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Dzefi-Tettey K, Edzie EKM, Brakohiapa EK, Amaning OA, Piersson AD. Terson's syndrome leading to fatal outcome in a 36-year-old woman: A case report. Radiol Case Rep 2024; 19:1827-1831. [PMID: 38420340 PMCID: PMC10899035 DOI: 10.1016/j.radcr.2024.01.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Terson's syndrome occurs as a result of intraocular hemorrhage associated with intracranial hemorrhage, but was formerly used to describe vitreous hemorrhage associated with Aneurysmal Subarachnoid Hemorrhage (SAH). We present a case of a 36-year-old woman who was not a known hypertensive but presented with a sudden onset of loss of vision in both eyes and a few hours later became deeply unconscious. A computed tomography (CT) scan of the head revealed massive intracerebral hemorrhage with intraventricular extension secondary to severe hypertension and bilateral acute retinal hemorrhages due to the acute rise in intracranial pressure and the recently described ocular glymphatic system provides a novel perspective on the pathophysiology. A diagnosis of Terson's syndrome was made but unfortunately, her clinical condition deteriorated and she expired a few hours after the CT scan. Terson's syndrome is usually associated with poor clinical outcomes from increased intracranial pressure. Implication for clinical practice is that radiologists should critically examine the orbits during imaging for retinal hemorrhage in the setting of severe intracranial hemorrhage for the necessary ophthalmological and neurosurgical interventions to be made since most patients present with sudden onset of loss of vision.
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Affiliation(s)
| | - Emmanuel Kobina Mesi Edzie
- Department of Medical Imaging, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
| | | | | | - Albert Dayor Piersson
- Department of Imaging Technology and Sonography, University of Cape Coast, Cape Coast, Ghana
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2
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Stevanovic M, Eliott D. Terson Syndrome: A Review of the Literature. Int Ophthalmol Clin 2024; 64:89-106. [PMID: 38525984 DOI: 10.1097/iio.0000000000000502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
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3
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Göttsche J, Knospe V, Sauvigny T, Schweingruber N, Grensemann J, Spitzer MS, Westphal M, Skevas C, Czorlich P. Terson Syndrome in Patients with Aneurysmal Subarachnoid Hemorrhage: A 10-Year Single-Center Experience. Neurocrit Care 2023; 39:155-161. [PMID: 36949361 PMCID: PMC10499731 DOI: 10.1007/s12028-023-01701-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/14/2023] [Indexed: 03/24/2023]
Abstract
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.
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Affiliation(s)
- Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Volker Knospe
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils Schweingruber
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin S Spitzer
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christos Skevas
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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4
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Lima-Fontes M, Leuzinger-Dias M, Rodrigues R, Barros-Pereira R, Falcão M, Fernandes V, Alves-Faria P, Falcão-Reis F, Rocha-Sousa A. Terson Syndrome - Clinical Presentation, Management, and Visual Outcomes in a Tertiary Centre. Clin Ophthalmol 2023; 17:351-359. [PMID: 36721665 PMCID: PMC9884450 DOI: 10.2147/opth.s396781] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/09/2023] [Indexed: 01/27/2023] Open
Abstract
Purpose The purpose of this study was to characterize the clinical presentation, management strategy and visual outcomes of patients diagnosed with Terson syndrome and followed in a tertiary centre in Portugal. Patients and Methods A single-centre retrospective study was performed, based on the survey review of the medical records of every consecutive patient diagnosed with Terson syndrome and followed from January 2018 to August 2021. The change in best-corrected visual acuity (BCVA) from baseline to the final evaluation was the primary outcome. Results Fifteen eyes from 8 patients (50% female) were included. The mean age at diagnosis was 55±7 years. The neurological event was traumatic brain injury in 37.5% (n=3) and subarachnoid haemorrhage in 62.5% of the patients (n=5). Bilateral intraocular haemorrhage occurred in 875% (n=7) of the patients. Vitreous and preretinal haemorrhages occurred each in 66.7% (n=10), intraretinal in 30% (n=3) and subretinal in 13.3% (n=2) of the eyes. In 40% of the eyes (n=6), spontaneous resolution of intraocular haemorrhage occurred, while PPV was performed in the remaining 60% (n=9). Ocular haemorrhage detection occurred 58.47 ± 40.94 days after the neurological event (range 11 to 121 days). Baseline BCVA was 1.11 ± 1.01 logMAR and improved to 0.32 ± 0.69 logMAR in the follow-up period (p=0.004). A positive correlation was found between initial and final BCVA (Spearman's rho = 0.643, p=0.01). Baseline BCVA of eyes undergoing PPV was lower than of those conservatively managed (1.84±0.72 vs 0.20±0.28 logMAR, p<0.001). However, there were no statistically significant differences in final BCVA after surgery or observation (0.56 ± 0.90 vs 0.04 ± 0.04 logMAR, p=0.149). Longer periods between the neurological and the ophthalmological diagnosis were correlated with worse final BCVA (Spearman's rho = 0.688, p=0.005). Conclusion Terson syndrome is a potential cause of irreversible visual loss. Diagnosis delay may affect visual prognosis. PPV is indicated when intraocular haemorrhage is dense and does not resolve spontaneously or when visual acuity at presentation is low, allowing for good visual outcomes with minimal complications.
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Affiliation(s)
- Mario Lima-Fontes
- Ophthalmology Department, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal,Correspondence: Mario Lima-Fontes, Department of Ophthalmology, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal, Email
| | - Mariana Leuzinger-Dias
- Ophthalmology Department, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal
| | - Rita Rodrigues
- Ophthalmology Department, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal
| | - Ricardo Barros-Pereira
- Ophthalmology Department, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal
| | - Manuel Falcão
- Ophthalmology Department, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal,Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
| | - Vítor Fernandes
- Ophthalmology Department, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal
| | - Pedro Alves-Faria
- Ophthalmology Department, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal,Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
| | - Fernando Falcão-Reis
- Ophthalmology Department, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal,Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
| | - Amândio Rocha-Sousa
- Ophthalmology Department, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal,Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
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5
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Foulsham W, North VS, Botsford BW, Dinkin MJ, Henderson F, Godfrey KJ, D'Amico DJ, Schwartz TH, Orlin A. Multilayered macular hemorrhages as an unusual complication of transorbital neuroendoscopic surgery. Am J Ophthalmol Case Rep 2022; 26:101556. [PMID: 35514795 PMCID: PMC9062224 DOI: 10.1016/j.ajoc.2022.101556] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/12/2022] [Accepted: 04/20/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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6
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Dmytriw AA, Chalif J, Chen J, Du R. Unilateral Terson Syndrome Following Distal Middle Cerebral Artery Aneurysm Rupture. Neurohospitalist 2022; 12:422-423. [PMID: 35419148 PMCID: PMC8995602 DOI: 10.1177/19418744211067038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Adam A. Dmytriw
- Neuroradiology and Neurointervention Service, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
| | - Joshua Chalif
- Neurosurgical Service, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jason Chen
- Neurosurgical Service, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
| | - Rose Du
- Neuroradiology and Neurointervention Service, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
- Neurosurgical Service, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
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7
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Kumaria A, Gruener AM, Dow GR, Smith SJ, Macarthur DC, Ingale HA. An explanation for Terson syndrome at last: the glymphatic reflux theory. J Neurol 2021; 269:1264-1271. [PMID: 34170402 DOI: 10.1007/s00415-021-10686-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/20/2021] [Accepted: 06/21/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Ashwin Kumaria
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK.
| | - Anna M Gruener
- School of Medicine, University of Nottingham, Nottingham, UK.,Department of Ophthalmology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Graham R Dow
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
| | - Stuart J Smith
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK.,School of Medicine, University of Nottingham, Nottingham, UK
| | - Donald C Macarthur
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK.,School of Medicine, University of Nottingham, Nottingham, UK
| | - Harshal A Ingale
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
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8
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Albanna W, Conzen C, Weiss M, Seyfried K, Kotliar K, Schmidt TP, Kuerten D, Hescheler J, Bruecken A, Schmidt-Trucksäss A, Neumaier F, Wiesmann M, Clusmann H, Schubert GA. Non-invasive Assessment of Neurovascular Coupling After Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Trial Using Retinal Vessel Analysis. Front Neurol 2021; 12:690183. [PMID: 34194387 PMCID: PMC8236540 DOI: 10.3389/fneur.2021.690183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/18/2021] [Indexed: 12/17/2022] Open
Abstract
Objective: Delayed cerebral ischemia (DCI) is a common complication after aneurysmal subarachnoid hemorrhage (aSAH) and can lead to infarction and poor clinical outcome. The underlying mechanisms are still incompletely understood, but animal models indicate that vasoactive metabolites and inflammatory cytokines produced within the subarachnoid space may progressively impair and partially invert neurovascular coupling (NVC) in the brain. Because cerebral and retinal microvasculature are governed by comparable regulatory mechanisms and may be connected by perivascular pathways, retinal vascular changes are increasingly recognized as a potential surrogate for altered NVC in the brain. Here, we used non-invasive retinal vessel analysis (RVA) to assess microvascular function in aSAH patients at different times after the ictus. Methods: Static and dynamic RVA were performed using a Retinal Vessel Analyzer (IMEDOS Systems GmbH, Jena) in 70 aSAH patients during the early (d0-4), critical (d5-15), late (d16-23) phase, and at follow-up (f/u > 6 weeks) after the ictus. For comparison, an age-matched cohort of 42 healthy subjects was also included in the study. Vessel diameters were quantified in terms of the central retinal arterial and venous equivalent (CRAE, CRVE) and the retinal arterio-venous-ratio (AVR). Vessel responses to flicker light excitation (FLE) were quantified by recording the maximum arterial and venous dilation (MAD, MVD), the time to 30% and 100% of maximum dilation (tMAD30, tMVD30; tMAD, tMVD, resp.), and the arterial and venous area under the curve (AUCart, AUCven) during the FLE. For subgroup analyses, patients were stratified according to the development of DCI and clinical outcomes after 12 months. Results: Vessel diameter (CRAE, CRVE) was significantly smaller in aSAH patients and showed little change throughout the whole observation period (p < 0.0001 vs. control for all time periods examined). In addition, aSAH patients exhibited impaired arterial but not venous responses to FLE, as reflected in a significantly lower MAD [2.2 (1.0-3.2)% vs. 3.6 (2.6-5.6)% in control subjects, p = 0.0016] and AUCart [21.5 (9.4-35.8)%*s vs. 51.4 (32.5-69.7)%*s in control subjects, p = 0.0001] on d0-4. However, gradual recovery was observed during the first 3 weeks, with close to normal levels at follow-up, when MAD and AUCart amounted to 3.0 [2.0-5.0]% (p = 0.141 vs. control, p = 0.0321 vs. d5-15) and 44.5 [23.2-61.1]%*s (p = 0.138 vs. control, p < 0.01 vs. d0-4 & d5-15). Finally, patients with clinical deterioration (DCI) showed opposite changes in the kinetics of arterial responses during early and late phase, as reflected in a significantly lower tMAD30 on d0-4 [4.0 (3.0-6.8) s vs. 7.0 (5.0-8.0) s in patients without DCI, p = 0.022) and a significantly higher tMAD on d16-23 (24.0 (21.0-29.3) s vs. 18.0 (14.0-21.0) s in patients without DCI, p = 0.017]. Conclusion: Our findings confirm and extend previous observations that aSAH results in sustained impairments of NVC in the retina. DCI may be associated with characteristic changes in the kinetics of retinal arterial responses. However, further studies will be required to determine their clinical implications and to assess if they can be used to identify patients at risk of developing DCI. Trial Registration: ClinicalTrials.gov Identifier: NCT04094155.
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Affiliation(s)
- Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.,Institute for Neurophysiology, University of Cologne, Cologne, Germany
| | - Catharina Conzen
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | | - Konstantin Kotliar
- Department of Medical Engineering and Technomathematics, FH Aachen University of Applied Sciences, Aachen, Germany
| | | | - David Kuerten
- Department of Ophthalmology, RWTH Aachen University, Aachen, Germany
| | - Jürgen Hescheler
- Institute for Neurophysiology, University of Cologne, Cologne, Germany
| | - Anne Bruecken
- Department of Intensive Care and Intermediate Care, RWTH Aachen University, Aachen, Germany
| | | | - Felix Neumaier
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
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9
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Terson syndrome caused by intraventricular hemorrhage associated with arteriovenous malformation: Case report. Neurochirurgie 2020; 67:526-528. [PMID: 33147446 DOI: 10.1016/j.neuchi.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/20/2020] [Accepted: 10/23/2020] [Indexed: 11/22/2022]
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10
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Stewart MW, Hasan SA, Collins C, Stanko C, Summer J, Brazis PW, Tawk R, Freeman WD. Can Baseline Computed Tomography Scans Be Used to Identify Patients at High Risk of Vision Loss due to Terson Syndrome? Am J Ophthalmol 2020; 211:217-228. [PMID: 31562856 DOI: 10.1016/j.ajo.2019.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 09/14/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Michael W Stewart
- Department of Ophthalmology, Mayo Clinic Florida, Jacksonville, Florida, USA.
| | - Syed A Hasan
- Department of Ophthalmology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Christina Collins
- Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Carlene Stanko
- Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Jennifer Summer
- Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Paul W Brazis
- Department of Ophthalmology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Rabih Tawk
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - W David Freeman
- Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida, USA
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11
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Citirik M, Tekin K, Teke MY. Terson syndrome with persistent vitreous hemorrhage following traumatic brain injury. Saudi J Ophthalmol 2020; 33:392-397. [PMID: 31920451 PMCID: PMC6950947 DOI: 10.1016/j.sjopt.2018.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 11/05/2018] [Accepted: 11/27/2018] [Indexed: 11/30/2022] Open
Abstract
The objective of this study was to report clinical findings and surgical outcomes of 3 patients with persistent vitreous hemorrhage diagnosed as Terson syndrome (TS). Posterior segment changes, optical coherence tomography scans, fundus autofluorescence images, and fundus fluorescein angiography findings of patients were evaluated and pars plana vitrectomy (PPV) was performed on 3 eyes of three patients. All eyes operated after 6 months from the date of injury and final visual acuities were 20/200, 20/60 and 20/30. PPV is found as a safe and effective procedure for vitreous hemorrhage in TS. Delayed surgery in a young patient predicts a worse outcome.
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Affiliation(s)
- Mehmet Citirik
- University of Health Sciences, Ankara Ulucanlar Eye Education and Research Hospital, Ankara, Turkey
| | - Kemal Tekin
- University of Health Sciences, Ankara Ulucanlar Eye Education and Research Hospital, Ankara, Turkey
| | - Mehmet Yasin Teke
- University of Health Sciences, Ankara Ulucanlar Eye Education and Research Hospital, Ankara, Turkey
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12
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Hong EH, Seong M, Yeom H, Choi S, Choi KS, Kang MH, Cho H, Shin YU. Incidence of Terson Syndrome in Treated Subarachnoid Hemorrhage in South Korea: a National Health Insurance Database Study. Sci Rep 2019; 9:19048. [PMID: 31836842 PMCID: PMC6911003 DOI: 10.1038/s41598-019-55566-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/29/2019] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Eun Hee Hong
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, Korea
| | - Mincheol Seong
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, Korea
| | - Hosuck Yeom
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, Korea
| | - Sungyong Choi
- Big Data Division, Seoul Metropolitan Government, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Korea
| | - Min Ho Kang
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, Korea
| | - Heeyoon Cho
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, Korea.
| | - Yong Un Shin
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, Korea.
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13
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Liu X, Yang L, Cai W, Gao L, Li Y. Clinical features and visual prognostic indicators after vitrectomy for Terson syndrome. Eye (Lond) 2019; 34:650-656. [PMID: 31455901 DOI: 10.1038/s41433-019-0547-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 04/29/2019] [Accepted: 05/28/2019] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To determine clinical characteristics and identify factors associated with better visual outcomes in patients who had vitrectomy for vitreous haemorrhage (VH) associated with Terson syndrome (TS). METHODS The records of 48 patients (54 corresponding eyes) who underwent vitrectomy for VH associated with TS from January 2008 to December 2017 were retrospectively reviewed. The main outcome measure was the final postoperative visual acuity. RESULTS At the last visit, 34 eyes (63.0%) achieved a BCVA of 0.3 or better. Eyes associated with traumatic brain injury had a better visual outcome than those with primary intracerebral haemorrhage (P = 0.042). In the primary intracerebral haemorrhage group, patients with hypertension-induced intracranial haemorrhage (IH) showed poorer final visual acuities than the ruptured intracranial aneurysm group (P = 0.023). In the delayed vitrectomy group, epiretinal membrane and peripheral retina changes were more common (P < 0.05). However, the difference in final visual acuity between the early and delayed vitrectomy groups was not significant (P = 0.69). CONCLUSION Most of the patients obtained visual recovery after vitrectomy for TS. VH associated with ruptured intracranial aneurysm or traumatic brain injury or eyes without retinal haemorrhage are predictive of better prognosis. Although the timing of vitrectomy was not related to the final postoperative visual outcome, early vitrectomy by three months seems to suggest less epiretinal membrane formation, retinal tears, and retinal detachments.
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Affiliation(s)
- Xin Liu
- Eye Center, The Second Hospital of Jilin University, #218 Ziqiang Street, Changchun, 130000, Jilin, China
| | - Longfei Yang
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetics, The Second Hospital of Jilin University, #218 Ziqiang Street, Changchun, 130000, Jilin, China
| | - Wenrui Cai
- Eye Center, The Second Hospital of Jilin University, #218 Ziqiang Street, Changchun, 130000, Jilin, China
| | - Linlin Gao
- Eye Center, The Second Hospital of Jilin University, #218 Ziqiang Street, Changchun, 130000, Jilin, China
| | - Yaping Li
- Eye Center, The Second Hospital of Jilin University, #218 Ziqiang Street, Changchun, 130000, Jilin, China.
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Subarachnoid Hemorrhage in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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15
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16
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Leonardo Gordinho A, Rosado S, Mesquita T, Ferreira NR. Blind spot: blindness as initial presentation of subarachnoid haemorrhage. BMJ Case Rep 2018; 2018:bcr-2017-222745. [PMID: 29636335 DOI: 10.1136/bcr-2017-222745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 47-year-old Caucasian man with arterial hypertension was admitted after a seizure. At the emergency department, he presented with high blood pressure, bilateral vision loss (evidenced by unresponsiveness to threatening stimuli), right hemiplegia and severe agitation. The brain CT angiography showed a diffuse basal cisterns subarachnoid haemorrhage with a ruptured basilar aneurysm. He was admitted for neurovascular procedure and embolisation. The patient's neurological examination improved but blindness persisted. A funduscopic examination revealed a left eye vitreous haemorrhage and diffuse retinal haemorrhages in the posterior pole. Assuming the haemorrhages were the cause of blindness, Terson syndrome was diagnosed. The patient underwent vitrectomy surgery being discharged 5 days later maintaining left eye blindness and able to count fingers from 1 m distance with the right eye. Two months after discharge, he was re-evaluated at our clinic with left eye blurred vision and almost normal right eye visual acuity.
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Affiliation(s)
| | - Steeve Rosado
- Department of Medicine, Hospital Beatriz Angelo, Loures, Portugal
| | - Teresa Mesquita
- Department of Medicine, Hospital Beatriz Angelo, Loures, Portugal
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Choi MS, Lee JH, Song JH, Lim YC. Prognostic Factors Affecting Visual Recovery in Terson Syndrome with Aneurysmal Subarachnoid Hemorrhage. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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18
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Conzen C, Albanna W, Weiss M, Kürten D, Vilser W, Kotliar K, Zäske C, Clusmann H, Schubert GA. Vasoconstriction and Impairment of Neurovascular Coupling after Subarachnoid Hemorrhage: a Descriptive Analysis of Retinal Changes. Transl Stroke Res 2017; 9:284-293. [PMID: 29119370 DOI: 10.1007/s12975-017-0585-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 11/25/2022]
Abstract
Impaired cerebral autoregulation and neurovascular coupling (NVC) contribute to delayed cerebral ischemia after subarachnoid hemorrhage (SAH). Retinal vessel analysis (RVA) allows non-invasive assessment of vessel dimension and NVC hereby demonstrating a predictive value in the context of various neurovascular diseases. Using RVA as a translational approach, we aimed to assess the retinal vessels in patients with SAH. RVA was performed prospectively in 24 patients with acute SAH (group A: day 5-14), in 11 patients 3 months after ictus (group B: day 90 ± 35), and in 35 age-matched healthy controls (group C). Data was acquired using a Retinal Vessel Analyzer (Imedos Systems UG, Jena) for examination of retinal vessel dimension and NVC using flicker-light excitation. Diameter of retinal vessels-central retinal arteriolar and venular equivalent-was significantly reduced in the acute phase (p < 0.001) with gradual improvement in group B (p < 0.05). Arterial NVC of group A was significantly impaired with diminished dilatation (p < 0.001) and reduced area under the curve (p < 0.01) when compared to group C. Group B showed persistent prolonged latency of arterial dilation (p < 0.05). Venous NVC was significantly delayed after SAH compared to group C (A p < 0.001; B p < 0.05). To our knowledge, this is the first clinical study to document retinal vasoconstriction and impairment of NVC in patients with SAH. Using non-invasive RVA as a translational approach, characteristic patterns of compromise were detected for the arterial and venous compartment of the neurovascular unit in a time-dependent fashion. Recruitment will continue to facilitate a correlation analysis with clinical course and outcome.
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Affiliation(s)
- Catharina Conzen
- Department of Neurosurgery, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - David Kürten
- Department of Ophthalmology, RWTH Aachen University, Aachen, Germany
| | | | - Konstantin Kotliar
- Department of Medical Engineering and Technomathematics, FH Aachen University of Applied Sciences, Aachen, Germany
| | - Charlotte Zäske
- Department of Neurosurgery, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
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Fonseca APA, Rosa Júnior M. Terson's syndrome: an important differential diagnosis of subarachnoid hemorrhage. Radiol Bras 2017; 50:346-347. [PMID: 29085176 PMCID: PMC5656083 DOI: 10.1590/0100-3984.2016.0053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Ana Paula Alves Fonseca
- Hospital Universitário Cassiano Antônio Morais da Universidade Federal do Espírito Santo (HUCAM-UFES), Vitória, ES, Brazil
| | - Marcos Rosa Júnior
- Hospital Universitário Cassiano Antônio Morais da Universidade Federal do Espírito Santo (HUCAM-UFES), Vitória, ES, Brazil
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20
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Mao X, You Z. 25G compared with 20G vitrectomy under Resight non-contact wide-angle lenses for Terson syndrome. Exp Ther Med 2017; 14:1193-1197. [PMID: 28810578 DOI: 10.3892/etm.2017.4592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 11/04/2016] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to compare the effectiveness of 25G vitrectomy to standard 20G vitrectomy for treatment of Terson syndrome under Resight non-contact wide-angle lenses. This was a case-control study of 20 patients with Terson syndrome (study group) that underwent 25G vitrectomy under Resight non-contact wide-angle lenses, with those of 20 matched patients that underwent 20G vitrectomy (control group). Medical records were reviewed from between July 2011 and October 2013. Data included results of the Early Treatment Diabetic Retinopathy Study examination, ophthalmology B-scan ultrasonography and fundus photography. The mean age, follow-up time, the preoperative visual acuity of LogMAR and the preoperative intraocular pressure (IOP) were all comparable in the two groups (all P>0.05). There were statistically significant differences in postoperative visual acuity of LogMAR compared with preoperative visual acuity (P<0.001) in both groups, but no difference between the groups (P=0.845). However, the operative times (13.5 min in study group vs. 42 min in control group) and post-operative IOP at day 1 (13.5 vs. 20 mmHg) were significantly reduced in the study group compared to the control group (P<0.001). Therefore, the present findings suggest that 25G Vitrectomy for Terson syndrome under Resight non-contact wide-angle lenses can achieve a significantly shorter operative time and lower post-operative IOP compared with 20G Vitrectomy.
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Affiliation(s)
- Xinbang Mao
- Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Zhipeng You
- Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
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21
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Narayanan R, Taylor SC, Nayaka A, Deshpande R, St Aubin D, Hrisomalos FN, Hu J, Rajagopal R, Tewari A, Apte RS. Visual Outcomes after Vitrectomy for Terson Syndrome Secondary to Traumatic Brain Injury. Ophthalmology 2016; 124:118-122. [PMID: 27817917 DOI: 10.1016/j.ophtha.2016.09.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/31/2016] [Accepted: 09/12/2016] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
| | - Stanford C Taylor
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri
| | | | | | - Daniel St Aubin
- Kresge Eye Institute, Department of Ophthalmology, Wayne State University School of Medicine, Detroit, Michigan
| | - Frank N Hrisomalos
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri
| | - Jonathan Hu
- Kresge Eye Institute, Department of Ophthalmology, Wayne State University School of Medicine, Detroit, Michigan
| | - Rithwick Rajagopal
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri
| | - Asheesh Tewari
- Kresge Eye Institute, Department of Ophthalmology, Wayne State University School of Medicine, Detroit, Michigan
| | - Rajendra S Apte
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri.
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Intraocular Silicone Oil Masquerading as Terson Syndrome. Case Rep Ophthalmol Med 2016; 2016:4942109. [PMID: 27747119 PMCID: PMC5055946 DOI: 10.1155/2016/4942109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/31/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction. Terson syndrome is described as intraocular hemorrhage in association with any type of intracranial hemorrhage and is associated with higher mortality rate and vision loss. Intraocular hemorrhage in Terson syndrome may be diagnosed using computed tomography but there are false positive results. Silicone oil which is widely used for internal tamponade of complicated retinal detachments has high attenuation on computed tomography and hyperintensity on T1-weighted magnetic resonance imaging that can mimic intraocular hemorrhage. This report shows that silicone oil is another origin of false positive results in interpreting CT findings for detecting Terson syndrome. Case Report. A 71-year-old diabetic woman presented with loss of consciousness. Brain computed tomography revealed right cerebellar hemorrhage and ventricular hemorrhage and hyperdensity in vitreous cavity of the left eye that was initially interpreted as vitreous hemorrhage. Terson syndrome was the initial diagnosis but ophthalmoscopic examination and brain MRI showed that the left eye had silicone oil tamponade. Conclusion. Without knowing the history of previous vitreoretinal surgery, CT scan findings of intraocular silicone oil may be interpreted as vitreous hemorrhage. In patients with concomitant intracranial hemorrhage, it can masquerade as Terson syndrome.
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23
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Czorlich P, Skevas C, Knospe V, Vettorazzi E, Westphal M, Regelsberger J. Terson's syndrome - Pathophysiologic considerations of an underestimated concomitant disease in aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2016; 33:182-186. [PMID: 27452126 DOI: 10.1016/j.jocn.2016.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/28/2016] [Accepted: 04/02/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany.
| | - Christos Skevas
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Volker Knospe
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
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Terson syndrome in aneurysmal subarachnoid hemorrhage-its relation to intracranial pressure, admission factors, and clinical outcome. Acta Neurochir (Wien) 2016; 158:1027-36. [PMID: 27038169 DOI: 10.1007/s00701-016-2766-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/29/2016] [Indexed: 10/22/2022]
Abstract
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.
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25
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Lee GI, Choi KS, Han MH, Byoun HS, Yi HJ, Lee BR. Practical Incidence and Risk Factors of Terson's Syndrome: A Retrospective Analysis in 322 Consecutive Patients with Aneurysmal Subarachnoid Hemorrhage. J Cerebrovasc Endovasc Neurosurg 2015; 17:203-8. [PMID: 26526120 PMCID: PMC4626343 DOI: 10.7461/jcen.2015.17.3.203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 06/18/2015] [Accepted: 07/08/2015] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Gun-Ill Lee
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Myung-Hoon Han
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Hyoung-Soo Byoun
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Byung-Ro Lee
- Department of Ophthalmology, Hanyang University Medical Center, Seoul, Korea
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Bäuerle J, Gross NJ, Egger K, Neubauer J, Niesen WD, Buttler KJ, Lagrèze WA, Reinhard M. Terson's Syndrome: Diagnostic Comparison of Ocular Sonography and CT. J Neuroimaging 2015; 26:247-52. [DOI: 10.1111/jon.12285] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 06/18/2015] [Accepted: 07/03/2015] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jochen Bäuerle
- Department of Neurology; University Medical Center Freiburg; Freiburg Germany
| | - Nikolai J. Gross
- Department of Ophthalmology; University Medical Center Freiburg; Freiburg Germany
| | - Karl Egger
- Department of Neuroradiology; University Medical Center Freiburg; Freiburg Germany
| | - Jakob Neubauer
- Department of Neuroradiology; University Medical Center Freiburg; Freiburg Germany
| | - Wolf-Dirk Niesen
- Department of Neurology; University Medical Center Freiburg; Freiburg Germany
| | - Klaus-Jürgen Buttler
- Department of Neurology; University Medical Center Freiburg; Freiburg Germany
- Department of Neurosurgery; University Medical Center Freiburg; Freiburg Germany
| | - Wolf A. Lagrèze
- Department of Ophthalmology; University Medical Center Freiburg; Freiburg Germany
| | - Matthias Reinhard
- Department of Neurology; University Medical Center Freiburg; Freiburg Germany
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Ocular ultrasound as an easy applicable tool for detection of Terson's syndrome after aneurysmal subarachnoid hemorrhage. PLoS One 2014; 9:e114907. [PMID: 25502695 PMCID: PMC4263478 DOI: 10.1371/journal.pone.0114907] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/14/2014] [Indexed: 11/26/2022] Open
Abstract
Introduction Intraocular hemorrhage in patients suffering from aneurysmal subarachnoid hemorrhage is known as Terson's syndrome and is an underestimated but common pathology. We therefore designed a prospective single-blinded study to evaluate the validity of ocular ultrasound compared to the gold standard indirect funduscopy in the diagnosis of Terson's syndrome. Material and Methods Fifty-two patients (104 eyes in total) suffering from aneurysmal subarachnoid hemorrhage were enrolled in this study. Two investigators independently performed a single-blinded ocular ultrasound using a standard intensive care ultrasound system to detect an intraocular hemorrhage. Indirect funduscopy following iatrogenic mydriasis served as the gold standard for confirmation or exclusion of an intraocular hemorrhage. Statistical analyses were performed to evaluate the sensitivity and specificity, positive and negative predictive values of the method as well as the learning curve of ocular ultrasound. Results Indirect funduscopy detected Terson's syndrome in 11 of 52 (21.2%) respectively in 21 of 104 (20.2%) eyes in patients suffering from subarachnoid hemorrhage. Sensitivity and specificity increased with the number of ocular ultrasound examinations for both investigators, reaching 81.8% and 100% respectively. Positive and negative predictive values were different for both investigators (63.6% vs. 100% positive and 100% vs. 95.7% negative) but were both correlated to the amount of intraocular hemorrhage. A low Glasgow Coma scale (p = 0.015) and high Hunt & Hess grade (p = 0.003) was associated with a higher rate of Terson's syndrome. Conclusions Ocular ultrasound using standard ultrasound equipment has been confirmed as a reliable, easy-to-handle bedside screening tool for detecting Terson's syndrome. Nevertheless funduscopy remains the gold standard to detect Terson's syndrome.
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Terson syndrome in subarachnoid hemorrhage, intracerebral hemorrhage, and traumatic brain injury. Neurosurg Rev 2014; 38:129-36; discussion 136. [PMID: 25173620 DOI: 10.1007/s10143-014-0564-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/19/2014] [Accepted: 05/24/2014] [Indexed: 12/20/2022]
Abstract
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.
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Skevas C, Czorlich P, Knospe V, Stemplewitz B, Richard G, Westphal M, Regelsberger J, Wagenfeld L. Terson's Syndrome—Rate and Surgical Approach in Patients with Subarachnoid Hemorrhage. Ophthalmology 2014; 121:1628-33. [DOI: 10.1016/j.ophtha.2014.02.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 02/14/2014] [Accepted: 02/14/2014] [Indexed: 11/29/2022] Open
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Obuchowska I, Turek G, Mariak Z, Mariak Z. Early Intraocular Complications of Subarachnoid Haemorrhage after Aneurysm Rupture. Neuroophthalmology 2014; 38:199-204. [PMID: 27928299 DOI: 10.3109/01658107.2014.911918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 03/26/2014] [Accepted: 03/28/2014] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
| | - Grzegorz Turek
- Department of Neurosurgery, Medical University of Bialystok Bialystok Poland
| | - Zenon Mariak
- Department of Neurosurgery, Medical University of Bialystok Bialystok Poland
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Koskela E, Pekkola J, Kivisaari R, Kivelä T, Hernesniemi J, Setälä K, Laakso A. Comparison of CT and clinical findings of Terson's syndrome in 121 patients: a 1-year prospective study. J Neurosurg 2014; 120:1172-8. [DOI: 10.3171/2014.2.jns131248] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | - Johanna Pekkola
- 2Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland
| | - Riku Kivisaari
- 3Neurosurgery, Helsinki University Central Hospital; and
| | | | | | | | - Aki Laakso
- 3Neurosurgery, Helsinki University Central Hospital; and
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Rheinboldt M, Francis K, Parrish D, Harper D, Blase J. Terson syndrome in conjunction with ruptured intracranial aneurysm and penetrating intracranial injury: a review of two cases. Emerg Radiol 2013; 21:215-8. [PMID: 24174125 DOI: 10.1007/s10140-013-1172-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 10/17/2013] [Indexed: 11/30/2022]
Abstract
Terson syndrome, the presence of intraocular hemorrhage in the setting of acutely elevated intracranial pressure, was historically described in conjunction with acute subarachnoid hemorrhage; however, more recently, it has been associated with a gamut of intracranial pathophysiology ranging from blunt or penetrating injury to neurosurgical procedures. We describe two cases of profound intracranial injury, secondary to ballistic injury, and a ruptured intracranial aneurysm, in which posterior chamber ocular hemorrhage was noted on CT imaging. Though the outcome in such cases, as with ours, is often poor, the findings are germane to clinical care as the presence of Terson syndrome has been noted to be a negative prognostic factor in multiple clinical reviews. Additionally, clinical recovery can be impacted adversely by lasting visual deficits or retinal degradation in the absence of timely ophthalmologic intervention.
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Affiliation(s)
- Matt Rheinboldt
- Department of Emergency Radiology, Henry Ford Hospital, Detroit, MI, USA,
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Gress DR, Wintermark M, Gean AD. A case of Terson syndrome and its mechanism of bleeding. J Neuroradiol 2013; 40:312-4. [PMID: 24095292 DOI: 10.1016/j.neurad.2013.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 07/10/2013] [Accepted: 07/11/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Daryl R Gress
- Department of Neurology, University of Virginia, Charlottesville, Virginia, United States
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Abstract
Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular disease. Outcome after SAH is mainly determined by the initial severity of the hemorrhage. Neuroimaging, in particular computed tomography, and aneurysm repair techniques, such as coiling and clipping, as well as neurocritical care management, have improved during the last few years. The management of a patient with SAH should have an interdisciplinary approach with case discussions between the neurointensivist, interventionalist and the neurosurgeon. The patient should be treated in a specialized neurointensive care unit of a center with sufficient SAH case volume. Poor-grade patients can be observed for complications and delayed cerebral ischemia through continuous monitoring techniques in addition to transcranial Doppler ultrasonography such as continuous electroencephalography, brain tissue oxygenation, cerebral metabolism, cerebral blood flow and serial vascular imaging. Neurocritical care should focus on neuromonitoring for delayed cerebral ischemia, management of hydrocephalus, seizures and intracranial hypertension, as well as of medical complications such as hyperglycemia, fever and anemia.
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Affiliation(s)
- Katja E Wartenberg
- Neurocritical Care Unit, Department of Neurology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120 Halle (Saale), Germany
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Editors’ Introduction. Neuroophthalmology 2013. [DOI: 10.3109/01658107.2013.767119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Visser F, Rinkel GJE. Isolated headache in general practice: determinants for delay in referral in patients with subarachnoid haemorrhage. Eur J Gen Pract 2012; 18:149-53. [PMID: 22954194 DOI: 10.3109/13814788.2012.685711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A delay in diagnosing aneurismal subarachnoid haemorrhage (SAH) occurs in a substantial proportion of patients who present with headache as the only symptom. OBJECTIVE To identify determinants for a delay in referral in patients with SAH, who present with isolated headache to the general practitioner (GP). METHODS For all 112 patients with SAH admitted to the hospital between October 2008 and June 2009, we sent a questionnaire to the GPs asking for details presented during the initial GP visit. In this retrospective study, we included 31 patients with SAH who initially presented with isolated headache. We assessed acuteness of headache onset, history of headaches and a patient delay as determinants for delayed referral (> 2 h after a visit to the GP), by calculating risk ratios (RRs) with corresponding 95% confidence intervals (CIs). RESULTS Referral was delayed in 18 of these 31 patients. The delay occurred in all 10 patients in whom the GP was unaware of the acute onset of headache and in 8 of 21 patients in whom the GP was aware of this symptom (RR: 2.6; 95% CI: 1.5-4.5). A history of headaches (RR: 1.8; 95% CI: 1.1-3.0) and a patient delay (RR: 2.1; 95% CI: 1.0-4.5) also increased the probability of delayed referral. CONCLUSION In patients with SAH who presented with isolated headache to the GP, GP's unawareness of the acute onset of the headache, a history of headaches and late presentation by the patient increased the probability of delayed referral.
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Affiliation(s)
- Femke Visser
- Department of Neurology, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands.
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Wu LN, He T, Xing YQ, Shen Y. Incidence of Terson’s Syndrome in Patients with SAH in a Chinese Hospital. Curr Eye Res 2012; 38:97-101. [DOI: 10.3109/02713683.2012.715713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Stienen MN, Lücke S, Gautschi OP, Harders A. Terson haemorrhage in patients suffering aneurysmal subarachnoid haemorrhage: a prospective analysis of 60 consecutive patients. Clin Neurol Neurosurg 2012; 114:535-8. [PMID: 22472353 DOI: 10.1016/j.clineuro.2011.10.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Revised: 10/16/2011] [Accepted: 10/22/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The concomitance of vitreous/subhyaloid haemorrhage (Terson syndrome; TS) and aneurysmal subarachnoid haemorrhage (aSAH) is commonly underestimated. The aim of this study was to determine the incidence of TS and to identify parameters that predispose its development, indicate the severity of the underlying disease, and predict outcome. METHODS Sixty consecutive patients suffering from aSAH were included in this study. The admitting Glasgow Coma Scale scores (GCS), Hunt & Hess (H&H) and Fisher grades were documented. All participants were ophthalmologically examined. The outcome at discharge was estimated using the Glasgow Outcome Scale (GOS). RESULTS Of the 60 patients admitted for aSAH, eleven (18.3%) displayed TS within 24h after aneurysm rupture. Statistical analysis revealed a significant relation between TS and either high Fisher- (3.0 vs. 2.32; p=0.008) or H&H- (4.09 vs. 2.69; p=0.001) and low GCS- (5.55 vs. 12.87; p<0.001) scores. Compared with the non-TS group, patients with TS displayed generally worse outcomes (mean GOS 2.09 vs. 3.53; p=0.007), including a significantly higher mortality (36.4 vs. 10.2%; p=0.028). CONCLUSION Terson syndrome is likely to occur in severe aSAH with poor admission scores and indicates a worse functional outcome. An ophthalmological examination is strongly recommended in aSAH patients with poor admission scores.
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Affiliation(s)
- Martin N Stienen
- Department of Neurosurgery, University Hospital Bochum-Langendreer, In der Schornau 23-25, 44892 Bochum-Langendreer, Germany
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Obuchowska I, Turek G, Mariak Z, Kochanowicz J, Mariak Z. Late ophthalmological assessment of patients with subarachnoid hemorrhage and clipping of cerebral aneurysm. Acta Neurochir (Wien) 2011; 153:2127-36. [PMID: 21922215 DOI: 10.1007/s00701-011-1161-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 09/02/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE To estimate prospectively late ocular manifestations in patients after aneurysmal subarachnoid hemorrhage (SAH) treated with aneurysm clipping. METHODS Forty-six patients (12 men and 34 women), 23-69 years of age, were included in this study. A conventional ophthalmological examination, visual evoked potentials (VEPs), and static perimetry were performed on all patients. The mean interval between the onset of SAH and the aforementioned examination was 1.9 ± 1.3 years (range 0.5-5 years). The following were compared between patients with affected and non-affected visual fields as well as between those with normal and abnormal VEPs: sex, age, time from SAH to surgery, Hunt and Hess scale, Glasgow Coma Scale, Glasgow Outcome Scale, grading of SAH according to the Fisher scale, and the size and site of aneurysm. RESULTS Visual field defects were found in 23 patients (50%). In all of these patients, both eyes were affected. The most frequent type of visual field defects were: constricted field (47.8%), multiple peripheral foci (26.1%), and superior field defect (17.4%). There was no significant relationship between the analyzed factors and the occurrence of visual field defects, although statistical significance was almost observed in respect to the Fisher scale (p = 0.055). Deterioration in VEPs was observed in nine patients (19.6%). In the group of patients with abnormal VEPs, the time from onset of SAH to surgery was 2.6 ± 1.8 days, whereas in the group of patients with normal VEPs this time amounted to 6.4 ± 2.4 days (p = 0.02). In patients with no changes in VEPs, the mean Fisher score was significantly higher than in the group with abnormal VEPs (2.8 ± 0.6 vs 2.0 ± 0.4 respectively, p = 0.04). CONCLUSION Visual field defects and VEP deterioration are frequent late ocular manifestations of SAH treated with aneurysm clipping. Damage to the visual pathway correlates with the severity of SAH and timing of aneurysmal surgery.
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Sung W, Arnaldo B, Sergio C, Juliana S, Michel F. Terson's syndrome as a prognostic factor for mortality of spontaneous subarachnoid haemorrhage. Acta Ophthalmol 2011; 89:544-7. [PMID: 20003110 DOI: 10.1111/j.1755-3768.2009.01735.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the prognosis of mortality in patients with spontaneous subarachnoid haemorrhage associated with Terson's syndrome. METHODS A prospective, consecutive case series study was conducted in patients admitted to the emergency room with a diagnosis of acute subarachnoid haemorrhage. After a complete neurological examination, funduscopic examination using binocular indirect ophthalmoscopy under mydriasis was performed upon admission and at days 3, 7, 30 and 60 after the onset. In all cases, the diagnosis of intracranial bleeding was made by computerized tomography, and the clinical condition was graded according to the Hunt & Hess and Glasgow coma scales. RESULTS Forty-seven patients with the diagnosis of subarachnoid haemorrhage were enrolled. Forty-four cases were associated with a ruptured aneurysm and three cases with arterio-venous malformation. Fourteen patients (29%) were diagnosed with Terson's syndrome. Seven patients (50%) with Terson's syndrome died, whereas death occurred in three patients (9%) without Terson's syndrome (p = 0.002). Ocular findings in Terson's syndrome were preretinal, intraretinal, sub-retinal and vitreous haemorrhage. Associated ocular findings included third-nerve palsy, papilloedema and subconjunctival haemorrhage. CONCLUSION The presence of Terson's syndrome was associated with an increased mortality rate (50% versus 9%; p < 0.01). Therefore, patients with the diagnosis of intracranial haemorrhage should be submitted to a funduscopic examination, because the presence of intraocular haemorrhage is an important life-threatening prognostic factor.
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Affiliation(s)
- Watanabe Sung
- Department of Ophthalmology, Federal University of São Paulo, Brazil.
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Hassan A, Lanzino G, Wijdicks EFM, Rabinstein AA, Flemming KD. Terson’s Syndrome. Neurocrit Care 2011; 15:554-8. [DOI: 10.1007/s12028-011-9555-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
A 51-year-old male was admitted following subarachnoid hemorrhage (SAH) (Figure 1). His Glasgow coma score was 15. Other than headache and a defect in his right visual field, his neurological exam was normal. Cerebral angiography demonstrated a 3 mm anterior communicating artery aneurysm which was successfully excluded with endovascular coiling. Due to persistent visual complaints, an ophthalmology consult was obtained, which revealed a scotoma of the right eye. Fundoscopy demonstrated a large subhyaloid hemorrhage of the right eye (Figure 2), and a small retinal hemorrhage with papilledema of the left eye. Intraocular pressure was slightly higher than normal, 31 mmHg, in both eyes. The diagnosis of Terson’s syndrome (TS) was made, and the decision was made to follow him conservatively for at least six months.
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Ko F, Knox DL. The Ocular Pathology of Terson's Syndrome. Ophthalmology 2010; 117:1423-9.e2. [DOI: 10.1016/j.ophtha.2009.11.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Revised: 11/18/2009] [Accepted: 11/18/2009] [Indexed: 02/08/2023] Open
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