Terson's syndrome as a prognostic factor for mortality of spontaneous subarachnoid haemorrhage

Bilateral Subinternal Limiting Membrane Crystalline Deposits Secondary to Terson Syndrome

Background

We report the case of bilateral, subinternal limiting membrane crystalline deposits in a patient with Terson syndrome, describe the possible pathogenesis, and highlight management. Case Presentation. A 24-year-old male with a history of traumatic massive parenchymal and subdural frontal hemorrhage presented to our clinic seven months after a motor vehicle accident, prolonged hospitalization, and rehabilitation, complaining of decreased vision in both eyes. The Snellen visual acuity was 1/60 in the right eye, and 6/60 in the left eye. Fundus examination showed an organized white vitreous hemorrhage in both eyes with almost no view of the retina. The anterior segments were normal. He underwent a 25-gauge pars plana vitrectomy in both eyes. During the surgery, golden crescent-shaped sediment consisting of small crystals was observed under the internal limiting membrane in both eyes: anterior to the inferior temporal vascular arcade in the right eye and posterior to it in the left eye. Internal limiting membrane (ILM) peeling after staining with ILM-blue dye was performed in the left eye, where the finding involved the macula. One year after the surgery, visual acuity significantly improved to 6/8.5 on the right and 6/6 on the left. Epiretinal membrane formation was observed in the right eye, where ILM peeling was not performed.

Conclusion

Subinternal limiting membrane crystalline deposit finding is a rare condition. Consider performing internal limiting membrane peeling and sediment removal in cases with macular involvement. In cases where crystals are concentrated outside of the macula, follow-up may be considered.

Terson Syndrome in Patients with Aneurysmal Subarachnoid Hemorrhage: A 10-Year Single-Center Experience

BACKGROUND

Terson syndrome (TS), an intraocular hemorrhage associated with aneurysmal subarachnoid hemorrhage (aSAH), occurs in up to 46% of all patients with subarachnoid hemorrhage. Despite its high incidence, TS is underrepresented in the literature, and patients with aSAH are sometimes not systematically evaluated for the presence of TS in clinical practice. This work aims to raise awareness of TS, reevaluate previous scientific findings, describe risk factors associated with the occurrence of TS, and present our local diagnostic and treatment concept.

METHODS

All patients with aSAH treated at our institution between October 2010 and May 2020 were included in this retrospective study. The frequency of ophthalmological screening by indirect funduscopy, as well as the results, was investigated. In addition, the collection and statistical analysis of epidemiological and clinical data was performed using χ2, Kruskal-Wallis, and analysis of variance testing; multivariate regression; and receiver operating characteristic analysis. The significance level was set at p < 0.05.

RESULTS

A total of 617 patients were treated for aSAH in our institution. Of these, 367 patients (59.5%) were ophthalmologically examined for the presence of TS. The rate of TS in the examined patients was 21.3% (n = 78). Patients with TS had significantly higher Fisher and World Federation of Neurosurgical Societies (WFNS) scores (p < 0.0001). Regression analyses showed WFNS grade (p = 0.003) and the occurrence of seizures (p = 0.002) as independent predictors of TS, as did receiver operating characteristic analyses, which had a significant area under the curve of 0.66 for the combination of WFNS grade and seizures. For 12 (15.4%) patients, the TS had to be surgically treated by pars plana vitrectomy in a total of 14 eyes, which resulted in significant improvement of visual function in all patients: mean preoperative best-corrected visual acuity was 0.03 (± 0.08) versus 0.76 (± 0.21) postoperatively (p < 0.001).

CONCLUSIONS

TS is a common complication in patients with aSAH, affecting approximately one in five patients. A higher WFNS grade and the occurrence of seizures are associated with TS; therefore, screening for TS should be performed in these patients.

Terson Syndrome: Not to Be Missed in Patients with Disorders of Consciousness

The diagnosis of clinical cognitive motor dissociation (^cCMD) can be hindered by pitfalls during standardized clinical evaluation based on gold-standard neurobehavioral rating scales. We introduce here a new pitfall, by reporting two cases of Terson syndrome (TS) after subarachnoid haemorrhage (SAH) caused by the rupture of an anterior communicant artery aneurysm, hospitalized in the Acute Neurorehabilitation Unit (ANR) of CHUV. TS is reported to occur in 8-19.3% of patients suffering from SAH. It can lead to significant visual impairment and if unrecognized, may impair the patient's capacity to interact appropriately with the environment; it thus presents an important pitfall in recognizing clinical cognitive-motor dissociation (^cCMD) in patients with altered states of consciousness. An early ophthalmological exam should be considered in all patients with SAH and disorders of consciousness or visual complaints.

Multilayered macular hemorrhages as an unusual complication of transorbital neuroendoscopic surgery

Purpose

To report a case of multilayered intraocular hemorrhage at the posterior pole as a complication of transorbital neuroendoscopic surgery.

Observations

Our patient underwent an uncomplicated endoscopic transorbital resection of a left sphenoid wing meningioma. In the immediate post-operative period, the patient reported blurred vision of her left eye, and dilated fundus examination demonstrated multilayered hemorrhages at the posterior pole. No intracranial hemorrhage was identified on post-operative imaging. Due to persistent subnormal visual acuity and non-clearing hemorrhage over several weeks of follow-up, a pars plana vitrectomy with peeling of the internal limiting membrane was performed to clear the hemorrhagic component obscuring the macula.

Conclusions and Importance

We report the first case of multilayered intraocular hemorrhages at the posterior pole, mimicking Terson syndrome, in the absence of intracranial hemorrhage or elevated intracranial pressure as a complication of transorbital surgery.

An explanation for Terson syndrome at last: the glymphatic reflux theory

Terson Syndrome (TS) describes the presence of intraocular hemorrhage in patients with intracranial hemorrhage, typically subarachnoid hemorrhage. Despite TS being a well-defined and frequently occurring phenomenon, its pathophysiology remains controversial. This review will present the current understanding of TS, with view to describing a contemporary and more plausible pathomechanism of TS, given recent advances in ophthalmic science and neurobiology. Previously proposed theories include a sudden rise in intracranial pressure (ICP) transmitted to the optic nerve sheath leading to rupture of retinal vessels; or intracranial blood extending to the orbit via the optic nerve sheath. The origin of blood in TS is uncertain, but retinal vessels appear to be an unlikely source. In addition, an anatomical pathway for blood to enter the eye from the intracranial space remains poorly defined. An ocular glymphatic system has recently been described, drainage of which from the globe into intracranial glymphatics is reliant on the pressure gradient between intraocular pressure and intracranial pressure. The glymphatic pathway is the only extravascular anatomical conduit between the subarachnoid space and the retina. We propose that subarachnoid blood in skull base cisterns near the optic nerve is the substrate of blood in TS. Raised ICP causes it to be refluxed through glymphatic channels into the globe, resulting in intraocular hemorrhage. We herewith present glymphatic reflux as an alternative theory to explain the phenomenon of Terson Syndrome.

Can Baseline Computed Tomography Scans Be Used to Identify Patients at High Risk of Vision Loss due to Terson Syndrome?

PURPOSE

To determine if routinely performed computed tomographic (CT) scanning in patients with aneurysmal subarachnoid hemorrhages (aSAHs) is sufficient to identify patients at high risk of vision loss due to Terson syndrome (TS).

METHODS

Consecutive patients with a diagnosis of aSAH admitted to the neurologic intensive care unit of a regional referral hospital over a 3-year period were prospectively evaluated. Head CT scans performed in the emergency department were assessed for the presence of a "crescent sign" (evidence of significant subinternal limiting membrane hemorrhage). Dilated funduscopic examinations were performed by an ophthalmologist, masked to the results of the CT scan, to identify retinal and vitreous hemorrhages consistent with TS. Retinal hemorrhages were categorized according to size-those smaller than 2 mm in diameter were deemed low risk (lrTS) for vision loss and those larger than 2 mm in diameter were deemed high risk (hrTS) for vision loss.

RESULTS

One hundred seventeen patients with aSAH were enrolled in the study. The overall incidence of TS was 24.9% (29 of 117 patients; 12 were bilateral). Compared to patients without TS, those with TS had a higher Fisher Hemorrhage Grade and a lower mean (±standard deviation) GCS score (8.66 ± 4.97 vs 12.09 ± 1.10; P < 0.001). The CT crescent sign was positive in 7 patients (6.0%), 6 (5.1%; 2 were bilateral) of whom were found to have hrTS. Of the 110 patients without a CT crescent sign, 88 (75.1%) patients did not have TS, 21 had lrTS, and 1 patient had hrTS in one eye. The CT crescent sign was highly sensitive (85.7%) and specific (99.1%) for diagnosing hrTS.

CONCLUSION

The CT crescent sign is a highly sensitive and specific marker for hrTS. CT scanning may replace routine ophthalmologic examinations to identify patients at risk of vision loss due to aSAH.

Incidence of Terson Syndrome in Treated Subarachnoid Hemorrhage in South Korea: a National Health Insurance Database Study

The aim of this study is to investigate the incidence and mortality of Terson syndrome in patients with treated subarachnoid hemorrhage (SAH) in South Korea. In this nationwide, population-based study, we used the National Health Insurance(NHI) database (2011–2015) to identify patients aged ≥18 years. Newly diagnosed non-traumatic SAH, treated using clipping or coil embolization, were identified, and Terson syndrome was defined as newly diagnosed retinal or vitreous hemorrhage within 3 months of SAH diagnosis. We identified 22,864 patients with treated SAH (tSAH), 196 of whom had Terson syndrome, with the cumulative incidence during 5 years of 0.86% (95% CI: 0.74–0.98): 1.10% (95% CI: 0.88–1.33) in men and 0.71% (95% CI, 0.58–0.85) in women. The cumulative incidence of Terson syndrome in patients aged under 40 was higher than in those aged 40 or over (1.41% vs. 0.81%; p = 0.007). The mortality rate of Terson syndrome in patients with tSAH was not different from that in those without Terson syndrome (4.08% vs. 7.30%; p = 0.089). This was the first nationwide epidemiological study of Terson syndrome using a population-based database. The incidence of Terson syndrome in patients with tSAH was higher in those age under 40 than in those aged 40 or over.

OUTCOMES OF VITRECTOMY IN TERSON SYNDROME: A Multicenter Canadian Perspective

PURPOSE

To characterize the presentation of Terson syndrome, the occurrence of a vitreous hemorrhage in association with intracranial hemorrhage, and report on the outcomes of vitrectomy at two major centers in Canada.

METHODS

Retrospective chart review of consecutive patients with Terson syndrome undergoing vitrectomy by retina specialists over the last 10 years. Primary outcome was the change in best-corrected visual acuity (BCVA) at 3 months from baseline. Secondary outcomes included the association between baseline BCVA and final BCVA, and the association between final BCVA and timing of surgery (early vs. later than 90 days).

RESULTS

A total of 14 eyes of 11 patients were included. The mean time between observation of intraocular hemorrhage and vitrectomy was 160 days. Baseline preoperative BCVA was logarithm of the minimum angle of resolution 1.57 ± 1.03 (Snellen 20/740), which improved to logarithm of the minimum angle of resolution 0.53 ± 0.82 (Snellen 20/70) at the final postoperative follow-up, P = 0.01. Baseline BCVA was not significantly correlated with final BCVA, Spearman's rho = 0.016, P = 0.957. Final BCVA did not significantly differ between those who had surgery before 90 days compared with after 90 days, P = 0.087.

CONCLUSION

Vitrectomy is safe and effective and should be considered for nonclearing vitreal bleeding due to Terson syndrome. Ocular hemorrhaging in Terson syndrome can be observed conservatively for spontaneous improvement without the risk of reduced visual potential. Ophthalmic evaluation should be considered promptly after intracranial hemorrhage.

Bedside optical coherence tomography for Terson's syndrome screening in acute subarachnoid hemorrhage: a pilot study

OBJECTIVE

Approximately 10% of patients with subarachnoid hemorrhage (SAH) become permanently, legally blind. The average cost of lifetime support and unpaid taxes for each blind person amounts to approximately $900,000. This study evaluates the feasibility and potential role of bedside optical coherence tomography (OCT) in Terson’s syndrome (TS) in patients with acute SAH (aSAH) and its potential role in blindness prevention.

METHODS

The authors conducted an open-label pilot study, in which 31 patients with an angiographic diagnosis of aSAH were first screened for TS with dilated funduscopy and then with OCT in the acute phase and at 6-week followup visits. Outpatient mood assessments (Patient Health Questionnaire–depression module, Hamilton Depression Scale), and quality of life general (NIH Patient-Reported Outcomes Measurement Information System) and visual scales (25-item National Eye Institute Visual Functioning Questionnaire) were measured at 1 and 6 weeks after discharge. Exclusion criteria included current or previous history of severe cataracts, severe diabetic retinopathy, severe macular degeneration, or glaucoma.

RESULTS

OCT identified 7 patients with TS, i.e., a 22.6% incidence in our aSAH sample: 7 in the acute phase, including a large retinal detachment that was initially missed by funduscopy and diagnosed by OCT in follow-up clinic. Dilated retinal funduscopy significantly failed to detect TS in 4 (57.1%) of these 7 cases. Intraventricular hemorrhage was significantly more common in TS cases (85.7% vs 25%). None of the participants experienced any complications from OCT examinations. Neither decreased quality of life visual scale scores nor a depressed mood correlated with objective OCT pathological findings at the 6-week follow-up after discharge. There were no significant mood differences between TS cases and controls.

CONCLUSIONS

OCT is the gold standard in retinal disease diagnosis. This pilot study shows that bedside OCT examination is feasible in aSAH. In this series, OCT was a safe procedure that enhanced TS detection by decreasing false-negative/inconclusive funduscopic examinations. It allows early diagnosis of macular holes and severe retinal detachments, which require acute surgical therapy to prevent legal blindness. In addition, OCT aids in ruling out potential false-positive visual deficits in individuals with a depressed mood at follow-up.

Visual Outcomes after Vitrectomy for Terson Syndrome Secondary to Traumatic Brain Injury

PURPOSE

To evaluate visual outcomes after vitrectomy for intraocular hemorrhages secondary to traumatic brain injury.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

A total of 28 eyes in 20 patients undergoing vitrectomy for Terson syndrome secondary to traumatic brain injury between 1997 and 2015.

METHODS

We reviewed the records of patients undergoing a standard 20-gauge or 23-gauge pars plana vitrectomy for intraocular hemorrhages secondary to traumatic brain injury, and the timing of vitrectomy in relation to the inciting intracranial event was recorded.

MAIN OUTCOME MEASURES

The primary outcome measure was the change in the preoperative visual acuity score at postoperative month 1 and at the last noted clinic appointment.

RESULTS

A total of 28 eyes in 20 patients (all male) underwent pars plana vitrectomy for intraocular hemorrhages secondary to traumatic brain injury. The mean preoperative baseline logarithm of the minimum angle of resolution (logMAR) (Snellen) best-corrected visual acuity (BCVA) was 1.81±0.56 (20/1290). At 1-month postoperative follow-up, the mean BCVA was 0.30±0.33 (20/40). At the date of the last follow-up, the mean BCVA was 0.15±0.24 (20/30) and the median BCVA was 0.00 (20/20). Although the difference between preoperative and postoperative BVCA was significantly different at 1 month and the final postoperative clinic visits (P < 0.001), there was not a correlation between preoperative visual acuity as a predictor of final postoperative visual acuity outcome (r=-0.32; P = 0.09; 95% confidence interval [CI] -0.62 - 0.06). At the date of the last follow-up, the differences in visual outcomes between the individuals undergoing vitrectomy within 3 months of the inciting event, 0.08±0.15 (20/25), were not significantly different than those undergoing surgical intervention after 3 months, 0.18±0.27 (20/30) (P = 0.28). Three cases among those undergoing vitrectomy after 3 months were complicated by retinal detachment, none of which resulted in a BCVA worse than when the patient originally presented preoperatively.

CONCLUSIONS

In this retrospective series of patients without other ocular pathology, surgical intervention effectively provided rapid visual recovery in the majority of individuals with intraocular hemorrhages secondary to traumatic brain injury, irrespective of the timing of vitrectomy or of preoperative visual acuity.

Terson's syndrome - Pathophysiologic considerations of an underestimated concomitant disease in aneurysmal subarachnoid hemorrhage

Terson syndrome (TS) is a common and underestimated concomitant disease in patients suffering from subarachnoid hemorrhage (SAH). Aim of this study was to evaluate the influence of an initial unconsciousness and raised intracranial pressure (ICP) on the development of TS. We performed a retrospective analysis of 213 prospective collected SAH patients screened for TS to investigate the impact of an initial unconsciousness and raised ICP on the development of TS. A univariate analysis followed by a multivariate logistic regression model was performed to identify risk factors that are associated with TS. The findings are all discussed and correlated with the present pathophysiologic considerations of TS. The rate of TS in this study was 23.9%. A higher risk of TS in the univariate analysis was associated with a Glasgow Coma scale⩽7 (p=0.001), higher Hunt and Hess grade (p=0.001), Fisher grade IV (p=0.002), intracerebral hemorrhage (p=0.011), initial unconsciousness (p=0.013) and an ICP of ⩾25mmHg (p<0.001). An ICP of ⩾25mmHg was the only independent predictor for TS in the multivariate analysis (p=0.007). TS patients had a higher mortality (p=0.012) and a higher risk for a worse long-term outcome (p=0.002). Notable that 5 of 51 TS patients (9.8%) in this study developed TS with no raised ICP or initial unconsciousness. Terson syndrome is a common concomitant disease in SAH patients. The pathomechanism leading to TS is not exclusively related to raised ICP levels and/or unconsciousness. However, these factors may be associated with a high percentage of TS.

Terson syndrome in aneurysmal subarachnoid hemorrhage-its relation to intracranial pressure, admission factors, and clinical outcome

BACKGROUND

A large number of reports have not been able to clarify the pathophysiology of Terson syndrome (TS) in aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

Prospective single-center study on aSAH patients. Fundoscopic and radiological signs of TS were assessed. The opening intracranial pressure (ICP) in patients who required a ventriculostomy was recorded with a manometer.

RESULTS

Six out of 36 included patients had TS (16.7 %), which was associated with unfavorable admission scores. Twenty-nine patients (80.5 %) required ventriculostomy; TS was associated with higher ICP (median, 40 vs. 15 cm cmH2O, p = .003); all patients with TS had pathological ICP values of >20 cmH2O. Patients with a ruptured aneurysm of the anterior cerebral artery complex were ten times as likely to suffer from TS (OR 10.0, 95 % CI 1.03-97.50). Detection of TS on CT had a sensitivity of 50 %, a specificity of 98.4 %, a positive predictive value of 83.3 %, and a negative predictive value of 92.4 %. Mortality was 45 times as high in patients with TS (OR 45.0, 95 % CI 3.86-524.7) and neurologic morbidity up until 3 months post-aSAH was significantly higher in patients with TS (mRS 4-6; 100 vs. 17 %; p = .001).

CONCLUSIONS

Our findings demonstrate an association between raised ICP and the incidence of TS. TS should be ruled out in aSAH patients presenting comatose or with raised ICP to ensure upfront ophthalmological follow-up. In alert patients without visual complaints and a TS-negative CT scan, the likelihood for the presence of TS is very low.

Practical Incidence and Risk Factors of Terson's Syndrome: A Retrospective Analysis in 322 Consecutive Patients with Aneurysmal Subarachnoid Hemorrhage

Objective

Terson's syndrome, a complication of visual function, has occasionally been reported in patients with aneurysmal subarachnoid hemorrhage (SAH), however the factors responsible for Terson's syndrome in aneurysmal SAH patients have not yet been fully clarified. In this study, we report on potential risk factors for prediction and diagnosis of Terson's syndrome in the earlier stage of the disease course in patients with aneurysmal SAH.

Materials and Methods

The authors retrospectively analyzed the data of 322 consecutive patients who suffered from aneurysmal SAH in a single institution between Jan. 2007 and Dec. 2013. Medical records including demographics, neurologic examination, and radiologic images were collected to clarify the risk factors of Terson's syndrome. Patients with visual problem were consulted to the Department of Ophthalmology.

Results

Among 332 patients with aneurysmal SAH, 34 patients were diagnosed as Terson's syndrome. Four individual factors, including World Federation of Neurosurgical Societies (WFNS) grade at admission, aneurysm size, method of operation, and Glasgow outcome scale showed statistically significant association with occurrence of Terson's syndrome. Of these, WFNS grade at admission, aneurysm size, and method of operation showed strong association with Terson's syndrome in multivariate analysis. Terson's syndrome accompanied by papilledema due to increased intracranial pressure led to permanent visual complication.

Conclusion

In patients with aneurysmal SAH, the patients' WFNS grade at admission, the size of the aneurysms, particularly the diameter of the aneurysm dome, and the method of operation might influence development of Terson's syndrome.

Subarachnoid hemorrhage-negative Terson syndrome after balloon-assisted coil embolization in a patient with underlying antiphospholipid antibody syndrome

PURPOSE

To report subarachnoid hemorrhage-negative Terson syndrome after coil embolization of an unruptured intracranial aneurysm in a patient with underlying antiphospholipid syndrome.

METHODS

Retrospective case report. A 48-year-old woman with underlying antiphospholipid syndrome.

RESULTS

Our patient underwent balloon-assisted coil embolization of an unruptured right internal carotid artery aneurysm. There was herniation of the second coil requiring coil retrieval with subsequent nonflow limiting herniation of the first coil left in situ on anticoagulation. In the immediate postprocedure period, she developed preretinal, intraretinal, and vitreous hemorrhages requiring temporary withholding of anticoagulation therapy with careful resumption. Visual acuity was counting fingers and there was an afferent pupillary defect. Two week after discharge, the patient underwent a pars plana vitrectomy for dense breakthrough vitreous hemorrhage. Four weeks after pars plana vitrectomy, her visual acuity was 20/400.

CONCLUSION

Terson syndrome should be considered in a patient with visual symptoms after not only aneurysmal subarachnoid hemorrhage but also non-subarachnoid hemorrhage elective aneurysm coiling as demonstrated by our case.

Incidence, Morbidity, and Mortality of Terson Syndrome in Hamilton, Ontario

Objective

Evaluate the incidence, neurologic morbidity, and mortality of patients with Terson syndrome.

Methods

Consecutive patients admitted to the Hamilton General Hospital from May 2012 to May 2013 with a diagnosis of spontaneous subarachnoid hemorrhage (SAH) were recruited. Funduscopic examinations were performed under pharmacological mydriasis. Outcome measures included: (1) the presence or absence of Terson syndrome; (2) The Glasgow Coma Scale (GCS), Hunt and Hess scale (H&H), and SAH Fisher score upon admission to the hospital; (3) the modified Rankin score upon discharge; and (4) and all-cause mortality.

Results

Forty-six patients were included and 10 had Terson syndrome (21%). The median H&H, GCS, and Fisher scores were 4, 6.5, and 4.0 for patients with Terson syndrome vs. 2, 14, and 3 for patients without Terson syndrome (p=0.0032, 0.0052, and 0.031), respectively. The median Rankin score was 6 for patients with Terson syndrome vs. 3.5 for patients without Terson syndrome (p=0.0019). The odds of all-cause mortality with Terson syndrome vs. no Terson syndrome was 12: 1 (95% confidence interval 2.33-61.7), p =0.003. Only four of the 10 patients with Terson syndrome survived.

Conclusions

Based on this study, approximately one-fifth of patients admitted to the hospital with a spontaneous SAH could have Terson syndrome. Patients with Terson syndrome have significantly worse GCS and H&H scores upon admission to the hospital, lower modified Rankin scores upon discharge, and greater mortality. Thus, Terson syndrome is not rare among patients with SAH and carries a worse prognosis.

Terson syndrome in subarachnoid hemorrhage, intracerebral hemorrhage, and traumatic brain injury

This prospective trial was designed to evaluate the incidence of Terson syndrome in patients suffering from subarachnoid hemorrhage, intracerebral hemorrhage, or traumatic brain injury and whether consequences necessarily derive from the intraocular hemorrhage itself. Two ophthalmologic examinations were performed to identify patients with Terson syndrome. Data on initial Glasgow Coma Scale, Hunt and Hess and Fisher grades, aneurysm site and diameter, and volume of hemorrhage in intracerebral hemorrhage patients were correlated to the location and course of Terson syndrome. Follow-up was performed after 3 months, including clinical and ophthalmologic investigations. The data showed that 16 of 83 subarachnoid hemorrhage patients (19.3%), 2 of 22 intracerebral hemorrhage patients (9.1%), and 1 of 32 traumatic brain injury patients (3.1%) suffered from Terson syndrome. Low Glasgow Coma Scale (p = 0.002), high Hunt and Hess grade (p < 0.001), and high Fisher grade (p = 0.002) were found to be associated with a higher incidence of Terson syndrome. The neurological outcome in subarachnoid hemorrhage patients suffering from Terson syndrome was worse compared with that of subarachnoid hemorrhage patients without Terson syndrome (p = 0.005), and vitrectomy was performed in seven eyes of six patients due to poor visual acuity. Terson syndrome is underestimated in patients with subarachnoid hemorrhage and a rare pathology in intracerebral hemorrhage as well as in traumatic brain injury patients. Spontaneous regression of the intraocular hemorrhage may be seen, but in half of the patients, vitrectomy is necessary to prevent permanent visual deterioration.

Early Intraocular Complications of Subarachnoid Haemorrhage after Aneurysm Rupture

The aim of this study was to identify factors predisposing for early intraocular complications of aneurysmal subarachnoid haemorrhage (SAH). The authors analysed 96 selected cases of aneurysmal SAH. Forty patients (42%) demonstrated abnormal fundus findings, including disc swelling (13.5%), retinal haemorrhages (23%), and vitreous haemorrhage (5%). The incidence of intraocular pathologies was significantly higher in patients who lost consciousness at the onset of SAH, were admitted with high scores of the Hunt-Hess and Fisher scales and low score of the Glasgow Coma Scale, as well as in those with arterial hypertension, more sizable aneurysm, and older.

Comparison of CT and clinical findings of Terson's syndrome in 121 patients: a 1-year prospective study

Object

Terson's syndrome (TS) is a vitreous hemorrhage in association with subarachnoid hemorrhage (SAH). Its diagnosis is often delayed, which may result in vision loss secondary to treatable conditions. Methods to hasten early diagnosis and consequent ophthalmic referral are desirable. The aims of this study were 1) to assess the specificity and sensitivity of conventional head CT for diagnosing TS in patients with aneurysmal SAH (aSAH); and 2) to determine the incidence of TS and its association with age, sex, aSAH severity, and overall mortality.

Methods

Patients admitted to Helsinki University Central Hospital who underwent surgery or endovascular treatment for a ruptured intracranial aneurysm during 2011 were participants in this prospective study. They underwent serial dilated fundoscopic examinations during a 6-month period. Two radiologists independently reviewed ocular findings suggestive of TS on conventional CT head scans obtained in all patients as a routine diagnostic procedure. Associations between TS and relevant clinical, radiological, and demographic data were analyzed with uni- and multivariate logistic regression.

Results

Of 121 participants, 13 (11%) presented with TS, and another 22 (18%) with intraretinal hemorrhages. For reviewing CT head scans, the overall observed agreement between the 2 raters was 96% (116 of 121 cases), with a substantial κ of 0.69 (95% CI 0.56–0.82). The sensitivity of the CT findings for TS was 42%, and the specificity was 97%. Associations of the World Federation of Neurosurgical Societies (WFNS) and Hunt and Hess grades on admission, the presence of intracerebral hemorrhage, female sex, and aneurysm length with TS were all statistically significant. Logistic regression demonstrated that sex and WFNS grade were independently associated with TS and provided the best fit to the data.

Conclusions

Routinely looking for TS findings in CT head scans may prove valuable in clinical practice. Terson's syndrome is associated with female sex and poor clinical condition on admission.