Review ArticleTerson's syndrome, the current concepts and management strategies: A review of literature
Introduction
Intraretinal hemorrhage with subarachnoid hemorrhage (SAH) was first described by Moritz Litten in 1881 and named after Albert Terson in 1900, who described the Syndrome of vitreous hemorrhage in association with SAH in a patient [1]. The definition of Terson's Syndrome has since evolved after histopathological research revealed that intraocular hemorrhage in Terson's Syndrome could also be in the retinal, sub-retinal, and sub-hyaloid spaces and after identification of other etiologies (Fig. 1A). This warranted expansion to the historical definition; at present, Terson's Syndrome generally reflects an intraocular hemorrhage secondary to an acutely raised intracranial pressure (ICP), often associated with intracranial hemorrhage or traumatic brain injury (TBI) [2], [3], [4], [5], [6]. The presence of Terson's Syndrome in the setting of SAH is a poor prognostic sign. It is associated with worse clinical outcomes and higher mortality rate compared to a SAH presentation devoid of ocular manifestations [7], [8], [9], [10], [11].
Terson's Syndrome is often an overlooked complication of SAH and is underdiagnosed given ophthalmologic examination is not routinely performed and some patients are unable to convey their visual complaints due to their critical condition [12], [13], [14], [15]. However, given the prognostic implications on mortality and morbidity, identification and management of Terson's Syndrome can help preserve vision and circumvent complications associated with the disease.
The purpose of this review is to discuss the etiopathogenesis, clinical features, and management of Terson's Syndrome and to highlight the visual implications and importance of timely diagnosis and management.
Section snippets
Etiology
Terson's Syndrome is generally caused by or linked to conditions that trigger an acute increase in ICP [2], [4], [5], [16]. Both aneurysmal and non-aneurysmal origins have been described. The reported overall incidence of TS from all causes ranges between 5% and 42% [8], [10], [17], [18]. This broad variation in incidence can be explained by varying sample sizes of each study, varying definitions, and different diagnostic modalities used.
Clinical presentation
Patients show variable clinical presentations depending on the extent of intraocular bleeding and preceding neurological state [6].
Assesment and diagnosis
The diagnosis of Terson's Syndrome is made using clinical presentation and Fundoscopy. Imaging techniques may be useful in confirming and establishing the diagnosis. Fundoscopy using an indirect ophthalmoscope (Fig. 2) is the gold standard for diagnosis of vitreous or sub-hyaloid hemorrhage in Terson's Syndrome [58]. Direct ophthalmoscopy can be used in an emergency setting. Given the prognostic implications of Terson’s Syndrome on morbidity and mortality, ophthalmologic examination is
Management
The available treatment options for Terson's Syndrome include conservative ophthalmic treatment and surgery. The management algorithm for Terson's Syndrome is presented in Fig. 4.
Conclusion
Terson's Syndrome describes an intraocular hemorrhage secondary to an acutely raised ICP. Aneurysmal and non-aneurysmal etiologies have been identified. Diagnosis using clues from clinical presentation, fundoscopy, and imaging is vital as it can help preserve vision and avoid complications. Ophthalmologic examination is advised for all patients with SAH on hospital admission and those with acutely raised ICP or visual disturbance with unknown etiology. A period of observation should be
Funding statement
This study was not funded by any grant funding or industry support.
Disclosures
None.
Declaration of Competing Interest
None.
References (79)
- et al.
Terson syndrome with persistent vitreous hemorrhage following traumatic brain injury
Saudi J. Ophthalmol.
(2019) - et al.
Terson’s syndrome - pathophysiologic considerations of an underestimated concomitant disease in aneurysmal subarachnoid hemorrhage
J. Clin. Neurosci.
(2016) - et al.
Terson haemorrhage in patients suffering aneurysmal subarachnoid haemorrhage: a prospective analysis of 60 consecutive patients
Clin. Neurol. Neurosurg.
(2012) - et al.
Ruptured vertebral artery dissecting aneurysm as a risk factor for ocular symptoms accompanied with subarachnoid hemorrhage
World Neurosurg.
(2018) - et al.
Microsurgical observation of the posterior vitreous in patients with vitreous hemorrhage caused by Terson syndrome
Am. J. Ophthalmol. Case Rep.
(2020) - et al.
Terson syndrome: a case report suggesting the mechanism of vitreous hemorrhage
Ophthalmology
(2001) Subarachnoid hemorrhage: intraocular symptoms and their pathogenesis
Am. J. Ophthalmol.
(1954)- et al.
Visual outcomes after vitrectomy for Terson syndrome secondary to traumatic brain Injury
Ophthalmology
(2017) - et al.
Pars plana vitrectomy with intraoperative optical coherence tomography for sub-internal limiting membrane fibrosis excision in a child with Terson syndrome: Surgical and pathological correlation
Am. J. Ophthalmol. Case Rep.
(2019) - et al.
Long-term visual outcome in Terson syndrome
Ophthalmology
(1991)
Epiretinal membrane formation in Terson syndrome
Jpn. J. Ophthalmol.
Terson’s syndrome in a pregnant woman: a fatal presentation
J. Acute Dis.
Results of vitrectomy and the significance of vitreous hemorrhage in patients with subarachnoid hemorrhage
Ophthalmology
Terson’s syndrome--rate and surgical approach in patients with subarachnoid hemorrhage: a prospective interdisciplinary study
Ophthalmology
[Atypical presentation of Terson syndrome: presentation of a case]
Neurologia
De l′hémorrhagie dans le corps vitre au cours de l′hémorrhagie cerebrale
Clin. Ophthalmol.
Terson’s syndrome due to aneurismal subarachnoid hemorrhage
Anwer Khan Mod. Med. Coll. J.
A patient of terson’s syndrome for ocular surgery: perianesthetic concerns
Saudi J. Anaesth.
Possible methods of blood entrance in Terson syndrome
Ophthalmic Surg. Lasers Imaging
Terson’s syndrome: a reversible cause of blindness following subarachnoid hemorrhage
J. Neurosurg.
Terson syndrome in aneurysmal subarachnoid hemorrhage-its relation to intracranial pressure, admission factors, and clinical outcome
Acta Neurochir. (Wien. )
A systematic review of Terson’s syndrome: frequency and prognosis after subarachnoid haemorrhage
J. Neurol. Neurosurg. Psychiatry
Terson’s syndrome in spontaneous subarachnoid hemorrhage: a prospective study in 60 consecutive patients
J. Neurosurg.
Incidence, morbidity, and mortality of Terson syndrome in Hamilton, Ontario
Can. J. Neurol. Sci. Le. J. Can. Des. Sci. Neurol.
Prognostic factors affecting visual recovery in Terson syndrome with aneurysmal subarachnoid hemorrhage
J. Neurocrit. Care
Terson’s syndrome: neurosurgical considerations on the subject of a rare case with ophthalmological sequelae
Arq. Bras. De. Neurocir.: Braz. Neurosurg.
Terson syndrome in subarachnoid hemorrhage, intracerebral hemorrhage, and traumatic brain injury
Neurosurg. Rev.
Terson syndrome secondary to subarachnoid hemorrhage: a case report and literature review
World Neurosurg.
Ocular findings in raised intracranial pressure: a case of Terson syndrome in a 7-month-old infant
Am. J. Forensic Med Pathol.
Bedside optical coherence tomography for Terson’s syndrome screening in acute subarachnoid hemorrhage: a pilot study
J. Neurosurg.
Comparison of CT and clinical findings of Terson’s syndrome in 121 patients: a 1-year prospective study
J. Neurosurg.
Clinical characteristics of asymptomatic Terson syndrome in the patients with aneurysmal subarachnoid hemorrhage
Int J. Ophthalmol.
Early intraocular complications of subarachnoid haemorrhage after aneurysm rupture
Neuroophthalmology
Practical incidence and risk factors of Terson’s syndrome: a retrospective analysis in 322 consecutive patients with aneurysmal subarachnoid hemorrhage
J. Cereb. Endovasc. Neurosurg.
Unilateral vitreous haemorrhage secondary to caudal epidural injection: a variant of Terson’s syndrome
Br. J. Ophthalmol.
Subarachnoid hemorrhage-negative Terson syndrome after balloon-assisted coil embolization in a patient with underlying antiphospholipid antibody syndrome
Retin Cases Brief. Rep.
A rare case of systemic lupus erythematosis with severe thrombocytopenia leading to Terson syndrome
IOSR J. Dent. Med. Sci.
Bilateral retinal hemorrhage after endoscopic third ventriculostomy: iatrogenic Terson syndrome: case report
J. Neurosurg.
Optic nerve sheath and retinal hemorrhages associated with the shaken baby syndrome
Arch. Ophthalmol.
Cited by (15)
Terson's syndrome leading to fatal outcome in a 36-year-old woman: A case report
2024, Radiology Case ReportsMan with abnormal ocular CT scan
2023, Visual Journal of Emergency MedicineComment on “Terson's syndrome, the current concepts and management strategies: A review of literature”
2022, Clinical Neurology and NeurosurgeryTerson syndrome: Two case reports
2022, International Journal of Surgery Case ReportsCitation Excerpt :The main monitoring parameters are visual acuity and the evolution of the intraocular hemorrhage, but above all, the early detection of the appearance of other elements compromising the visual prognosis. Monitoring is then clinical but also radiological by ocular ultrasound or even other explorations such as OCT. [2,14] If the hemorrhage does not resolve or does not progress well, a pars plana vitrectomy is indicated, especially for intravitreal hemorrhage [5,14]. However, a surgical approach is not possible in the presence of intraretinal hemorrhage [15].
Characterization of retinal hemorrhages delimited by the internal limiting membrane
2024, Indian Journal of Ophthalmology