Presentation
New onset vertigo, headache, and vomiting. Recent neck manipulation.
Patient Data
Non-contrast CT brain
Normal. No hemorrhage or established ischemic stroke.
CT angiogram
Multiple heterogenously enhancing masses in the left neck adjacent to the thyroid and along the carotid space. The inferior-most mass is closely related and possibly in continuity with the left lobe of the thyroid, which is heterogeneous with multiple nodules and generally appears very similar to the other masses. It is located behind the internal jugular vein, which is displaced and compressed anteriorly and anterior to the common carotid artery. The most superior of the masses is at the left common carotid bifurcation and splays the left ICA and ECA.
The imaged lung apices are clear. Moderate stenosis of the proximal left cervical ICA, from external compression from the mass at the left CCA bifurcation. Normal opacification of the left ICA distal to this. Co-dominant vertebral arteries. Bilateral foetal posterior cerebral arteries and a left sided PCOM infundibulum. No intracranial aneurysm, large vessel occlusion or other vascular abnormality identified.
Conclusion
Three heterogeneously enhancing masses in the left neck, related to the thyroid gland and carotid space. A thyroid cancer with nodal metastases is most likely. Surgical referral and ultrasound with guided biopsy is recommended.
Case Discussion
The patient went on to have a biopsy of the left lobe of the thyroid and left-sided adjacent mass.
Histology
Left-sided mass: the smears are cellular, containing malignant cells presenting in monolayered sheets, crowded groups and papillae. The malignant cells have fine chromatin, nuclear grooves, intranuclear inclusions, conspicuous nucleoli and variable amounts of cytoplasm. The background contains pigmented macrophages, multinucleated giant cells, occasional neutrophils, scant thick amorphous material, lymphocytes and red blood cells.
Left thyroid lobe: The smears are cellular, containing malignant cells presenting in monolayered sheets, crowded groups and papillae. The malignant cells have fine chromatin, nuclear grooves, intranuclear inclusions, conspicuous nucleoli and variable amounts of cytoplasm. The background contains pigmented macrophages, multinucleated giant cells, occasional neutrophils, lymphocytes, scant thick colloid and red blood cells.
Final diagnosis
Metastatic papillary thyroid carcinoma.
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