What clinical features are most useful to distinguish definite multiple system atrophy from Parkinson's disease?

Objectives-Few studies have attempted to identify what premortem features b est differentiate multiple system atrophy (MSA) from Parkinson's disease (P D). These studies are limited by small sample size, clinical heterogeneity, or lack of postmortem validation. We evaluated the sensitivity and specifi city of different clinical features in distinguishing pathologically establ ished MSA from PD. Methods-One hundred consecutive cases of pathologically confirmed PD and 38 cases of pathologically confirmed MSA in one Parkinson's disease brain ban k were included. All cases had their clinical notes reviewed by one observe r (AH). Clinical features were divided into two groups: those occurring up to 5 years after onset of disease and those occurring up to death. Statisti cal analysis comprised multivariate logistic regression analysis to choose and weight key variables for the optimum predictive model. Results-The selected early features and their weightings were: autonomic fe atures (2), poor initial levodopa response (2), early motor fluctuations (2 ), and initial rigidity (2). A cut off of 4 or more on the ROC curve result ed in a sensitivity of 87.1% and specificity of 70.5%. A better predictive model occurred if the following features up to death were included: poor re sponse to levodopa (2), autonomic features (2), speech or bulbar dysfunctio n (3), absence of dementia (2), absence of levodopa induced confusion (4), and falls (4). The resulting ROC curve based on individual scores showed a best cut off score of at least 11 of 17 (sensitivity 90.3%, specificity 92. 6%). Conclusions-Predictive models may help differentiate MSA and PD premortem. Hitherto poorly recognised features, suggestive of MSA, included preserved cognitive function and absence of psychiatric effects from antiparkinsonian medication. Diagnostic accuracy was higher in those models taking into acc ount all clinical features occurring up to death. Further studies need to b e based on new incident cohorts of parkinsonian patients with subsequent ne uropathological evaluation.