Complications related to thyroidectomy among patients with hyperthyroidism: Exploring the potential for ambulatory surgery.

BACKGROUND: Total thyroidectomy for hyperthyroidism is typically followed by overnight admission to monitor for complications including thyrotoxicosis. Outpatient thyroid surgery is increasingly common, but its safety in patients with hyperthyroidism has not been well studied. METHODS: This retrospective study reviewed 183 patients with hyperthyroidism who underwent total thyroidectomy from 2015 to 2022 at one urban, academic center. The main outcomes were rates of thyroid storm, surgical complications, and 30-day ED visits and readmissions. RESULTS: Among 183 patients with hyperthyroidism (mean age, 45 ± 14.5 years; 82.5% female), there were no cases of thyroid storm and complications included recurrent laryngeal nerve (RLN) palsy (7.0%), symptomatic hypocalcemia (4.4%), and hematoma (1.6%). ED visits were present in 1.1% and no patients were readmitted. CONCLUSION: Total thyroidectomy was not associated with thyroid storm and <6% of patients required inpatient management. Ambulatory total thyroidectomy for hyperthyroidism warrants further consideration through identification of predictive factors for postoperative complications.

Thyroid Storm-Induced Refractory Multiorgan Failure Managed by Veno-Arterial Extracorporeal Membrane Oxygenation Support: A Case-Series.

BACKGROUND Severe hyperthyroidism, including thyroid storm, can be precipitated by acute events, such as surgery, trauma, infection, medications, parturition, and noncompliance or stoppage of antithyroid drugs. Thyroid storm is one of the serious endocrinal emergencies that prompts early diagnosis and treatment. Early occurrence of multiorgan failure is an ominous sign that requires aggressive treatment, including the initiation of extracorporeal membrane oxygenation (ECMO) support as a bridge to stability and definitive surgical treatment. Most adverse events occur after failure of medical therapy. CASE REPORT We described 4 cases of fulminating thyroid storm that were complicated with multiple organ failure and cardiac arrest. The patients, 3 female and 1 male, were between 39 and 46 years old. All patients underwent ECMO support, with planned thyroidectomy. Three survived to discharge and 1 died after prolonged cardiac arrest and sepsis. All patients underwent peripheral, percutaneous, intensivist-led cannulation for VA-ECMO with no complications. CONCLUSIONS Early recognition of thyroid storm, identification of the cause, and proper treatment and support in the intensive care unit is essential. Patients with thyroid storm and cardiovascular collapse, who failed to improve with conventional supportive measures, had the worst prognosis, and ECMO support should be considered as a bridge until the effective therapy takes effect. Our case series showed that, in patients with life-threatening thyroid storm, VA-ECMO can be used as bridge to stabilization, definitive surgical intervention, and postoperative endocrine management. Interprofessional team management is essential, and early implantation of VA-ECMO is likely beneficial in patients with thyroid storm after failure of conventional management.

A Rare Case of Painless Destructive Thyroiditis Resulting in Thyroid Storm.

Thyroid storm is a life-threatening clinical condition that is usually triggered by untreated or interrupted treatment of Graves' disease, leading to the sudden onset of severe thyrotoxicosis, which requires an immediate diagnosis and treatment based on diagnostic criteria. Cases of thyroid storm caused by painless/painless subacute thyroiditis are very rare. We herein report an 85-year-old man with features of severe thyrotoxicosis caused by painless/painless subacute thyroiditis who had no uptake of 99mTcO4 and was negative for thyroid-stimulating hormone receptor antibodies. In thyroid storm patients in whom the findings are inconsistent with Graves' disease, careful follow-up and management are necessary, assuming the possibility of painless or painless subacute thyroiditis.

Takotsubo cardiomyopathy with left ventricle thrombus caused by subacute thyroiditis.

We report a rare case of takotsubo cardiomyopathy caused by subacute thyroiditis in a man in his 50s. He went to the doctor with complaints of loss of appetite, diarrhoea, chills and general malaise. He had consciousness disturbance, thyrotoxicosis and thyroid-stimulating hormone (TSH) suppression. Thyroglobulin and C reactive protein levels in the blood were elevated, but TSH receptor antibody, thyroid-stimulating antibody, antithyroglobulin antibody and antithyroid peroxidase antibody were not. We began treatment with prednisolone and propranolol after he was diagnosed with thyroid storm caused by subacute thyroiditis. The ECG revealed inverted T waves on the fifth day after admission. He was newly diagnosed with takotsubo cardiomyopathy on the day. A large thrombus was detected in the left ventricle, requiring anticoagulation therapy. Thus, even if there are no findings of takotsubo cardiomyopathy or thrombus at the onset of thyroid storm, appropriate monitoring is required because they can develop during the treatment course.

Anaesthesiology perspective on a multidisciplinary approach to optimal perioperative management of a patient with giant peptic ulcer perforation caused by the physiological stress of a thyroid storm necessitating emergent laparotomy.

Thyroid storm is a rare, fatal complication of thyrotoxicosis that necessitates aggressive medical treatment. We present a case of a patient who developed duodenal ulcer perforation as a result of a thyroid storm caused by Graves' thyrotoxicosis. In addition to life-threatening intra-abdominal sepsis complicated by high anion-gap metabolic acidosis, he was found to have severely deranged thyroid hormone levels and clinical features compatible with thyroid storm based on the Burch-Wartofsky Score. Diagnosis and management of such patients with compromised gastrointestinal (GI) tract present a remarkable clinical challenge to the anaesthetist and the intensivists. Multidisciplinary care with rapid preoperative optimisation, careful intraoperative anaesthetic techniques and postoperative care resulted in excellent outcomes. This case report sheds light on how to tailor general anaesthesia to minimise physiological derangement associated with thyroid storm and re-establish homeostasis in patients presenting for emergent surgery, particularly those with GI dysfunction.

A Case of Thyroid Storm Caused by Thyroiditis.

Thyroid storm occurs when thyroid hormones are released causing a hyperadrenergic state resulting in potentially life-threatening cardio-respiratory effects. The most common cause of thyroid storm is thyrotoxicosis secondary to Graves disease. Alternatively, subacute thyroiditis (SAT) is usually a self-limited condition consisting of painful inflammation of thyroid gland, often associated with viral illness. Transient hyperthyroidism is a common finding in SAT; however, thyroid storm is an extremely rare complication of SAT. We report the sixth recorded case of SAT associated with thyroid storm.

[Multimodal anesthesia in a patient with Graves' disease and thyrotoxicosis: A case report]. / Anestesia multimodal en paciente con enfermedad de Graves y tirotoxicosis: reporte de caso.

Background: Hyperthyroidism is the increase in the synthesis and secretion of thyroid hormones. It is rare but serious in children and constitutes approximately 5% of all cases; 15% manifests before 10 years of age. The peak of presentation and the majority of cases (80%) are diagnosed around 10-15 years of age. Adolescence is usually the stage with the highest incidence and it is more frequent in women (5:1). Acute thyrotoxic crisis or thyroid storm is rare and only occurs in a poorly controlled hyperthyroid patient or in a hyperthyroid patient undergoing emergency surgery. It is manifested by fever, extreme tachycardia, tachyarrhythmia with atrial fibrillation, vomiting, diarrhea, agitation and mental confusion. Clinical case: 17-year-old adolescent with Graves' disease with uncontrolled clinical manifestations that did not respond to medical treatment and was scheduled for radical thyroidectomy. 35 points were obtained on the Burch and Wartofsky Scale. It was managed with general anesthesia, reducing stimuli for airway and regional control to reduce surgical stimuli. Adjuvant medications such as magnesium sulfate for intraoperative stability were used. Conclusion: Multimodal anesthesia managed to avoid thyroid storm, postoperative pain, as well as other complications.

Introducción: el hipertiroidismo es el incremento en la síntesis y secreción de hormonas tiroideas. Es raro pero grave en la edad pediátrica y constituye aproximadamente el 5% de todos los casos; el 15% se presenta antes de los 10 años. El pico de presentación y la mayoría de los casos (80%) se diagnostican hacia los 10-15 años. La adolescencia es la etapa de mayor incidencia y más frecuente en mujeres (5:1). La crisis tirotóxica aguda o tormenta tiroidea es rara y solo se presenta en un hipertiroideo mal controlado o en un paciente hipertiroideo intervenido de urgencia. Se manifiesta con fiebre, taquicardia extrema, taquiarritmia con fibrilación auricular, vómito, diarrea, agitación y confusión mental. Caso clínico: adolescente de 17 años con enfermedad de Graves con manifestaciones clínicas descontroladas, la cual no respondió a tratamiento médico y se programó para tiroidectomia radical. Se obtuvieron 35 puntos en la Escala de Burch y Wartofsky. Se manejó con anestesia general y fueron disminuyendo los estímulos para control de vía aérea y regional a fin de disminuir los estímulos quirúrgicos. Se usaron medicamentos adyuvantes como sulfato de magnesio para la estabilidad transoperatoria. Conclusión: la anestesia multimodal logró evitar la tormenta tiroidea, el dolor postoperatorio, así como otras complicaciones.

Takotsubo cardiomyopathy in the setting of thyroid storm.

A woman in her 50s with a background of chronic obstructive pulmonary disease secondary to smoking presented with intermittent chest tightness, dyspnoea and vomiting for 4 days. A presumed diagnosis of acute coronary syndrome (ACS) was made based on dynamic ischaemic ECG changes and elevation in high-sensitivity cardiac troponin T levels. She underwent emergent coronary angiography which demonstrated mild coronary artery disease with left ventriculography suggestive of mid-wall variant Takotsubo cardiomyopathy. Thyroid function tests performed to investigate sinus tachycardia were consistent with hyperthyroidism, and her thyroid-stimulating hormone receptor antibody was elevated. A diagnosis of thyroid storm was made in the setting of a newly diagnosed Graves' disease and the patient was subsequently commenced on guideline-based therapy. This case demonstrates that Takotsubo cardiomyopathy, a mimic of ACS, is a possible complication of thyroid storm and therefore hyperthyroidism should be considered in the list of differentials in patients presenting with Takotsubo cardiomyopathy.

Postoperative thyroid crisis in an 11-year old male with McCune-Albright syndrome and atypical triiodothyronine hyperthyroidism: A case report.

RATIONALE: McCune-Albright syndrome (MAS) is a rare heterogeneous clinical disease caused by sporadic, somatic, and postzygotic mutations. Thyroid crisis is even rare in patients with MAS, and we report the clinical outcomes of the first case of a MAS patient with atypical triiodothyronine (T3) hyperthyroidism who developed thyroid crisis after orthopedic surgery. PATIENT CONCERNS: The patient with MAS and atypical T3 hyperthyroidism was an 11-year-old man who had undergone surgery for a right femur fracture and shepherd bending deformity. His main symptoms were dizziness, nausea, and vomiting with elevated body temperature because of developed thyroid crisis. Thyroid function tests showed high T3 and remarkably high free T3 levels, and remarkably increased thyrotropin level, but unchanged thyroxine and free thyroxine levels. DIAGNOSIS: The patient was diagnosed with postoperative thyroid crisis following surgery for a right femur fracture, shepherd bending deformity, and MAS with atypical T3 hyperthyroidism. INTERVENTIONS: Propranolol was intravenously administered. The therapy included intravenous hydrocortisone, a saturated solution of potassium iodine and propylthiouracil, and continuous physical cooling. OUTCOMES: The patient was discharged after achieving a stable condition with normal thyroid and liver function after surgery because of active anti-thyroid crisis treatment. LESSONS: The operation of such patients should focus on the pre-operative heart rate, platelet level, and thyroid hormone levels. Abnormal values should be adjusted to the normal range, and such patients should achieve complete hemostasis and transfuse with blood following surgery anemia.

Getting around the gut: a unique management challenge of thyroid storm precipitated by amphetamine-associated duodenal ischaemia leading to compromised enteric absorption.

Thyroid storm is a rare, life-threatening endocrine emergency with a high mortality rate of up to 30%. We present a unique management challenge of a critically ill patient who developed thyroid storm in the setting of a duodenal perforation from amphetamine-associated non-occlusive mesenteric ischaemia. The diagnosis of 'thyroid storm' was made based on clinical criteria and a Burch-Wartofsky score of 100. During emergent exploratory laparotomy, a 1 cm duodenal perforation with surrounding friable tissue was found and repaired. Intraoperatively, a nasogastric tube was guided distal to the area of perforation to allow for enteric administration of medications, which was critical in the setting of thyroid storm. Therapeutic plasma exchange achieved biochemical control of our patient's thyroid storm but ultimately did not prevent in-hospital mortality.

Risk of perioperative thyroid storm in hyperthyroid patients: a systematic review.

BACKGROUND: Thyroid storm is a feared complication in patients with hyperthyroidism undergoing surgery. We assessed the risk of thyroid storm for different preoperative treatment options for patients with primary hyperthyroidism undergoing surgery. METHODS: Pubmed, EMBASE, and The Cochrane Library were searched systematically for all studies reporting on adult hyperthyroid patients undergoing elective surgery under general anaesthesia. Selected studies were categorised based on preoperative treatment: no treatment, antithyroid medication (thionamides), iodine, ß-blocking medication, or a combination thereof. Treatment effect, that is restoring euthyroidism, was extracted from the publications if available. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) or the Cochrane Risk of Bias tool for randomised studies. RESULTS: The search yielded 7009 articles, of which 26 studies published between 1975 and 2020 were selected for critical appraisal. All studies had moderate to critical risk of bias, mainly attributable to risk of confounding, classification of intervention status, and definition of the outcome. All studies reported on thyroidectomy patients. We found no randomised studies comparing the risk of thyroid storm between treated and untreated patients. Cases of thyroid storm were reported in all treatment groups with incidences described ranging from 0% to 14%. CONCLUSION: Evidence assessing the risk of perioperative thyroid storm is of insufficient quality. Given the seriousness of this complication and the impossibility of identifying patients at increased risk, preoperative treatment of these patients remains warranted.

The challenges of radioiodine treatment for incontinent paediatric patients with complex care needs.

OBJECTIVE: A thyrotoxic paediatric patient with incontinence, autism and Down's syndrome was referred for radioiodine therapy. Here, the risk assessment methodology and measures taken to deliver a legally compliant treatment that was acceptable to the family are described. METHODS: Prior risk assessment indicated that the most active incontinence waste would require decay storage until it could be transported for disposal. The Health and Safety Executive (HSE) indicated that school staff would be occupationally exposed under the Ionising Radiations Regulations (2017) based on the patient's retained activity. To avoid the need for HSE registration, it was advised that the patient's return to school may need to be delayed slightly. Post-treatment, confirmatory waste and patient dose rate measurements were made to refine the advised time scales. RESULTS: Domestic waste disposal resumed at 28 days. The patient recommenced schooling a few days after their school reopened after the summer break. The school underwent HSE notification. CONCLUSION: Careful planning allowed us to provide a safe, compliant treatment regarding waste management and occupational exposure. ADVANCES IN KNOWLEDGE: Incontinent 131I outpatient treatments require detailed, patient specific waste management. The HSE considered school staff as occupationally exposed by the patient well after normal social restrictions had ended.

Epidemiology and factors associated with mortality of thyroid storm in Taiwan: a nationwide population-based study.

Thyroid storm is a rare and life-threatening disease. However, its prevalence, incidence, and mortality rate in Chinese population are unknown. We performed a retrospective study using the Taiwan Health and Welfare Data. Patients admitted owing to thyrotoxicosis were divided into thyroid storm group and non-thyroid storm group. We assessed thyroid storm prevalence, incidence, complications, and mortality rate. Multiple Cox regression was performed to estimate the hazard ratio for the mortality risk. Overall, 1244 thyroid storm patients and 83,874 thyrotoxicosis patients without thyroid storm were included. Most thyroid storm patients were female (67.9%) with ages ranging from 30 to 44 years (33.4%), and most thyroid storm cases occurred during the summer season. The prevalence of thyroid storm was 1.48% (1244/83,874). The incidence rate of thyroid storm was 0.55 per 100,000 persons per year and 6.28 per 100,000 hospitalized patients per year. The overall 14-, 28-, and 90-day mortality rates of thyroid storm patients were 5.23%, 6.59%, and 8.12%, respectively. Thyroid storm, older age, male, and underlying ischemic stroke, myocardial infarction, heart failure, kidney disease, atrial fibrillation, depression, chronic obstructive pulmonary disease, diabetes mellitus, cancer, end stage renal diseases were associated with a significantly higher risk of mortality. In conclusion, the 90-day mortality rate of thyroid storm was high and was commonly associated with multiorgan failure and shock. Therefore, clinical physicians should identify thyroid storm and treat it accordingly.

[Thyroid storm and diabetic ketoacidosis (DKA) in a previously healthy male - a significant differential diagnostic challenge]. / Tyreotoxisk kris maskerades av ketoacidos.

Thyroid storm is a potentially lethal condition sometimes seen in cases of untreated thyrotoxicosis. Hypermetabolism, fever, and tachycardia are typical symptoms of the increased thyroid hormone activity. Thyroid storm is often triggered by infection, trauma or recent surgery and rarely by other causes. We present a case of thyroid storm and diabetic ketoacidosis (DKA) in a previously healthy male. After extensive lab testing, the patient was found to have both an undiagnosed type 1 diabetes and Graves disease. This combination of underlying conditions and the combined presentation of thyroid storm and DKA pose a significant differential diagnostic challenge, and this case report reminds us to think broadly when presented with an atypical case.

Flushing Disorders Associated with Gastrointestinal Symptoms: Part 2, Systemic Miscellaneous Conditions.

Flushing disorders with involvement of the gastrointestinal tract represent a heterogeneous group of conditions. In part 1 of this review series, neuroendocrine tumors (NET), mast cell activation disorders (MCAD), and hyperbasophilia were discussed. In this section we discuss the remaining flushing disorders which primarily or secondarily involve the gastrointestinal tract. This includes dumping syndrome, mesenteric traction syndrome, rosacea, hyperthyroidism and thyroid storm, anaphylaxis, panic disorders, paroxysmal extreme pain disorder, and food, alcohol and medications. With the exception of paroxysmal pain disorders, panic disorders and some medications, these disorders presents with dry flushing. A detailed and comprehensive family, social, medical and surgical history, as well as recognizing the presence of other systemic symptoms are important in distinguishing the different disease that cause flushing with gastrointestinal symptoms.

Use of low-dose neostigmine intravenously in the treatment of thyroid storm-induced severe tachycardia in patient during huge pelvic mass resection: A case report and review of literature.

RATIONALE: Thyroid storm is a rare and life-threatening metabolic crisis because of an emergent release of excess thyroid hormone. Sinus tachycardia induced by excess thyroid hormone may result in congestive heart failure due to decreased diastolic filling time. PATIENT CONCERNS: A controlled hyperthyroidism patient with severe sinus tachycardia. DIAGNOSES: A controlled hyperthyroidism patient was induced thyroid storm during huge pelvic mass resection. INTERVENTIONS: Application of low-dose neostigmine and ß-antagonist esmolol to control the heart rate (HR) avoided hemodynamic collapse. OUTCOMES: The patient improved dramatically following application of low-dose neostigmine instead of esmolol to control the HR avoided hemodynamic collapse. LESSONS: Our case suggests that neostigmine, an acetylcholinesterase inhibitor, may warrant further investigation in patients with thyroid storm-induced severe sinus tachycardia.

[Treatment of hyperthermia].

Hyperthermia is an uncontrolled elevation of body temperature exceeding the body's ability to dissipate heat. Hyperthermia can result in dangerously high core temperatures and can rapidly become fatal. Common causes include heat stroke, malignant hyperthermia, serotonin syndrome, neuroleptic syndrome, a few endocrine emergencies as well as numerous intoxications. Rapid diagnosis and prompt cooling are pivotal, since the condition triggers a cascade of metabolic events which may progress to irreversible injury or death. Ice-water immersion and evaporative cooling are the methods of choice.

Tormenta tiroidea asociada a disfunción multiorgánica / Thyroid storm associated with multiorganic dysfunction

La tormenta tiroidea es una condición infrecuente y potencialmente fatal. En la literatura han sido descritas varias presentaciones inusuales de la misma; sin embargo, la disfunción multiorgánica es rara vez vista. Aquí describimos un caso en una mujer de 36 años de edad con enfermedad de Graves subyacente no diagnosticada hasta entonces, quien inició su sintomatología con una tormenta tiroidea. Su score de Burch y Wartofsky fue de 50/140. Desarrolló falla hepática aguda, falla renal aguda, acidosis láctica, falla cardíaca, bicitopenia, coagulopatía y rabdomiolisis. La disfunción multiorgánica se revirtió gracias a la pronta instauración de los esteroides, ciclofosfamida, plasmaféresis y posterior tiroidectomía. La dificultad reside en reconocer las variadas presentaciones de la enfermedad y ofrecer un tratamiento apropiado cuando se enfrenta a las contraindicaciones o las fallas terapéuticas del tratamiento convencional.

Thyroid storm is a rare and potentially fatal condition. Unusual presentations in patients with thyroid storm have been described but multiorganic dysfunction is uncommonly seen. We describe the case of a 36-year-old woman with unknown underlying Graves´s disease who developed thyroid storm. The thyroid storm score of Burch and Wartofsky was 50/140. This was complicated by acute liver failure, acute kidney injury, lactic acidosis, heart failure, bi-cytopenia, coagulopathy and rhabdomyolysis. The severe multiorgan dysfunction was reversed by prompt institution of steroids, cyclophosphamide and plasma exchange before thyroidectomy. Main difficulty lies in recognizing its varied presentations and offering appropriate treatment when physician faces either failure or contraindications of conventional therapy.

Thyrotoxic and pheochromocytoma multisystem crisis: a case report.

BACKGROUND: Thyrotoxic crisis and pheochromocytoma multisystem crisis are rare, life-threatening, emergency endocrine diseases with various clinical manifestations. Here we report a case of a patient who simultaneously developed thyrotoxic crisis and pheochromocytoma multisystem crisis and required intensive cardiovascular management. CASE PRESENTATION: A 60-year-old Asian man experienced nausea and vomiting, and subsequently developed dyspnea and cold sweats while farming. His serum free thyroxine, free triiodothyronine, and thyrotropin receptor antibody levels were elevated at 2.9 ng/dL, 7.2 pg/dL, and 4.7 IU/L, respectively. Serum thyrotropin levels were suppressed at less than 0.01 µIU/mL. Thyroid echography demonstrated no thyroid swelling (23 × 43 mm). A whole body computed tomography was performed for systemic evaluation. This revealed exophthalmos and a mass of size 57 × 64 mm in the anterior pararenal space. Based on these findings, we made an initial diagnosis of thyrotoxic crisis secondary to exacerbation of Grave's hyperthyroidism. Treatment was begun with an iodine agent at a dose of 36 mg/day, thiamazole at a dose of 30 mg/day, and hydrocortisone at a dose of 300 mg daily for 3 consecutive days. To control tachycardia, continuous intravenously administered propranolol and diltiazem infusions were given. At the same time, small doses of doxazosin and carvedilol were used for both alpha and beta adrenergic blockade. On hospital day 5, his blood pressure and serum catecholamine concentrations (adrenalin 42,365 pg/mL, dopamine 6409 pg/mL, noradrenalin 72,212 pg/mL) were still high despite higher beta blocker and calcium channel blocker doses. These findings contributed to the diagnosis of pheochromocytoma multisystem crisis with simultaneous thyrotoxic crisis. We increased the doses of doxazosin and carvedilol, which stabilized his hemodynamic status. On hospital day 16, metaiodobenzylguanidine scintigraphy showed high accumulation in the right adrenal gland tumor. After retroperitoneal laparoscopic adrenalectomy on hospital day 33, his condition stabilized. He was discharged on hospital day 58. CONCLUSIONS: Since he required more intensive cardiovascular management for thyrotoxic crisis, beta blockade was increased under intensive care unit monitoring even though initial alpha blockade is recommended in pheochromocytoma. When these crises occur simultaneously, cardiovascular management can be very challenging.

[Thyroid Storm Precipitated by Intracranial Surgery in a Woman with No History of Thyroid Disease.]

Severe medical stress can trigger thyroid storm, an endocrine emergency that affects consciousness. This case report describes a 43-year-old female patient transferred to our hospital with right motor hemipare- sis. Her medical history included untreated hyperten- sion, but no history of thyroid disease. Emergency magnetic resonance imaging (MRI)of the head revealed bilateral moyamoya disease and ischemic stroke in the right watershed region of the brain. The right superfi- cial temporal artery was anastomosed to the middle cerebral artery on day 71 of hospitalization due to repeated brain infarctions after admission. Although anesthesia was without incident, the patient gradually developed postoperative disturbed consciousness, hypertension and tachycardia, which we considered were the result of craniotomy or insufficient brain per- fusion, until a nurse found a swelling on the patient's neck. Hyperthyroidism was confirmed by laboratory data and an endocrinologist concluded that thyroid storm had caused her symptoms. Thyroid storm should be considered in the differential diagnosis of patients who present with disturbed consciousness after intracranial surgery.