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Ann Med Surg (Lond)
Ann Med Surg (Lond)
MS9
Annals of Medicine and Surgery
2049-0801
Lippincott Williams & Wilkins Hagerstown, MD

AMSU-D-24-01155
10.1097/MS9.0000000000002435
00105
3
Case Reports
Terson syndrome in association with sub-arachnoid hemorrhage: a case report
Phuyal Prakash MD aprakashktm017@gmail.com

https://orcid.org/0009-0001-3344-5925
Chhetri Suchit Thapa MBBS b*chhetrisuchit123@gmail.com

Khanal Deepa MBBS ckhanaldipu7860@gmail.com

Phuyal Subash MD adrsphuyal17@gmail.com

Paudel Sushanta MBBS bpaudelsushanta1998@gmail.com

Hamal Dipson MBBS bdipsonhamal32@gmail.com

Regmi Bishal MBBS bregmeebishal@gmail.com

a Department of Neuroradiology, Upendra Devkota Memorial National Institute of Neurology and Allied Sciences
b Nepalese Army Institute of Health Sciences, Kathmandu
c Manipal College of Medical Sciences, Pokhara, Nepal
* Corresponding author. Address: Nepalese Army Institute of Health Sciences, Kathmandu, Nepal. Tel.: +977 980 832 9527. E-mail: chhetrisuchit123@gmail.com (S. T. Chhetri).
9 2024
7 8 2024
86 9 56185621
8 6 2024
26 7 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

Introduction:

Terson syndrome is characterized by intraocular hemorrhage, which includes retinal, subretinal, subhyaloid, and vitreous hemorrhages, typically associated with sub-arachnoid, intracerebral, and traumatic brain injuries. The incidence of Terson syndrome varies significantly, ranging from 10 to 40% following sub-arachnoid hemorrhage.

Case presentation:

A 48-year-old woman presented to the emergency department with a loss of consciousness for 1 h, 8 h prior to presentation, accompanied by teeth clenching, upward rolling of eyes, and frothing from the mouth. A non-contrast-enhanced computed tomography scan of the head revealed sub-arachnoid hemorrhage. Two days post-admission, the patient experienced decreased vision. Visual acuity tests showed significant impairment, and fundus examination revealed vitreous hemorrhage in both eyes. Digital subtraction angiography identified an aneurysm in the V4 segment of the left vertebral artery. Following flow diverter placement, the patient’s visual acuity improved and normalized after 21 days.

Discussion:

Terson syndrome is often linked with sub-arachnoid hemorrhage due to elevated intracranial pressure. It frequently occurs with aneurysms of the anterior communicating or internal carotid arteries. Diagnosis is often delayed until after patient stabilization. Ophthalmic evaluations, such as fundoscopic examinations and ocular ultrasonography, are crucial for early detection. The presence of Terson Syndrome correlates with higher mortality rates in SAH patients. While spontaneous resolution of intraocular hemorrhage is common, some cases necessitate surgical intervention for quicker recovery.

Conclusion:

Comprehensive ophthalmic assessments in sub-arachnoid hemorrhage patients are essential for early detection and intervention, potentially preventing long-term visual impairment.

Keywords:

case report
sub-arachnoid hemorrhage
Terson syndrome
visual acuity
OPEN-ACCESSTRUE
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pmcIntroduction

Highlights

Terson syndrome involves intraocular hemorrhage associated with sub-arachnoid, intracerebral, and traumatic brain injuries.

The presence of Terson syndrome correlates with higher mortality rates in sub-arachnoid hemorrhage patients.

Early ophthalmic evaluations such as fundoscopic examinations and ocular ultrasonography are crucial for diagnosing Terson syndrome, which is often delayed until patient stabilization.

Comprehensive ophthalmic assessments in sub-arachnoid hemorrhage patients are essential for early intervention, potentially preventing long-term visual impairment.

Terson syndrome, first described by Albert Terson, a French ophthalmologist, is characterized by intraocular hemorrhage, which includes retinal, subretinal, subhyaloid, and vitreous hemorrhages, in association with sub-arachnoid, intracerebral, and traumatic brain injury1. Its incidence is variable, ranging from 10 to 40% after sub-arachnoid hemorrhage, as reported in various studies1,2.

One theory suggesting the origin of the hemorrhage is that the raised intracranial pressure (ICP) leads to the effusion of cerebrospinal fluid into the optic nerve sheath. This causes the dilation of the retrobulbar aspect of the sheath, resulting in compression of the central retinal vein and retinochoroidal veins, which increases venous pressure and causes the retinal vessels to rupture3.

Terson syndrome is associated with a decrease in visual acuity but is underdiagnosed in most cases due to the patient’s inability to convey their visual complaints. A multidisciplinary approach is required for management, involving neurosurgery to stabilize the patient, followed by the management of intraocular hemorrhage. Intraocular hemorrhage is managed conservatively in mild cases, while pars plana vitrectomy is considered for bilateral cases and for patients whose hemorrhage doesn’t resolve spontaneously after an observational period3,4. This report describes a case of Terson Syndrome occurring in conjunction with sub-arachnoid hemorrhage. This case report adheres to the SCARE checklist5.

Case report

A 48-year-old woman presented to our emergency department with a chief complaint of loss of consciousness for 1 h, 8 h prior to presentation, associated with clenching of teeth, upward rolling of eyes, and frothing from the mouth. She has a known history of migraine headaches. She reported experiencing headaches on and off for the past 5 days and one episode of vomiting. There was no history of limb weakness, traumatic head injury, or fever.

On examination, her Glasgow Coma Scale was 15/15. The cranial nerves were found to be intact. There were no signs of meningism. Bilateral grade II deep tendon reflexes with bilateral upgoing plantar reflexes were noted. There were no other neurological findings. Relevant investigations were carried out. A non-contrast-enhanced computed tomography (NCCT) scan of the head showed sub-arachnoid hemorrhage, as shown in Figure 1. Echocardiography performed by a cardiology consultant showed normal left ventricular wall motion with no echogenic clot or mass. The left ventricular ejection fraction was 65%.

Figure 1 Non-contrast-enhanced computed tomography of head showing sub-arachnoid hemorrhage.

Two days after admission, the patient complained of decreased vision. A visual acuity test of both eyes was performed and revealed a visual acuity of 6/60 in the left eye and 6/30 in the right eye. Fundus examination revealed vitreous hemorrhage in both eyes, as shown in Figure 2A and B. Digital subtraction angiography (DSA) was performed, revealing an aneurysm of the V4 segment of the left vertebral artery, as shown in Figure 3. A flow diverter placement was performed. Post-procedure, good apposition of the flow diverter with the wall of the artery and good distal flow were noted. A visual acuity test was repeated four days after the procedure, revealing 6/20 in the left eye and 6/12 in the right eye. Her vision gradually improved and returned to normal after 21 days.

Figure 2 (A, B) Fundoscopic examination showing collection of blood in the vitreous chamber of left and right eyes after sub-arachnoid hemorrhage.

Figure 3 Digital subtraction angiography (DSA) showing aneurysm of the V4 segment of the left vertebral artery.

Discussion

Terson syndrome is often observed in relation to sub-arachnoid hemorrhage (SAH), and the increase in intracranial pressure is regarded as the underlying cause6. It is most commonly seen with the rupture of aneurysms, frequently involving the anterior communicating artery or the internal carotid artery4. The incidence of Terson syndrome in patients with SAH varies among studies. For instance, one study found Terson syndrome present in 13% of patients with SAH1, while a study by Sung et al.7 reported it in 29% of SAH patients. Contrastingly, a much higher incidence, specifically 53%, was observed regarding vitreous hemorrhage in patients with sub-arachnoid hemorrhage8.

Many cases of Terson syndrome go unreported because ophthalmic examinations are often performed only after the stabilization of the patient. Ophthalmological evaluations, such as fundoscopic examinations and ocular ultrasonography, play a vital role in the early diagnosis of Terson syndrome6,9. Additionally, CT and MRI scans showing half-moon-shaped hyperintensity of the retina have been reported to have 66.7% sensitivity in diagnosing Terson Syndrome.

Various studies indicate that the presence of Terson syndrome is associated with a higher mortality rate in patients with SAH. For example, a study by Skevas et al. found that patients with Terson syndrome had a mortality rate of 40–60%, which is 3 to 9 times higher compared to patients with SAH without visual manifestations10. Similar findings were noted, with a 50–90% mortality rate in patients with intraocular hemorrhage associated with SAH, compared to 10% in non-Terson syndrome patients11,12. A study by Gutierrez Diaz indicated that the mortality rate was 50% in patients with Terson Syndrome, compared to 20% in those without it13.

Spontaneous resolution of intraocular hemorrhage occurs in most cases, typically over several months. However, some cases require surgical procedures like vitrectomy to expedite visual recovery. The management of Terson syndrome varies from patient to patient and should consider factors such as the extent of hemorrhage, involvement of both eyes, co-existing retinal detachment, and the individual needs of the patient. Measures like head elevation, bed rest, increasing fluid intake, and avoiding anticoagulants are known to be effective in management4,9.

Our patient presented with a history of loss of consciousness. Digital subtraction angiography showed an aneurysm on the V4 segment of the left vertebral artery. She also complained of decreased vision in both eyes. Fundus examination revealed vitreous hemorrhage in both eyes. Flow diverter placement was performed, and post-procedure imaging showed good blood flow. Her visual acuity gradually improved and returned to normal after 21 days.

Conclusion

This case report underscores the serious nature of Terson syndrome and its link to sub-arachnoid hemorrhage. Timely diagnosis and a multidisciplinary treatment approach are crucial for enhancing patient outcomes. In this instance, early detection and intervention, including the placement of a flow diverter, resulted in notable improvement in visual acuity. This case highlights the necessity of comprehensive ophthalmic assessments in SAH patients, as early identification and treatment can avert long-term visual impairment.

Ethical approval

This is a case report, therefore, it did not require ethical approval from ethics committee.

Consent

Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the editor-in-chief of this journal on request.

Source of funding

The study did not receive any grant from funding agencies in the public, commercial or not-for-profit sectors.

Author contribution

P.P.: conceptualization; data curation; supervision; validation; visualization; writing—original draft; writing—review and editing. S.T.C.: conceptualization; data curation; supervision; validation; visualization; writing—original draft; writing—review and editing. D.K.: data curation; validation; visualization; writing—original draft; writing—review and editing. S.P.: validation; visualization; writing—original draft; writing—review and editing. S.P.: validation; visualization; writing—original draft; writing—review and editing. D.H.: validation; visualization; writing—original draft; writing—review and editing. B.R.: validation; visualization; writing—original draft; writing—review and editing.

Conflicts of interest disclosure

The authors declare no conflict of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Prakash Phuyal.

Data availability statement

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
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