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Understanding Your MSA Diagnosis

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Multiple System Atrophy (MSA) is a rare, progressive neurodegenerative disorder often initially misdiagnosed as Parkinson's disease. Diagnosis relies on identifying core symptoms like autonomic failure and movement issues, which are categorized into MSA-P (Parkinsonian) or MSA-C (Cerebellar) subtypes.

Key Takeaways

  • • Multiple System Atrophy (MSA) is a rare neurodegenerative disorder affecting movement and involuntary functions like blood pressure.
  • • MSA is often misdiagnosed as Parkinson's disease early on because they share similar movement symptoms like stiffness and tremors.
  • • There are two main subtypes: MSA-P, which features Parkinson-like movement issues, and MSA-C, which primarily affects balance and coordination.
  • • Diagnosis relies on updated 2022 criteria that evaluate core symptoms, supporting features, and specific findings on a brain MRI.

Receiving a diagnosis of Multiple System Atrophy (MSA) can feel overwhelming, especially because it is a condition many people—including some healthcare professionals—have never heard of [1]. MSA is a rare, progressive neurodegenerative disorder that affects the systems in your brain responsible for movement and involuntary functions, like blood pressure and bladder control [2][3].

Because MSA is rare, with an estimated prevalence of roughly 3 to 5 out of every 100,000 people in the general population (though the incidence is higher in adults over 50), many local doctors may have limited experience treating it [4]. It is very common for MSA to be initially misdiagnosed as Parkinson’s disease because the early symptoms, such as tremors or stiffness, look very similar [1][5].

What is Multiple System Atrophy?

MSA is classified as a synucleinopathy, meaning it involves the abnormal buildup of a protein called alpha-synuclein [2]. In MSA, this protein clusters into Glial Cytoplasmic Inclusions (GCIs) within cells called oligodendrocytes, which normally help protect your nerve fibers [6][7]. As these clusters grow, they cause inflammation and damage to the brain’s “white matter,” leading to the loss of nerve cells [6][8].

The disease typically begins in middle age, with most people noticing their first symptoms between the ages of 55 and 65 [9]. It is a progressive condition. While every person’s journey is different, building a specialized care team early is the best way to manage symptoms and maintain your quality of life [10].

The 2022 Diagnostic Criteria

In 2022, the International Parkinson and Movement Disorder Society (MDS) updated the guidelines for diagnosing MSA to help doctors identify the disease more accurately and earlier [11][12]. Your doctor may use these three categories to describe your diagnosis:

  • Clinically Established MSA: This is the most certain clinical diagnosis. It requires specific core symptoms (like severe autonomic failure or movement issues) combined with at least two “supporting features” and specific findings on a brain MRI (Magnetic Resonance Imaging) [11][13].
  • Clinically Probable MSA: This category is used when a patient has the core symptoms of MSA but may not yet show the specific brain changes on an MRI. This category is designed to be highly sensitive, meaning it helps catch the disease early even if all the “established” markers aren’t present yet [12][11].
  • Possible Prodromal MSA: This is a research category for people who show very early signs—such as REM Sleep Behavior Disorder (acting out dreams) or mild autonomic issues—that suggest they may develop MSA in the future [11].

The Two Main Types of MSA

Doctors further categorize MSA based on which symptoms are most prominent:

  1. MSA-P (Parkinsonian type): The primary symptoms are movement-related, such as slowness, stiffness, and tremors, similar to Parkinson’s disease [14][15].
  2. MSA-C (Cerebellar type): The primary symptoms involve balance, coordination, and speech, often resulting in a “drunken” gait or slurred speech [14][15].

In North America and Europe, the MSA-P subtype is more common, while in other regions like Japan, MSA-C is more frequently diagnosed [16].

Why the Diagnosis is Difficult

The path to an MSA diagnosis is often long and frustrating. Because of the “symptomatic overlap” with Parkinson’s, many patients are treated for Parkinson’s for years before “red flags” appear [1][5]. These red flags—such as a very rapid decline in walking ability, severe fainting spells (orthostatic hypotension) shortly after diagnosis, or making a high-pitched whistling sound while sleeping (stridor)—often help specialists pivot to an MSA diagnosis [17][18].

While there is currently no cure, a clear diagnosis is the first step toward building a care team that understands the specific challenges of MSA and can help manage symptoms to improve quality of life.

Frequently Asked Questions

Why is MSA often misdiagnosed as Parkinson's disease?
Early symptoms of Multiple System Atrophy, such as tremors and stiffness, look very similar to Parkinson's disease. It often takes a rapid decline in mobility or the appearance of specific 'red flags' like severe fainting spells for specialists to recognize it is actually MSA.
What is the difference between MSA-P and MSA-C?
MSA-P is the Parkinsonian subtype, where symptoms mainly involve slow movement, stiffness, and tremors. MSA-C is the Cerebellar subtype, which primarily causes issues with balance, coordination, and slurred speech.
What are the red flag symptoms of Multiple System Atrophy?
Key red flags that point to MSA rather than Parkinson's include a rapid decline in walking ability, severe fainting spells when standing up (orthostatic hypotension), and a high-pitched whistling sound during sleep called stridor.
How do doctors diagnose MSA?
Doctors diagnose MSA using the 2022 MDS criteria, which look at core symptoms like autonomic failure and movement issues. They evaluate these symptoms alongside brain MRIs and other supporting features to classify the diagnosis as clinically established or probable.

Questions for Your Doctor

  • • What specific 'red flags' or symptoms led to my diagnosis of MSA instead of Parkinson's disease?
  • • Based on the 2022 MDS criteria, is my diagnosis classified as 'Clinically Established' or 'Clinically Probable'?
  • • Does my MRI show specific signs like the 'hot cross bun' sign or putaminal atrophy?
  • • Which subtype of MSA do I have—the parkinsonian type (MSA-P) or the cerebellar type (MSA-C)?
  • • How many other patients with MSA have you or this clinic treated in the past year?
  • • What is the plan for monitoring my autonomic functions, such as blood pressure and bladder health?

Questions for You

  • • When did I first notice my symptoms, and how quickly have they changed since then?
  • • Have I experienced 'fainting spells' or dizziness when standing up?
  • • Has my partner or family noticed me acting out dreams or making unusual noises (like stridor) while I sleep?
  • • How much do my symptoms interfere with my daily mobility and balance right now?

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References

  1. 1

    Clinical value of serum miR-451 in early diagnosis of multiple system atrophy from parkinson's disease and outcomes prediction.

    Shi T, Jia Z

    Acta neurologica Belgica 2025; doi:10.1007/s13760-025-02870-4.

    PMID: 40848180
  2. 2

    A historical review of multiple system atrophy with a critical appraisal of cellular and animal models.

    Marmion DJ, Peelaerts W, Kordower JH

    Journal of neural transmission (Vienna, Austria : 1996) 2021; (128(10)):1507-1527 doi:10.1007/s00702-021-02419-8.

    PMID: 34613484
  3. 3

    Does the Type of Multisystem Atrophy, Parkinsonism, or Cerebellar Ataxia Impact on the Nature of Sleep Disorders?

    Ferini-Strambi L, Marelli S, Combi R

    Current neurology and neuroscience reports 2016; (16(12)):105 doi:10.1007/s11910-016-0704-z.

    PMID: 27844341
  4. 4

    Estimating the prevalence and incidence of multiple system atrophy in the USA: Insights from a national claims database.

    Kaplan S, Xie H, Wang J

    Parkinsonism & related disorders 2023; (117()):105920 doi:10.1016/j.parkreldis.2023.105920.

    PMID: 37951144
  5. 5

    [Diagnosis of MSA-P and PSP-P in Early Stage].

    Yamawaki T

    Brain and nerve = Shinkei kenkyu no shinpo 2020; (72(4)):331-343 doi:10.11477/mf.1416201532.

    PMID: 32284458
  6. 6

    Brain injections of glial cytoplasmic inclusions induce a multiple system atrophy-like pathology.

    Teil M, Dovero S, Bourdenx M, et al.

    Brain : a journal of neurology 2022; (145(3)):1001-1017 doi:10.1093/brain/awab374.

    PMID: 35285474
  7. 7

    Neuropathology of Parkinson's Disease and Parkinsonism.

    Dickson DW

    Cold Spring Harbor perspectives in medicine 2025; doi:10.1101/cshperspect.a041610.

    PMID: 40324812
  8. 8

    Genes to treat excitotoxicity ameliorate the symptoms of the disease in mice models of multiple system atrophy.

    Glat MJ, Stefanova N, Wenning GK, Offen D

    Journal of neural transmission (Vienna, Austria : 1996) 2020; (127(2)):205-212 doi:10.1007/s00702-020-02158-2.

    PMID: 32065333
  9. 9

    Late-onset multiple system atrophy: Neuropathological features associated with slow disease progression.

    Ozawa M, Saito R, Konno T, et al.

    Brain pathology (Zurich, Switzerland) 2025; (35(5)):e70016 doi:10.1111/bpa.70016.

    PMID: 40389287
  10. 10

    My Treatment Approach to Multiple System Atrophy.

    Coon EA, Ahlskog JE

    Mayo Clinic proceedings 2021; (96(3)):708-719 doi:10.1016/j.mayocp.2020.10.005.

    PMID: 33673922
  11. 11

    The Movement Disorder Society Criteria for the Diagnosis of Multiple System Atrophy.

    Wenning GK, Stankovic I, Vignatelli L, et al.

    Movement disorders : official journal of the Movement Disorder Society 2022; (37(6)):1131-1148 doi:10.1002/mds.29005.

    PMID: 35445419
  12. 12

    Pathological Validation of the MDS Criteria for the Diagnosis of Multiple System Atrophy.

    Virameteekul S, Revesz T, Jaunmuktane Z, et al.

    Movement disorders : official journal of the Movement Disorder Society 2023; (38(3)):444-452 doi:10.1002/mds.29304.

    PMID: 36606594
  13. 13

    Validation Study of the MDS Criteria for the Diagnosis of Multiple System Atrophy in the Mayo Clinic Brain Bank.

    Sekiya H, Koga S, Murakami A, et al.

    Neurology 2023; (101(24)):e2460-e2471 doi:10.1212/WNL.0000000000207905.

    PMID: 37816641
  14. 14

    An update on the cerebellar subtype of multiple system atrophy.

    Ciolli L, Krismer F, Nicoletti F, Wenning GK

    Cerebellum & ataxias 2014; (1()):14 doi:10.1186/s40673-014-0014-7.

    PMID: 26331038
  15. 15

    Recent advances in neuropathology, biomarkers and therapeutic approach of multiple system atrophy.

    Koga S, Dickson DW

    Journal of neurology, neurosurgery, and psychiatry 2018; (89(2)):175-184 doi:10.1136/jnnp-2017-315813.

    PMID: 28860330
  16. 16

    Multiple system atrophy: clinicopathological characteristics in Japanese patients.

    Ozawa T, Onodera O

    Proceedings of the Japan Academy. Series B, Physical and biological sciences 2017; (93(5)):251-258 doi:10.2183/pjab.93.016.

    PMID: 28496050
  17. 17

    Pervasive and diffuse muscle activity during REM sleep and non-REM sleep characterises multiple system atrophy in comparison with Parkinson's disease.

    Silvani A, Baldelli L, Giannini G, et al.

    Journal of sleep research 2023; (32(2)):e13721 doi:10.1111/jsr.13721.

    PMID: 36054178
  18. 18

    Natural history of multiple system atrophy in the USA: a prospective cohort study.

    Low PA, Reich SG, Jankovic J, et al.

    The Lancet. Neurology 2015; (14(7)):710-9.

    PMID: 26025783

This page is for informational purposes only and does not replace professional medical advice. Always consult a neurologist or movement disorder specialist regarding a Multiple System Atrophy (MSA) diagnosis and symptom management.

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