Neuropathology of multiple system atrophy: New thoughts about pathogenesis

Multiple system atrophy (MSA) is a fatal adult‐onset neurodegenerative disorder of uncertain etiology, clinically manifesting with autonomic failure associated with parkinsonism, cerebellar dysfunction, and pyramidal signs in variable combination. The pathological process affects central autonomic, striatonigral, and olivopontocerebellar systems. These show varying degrees of neurodegeneration and underlie the stratification of the heterogenous disorder into MSA‐P and MSA‐C clinical variants, which correlate to the morphologic phenotypes of striatonigral degeneration and olivopontocerebellar atrophy (MSA‐C). The lesions are not limited to these most consistently and severely affected systems but may involve many other parts of the central, peripheral, and autonomic nervous systems, underpinning the multisystem character of MSA. The histological core feature are glial cytoplasmic inclusions (GCIs, Papp‐Lantos bodies) in all types of oligodendroglia that contain aggregates of misfolded α‐Synuclein (α‐Syn). In addition to the ectopic appearance of α‐Syn in oligodendrocytes and other cells, oxidative stress, proteasomal and mitochondrial dysfunction, excitotoxiciy, neuroinflammation, metabolic changes, and energy failure are important contributors to the pathogenesis of MSA, as shown by various neurotoxic and transgenic animal models. Although the basic mechanisms of α‐Syn–triggered neurodegeneration are not completely understood, neuron‐to‐oligodendrocyte transfer of α‐Syn by prion‐like spreading, inducing oligodendroglial and myelin dysfunction associated with chronic neuroinflammation, are suggested finally to lead to a system‐specific pattern of neurodegeneration. © 2014 International Parkinson and Movement Disorder Society