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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ozer F, Tokuc EO, Albayrak MGB, Akpinar G, Kasap M, Karabas VL. Comparison of before versus after intravitreal bevacizumab injection, growth factor levels and fibrotic markers in vitreous samples from patients with proliferative diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol 2022. [PMID: 35028761 DOI: 10.1007/s00417-021-05515-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/07/2021] [Accepted: 11/24/2021] [Indexed: 11/04/2022] Open
Abstract
PURPOSE In diabetic retinopathy patients, intravitreal bevacizumab (IVB) injections are widely used to facilitate dissection of retinal fibrovascular membranes during surgery, reduce the rate of perioperative hemorrhage, and prevent recurrent neovascularization. Previous studies have shown that IVB may worsen fibrosis and thereby impair vision. The aim of this study was to determine which markers are associated with fibrosis. METHODS Twenty-three patients with proliferative diabetic retinopathy (PDR) underwent pars plana vitrectomy (PPV) with IVB pretreatment for intraocular hemorrhage (IOH) and/or tractional retinal detachment (TRD). Vitreous samples were obtained at the time of IVB injection and again at the beginning of PPV, about a week later. Using Western blot analysis, the concentrations of vascular endothelial growth factor (VEGF), placental growth factor (PIGF), insulin like growth factor-1 (IGF-1), angiogenin-1 (Ang-1), and vascular endothelial cadherin (VE-cadherin) were measured in vitreous samples. RESULTS After treatment with IVB, VEGF, PIGF, and VE-cadherin concentrations in the vitreous significantly decreased (p < 0.001, p < 0.001, and p = 0.001, respectively), whereas the concentrations of IGF-1 increased (p = 0.001). There were no significant changes in Ang-1 concentrations in the vitreous after IVB injection (p = 0.732). There were no statistically significant differences in VEGF-A, PIGF, VE-cadherin, IGF, and Ang-1 levels before and after IVB injection when the IOH and TRD groups underwent subgroup analysis (p = 0.696, p = 0.516, p = 0.498, p = 0.188, and p = 0.243, respectively). CONCLUSION The levels of VEGF and other cytokines changed in the vitreous after IVB. The adverse effects associated with IVB, such as fibrosis, may result from modulation of vitreous cytokine concentrations. In the treatment of PDR, drugs that optimize the effects of PIGF, IGF-1, and VE-cadherin to reduce these side effects may be useful.
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Issiaka M, Mchachi A, Rachid R, Belhadji MEL, Mahazou I, Banao M. Terson syndrome: Two case reports. Int J Surg Case Rep 2021; 90:106700. [PMID: 34953428 DOI: 10.1016/j.ijscr.2021.106700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/11/2021] [Accepted: 12/14/2021] [Indexed: 11/22/2022] Open
Abstract
Purpose Vitreous or retinal hemorrhage occurring in association with subarachnoid hemorrhage (SAH) is known as Terson syndrome (TS). Its incidence is of the order of 10–50% after subarachnoid hemorrhage. We report two cases of TS with different clinical presentations, different managements, and a good final prognosis, which were managed at the Ibn Rochd hospital in Casablanca. Observations We report two cases of TS. The first one occurred in a 55-year-old hypertensive man following a ruptured aneurysm of the internal carotid artery, revealed by a decrease in visual acuity concomitant with the neurological symptomatology. The evolution was favorable after specialized neurological management and spontaneous resorption of the intravitreal hemorrhage was obtained 3 months after the acute episode with good visual recovery. The second case was that of a 45-year-old man who presented with an intravitreal hemorrhage of the right eye, 24 h after severe head trauma responsible for a bifrontal extradural hematoma. The B-mode ocular ultrasound discovery of a retinal detachment with persistent hemorrhage led to the indication of a pars plana vitrectomy with retinal tamponade, which allowed visual rehabilitation without recurrence after 1 year. Conclusions Ophthalmologic evaluation by specialized examination and radiology (ocular ultrasound, OCT) is necessary for all patients with TS because early diagnosis and treatment can prevent visual loss and associated complications. Treatment of TS can be conservative and based on periodic monitoring. A pars plana vitrectomy is considered in some cases. The etiopathogenesis of TS has been controversial since its appearance. The latest studies speak of a mechanism: the theory of glymphatic reflux TS may occur in an atraumatic context but there is often the notion of intracranial hyperpressure. The prognosis remains better in the absence of other complications and cases of early and adequate management.
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Aboulhosn R, Raju B, Jumah F, Majmundar N, Prenner J, Matin T, Roychowdhury S, Singla A, Khandelwal P, Nanda A, Gupta G. Terson's syndrome, the current concepts and management strategies: A review of literature. Clin Neurol Neurosurg 2021; 210:107008. [PMID: 34775364 DOI: 10.1016/j.clineuro.2021.107008] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 10/03/2021] [Accepted: 10/21/2021] [Indexed: 10/20/2022]
Abstract
Terson's Syndrome describes intraocular hemorrhage secondary to an acutely raised intracranial pressure (ICP). Although Terson's Syndrome is common amongst patients with subarachnoid hemorrhage (SAH), it is underdiagnosed and often overlooked. This review discusses the current understanding of the etiopathogenesis, clinical features, and management of Terson's Syndrome and highlights the visual and prognostic implications to stress the importance of timely diagnosis and management. The origin of intraocular hemorrhage in Terson's Syndrome has been debated. A recognized theory suggests that an acutely raised ICP induces effusion of cerebrospinal fluid into the optic nerve sheath which dilates the retrobulbar aspect of the sheath in the orbit. Dilatation mechanically compresses the central retinal vein and retinochoroidal veins resulting in venous hypertension and rupture of thin retinal vessels. A commonly reported clinical feature is decreased visual acuity and blurred vision. These may be accompanied by symptoms of increased ICP including loss of consciousness and headache. Diagnosis is established using evidence from the clinical presentation, ophthalmoscopy, and, when required, imaging including B-mode ultrasound, CT, MRI, and fluorescein angiography. Terson's Syndrome is managed conservatively by observation for mild cases and with vitrectomy for bilateral cases and for patients whose hemorrhage has not spontaneously resolved after an observational period. Terson's Syndrome can be used as a prognostic indicator of morbidity and mortality in underlying pathology like SAH. Fundoscopy of patients with SAH, acutely raised ICP or visual disturbance with unknown etiology can help establish a timely Terson's Syndrome diagnosis. This may avoid the risk of permanent visual impairment.
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Affiliation(s)
- Rabii Aboulhosn
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Forester Hill, Aberdeen, UK
| | - Bharath Raju
- Department of Neurosurgery, Rutgers, Robert Wood Johnson Medical School & University, Hospital, New Brunswick, NJ, USA
| | - Fareed Jumah
- Department of Neurosurgery, Rutgers, Robert Wood Johnson Medical School & University, Hospital, New Brunswick, NJ, USA
| | - Neil Majmundar
- Department of Neurosurgery, Rutgers, Robert Wood Johnson Medical School & University, Hospital, New Brunswick, NJ, USA
| | - Jonathan Prenner
- Department of Ophthalmology, Rutgers, Robert Wood Johnson Medical School & University, Hospital, New Brunswick, NJ, USA
| | - Tariq Matin
- Department of Interventional Radiology, Narayana Superspecialty Hospital, Nathupur, Gurugram, Haryana 122002, India
| | - Sudipta Roychowdhury
- Department of Neurosurgery, Rutgers, Robert Wood Johnson Medical School & University, Hospital, New Brunswick, NJ, USA
| | - Amit Singla
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Priyank Khandelwal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Anil Nanda
- Department of Neurosurgery, Rutgers, Robert Wood Johnson Medical School & University, Hospital, New Brunswick, NJ, USA
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers, Robert Wood Johnson Medical School & University, Hospital, New Brunswick, NJ, USA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Sharma RA, Garza PS, Biousse V, Samuels OB, Newman NJ, Bruce BB. Ocular Fundus Abnormalities in Acute Subarachnoid Hemorrhage: The FOTO-ICU Study. Neurosurgery 2021; 88:278-284. [PMID: 32970100 DOI: 10.1093/neuros/nyaa411] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/28/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ocular fundus abnormalities, especially intraocular hemorrhage, may represent a clinically useful prognostic marker in patients with acute subarachnoid hemorrhage (SAH). OBJECTIVE To evaluate associations between ocular fundus abnormalities and clinical outcomes in acute SAH. METHODS Prospective evaluation of acute SAH patients with ocular fundus photography at bedside. Multivariable logistic models were used to evaluate associations between fundus abnormalities and poor outcome (inpatient death, care withdrawal, or discharge Glasgow Outcome Score <4) and intensive care unit (ICU) and hospital lengths-of-stay, controlling for APACHE II score, respiratory failure at ICU admission, Hunt & Hess score, aneurysmal etiology, age, and sex. RESULTS Fundus abnormalities were present in 29/79 patients with acute SAH (35.4%), and 20/79 (25.3%) had intraocular hemorrhage. In univariate analyses, poor outcomes were more likely among patients with fundus abnormalities vs without (15/28 [53.6%] vs 15/51 [29.4%], P = .03); median length of ICU stay was longer in patients with intraocular hemorrhage than without (18 d [interquartile range (IQR) 12-25] vs 11 [IQR 7-17], P = .03). Logistic regression with fundus abnormality as predictor of interest showed that male sex (odds ratio [OR] 5.33 [95% CI 1.09-26.0], P = .045), higher APACHE II (OR, per 1-point increase, 1.35 [95% CI 1.08-1.78], P = .01), and aneurysmal etiology (OR 4.35 [95% CI 1.01-22.9], P = .048), but not fundus abnormalities (OR 1.56 [95% CI 0.43-5.65], P = .49) or intraocular hemorrhage (OR 1.28 [95% CI 0.26-5.59], P = .75) were associated with poor outcome. CONCLUSION Although ocular fundus abnormalities are associated with disease severity in SAH, they do not add value to patients' acute management beyond other risk factors already in use.
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Affiliation(s)
- Rahul A Sharma
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Philip S Garza
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Owen B Samuels
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.,Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Beau Benjamin Bruce
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia.,Department of Epidemiology, Emory University School of Medicine, Atlanta, Georgia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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