Multiple System Atrophy

This article provides up-to-date diagnosis and management concepts for patients with multiple system atrophy, a rare, sporadic, adult-onset, progressive, and fatal neurodegenerative disorder that is characterized mainly by autonomic and motor dysfunction. Making an accurate and early diagnosis of multiple system atrophy remains challenging because of its clinical complexity and similarity in presentation to other neurodegenerative diseases. The clinical diagnosis of multiple system atrophy is based on the patient's symptoms of autonomic dysfunction with levodopa-resistant parkinsonism or cerebellar ataxia, alongside neuroimaging characteristics and exclusion of mimics. The 2022 International Parkinson and Movement Disorder Society criteria enable an accurate and early diagnosis of clinically established multiple system atrophy, clinically probable multiple system atrophy, prodromal possible multiple system atrophy, and the definite pathologic diagnosis of multiple system atrophy. The management of multiple system atrophy remains symptomatic in the control of parkinsonism, ataxia, autonomic dysfunction, and other motor and nonmotor symptoms, with an updated multidisciplinary and multisystem approach including palliative care. Advances in brain imaging and molecular biomarker research and efforts to develop disease-modifying agents have shown promise to improve diagnosis and treatment of this disorder. Updated standards guide the clinical diagnosis and management of multiple system atrophy with a multidisciplinary and multisystem approach, and this article summarizes clinical best practices and emerging advances in multiple system atrophy.