Terson's syndrome

Terson's syndrome is intraocular hemorrhage (IOH) subsequent to subarachnoid hemorrhage (SAH). Its presence is associated with higher mortality in SAH. We report a case of Terson's syndrome and review the literature.

A 71-year-old Caucasian gentleman collapsed and became comatose. Past medical history was notable for chronic anticoagulation for previous transient ischemia attacks. CT head scans showed severe SAH of Fisher grade 4 and a lesion suspicious for aneurysm. Formal angiography confirmed a supraclinoid right internal carotid artery aneurysm which was coiled. ICU admission was complicated by a stormy course. The patient eventually regained consciousness and was transferred to a regular ward. On hospital day 20, impaired vision was noted. Review of CT head scans revealed previously missed retinal hemorrhages and funduscopy confirmed vitreous hemorrhage. However, the patient remained in a poor neurologic state and expired several days later.

Terson's syndrome occurs in up to 40% of acute aneurysmal bleeds. The sudden spike in intracranial pressure (ICP) with aneurysmal rupture is thought to underlie the cause of IOH as well as the high incidence of coma, higher Hunt and Hess grades, and mortality in these patients. Gold-standard diagnosis is funduscopy, and retinal hemorrhages may occasionally be seen on CT.

Terson's syndrome occurs frequently following SAH, although it is under-reported. Suspected visual loss following SAH should prompt a search for Terson's syndrome by funduscopy, as its presence is an adverse prognostic factor.