Hyperthyroidism is a clinical picture that is caused by too much secretion of thyroid hormones. Thyrotoxicosis is an exagerated form of hyperthyroidism characterized by excessively high levels of blood thyroid hormone levels. It is a life-threatening condition and must be treated urgently.
In hyperthyroidism, thyroid hormone levels are high and TSH levels are low in the blood. Clinical manifestations of hyperthyroidism include nervousness, insomnia, sweating, tremor, flushing, alopesia, weight loss, palpitation and eye bulging (exophtalmia). The most common cause of hyperthyroidism (in more than 80% of cases) is Graves disease. In this condition, the body produces antibodies called (thyrotropin receptor antibodies, TRaB). These antibodies attach to the surface of thyroid cells and cause these cells to work too much causing overproduction of thyroid hormones. In this condition, the thyroid gland becomes enlarged and there is edema, inflammation and increased vascularity. The most prominent physical finding is eye bulging (exophtalmia), which is quite characteristic for this disease. The Graves disease is seen 7-8 times more common in women compared to men.
Is there anything new in the treatment?
In Graves disease, the classic treatment options are antithyroid medications, radioactive iodine and surgery. Generally, antithyroid pills are tried first. If this fails or is not sufficient, patients are treated either with radioactive iodine or surgical operation. Another option in the management of Graves disease is embolization, in which 3 out of 4 feeding vessels of thyroid gland are plugged with a simple angiography procedure. After embolization, the thyroid tissue fed by the occluded vessels becomes smaller in size and hormonally less active.
Embolization has been successfully used in the treatment of Graves disease in many centers for the last 2 decades. Studies indicate that in nearly 70-80% of the patients, hormone levels return to normal, symptoms of hyperthyroidism diminish, the size of the thyroid becomes normal and antibodies against the thyroid tissue (TRaB) decrease in the blood. The side effects of embolization procedure are generally mild and typically include neck pain, fatigue and subclinical hyperthyroidism that lasts for some weeks. The most important advantages of embolization are as follows:
There is no incision or suture in the neck
No general anesthesia is required
Hospital stay is only one night
It may correct hyperthyroidism without surgery and radiation
Since the thyroid gland is preserved no hypothyroidism occurs after the treatment
Another cause of hyperthyroidism is toxic thyroid nodules that secrete too much hormones. These nodules may be single (solitary) or multiple (MNG). For single toxic nodules, the ideal treatment is percutaneous ablation. Because in this procedure, both the nodule and hyperthyroidism can betreated in a single session and the normal thyroid gland is preserved. Many studies in the literature clearly indicate that both thermal ablations (laser, radiofrequency, microwave) and alcohol ablation are very successful in the treatment of toxic and nontoxic thyroid nodules.
If there are multiple nodules in a patient with hyperthyroidism, percutaneous ablation can still be used. But in this case, it must be made clear which nodule(s) is toxic (responsible for hyperthyroidism). This can be done with a simple test called thyroid scintigraphy. If the toxic nodules are single or several and they can be identified using ultrasound + scintigraphy, percutaneous ablation is feasible and successfully treat both the nodules and hyperthyroidism. If the toxic nodules are too many or can not be identified with ultrasound + scintigraphy, then they can be treated with embolization, as in Graves disease.
In our 20 year-old patient with Graves disease, Doppler ultrasound typically shows increased number of thyroid vessels (inferno pattern). With a simple angiography procedure, 3 out of 4 thyroid arteries were occluded with small particles (embolization). Three months after the treatment, the patient has no symptoms and her hormone levels became normal.
In our 23 year-old patient with hyperthyroidism, a 33x28x27 mm toxic nodule was seen on ultrasound and treated with laser ablation. Six months after the treatment, a follow-up ultrasound shows 76% volume reduction in the nodule. The thyroid hormone (T3, T4 and TSH) levels have returned to normal and the patient is currently symptom free.
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