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NEUROIMAGE
Year : 2018  |  Volume : 66  |  Issue : 4  |  Page : 1202-1203

Terson's syndrome diagnosed on ocular ultrasound


1 Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
2 Department of Neurosurgery, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Date of Web Publication18-Jul-2018

Correspondence Address:
Dr. Gentle Sunder Shrestha
Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Maharajgunj, Kathmandu
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.237011

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How to cite this article:
Shrestha GS, Sedain G. Terson's syndrome diagnosed on ocular ultrasound. Neurol India 2018;66:1202-3

How to cite this URL:
Shrestha GS, Sedain G. Terson's syndrome diagnosed on ocular ultrasound. Neurol India [serial online] 2018 [cited 2018 Aug 17];66:1202-3. Available from: http://www.neurologyindia.com/text.asp?2018/66/4/1202/237011




Sir,

A 62-year old male patient, with no medical history and no previous ocular symptoms, presented with sudden onset of headache and vomiting followed by decreased level of consciousness of 2 h duration. There was no history of trauma. He was intubated as he had a low Glasgow Coma Scale (GCS, E1V2M3). Computed tomography (CT) of the head revealed a left cerebellar hematoma with surrounding edema, dilated temporal horns, and effaced fourth ventricle [Figure 1]. Ocular sonography was performed using linear array transducer (frequency range of 6–13 MHz) to measure the optic nerve sheath diameter, which was 6.3 mm. Incidentally, hyper-echogenic opacities were observed in the posterior chamber of the globe [Figure 2], the positions of which changed during the involuntary movement of the eyes [Video 1]. The findings were consistent with vitreous hemorrhage and were more marked in the right eye. Fundoscopy revealed the presence of a red haze obscuring the retina, with preserved pupillary reflex. The patient was diagnosed with vitreous hemorrhage. The common possible differential diagnoses were rupture of retinal vessels due to trauma or anticoagulant therapy, proliferative diabetic retinopathy, and Valsalva retinopathy. The patient underwent an urgent evacuation of the clot. He was extubated after 3 days and his vision gradually improved over the next 3 weeks.
Figure 1: CT scan of the head of the patient showing the left cerebellar hematoma with surrounding edema, dilated temporal horns, and effaced fourth ventricle

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Figure 2: Ocular sonography of the patient showing hyper-echogenic opacities in the posterior chamber of the globe, which changed during movements of the eyes

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Terson's syndrome is described as any form of intraocular hemorrhage in patients with subarachnoid hemorrhage, traumatic brain injury, or intracerebral hemorrhage.[1] Vitreous hemorrhage is the most common pattern observed. Sudden transient increase in intracranial pressure has been postulated to be the pathophysiological mechanism that is responsible for the occurrence of intraocular hemorrhage.[2] Terson's syndrome is often underdiagnosed, especially in patients with decreased level of consciousness. Fundoscopy is the gold standard for diagnosis, but it requires an iatrogenic mydriasis, which may hamper the assessment of pupillary size and response to light, an important physical examination finding, especially in patients with raised intracranial pressure and impending herniation.[3] Ocular sonography has been demonstrated to be a reliable and easily performed bedside point-of-care examination, which can be helpful for the early detection of Terson's syndrome,[4] especially in patients with an altered level of consciousness and raised intracranial pressure, as was seen in our patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Medele RJ, Stummer W, Mueller AJ, Steiger HJ, Reulen HJ. Terson's syndrome in subarachnoid hemorrhage and severe brain injury accompanied by acutely raised intracranial pressure. J Neurosurg 1998;88:851-4.  Back to cited text no. 1
    
2.
Shaw HE Jr, Landers MB 3rd. Vitreous hemorrhage after intracranial hemorrhage. Am J Ophthalmol 1975;80:207-13.  Back to cited text no. 2
    
3.
Frizzell RT, Kuhn F, Morris R, Quinn C, Fisher WS 3rd. Screening for ocular hemorrhages in patients with ruptured cerebral aneurysms: A prospective study of 99 patients. Neurosurgery 1997;41:529-33.  Back to cited text no. 3
    
4.
Czorlich P, Burkhardt T, Knospe V, Richard G, Vettorazzi E, Wagenfeld L, et al. Ocular ultrasound as an easy applicable tool for detection of Terson's syndrome after aneurysmal subarachnoid hemorrhage. PLoS One 2014;9:e114907.  Back to cited text no. 4
    


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