| Subject |
Carotid Artery, Internal, pathology; Carotid Artery, Internal, physiopathology; Disease Progression; Embolization, Therapeutic; Headache, etiology; Humans; Male; Middle Older people; Optic Nerve, blood supply; Optic Nerve, pathology; Optic Nerve, radiography; Optic Nerve Diseases, etiology; Optic Nerve Diseases, pathology; Optic Nerve Diseases, radiography; Subarachnoid Hemorrhage, complications; Subarachnoid Hemorrhage, pathology; Subarachnoid Hemorrhage, radiography; Syndrome; Tomography, X-Ray Computed; Vitreous Body, blood supply; Vitreous Body, pathology; Vitreous Body, physiopathology; Vitreous Hemorrhage, etiology; Vitreous Hemorrhage, radiography; Vitreous Hemorrhage, ultrasonography |
| OCR Text |
Show PHOTO ESSAY Terson Syndrome With Bilateral Optic Nerve Sheath Hemorrhage Chiaki D. Gauntt, MD, PhD, Richard G. Sherry, MD, and Chithra Kannan, MD FIG. 1. The CT scan shows extensive hemorrhage in the subarachnoid space (*) and in the sheaths surrounding the intraorbital optic nerves { arrowhead). A subhyaloid hemorrhage is also evident in the posterior globes adjacent to the optic discs { arrows). Abstract: A 53- year- old man presented with an acute headache and mental status changes due to rupture of an anterior choroidal artery aneurysm. A preoperative CT scan demonstrated subarachnoid hemorrhage, bilateral optic nerve sheath hemorrhage, and bilateral intraocular hemorrhage. Ophthalmoscopy and B- scan ocular ultrasound disclosed vitreous hemorrhages, features consistent with Terson syndrome. This is the first CT report of Terson syndrome showing bilateral optic nerve sheath hemorrhage. (/ Neuro- Ophthalmol 2007; 27: 193- 194) Departments of Neurology ( CDG) and Radiology ( RGS, CK), University of Louisville School of Medicine, Louisville, Kentucky. Address correspondence to Chiaki D. Gauntt, MD, PLLC, 6307 Mint Spring Branch Road, Prospect, KY 40059; E- mail: cgauntt@ gaunttmd. com A 53- year- old Vietnamese man had the acute onset of severe headache, weakness, and depressed consciousness and was admitted to the hospital. He had no significant past medical or ocular problems and was not taking any medication. The preoperative CT scan ( Fig. 1) clearly depicted extensive subarachnoid hemorrhage in the basal cisterns and in the intraorbital optic nerve segments. Hemorrhage was also conspicuous in the posterior globes adjacent to the optic discs. Its proximity to the optic discs suggested that it was subhyaloid. Lumbar puncture confirmed a subarachnoid hemorrhage. Cerebral angiography demonstrated an aneurysm arising from the origin of the right anterior choroidal artery. The patient underwent emergency external ventriculostomy and later endovascular coil treatment of the aneurysm. One week after admission, the patient's general condition stabilized and the first complete eye examination J Neuro- Ophthalmol, Vol. 27, No. 3, 2007 193 J Neuro- Ophthalmol, Vol. 27, No. 3, 2007 Gauntt et al FIG. 2. B- scan ultrasonography shows posterior vitreous hemorrhage in both eyes. was performed. Vision was not assessed because the patient was stuporous. Pupils were 3 mm and equal, responding to light stimulation without a relative afferent pupillary defect. Anterior segment examination showed no abnormalities and intraocular pressures were normal. Dilated fundus examination revealed extensive vitreous hemorrhage in both eyes with no view of either retina. B- scan ultrasonography of the eyes demonstrated findings consistent with large amounts of intraocular hemorrhage dispersed in the vitreous cavity bilaterally ( Fig. 2). The patient received physical therapy and was transferred to a rehabilitation facility, with a plan of possible future vitrectomy. This patient had Terson syndrome, intraocular hemorrhage due to acutely elevated intracranial pressure usually associated with subarachnoid hemorrhage or severe head trauma ( 1- 7). To our knowledge, neuroimaging of an intrasheath hemorrhage in Terson syndrome has not been previously reported. The mechanism of Terson syndrome has been extensively debated ( 8- 12). The earliest speculation was that intracranial blood extends directly into the intraocular space. Some investigators believe that the increased intracranial pressure is transmitted to the retinal veins, causing their rupture ( 8,9). Other authors ( 11,12) propose a mechanism in which a sudden rise in intracranial pressure is transmitted through the optic nerve sheath to the optic nerve head, causing rupture of the peripapillary capillaries. Clinically the intraocular hemorrhage may be seen as subretinal, retinal, preretinal or subhyaloid, or intravitreal. Subhyaloid hemorrhage may disperse into the vitreous cavity as seen in our patient. The intraocular hemorrhage spontaneously resolves in several months in most patients. Vitrectomy is occasionally needed in patients with non-resolving vitreous hemorrhage. REFERENCES 1. Fahmy JA. Fundal haemorrhages in ruptured intracranial aneurysms. I. Material, frequency and morphology. Acta Ophthalmol ( Copenh) 1973; 51: 289- 98. 2. Fahmy JA. Fundal haemorrhages in ruptured intracranial aneurysms. II. Correlation with the clinical course. Acta Ophthalmol ( Copenh) 1973; 51: 299- 304. 3. Weingeist TA, Goldman EJ, Folk JC, et al. Terson's syndrome: clinicopathologic correlations. Ophthalmology 1986; 93: 1435^ 2. 4. Walsh FB, Hedges TR Jr. Optic nerve sheath hemorrhage: The Jackson Memorial Lecture. Am J Ophthalmol 1951; 34: 509- 27. 5. Manschot WA. Subarachnoid hemorrhage: intraocular symptoms and their pathogenesis. Am J Ophthalmol 1954; 38: 501- 5. 6. Muller PJ, Deck JH. Intraocular and optic nerve sheath hemorrhage in cases of sudden intracranial hypertension. J Neurosurg 1974; 41: 160- 6. 7. Ogawa T, Kitaoka T, Dake Y. Terson syndrome: a case report suggesting the mechanism of vitreous haemorrhage. Ophthalmology 2001; 108: 1654- 6. 8. Iwase T, Tanaka N. Bilateral subretinal haemorrhage with Terson's syndrome. Graefes Arch Clin Exp Ophthalmol 2006; 244: 507- 9. 9. Khan SG, Frenkel M. Intravitreal hemorrhage associated with rapid increase in intracranial pressure ( Terson's syndrome). Am J Ophthalmol 1975; 80: 37^ 3. 10. McCarron MO, Alberts MJ, McCarron P. A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2004; 75: 491- 3. 11. Medele RJ, Stummer W, Mueller AJ, et al. Terson's syndrome in subarachnoid hemorrhage and severe brain injury accompanied by acutely raised intracranial pressure. J Neurosurg 1998; 88: 851^ k 12. Pfausler B, Belcl R, Metzler R, et al. Terson's syndrome in spontaneous subarachnoid hemorrhage: a prospective study in 60 consecutive patients. J Neurosurg 1996; 85: 392- 4. 194 © 2007 Lippincott Williams & Wilkins |
