Moyamoya syndrome associated with graves' disease: A case report

We are reporting a case of 28-year-old young lady who presented with sensory stroke. Magnetic resonance imaging (MRI) of brain showed bilateral watershed infarcts in middle and anterior cerebral territories. Brain angiography showed stenosis of supraclinoid portion of both internal carotid arteries (ICAs) without any moyamoya vessels (collaterals). Contrast MRI of brain showed enhancement of vessel wall in supraclinoid portion of both ICAs suggestive of inflammation. She was a known case of hyperthyroidism on irregular treatment. Work up for vasculitis was negative. Temporal artery biopsy was normal. She was diagnosed as a case of moyamoya syndrome associated with Graves' disease. She showed good response to immunosuppressants, aspirin, and treatment of hyperthyroidism. She had no ischemic events for 6 months but was later lost to follow-up. After 1 year she again presented with two episodes of transient ischemic attacks. Repeat imaging showed reduction in the wall thickening and enhancement and no new infarcts.