Chronic emesis due to compression of the area postrema by the posterior inferior cerebellar artery: resolution following microvascular decompression

Abstract

<jats:p>Chronic emesis may result from a variety of causes. To the authors' knowledge, compression of the area postrema by regional vessels resulting in chronic emesis has not been reported.</jats:p> <jats:p>The authors report on a child who presented with chronic medically intractable emesis and significant weight loss requiring jejunostomy feeding. Surgical exploration of the posterior cranial fossa found unilateral compression of the area postrema by the posterior inferior cerebellar artery. Microvascular decompression resulted in postoperative and long-term resolution of the patient's emesis.</jats:p> <jats:p>Although apparently very rare, irritation of the area postrema from the posterior inferior cerebellar artery with resultant medically intractable chronic emesis may occur. Therefore, the clinician should be aware of this potential etiology when dealing with such patients.</jats:p>

Neurenteric Cyst of the Area Postrema

“…NCs typically stain positive for cytokeratin, EMA, and CEA. CA19-9 is also sometimes used; however, there is no specific or definitive NC-associated marker [ 13 , 14 ]. Baker and Bernat classified spinal cord NCs into three histological types: Type A cysts feature columnar or cuboidal epithelium with or without ciliation; Type B cysts also include mucinous or serous glands and fluid production; and Type C cysts also include ependymal or glial tissue [ 3 ].…”

“…While arachnoid cysts are often treated without surgical intervention, total surgical resection is strongly recommended for NCs. Radiologically, the presence of a nonenhancing, round lobule that is isointense or marginally hyperintense relative to CSF on T 1 -weighted MRI scans and vastly hyperintense on T 2 -weighted MRI scans suggests the presence of an NC [ 5 , 13 , 14 , 16 ]. The radiological characteristics of NCs are likely due to the high proteinaceous content of the cysts, as well as fluid mobility within the cyst [ 15 ].…”

Atlantoaxial Instability Resulting in Intractable Nausea in a Person with C5 Complete Spinal Cord Injury: A Case Report

“…Autonomic dysreflexia (AD) in complete SCI lesions higher than T6 can also present with nausea . Literature demonstrates that the area postrema that has projections to the nucleus tractus solitarus may be affected by posterior inferior cerebellar artery ischemia, potentially contributing to nausea if a patient with SCI has vascular compromise . This report demonstrates a rare case of severe, refractory nausea and resultant emesis and feeding intolerance in a young female 1 month following cervical SCI.…”

“…3 It can be activated to induce nausea and emesis by either direct or indirect noxious stimulation from the gastrointestinal (GI) tract, cerebral cortex and thalamus, vestibular region, or the chemoreceptor zone (also known as the "area postrema"). 3,6 The chemoreceptor zone lies outside the blood-brain barrier, between the fourth ventricle and medulla, and has projections to the nucleus tractus solitarus. Opioids trigger nausea and vomiting through both the chemoreceptor zone via mu and kappa pathways or via the vestibular pathway.…”

“…5 Literature demonstrates that the area postrema that has projections to the nucleus tractus solitarus may be affected by posterior inferior cerebellar artery ischemia, potentially contributing to nausea if a patient with SCI has vascular compromise. 6 This report demonstrates a rare case of severe, refractory nausea and resultant emesis and feeding intolerance in a young female 1 month following cervical SCI. It demonstrates the importance of persistent investigation of common symptoms such as nausea that may be the manifestation of a lifethreatening issue.…”