|Year : 2014 | Volume
| Issue : 1 | Page : 29-31
Clinical suspicion of preexisting hypothyroidism presenting with uncommon features in a patient with extra dural hematoma of brain and further management strategy: A surgical challenge in emergency hours
Mani Charan Satapathy1, Dharitri Dash2, Charan Panda2, Koresh Prasad Dash2
1 Department of Neurosurgery, S.C.B. Medical College, Cuttack, Odisha, India
2 Department of General Surgery, M.K.C.G. Medical College, Brahmapur, Odisha, India
|Date of Web Publication||21-May-2014|
Mani Charan Satapathy
Department of Neurosurgery, S.C.B. Medical College, Cuttack 753 001, Odisha
Source of Support: None, Conflict of Interest: None
Hypothyroidism can be well-diagnosed with classical clinical signs, but not always. Extradural hematomas (EDH) are usually characterized by a rapidly progressing clinical course within few hours necessitating early surgical intervention. Surgical management of EDH with hypothyroidism is really a challenging issue for treating surgeon in the emergency hour, as the ultimate outcome depends on the further consequences of EDH and the ongoing metabolic stress due to hypothyroidism. A 53-year-old woman presented to us with a h/o head injury with dry, coarse, pale skin, and sunken face but without goiter with computed tomography scan of brain suggestive of right temporoparietal EDH. Clinical suspicion to be a case of hypothyroidism from these uncommon features was confirmed upon thyroid function test (TFT). Without delay, we planned for emergency craniotomy and evacuated the extradural blood clots ↓ local anesthesia avoiding the bad impact of regional anesthesia over hypothyroidism. Postoperatively, we supplemented levothyroxine through Ryle's tube, thus surviving the patient of EDH as well as hypothyroidism. Hence, clinical suspicion of some common comorbidity (e.g. hypothyroidism) can enlighten the treating surgeon to plan for further management strategy as reflected in our case.
Euthyroid sick syndrome, extra dural hematomas, Glasgow coma score, hypothyroidism, levothyroxine, local anesthesia, thyroid
|How to cite this article:|
Satapathy MC, Dash D, Panda C, Dash KP. Clinical suspicion of preexisting hypothyroidism presenting with uncommon features in a patient with extra dural hematoma of brain and further management strategy: A surgical challenge in emergency hours. Saudi Surg J 2014;2:29-31
|How to cite this URL:|
Satapathy MC, Dash D, Panda C, Dash KP. Clinical suspicion of preexisting hypothyroidism presenting with uncommon features in a patient with extra dural hematoma of brain and further management strategy: A surgical challenge in emergency hours. Saudi Surg J [serial online] 2014 [cited 2023 Mar 29];2:29-31. Available from: https://www.saudisurgj.org/text.asp?2014/2/1/29/132903
| Introduction|| |
Hypothyroidism patients commonly present with the classical symptoms such as fatigue, loss of energy, lethargy, weight gain, decreased appetite, cold intolerance, dry skin, hair loss, sleepiness, depression, emotional lability, constipation, menstrual disturbances, impaired fertility, decreased perspiration, hoarseness with classical clinical signs such as weight gain, dry skin, pallor, coarse, brittle, straw-like hair, loss of scalp hair, axillary hair, pubic hair, or a combination, dull facial expression, coarse facial features, periorbital puffiness, macroglossia, goiter (simple or nodular), hoarseness, decreased systolic blood pressure (BP) and increased diastolic BP, bradycardia, pericardial effusion, abdominal distention, ascites (uncommon), hypothermia (only in severe hypothyroid states), nonpitting edema (myxedema), pitting edema of lower extremities, hyporeflexia with delayed relaxation, ataxia, or both. Signs found in hypothyroidism are usually subtle, and their detection requires a careful physical examination. Moreover, such signs are often dismissed as part of aging; however, clinicians should consider a diagnosis of hypothyroidism when they are present.
Presence of goiter though a classical thought, but not always. Hence, the clinician should not search for goiter always, rather suspect hypothyroidism if some of these are present on examination and investigate for thyroid function test (TFT) immediately to establish the diagnosis. Extradural hematomas (EDH) had great impact on cerebral auto-regulation causing raised intracranial pressure leading to coning and death and thus, the need for early surgical intervention. Surgical management of EDH with hypothyroidism is really a challenging issue for treating surgeon in emergency hour, as the ultimate outcome depends on time since trauma, interval between admittance and operation, location of hematomas, associated comorbidities (e.g. hypothyroidism) and the type of anesthesia. As the stress of surgery and general anesthesia have direct effect on pituitary-thyroid axis with alteration in concentrations of thyroid-stimulating hormone (TSH) and T3, perioperative euthyroid state is always necessary to obtain the best possible results from any surgical intervention. Therefore, the treating surgeon must consider the impact of any associated factor over the surgically treatable pathology while considering further strategy of management.
| Case Report|| |
We had a 53-year-old woman presented in the emergency hour with h/o head injury due to road traffic accident (pedestrian hit by a motorcyclist from side) with LOC (+) since then. On examination, Glasgow coma score (GCS)-11, pulse-54/min, BP-140/90 mm Hg, and pupils-mid dilated sluggishly reacting bilaterally. She had dry, coarse, pale skin, and sunken face without thyroid enlargement [Figure 1] with computed tomography scan of brain suggestive of right temporoparietal EDH [Figure 2]a]. We suspected and investigated her for hypothyroidism based on these clinical findings. Her TFT values were T3-0.25 ng/mL, T4-2.39 μg/dL, and TSH-71.20 μu/mL. Thyroid antibody profile revealed thyroid peroxidase antibody-25 IU/mL, thyroglobulin antibody-10 IU/mL, TSH receptor (TRAb)-1.55 IU/L suggestive of normal values. Understanding the bad impact of general anesthesia upon it, immediately we proceeded for right temporoparietal free flap craniotomy ↓ local anesthesia with evacuation of 100 ml EDH blood, with postoperative T4 (100 μg/day) through Ryle's tube. Repeat computed tomography on the 4 th postoperative day revealed complete evacuation of EDH [Figure 2]b], and she was discharged on the 7 th postoperative day with GCS-15 with improvement of her hypothyroid status. She is on regular follow-up until date at endocrinology as well as neurosurgery outpatients department.
|Figure 1: Dry, coarse, pale skin, and sunken face without thyroid enlargement|
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|Figure 2: (a) Preoperative computed tomography scan of brain showing hyperdense biconvex lesion in the right temporoparietal region suggestive of extradural hematomas (EDH) (b) postoperative CT scan of brain showing complete removal of EDH|
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| Discussion|| |
The ultimate result of surgical treatment for EDH depends on associated diseases, e.g. hypothyroidism in our case. We should plan and decide the proper treatment modality for such a case in emergency hour considering thyroid hormone physiology, impact of surgery on hypothyroidism, type of anesthesia suitable for the situation and perioperative maintenance of euthyroid status.
Thyroid hormones have pleotropic actions in virtually every organ system, playing a crucial role in cardiac contractility, vascular tone, water and electrolyte balance, and normal function of the central nervous system. A euthyroid state is always necessary to obtain the best possible results from any kind of surgical intervention. 
Not only does hypothyroidism have a significant effect on different surgical parameters, but the reverse is also true. The stress of surgery has a direct effect on the thyroid axis with alteration in concentrations of TSH and T3. Patients undergoing surgery will manifest the classic euthyroid sick syndrome (ESS). , Serum reverse T3 (rT3) remains unchanged early in surgery, but then its levels usually increase and stay elevated until the 4 th or 5 th postoperative day. Surgery induces an increase in serum cortisol, which may precede the changes seen in the thyroid axis, suggesting a possible causal relationship. This relationship, however, may be oversimplified because the same changes in the thyroid axis were noted in other studies in which the rise of cortisol with surgery was abolished. At the time, elderly patients undergoing emergent surgery were evaluated, similar changes were noted. 
Considering general anesthesia, total T3 is decreased 30 min after induction and remains low for at least 24 h postoperatively. Free T3 is also decreased slightly, after an initial increase in the absolute percentage of free hormone on the day of the surgery. Free T4 seems to respond similarly to free T3. Serum total T4 will vary depending on type of anesthesia, with an increase associated with general anesthesia, whereas a slight decrease in T4 is seen with epidural anesthesia. Serum TSH concentrations remain unchanged with the exception of an increase seen at the time hypothermia is induced. 
Classic signs of hypothyroidism, such as the dry skin, a slowed deep tendon reflex relaxation phase, bradycardia, hypothermia or the presence of goiter must be sought. We must suspect hypothyroidism if some of these are present on examination and investigate for TFT without delay. In case of mild (subclinical) hypothyroidism, the presence of antithyroid antibodies can help predict how likely the patient will develop hypothyroidism that eventually causes symptoms and to rule out autoimmune basis.
Low serum free T4 and significantly elevated TSH are not consistent with ESS and are suggestive of hypothyroidism. If such a picture is present, replacement with T4 is indicated to render the patient euthyroid.  Levothyroxine (LT4) monotherapy remains the treatment of choice for hypothyroidism. We administered eltroxin (100 μg/day) through Ryle's tube and the hormonal status on the 7 th postoperative day reflected dramatic improvement.
The treatment goals for hypothyroidism are to reverse clinical progression and correct metabolic derangements, as evidenced by normal blood levels of TSH and free thyroxin (T4). Thyroid hormone is administered to supplement or replace endogenous production. In general, hypothyroidism can be adequately treated with a constant daily dose of LT4.
| Conclusion|| |
It is stressed that a strict vigilance is always to be kept for general examination findings related to common endocrine diseases relevant to the particular region. We should not rely necessarily on the classical presentation always and patients with clinical suspicion of a disease should be subjected to relevant laboratory tests to establish the diagnosis of associated comorbid state to ease out further plan and management from anesthetic as well as surgical aspects. Early diagnosis and immediate surgical intervention of EDH had a good outcome, even with associated disease provided the complete assessment and timely management were proper and individualized.
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[Figure 1], [Figure 2]