Abstract SNACC-12

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Terson syndrome: Atypical presentation and the need for fundoscopic evaluation

Castelbuono J, Camp N, Lewis C, Walsh M, Langdon R
University of Tennessee Medical Center Knoxville, Knoxville, Tennessee, USA

Terson Syndrome (TS), defined as intraocular hemorrhage in the presence of subarachnoid hemorrhage (SAH), is associated with mean Hunt and Hess grades greater than three and GCS scores less than eight (1,2). TS has also been shown to herald higher mortality rates (1,2,3). This study reports the case of a patient with an aneurysmal SAH, found to have TS, who presented with a low-grade Hunt and Hess score of 2 and a GCS of 15.
A 54-year-old Caucasian woman presented with nausea, vomiting, nuchal rigidity and left eye droop. CT angiography revealed a basilar tip aneurysm with diffuse SAH. She underwent successful primary coiling with no complications. On hospital day two she complained of blue floaters in her vision. Fundoscopic exam revealed extensive bilateral retinal and pre-retinal hemorrhages. Intraocular images were obtained using a WelchAllyn PanOptic ophthalmoscope with a Welch Allyn iExaminer attached to an iPhone 4S. This method enabled bedside evaluation and image capture without pupillary dilation. Best corrected visual acuity was 20/60 O.U.
Hospitalization was complicated by intermittent elevated velocities on TCD with associated GCS scores of 13, requiring stent coiling and intra-arterial vasodilation. She continued perceiving floaters but otherwise remained stable during her 2-week stay. She was discharged home with plans for follow up with ophthalmology.
The overall incidence of TS approximates 10-20% of patients who sustain aneurysmal SAH and it has been postulated that earlier detection may improve prognostication and decrease the incidence of chronic vision loss (4). Fundoscopic evaluation remains the standard method for detecting Terson hemorrhage, however this is often performed in a delayed setting (1). This delay is likely due to the need for pupillary dilation and ophthalmology evaluation. Serial fundoscopic examinations should be initiated early, as initial presentation of Terson hemorrhages have been documented to occur between 1 hour and 47 days after the inciting event (1).
TS is commonly found in aneurysmal SAH patients with high grade Hunt and Hess, and low GCS scores. However, cases of TS have been found in patients with low grade Hunt and Hess and higher GCS scores, as in our case. Because TS has been linked with worsened mortality rates and in some cases residual ocular defects, all patients with aneurysmal SAH should be evaluated for intraocular hemorrhage.
1. Fountas KN, et al. Terson hemorrhage in patients suffering aneurysmal subarachnoid hemorrhage: predisposing factors and prognostic significance. J Neurosurg. 2008; 109:439-44.
2. McCarron MO, Alberts MJ, McCarron P. A systematic review of Terson’s syndrome: frequency and prognosis after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 2004; 75:491-3.
3. Sung W, Arnaldo B, Sergio C, Juliana S, Michel F. Terson's syndrome as a prognostic factor for mortality of spontaneous subarachnoid haemorrhage. Acta Ophthalmol. 2011 Sep;89(6):544-7. doi: 10.1111/j.1755-3768.2009.01735.x. Epub 2009 Dec 9.
4. Swallow CE, et al. Terson syndrome: CT evaluation in 12 patients. AJNR Am J Neuroradiol 1998;19:743–747.

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