Middle age male patient admitted for evaluation of syncope. He has a history of coronary artery disease, severe pulmonary HTN, COPD, anemia of chronic disease, Osteoarthritis, left vocal cord paralysis, orthostatic hypotension, unsteady gaits and previous syncopal episode. CT head imaging remarkable for cerebellar atrophy. MRI done showed moderate cerebellar atrophy, midbrain atrophy with hummingbird sign and hot cross bun sign in the pons representing neurodegenerative disease multisystem atrophy and progressive supranuclear palsy. The above constellation of symptoms and image findings are consistent with Multiple System Atrophy C-subtype. Multiple system atrophy (MSA) is a sporadic [although mutations in the…