European Journal of Neurology 2001, 8: 723±724

CLINICAL CORRESPONDENCE

A case with cerebral thrombosis receiving tamoxifen treatment
G. Akdala, B. DoÈnmeza, H. C
Ë akmakcËõb and G. GuÈlmen Yenera
a

Department of Neurology and bRadiology, Dokuz EyluÈl University, School of Medicine, Izmir-Turkey

Keywords:

cerebral thrombosis,
tamoxifen
Received 16 February 2001
Accepted 11 June 2001

Cerebral sinus thrombosis (CST) is known to be related to a number of underlying
aetiologies including otitis media, trauma, pregnancy, birth control pills, tumours,
malnutrition, dehydration, haematologic disorders and malignancy (Fishman, 2000;
Raizer and Abbott, 2000). We present the case of a patient with breast cancer receiving
the antioestrogen drug tamoxifen who developed CST.
A 40-year-old female presented as an emergency with a 10-day history of headache
and left sided weakness. On questioning her past medical history included a diagnosis
of breast cancer 3 years ago treated by radical mastectomy and tamoxifen 20 mg daily.
At the time of admission, neurologic examination revealed a mild left sided
hemiparesis and a present Babinksi sign. Non-contrast enhanced tomography was
normal. Magnetic resonance imaging (MRI) showed thrombosis in the superior
sagittal sinus, right lateral sinus and jugular vein in addition venous infarction in the
right temporal lobe was present (Figs 1a and b). Routine haematology and
biochemistry was normal. Anticoagulation tests, antithrombin III, protein S and C
levels were also found to be normal. She was treated with anticoagulation therapy and
her hemiparesis improved within 3 days. Control MRI showed the resorption of the
venous infarction and resolution of the thrombosis (Fig. 1c).

Discussion
Cerebral sinus thrombosis is associated with a number
of well described conditions, but in 30% of cases no
underlying aetiology can be identi®ed (Allogren and
Abbott, 1975). Our patient had previously been diagnosed with breast cancer and was currently taking
tamoxifen therapy. She had two known contributing
factors for thrombosis; cancer and antioestrogen treatment. Systemic thrombosis is well recognised in cancer
patients because of malignancy associated hypercoagulability, metastatic spread, direct tumour in®ltration
or as a complication of treatment, the latter two are
especially seen in haematological malignancies (Raizer
and DeAngelis, 2000). The aetiologic factor for sinus
thrombosis in our patient does not seem to be the
cancer itself. Thrombosis has previously been reported
of during antioestrogen therapy (Saphner et al., 1991;
Meier and Jick, 1998). Saphner et al. (1991) reported a
5.4% increased incidence of both venous and arterial
thrombosis in patients who received adjuvant tamoxifen compared with patients on no tamoxifen (Saphner
et al., 1991). In that study, venous complications
related to tamoxifen treatment included deep venous
thrombosis and mesenteric vein thrombosis however,
there were no causes of cerebral thrombosis. Raizer and

DeAngelis (2000) reported twenty patients with cancer
who had developed CST. Three patients out of 20 were
receiving antioestrogen therapy ± (arimidex or tamoxifen) (Raizer and DeAngelis, 2000).
Taking into account the fact that our patient had no
signs of active malignancy and previous reports of
tamoxifen related thrombosis it seems highly likely that
tamoxifen was the underlying cause for our patient's
CST.
Physicians should be aware of this uncommon but
serious side-e€ect of tamoxifen therapy especially with
the more widespread use of tamoxifen.

References
Allroggen H, Abbott RJ (2000). Cerebral venous sinus
thrombosis. Postgrad Med 76:12±15.
Fishman RA (2000). Cerebral veins and sinuses. In: Rowland
LP, ed. Merritt's Neurology. Philadelphia Lippincott
Williams Wilkins, pp. 268±274.
Meier CR, Jick H (1998). Tamoxifen, risk of idiopathic
venous thromboembolism. Br J Clin Pharmacol 45:608±612.
Raizer J, DeAngelis LM (2000). Cerebral sinus thrombosis
diagnosed by MRI and MR venography in cancer patients.
Neurology 54:1222±1226.
Saphner T, Tormey CD, Gary R (1991). Venous, arterial
thrombosis in patients who received adjuvant therapy for
breast cancer. J Clin Oncol 9:286±294.

Correspondence: GuÈlden Akdal MD, Department of Neurology,
_
Dokuz EyluÈl University, School of Medicine, Izmir
±Turkey
(fax: 90 232277 77 21; e-mail: gulden.akdal@deu.edu.tr).

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G. Akdal et al.

Figure 1 T1 weighted contrast enhanced axial (a) and coronal (b)
images show unenhancing thrombus in superior sagittal sinus and
venous heamorrhagic infarction in the right temporal lobe.
Control T1 weighted contrast enhanced MRI image (c) reveals
resolution of the thrombus in superior sagittal sinus.

ã 2001 EFNS European Journal of Neurology 8, 723±724