Terson Syndrome in Patients with Aneurysmal Subarachnoid Hemorrhage: A 10-Year Single-Center Experience

Abstract

Background: Terson syndrome (TS), an intraocular hemorrhage associated with aneurysmal subarachnoid hemorrhage (aSAH), occurs in up to 46% of all patients with subarachnoid hemorrhage. Despite its high incidence, TS is underrepresented in the literature, and patients with aSAH are sometimes not systematically evaluated for the presence of TS in clinical practice. This work aims to raise awareness of TS, reevaluate previous scientific findings, describe risk factors associated with the occurrence of TS, and present our local diagnostic and treatment concept.

Methods: All patients with aSAH treated at our institution between October 2010 and May 2020 were included in this retrospective study. The frequency of ophthalmological screening by indirect funduscopy, as well as the results, was investigated. In addition, the collection and statistical analysis of epidemiological and clinical data was performed using χ², Kruskal-Wallis, and analysis of variance testing; multivariate regression; and receiver operating characteristic analysis. The significance level was set at p < 0.05.

Results: A total of 617 patients were treated for aSAH in our institution. Of these, 367 patients (59.5%) were ophthalmologically examined for the presence of TS. The rate of TS in the examined patients was 21.3% (n = 78). Patients with TS had significantly higher Fisher and World Federation of Neurosurgical Societies (WFNS) scores (p < 0.0001). Regression analyses showed WFNS grade (p = 0.003) and the occurrence of seizures (p = 0.002) as independent predictors of TS, as did receiver operating characteristic analyses, which had a significant area under the curve of 0.66 for the combination of WFNS grade and seizures. For 12 (15.4%) patients, the TS had to be surgically treated by pars plana vitrectomy in a total of 14 eyes, which resulted in significant improvement of visual function in all patients: mean preoperative best-corrected visual acuity was 0.03 (± 0.08) versus 0.76 (± 0.21) postoperatively (p < 0.001).

Conclusions: TS is a common complication in patients with aSAH, affecting approximately one in five patients. A higher WFNS grade and the occurrence of seizures are associated with TS; therefore, screening for TS should be performed in these patients.

Keywords: Pars plana vitrectomy; Subarachnoid hemorrhage; Terson syndrome; Vitreous hemorrhage.

Fig. 1

Flowchart. The flowchart shows patient exclusions. ICU intensive care unit, TS Terson syndrome

Fig. 2

Receiver operating characteristic (ROC) curve. In this ROC curve, models for Terson syndrome prediction detected via multivariate logistic regression were displayed. Models were tested for correct outcome prediction against the null hypothesis. WFNS World Federation of Neurosurgical Societies

Fig. 3

Recommendation for the approach of patients with aneurysmal subarachnoid hemorrhage (aSAH) regarding potential Terson syndrome (TS). The figure shows the approach of screening and potential treatment of TS regarding optimal timing and methods. cCT cranial computed tomography, PPV pars plana vitrectomy, SAH subarachnoid hemorrhage