Teaching Case

The patient, an 83-year-old woman, suffering from ischemic heart disease and atrial fibrillation, on anticoagulant therapy, showed up to the Emergency Department with intense throat pain, painful swelling of the neck and evidence of breathing noises on chest auscultation.

The mucous membrane of the first respiratory tract was normal.

In the pre-contrast phase (Fig. 1A), CT showed an enlarged and heterogeneous thyroid gland with a large heterogeneous nodule in the inferior left thyroid with basal density (50-55 HU) consistent with intrathyroidal bleeding.

After administration of the contrast medium, arterial blush concerning for active haemorrhage was detected in the nodular formation at the left lobe (Fig. 1B), with an increase in blood extravasation in the venous (Fig. 1C) venous phases.

Super-selective catheterization of the inferior thyroidal artery (Fig. 2A) confirmed active bleeding from the inferior thyroid artery (Fig. 2B).

Embolization was performed with re-absorbable gelatin sponge Embocube. Angiography showed the positive outcome of the embolization with the absence of blood supply at the level of the treated area (Fig. 2C).

An ultrasound check was performed the morning after the procedure. After the administration of Sonovue contrast medium (2.5 cc) the complete devascularisation of the treated area was proved (Fig. 3).

Spontaneous hemorrhages of thyroid nodules are rare events, appearing sometimes in association with anticoagulant therapies. They mainly recognize a venous origin and tend to limit themselves [1].

In most cases, thyroid hemorrhages are related to preexisting conditions such as goiter, cysts, or nodules that increase the risk of bleeding. They present with sudden latero-cervical pain, sectorial enlargement of the gland, dysphagia, breathing difficulties and a sense of weight which spontaneously regress in a short time.

Intraglandular hemorrhages, which produce a critical size hematoma, with airway obstruction that requires intubation are rare; even rarer are massive bleedings that put the patient's survival at risk.

The most common causes include trauma [2], iatrogenic lesions [3], and spontaneous bleeding. Among the iatrogenic lesions, a primary role is represented by the lesions caused by FNAC with small needles (25-27 gauge) [4, 5].

Spontaneous haemorrhages are even rarer [6,7] and seem to be linked to the presence of hypervascularized nodules, occurring more frequently with the concurrent use of anticoagulants.

Although the ultrasound of  the neck can detect the presence of structural alterations of the thyroid gland, this method does not allow the detection of active arterial blush.

Thyroid haemorrhage is best diagnosed with computed tomography with contrast medium which well defines the presence and the extent of active bleeding and the potential mediastinum involvement.

As mentioned, in most circumstances the treatment of haemorrhages is conservative. In serious cases, the airway patency should be secured with endotracheal intubation or performing an emergency tracheostomy [8]. In addition, the surgical removal of part or all of the thyroid gland may be necessary in the case of incoercible bleeding.

Endovascular embolization of the thyroid has already been proposed for treatment of hyperfunctioning goiters with thyrotoxic crisis [9] or in the treatment of cervicomediastinal goiter as a preoperative procedure, or as an alternative to thyroid resection [10].

Thyroid blood supply is achieved through two superior thyroid arteries, the first branches of the external carotid artery, two inferior thyroid arteries that originates as terminal arteries from the thyrocervical trunk, and sometimes by an additional artery, the thyroid ima artery that reaches the gland from below at the isthmus level.

In our case, embolization was first performed via a selective catheterization of the common carotid artery and subclavian artery and then through a superselective catheterization of the thyroid-cervical trunk. Then with a microcatheter we performed a superselective catheterization of the small vessels afferent to the thyroid nodule, site of haemorrhage.

We used re-absorbable gelatin sponge particles to avoid non-target embolization with permanent embolic agents; furthermore because of small vessels size and their tortuous anatomy we tought that delivering the coil to the bleeding site was not safe.

The patient’s postprocedural course was uneventful.

This procedure avoided a more invasive treatment which would have otherwise been necessary given the persistence of the bleeding.

Endovascular treatment in thyroid active arterial haemorrhages has proved to be an effective, safe, and rapid therapeutic solution.