Bilateral Terson Syndrome Secondary to Anterior Communicating Artery Aneurysm Rupture Associated With Spontaneous Subarachnoid Hemorrhage

Clinical Correspondence Section Editors: Robert Avery, DO Karl C. Golnik, MD Caroline Froment, MD, PhD An-Guor Wang, MD Bilateral Terson Syndrome Secondary to Anterior Communicating Artery Aneurysm Rupture Associated With Spontaneous Subarachnoid Hemorrhage Xin-zhi Song, MD, Ling Li, MD, PhD, Jie Pan, BS, Xue-mei Zhang, BS, Jian-Jun Ma, BS T erson syndrome is an intraocular hemorrhage secondary to subarachnoid hemorrhage (SAH). The hemorrhage positions include preretinal, intraretinal, and/or vitreous. Aneurysmal SAH is the most common cause of Terson syndrome; moreover, the latter can lead to temporary vision loss or even permanent blindness if severe. In particular, Terson syndrome is not uncommon, and the prevalence rate is reported to be 8%–44% (1). However, it is rare for Terson syndrome to occur twice, respectively, in 1 patient. In this study, we report a case of bilateral Terson syndrome secondary to anterior communicating artery aneurysm rupture associated with spontaneous SAH. A 63-year-old man with headache, vomiting, and gatism presented to the emergency department. His medical history only included coronary artery disease and hypertension. A computed tomography (CT) scan on the day of event revealed SAH. Digital subtraction angiography showed anterior communicating artery aneurysm rupture, and coil embolization was performed immediately. One week later, SAH was completely absorbed, but he complained of blurred vision in the right eye. The visual acuity (VA) was hand motion with no obvious abnormality in the anterior segment examinations. B-ultrasound indicated complete posterior vitreous detachment with vitreous and preretinal hemorrhage (VPH). However, vitreous hemorrhage (VH) did not change significantly 1 month later. Therefore, a standard pars plana vitrectomy (PPV) was conducted. After removing VPH, no retinal detachment (RD) or subretinal hemorrhage was found. There were no complications during or after PPV. The corrected VA was 20/25 in the right eye at postoperative 3 days. But unfortunately, original images for the first episode of SAH and right eye VH were not available because the patient was treated in other hospital. Department of Ophthalmology (XZS, JP, XMZ, JJM), Gansu Provincial Hospital, Lanzhou, China. Gansu University Key Laboratory for Molecular Medicine and Chinese Medicine Prevention and Treatment of Major Diseases (LL), Gansu University of Chinese Medicine, Lanzhou, China. This work was supported by Internal Research Fund project of Gansu Provincial Hospital 21GSSYC-9. The authors report no conflicts of interest. Address correspondence to Xin-zhi Song, MD, Gansu Provincial Hospital, 204 Donggang West Road, Lanzhou 730000, China; E-mail: [e-mail] e204 Another 21 months passed, coronary angiography– guided stent implantation was performed for the patient. A sudden loss of consciousness occurred 3 days after the operation. An immediate CT scan revealed SAH again (Fig. 1). The digital subtraction angiography and surgical methods were as same as those of last time. Ten days later, he recovered from the disturbance of consciousness and complained of decreased vision in the left eye. The visual acuity was 20/25 in the right eye and hand motion in the left eye, respectively. No obvious abnormality was detected in the anterior segment examinations of both eyes. B-ultrasound disclosed vitreous punctate opacity of right eye and left eye VPH (Fig. 2A). Fundus examination showed scattered punctate hemorrhage of the right eye (Fig. 2C) and unclear of the left eye. After 3 months’ treatment, SAH was completely absorbed. However, left eye VH had no significant change. B-ultrasound disclosed vitreous punctate opacity of the right eye and massive VH and localized RD of the left eye (Fig. 2B). Fundus examination showed scattered punctate hemorrhage of the right eye had been almost absorbed (Fig. 2D) and still unclear of the left eye. Consequently, PPV combined with silicone oil tamponade was performed for the left eye. There were no complications during or after surgery. Silicone oil was removed 3 months later. The corrected VA at postoperative 1 week was 20/50 in the left eye. Fundus examination showed the right eye without hemorrhage and epiretinal proliferative membrane under optic disc of the left eye (Fig. 2E and F). In 1900, Albert Terson first reported SAH-related VH. Since then, the disease has been named Terson. With further study, Terson syndrome is not limited to VH secondary to SAH. Any types of intracranial hemorrhage combined with vitreous and/or retinal hemorrhage are called Terson syndrome. There are mainly 2 possible pathophysiological mechanisms of aneurysmal SAH combined with Terson syndrome. First, the scleral cribriform plate connects the peripapillary subdural space with the intracranial subarachnoid space, maintaining pressure gradient on both sides. Under physiological conditions, subarachnoid hemorrhage will not enter the eye directly. Because silicone oil was used as intraocular tamponade after vitrectomy, it was occasionally reported that silicone oil was Song et al: J Neuro-Ophthalmol 2023; 43: e204-e206 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Clinical Correspondence FIG. 1. CT scan on the day of the second onset of subarachnoid hemorrhage. The arrowheads indicate the coil use in the operation for the first subarachnoid hemorrhage. FIG. 2. Images after the second onset and at follow-up. Ten days after the second onset of subarachnoid hemorrhage, B-ultrasound showed vitreous and preretinal hemorrhage of the left eye (A); an Optos fundus photograph showed scattered punctate hemorrhage of the right eye (C). Three months later, B-ultrasound showed massive vitreous hemorrhage and limited retinal detachment (arrowhead) of the left eye (B); an Optos fundus photograph showed scattered punctate hemorrhage of the right eye had been almost absorbed (D). At last follow-up, an Optos fundus photograph showed scattered punctate hemorrhage of the right eye had been completed absorbed (E) and epiretinal proliferative membrane under optic disc (white arrowhead) of left eye (F). The relevant images after the first onset of subarachnoid hemorrhage was not collected (not shown). Song et al: J Neuro-Ophthalmol 2023; 43: e204-e206 e205 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Clinical Correspondence found in the subarachnoid space or even ventricle, indicating that intracranial hemorrhage might enter the eye under pathological conditions (2). Second, SAH causes sudden increase of intracranial pressure, spreading to the interorbital space of the optic nerve, resulting in central retinal vein oppression, venous circumfluence obstruction, elevated intraocular vein pressure, vascular rupture, and bleeding (3). Some studies have shown that Terson syndrome occurs more frequently in anterior circulation aneurysms, especially in anterior cerebral artery complex aneurysms, which are 10 times as many as other aneurysms (4). Both aneurysms of the patient occurred in the anterior communicating artery. The treatments of Terson syndrome include observation, medication, and surgery. VH can be absorbed naturally in most patients, and VA recovers within 1 year. The patients with less hemorrhage can wait for self-absorption, and the prognosis is better. However, in some cases, the hemorrhage removal may take several years or too massive to absorb by itself. If not treated in time, VH can cause deposition of blood components and inflammatory cells, fibrous proliferation, epiretinal membrane formation, and eventually traction RD development. In addition, the disintegration products of blood components may have long-term toxic effects on the retina with vision loss or serious vision damage. Therefore, vitrectomy should be performed in patients without signs of spontaneous hemorrhage absorption. At present, most scholars advocate early surgery (3). For this patient, both eyes had thick VH, whereas the left eye had thick VH mainly in the posterior pole. This may be related to coma or long-term bedridden of patients after craniocerebral surgery. Studies have confirmed that patients with a course of less than 3 months have better postoperative VA than that of e206 more than 3 months (5). For this patient, there was no significant change for right eye VH 1 month after SAH first onset and left eye VH 3 months after SAH second onset, respectively. Therefore, vitrectomy was performed to avoid further damage to VA. Although postoperative VA of both eyes improved significantly, the left eye was slightly worse than the right eye because of localized RD, which also confirmed the importance of early surgery. In conclusion, Terson syndrome, an uncommon eye–brain syndrome, may cause severe vision loss if not diagnosed and treated early. However, it is usually accompanied severe neurological manifestations and easy to miss diagnosis. Therefore, early diagnosis and treatment of Terson syndrome should be concerned by both neurologists and ophthalmologists. Early vitrectomy is an effective treatment for Terson syndrome. REFERENCES 1. 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Song et al: J Neuro-Ophthalmol 2023; 43: e204-e206 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.