Successful conservative management of the spontaneous rupture of a superior thyroid artery aneurysm

We describe the first case report, to our knowledge, of successful conservative management of the spontaneous rupture of a superior thyroid artery (STA) aneurysm. This type of rupture is rare, where spontaneous cervico-mediastinal haemorrhage presents a real threat to life, because of potential cerebral hypoxia and airway compromise. The decision for conservative management was only after several attempts at radiological arterial coil embolization were unsuccessful, in the unsuitable surgical candidate. Institutional Review Board approval was obtained from the Western Health Low Risk Ethics Panel. An 80-year-old man presented with sudden onset painful midline neck swelling, associated voice hoarseness and odynophagia. He denied trauma, new medications or previous goitre. The patient was on aspirin and had multiple medical co-morbidities including hypertension, primary hypothyroidism and chronic heart failure. Examination showed neck mass with extensive bruising over anterior chest (Fig. 1), with no movement on swallowing or tongue protrusion. Bilateral vocal cord movement was normal on nasendoscopy; however, the entire anatomy appeared displaced posteriorly. There was no stridor, stertor or dyspnoea and oxygen saturation was 97% on room air. Biochemical investigations revealed a haemoglobin drop from 111 g/L to 93 g/L with no coagulopathy identified. Computed tomography with angiogram contrast (CTA) revealed a large bi-lobed haematoma in the thyroid region measuring 8.0 ¥ 5.0 ¥ 6.9 cm (Fig. 2). The right STA was aneurysmal with likely arteriovenous malformation (Fig. 3). There was 20% tracheal narrowing over the C7 vertebral body with moderate tracheal deviation to the right. Emergency angiography was performed. Initial canalization of the right external carotid artery (ECA) identified a tiny right STA. A small amount of contrast extravasation was noted. Subsequent attempts of right ECA re-canalization were unsuccessful, however, for super-selective study of the STA. No coils were deployed. Anaesthetics, intensive care unit (ICU) and vascular surgery input were sought. Though surgical exploration was considered, conservative management was recommended given patient’s age, co-morbidities and risk of surgery. He did not require intubation, tracheotomy or ICU stay. Repeat CTA on day 3 showed interval reduction in haematoma, to 7.5 cm ¥ 4.0 cm ¥ 6.6 cm, with no evidence of ongoing bleeding or false aneurysm. The right STA remained visible; however, there was no evidence of further extravasation or aneurysm of this vessel. The patient was clinically stable and transferred to rehabilitation with head and neck outpatient clinic review.