-- • European Journal of CardiOthoracic Surgery Letters to the editor rE Sprmger-Verlag 1995 _ _ Eur J Cardio-thorac Surg (1995) 9 : 7 1 7 - 7 1 8 Cerebral ischemia from thoracic goiter M. E. Ribet, E. Mensier, D. Caparros-Lefebvre, F. Auber Hopital Calmette (Chirurgae), CHU, F-59037 Lille Cedex, France Most ischemic cerebral disturbances result from narrowing or occlusion of brain vessels. Other causes include cardiac disorders, subclavian steal syndrome, thrombocytosis, c h a n g e s i n h e m o g l o b i n o f f i b r i n o g e n c o n c e n t r a t i o n and hypotension. The extracranial circulation can account for cerebral ischemia, from transient ischemic attacks ( T I A ) to s t r o k e , d u e to m o d i f i c a t i o n s o f a n a t o m y a n d f l o w o f a r t e r i e s at t h e c e r v i c o t h o r a c i c l e v e l . T h e r e s p o n s i b i l ities of carotid, vertebral and subclavian arteries have been w e l l d o c u m e n t e d . T h e r o l e o f t h e t h y r o i d g l a n d a n d its v e s sels h a s b e e n d i s c u s s e d l e s s o f t e n . It c o u l d b e c o n s i d e r e d in the following two cases. Case 1 A 39-year-old truck driver had been unable to work for 2 years because of frequent TIA causing left-sided hemiparesls. Computed tomography (CT) scans showed an area of low density in the right parietal lobe (Fig. 1). Anglography of the cervical and cerebral vessels revealed no stenosis or other anomaly Blood pressure, blood count and biology were normal However the patient had a cervicothoracic goiter, without any symptom of thyroid disorder or any sign of compression. No treatment of this goiter had ever been considered. A new angiogram of the aortic arch showed both carotids originatIng from a common trunk shared with the right subclavian artery. The carotids were pushed apart but were not compressed. The right thyroid arteries were enlarged (Fig. 2). It was decided to proceed with thyroidectomy, as frequent TIA had left the patient with a motor deficit and decreased sensitivity on the left side and as not other cause of this disorder could be found. In March 1979, subtotal bilateral resectmn of the goiter was performed through a cervicotomy. It was benign. One month later the patient had recovered his sensitivity and his motricity had improved. In 1994 he was leading a normal life, driving a truck and had not had any more trouble for 15 years. Received for publication: January 25, 1995 Accepted for publication: April 27, 1995 Correspondence to: M. E. Ribet Case 2 A 48-year-old lady had a motor cycle accident in 1985, with cerebral commotion and no after-effect. In May 24, 1988, she became unconscious, with no tongue biting or urinary loss. She recovered after 3 h. Clinical examination was normal. Electroencephalograph (EEG) showed right temporal paroxymal waves. Brain CT scans showed diffuse edema. Chest radiograms and CT scans suggested the existence of a medlastinal goiter, hypervascularlzed on its surface with aspects of deep necrosis (Fig. 3). Thyroid hormone assays were normal. A scintlgram showed no fixation. An anglogram of the aortic arch showed an enlargement of the thyrocervical trunk with voluminous inferior arteries. In June 1993, a cervico-sternotomy revealed a mediastinal retrovascular goiter, pedunculated on the left cervical thyroid lobe and crossing the mediastmum to the right. The cervical gland appeared normal otherwise. The mediastinal mass was resected. It was benign. Twenty-two months later the patient had had no more attacks, with no further treatment. Clinical examination, EEG and cerebral magnetic resonance imaging (MRI) were all normal. Although cerebral disorders m relation to an impaared superior caval venous return (which did not exist in these two cases) are known and accidents from modified cervicothoracic arterial patterns have been explained and detaded, the importance of thyroid gland and arteries as causes of cerebral ischemia has not often been discussed. In 1978, Le Brigand and associates [2] operated on a patient with a cervicothoracic goiter who had transient attacks of right hemiplegia with aphasia when he extended his neck and threw his head backwards. Thyroidectomy cured him, but the duration of followup was not given In 1986, Gadisseux and associates [1] described a case of recurrent TIA resolved after the removal of a voluminous retrotracheal goiter. Six months after surgery, the patient was free of symptoms. Previously, Mueller and Hmck [3] and Trevino [4] had brought attentmn to thyrocervical collateral channels secondary to the obhteratlon of the subclavian arteries beyond the vertebral oririces. Though it is admitted that a proximal steal in the common carotid artery in the absence of distal stenosis, for example when using this vessel for bypass, does not give rise to any cerebral symptom, these two cases suggest the contrary: the neurological disorders &sappeared after the resection of the thoracic goiters. Arterial compression and steal probably added up m the two patients. The follow-up is in favor of this mechanism in spite of hemodynamic lack of evidence. In practical terms, these cases advocate the necessity of chest radiograms and of heart-to-brain angiograms in patients presenting with otherwise unexplained cerebral symptoms 718 Fig. 1. Case 1: Low density area in the brain right parietal lobe Fig. 2. Case 1: Cervicothoracm goiter, carotid anomaly and enlargement of thyroid arteries Fig. 3. Case 2: Mediastinal mass, both hypervascularized (02) and necrotic (0]) References : ,y ,9 1. Gadlsseux R Mmette P, Trigaux JR Michel L (1986) Cerebrovascular circulation "steal" syndrome secondary to a voluminous retrotracheal goitre. Int Surg 71:107-109 2. Le Brigand H, Loutre JC, Nehlil J (1978) Accidents ischdmiques c6r6braux par goitre plongeant endothoracique. Rev Neurol 134:625-626 3. Mueller RL, Hinck VC (1967) Thyrocervical steal. Am J Roentgen 101:128-129 4. Trevino RJ (1970) Thyrocervical steal syndrome. Arch Otolaryng 92: 177-180