Approach Considerations

Neurologic manifestations in thyroid diseases are manageable on an outpatient basis. Therapy is maintained for months (if not years). In most cases, neurologic abnormalities slowly resolve.

Thyroid storm and myxedema coma are exceptions. Both are emergencies that require aggressive treatment in the ICU. The mortality rate of thyroid storm can be as high as 20–40%. The symptoms usually are exaggerated manifestations of the symptoms seen in hyperthyroidism; a superimposed infection and the stress associated with it would exacerbate the symptoms. Fever, abdominal pain, delirium, and psychosis can occur. The patient may become obtunded. Thyroid storm should be suspected in any patient with severe hyperpyrexia, tachycardia, and a goiter.

Medical Care

Neurologic manifestations in thyroid disease generally develop slowly. They are diagnosed months or years after initial endocrine problems. Patients seek care after developing characteristic systemic signs and symptoms.

Polyneuropathy is rarely the initial manifestation of undetected hypothyroidism. Metastatic thyroid carcinoma rarely presents as an initial brain metastatic lesion.

Chorea-ballism has been reported sporadically. Chorea has been associated with elevated levels of antithyroid antibodies, with the symptoms responding to oral steroid treatment.

Interestingly, one study reports that mild hypothyroidism is associated with better survival of ambulatory elderly patients after acute stroke.^[25]

Several reports of intracranial vascular disease (arterial occlusion, superior sagittal sinus thrombosis, cerebral vein thrombosis) have been reported associated with both hypothyroidism and hyperthyroidism. However, the patients had multiple pathologies, and a clear correlation with thyroid disease is difficult to establish.^{[26, 27, 28]}

Pregnant patients require follow-up at least monthly. Closely observe these newborns for thyroid disease.

Surgical Care

Surgery is indicated in the treatment of thyroid masses and large goiters.

Consultations

The following consultations may be warranted:

Internal medicine/endocrinologist
Head and neck surgeon
Nuclear medicine specialist
Radiation oncologist
Pathologist

Diet

Iodine deficiency is not widespread in the United States, although immigrants from areas of endemic deficiency may require dietary consultation. Pregnant women may require more careful screening.

Medication

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