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Table 2 Red flags for MSA, reproduced with the courtesy of Wiley and Sons [85]

From: An update on the cerebellar subtype of multiple system atrophy

Red flag Definition
Early instability with recurrent falls within 3 years of disease onset
Rapid progression “wheelchair sign”: dependent < 10 years from disease onset
Orofacial dystonia based on clinical judgment
Camptocormia prolonged episodes of forward trunk flexion
Pisa syndrome prolonged episodes of lateral trunk flexion
Disproportionate antecollis severe neck flexion, minor flexion elsewhere
Contractures of hands or feet excluding Dupuytren’s or contracture due to other known cause
Jerky tremor irregular postural or action tremor of the hands and/or fingers with definite myoclonus
Diurnal inspiratory stridor based on clinical judgment
Nocturnal inspiratory stridor based on clinical judgment
Inspiratory sighs involuntary deep inspiratory sighs/gasps
Severe dysphonia based on clinical judgment
Severe dysarthria based on clinical judgment
Severe dysphagia based on clinical judgment
REM sleep behavior disorder intermittent loss of muscle atonia and appearance of elaborate motor activity (striking out with arms in sleep often with talking/shouting) associated with dream mentation
Sleep apnoea prolonged arrests of breathing
Excessive snoring increase from premorbid level, or newly arising
Cold hands/feet new development of coldness and color change – purple/blue – of extremities, with blanching on pressure and poor circulatory return
Raynaud’s phenomenon new emergence of painful “white fingers”
Emotional incontinence – crying Inappropriate crying without sadness
Emotional incontinence – laughing Inappropriate laughing without mirth
Past history of documented hypertension based on clinical judgment