Cerebral Venous Thrombosis in an Elderly Adult Treated with Diethylstilbestrol

Abstract

To the Editor: Cerebral venous thrombosis (CVT) is rare in elderly adults. Multiple risk factors are known to lead to a CVT, in particular, drugs such as estrogens, cytotoxics (e.g., thalidomide), corticosteroids, and others. Herein is reported the case of an individual with prostate cancer in remission treated with diethylstilbestrol and in whom a CVT was diagnosed during the course of an examination for isolated headache. Isolated headaches due to CVT are rarely seen in elderly adults.1 Thromboembolic complications due to this hormone therapy are well known, but no CVT has been previously reported in the literature. In May 2012, an 81-year-old man was admitted for a 7-month history of right hemicrania and retro-orbital pain without nausea, vomiting, focal neurological signs, visual disorder, or seizure. His past medical history included prostate cancer (2003) treated with diethylstilbestrol since September 2009. He had no history of migraine. His medication consisted of diethylstilbestrol (1 mg/d). He was self-sufficient except for meals, and his cognitive function was intact. He had a dental infection (pericoronitis) a few weeks before admission that was treated with 5 days of spiramycin and metronidazole followed by dental extraction. Clinical examination revealed no fever, no focal neurological signs, impaired consciousness, or changes in mental status. His hemodynamic status was normal, as was his general examination. Laboratory studies revealed normal blood count, electrolytes, serum creatinine, C-reactive protein, coagulation studies, and prostate-specific antigen (PSA). Brain magnetic resonance imaging showed thrombosis in the right lateral sinus without any lesion in the parenchyma (Figure 1). He was admitted to the Geriatric Department and received anticoagulation and analgesics. The diethylstilbestrol was discontinued because it is known to be a potential etiological factor. His clinical course slowly improved, but moderate headaches were still present 9 months after discharge. He had no further thrombotic events. No other treatment was given in place of diethylstilbestrol for his prostate cancer because it appeared to be well controlled. Cerebral venous thrombosis is rare, especially in elderly adults. In a prospective series of 624 individuals with CVT, 51 (8.2%) were aged 65 and older, and only four (0.64%) were aged 80 and older.1 Headache is the earliest and most frequent symptom but is rarely isolated,2 particularly in elderly adults, in whom the prognosis is worse (49% made a complete recovery vs 82% in younger individuals).1 Impaired consciousness and mental changes are more frequent in elderly adults.1 The current case was atypical because the usually observed symptoms were absent, and he had a favorable prognosis (no deficit or dependence). A multitude of conditions have been found to be risk factors for CVT. The most common conditions are hereditary thrombophilia, pregnancy and puerperium, postoperative state, intracranial and local infections, and the use of oral contraceptives. The cause of CVT is frequently multifactorial, and in fewer than 20–35% of cases, no clear risk factor is identified.3 Cancers can lead to CVT and are statistically more significant1 in elderly adults, although the individual described herein was in remission at that time, and this complication is rare. More than 5% of men diagnosed with prostate cancer have a past history of a thromboembolic event even when no traditional risk factors for venous thromboembolism4 are present. A case of CVT was reported in an individual with prostate cancer (with high PSA) without any risk factors.5 In the current case, no other cancer was detected. The dental infection was not sufficient to lead a CVT, and the dental CT scan excluded any deep infection. Prothrombotic screening was normal. In younger individuals, estrogen therapy can lead to CVT. High estrogen levels (≥50 μg) increase the risk of venous and arterial thromboses. Each diethylstilbestrol dose contained 3.33 mg of estrone, but no CVT has been previously described in the literature In France, only five cases of thromboembolic complications that seemed to be related to diethylstilbestrol treatment have been reported, but no case of CVT. In this patient, the chronology of the clinical course strongly suggests that diethylstilbestrol was the etiological factor involved. Cerebral venous thrombosis is rarely found to be the cause of isolated headache, especially in elderly patients. Diethylstilbestrol can provoke venous and arterial thrombosis, but no published report has ever suggested that it can cause CVT. This case report is also atypical because the prognosis was so favorable. We thank Dr. Donald Schwartz for correcting the English version. Conflict of Interest: The editor finds no conflict of interest for any of the authors. Author Contributions: Elodie Ponce took care of the patient and prepared and wrote the paper. Karl Mondon participated in the writing and revised the final version. Jean-Philippe Cottier acquired and interpreted the MRI scan. Yves Gruel explored the coagulation and thrombophilia. Caroline Hommet revised and approved the final version. Sponsor's Role: None.