Isolated Area Postrema Syndrome Preceding the Diagnosis of Giant Cell Arteritis

Abstract

ObjectiveWe report a case of biopsy-proven giant cell arteritis after an initial presentation of area postrema syndrome.MethodsA 65-year-old man was evaluated using MRI, temporal artery biopsy, and ultrasound.ResultsThe patient presented with refractory nausea, vomiting, and hiccups that caused weight loss without any other neurologic or clinical symptoms. His MRI scan 15 days later revealed a hyperintense sign on the area postrema with no abnormal diffusion or contrast enhancement, compatible with isolated area postrema syndrome. An extensive workup for inflammation and other etiologies including neuromyelitis optica spectrum disorder (NMOSD), myelin oligodendrocyte glycoprotein antibody disorder, and multiple sclerosis (MS) showed negative results. The patient responded to treatment with methylprednisolone. Two months after the initial clinical manifestation, the patient developed fatigue, headache, and scalp tenderness. He was diagnosed with giant cell arteritis after ultrasonography and biopsy were performed. He responded well to oral glucocorticoids and had only 1 relapse during tapering. He has not had arteritic ischemic optic neuropathy or any new episodes of area postrema syndrome.DiscussionThis case demonstrates the importance of expanding the differential diagnosis in patients with area postrema syndrome and no other signs of NMOSD.

Giant-cell arteritis related strokes: scoping review of mechanisms and rethinking treatment strategy?

“…Nevertheless, cases of strokes with parietal inflammation but no apparent stenosis of the vertebral arteries have been reported. For example, a case of minute stroke in the area postrema was associated only with a vertebral halo sign but no stenosis ( 192 ). Other reports describe cases of transient vertebrobasilar attacks or Wallenberg syndrome with vertebral artery inflammation and no stenosis (79, 131#3, 178).…”