When levodopa fails to improve parkinsonism and also worsens blood pressure, reconsider the diagnosis and look for MSA on MRI, including the hot cross bun sign in the pons. In any patient with early falls, vertical gaze palsy, and severe axial rigidity, initiate the PSP workup and counsel the family that levodopa is unlikely to provide lasting benefit.

Brain MRI will typically reveal clear structural atrophy in the cerebellum, pons, and medulla, along with inferior olivary degeneration; Management often relies on practical aids like bedside urinals and condom catheters, or utilizing intermittent self-catheterization; Because these individuals have a severely impaired autonomic thermoregulatory system, heat exposure can cause them to develop dangerously high core body temperatures, or hyperthermia; Also use anticholinergic medications to control detrusor hyperreflexia, treating surgery strictly as a last resort; Unfortunately, its efficacy is quite limited, only about one-third of these individuals show any clinical response, and to make matters worse, levodopa can actually aggravate their orthostatic hypotension