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Thyrotoxicosis and cerebral venous sinus thrombosis, causality or chance alone?
Tirotoxicosis y trombosis de senos venosos cerebrales, ¿causalidad o azar?
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "462" "paginaFinal" => "463" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "María Merino, María Guadalupe Guijarro, Paloma Iglesias, Yolanda Aladro, Paloma Montero" "autores" => array:5 [ 0 => array:4 [ "nombre" => "María" "apellidos" => "Merino" "email" => array:1 [ 0 => "marietta84@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María Guadalupe" "apellidos" => "Guijarro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Paloma" "apellidos" => "Iglesias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Yolanda" "apellidos" => "Aladro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Paloma" "apellidos" => "Montero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario de Getafe, Getafe, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neurología, Hospital Universitario de Getafe, Getafe, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tirotoxicosis y trombosis de senos venosos cerebrales, ¿causalidad o azar?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 950 "Ancho" => 951 "Tamanyo" => 93004 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">MRI of the brain showing signal hyperintensity of the superior longitudinal sinus, the straight sinus, and the proximal portion of the transverse sinuses.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cerebral sinus venous thrombosis is an uncommon cause of stroke. Three factors usually predispose to venous thrombosis: hypercoagulability states, venous stasis, and blood vessel wall changes.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In patients with thyrotoxicosis, the increased activity of factor VIII,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> amongst others, results in a hypercoagulability state and has been reported as being a factor which predisposes to cerebral sinus venous thrombosis. Cases reported in the literature suggest that the causative relationship between both is significantly higher than would be expected by chance alone.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> A case illustrating this association is reported below.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 30-year-old male with a history of migraine since 12 years of age who was being treated with tricyclic antidepressants attended the emergency room for migraine worsening over the previous week. He reported throbbing holocranial headache associated with photopsia, as well as paresthesia in the right half of the face and right upper limb. When questioned, the patient reported both a loss of approximately 8–10<span class="elsevierStyleHsp" style=""></span>kg in weight and hyperhydrosis over the previous year. A physical examination revealed bilateral grade II/IV papilledema at eye fundus, with no neurological focal signs. The examination was otherwise normal, with a heart rate of 80 beats per minute, and no fine distal tremor, exophthalmos, or goiter.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A supplemental complete blood count showed normal results, except for elevated fibrinogen levels (516.9<span class="elsevierStyleHsp" style=""></span>mg/dL; normal range, 200–400).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Thyroid function tests provided results consistent with hyperfunction: FT4 4.54<span class="elsevierStyleHsp" style=""></span>ng/dL (NR, 0.9–1.7), TSH 0.01<span class="elsevierStyleHsp" style=""></span>μU/mL (NR, 0.27–4.5), FT3 8.61<span class="elsevierStyleHsp" style=""></span>pg/mL (NR, 2–4.4).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Tests for autoimmunity markers (antinuclear, ANCA, anticardiolipin, antimitochondrial, antimicrosomal, anti-TSH receptor, and antithyroglobulin antibodies) were only positive for the latter, with values of 363<span class="elsevierStyleHsp" style=""></span>U/mL (NR, <280).</p><p id="par0035" class="elsevierStylePara elsevierViewall">A hypercoagulability study showed a chromogenic factor VIII level<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>120% (NR, 80–110) and a von Willebrand factor Ag level of 112% (NR, 80–110). No changes were found in any other proteins tested (antithrombin III, protein C, protein S, von Willebrand factor, A2-antiplasmin antibodies, plasminogen, and protein C resistance test).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Because of the findings of hyperthyroidism, thyroid gammagraphy was performed, which showed diffuse hyperplasia with increased uptake. MRI of the brain (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), performed because of clinical signs of paresthesia, showed signal hyperintensity at the superior longitudinal sinus, the confluence of sinuses, the straight sinus, and the proximal portion of the transverse sinuses consistent with subacute dural sinus thrombosis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Cerebral sinus venous thrombosis secondary to hyperthyroidism was suspected, and treatment was started with low molecular weight heparin and subsequently with coumarins, tapering corticosteroids, and low-dose thiamazole (5<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h).</p><p id="par0050" class="elsevierStylePara elsevierViewall">After two weeks of treatment with thiamazole (10<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h), the patient was asymptomatic and showed subclinical hyperthyroidism: FT4 0.93<span class="elsevierStyleHsp" style=""></span>ng/dL (NR, 0.9–1.7), TSH 0.02<span class="elsevierStyleHsp" style=""></span>μU/mL (NR, 0.27–4.5), FT3 2.15<span class="elsevierStyleHsp" style=""></span>pg/mL (NR, 2–4.4); the dose was therefore decreased to 2.5<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0055" class="elsevierStylePara elsevierViewall">One month later, hormone values were within the normal range (FT4 0.98<span class="elsevierStyleHsp" style=""></span>ng/dL (NR, 0.9–1.7), TSH 0.81<span class="elsevierStyleHsp" style=""></span>μU/mL (NR, 0.27–4.5), FT3 2.99<span class="elsevierStyleHsp" style=""></span>pg/mL (NR, 2–4.4)), and antithyroid treatment was therefore discontinued.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient is currently asymptomatic and only receives oral anticoagulant therapy.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Although additional clinical trials are needed to confirm the association between coagulation/fibrinolysis disorders and thyroid function changes, the current evidence suggests that coagulation changes depend on the type of thyroid change. Patients with hypothyroidism usually appear to have an increased risk of bleeding, while hyperthyroid patients are more prone to arterial thrombosis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Several pathogenetic mechanisms predisposing hyperthyroid patients to a hypercoagulability state have been proposed, but the exact pathogenetic pathway is yet to be fully elucidated. Some of the changes found by different authors include increased plasma von Willebrand factor levels, improved platelet function, and increased factor II, VII, VIII, and X factors.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6,7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The evidence reported for an association of hyperthyroidism and venous thrombosis is limited to a few case reports. According to a review by Franchini et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> documenting 34 cases of venous thrombosis in patients with hyperthyroidism, thrombosis occurred in 80% of these patients in uncommon locations such as the splanchnic and, more frequently, the cerebral venous systems, which was the one involved in the reported patient. Subacute and chronic venous thromboses were also more common than acute thrombosis.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Squizzato et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> reported 13 cases of acute cerebral sinus venous thrombosis associated with thyroid disease. The most common etiology of hyperthyroidism was Graves–Basedow disease, and a hypercoagulability state and even vascular compression in the event of large goiter were suggested as a pathogenetic mechanism.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the reported case, autoimmune hyperthyroidism could have been Hashimoto toxicosis instead of Graves–Basedow disease. Both of them may show diffuse hyperuptake at gammagraphy, but the absence of positive TSH receptor antibodies and the good response to antithyroid treatment suggest Hashimoto toxicosis as the first possibility, despite the fact that 10% of patients with Graves–Basedow disease test negative for these antibodies.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Thus, although there are many risk factors for the development of cerebral sinus venous thrombosis, such as hereditary thrombophilia, oral contraceptives, pregnancy, and postpartum, hyperthyroidism should always be considered.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6,8</span></a> In patients with hyperthyroidism and neurological symptoms, the diagnosis of cerebral sinus venous thrombosis should also be suspected and coagulation tests should be performed.</p><p id="par0095" class="elsevierStylePara elsevierViewall">If this potential causal relationship is supported by larger observational studies, this may have significant clinical implications, particularly for prevention and treatment.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Merino M, et al. Tirotoxicosis y trombosis de senos venosos cerebrales, ¿causalidad o azar? Endocrinol Nutr. 2012;59(7):462–3.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 950 "Ancho" => 951 "Tamanyo" => 93004 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">MRI of the brain showing signal hyperintensity of the superior longitudinal sinus, the straight sinus, and the proximal portion of the transverse sinuses.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thyroid diseases and cerebrovascular disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 0 | 5 |
| 2024 October | 33 | 3 | 36 |
| 2024 September | 40 | 7 | 47 |
| 2024 August | 43 | 7 | 50 |
| 2024 July | 30 | 3 | 33 |
| 2024 June | 37 | 3 | 40 |
| 2024 May | 26 | 10 | 36 |
| 2024 April | 41 | 19 | 60 |
| 2024 March | 45 | 6 | 51 |
| 2024 February | 44 | 7 | 51 |
| 2024 January | 65 | 7 | 72 |
| 2023 December | 68 | 7 | 75 |
| 2023 November | 58 | 15 | 73 |
| 2023 October | 58 | 10 | 68 |
| 2023 September | 53 | 2 | 55 |
| 2023 August | 39 | 4 | 43 |
| 2023 July | 43 | 7 | 50 |
| 2023 June | 46 | 7 | 53 |
| 2023 May | 71 | 5 | 76 |
| 2023 April | 42 | 5 | 47 |
| 2023 March | 74 | 3 | 77 |
| 2023 February | 58 | 12 | 70 |
| 2023 January | 56 | 12 | 68 |
| 2022 December | 60 | 8 | 68 |
| 2022 November | 48 | 18 | 66 |
| 2022 October | 53 | 10 | 63 |
| 2022 September | 30 | 21 | 51 |
| 2022 August | 41 | 8 | 49 |
| 2022 July | 25 | 14 | 39 |
| 2022 June | 24 | 14 | 38 |
| 2022 May | 26 | 12 | 38 |
| 2022 April | 29 | 18 | 47 |
| 2022 March | 43 | 10 | 53 |
| 2022 February | 59 | 8 | 67 |
| 2022 January | 64 | 10 | 74 |
| 2021 December | 23 | 8 | 31 |
| 2021 November | 34 | 22 | 56 |
| 2021 October | 28 | 7 | 35 |
| 2021 September | 40 | 11 | 51 |
| 2021 August | 31 | 9 | 40 |
| 2021 July | 31 | 8 | 39 |
| 2021 June | 25 | 11 | 36 |
| 2021 May | 57 | 10 | 67 |
| 2021 April | 112 | 25 | 137 |
| 2021 March | 57 | 3 | 60 |
| 2021 February | 35 | 10 | 45 |
| 2021 January | 40 | 12 | 52 |
| 2020 December | 50 | 14 | 64 |
| 2020 November | 44 | 9 | 53 |
| 2020 October | 26 | 6 | 32 |
| 2020 September | 28 | 8 | 36 |
| 2020 August | 30 | 7 | 37 |
| 2020 July | 17 | 19 | 36 |
| 2020 June | 15 | 13 | 28 |
| 2020 May | 29 | 7 | 36 |
| 2020 April | 33 | 9 | 42 |
| 2020 March | 30 | 3 | 33 |
| 2020 February | 33 | 6 | 39 |
| 2020 January | 24 | 4 | 28 |
| 2019 December | 22 | 9 | 31 |
| 2019 November | 21 | 12 | 33 |
| 2019 October | 24 | 5 | 29 |
| 2019 September | 23 | 7 | 30 |
| 2019 August | 32 | 9 | 41 |
| 2019 July | 43 | 9 | 52 |
| 2019 June | 54 | 30 | 84 |
| 2019 May | 87 | 41 | 128 |
| 2019 April | 41 | 37 | 78 |
| 2019 March | 15 | 10 | 25 |
| 2019 February | 11 | 14 | 25 |
| 2019 January | 10 | 16 | 26 |
| 2018 December | 13 | 9 | 22 |
| 2018 November | 11 | 12 | 23 |
| 2018 October | 16 | 12 | 28 |
| 2018 September | 29 | 3 | 32 |
| 2018 August | 8 | 6 | 14 |
| 2018 July | 2 | 13 | 15 |
| 2018 June | 5 | 8 | 13 |
| 2018 May | 8 | 8 | 16 |
| 2018 April | 8 | 5 | 13 |
| 2018 March | 11 | 7 | 18 |
| 2018 February | 6 | 3 | 9 |
| 2018 January | 8 | 9 | 17 |
| 2017 December | 6 | 11 | 17 |
| 2017 November | 11 | 15 | 26 |
| 2017 October | 16 | 15 | 31 |
| 2017 September | 14 | 28 | 42 |
| 2017 August | 20 | 13 | 33 |
| 2017 July | 14 | 11 | 25 |
| 2017 June | 22 | 22 | 44 |
| 2017 May | 25 | 9 | 34 |
| 2017 April | 18 | 13 | 31 |
| 2017 March | 55 | 24 | 79 |
| 2017 February | 73 | 21 | 94 |
| 2017 January | 29 | 4 | 33 |
| 2016 December | 29 | 8 | 37 |
| 2016 November | 44 | 12 | 56 |
| 2016 October | 35 | 15 | 50 |
| 2016 September | 16 | 12 | 28 |
| 2016 August | 18 | 6 | 24 |
| 2016 July | 19 | 4 | 23 |
| 2016 June | 21 | 12 | 33 |
| 2016 May | 24 | 11 | 35 |
| 2016 April | 17 | 13 | 30 |
| 2016 March | 27 | 8 | 35 |
| 2016 February | 25 | 14 | 39 |
| 2016 January | 25 | 7 | 32 |
| 2015 December | 22 | 13 | 35 |
| 2015 November | 26 | 12 | 38 |
| 2015 October | 37 | 20 | 57 |
| 2015 September | 28 | 10 | 38 |
| 2015 August | 16 | 10 | 26 |
| 2015 July | 13 | 12 | 25 |
| 2015 June | 11 | 8 | 19 |
| 2015 May | 23 | 18 | 41 |
| 2015 April | 17 | 17 | 34 |
| 2015 March | 16 | 22 | 38 |
| 2015 February | 7 | 23 | 30 |
| 2015 January | 27 | 7 | 34 |
| 2014 December | 38 | 12 | 50 |
| 2014 November | 31 | 0 | 31 |
| 2014 October | 31 | 4 | 35 |
| 2014 September | 36 | 0 | 36 |
| 2014 August | 20 | 9 | 29 |
| 2014 June | 3 | 0 | 3 |
| 2014 May | 1 | 2 | 3 |
| 2013 June | 1 | 0 | 1 |
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