Objective: To describe a patient with SREAT in whom an initial diagnosis of a stroke was made

Background: Acute ataxia is a clinical setting where stroke should be considered as an  etiology, since it is one of the most prevalent disease seen in neurology practice. Nevertheless, there are several entities that due to their low prevalence, are rarely thought of. Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) is a disease with low prevalence, probably as a result of being underdiagnosed, which can present with a  wide  range of clinical manifestations.

Method: Case report

Results: A 57-year-old male with a history of type 2 diabetes mellitus who developed a rapidly progressive tremor in his left hand, which later involved the ipsilateral lower limb, leading to gait instability. Initially, he was presumed to have sustained a stroke.

Neurological examination revealed right internuclear ophthalmoplegia, severe hemiataxia in his left hand with superimposed myoclonus, bilateral choreiform movements and neuropsychiatric symptoms including impulsivity and confabulation. Brain MRI showed brain stem malacia with diffuse gliosis, nonspecific white matter hyperintensities and meningeal enhancement without a clear anatomical correlation to his symptoms. Lumbar puncture findings were unremarkable. Further workup ruled out metabolic abnormalities, neuroinfection and vasculitis. Serologic testing revealed an increase in anti-TPO antibodies. The patient received a five-day course of methylprednisolone, resulting in a notable reduction in ataxia.

His clinical improvement following corticosteroid therapy, along with serologic findings of antiTPO supported a diagnosis of immune-mediated ataxia in the context of SREAT

Conclusion: SREAT is a clinical entity characterized by a heterogeneous presentation (1). This case illustrates a patient who initially presented with upper limb tremor and severe ataxia, which led to an early suspicion of a stroke due to the remarkably rapid onset and progression of symptoms. Notably, vasculitis is the underlying pathological process of STREAT, and it plays a crucial role in shaping its clinical manifestations (2).  Even Though it has been reported before, ataxia as the main symptom is quite rare in SREAT (3). Despite a delayed diagnosis and  severe ataxia, the steroid administration  yielded significant symptom improvement.

References: 1. Schneider SA, Tschaidse L, Reisch N. Thyroid Disorders and Movement Disorders—A Systematic Review. Mov Disord Clin Pract. 3 de febrero de 2023;10(3):360-8.
2. Chaudhuri J, Mukherjee A, Chakravarty A. Hashimoto’s Encephalopathy: Case Series and Literature Review. Curr Neurol Neurosci Rep. 2023;23(4):167-75.
3. Wei C, Shen Y, Zhai W, Shang T, Wang Z, Wang Y, et al. Hashimoto’s encephalopathy with cerebellar ataxia as the main symptom: A case report and literature review. Front Neurol. 23 de agosto de 2022;13:970141.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/sreat-with-cerebellar-involvement-when-tremor-mimics-stroke-a-case-report/