Multiple system atrophy - the cerebellar type with "hot cross bun sign" on MRI

Multiple system atrophy (MSA) is an adult onset, progressive, idiopathic neurodegenerative disease that clinically manifest as MSA-C with cerebellar signs predominant, MSA-P with Parkinsonian features predominant and MSA-A with autonomic signs and symptoms. MRI has an important role in its diagnosis with a characteristic finding described as "hot cross bun" sign seen in MSA of cerebellar type (MSA-C). We have seen two cases of MSA-C referred to Radiology Department, Civil Hospital Karachi in February 2017 and March 2017 who presented with difficulty in walking and speech and foecal and urinary incontinence. The MRI showed atrophy of pons, cerebellum and middle cerebellar peduncles with cruciform hyperintense signals in pons (hot cross bun sign). Multiple system atrophy has no specific treatment so the patients were on supportive therapy. We are reporting these interesting cases along with the clinical and radiological findings as well as literature review.