Terson syndrome refers to vitreous hemorrhage associated with subarachnoid hemorrhage, however, some authors include retinal hemorrhage as well. The syndrome is a poor prognostic marker in patients with subarachnoid hemorrhage.
Terson syndrome has been reported to occur in 13-50% of patients with subarachnoid hemorrhage 1-3.
In addition to clinical features of severe subarachnoid hemorrhage, such as headache and coma, patients present with varying degrees of vision loss 4. Fundoscopic examination is diagnostic, with patients having evidence of vitreous hemorrhage (and perhaps other intraocular hemorrhage) 1.
Severe subarachnoid hemorrhage, as demonstrated by a low Glasgow coma scale, a high Hunt and Hess grade, and/or a high Fisher grade, have been found to be associated with a higher incidence of Terson syndrome 5.
In this setting, intraocular hemorrhage is thought to be a consequence of a sudden increase in intracranial pressure causing obstruction of the central retinal vein as well as retinal venous stasis, which in turn results in vitreous and intraretinal hemorrhages 2.
A similar syndrome has been reported to occur with subdural hematomas, epidural hematomas, and traumatic brain injury, all cases postulated to be also due to increased intracranial pressure 1,5. Some authors also term these similar presentations under the banner of Terson syndrome 1,5.
The red blood cells sediment and compact near the posterior hyaloid surface of detached vitreous and scanning shows echoes of increasing density in the posterior gel. Degenerating blood cells give rise to lower density echoes and color the posterior vitreous known as Ochre membrane. Subvitreal hemorrhage may sediment to form a fluid level behind the collapsing gel.
On CT evaluation, retinal nodularity and crescentic hyperdensity, relative to the vitreous humor, in the posterior globe in association with subarachnoid hemorrhage are highly suggestive of this diagnosis 7.
Treatment and prognosis
Although spontaneous regression of the hemorrhage is seen in up to half of all patients, the condition may require operative intervention with vitrectomy, particularly in the setting of bilateral vitreous hemorrhages 1,5. The neurological outcome and overall prognosis is worse in subarachnoid hemorrhage patients with Terson syndrome, compared to those without 1,3,5.
History and etymology
Although the condition is named after Albert Terson (1867-1935), a French ophthalmologist, who described it in 1900 3,8, the first case was actually described a few years earlier in 1881 by Moritz Litten (1845-1907), a German physician 3,9.
- 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. Journal of neurosurgery. 88 (5): 851-4. doi:10.3171/jns.1998.88.5.0851 - Pubmed
- 2. Ness T, Janknecht P, Berghorn C. Frequency of ocular hemorrhages in patients with subarachnoidal hemorrhage. Graefes Arch. Clin. Exp. Ophthalmol. 2005;243 (9): 859-62. doi:10.1007/s00417-005-1131-z - Pubmed citation
- 3. McCarron MO, Alberts MJ, McCarron P. A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage. Journal of neurology, neurosurgery, and psychiatry. 75 (3): 491-3. Pubmed
- 4. Prost ME. [Clinical manifestations and treatment of Terson's syndrome]. Klinika oczna. 98 (5): 371-4. Pubmed
- 5. Czorlich P, Skevas C, Knospe V, Vettorazzi E, Richard G, Wagenfeld L, Westphal M, Regelsberger J. Terson syndrome in subarachnoid hemorrhage, intracerebral hemorrhage, and traumatic brain injury. Neurosurgical review. 38 (1): 129-36; discussion 136. doi:10.1007/s10143-014-0564-4 - Pubmed
- 6. Vanderlinden RG, Chisholm LD. Vitreous hemorrhages and sudden increased intracranial pressure. Journal of neurosurgery. 41 (2): 167-76. doi:10.3171/jns.1974.41.2.0167 - Pubmed
- 7. Swallow CE, Tsuruda JS, Digre KB et-al. Terson syndrome: CT evaluation in 12 patients. AJNR Am J Neuroradiol. 1998;19 (4): 743-7. AJNR Am J Neuroradiol (abstract) - Pubmed citation
- 8. Terson A. De l’hémorrhagie dans le corps vitre au cours de l’hémorrhagie cerebrale. Clin Ophthalmol. 1900;6:309–12.
- 9. Litten M. Ueber Einige vom Allgemein-Klinischen Standpunkt aus Interessante Augenveränderungen. Berl Klin Wochenschr. 1881;18:23–7.