorize MSA.) (See DDx.)

Table 2a. Main Features for the Diagnosis of MSA (Open Table in a new window)

Clinical Domain

Feature

Comment

Autonomic

dysfunction

Severe orthostatic hypotension (OH)

Asymptomatic

Symptomatic

OH is defined as blood pressure fall by at least 30mm Hg systolic and 15mm Hg diastolic within 3 minutes of standing from a previous 3-minute interval in the recumbent position.**

Urogenital dysfunction

Urinary incontinence (UI) or incomplete bladder emptying

UI is defined as persistent, involuntary, partial or total bladder emptying.

ED usually occurs before symptomatic OH.***

Erectile dysfunction (ED) in men

Parkinsonian features

(87% incidence *)

Bradykinesia (BK)

BK is slowness of voluntary movement with progressive reduction in speed and amplitude during repetitive actions.

PI not caused by primary visual, vestibular, cerebellar, or proprioceptive dysfunction.

Rigidity

Postural instability (PI)

Tremor – Postural, resting, or both

Cerebellar dysfunction

(54% incidence *)

Gait ataxia (GA)

GA is a wide-based stance with steps of irregular length and direction.

Sustained gaze-evoked nystagmus

Ataxic dysarthria

Limb ataxia

Oculomotor dysfunction

Coritcospinal tract dysfunction

Extensor plantar response with hyperreflexia

Babinsky sign, Pyramidal sign

*Incidence of clinical features recorded during the lifetimes of 203 patients (Gilman et al [2] ).

**OH caused by drugs, food, temperature, deconditioning, or diabetes are excluded.

***ED does not count in the definition of onset of disease, because it is a general feature in older people.

Table 2b. Additional Features for the Diagnosis of Possible MSA* (Open Table in a new window)

Category

Additional Features

 

Possible

MSA-P

Possible

MSA-C

Babinski sign with hyperreflexia

Stridor

 

Possible

MSA-P

Rapidly progressive parkinsonism

Poor response to levodopa

Postural instability within 3 years of motor onset

Gait ataxia, cerebellar dysarthria, limb ataxia, or cerebellar oculomotor dysfunction

Dysphagia within 5 years of motor onset

Atrophy on magnetic resonance imaging (MRI) of putamen, middle cerebellar peduncle, pons, or cerebellum

Hypometabolism on 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) scanning in putamen, brainstem, or cerebellum

 

Possible

MSA-C

 

Parkinsonism (bradykinesia and rigidity)

Atrophy on MRI of the putamen, middle cerebellar peduncle, or pons

Hypometabolism on FDG-PET in the putamen

Presynaptic striatonigral dopaminergic denervation on single-photon emission computed tomography (SPECT) or PET scanning

*Modified from second consensus [6]

 

Table 3. Characteristics That Do Not Support the Diagnosis of MSA (Open Table in a new window)

Procedure

Nonsupporting Features

History taking

Symptomatic onset at < 30 years

Onset after age 75 years

Family history of ataxia or parkinsonism

Systemic diseases or other identifiable causes for features listed in Table 2a

Hallucinations unrelated to medication

Dementia

Physical examination

Classic parkinsonian pill-rolling rest tremor

Clinically significant neuropathy

Prominent slowing of vertical saccades or vertical supranuclear gaze palsy

Evidence of focal cortical dysfunction, such as aphasia, alien limb syndrome, and parietal dysfunction

Laboratory study

Metabolic, molecular genetic, and imaging evidence of alternative cause of features listed in Table 2a

White matter lesions suggesting multiple sclerosis

MSA can be ascertained as possible, probable, or definite MSA (see Table 4, below), based on autonomic and urogenital features, on the presence of parkinsonism, and on cerebellar dysfunction, as well as on additional features (see tables 2a and 2b, above).

Only pathologic findings of high density of alpha-synuclein-positive glial cytoplasmic inclusions (GCIs) and degenerative changes in the striatonigral or olivopontocerebellar pathways can definitively confirm the diagnosis of MSA. (See Workup.)

Table 4. Diagnostic Categories of MSA (Open Table in a new window)

Category

Definition

Possible MSA

A sporadic, progressive, adult (>30y) with onset disease* characterized by the following:

Parkinsonism or cerebellar syndrome

At least 1 feature of autonomic or urogenital dysfunction

At least 1 of the additional features from Table 2b

Probable MSA

A sporadic, progressive, adult (>30y) with onset disease* characterized by the following:

Autonomic failure involving urinary dysfunction

Poorly levodopa-responsive parkinsonism or cerebellar dysfunction

Definitive MSA

A sporadic, progressive, adult (>30y) with onset disease pathologically confirmed by presence of high density GCIs in association with degenerative changes in striatonigral and olivopontocerebellar pathways

*Disease onset is defined as the initial presentation of any parkinsonian or cerebellar motor problems or autonomic features (except erectile dysfunction).

Red flags supporting the diagnosis of MSA include the following:

Orofacial dystonia

Disproportionate antecollis

Severe anterior flexion of the spine (camptocormia)

Severe lateral flexion of the spine (Pisa syndrome)

Contractures of hands and feet

Inspiratory sighs

Severe dysphonia

Severe dysarthria

New or increased snoring

Cold hands and feet

Pathologic laughter or crying

Jerky myoclonic postural/action tremor

A variety of resources are available for patient education. These include the Web sites of the Multiple System Atrophy Coalitions, Autonomic Disorder Consortium of the Clinical Rare Diseases Research Network, and Vanderbilt Autonomic Dysfunction Center.

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. [8] 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 [9] and genetic alterations with abnormal expansion of 1 allele of the SCA type 3 gene has been reported. [10] 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. [11, 12]

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.)

Table 5. Clinicopathologic Correlations (Open Table in a new window)

Clinical Symptom

Pathologic Findings and Location of Damage or Cell Loss

Orthostatic hypotension

Primary preganglionic damage of intermediolateral cell columns

Urinary incontinence (not retention)

Preganglionic cell loss in spinal cord (intermediolateral cell columns), related to detrusor hyperreflexia caused mainly by loss of inhibitory input to pontine micturition center (rather than to external urethral sphincter denervation alone)

Urinary retention caused by detrusor atonia

Sacral intermediolateral cell columns

Cerebellar ataxia

Cell loss in inferior olives, pontine nuclei, and cerebellar cortex

Pyramidal signs

Pyramidal tract demyelination

Extensor plantar response

Pyramidal tract lesion

Hyperreflexia

Pyramidal tract lesion

Motor abnormalities

GCIs in cortical motor areas or basal ganglia

Akinesia

Putamen, globus pallidus

Rigidity

Putaminal (not nigral) damage

Limb and gait ataxia

Inferior olives, basis pontis

Decreased or absent levodopa responsiveness

Striatal cell loss, loss of D1 and D2 receptors in striatum or impaired functional coupling of D1 and D2 receptors

Nystagmus

Inferior olives, pontine nuclei

Dysarthria

Pontine nuclei

Laryngeal stridor

Severe cell loss in nucleus ambiguus or biochemical defect causing atrophy of posterior cricoarytenoid muscles

Excessive daytime sleepiness

Loss of putative wake-active ventral periaqueductal gray matter dopaminergic neurons [13]

Adapted from Wenning et al and other sources.

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. [14, 15]

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.

In the European Union (EU), the prevalence rates show 4-5 cases per 100,000 persons. The incidence rate is about 0.6 cases per 100,000 persons per year. [16]

In the United Kingdom, the crude prevalence of MSA, including all probable and possible cases, is 3.3 per 100,000 population. [17]

In Iceland, the incidence is 0.6 per 100,000 and prevalence is 3.1 per 100,000. [18]

In Japan, the prevalence is 13.1 per 100,000 individuals. The mean annual incidence is 0.68. [19]

MSA has been encountered in Caucasian, African, and Asian populations. In Western countries, MSA-P predominates, occurring in 66-82% of patients. In Eastern countries (e.g., Japan), MSA-C is common, occurring in 67% of patients.

The disease more often affects men than women. The female-to-male ratio is around 1:2. (A ratio of 1:3-9 has also been reported.) However, the early and easy diagnosis of impotence may have led to the male statistical predominance of MSA. The mean age at onset in MSA is 52.5-55 years. The disease progresses over intervals of 1-18 years.

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. [20]

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Term

Period

Authors

Comments

Olivopontocerebellar atrophy (OPCA)

1900

Dejerine and Thomas

Introduction of the term olivopontocerebellar atrophy

Orthostatic hypotension (OH)

1925

Bradbury and Eggleston

Introduction of autonomic failure as a clinical syndrome

Shy-Drager syndrome (SDS)

1960

Shy and Drager

Origin of this term as a neuropathologic entity with parkinsonism and autonomic failure with OH

Striatonigral degeneration (SND)

1960

Van der Eecken et al

Description of SND

Multiple system atrophy (MSA)

1969

Graham and Oppenheimer

Introduction of the term MSA, which represents SDS, SND, and OPCA as 1 entity

Glial cytoplasmic inclusions (GCIs)

1989

Papp et al, Matsuo et al

Discovery of GCIs as hallmark of MSA

Alpha-synuclein inclusion

1998

Spillantini et al, Wakabayashi et al

Alpha-synuclein immunostaining as a sensitive marker of MSA

MSA classification

1996-1999

Consensus Committee

Classification of MSA based on clinical domains and features and neuropathology

Unified MSA Rating Scale (UMSARS)

2003

European MSA Study Group

Unified MSA Rating Scale as a standard to define MSA symptoms [4, 5]

Second consensus for MSA

2007

Consensus Committee

New definition of MSA with simplified criteria

Clinical Domain

Feature

Comment

Autonomic

dysfunction

Severe orthostatic hypotension (OH)

Asymptomatic

Symptomatic

OH is defined as blood pressure fall by at least 30mm Hg systolic and 15mm Hg diastolic within 3 minutes of standing from a previous 3-minute interval in the recumbent position.**

Urogenital dysfunction

Urinary incontinence (UI) or incomplete bladder emptying

UI is defined as persistent, involuntary, partial or total bladder emptying.

ED usually occurs before symptomatic OH.***

Erectile dysfunction (ED) in men

Parkinsonian features

(87% incidence *)

Bradykinesia (BK)

BK is slowness of voluntary movement with progressive reduction in speed and amplitude during repetitive actions.

PI not caused by primary visual, vestibular, cerebellar, or proprioceptive dysfunction.

Rigidity

Postural instability (PI)

Tremor – Postural, resting, or both

Cerebellar dysfunction

(54% incidence *)

Gait ataxia (GA)

GA is a wide-based stance with steps of irregular length and direction.

Sustained gaze-evoked nystagmus

Ataxic dysarthria

Limb ataxia

Oculomotor dysfunction

Coritcospinal tract dysfunction

Extensor plantar response with hyperreflexia

Babinsky sign, Pyramidal sign

*Incidence of clinical features recorded during the lifetimes of 203 patients (Gilman et al [2] ).

**OH caused by drugs, food, temperature, deconditioning, or diabetes are excluded.

***ED does not count in the definition of onset of disease, because it is a general feature in older people.

Category

Additional Features

 

Possible

MSA-P

Possible

MSA-C

Babinski sign with hyperreflexia

Stridor

 

Possible

MSA-P

Rapidly progressive parkinsonism

Poor response to levodopa

Postural instability within 3 years of motor onset

Gait ataxia, cerebellar dysarthria, limb ataxia, or cerebellar oculomotor dysfunction

Dysphagia within 5 years of motor onset

Atrophy on magnetic resonance imaging (MRI) of putamen, middle cerebellar peduncle, pons, or cerebellum

Hypometabolism on 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) scanning in putamen, brainstem, or cerebellum

 

Possible

MSA-C

 

Parkinsonism (bradykinesia and rigidity)

Atrophy on MRI of the putamen, middle cerebellar peduncle, or pons

Hypometabolism on FDG-PET in the putamen

Presynaptic striatonigral dopaminergic denervation on single-photon emission computed tomography (SPECT) or PET scanning

*Modified from second consensus [6]

Procedure

Nonsupporting Features

History taking

Symptomatic onset at < 30 years

Onset after age 75 years

Family history of ataxia or parkinsonism

Systemic diseases or other identifiable causes for features listed in Table 2a

Hallucinations unrelated to medication

Dementia

Physical examination

Classic parkinsonian pill-rolling rest tremor

Clinically significant neuropathy

Prominent slowing of vertical saccades or vertical supranuclear gaze palsy

Evidence of focal cortical dysfunction, such as aphasia, alien limb syndrome, and parietal dysfunction

Laboratory study

Metabolic, molecular genetic, and imaging evidence of alternative cause of features listed in Table 2a

White matter lesions suggesting multiple sclerosis

Category

Definition

Possible MSA

A sporadic, progressive, adult (>30y) with onset disease* characterized by the following:

Parkinsonism or cerebellar syndrome

At least 1 feature of autonomic or urogenital dysfunction

At least 1 of the additional features from Table 2b

Probable MSA

A sporadic, progressive, adult (>30y) with onset disease* characterized by the following:

Autonomic failure involving urinary dysfunction

Poorly levodopa-responsive parkinsonism or cerebellar dysfunction

Definitive MSA

A sporadic, progressive, adult (>30y) with onset disease pathologically confirmed by presence of high density GCIs in association with degenerative changes in striatonigral and olivopontocerebellar pathways

*Disease onset is defined as the initial presentation of any parkinsonian or cerebellar motor problems or autonomic features (except erectile dysfunction).

Clinical Symptom

Pathologic Findings and Location of Damage or Cell Loss

Orthostatic hypotension

Primary preganglionic damage of intermediolateral cell columns

Urinary incontinence (not retention)

Preganglionic cell loss in spinal cord (intermediolateral cell columns), related to detrusor hyperreflexia caused mainly by loss of inhibitory input to pontine micturition center (rather than to external urethral sphincter denervation alone)

Urinary retention caused by detrusor atonia

Sacral intermediolateral cell columns

Cerebellar ataxia

Cell loss in inferior olives, pontine nuclei, and cerebellar cortex

Pyramidal signs

Pyramidal tract demyelination

Extensor plantar response

Pyramidal tract lesion

Hyperreflexia

Pyramidal tract lesion

Motor abnormalities

GCIs in cortical motor areas or basal ganglia

Akinesia

Putamen, globus pallidus

Rigidity

Putaminal (not nigral) damage

Limb and gait ataxia

Inferior olives, basis pontis

Decreased or absent levodopa responsiveness

Striatal cell loss, loss of D1 and D2 receptors in striatum or impaired functional coupling of D1 and D2 receptors

Nystagmus

Inferior olives, pontine nuclei

Dysarthria

Pontine nuclei

Laryngeal stridor

Severe cell loss in nucleus ambiguus or biochemical defect causing atrophy of posterior cricoarytenoid muscles

Excessive daytime sleepiness

Loss of putative wake-active ventral periaqueductal gray matter dopaminergic neurons [13]

Adapted from Wenning et al and other sources.

Characteristic

MSA

Parkinson Disease

Response to chronic levodopa therapy*

Poor or unsustained motor response because of loss of postsynaptic dopamine receptors

Initial improvement in 30% of patients with MSA, but 90% were unresponsive over a longer time; 50% develop levodopa-induced dyskinesia of orofacial and neck muscles

Good response

Effects on striatonigral transmission

Presynaptic and postsynaptic; dopaminergic cell bodies in substantia nigra and their terminals in striatum, as well as their striatal target cells, have reduced dopamine receptors

Presynaptic

Symmetry of movement disorder

Possibly asymmetrical

No data

Progression of symptoms

Rapid

Slow

Postural instability and falling**

Early

Fast progression

Worsen >20% of UPDRS scale**

Late

Less progression (< 10%)

Progress of disability

Relatively fast disability; 30% decrease of activities of daily living in 1 year; 40% of patients in a wheelchair within 5 years (wheel chair sign)

Relatively slow disability

Abnormal speech

Severely affected speech in 30% of patients with MSA

Dysarthrophonia and severe dysarthria are common

Less affected

Abnormal Respiration

Abnormal aspiration, inspiratory gasps, and stridor in 60% of patients with MSA

Stridor caused by paralysis of vocal cord occurs especially at night but is also present during day

Less common

Lewy bodies (hyaline eosinophilic cytoplasmic neuronal inclusions)

Not present***

Primarily in substantia nigra

Cytoplasmic inclusions (immunocytochemical reaction with antibodies to alpha synuclein)

Glial inclusions; argyrophilic cellular inclusions in oligodendrocytes

Absent

Thermoregulation, skin perfusion

Cold hands and decrease of warm-up after cold-pack stimulus

Normal

Caudate-putamen index of dopamine uptake (on positron emission tomography [PET] scanning)

Decreased in putamen and caudate

Decreased in putamen with smaller decrease in caudate

Growth hormone release with intravenous (IV) injection of clonidine

No release; dysfunction of hypothalamic-pituitary pathway (alpha2-adrenoceptor-hypothalamic deficit)

Increase of growth hormone, intact function

* A positive response to levodopa is defined as a significant improvement of motor features during 3 months’ application of escalating doses of levodopa with a peripheral decarboxylase inhibitor. [6]

** Postural instability as defined by item 30 of the Unified Parkinson’s Disease Rating Scale (UPDRS) part III (motor examination). [6]

*** Pakiam et al reported that patients with diffuse Lewy-body disease may present with parkinsonism and prominent autonomic dysfunction, fulfilling some proposed criteria for the striatonigral form of MSA. [27]

Characteristic

MSA

Pure Autonomic Failure

CNS involvement

Multiple involvement

Unaffected

Site of lesion

Mainly preganglionic, central; degeneration of intermediolateral cell columns; ganglionic neurons relatively intact

Mainly postganglionic; loss of ganglionic neurons

Progression

Fast; median survival 6.5-9.5 years

Slow; some patients survive >10-30 years

Prognosis

Poor

Good

Extrapyramidal involvement

Common

Not present

Cerebellar involvement

Common

Not present

Gastrointestinal symptoms

Uncommon

Absent, except constipation

Plasma supine norepinephrine level

Normal

Reduced

Antidiuretic hormone (ADH) response to tilt

Impaired because of catecholaminergic denervation of hypothalamus (but normal ADH response to osmotic stimuli)

Maintained

Adrenocorticotropic hormone and beta-endorphin response to hypoglycemia

Impaired because of central cholinergic dysfunction or dysfunction of adrenergic input to paraventricular nucleus

Normal

Growth hormone release with clonidine IV injection

No release, dysfunction of hypothalamic-pituitary pathway (alpha2-adrenoceptor-hypothalamic deficit)

Increase of growth hormone; intact function

Substance P, catecholamine, 5-HT, and acetylcholine markers in cerebrospinal fluid

Decreased levels

No data

Lewy bodies

Mostly absent

Present in autonomic neurons

BP response to oral water intake

Increased

Increased but variable

BP response to ganglionic blockade

Profound decrease

Modest decrease

 

GCIs in MSA

Lewy Bodies in Parkinson Disease

Neurofibrillary Pathology in Alzheimer Disease

Glial Lesions in Corticobasal and Progressive Supranuclear Palsy

Shape

Sickle shaped to flame shaped to ovoid, various neurofibrillary tangles

Target-shaped inclusions

Tangles

Tufted astrocytes, coiled bodies

Membrane

No limiting membrane; tubular profiles and electrodense granules

Present

Present

Present

Ultrastructure

Loosely aggregated filaments

No data

No data

Astrocytic plaques

Immunocytochemistry

Ubiquitin positive, alpha-B-crystallin (synuclein) positive, alpha- and beta-tubulin positive, tau-protein positive

Hyaline eosinophilic cytoplasmic neuronal inclusions, ubiquitin

No data

Absence of phosphorylated tau

Localization

In oligodendroglial cells and neurons

In neuronal cells and oligodendroglial cells

No data

No data

Class

Drug

Description or Mechanism

Corticosteroids

Fludrocortisone (Florinef)

Mineralocorticoid; sodium retention, primarily in extravascular compartment, causes tissue edema to venous capacitance bed in lower extremity. With this edema, venous bed accommodates decreased volume of blood in an upright posture (high doses, late effect); increases sensitivity to norepinephrine (even with small doses)

Sympathomimetic amines

Midodrine

Alpha1-adrenoreceptor agonist acts directly on vasculature, causes venous and arteriolar vasoconstriction

 

Droxidopa

 

Droxidopa is a synthetic precursor of norepinephrine. It acts by conversion to norepinephrine in the body.

Recombinant erythropoietin (EPO)

Epoetin alfa

Increases sensitivity to pressor effects of angiotensin II; increases plasma endothelin level; increases cytosolic free calcium in vascular smooth muscle; increases intravascular volume

NSAIDs

Indomethacin, ibuprofen

Inhibition of vasodilator prostaglandins proposed but not proven

Antihistamines

Diphenhydramine, cimetidine

Reduce vasodilatation caused by histamine release

Somatostatin analogs

Octreotide

Reduce splanchnic capacitance

Vasopressin agonists

Desmopressin (DDAVP)

Vasopressin analogs; no effect on V1 receptors, which are responsible for vasopressin-induced vasoconstriction; acts on V2 receptors on renal tubuli, which are responsible for antidiuretic effect; prevents nocturnal diuresis, raises BP in morning

Other sympathomimetics

Yohimbine

Alpha2-adrenoreceptor antagonist

Caffeine

Adenosine receptor antagonist

André Diedrich, MD, PhD Research Professor of Medicine, Adjunct Research Professor of Biomedical Engineering, Director of the Analytical and Phenotyping Core, Autonomic Dysfunction Center, Vanderbilt University School of Medicine

André Diedrich, MD, PhD is a member of the following medical societies: American Autonomic Society

Disclosure: Nothing to disclose.

David Robertson, MD Director, Clinical and Translational Research Center, Vanderbilt Institute for Clinical and Translational Research, Principal Investigator, Autonomic Rare Disease Clinical Research Consortium, Elton Yates Professor of Medicine, Pharmacology, and Neurology, Vanderbilt University School of Medicine

David Robertson, MD is a member of the following medical societies: American Heart Association, Association of American Physicians

Disclosure: Nothing to disclose.

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida Morsani College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Acorda, Livanova, Eisai, Greenwich, Lundbeck, Neuropace, Sunovion, Upsher-Smith.<br/>Serve(d) as a speaker or a member of a speakers bureau for: Livanova, Eisai, Greenwich, Lundbeck, Neuropace, Sunovion.<br/>Received research grant from: Acorda, Livanova, Greenwich, Lundbeck, Sepracor, Sunovion, UCB, Upsher-Smith.

Nestor Galvez-Jimenez, MD, MSc, MHA Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida

Nestor Galvez-Jimenez, MD, MSc, MHA is a member of the following medical societies: American Academy of Neurology, American College of Physicians, and Movement Disorders Society

Disclosure: Nothing to disclose.

Christopher Luzzio, MD Clinical Assistant Professor, Department of Neurology, University of Wisconsin at Madison School of Medicine and Public Health

Christopher Luzzio, MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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