Wang Hong-Kai, Huang Wen-Hsuan, Chen Ko-Ting
Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou.
Department of General Surgery, Saint Paul's Hospital.
Medicine (Baltimore). 2020 Nov 13;99(46):e22664. doi: 10.1097/MD.0000000000022664.
Hyperthyroidism-related anterior circulation ischemic events have been well documented; however, posterior circulation infarction is rarely reported, not to mention with superior mesenteric artery syndrome (SMAS), which has never been reported concurrently. We describe, to the best of our knowledge, the first case of hyperthyroidism-related cerebellar infarction accompanied with SMAS.
A 22-year-old women presented with palpitation, postprandial vomiting, and acute body weight loss. Enlarged thyroid gland was discovered in physical examination and Graves disease was diagnosed by blood test; therefore, Propylthiouracil and β-blocker were prescribed. Sudden onset conscious disturbance accompanied with apnea was noted during hospitalization.
Computed tomography (CT) revealed cerebellar infarction with severe cerebellar swelling and tonsil herniation; hence, emergent suboccipital craniotomy and bilateral tonsillectomy were performed.
Nevertheless, persisted poor passage of liquid diet during nasogastric tube feeding was noted after operation. CT of abdomen showed a sharp aorta-SMA angle (15°) and a short distance between aorta and SMA (6 mm) indicating a diagnosis of SMAS.
After parental nutrition supplement and progressive rehabilitation program, she recovered to a modified Rankin Scale of 3.
Although rarely reported, hyperthyroidism-related sympathetic hyperstimulation, vasculopathy could result in potentially deadly posterior circulation infarction. Furthermore, SMAS should be considered in the cases of hyperthyroidism with prolonged gastrointestinal symptoms even after treatment and should be treated simultaneously, since SMAS exacerbates depletion of intravascular volume. Further study to clarify the relation between hyperthyroidism and posterior circulation hemodynamic status is suggested.
甲状腺功能亢进相关的前循环缺血事件已有充分记录；然而，后循环梗死很少被报道，更不用说与肠系膜上动脉综合征（SMAS）同时出现了，目前尚未有此类并发报道。据我们所知，我们描述了首例甲状腺功能亢进相关的小脑梗死伴SMAS病例。
一名22岁女性出现心悸、餐后呕吐和体重急剧下降。体格检查发现甲状腺肿大，血液检查诊断为格雷夫斯病；因此，开具了丙硫氧嘧啶和β受体阻滞剂。住院期间出现突发意识障碍并伴有呼吸暂停。
计算机断层扫描（CT）显示小脑梗死，伴有严重的小脑肿胀和扁桃体疝；因此，进行了紧急枕下开颅和双侧扁桃体切除术。
然而，术后经鼻胃管喂养时，流食通过情况持续不佳。腹部CT显示腹主动脉与肠系膜上动脉夹角尖锐（15°），腹主动脉与肠系膜上动脉之间距离短（6毫米），提示诊断为SMAS。
经过肠外营养补充和逐步康复计划，她恢复到改良Rankin量表评分为3分。
尽管报道较少，但甲状腺功能亢进相关的交感神经过度刺激、血管病变可能导致潜在致命的后循环梗死。此外，对于甲状腺功能亢进且即使经过治疗仍有长期胃肠道症状的患者，应考虑SMAS，并且应同时进行治疗，因为SMAS会加剧血管内容量的消耗。建议进一步研究以阐明甲状腺功能亢进与后循环血流动力学状态之间的关系。
