Diagnostic imaging in thyrotoxicosis

In thyrotoxicosis, imaging procedures, mainly scintigraphy, color Doppler sonography and radioiodine uptake test are used in the differential diagnosis as well as in the morphofunctional evaluation of the thyroid before and after therapy (mainly pharmacological or with radioiodine). Radioiodine uptake test differentiates high uptake thyrotoxicosis (Graves'disease, toxic nodular goiter) and low uptake thyrotoxycosis (subacute or silent thyroiditis, ectopic thyrotoxicosis, iodine-induced hyperthyroidism). In Graves'disease scintigraphy shows thyroid enlargement with intense homogeneous tracer uptake; rarely nodules with no uptake are present. On color Doppler sonography, a part from enlargement, typical findings are: diffuse structural hypoechogenicity (at times with echoic nodules), parenchymal hypervascularization ('thyroid inferno'), high systolic velocities (PSV >70-100 cm/sec) in inferior thyroid arteries. Scintigraphy is the only method able to evidence an autonomously functioning thyroid nodule and stage it (in association to clinical findings and TSH, FT₃,FT₄ determination) as: toxic, non toxic (or pretoxic) and compensated, depending on whether there is inhibition of extranodular tissue. A scintigraphically 'hot' nodule appears hypervascularized on color Doppler sonography (especially in the toxic or pre-toxic phase) with high PSV (>50-70 cm/sec) in the ipsilateral inferior thyroid artery. The most reliable parameters in the evaluation of the therapeutic efficacy are: decrease in thyroid (Graves'disease) or nodular (autonomously functioning nodule) volume; decreased radioiodine uptake (Graves'disease); functional recovery of suppressed parenchyma (autonomously functioning nodule); decreased PSV in the inferior thyroid arteries.