Objective: This prospective cohort study investigated the role of neuroimaging for the early and accurate identification of multiple system atrophy (MSA) in patients with indeterminate autonomic dysfunction.

Background: Multiple system atrophy (MSA) is a rapidly progressive neurodegenerative disorder for which early diagnosis is becoming increasingly important in the era of emerging disease-modifying therapies. However, current diagnostic and research criteria require autonomic dysfunction as an entry feature, which may exclude patients in the earliest disease stage because motor symptoms can precede autonomic failure.

Method: We recruited patients with suspected MSA based on clinical manifestation or neuroimaging findings from May 2024 to October 2025. The Movement Disorder Society criteria for MSA was used and exclusion rules were strictly applied. But patients without dysautonomia were also included if they exhibited the MRI markers and supportive clinical features of MDS criteria. Clinical symptoms were evaluated by unified MSA rating scale and autonomic function was assessed with head-up tilt test (HUT). Typical signs on brain magnetic resonance imaging (MRI), such as putaminal rim sign, hot-cross burn sign and middle cerebellar peduncle sign, were checked. We compared clinical and demographic data between MSA patients with and without OH.

Results: In total 45 enrolled subjects, OH was detected by tilt-table testing in 46.7% whereas only 47.6% of those with confirmed OH reported orthostatic dizziness. There was no difference in demographic and clinical data between subjects with and without OH. Characteristic MRI abnormalities were identified in 41(91.1%) patients at early symptomatic stages.

Conclusion: Our results demonstrated MRI abnormalities can precede objective autonomic dysfunction, suggesting that early imaging markers may aid timely MSA recognition and support future diagnostic frameworks.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/revisiting-prodromal-diagnostic-criteria-in-msa-the-need-for-early-mri-based-diagnosis/