title: Significance of the hot-cross bun sign on T2*-weighted MRI for the diagnosis of multiple system atrophy.
abstract: Although the sensitive detection of putaminal iron deposition by T2*-weighted imaging (T2*-WI) is of diagnostic value for multiple system atrophy (MSA), the diagnostic significance of the pontine hot-cross bun (HCB) sign with increased ferritin-bound iron in the background remains unknown. We retrospectively evaluated the cases of 33 patients with cerebellar-form MSA (MSA-C) and 21 with MSA of the parkinsonian form (MSA-P) who underwent an MRI study with a 1.5-T system. Visualization of the HCB sign, posterior putaminal hypointensity and putaminal hyperintense rim on T2*-WI was assessed by two neurologists independently using an established visual grade, and were compared with those on T2-weighted imaging (T2-WI). The visual grade of pontine and putaminal signal changes was separately assessed for probable MSA (advanced stage) and possible MSA (early stage). T2*-WI demonstrated significantly higher grades of HCB sign than T2-WI (probable MSA-C, n = 27, p < 0.001; possible MSA-C, n = 6, p < 0.05; probable MSA-P, n = 13, p < 0.01). The visual grade of the HCB sign on T2*-WI in the possible MSA-C patients was comparable to that in the probable MSA-C patients. Although the HCB sign in MSA-P was of lower visual grade than in MSA-C even on T2*-WI, some patients showed evolution of the HCB sign preceding the appearance of the putaminal changes. These findings suggest that T2*-WI is of extreme value for detecting the HCB sign, which is often cited as a hallmark of MSA. The appearance of the HCB sign on T2*-WI might not only support but also improve the diagnosis of MSA.
authors.affiliation: Department of Gastroenterology and Neurology, Kagawa University Faculty of Medicine, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan, kdeguchi@med.kagawa-u.ac.jp.
authors.forename: Kazushi
authors.initials: K
authors.lastname: Deguchi
authors.forename: Kazuyo
authors.initials: K
authors.lastname: Ikeda
authors.forename: Kodai
authors.initials: K
authors.lastname: Kume
authors.forename: Tadayuki
authors.initials: T
authors.lastname: Takata
authors.forename: Yohei
authors.initials: Y
authors.lastname: Kokudo
authors.forename: Masaki
authors.initials: M
authors.lastname: Kamada
authors.forename: Tetsuo
authors.initials: T
authors.lastname: Touge
authors.forename: Naomi
authors.initials: N
authors.lastname: Honjo
authors.forename: Tsutomu
authors.initials: T
authors.lastname: Masaki
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000690:Amyotrophic Lateral Sclerosis / Q000175:diagnosis* / Q000503:physiopathology; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011149:Pons / Q000473:pathology*; D011699:Putamen / Q000473:pathology*; D012189:Retrospective Studies
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