title: Multiple system atrophy: prognostic indicators of survival.
abstract: Neurological and autonomic presentation in multiple system atrophy (MSA) may predict early mortality. Quantification of early autonomic failure as a mortality predictor is lacking. Early neurological and autonomic clinical features were retrospectively reviewed in 49 MSA cases (median age at onset, 56.1 years; 16 women) confirmed by autopsy at Mayo Clinic. When available, the 10-point composite autonomic severity score derived from the autonomic reflex screen provided quantification of the degree of autonomic failure and thermoregulatory sweat test quantitated body surface anhidrosis. Symptoms at onset were autonomic in 50%, parkinsonian in 30%, and cerebellar in 20% of cases. Survival (median [95% confidence interval]) was 8.6 [6.7-10.2] years. Survival was shorter in patients with early laboratory evidence of generalized (composite autonomic severity score ≥ 6) autonomic failure (7.0 [3.9-9.8] vs. 9.8 [4.6-13.8] years; P = 0.036), and early requirement of bladder catheterization (7.3 [3.1-10.2] vs. 13.7 [8.5-14.9] years; P = 0.003) compared with those without these clinical features. On Cox proportional analysis, prognostic indicators of shorter survival were older age at onset (hazard ratio [95% confidence interval], 1.04 [1.01-1.08]; P = 0.03), early requirement of bladder catheterization (7.9 [1.88-38.63]; P = 0.004), and early generalized (composite autonomic severity score ≥ 6) autonomic failure (2.8 [1.01-9.26]; P = 0.047). Gender, phenotype, and early development of gait instability, aid-requiring ambulation, orthostatic symptoms, neurogenic bladder, or significant anhidrosis (thermoregulatory sweat test ≥ 40%) were not indicators of shorter survival. Our data suggest that early development of severe generalized autonomic failure more than triples the risk of shorter survival in patients with MSA.
authors.affiliation: Department of Neurology, Medical College of Wisconsin, Milwaukee, WI.
authors.forename: Juan J
authors.initials: JJ
authors.lastname: Figueroa
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Singer
authors.forename: Ajay
authors.initials: A
authors.lastname: Parsaik
authors.forename: Eduardo E
authors.initials: EE
authors.lastname: Benarroch
authors.forename: J Eric
authors.initials: JE
authors.lastname: Ahlskog
authors.forename: Robert D
authors.initials: RD
authors.lastname: Fealey
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Parisi
authors.forename: Paola
authors.initials: P
authors.lastname: Sandroni
authors.forename: Jay
authors.initials: J
authors.lastname: Mandrekar
authors.forename: Valeria
authors.initials: V
authors.lastname: Iodice
authors.forename: Phillip A
authors.initials: PA
authors.lastname: Low
authors.forename: James H
authors.initials: JH
authors.lastname: Bower
mesh_terms: D017668:Age of Onset; D000368:Aged; D001342:Autonomic Nervous System Diseases / Q000209:etiology; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019578:Multiple System Atrophy / Q000150:complications / Q000175:diagnosis* / Q000401:mortality*; D011379:Prognosis; D016016:Proportional Hazards Models; D012307:Risk Factors
keywords: MSA; autonomic failure; mortality; survival