Hot Cross Bun Sign In Multiple System Atrophy

A 48-year old woman presented with progressive imbalance and postural dizziness for one year. She had worsening urinary incontinence for the previous four years. Her examination revealed a cerebellar ataxia with superimposed parkinsonism. She had Babinski signs and her extremities were cold and mottled. She was diagnosed with multiple system atrophy (MSA). MRI brain demonstrated a hot cross bun sign.