Presentation
PEA cardiac arrest, preceded by a history of occipital headache and neck pain. Intracerebral hemorrhage?
Patient Data
There is diffuse subarachnoid hemorrhage within the basal cisterns, sulci and all ventricles. There is a 12 mm rounded high attenuation area centered on the left MCA probably representing an MCA aneurysm.
The optic nerves appear thickened bilaterally likely secondary to papilledema. In addition, there is a high attenuation area within the left posterior globe likely reflecting hemorrhage, Terson syndrome.
No tonsillar or uncal herniation. There is widespread sulcal effacement.
Opinion: Extensive, diffuse subarachnoid hemorrhage likely secondary to left MCA aneurysm rupture.
Case Discussion
This case shows an extensive subarachnoid hemorrhage with blood in the posterior globe. The combination of these features is known as Terson syndrome.
Subarachnoid hemorrhage has multiple grading systems, both clinically and radiologically based:
Fisher (1980)
- I – no blood
- II – diffuse deposition of SAH without clots or layers of blood >1 mm
- III – localized clots and/or vertical layers of blood >1 mm thickness
- IV – diffuse or no subarachnoid blood but intracerebral or intraventricular clots
Validated to predict the likelihood of vasospasm.
Claassen Scale (2004)
- 5 grades
Predicts the risk of delayed cerebral ischemia, combines additive risk from SAH and IVH.
Ogilvy and Carter (1998)
- combines clinical and radiological findings
- combination of age, Hunt-Hess grade, Fisher grade, and aneurysm size and age
- studies of this are flawed
- minimal inter-observer variability
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