Isolated Area Postrema Syndrome (APS) presenting as intractable nausea and vomiting (NMOSD)

 Area Postrema (AP) is an emetic reflex center, one of the circum-ventricular organs that is outside the blood-brain barrier(BBB). It is located in the dorsal aspect of the medulla, at the caudal end of the fourth ventricle. AP along with Nucleus Tractus Solitarius (NTS) and dorsal motor nucleus of Vagus forms the dorsal vagal complex, where most of the vagal afferents terminate. AP by its location outside the BBB is exposed to the toxins in the blood. Activation of the AP brings nausea and vomiting, due to its projections into the NTS. 

AP through its hypothalamic,brainstem connections also regulate fluid balance, immunomodulation etc. It also chemo-sensitive neurons regulating hiccups. 

Neuro Myelitis Optic Spectrum of Disorders (NMOSD) are a group of autoimmune inflammatory demyelinating diseases of the CNS. Most of these show characteristic antibody to aquaporin-4 (AQP-4) water channel. 

 Attacks of intractable nausea, vomiting or hiccups (INVH) in the presence of a dorsal medullary lesion is called as the Area Postrema Syndrome (APS) and upto 30% of NMOSD patients will have APS during their disease course. 

NMOSD lesions in the Area Postrema shows loss of AQP-4 immunoreactivity and inflammation and characteristically lacks necrosis and demyelination which is seen in spinal cord and optic lesions, explaining reversibility of the symptoms. Patients have to tested for Serum and CSF AQP4-IgG antibodies. 

Isolated APS is easily mistaken clinically and is often attributed initially to other causes like gastritis including H.Pylori, GERD, Cholecystitis, Pancreatitis, food poisoning, gastroparesis etc. 

Immunotherapy usually results in rapid relief of symptoms usually within 2-3 days, responding to Methyl Prednisolone or Immunotherapy in most cases. Refractory cases may need drugs like Azathioprine, MMF, Rituximab.   

Below are the MRI images of a young female with intractable nausea and vomiting. 

T2 and T2 FLAIR hyperintensity noted in the region of the Area Postrema, called the Inverted-V sign.

Bilateral symmetrical normal optic nerves.

No restricted diffusion seen in the abnormal signal areas of Area Postrema.

Corresponding sagittal T2 FLAIR image showing the level of Area Postrema.
Abnormal signal intensity is also seen in the inferior colliculi of midbrain in the sagittal image. 

Diagram showing the location of AP, NTS in the dorsal medulla.