Background: Spontaneous thyroid gland hemorrhage is a rare event. The present retrospective study considers its clinical impact and management in a referral center. Methods: Clinical records of adult patients accessed in the last 10 years (2009-2018) in the Emergency Department of Policlinico Gemelli IRCCS were reviewed to study patients with spontaneous thyroid nodule hemorrhage. All demographic and radiological or surgical parameters were included, with special attention to the characteristics of thyroid disease and clinical management. Results: Among the 631,129 adults, who were registered during the period considered, 59 consecutive patients were included in the study. The mean age was 48.3 ± 14.3 years with a prevalence of females. The main symptoms were acute neck pain, dyspnea and dysphagia. All patients underwent ultrasound evaluation; CT scan was performed on only three patients, finding one case of active intra-nodular bleeding requiring urgent surgery. Six required hospitalization; the others were discharged and referred for ambulatory endocrinology follow-up. Among them, seven patients underwent surgery in the next six months, with malignant disease found in three cases (5.1%). Conclusion: Intra-thyroidal spontaneous hemorrhage is a rare event occurring in multinodular as well as in single nodule thyroid disease. Although the clinical course is mostly benign, this condition should be carefully evaluated as, in rare circumstances, active bleeding could induce airway obstruction with the need for emergency surgery. Patients should be referred to endocrinology ambulatory follow up because bleeding could arise as first sign of malignant lesion in some cases.