Morphological differences between the two major subtypes of multiple system atrophy with cognitive impairment

Objective: To compare the neuropathology between two types of multiple system atrophy - parkinsonismpredominant (MSA-P) and cerebellar ataxia-predominant (MSA-C) with cognitive impairment. Material & methods: 35 cases of MSA-P (mean age at death 60.5 +/- 7.8 years) and 15 cases of MSA-C (mean age at death 61.3 +/- 6.8 years), 35.% of which associated with mild to moderate cognitive impairment and one with severe dementia, were examined neuropathologically with semiquantitative evaluation of both alpha-synuclein and Alzheimer pathologies, including cerebral amyloid angiopathy (CAA) and other co-pathologies.Results: While the mean age at death of both MSA subgroups was similar, the age at onset and duration of disease were slightly higher in the MSA-C group. In line with the classification, the alpha Syn pathology glial and neuronal inclusions in both the cortex and brainstem were significantly higher in the MSA-P group. With regard to the Alzheimer disease pathology, tau load in cases with mild to moderate cognitive impairment was slightly but not significantly higher in the MSA-P group, one with severe dementia showing fully developed Alzheimer copathology, while the amyloid-8 (A8) load including the CAA was higher in the MSA-C group. The presence of Lewy co-pathology in this series (20%), being similar to that of other MSA cohorts, was more frequent in MSA cases with mild to severe cognitive impairment, but did not differ between the two subgroups and seems not essentially important for MCI in MSA.Conclusions: In agreement with previous clinical studies that reported more severe cognitive dysfunction in patients with MSA-P, the present neuropathological study showed increased tau pathology in MSA-P and one with severe Alzheimer co-pathology, but only slightly increased amyloid pathology in the MSA-C group. Lewy copathology was more frequent in MSA-P cases with cognitive decline. In view of the limited data about the pathobiological basis of cognitive impairment in MSA, further studies to elucidate the differences between the two phenotypes are urgently needed.