title: Markedly asymmetric presentation in multiple system atrophy.
abstract: BACKGROUND
  Multiple system atrophy (MSA) presents with fairly symmetrical, levodopa unresponsive parkinsonism and additional features like autonomic dysfunction, cerebellar and corticospinal tract involvement. Marked asymmetry in atypical parkinsonism suggests alternative diagnosis like Corticobasal syndrome (CBS).
  
  
  METHODS
  We describe five unusual cases, who presented initially with markedly asymmetric parkinsonism, rigid dystonic abnormal limb posturing and subsequently developed clinical and/or radiological features consistent with probable MSA-P.
  
  
  RESULTS
  Using the internationally accepted diagnostic criteria, the patients fulfilled the diagnostic criteria for probable MSA-P after 5 years from disease onset. Case 4 and 5 had characteristic MRI features and Case 2 was pathologically confirmed.
  
  
  CONCLUSIONS
  We use these cases to highlight that MSA-P MSA-P can present rarely with very marked asymmetry, dystonic limb and myoclonic jerks leading to a diagnosis of CBS at onset.
authors.affiliation: Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom.
authors.forename: Amit
authors.initials: A
authors.lastname: Batla
authors.forename: Maria
authors.initials: M
authors.lastname: Stamelou
authors.forename: Katerina
authors.initials: K
authors.lastname: Mensikova
authors.forename: Michaela
authors.initials: M
authors.lastname: Kaiserova
authors.forename: Lucie
authors.initials: L
authors.lastname: Tuckova
authors.forename: Petr
authors.initials: P
authors.lastname: Kanovsky
authors.forename: Niall
authors.initials: N
authors.lastname: Quinn
authors.forename: Kailash P
authors.initials: KP
authors.lastname: Bhatia
mesh_terms: D017668:Age of Onset; D000368:Aged; D000381:Agraphia / Q000209:etiology; D001284:Atrophy; D001342:Autonomic Nervous System Diseases / Q000209:etiology; D001921:Brain / Q000473:pathology; D001933:Brain Stem / Q000473:pathology; D002531:Cerebellum / Q000473:pathology; D005260:Female; D007839:Functional Laterality / Q000502:physiology*; D006801:Humans; D007024:Hypotension, Orthostatic / Q000209:etiology / Q000503:physiopathology; D007593:Joint Instability / Q000209:etiology / Q000503:physiopathology; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D019578:Multiple System Atrophy / Q000473:pathology / Q000503:physiopathology*; D009207:Myoclonus / Q000209:etiology; D011699:Putamen / Q000473:pathology; D012893:Sleep Wake Disorders / Q000209:etiology
keywords: Asymmetry; Atypical parkinsonism; Corticobasal degeneration; Corticobasal syndrome; Multiple system atrophy; Parkinsonism