Brandon M. Mazal, DO
Resident Physician
SUNY Upstate Physical Medicine and Rehabilitation
Syracuse, New York, United States
.jpg "Margaret A. Turk, MD photo")
Margaret A. Turk, MD
Distinguished Service Professor
SUNY Upstate
Syracuse, New York, United States
Waleed Hamam, MD
Attending Physician
SUNY Upstate Physical Medicine and Rehabilitation
Syracuse, New York, United States
31-year-old male with no significant medical history, felt unwell for two weeks with muscle aches and tremors, before presenting to hospital via ambulance after wife found him unresponsive. CT head positive for large left MCA infarct. He was experiencing new atrial fibrillation with RVR, hyperthermia, remarkably elevated thyroid hormones/thyroid peroxidase antibody, and remarkably decreased TSH indicating thyroid storm, which was likely the precipitating cause of cardioembolic stroke.
Case Description:
Patient underwent thrombectomy, however due to cerebral edema/midline shift, he required decompressive hemicraniectomy. Deficits included complete right hemiplegia, global aphasia with mutism, dysphagia with PEG tube placement. He was admitted to acute rehabilitation; physiatrist coordinated rehabilitation needs and managed multiple medical consultants’ recommendations, resulting drug interactions, side effects. He was started on therapeutic enoxaparin, began trialing soft diet/thickened liquids, had transaminitis secondary to methimazole (thyroid hormone inhibitor), bradycardia secondary to diltiazem plus propranolol, and no significant improvement in thyroid labs. By discharge, he was cleared for regular solids/thin liquids, transitioned from enoxaparin to apixaban, switched to propylthiouracil (lowers thyroid production) with improved liver enzymes, heart rate stabilized transitioning from propranolol to metoprolol. His participation in rehabilitation increased with medical stabilization.
Discussions:
Thyroid storm is a rare condition which can lead to atrial fibrillation in minority of cases. Even when patients do develop atrial fibrillation, ischemic stroke is infrequent. The vast majority of patients who experience these complications have known history of hyperthyroidism, however stroke may be the initial p</span>resentation leading to new diagnosis of hyperthyroidism. High degree of suspicion to diagnose/treat thyroid storm to prevent complications is imperative. Endocrinologic dysfunction must be considered in patients without typical risk factors who present with stroke. Weighing patients’ clinical response to treatment against laboratory data and balancing recommendations from consulting providers while keeping resultant effects on each organ system in mind are crucial elements to care.
Conclusions:
