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|Year : 2014 | Volume
| Issue : 5 | Page : 575-576
Ocular reverberations of an intracranial blast: A neurosurgical image
Amey Savardekar, Vikas Maheshwari, Harsimrat Bir Singh Sodhi, Pravin Salunke
Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||12-Nov-2014|
Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Savardekar A, Maheshwari V, Sodhi HB, Salunke P. Ocular reverberations of an intracranial blast: A neurosurgical image. Neurol India 2014;62:575-6
A 20-year-male presented with sudden onset headache and loss of left eye vision. Fundus examination showed preretinal bleed with red glow [Figure 1]a. Plain computed tomography (CT) of the head showed left thin acute subdural hematoma (SDH) without any subarachnoid hemorrhage (SAH) [Figure 1]b. Digital subtraction angiography (DSA) [Figure 1]c and d showed saccularinternal carotid artery (ICA) aneurysm measuring 7.2 × 4.3 mm with neck of 2 mm, just proximal to the origin of anterior choroidal artery. Patient underwent left pterional craniotomy, evacuation of acute SDH, and clipping of the aneurysm. Intraoperatively, there was no evidence of SAH and the aneurysm was seen to be arising from choroidal segment of ICA, directed posterolaterally. Postoperatively, vision in left eye gradually improved and was normal at 3-months follow-up.
|Figure 1: (a) Fundoscopic image of left eye showing the 'red glow' of preretinal bleed. The periphery of the fundus is normal. (b) Computed tomography of the head at presentation showing left frontotemporal subdural hematoma, without any evidence of subarachnoid hemorrhage. (c and d) Cerebral digital subtraction angiography (anteroposterior and lateral views) showing posterolaterally directed saccular aneurysm arising from the choroidal segment of the left internal carotid artery|
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Aneurysmal SAH are associated with intraocular hemorrhages (i.e. retinal, subhyaloid, orvitreous), in 10-40% of cases.  Incidence of acute SDH, secondary to ruptured intracerebral aneurysm is well-documented, accounting for 0.5-8% of all cases.  However, acute SDH without radiologic evidence of SAH, is rare.  The entity of intraocular hemorrhage, in association with aneurysmal SDH, without radiological evidence of SAH, is exceedingly rare. ,
Although it has been less studied as an individual clinical feature, preretinal hemorrhage, as documented in our patient, is often thought to precede vitreous hemorrhage.  The pathogenesis of intraocular hemorrhage, secondary to aneurysmal rupture may be attributed to increased intracranial pressure, which may force blood into the subarachnoid space and along the optic nerves heath into the preretinal space; or the sudden rise inintracranial pressure may lead to a decrease in venous return to the cavernous sinus or obstruct the retinochoroidalanastomoses and central retinal vein, culminating in venous stasis and hemorrhage.  The latter pathogenetic mechanism explains the association of Terson's syndrome with pathological conditions other than SAH.  The preretinal hemorrhage and resulting monocular blindness observed in our patient is likely explained by this hypothesis.
The visual outcome has been documented to be excellent in the majority of cases of Terson's syndrome.  Our patient's vision improved to normal with resolution of the preretinal bleed. However, Terson's syndrome can be associated with the development of proliferative retinopathy, retinal breaks, retinal detachment, and cataract; hence, accurate diagnosis and regular follow-up of vision loss following aneurysmal rupture is essential. ,
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