Gilman et al developed criteria for multiple system atrophy (MSA) developed at a consensus conference. Participants were from multiple institutions in North America and Europe.


Clinical domains:

(1) autonomic and urinary dysfunction

(2) Parkinsonism

(3) cerebellar dysfunction

(4) corticospinal dysfunction


Autonomic or urinary dysfunction - at least one of the following:

(1) orthostatic hypotension

(1a) as feature: drop in systolic >= 20 mm Hg OR in diastolic = 10 mm Hg

(1b) as criterion: drop in systolic >= 30 mm Hg OR in diastolic = 15 mm Hg

(2) urinary incontinence (involuntary partial or complete bladder emptying and/or erectile dysfunction in male)


Parkinsonism - both of the following:

(1) bradykinesia (slowness of voluntary movement with progressive decrease in speed and amplitude during repetitive actions)

(2) one or more of the following:

(2a) rigidity

(2b) postural instability (not due to primary visual, vestibular, cerebellar or proprioceptive dysfunction)

(2c) tremor (resting and/or postural)


Cerebellar dysfunction - both of the following:

(1) gait ataxia

(2) one or more of the following:

(2a) ataxic dysarthria

(2b) limb ataxia

(2c) sustained gaze-evoked nystagmus


Corticospinal dysfunction:

(1) extensor plantar response with hyper-reflexia

Number of Clinical Domains Met

Additional Findings

Diagnostic Category


poor response to levodopa and a feature from another domain



at least 2 features from 2 other domains


autonomic failure or urinary dysfunction

poor response to levodopa


autonomic failure or urinary dysfunction

cerebellar dysfunction



pathologic features present




• Pathologic features = presence of a high density of glial cytoplasmic inclusions AND degeneration in the nigrostriatal and olivopontocerebellar pathways. If a brain exam fails to find these then I would assume the diagnosis is excluded.

• In the note to corticospinal tract dysfunction it says that it is not used in defining the diagnosis of MSA, which implies that it cannot be used as a clinical domain for the "possible" category. It might be useable as an additional feature for the "possible" category.


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