Motor Cortical Stimulation for Parkinsonism in Multiple System Atrophy

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Abstract
MULTIPLE SYSTEM atrophy (MSA) is a progressive neurodegenerative illness that consists of autonomic and pyramidal dysfunction, with either a predominance of parkinsonism or cerebellar symptoms1,2 or a variable combination of these. The clinical phenotype depends on the distribution of neuronal loss, gliosis, and glial cytoplasmic inclusions (GCIs), the hallmark pathologic feature of the condition.3,4 Parkinsonian features in MSA include tremor (more often postural and action tremor than typical rest tremor), rigidity, bradykinesia, and postural instability, all of which are usually poorly or only transiently responsive to levodopa. The natural history of this condition is one of rapidly progressive disability over a few years, typically with loss of the ability to ambulate, complete dependence, and eventual death from the complications of an immobile bed-bound state. The median survival from diagnosis is estimated to be between 5 to 6 years, with early and more prominent autonomic symptoms thought to shorten survival.5 Basal ganglia surgery, including pallidotomy6,7 and striatal fetal dopaminergic cell transplantation,8,9 have been ineffective in improving the symptoms or altering the natural history of the disease.