a 47-year - old man presented with a two - day history of weakness in the left limb , prickling in the left part of the body and headache . two months before , a high - risk non - seminomatous germ cell tumor with embryonal carcinoma stage i according to the uicc / ajcc classification was diagnosed , with presence of lymphatic invasion . adjuvant chemotherapy with two cycles of cisplatin , etoposide and bleomycin ( bep ) was started four weeks after radical orchiectomy . at the time of his admittance he had received two full doses of cisplatin and etoposide and four full doses of bleomycin . during chemotherapy he suffered from asthenia , nausea , loss of appetite and dehydration requiring intravenous rehydration . the patient stopped smoking one year ago with a total of three pack years and drank up to two glasses of wine or beer daily until the start of the chemotherapy . subsequent magnetic resonance imaging ( mri ) scan showed a cerebral sinus venous thrombosis in the superior sagittal sinus ( fig . 1 ) , as well as in the right sigmoid and both transverse sinuses with bilateral venous congestion associated with cytotoxic edema within the precentral gyri ( fig . symptoms resolved completely within a month . the remaining chemotherapy with one administration of bleomycin was given . after three months , the mri scan showed a residual thrombus in the right transverse sinus , the right sigmoid sinus and the superior sagittal sinus , respectively . so far , there has been no sign of a relapse of the testicular cancer . a high - risk non - seminomatous germ cell tumor with embryonal carcinoma stage i , according to the uicc / ajcc classification , with presence of lymphatic invasion was found in a 29-year - old man . after three months of active surveillance , retroperitoneal lymphadenopathy was diagnosed and chemotherapy with three cycles of bep was initiated . on day 10 of the second cycle the patient was admitted with a headache which had persisted for two days . on the way to the hospital a generalized epileptic seizure occurred . computed tomography ( ct ) scan of the brain showed a cerebral sinus venous thrombosis in the superior sagittal sinus , a subarachnoid hemorrhage in the right frontal region and the left precentral sulcus , with a hemorrhage in the right frontal lobe due to venous congestion ( fig . 3 ) . therapy , initially with unfractionated heparin and then with low - molecular dalteparine , and an antiepileptic therapy with phenytoin was started and symptoms resolved quickly . the chemotherapy was changed to carboplatin instead of cisplatin . on day 10 of the third cycle ct scans of the chest and abdomen showed no residual sign of the testicular cancer . a 47-year - old man presented with a two - day history of weakness in the left limb , prickling in the left part of the body and headache . two months before , a high - risk non - seminomatous germ cell tumor with embryonal carcinoma stage i according to the uicc / ajcc classification was diagnosed , with presence of lymphatic invasion . adjuvant chemotherapy with two cycles of cisplatin , etoposide and bleomycin ( bep ) was started four weeks after radical orchiectomy . at the time of his admittance he had received two full doses of cisplatin and etoposide and four full doses of bleomycin . during chemotherapy he suffered from asthenia , nausea , loss of appetite and dehydration requiring intravenous rehydration . the patient stopped smoking one year ago with a total of three pack years and drank up to two glasses of wine or beer daily until the start of the chemotherapy . subsequent magnetic resonance imaging ( mri ) scan showed a cerebral sinus venous thrombosis in the superior sagittal sinus ( fig . 1 ) , as well as in the right sigmoid and both transverse sinuses with bilateral venous congestion associated with cytotoxic edema within the precentral gyri ( fig . symptoms resolved completely within a month . the remaining chemotherapy with one administration of bleomycin was given . after three months , the mri scan showed a residual thrombus in the right transverse sinus , the right sigmoid sinus and the superior sagittal sinus , respectively . so far , there has been no sign of a relapse of the testicular cancer . a high - risk non - seminomatous germ cell tumor with embryonal carcinoma stage i , according to the uicc / ajcc classification , with presence of lymphatic invasion was found in a 29-year - old man . after three months of active surveillance , retroperitoneal lymphadenopathy was diagnosed and chemotherapy with three cycles of bep was initiated . on day 10 of the second cycle the patient was admitted with a headache which had persisted for two days . on the way to the hospital a generalized epileptic seizure occurred . computed tomography ( ct ) scan of the brain showed a cerebral sinus venous thrombosis in the superior sagittal sinus , a subarachnoid hemorrhage in the right frontal region and the left precentral sulcus , with a hemorrhage in the right frontal lobe due to venous congestion ( fig . 3 ) . therapy , initially with unfractionated heparin and then with low - molecular dalteparine , and an antiepileptic therapy with phenytoin was started and symptoms resolved quickly . the chemotherapy was changed to carboplatin instead of cisplatin . on day 10 of the third cycle ct scans of the chest and abdomen showed no residual sign of the testicular cancer . thromboembolic events such as pulmonary embolism , arterial or deep venous thrombosis and cerebral ischemic stroke are rare but known complications during chemotherapy for germ cell cancer . in patients with germ cell cancer , elevated serum lactate dehydrogenase , a high body surface area ( > 1.9 m ) , cisplatin - related hypomagnesemia , damage of the vascular endothelium , elevation of von willebrand factor plasma levels , liver metastases and high doses of corticosteroids (  80 mg dexamethasone per cycle ) apart from von willebrand factor plasma levels , which were not measured , none of these risk factors were present . interestingly , most patients with germ cell cancer who showed a thromboembolic complication had embryonal carcinoma , as it was seen in our two cases . chemotherapy with cisplatin , etoposide and bleomycin is the standard treatment for germ cell cancer , both in the adjuvant setting as well as for advanced stages and it has resulted in high remission rates and improved survival . cisplatin and bleomycin have been associated with acute and long - term vascular toxicity , such as cardiovascular events , thromboembolic events or raynaud 's phenomenon . an extensive retrospective analysis found that patients undergoing cisplatin - based chemotherapy are at higher risk for thromboembolic events if they suffer from germ cell cancer rather than other tumors . while there is abundant literature on thromboembolic complications in patients with testicular cancer , very few cases of cerebral sinus thrombosis have been reported thus far . established risk factors for cerebral sinus venous thrombosis in general are inherited or acquired thrombophilia , nephritic syndrome , chronic inflammatory diseases , infections , pregnancy and puerperium , hormonal contraception or dehydration [ 5 , 6 ] . it is more common in women than in men , with a female - to - male ratio of 3:1 . in the international study on cerebral venous and dural sinuses thrombosis , local tumor compression , hypercoagulable state and antineoplastic drugs like tamoxifene or l - asparaginase are risk factors according to a statement for healthcare professionals from the american heart association and american stroke association . cerebral sinus venous thrombosis associated with chemotherapy not due to the above - mentioned drugs or to a local tumor compression has so far been described in a patient with colon cancer treated with folfiri / bevacizumab , in a patient with a brain tumor treated with temozolomide , focal brain radiotherapy plus bevacizumab   and an adolescent with ewing sarcoma treated with cisplatin , ifosfamide , adriamycin , and vincristine . in a further patient with malignant cutaneous melanoma this etiology can be excluded in our two patients : in the first case , chemotherapy was given in the adjuvant setting and only retroperitoneal lymphadenopathy was known in the second case . to the best of our knowledge only two other cases with cerebral sinus venous thrombosis following chemotherapy for germ cell cancer have been described in the literature so far . karam and koussa   described two cases of cerebral dural sinus thrombosis following cisplatin - based chemotherapy . as in our cases , one of them had a germ cell carcinoma and underwent chemotherapy with cisplatin , etoposide and methylprednisolone . , we hypothesized that cisplatin - related hypercoagulability was the main risk factor for the occurrence of the cerebral sinus venous thrombosis according to the time interval between chemotherapy and the occurrence , and the missing risk factors for cancer - related thromboembolic events . in our second patient we felt that the platinum , as the most efficient class of drugs in this disease , should not be completely omitted . we therefore replaced cisplatin by carboplatin in the third cycle of the chemotherapy . nevertheless , this patient experienced a second episode of a cerebral sinus venous thrombosis . to the best of our knowledge this is the first report of cerebral venous sinus thrombosis associated to chemotherapy with carboplatin , etoposide or bleomycin in the literature . in patients with testicular cancer and platinum - based chemotherapy who present with neurological symptoms , cerebral sinus venous thrombosis should be considered in the differential diagnosis . clinicians should be aware of this rare but dangerous complication , which can be treated successfully .
we report on two patients with cerebral sinus venous thrombosis following chemotherapy with cisplatin , bleomycin and etoposide for non - seminomatous germ cell tumor . 
 headache and neurological deficits were the leading symptoms . 
 cancer and cisplatin chemotherapy are well - known risk factors for thromboembolic events . 
 the therapeutic strategy is an anticoagulant therapy . 
 symptoms are usually reversible within weeks under this therapy . 
 therefore , in patients with testicular cancer and chemotherapy who present with neurological symptoms , cerebral sinus venous thrombosis should be considered in the differential diagnosis .