Annals of Indian Academy of Neurology
: 2021  |  Volume : 24  |  Issue : 4  |  Page : 468-

Evaluation of multiple system atrophy subtypes with FDG-PET

Kurt Jellinger 
 Institute of Clinical Neurobiology, Vienna, Austria

Correspondence Address:
Dr. Kurt Jellinger
Institute of Clinical Neurobiology Alberichgasse 5/13, A-1150 Vienna

How to cite this article:
Jellinger K. Evaluation of multiple system atrophy subtypes with FDG-PET.Ann Indian Acad Neurol 2021;24:468-468

How to cite this URL:
Jellinger K. Evaluation of multiple system atrophy subtypes with FDG-PET. Ann Indian Acad Neurol [serial online] 2021 [cited 2023 Feb 8 ];24:468-468
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Seniaray N, et al. Recently analysed the functional spectrum of multiple system atrophy (MSA) using 18F-FDG PET/CT and 99mTc TRODAT-1 SPECT in 67 patients with clinically diagnosed MSA (29 MSA-P, 25 MSA-C and 13 mixed subtypes).[1] While dopamine transporter (DAT) imaging with TRODAT-1 SPECT cannot distinguish between MSA, PD, DLB and PSP and cannot differentiate MSA-P from PD and MSA-C, subtypes show characteristic patterns of FDG uptake on PET scan: MSA-P subjects showed diffuse hypometabolism in putamen-pallidum with relative sparing of the caudate nuclei, while in MSA-C patients hypometabolism was seen in cerebellum and brainstem. In mixed subtypes, variable hypometabolism in basal ganglia, cerebellum and brainstem was associated with that in fronto-parietal regions. Thus, FDG-PET may help in differentiating the subtypes of MSA in the presence of overlapping syndromes.

Targeting postsynaptic dopaminergic function using [123I] FP-CIT SPECT does not differentiate PD from MSA (both showing normal or increased signal),[2] DAT imaging showed more prominent and earlier DAT loss in anterior caudate and ventral putamen in MSA,[3] although normal DAT imaging does not exclude MSA.[4] In autopsy-confirmed cases, a greater asymmetry of striatal binding was seen in MSA than in PD,[5] but it is highly correlated with substantia nigra cell loss.[6] 18F-DOPA-PET showed more widespread basal ganglia dysfunction in MSA than in PD without evidence of early compensatory increase in DOPA uptake.[7] The above FDG-PET data confirm previous studies showing different patterns of decreased glucose metabolism between MSA-P and PD with a positive predictive value of 95%,[8],[9] while MSA-related patterns of metabolic topographies discriminated between normal, MSA, PSP and PD, and correlate with standard ratings of clinical stages and motor symptoms in MSA.[10] Moreover, they show further possibilities in differentiating the various subtypes of MSA. In conclusion, 18F-FDG PET provides a new basis for the differentiation of MSA-P and MSA-C,[11] reflecting distinct clinical features of MSA.[12] Future neuroimaging studies, such as Tau-PET will enlarge the diagnostic spectrum of MSA, its functional subtypes and its differentiation from other parkinsonian syndromes.


The author thanks Erich Mitter-Ferstl, PhD, for secretarial work.


1Seniaray N, Verma R, Ranjan R, Belho E, Mahajan H. Comprehensive Functional Evaluation of the Spectrum of Multi-System Atrophy with 18F-FDG PET/CT and 99mTc TRODAT-1 SPECT: 5 Year’s Experience from a Tertiary Care Center. Ann Indian Acad Neurol 2021;24:490-4.
2Brooks DJ, Seppi K. Proposed neuroimaging criteria for the diagnosis of multiple system atrophy. Mov Disord 2009;24:949-64.
3Nocker M, Seppi K, Donnemiller E, Virgolini I, Wenning GK, Poewe W, et al. Progression of dopamine transporter decline in patients with the Parkinson variant of multiple system atrophy: A voxel-based analysis of [123I] beta-CIT SPECT. Eur J Nucl Med Mol Imaging 2012;39:1012-20.
4McKinley J, O'Connell M, Farrell M, Lynch T. Normal dopamine transporter imaging does not exclude multiple system atrophy. Parkinsonism Relat Disord 2014;20:933-4.
5Perju-Dumbrava LD, Kovacs GG, Pirker S, Jellinger K, Hoffmann M, Asenbaum S, et al. Dopamine transporter imaging in autopsy-confirmed Parkinson's disease and multiple system atrophy. Mov Disord 2012;27:65-71.
6Kraemmer J, Kovacs GG, Perju-Dumbrava L, Pirker S, Traub-Weidinger T, Pirker W. Correlation of striatal dopamine transporter imaging with post mortem substantia nigra cell counts. Mov Disord 2014;29:1767-73.
7Levin J, Maass S, Schuberth M, Höglinger G. Multiple system atrophy. In: Falup-Pecurariu C, Ferreira J, Martinez-Martin P, Chaudhuri KR, editors. Movement Disorders Curricula. Wien: Springer; 2017. 183-92.
8Tang CC, Eidelberg D. Abnormal metabolic brain networks in Parkinson's disease from blackboard to bedside. Prog Brain Res 2010;184:161-76.
9Grimaldi S, Boucekine M, Witjas T, Fluchere F, Renaud M, Azulay JP, et al. Multiple system atrophy: Phenotypic spectrum approach coupled with brain 18-FDG PET. Parkinsonism Relat Disord 2019;67:3-9.
10Shen B, Wei S, Ge J, Peng S, Liu F, Li L, et al. Reproducible metabolic topographies associated with multiple system atrophy: Network and regional analyses in Chinese and American patient cohorts. Neuroimage Clin 2020;28:102416.
11Zhao P, Zhang B, Gao S, Li X. Clinical features, MRI, and 18F-FDG-PET in differential diagnosis of Parkinson disease from multiple system atrophy. Brain Behav 2020;10:e01827.
12Lee R, Shin JH, Choi H, Kim HJ, Cheon GJ, Jeon B. Variability of FP-CIT PET patterns associated with clinical features of multiple system atrophy. Neurology 2021;online Feb 3: doi 10.1212/WNL.0000000000011634.