Multiple system atrophy (MSA) may be difficult to distinguish clinically from other disorders, particularly in the early stages of the disease. A careful medical history and meticulous neurological examination remain the cornerstone for the accurate diagnosis of MSA. We report a case of 50 years old male patient with cerebellar ataxia, right side hemiplegia, dysphagia, aphasia, and constipation. MRI revealed atrophy with the abnormal signal intensity of pons, middle cerebellar peduncles, and olivary nucleus features indicating atrophy of the olivopontocerebellar pathway. Cruciform T2 hyperintense signal in pons extending along the middle cerebellar peduncles bilaterally giving ``hot cross bun’’ sign with T2 hyperintensities in the medulla & bilateral cerebellar hemisphere with mild cerebellar atrophy possibility of Multiple system atrophy (MSA-C type).
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