ESPE Abstracts

Background: Diabetic ketoacidosis is one of the precipitating factors that can evoke a thyroid storm. Thyroid storm may cause cerebral ischemia in moyamoya disease, which coexist in the patient with Graves’ disease.

Case presentation: A 16-year-old girl complaining of dizziness and palpitation visited emergency room, and was diagnosed with diabetic ketoacidosis (DKA) combined by hyperthyroidism. Thyroid storm occurred in 6 h after the start of DKA management. Burch and Wartofsky score was 65 points. Right hemiplegia developed during the thyroid storm and brain MR diffusion weighted images revealed multiple acute infarcts on the both hemispheres. MR angiography showed stenosis of both distal internal carotid arteries and both M1 portions of the middle cerebral arteries, consistent with moyamoya disease. After the acute management for the thyroid storm with methimazole, Lugol’s solution, and hydrocortisone, her neurologic symptoms were completely recovered in 1 month and free T₄ level was normalized in 2 months.

Conclusion: Thyroid storm may trigger cerebral ischemia in moyamoya disease and lead to rapid progression of the cerebrovascular occlusive disease. As the simultaneous occurrence of diabetic ketoacidosis, thyroid storm, and cerebrovascular accident in moyamoya disease highly elevates morbidity and mortality, prompt recognition, and management are critical to save life.