359. Transient Ischemic attacks from Moya Moya disease associated with Graves disease during Pregnancy: A case report

Abstract

Background Moya moya disease(MMD) is a rare idiopathic progressive vasculopathy,characterised by stenosis of the terminal portion of the internal carotid arteries and proximal portions of its major branches with the development of a thin collateral network of small vessels.It presents in young Asians with transient Ischemic attacks (TIAs), headaches,seizures,cognitive changes, ischemic or haemorrhagic strokes and is associated with many conditions including Graves disease. Case description 31 year old female with Graves disease (poorly controlled due to non-compliance) and previous 2 normal pregnancies presented during the third trimester of her 3rd pregnancy with intermittent headaches associated with right sided numbness of face and extremities lasting for few seconds without any features of Preeclampsia that were treated symptomatically.She had fluctuant thyroid function during her pregnancy and normal vaginal delivery at 40 weeks. She presented 2 months postpartum with severe headache and right sided numbness lasting for an hour without any features of Preeclampsia. She was thyrotoxic (FT4:51 pmol/L,FT3:16.6 pmol/L, TSH Although the Magnetic resonance imaging of the brain showed no infarcts and revealed features of MMD, the CT-Angiography of the Brain reported features suspicious of Takayasu’s arteritis with no evidence of it on Aortogram. She was treated with Aspirin, atorvastatin, carbimazole and a short course of Steroids. Discussion Awareness of the association between Graves’ disease and MMD in younger patients presenting with stroke like symptoms is important as early diagnosis and treatment of MMD in the setting of Graves Disease may prevent severe neurologic sequelae and eliminate the need for surgical intervention. Fluctuations in baseline thyroid function for patients with known Graves’ disease may be a potentiating factor in exacerbating Moyamoya vasculopathy. Most centres prefer caesarean delivery for patients with MMD to avoid haemodynamic instability.