The aim of this study is to evaluate the frequency of red flags and other associated symptoms in patients with multiple system atophy (MSA) and to determine whether the frequency of these symptoms was different between parkinsonian (MSA-P) and cerebellar (MSA-C) subtype and between early and advanced MSA.

MSA patients present a variety of symptoms or signs. Some of these symptoms are included in the additional features of the current diagnostic criteria for possible MSA or provided as supporting features which are not essential elements of the current diagnostic criteria but helpful to increase the clinical suspicion of MSA.

104 patients with probable or possible MSA were included. Patients with MSA were classified by predominant motor presentation into MSA-P, MSA-C and MSA-PC subtype at first clinic visit. We performed additional analysis by dividing the patients by disease duration of less than four years (Early MSA) and of four years or more (Advanced MSA).  The frequency of 17 features including red flags and other associated symptoms which commonly occur in MSA was assessed.

Dysarthria was the most prevalent feature(97.1%) followed by sexual(96.2%) and urinary(95.2%) dysfunction  in overall MSA. Orthostatic symptoms(64.4%) were detected lower than urinary dysfunction. Probable RBD showed 89.4% frequency. The frequency of constipation(84.6%) and dysphagia(74.0%) were also high. Snoring was detected 72.1%, but sleep apnea was detected relatively low(32.7%). Stridor showed 44.2% frequency. In advanced MSA, the frequency of most variables increased compared to early MSA and the increase is more pronounced in MSA-C than MSA-P.

Increasing awareness of red flags and other associated symptoms may assist clinicians to make an early, accurate diagnosis as well as to improve management in patients with MSA. The diagnostic accuracy can be improved if these features are appropriately reflected in the new diagnostic criteria for MSA.