Objective: To determine the onset and prevalence of prodromal non-motor symptoms in patients with multiple system atrophy (MSA), both parkinsonian (MSA-P) and cerebellar (MSA-C) forms.

Background: Cardiovascular and urinary autonomic dysfunction, and REM sleep behavior disorder are well described prodromal manifestations of MSA. However, their prevalence and time of onset relative to the onset of motor abnormalities (MA) is not well defined.

Method: We performed a retrospective review of patients evaluated at the NYU Dysautonomia Center with a diagnosis of possible or probable MSA over the last 3 years, including information on age at onset of orthostatic intolerance (OI), lower urinary tract symptoms (LUTS), probable RBD,  (pRBD) and motor abnormalities (MA). Chi-square tests were used for qualitative variables. Mann-Whitney U test was used to compare quantitative variables. Measures of dispersion are expressed as “mean ± standard deviation” or “median (p25 to p75)”.

Results: A total of 91 patients with MSA (29 MSA-C, 62 MSA-P) were included (49 men, 54%). Age of onset of MA was 58±8 in MSA-C and 60±9 in MSA-P (p=0.321). pRBD was reported in 93% of MSA-C patients, with onset at age 53±9; and in 87% in MSA-P at age 54±11 in (p=0.38). OI was present in 66% of MSA-C with onset at age 55±9; and in 95% of MSA-P at age 59±9 (p<0.001). LUTS were present in 100% of MSA-C, with onset at age 58±8, and in 100% of MSA-P with onset at age 59±10 (p=0.684). pRBD before MA was reported by 76% of MSA-C with an interval of 3 (1-5) years; and in 50% of MSA-P with an interval of 5 (2-7) years (p=0.491); OI before MA was reported by 14% of MSA-C with an interval of 2 (1-3) years , and by 24% of MSA-P, with an interval of 2 (1-5) years in (p=0.18); LUTS before MA was reported by 38% of MSA-C with an interval of 2 (1-3) years , and by 53% of MSA-P with an interval of 2 (1-4) years (p=0.035).

Conclusion: Prodromal symptoms of cardiovascular or urinary autonomic dysfunction occur in in ~50% of patients with MSA. Autonomic symptoms precede motor abnormalities by up to 5 years. While there was no difference in prevalence or onset of OI or pRBD between MSA-P and MSA-C, LUTS were more significantly more frequent in the prodromal stage in MSA-P.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/prodromal-non-motor-symptoms-in-multiple-system-atrophy-differences-between-cerebellar-and-parkinsonian-phenotypes/