Endovascular treatment of massive hemorrhage arising from inferior thyroid artery after fine needle aspiration of thyroid: a case report

Abstract

Background: Fine needle aspiration (FNA) of the thyroid gland is an effective and safe method for evaluating thyroid nodules; catastrophic complications following FNA of thyroid are rare. Massive hematomas with active bleeding leading to airway compromise are extremely rare complications of FNA, with only a few reported cases in literature.

Case presentation: An 80 year-old man presented to the emergency room with severe respiratory distress, four hours after undergoing thyroid FNA for the evaluation of a thyroid nodule. An axial neck computed tomography (CT) revealed a large hematoma in the retropharyngeal space that caused anterior deviation of the trachea, with extravasation of contrast media suggesting active bleeding within the hematoma. Right subclavian angiography identified active bleeding from the right inferior thyroid artery (ITA). Transcatheter arterial embolization (TAE) was successfully performed with n-Butyl cyanoacrylate (NBCA). Follow-up CT done three weeks after the procedure revealed a low-density lesion in the retropharyngeal space, indicating an old hematoma. The patient recovered well and was discharged 6 weeks later.

Conclusion: Massive hemorrhage arising from the ITA is a rare but possible complication following FNA, which can potentially be fatal. Appropriate preventive measures should be taken while performing FNA, especially in patients on long-term anticoagulant drugs, and prompt intervention is mandatory for patients with acute hematoma after FNA.

Keywords: Fine needle aspiration; Hemorrhage; Inferior thyroid artery; Thyroid gland; Transcatheter arterial embolization.

Fig. 1

Contrast-enhanced chest computed tomography (CT) taken before ultrasound-guided fine needle aspiration (FNA) of the thyroid gland reveals well-defined low density nodule in right lobe of thyroid gland

Fig. 2

a An axial neck CT take after thyroid FNA underwent on emergency department reveals a large hematoma (red asterisk) in the anterior neck space with anterior tracheal deviation and nodule in the right thyroid lobe with intra- and extra nodule air-bubbles caused by the fine needle aspiration. b Sagittal CT scan shows extravasation of contrast media suggesting active bleeding (red arrow) within the hematoma

Fig. 3

a Right subclavian angiography shows active bleeding (red arrow) in the neck, corresponding to the CT image. b Right thyrocervical trunk is selected and the culprit branch is identified as the right inferior thyroid artery (red arrow head)

Fig. 4

After superselection of the right ITA using microcatheter, embolization of the right ITA is performed using NBCA, and a post-embolization angiogram reveals successful hemostasis without active bleeding

Fig. 5

Follow-up CT taken three weeks after transcatheter arterial embolization reveals a low-density lesion indicating an old hematoma in the posterior neck space