Acute Thyrotoxicosis of Graves Disease Associated with Moyamoya Vasculopathy and Stroke in Latin American Women: A Case Series and Review of the Literature

Shah, Nirav; Khandelwal, Priyank; Perue, Gillian Gordon; Shah, Ashish H.; Barbarite, Eric; Ortiz, Gustavo; Forteza, Alejandro M.

doi:10.1016/j.wneu.2016.04.122

Cited by 12 publications

(26 citation statements)

References 43 publications

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“…It is rare for a patient to have MMS and GD and as of July 2016, to the best of our knowledge, there are about 87 cases in literature (1, 2). There was controversy if MMS and GD occurred by coincidence but recent evidence suggests otherwise.…”

Section: Discussionmentioning

confidence: 95%

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Fatal outcome in a Hispanic woman with moyamoya syndrome and Graves’ disease

Choi¹,

Suthakar

Farmand³

2016

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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SummaryWe describe the case of a young Hispanic female who presented with thyrotoxicosis with seizures and ischemic stroke. She was diagnosed with a rare vasculopathy – moyamoya syndrome. After starting antithyroid therapy, her neurologic symptoms did not improve. Acute neurosurgical intervention had relieved her symptoms in the immediate post-operative period after re-anastomosis surgery. However, 2 post-operative days later, she was found to be in status epilepticus and in hyperthyroid state. She quickly deteriorated clinically and had expired a few days afterward. This is the second case in literature of a fatality in a patient with moyamoya syndrome and Graves’ disease. However, unlike the other case report, our patient had undergone successful revascularization surgery. We believe her underlying non-euthyroid state had potentiated her clinical deterioration. Case studies have shown positive correlation between uncontrolled hyperthyroidism and stroke-like symptoms in moyamoya syndrome. Mostly all patients with these two disease processes become symptomatic in marked hyperthyroid states. Thus, it may be either fluctuations in baseline thyroid function or thyrotoxicosis that potentiate otherwise asymptomatic moyamoya vasculopathy.Learning points:Awareness of the association between Graves’ disease and moyamoya syndrome in younger patients presenting with stroke-like symptoms.Obtaining euthyroid states before undergoing revascularization surgery may protect the patient from perioperative mortality and morbidity.Although moyamoya disease is usually thought to be genetically associated, there are reports that thyroid antibodies may play a role in its pathogenesis and have an autoimmune link.Fluctuations in baseline thyroid function for patients with known Graves’ disease may be a potentiating factor in exacerbating moyamoya vasculopathy.

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Section: Discussionmentioning

confidence: 95%

“…(2) describes 8 patients with GD and MMS (7/8 being Latin American). All of their patients presented with ischemic strokes similar to our patient.…”

Section: Discussionmentioning

confidence: 99%

Fatal outcome in a Hispanic woman with moyamoya syndrome and Graves’ disease

Choi¹,

Suthakar

Farmand³

2016

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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“…These include Graves’ disease, systematic lupus erythematosus, and Sjögren syndrome [ 8 , 14 – 17 ]. In Graves’ disease, which results in hyperthyroidism, recent reports have highlighted the angiographic features of IAS, demonstrating that the involvement of the IC bifurcation and moyamoya vessels can be confirmed in 79.7 and 75.9% of the cases, respectively [ 8 ]. However, in other autoimmune diseases, including Hashimoto’s disease, detailed cerebral angiographic features have not been described in the literature to date.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, a recent study reported that the prevalence of anti-thyroid antibodies is higher in moyamoya disease, which is characterized by bilateral intracranial arterial stenosis (IAS), than in non-moyamoya stroke [7]. Intracranial angiographic examinations have widely been performed for Graves' disease, another autoimmune thyroid disease that can also induce ischemic stroke [8]. However, the intracranial vascular morphology and clinical course of Hashimoto's disease have poorly been documented.…”

Section: Introductionmentioning

confidence: 99%

Intracranial arterial stenosis associated with Hashimoto’s disease: angiographic features and clinical outcomes

et al. 2020

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Background Hashimoto’s disease has reportedly been associated with stroke; however, cerebrovascular morphology and clinical course remain poorly documented. The present study aimed to determine the angiographic features and clinical outcomes of intracranial arterial stenosis (IAS) associated with Hashimoto’s disease in a retrospective cohort. Methods Overall, 107 adult patients with IAS were screened for anti-thyroid antibodies; of these, 26 patients tested positive. The 42 affected hemispheres were classified into subgroups according to the steno-occlusion site and the development of abnormal collateral (moyamoya) vessels. These subgroups were dichotomized into moyamoya vessels positive (MM type) and negative (non-MM type). The initial presentation, IAS progression, and vascular events during the follow-up period were compared. Results The following sites of stenosis were identified: the bifurcation of the internal carotid artery in 11 (26.2%), M1 or A1 in 29 (69.0%), and more distal (M2-M4/A2-A4) in 2 (4.8%) hemispheres. Further, 17 hemispheres were categorized into the MM type and 25 were classified into the non-MM type. During the follow-up period (mean 2.5 years), IAS progression was identified in 8 (32%) hemispheres of the non-MM type and 0 (0%) hemispheres of the MM type (p = 0.041). Ischemic attacks occurred in 5 (20.0%) hemispheres of the non-MM type (4.6%/year) and 0 hemispheres of the MM type (p = 0.08). Further, 4 (23.5%) hemispheres of the MM type experienced intracerebral hemorrhage, whereas none of the non-MM type hemorrhaged (p = 0.012). Conclusions Hashimoto’s disease-associated IAS exhibits various angiographic morphologies, resulting in different clinical presentations. Screening for anti-thyroid antibodies and careful management based on vascular morphology appears important in adults with IAS.

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“…Graves’ disease (GD) is rarely complicated by moyamoya vasculopathy (MMV), resulting in ischemic stroke during thyrotoxicity [1, 2]. Management of GD is considered important to prevent recurrence [3], but MMV may progress despite the control of GD [4]. A case was recently reported in which the wall of the distal ICA was enhanced on contrast-enhanced (CE) T1-weighted imaging (T1WI), suggesting vasculitis [5].…”

Section: Introductionmentioning

confidence: 99%

Progressive stenosis and radiological findings of vasculitis over the entire internal carotid artery in moyamoya vasculopathy associated with graves’ disease: a case report and review of the literature

et al. 2019

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Background Moyamoya vasculopathy (MMV) associated with Graves’ disease (GD) is a rare condition resulting in ischemic stroke accompanied by thyrotoxicity. Radiological findings of vasculitis have been reported in the walls of distal internal carotid arteries (ICAs) in these patients; however, no reports have described in detail the processes of progression of the lesions in the proximal ICA. Moreover, treatments to prevent recurrence of ischemic stroke and progression of MMV have not yet been sufficiently elucidated. Case presentation We report a progressive case of MMV associated with GD and review the literature to clarify relationships among recurrence, progression, thyrotoxicity and treatment. Our patient developed cerebral infarction during thyrotoxicity with no obvious stenosis of ICAs. Five months later, transient ischemic attacks recurred with thyrotoxicity. Antiplatelet therapy and intravenous methylprednisolone stopped the attacks. Stenosis of the left ICA from the proximal to distal portion and champagne bottle neck sign (CBN) were found. She declined any surgery. Afterward, gradual progression with mild thyrotoxicity was observed. Eventually, we found smooth, circumferential, concentric wall thickening with diffuse gadolinium enhancement of the left ICA from the proximal to the distal portion on T1-weighted imaging, suggesting vasculitis radiologically. The clinical and radiological similarities to Takayasu arteritis encouraged us to provide treatment as for vasculitis of medium-to-large vessels. In a euthyroid state and after administration of prednisolone and methotrexate, improved flow in the cerebrovascular arteries on magnetic resonance angiography was observed. Based on our review of the literature, all cases with recurrence or progression were treated with anti-thyroid medication (ATM) alone and accompanied by thyrotoxicity. CBN was observed in all previous cases for which images of the proximal ICA were available. Conclusions We report the details of progressive stenosis from a very early stage and radiological findings of vasculitis over the entire ICA in MMV associated with GD. Cerebral infarction can occur with no obvious stenosis of the ICA. We treated the patient as per vasculitis of a medium-to-large vessel. Management of GD by ATM alone seems risky in terms of recurrence. Adequate management of GD and possible vasculitis may be important for preventing recurrence and progression. Electronic supplementary material The online version of this article (10.1186/s12883-019-1262-1) contains supplementary material, which is available to authorized users.

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Acute Thyrotoxicosis of Graves Disease Associated with Moyamoya Vasculopathy and Stroke in Latin American Women: A Case Series and Review of the Literature

Cited by 12 publications

References 43 publications

Fatal outcome in a Hispanic woman with moyamoya syndrome and Graves’ disease

Fatal outcome in a Hispanic woman with moyamoya syndrome and Graves’ disease

Intracranial arterial stenosis associated with Hashimoto’s disease: angiographic features and clinical outcomes

Progressive stenosis and radiological findings of vasculitis over the entire internal carotid artery in moyamoya vasculopathy associated with graves’ disease: a case report and review of the literature

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