An 82-year-old woman presented with a 9-month history of progressive headache and swelling of the left side of head. The patient experienced deterioration in their consciousness level and was brought into hospital. Examination revealed a localised swelling of the left of the skull of bony consistency with a smooth surface. The patient was confused; vitals were stable and the patient had papilloedema. The rest of the systemic examination was normal other than a scar on the neck, which on further questioning was found to be due to surgery on the thyroid 20 years previously. Follow-up of hospital records of the previous surgery reported a tissue diagnosis of follicular carcinoma. The patient had undergone a bone scan after surgery, which was negative for any metastases. The patient was discharged on replacement therapy of thyroxin 100 micrograms daily. None of the patient’s family members had any thyroid disease. An x ray of the skull was performed and revealed a huge lytic lesion on the left of the skull (fig 1). A CT scan of the head revealed a large sclerotic and lytic lesion compressing the left hemisphere with cerebral oedema and mid-line shift (figs 2, 3). MRI of the brain and skull was performed, and a large skull lesion with contrast enhancement was noted with intact duramatter but compressed left hemisphere and mid-line shift (figs 4, 5). Thyroid function was normal but thyroglobulin levels were markedly elevated.
Figure 1.
An x ray of the skull showing extensive metastases from thyroid carcinoma.
Figure 2.
A CT scan showing the lesion and mid-line shift due to compression by lesion.
Figure 3.
A CT scan of the skull bone window showing the lesion.
Figure 4.
A MRI scan showing a well delineated lesion between the scalp and meninges compressing the adjacent cerebral hemisphere.
Figure 5.
A MRI scan showing compressed adjacent cerebral hemisphere and collapsed lateral ventricle due to lesion.
The patient was admitted into intensive care where she further deteriorated and died 1 week later. A radioiodine scan would have been ideal to rule out other sites of metastases, but the patient died before any other intervention was possible.
We are presenting the interesting images of metastases to the skull from thyroid carcinoma without any direct invasion of underlying meninges or brain tissue.
Isolated skull metastasis from follicular thyroid carcinoma are well reported and treated, with some difficulty in primary diagnosis.1 Thyroid masses with underlying malignancy have been diagnosed with years of delay.2
Acknowledgments
We are grateful to the help rendered by our radiology department head Dr Bothania A Shakour and Mr L Phillip.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
REFERENCES
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