Terson's syndrome in subarachnoid hemorrhage and severe brain injury accompanied by acutely raised intracranial pressure

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The syndrome of retinal or vitreous hemorrhage in association with subarachnoid hemorrhage (SAH) is known as Terson's syndrome. The authors' purpose was to determine whether intraocular hemorrhage occurs with similar incidence when caused by severe brain injury accompanied by acutely raised intracranial pressure (ICP).</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Prospective ophthalmological examination was performed in 22 consecutive patients with SAH or severe brain injury and elevated ICP. Thirteen patients were admitted for SAH (World Federation of Neurological Surgeons Grades II–IV) and nine for severe brain injury (Glasgow Coma Scale scores 3–10). Monitoring of ICP was performed at the time of admission via a ventricular catheter. Initial ICP exceeded 20 mm Hg in all patients. Indirect ophthalmoscopy without induced mydriasis was performed within the 1st week after the acute event. Retinal or vitreous hemorrhage was seen in six (46%) of 13 patients with SAH and in four (44%) of nine patients with severe brain injury. Ocular bleeding was found bilaterally in three patients with SAH and in one patient with severe brain injury (18%). Six of the 10 patients with Terson's syndrome died as a result of their acute event.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The present results indicate that Terson's syndrome may be related to acute elevation of ICP, independent of its causes, and may occur with similar incidence in patients with severe brain injury and those with SAH. Because recognition and treatment of Terson's syndrome may prevent visual impairment and associated secondary damage to the eye, increased awareness of this entity in all patients with acute raised intracranial hypertension is recommended.</jats:p></jats:sec>

Frequency of ocular hemorrhages in patients with subarachnoidal hemorrhage

“…In these studies, incidences of vitreous hemorrhages of 8 and 27.3% were reported, respectively [5,6,9]. For all ocular hemorrhages frequencies of 17, 18, 27, 46, and 16.7% were observed [5,6,9,12,13]. In our series, only 5% (n=4) of patients suffered from intravitreal hemorrhages, three underwent vitrectomy, and 28% suffered from intraretinal hemorrhages.…”

“…In pathological studies [17] and also retrospective studies [3], intraocular involvement is reported to be related to the severity of the clinical symptoms. Also, the relationship between intracerebral pressure as a marker of the severity of SAH and Terson's syndrome is well known [12]. Patients with higher Hunt-Hess grades exhibited statistically a higher frequency of intraocular involvement.…”

“…The incidence of vitreous hemorrhages was lower (3-8%) than of other forms of intraocular involvement. Only five prospective studies have been published with 100, 99, 22, 22 and 60 patients, respectively [5,6,9,12,13]. In these studies, incidences of vitreous hemorrhages of 8 and 27.3% were reported, respectively [5,6,9].…”

“…The following subsequent rapid increase of the intravasal pressure causes retinal venous stasis, resulting in intraretinal and also intravitreal hemorrhages [11]. This theory is supported by the study of Medele et al [12], who found a significantly elevated intracranial pressure in patients with Terson's syndrome.…”

Diabetic retinopathy and estimated cerebrospinal fluid pressure. The Beijing eye study 2011

“…The results of our study agree with clinical observations and studies that increased brain pressure can be associated with retinal hemorrhages. In the case of an acute subarachnoidal hemorrhage with a marked increase in intracranial pressure, retinal hemorrhages and an intravitreal bleeding can develop as part of Terson's syndrome [18,19]. In other neurological disorders associated with brain edema and increased brain pressure such as mountain sickness, retinal hemorrhages can typically occur [20].…”