A 33-year-old woman woke up one morning to find that people's faces looked wrong. Their eyes appeared to slide toward the middle and merge into one. When she looked in a mirror, her own eyes looked fused too.
Neurologists at The Medical City in Pasig City, Philippines, traced the problem to cerebral venous sinus thrombosis, a blood clot in the veins that drain blood from the brain. Ronn Victor L. Azurin and Ester S. Bitanga described the case in Case Reports in Neurology, published online April 30, 2026.
The facial distortion, called prosopometamorphopsia, was the reason she sought care. The authors wrote that the most recent literature review contained no published reports of the symptom with this type of clot, and they found only one related prior case, describing a patient who saw one side of a face distorted with an extra eye.
A Headache, Then Faces That Merged
Eight days before she came to the emergency department, the woman developed a stiff neck and a throbbing headache at the back of her head on the right side, which she rated 8 out of 10. She took over-the-counter pain relievers, then a prescription anti-inflammatory, and the headache went away.
The day before her evaluation, the visual problem began when she woke up. Faces looked distorted, with both eyes joined horizontally at the midline, while the rest of people's bodies looked normal. She had no eye pain, redness, or double vision. The report includes a drawing she made on admission showing a normal face beside one with conjoined eyes.
She had no psychiatric history and did not smoke, drink, or use drugs. One detail stood out: 28 days earlier, she had started a combined oral contraceptive containing levonorgestrel and estradiol for the first time.
The Clue Behind Her Eyes
Her neurological exam was otherwise normal, with 20/20 vision and no visual field defects. But photographs of her optic nerves revealed papilledema, swelling that signals increased pressure inside the skull.
Contrast-enhanced MRI showed an extensive clot involving the superior sagittal sinus, the confluence where major venous channels meet, the right transverse and sigmoid sinuses, the upper right internal jugular vein, and cortical veins on both sides. There was no brain swelling or bleeding. Routine blood tests were normal, although clotting-disorder tests were not done.
She received the injectable blood thinner enoxaparin for three days and was then switched to the oral anticoagulant dabigatran, a choice the authors said was driven partly by the need for early discharge for financial reasons. Her distortions improved; she went home on day four and, at a two-week follow-up, her symptoms had completely resolved. She continued dabigatran for three months.
Dabigatran's use in this condition is supported by the RE-SPECT CVT trial, which found a low risk of recurrent clots and similar bleeding risk with dabigatran or warfarin. The authors noted that patients in that trial received injectable heparin for 5 to 15 days before switching, so her early transition is a limitation of the report.
Why a Clot Could Distort Faces
Face perception relies on specialized brain regions, including the fusiform face area in the occipitotemporal region. Most reported cases of prosopometamorphopsia involve strokes caused by blocked arteries, while others stem from seizures, migraine or trauma. The symptom is one of 42 visual symptoms described in Alice in Wonderland syndrome, a group of perceptual distortions. Distortions affecting both sides of the face have mainly been tied to lesions in the right or both occipital lobes, the brain's visual centers.
The authors suggested her bilateral distortion pointed to involvement of face-processing areas, but they acknowledged that the MRI showed no focal lesion in the classic regions, so that link remains speculative. They proposed that venous congestion or broader network disruption may have played a role. Because no EEG was performed, they also could not rule out seizure activity.
Recovery from prosopometamorphopsia varies. In a century-long review cited by the authors, 57% of reported patients recovered fully, 10% partially, and 13% not at all. This patient's distortion lasted about two days.
A Rare Clot with a Recognized Risk Factor
Cerebral venous thrombosis accounts for 0.5% to 3% of all strokes, according to a scientific statement from the American Heart Association, and it most often affects young people and women of reproductive age. Headache is the most common symptom. Seizures and nerve problems can also occur, but isolated visual distortion is unusual.
Estrogen-containing oral contraceptives are a recognized temporary risk factor, which led the authors to classify her clot as provoked. For clots with a clear trigger, current American and European guidance recommends 3 to 6 months of anticoagulation. The authors recommended further testing for an underlying clotting disorder.
They warned that isolated face distortion without other neurological deficits may be mistaken for a psychiatric problem and urged clinicians to ask about headache patterns and medications and to order brain imaging promptly.
This case does not mean birth control commonly causes this problem. People with concerns about hormonal contraception should talk with a clinician rather than stopping on their own. Anyone who develops a severe or unusual headache, vision changes, weakness or confusion should seek medical care right away.
Key Questions Answered
What is prosopometamorphopsia?
It is a rare condition in which faces appear distorted, with features that may look stretched, displaced, or merged.
What caused this woman's face distortions?
MRI showed cerebral venous sinus thrombosis, an extensive clot in the veins draining her brain, with signs of raised pressure inside the skull.
Was birth control involved?
She had started a combined estrogen-containing pill 28 days earlier. Such pills are a recognized risk factor, and her doctors classified the clot as provoked.
Did she recover?
Yes. After anticoagulation, her distortions improved within days, and her symptoms had completely resolved at two weeks.
What symptoms should prompt urgent care?
A severe or unusual headache, vision changes, weakness, confusion, or seizures warrant prompt medical evaluation.
Published by Medicaldaily.com
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