ORIGINAL ARTICLE Terson syndrome in subarachnoid hemorrhage, intracerebral hemorrhage, and traumatic brain injury Patrick Czorlich & Christos Skevas & Volker Knospe & Eik Vettorazzi & Gisbert Richard & Lars Wagenfeld & Manfred Westphal & Jan Regelsberger Received: 4 February 2014 /Revised: 19 May 2014 /Accepted: 24 May 2014 /Published online: 31 August 2014 # Springer-Verlag Berlin Heidelberg 2014 Abstract This prospective trial was designed to evaluate the incidence of Terson syndrome in patients suffering from sub- arachnoid hemorrhage, intracerebral hemorrhage, or traumatic brain injury and whether consequences necessarily derive from the intraocular hemorrhage itself. Two ophthalmologic examinations were performed to identify patients with Terson syndrome. Data on initial Glasgow Coma Scale, Hunt and Hess and Fisher grades, aneurysm site and diameter, and volume of hemorrhage in intracerebral hemorrhage patients were correlated to the location and course of Terson syn- drome. Follow-up was performed after 3 months, including clinical and ophthalmologic investigations. The data showed that 16 of 83 subarachnoid hemorrhage patients (19.3 %), 2 of 22 intracerebral hemorrhage patients (9.1 %), and 1 of 32 traumatic brain injury patients (3.1 %) suffered from Terson syndrome. Low Glasgow Coma Scale (p =0.002), high Hunt and Hess grade (p <0.001), and high Fisher grade (p =0.002) were found to be associated with a higher incidence of Terson syndrome. The neurological outcome in subarachnoid hemor- rhage patients suffering from Terson syndrome was worse compared with that of subarachnoid hemorrhage patients without Terson syndrome (p =0.005), and vitrectomy was performed in seven eyes of six patients due to poor visual acuity. Terson syndrome is underestimated in patients with subarachnoid hemorrhage and a rare pathology in intracere- bral hemorrhage as well as in traumatic brain injury patients. Spontaneous regression of the intraocular hemorrhage may be seen, but in half of the patients, vitrectomy is necessary to prevent permanent visual deterioration. Keywords Terson syndrome . Intraocular hemorrhage . Subarachnoid hemorrhage . Traumatic brain injury . Intracerebral hemorrhage Introduction Vitreous bleeding following subarachnoid hemorrhage (SAH) was first described by Moritz Litten [15] in 1881 and was named after French ophthalmologist Albert Terson [30]. By now, any kind of intraocular hemorrhage (IOH) such as vitre- ous (Fig. 1a, b), subhyaloid, or intraretinal hemorrhage in patients suffering from SAH, traumatic brain injury (TBI), or intracerebral hemorrhage (ICH) is described as Terson Syndrome (TS) [4, 17, 32]. Pathophysiologically, a sudden transient spike in intracerebral pressure is believed to be trans- mitted along the optic nerve sheath, resulting in a rupture of retinal vessels due to intraocular venous hypertension [8, 23]. TS is known as a secondary complication of SAH but seems to be far underestimated with respect to its incidence and clinical course. According to previous reports, up to 46 % of all SAH patients may suffer from IOH, leading to perma- nent blindness in some cases [6, 7, 14, 17, 22, 24–27, 35]. Only a few prospective studies have been published so far, and there are even fewer concerning the context of TS and ICH and TS and TBI. To determine the incidence and clinical course of TS in patients suffering from aneurysmal and perimesencephalic SAH, TBI, and ICH, a prospective interdisciplinary study Patrick Czorlich and Christos Skevas contributed equally. P. Czorlich (*) : M. Westphal : J. Regelsberger Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany e-mail: p.czorlich@uke.de C. Skevas : V. Knospe : G. Richard : L. Wagenfeld Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany E. Vettorazzi Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany Neurosurg Rev (2015) 38:129–136 DOI 10.1007/s10143-014-0564-4