Ohya et al.
International Journal of Emergency Medicine
https://doi.org/10.1186/s12245-023-00490-4(2023) 16:15

International Journal of
Emergency Medicine

Open Access

CASE REPORT

Diagnosis and treatment approaches
for simultaneous onset of subarachnoid
hemorrhage and thyroid storm: a case report
Aimi Ohya1†, Makoto Ohtake1,2*†, Yusuke Kawamura1, Taisuke Akimoto2, Masayuki Iwashita1,
Tetsuya Yamamoto3 and Ichiro Takeuchi1

Abstract
Background Subarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital.
Case presentation The patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden
disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were
Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal
carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 andfree T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia,
the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient’s symptoms improved, and she became lucid.
In this case, we believe that in the presence of untreated hyperthyroidism, the onset of subarachnoid hemorrhage
induced thyroid storm. Tachycardia of 130 bpm or higher, which is the diagnostic criterion for thyroid storm, rarely
occurs with subarachnoid hemorrhage. Therefore, we believe it is an important factor for recognizing the presence ofthe thyroid storm. In this case, clipping surgery was prioritized which resulted in a favorable outcome. However, it ispossible that invasive surgery may have exacerbated thyroid storm, suggesting that treatment should be tailored as
per patient’s condition.
Conclusion If a pulse rate of 130 bpm or higher is observed alongside subarachnoid hemorrhage, we recommend
considering the possibility of concomitant thyroid storm and testing for thyroid hormone. If concomitant thyroid
storm is present, we believe that a treatment plan tailored to the patient’s condition is critical, and early diagnosis willlead to a favorable outcome for the patient.
Keywords Subarachnoid hemorrhage, Thyroid storm, Tachycardia†

Aimi Ohya and Makoto Ohtake contributed equally to this work.

*Correspondence:
Makoto Ohtake
makoctnu@yokohama-cu.ac.jp
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Background
Approximately 80–90% of subarachnoid hemorrhages
are caused by ruptured cerebral aneurysms, and the casefatality rate at onset has been reported at 10–67% [1, 2].
Main symptoms are sudden headache, impaired consciousness, and vomiting. In addition, about 7–10% of
patients with subarachnoid hemorrhage may experience
heart failure symptoms with left ventricular wall dyskinesia [3]. In contrast, a thyroid storm refers to a pathological condition in which significant additional stressin the form of surgery, infection, and/or trauma occurs
in the presence of an underlying, untreated, or poorly
controlled thyroid-gland illness that initiates a breakdown of the compensatory mechanisms of the bodyagainst the impacts of thyroid hormone, resulting in alife-threatening condition [4, 5]. Irregular administration of antithyroid drugs, self-interruption, infection andtrauma, surgery, ischemic heart disease, cerebrovascular
accidents, and administration of iodine contrast media
are the triggers. Previous reports on thyroid storm showthat the case fatality rate is 50–90% when untreated and
10% or higher with appropriate treatment [6]. The following symptoms associated with thyroid storm are reported
frequently: central nervous symptoms such as restlessness and impaired consciousness with a Glasgow Coma
Scale (GCS) score of 14 or less (84.4% of patients); tachycardia of 130 beats per minute (bpm) or higher (76.2% of
patients); gastrointestinal symptoms such as vomiting,diarrhea, and jaundice (69.5% of patients); fever of 38 °C(41.5% of patients); and symptoms of heart failure such asa New York Heart Association classification of 4 or a Killip classification of III or higher (39.5% of patients) [6, 7].
Regarding the treatment of subarachnoid hemorrhage,
rebleeding and delayed cerebral vasospasms are important factors that worsen the prognosis of patients after the
onset of subarachnoid hemorrhage. Conservative treatment of ruptured cerebral aneurysms results in a 20–30%
occurrence rate of rebleeding in the first month, which
exacerbates outcomes; therefore, early surgical intervention for the prevention of rebleeding within 72 h of onset
is crucial [1, 8]. Reports suggest that surgery during the
cerebral vasospasm stage has many complications, andthus, it is recommended that the preventive treatment
for rebleeding after 72 h of onset should be performed
after the cerebral vasospasm stage [9]. Surgical interventions to prevent rebleeding include craniotomy andendovascular treatment. The recommendations are tochoose a treatment policy after a comprehensive assessment of the severity, site, and shape of the cerebral aneurysm along with treatment challenges, patient age, andother complications [2, 10]. In contrast, for the treatmentof thyroid storm, in addition to the swift administrationof antithyroid drugs, corticosteroids (hydrocortisone

300 mg/day or dexamethasone 8 mg/day) and potassium
iodide should be administered simultaneously [6, 11].
β-blockers with β1 selectivity are the first-line treatment
for tachycardia. In cases where the heart rate is 150 bpm
or higher, the condition may become severe; therefore,
treatment must be started proactively.
As discussed above, the clinical symptoms of subarachnoid hemorrhage and thyroid storm have much incommon, and it is difficult to recognize thyroid storm,
especially when subarachnoid hemorrhage and thyroid storm occur simultaneously. In this case report, we
describe a case of subarachnoid hemorrhage and thyroid
storm upon the first visit and discuss our diagnosis andtreatment policy along with a review of the literature.
This study protocol was reviewed and approved by theInstitutional Review Board, the Ethics Committee of the
Yokohama City University Medical Center (approval no.
B210400045). The study procedures were performed inaccordance with the ethical standards laid down in the1964 Declaration of Helsinki and its later amendments.
Written informed consent was obtained from this patient
for the publication of this case report.

Case presentation
A 52-year-old woman with no medical history experienced impaired consciousness while bathing and wasbrought to our hospital. The primary physical findings
upon her admission were a GCS score of E1V2M4, elevated blood pressure (208/145 mmHg) and tachycardia
with atrial fibrillation (180 bpm), respiratory rate of 30
breaths/min, and body temperature of 36.1 °C. Braincomputed tomography (CT) revealed subarachnoid
hemorrhage (Fisher group 2, World Federation Neurological Surgeons; WFNS Grade IV) associated witha ruptured aneurysm of the posterior communicatingartery branching from the left internal carotid artery(Fig. 1 a, b). A thyroid hormone test was performed
since tachycardia was also observed. High values of freeT3 (23.10 pg/dl) and free T4 (> 7.7 ng/dl) and low values of thyroid-stimulating hormone (TSH < 0.005 µIU/ml) were observed. As no thyroid dysfunction has beenaddressed previously, it was further determined to bea case of undiagnosed hyperthyroidism. In addition to
the clinical symptoms of tachycardia and diffuse thyroid swelling on imaging, probable Graves’ disease wasdiagnosed based on high T3 and T4 levels, low TSH
levels, and high thyrotropin receptor antibody levels(18.4 IU/l). Although tachycardia continued, vital signs
were stabilized, and the aneurysm was irregular with asize of 8 mm and was accompanied by bleb. Therefore,clipping surgery was performed on the same day to prevent re-rupture (Fig. 1 c, d). The patient’s intraoperative

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Fig. 1 Imaging findings. a Computed tomography (CT) scan of the brain revealing subarachnoid hemorrhage. b CT angiographic view showing ananeurysm of the posterior communicating artery branching from the left internal carotid artery (arrow). c Intraoperative view showing a ruptured
aneurysm* with bleb. d Postoperative axial CT imaging showing Sugita clip and no additional bleeding. e and f A diffusion-weighed magnetic
resonance (MR) imaging and MR angiographical scan showing the absence of cerebral infarction or cerebral vasospasm. *An, aneurysm; ICA,
internal carotid artery; MCA, middle cerebral artery; Pcom, posterior communicating arteryvital signs remained stable. After the operation, oral
thiamazole 30 mg/day and beta-blockers were initiatedas the treatment for hyperthyroidism and tachycardia,
respectively. However, disturbances of consciousness,fever (38.0 °C or higher), and tachycardia of 130 bpm
or higher persisted. Thus, we diagnosed the patient as
having a thyroid storm according to Japanese diagnostic criteria on the 3rd day [6, 7]. The dose of thiamazole was increased to 60 mg/day, and oral potassium
iodide (200 mg/day) as well as hydrocortisone (300 mg/day) was added (Fig. 2). This treatment was successful,and on the 7th day, the patient’s free T3 decreased to2.85 pg/dl, her heart rate improved to 100 bpm or less,and she became lucid. Brain magnetic resonance imaging (MRI) performed on the 14th day of hospitalization
did not show findings suggestive of cerebral vasospasm
or cerebral infarction (Fig. 1 e, f ). Drug dosages were
gradually tapered off as hydrocortisone was reduced to
30 mg/day on the 15th day, and thiamazole and potassium iodide were reduced to 30 mg/day and 50 mg/day,
respectively, for continuous administration. The patient
was transferred to a rehabilitation facility on the 20thday. Three months after the incident, the patient’s Glasgow Outcome Scale score indicated good recovery, andshe achieved a modified Rankin Scale score of 1.

Discussion and conclusions
Characteristics of our caseWe encountered a case of subarachnoid hemorrhage andthyroid storm upon admission. There are previous casereports of patients with hyperthyroidism who developed
subarachnoid hemorrhage [12, 13]. However, to the bestof our knowledge, none of these cases progressed to thyroid storm, and none has involved concomitant subarachnoid hemorrhage and thyroid storm, at the time ofinitial diagnosis. In this case, after the surgery, impaired
consciousness and tachycardiac atrial fibrillation of
130 bpm or higher persisted, and we determined that thepatient’s disturbances of consciousness were not solely
due to subarachnoid hemorrhage. Eventually, the patient
was diagnosed with thyroid storm [7]. Furthermore, it
is possible that the patient was already in a state of thyroid storm since admission, and this state may have been
exacerbated by the use of iodine contrast medium andsurgical invasion [14]. However, since the results of thepatient’s thyroid hormone tests were unavailable when acontrast-enhanced CT was performed on the first visit,
we believe that contrast-enhanced evaluation was unavoidable. If we detect thyroid storm in advance, previous
reports suggest that evaluation to confirm the cerebral
aneurysms should be performed by head magnetic resonance angiography (MRA), without contrast-enhanced

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Fig. 2 Progress chart documenting each clinical finding and drug dose. HR, heart rate; GCS, Glasgow Coma Scalemedium [15, 16]. However, MRA testing for patientswith subarachnoid hemorrhage with unstable vital signs
poses risks. We believe that evaluation according to thepatient’s condition is the best option. In this case, we
think that untreated hyperthyroidism, stress due to theonset of subarachnoid hemorrhage, and factors such as
iodine contrast agent use resulted in a thyroid storm.
Diagnosis for simultaneous subarachnoid hemorrhage
and thyroid storm

Subarachnoid hemorrhage and thyroid storm share many
common symptoms, and when they occur in a patientconcomitantly, they are not easy to diagnose and haveextremely high mortality rates [2, 6]. To prevent complications in these cases, it is important to make a reliable diagnosis upon admission or first visit and prioritize
treatment. In this case, diagnosis of thyroid storm wasdelayed to the 3rd day of hospitalization, after aneurysm clipping was performed. Subarachnoid hemorrhage
is relatively easy to diagnose due to imaging results inaddition to episodes including headache and impaired
consciousness. In contrast, diagnosis of thyroid storm isoften difficult because it has many symptoms like subarachnoid hemorrhage. It often develops in patients with
undiagnosed thyroid disease at the time of first visit.
Therefore, if subarachnoid hemorrhage is diagnosed first,
we believe it can be extremely difficult to diagnose concurrent thyroid storm. Although thyroid function tests

are important for diagnosis, it is impractical to perform
thyroid function tests in all subarachnoid hemorrhage
cases. Thus, it is necessary to screen patients who should
undergo thyroid function testing when they present
with subarachnoid hemorrhage. Thyroid function tests
should be performed for patients with typical symptomsof hyperthyroidism such as exophthalmos and abnormal
sweating or for patients with a history of thyroid disease. Furthermore, when the typical symptoms of hyperthyroidism are subtle or absent, it is difficult to make adefinitive assessment. We thus focus on the existence oftachycardia.
In subarachnoid hemorrhage, more than 90% of
patients exhibit abnormal electrocardiogram findingssuch as sinus bradycardia, sinus tachycardia, ST elevation, and QT prolongation [17, 18]. Summarizing pastdata on heart rate, the average heart rate was 75–86 bpm,
and approximately 20% of patients exhibit tachycardiaof 100 bpm or more [13, 19, 20]. However, tachycardiaof 130 bpm or more is rarely reported. Among 128 caseswith aneurysmal subarachnoid hemorrhage between
January 2013 and November 2021 at our hospital, theaverage heart rate at admittance was 83.8 ± 19.5 bpm(range, 40–180), and 23 patients (17.9%) had a heart rateof 100 or more. It is important to note that none of thesepatients, except the patient presented in this report, who
was the only patient diagnosed with thyroid storm, hadtachycardia above 130 bpm. However, in thyroid storm

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cases, approximately 80% of the patients have exhibitedtachycardia exceeding 130 bpm, which is the diagnostic criterion for thyroid storm [6, 7]. Thus, when tachycardia of 130 bpm or more is observed in patients with
subarachnoid hemorrhage, we recommend performing athyroid function test to differentiate thyroid storm.

treatment policies should be individually considered foreach case. It is necessary to consider thyroid storm as adifferential diagnosis when a patient presents with subarachnoid hemorrhage accompanied with tachycardia. A
thyroid hormone test should be performed in such cases.
In the future, we hope that this report will help diagnose
thyroid storm in subarachnoid hemorrhage cases withtachycardia among as many patients as possible, and that
more patients will have better outcomes.
In conclusion, in patients with subarachnoid hemorrhage who present with tachycardia of 130 bpm or
higher, the possibility of concomitant hyperthyroidism
should be considered first followed by thyroid hormone
tests. We suggest that whenever subarachnoid hemorrhage and thyroid storm occur concomitantly, patienttailored treatment plans should be considered, taking
into account the urgency and acuteness of each patient’s
condition. This will lead to improved outcomes amongsuch patients.

Treatment policy for simultaneous subarachnoid
hemorrhage and thyroid storm

Clear evidence on which disease should be prioritizedwith respect to treatment is absent when a combinationof subarachnoid hemorrhage and thyroid storm are diagnosed together. When surgery for subarachnoid hemorrhage is prioritized, surgical invasion may exacerbate thethyroid storm and worsen a patient’s condition. Delayed
surgery for subarachnoid hemorrhage may pose a riskof rebleeding and may lead to a fatal outcome. In previous reports, when thyroid storm treatment was prioritized over gastrointestinal and respiratory diseases, theresulting outcomes were good [11, 21]. In contrast, whensubarachnoid hemorrhage is conservatively treated, therebleeding rate is 3–4% on the first day of onset, 1–2%
per day during the following 4 weeks, and 20–30% in thefirst month [1, 22]. Poor outcomes during rebleeding episodes have been reported too. In this case, treatment forthyroid storm began a few days after aneurysm clipping
surgery due to the delayed diagnosis, and symptoms were
improved within a few days with a desirable outcome.
We believe that prioritization of surgical intervention forsubarachnoid hemorrhage is dependent on comprehensive assessment of the urgency of surgery based on thesize and shape of the cerebral aneurysm and the presenceof hematoma formation. Craniotomy and endovascular treatment are options to prevent rebleeding, but theiodine contrast medium used in endovascular treatment
has a high potential of exacerbating thyroid storm. Thus,
craniotomy seems to be the first choice. When thyroid
storm treatment is prioritized, it is recommended to pay
close attention to rebleeding and prevention of cerebral
vasospasm by sedation and antihypertensive therapy andto perform surgical intervention promptly when thyroid
function is stable, and the cerebral vasospasm period is
over.
This study had some limitations. Because this is a studyof a single case of concomitant subarachnoid hemorrhage
and thyroid storm, which has rarely been previously
reported, sufficient literature is unavailable. Since theconcomitant occurrence of these diseases is quite difficult
to diagnose, it is likely that in several previous cases, thyroid storm was overlooked with a poor outcome among
patients. Fortunately, we were able to achieve a good outcome in this case. However, this is ultimately a report of asingle case, and treatment priorities and other aspects ofAbbreviations
GCS	Glasgow coma scale
Bpm	Beats per minuteCT	Computed tomography
WFNS	World federation of neurosurgical societies
TSH	Thyroid-stimulating hormone
MRI	Magnetic resonance imaging
MRA	Magnetic resonance angiography
Acknowledgements
We would like to thank Editage for English language editing.
Authors’ contributions
Aimi Ohya and Makoto Ohtake came up with the conception and the design.
Aimi Ohya, Makoto Ohtake, Yusuke Kawamura and Taisuke Akimoto performed the clinical procedures. Aimi Ohya and Makoto Ohtake wrote the main
manuscript text. Masayuki Iwashita, Tetsuya Yamakoto and Ichiro Takeuchi critically revised the article. All authors read and approved the final manuscript.
Funding
This study was funded by the Japan Society for the Promotion of Science
KAKENHI (grant number 21K09105) to M. O.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated oranalyzed during the current study.

Declarations
Ethics approval and consent to participate
The study protocol was reviewed and approved by the Ethics Committee of
Yokohama City University Medical Center (approval no. B210400045). The
study procedures were performed in accordance with the ethical standards ofthe 1964 Declaration of Helsinki and its later amendments. Written informed
consent was obtained from the patient.
Consent for publication
Written informed consent for the publication of this case report was obtained
from the patient.
Competing interests
The authors declare no competing interests.

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Author details
1
Department of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Japan. 2 Department of Neurosurgery, Yokohama City
University Medical Center, Yokohama, Japan. 3 Department of Neurosurgery,
Yokohama City University Graduate School of Medicine, Yokohama, Japan.

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subarachnoid hemorrhage. Neurol Res. 2018;40(10):856–61.
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prognostication. Am J Emerg Med. 2012;30(5):732–6.
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Received: 18 May 2022 Accepted: 22 February 2023

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