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NEUROIMAGE
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1485-1486

Brain MRI in a Case of Recurrent Unexplained Vomiting and Bulbar Palsy: “Area Postrema Syndrome”


Department of Neurology, Kalinga Institute of Medical Sciences (KIMS), Bhubaneswar, Odisha, India

Date of Submission12-Oct-2018
Date of Decision22-Jul-2019
Date of Acceptance12-Nov-2019
Date of Web Publication30-Oct-2021

Correspondence Address:
Santosh K Dash
Department of Neurology, Kalinga Institute of Medical Sciences (KIMS), Bhubaneswar - 751 024, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329616

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How to cite this article:
Dash SK. Brain MRI in a Case of Recurrent Unexplained Vomiting and Bulbar Palsy: “Area Postrema Syndrome”. Neurol India 2021;69:1485-6

How to cite this URL:
Dash SK. Brain MRI in a Case of Recurrent Unexplained Vomiting and Bulbar Palsy: “Area Postrema Syndrome”. Neurol India [serial online] 2021 [cited 2021 Dec 2];69:1485-6. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1485/329616




A 32-year-old lady presented with complaints of recurrent vomiting for the last ten days and swallowing difficulty for three days. Symptoms started with severe nausea followed by recurrent vomiting which did not scale down with antiemetic drugs. The next day she developed hoarseness of voice, difficulty in swallowing, and gait ataxia. On examination, her vision and fundus were normal. Complete paralysis of 9th and 10th cranial nerves on the left side with brisk deep tendon reflexes were present. Severe ataxia was present. A provisional diagnosis of acute brain stem syndrome was made. Contrast brain MRI including spinal cord imaging was done. It showed signal changes in dorsal medulla with normal optic nerves and spinal cord [Figure 1],[Figure 2],[Figure 3]. Her CSF showed protein of 55 mg/dL and 22 cells with predominant lymphocytes. Her serum was positive for aqaporin-4 antibody (AQP-4). A final diagnosis of NMO spectrum disorder with area postrema syndrome was made. She was treated with intravenous methylprednisolone 1 gm daily for five days with partial recovery and was discharged with oral steroid and azathioprine. The area postrema is a medullary structure that controls vomiting and any pathological involvement of this region presented as intractable nausea, hiccups, and vomiting.[1] NMO spectrum disorder presenting as isolated area postrema syndrome is very rare.[2],[3] There are few cases reports in literature about the isolated brain stem involvement sparing the optic nerves and spinal cord. Our case, presented with a very common symptom of vomiting, turned out to be a rare manifestation of NMO spectrum disorder.
Figure 1: MRI Brain FLAIR sagittal sequence showing hyperintense signal changes in the dorsal medulla

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Figure 2: Axial FLAIR MRI image showing hyperintense signal changes in the dorsal medulla

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Figure 3: Axial T1 contrast MRI Brain image showing enhancing dorsal medullary lesion

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  References Top

1.
Miller AD, Leslie RA. The area postrema and vomiting. Frontiers in Neuroendocrinology 1994;15:30120.  Back to cited text no. 1
    
2.
Popescu BFG, Lennon VA, Parisi JE, Howe CL, Weigand SD, Cabrera-Gomez JA, et al. Neuromyelitis optica unique area postrema lesions: Nausea, vomiting, and pathogenic implications. Neurology 2011;76:1229-37.  Back to cited text no. 2
    
3.
Wang L, Su H, Qi J, Zhao K. Intractable nausea and vomiting as an uncommon presentation in an anti-aquaporin 4-positive patient. J Int Med Res 2018;46:3411-6.  Back to cited text no. 3
    


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