Differential diagnosis of hot cross bun sign

Multiple system atrophy (MSA) is a term that represents a group of neurodegenerative diseases characterized by different levels of autonomic, cerebellar, parkinsonism, and pyramidal features. Hereinafter, we report a case of an elderly male who presented to our hospital with progressive gait instability and slurred speech. On examination, an orthostatic decrease of blood pressure of standing was observed. The neurological examination showed cerebellar signs and symptoms. A brain magnetic resonance imaging showed radiologic findings of MSA. The diagnosis of probable MSA with predominant cerebellar ataxia was made.