Treating Intractable Nausea and Vomiting in Cerebellar and Medullary Stroke

Purpose

Cerebellar and medullary strokes are relatively rare, comprising only 1-4% of all cerebral infarctions [1–3]. Common symptoms include dizziness or vertigo, nausea, vomiting, and gait disturbance, with nausea and vomiting occurring > 50% of the time [4]. Despite the frequency of these symptoms, there is scarce literature on successful treatment regimens.

Methods

We report the case of a 48 year old male with history of diabetes mellitus II who presented with 10-days of nausea, vomiting, and rightsided weakness / paresthesias. MRI brain revealed infarcts in the inferomedial right cerebellum and posterior right medulla brainstem. Initial management of nausea and vomiting with ondansetron 4mg q6h and metoclopramide 10mg q8h proved ineffective.

Metoclopramide was discontinued and ondansetron increased to 8mg q8h. However, symptoms persisted followed by the development of hiccups. A more aggressive treatment plan was opted for, including chlorpromazine 25mg q4h for hiccups and prochlorperazine 10mg q6h for nausea. The patient saw marked improvement and was discharged on ondansetron 8mg q8h, prochlorperazine 10mg q6h, amitriptyline 25mg nightly, and a scopolamine patch every 3 days.

Results

On the patient's one week follow up in the resident clinic, the patient reported almost full resolution of nausea and vomiting.

Conclusion

Cerebellar and medullary infarcts may frequently present with nonspecific symptoms including intractable nausea and vomiting. Management is complex and may be confounded by underlying conditions with similar presentations. Implementation of successful treatment regimens may greatly expedite recovery and mitigate extraneous workup and expenses. This report details a successful option for treatment.