TOUCH MEDICAL MEDIA 120 Case Report Stroke Journal Publication Date: December 23, 2020 Anabolic Androgenic Steroid Abuse and Cerebral Venous Thrombosis—A Case Report Marlene Saraiva, João Pedro Marto, Ana Sofa Correia, and Miguel Viana Baptista Neurology Department, Egas Moniz Hospital, Lisbon, Portugal T here are a small number of published cases of cerebral venous thrombosis (CVT) associated with anabolic androgenic steroids (AASs). We present the case of a 27-year-old man who was admitted to the emergency room with a severe holocranial headache, nausea, vomiting, photophobia, and diplopia. He had no relevant past medical history, but he had been taking anabolic steroids for 1 year. The examination revealed papilledema and bilateral sixth nerve palsy. The computed tomography venography documented thrombosis of the left transverse and sigmoid sinuses. The patient was started on anticoagulant therapy with gradual improvement. The workup ruled out other causes of CVT. Despite the uncertainty about the exact mechanism by which AASs promote thrombosis, our case supports the conviction that high-dose and long-lasting AAS use should be considered a possible cause of CVT. Accordingly, it is of utmost importance to inquire about AAS use in case of suspected CVT. Keywords Anabolic androgenic steroids, cerebral venous thrombosis, steroid abuse Disclosures: Marlene Saraiva, João Pedro Marto, Ana Sofa Correia, and Miguel Viana Baptista have no fnancial or non-fnancial relationships or activities to declare in relation to this article. Review Process: Double-blind peer review. Compliance with Ethics: Informed consent was received from the patient involved in this case study. Authorship: The named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given fnal approval for the version to be published. Access: This article is freely accessible at touchNEUROLOGY.com © Touch Medical Media 2020. Received: May 8, 2020 Accepted: July 22, 2020 Published Online: December 23, 2020 Citation: US Neurology. 2020;16(2):120–2 Corresponding Author: Marlene Saraiva, Department of Neurology, Egas Moniz Hospital, Rua da Junqueira 126, 1349–019 Lisbon, Portugal. E: marlenesaraiva_@hotmail.com Support: No funding was received in the publication of this article. Cerebral venous thrombosis (CVT) is a rare condition. 1–3 While thrombophilias, contraceptive pill, hormonal replacement therapy, and neoplasms are well-established predisposing factors, steroid use is a less-common possible risk factor, particularly with regard to anabolic androgenic steroids (AAS). 1–4 We intend to describe what is known about AAS and present a case of CVT associated with AAS use in a young patient. Case presentation A 27-year-old man was admitted with a severe holocranial headache, nausea, vomiting, photophobia, and diplopia, which had begun 3 days before. He had no relevant past medical antecedent, no previous migrainous headache, nor any pertinent family history of hypercoagulability. However, he had been taking AASs for 1 year to increase muscle mass (intramuscular testosterone weekly, in addition to 400 mg of oxymetholone and 300 mg of nandrolone daily). On examination he had papilledema and bilateral sixth nerve palsy. Blood tests revealed thrombocytosis with 263,000 platelets/mm 3 without other alterations on hemogram like polycythemia. Computed tomography venography documented thrombosis of the left transverse and sigmoid sinuses (Figures 1 and 2). The workup ruled out other causes of CVT, such as hereditary thrombophilia, infection, or neoplasia. Autoimmune diseases and vasculitis syndromes were ruled out by appropriate investigations (e.g., screening for antinuclear antibodies [ANA], antiphospholipid antibodies [APLA], antineutrophil cytoplasmic antibodies [ANCA], cytoplasmic and perinuclear ANCA [cANCA and pANCA]). Vitamin B12, folic acid, and serum homocysteine levels were normal. The patient was started on anticoagulant therapy with enoxaparin 1 mg/kg every 12 hours. A combination of analgesics and acetazolamide were introduced because of refractory headache. The follow-up magnetic resonance imaging, performed 6 months later, showed resolution of thrombosis. Discussion There are two main types of steroids, namely corticosteroids and AASs; the latter carrying a greater risk of thrombosis. Since their synthesis in 1935, AASs began to be widely consumed: firstly, by the elite athletes to improve their sports performance, and then by the general population, especially the younger, with the purpose of increasing muscle mass as well as a recreational drug, disregarding their harmful effects. 5–6 In fact, AASs are synthetic derivatives of testosterone with a strong anabolic effect and only residual androgenic action. 7 For that reason, they are used to treat several medical conditions, namely many forms of anemia, especially aplastic anemia; acute and chronic wounds; renal failure (in combination with recombinant human erythropoietin); protein-calorie malnutrition