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Título

Alice in Wonderland Syndrome due to chronic cerebral venous thrombosis – A rare condition

RESUMO

Case Report: A 44-year-old man was admitted to the emergency department with sudden seizures and severe headache for 3 days. He had a history of pulsatile tinnitus for 2 years. The patient reported intermittent symptoms of visual illusion lasting about 10 seconds, characterized by self-perceived distortions of his body and people's faces, consistent with metamorphopsia. He also described oscillation in the size of objects suggesting micropsia and macropsia. Physical examination showed proptosis of the right eye. Fundoscopy showed no macular, vascular and optic nerve changes. Cranial computed tomography and angiotomography were performed, which suggested venous infarction and sinus thrombosis, respectively. The electroencephalogram indicated focal base epileptogenesis of the right occipital lobe due to a structural lesion. Treatment with 1500mg/day of valproic acid and 20mg/day of clobazam was initiated with complete resolution of metamorphopsia, including macropsia, and micropsia. Later, cerebral arteriography confirmed thrombosis of the superior sagittal sinus, transverse and sigmoid sinuses on the right. In addition, a tentorial dural arteriovenous fistula nourished by posterior branches of the middle meningeal artery and right occipital artery with drainage to cortical veins was visualized. Embolization of the arteriovenous fistula was performed, and apixaban 10 mg/day was started. The patient evolved with complete remission of headache and pulsatile tinnitus.
Discussion: Metamorphopsia is a misperception of the size of objects or body parts due to migraine, epilepsy, intoxication, or infectious cerebral diseases. They are referred to as Lilliputian hallucinations and were described as Alice in Wonderland Syndrome (AIWS). In the present case, the patient exhibited this syndrome due to focal epileptogenesis secondary to a venous infarction caused by a chronic cerebral venous thrombosis. To our knowledge, there is only one case of AIWS related to cerebral thrombosis reported in the literature.
Final considerations: AIWS is a rare condition caused by severe illness. Therefore, the early diagnosis is fundamental, and the treatment also needs to be directed at underlying diseases. This case report aims to familiarize neurologists with this uncommon condition.