Androgen-induced cerebral venous sinus thrombosis in a young body builder: case report

Androgen-induced cerebral venous sinus thrombosis in a young body builder: case report
Mohammad Ali Sahraian , Mahmood Mottamedi , Amir Reza Azimi and Babak Moghimi
Department of Neurology, Sina Hospital, Tehran University of Medical Sciences, Hassan Abad Square, Imam Khomini Street, Tehran, Iran

BMC Neurology 2004, 4:22 doi:10.1186/1471-2377-4-22

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2377/4/22

Received 21 September 2004

Accepted 3 December 2004

Published 3 December 2004

© 2004 Sahraian et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Outline Abstract

Abstract Background Case presentation Discussion Conclusions Lists of abbreviations Competing interests Authors' contributions Acknowledgements References Pre-publication history

Background Cerebral venous sinus thrombosis is an infrequent disease with a variety of causes. Pregnancy, puerperium, contraceptive pills and intracranial infections are the most common causes. The patient may present with headache, focal neurological deficits and seizures. The clinical outcome is highly variable and treatment with heparin is advised.

Case presentation The patient is a 22 year old male who presented with headache, repeated vomiting and papilledema. He was a bodybuilder doing exercise since 5 years ago, who had used nandrolone decaonoate 25 milligrams intramuscularly during the previous 5 months. Brain MRI and MRV showed superior sagital and transverse sinus thrombosis and extensive investigations did not reveal any known cause.

Conclusions We suggested that androgen was the predisposing factor in our patient. Androgens may increase coagulation factors or platelet activity and cause arterial or venous thrombosis. As athletes may hide using androgens it should be considered as a predisposing factor for thrombotic events in such patients.
Background

Cerebral venous sinus thrombosis (CVST) is a disease with a wide spectrum of non specific clinical signs and symptoms, including headache, focal neurological deficits, seizures and coma. The clinical outcome is highly variable; patients may recover completely or may develop severe and lasting neurological deficits [1]. There are many causes for this disease but the most common predisposing factors are pregnancy, puerperium, contraceptive pills, coagulopathies and intracranial infections [2]. There are few reports of patients with CVST after androgen therapy. We present a young bodybuilder man who developed CVST with abusing androgens for increasing muscle mass.

Outline Case presentation

Abstract Background Case presentation Discussion Conclusions Lists of abbreviations Competing interests Authors' contributions Acknowledgements References Pre-publication history

In May 2004 a 22 year old male was admitted to our department with chief complaints of headache and vomiting. The patient was well till 10 days prior to admission that developed progressive, intense bitemporal headache exacerbated with bending. The patient also had history of malaise, nausea and several episodes of vomiting from 3 days before admission. The only objective finding on physical examination was bilateral papilledema. The patient was a body builder doing exercise from 5 years ago who had used nandrolone decaonoate 25 mg once or twice a week during the last 5 months. He had injected 20 ampoules in this period. Brain computed tomography without contrast was done for the patient which showed cord sign, emergency MR imaging including T1 – T2, weighted and MRV showed prominent superior sagital and transverse sinus thrombosis. The C.S.F opening pressure was 480 mm/H2o without any other abnormality. Heparin 80 IU/kg started as loading dose then continued 1000 IU/ hr for 10 days. On the 5^thday of treatment headache resolved and warfarin added to heparin. Laboratory tests including antithrombin III activity, protein C, S factor V leiden, Plasma hemocystein and anticardiolipin were all within normal limits. The patient was discharged in a good condition and was maintained on 6 months warfarin protcol.

Outline Discussion

Abstract Background Case presentation Discussion Conclusions Lists of abbreviations Competing interests Authors' contributions Acknowledgements References Pre-publication history

There are few reports of CVST following androgen therapy [3], but there is just one reported case of CVST in androgen using young body builder [4]. The anabolic activity of testosterone and its derivatives is primarily manifested in its myotrophic actions which result in greater muscle mass and strength. This has led to widespread use of androgenic anabolic steroids by athletes at all levels. Nandrolone decaonoate is a synthetic anabolic steroid. In focus on homeostasis system the most important factors under testosterone regulation are fibrinogen, Plasminogen activator inhibitor-1 (PAI – 1) and platelet aggregability. The current data indicate that testosterone lowers fibrinogen and PAI – 1, however these anticoagulatory and profibrinolytic may be opposed by proaggregatory effects on platelets because high dosages of androgens were found to decrease cycloxygenase activity and thereby increase platelet functions [5]. Proaggregatory effect of testosterone and other synthetic androgens become more reliable theory for CVST, according to recent publication [6].
Conclusions

This case report presents a patient with CVST following exogenous androgen usage with a mechanism which is not completely understood, but it may be related to platelet activation or an increase in coagulation factors. As androgen use may be frequent and hidden in athletes, it may be an underestimated cause of cerebral venous thrombosis in young adults and careful history should be taken in these groups of patients.
Lists of abbreviations

CVST: cerebral venous sinus thrombosis PAI-1: Plasminogen activator inhibitor-1 MRI: magnetic resonance imaging MRV: magnetic resonance venography
Competing interests

The author(s) declare that they have no competing interests.
Authors' contributions

Figures

Figure 1
T1 weighted horizontal nonGd Images show transverse sinus thrombosis

Figure 2
T1 weighted sagital Images with Gd show thrombosis in sagital sinus

Figure 3
2D MR venogram shows sagital sinus thrombosis

M.A.S: Admitting and treating the case, preparing the article. M.M : Revising the article. A.R.A : searching previous articles, preparing case presentation part. B.M : searching previous articles, preparing background.
Acknowledgements

We are grateful to Mr. Hejrani for secretarial help and Mr. Solimani for preparing the photographs. It should be noted that written consent was obtained from the patient for publication of study.
References

1. Ameri A, Bousser MG: Cerebral venous sinus thrombosis.
Neurol clin 1992, 10:87-111.