Um cirurgião sob o olhar de Deus

Objetivo A síndrome de Terson (ST), também conhecida como hemorragia vítrea, é relatada em pacientes com hemorragia subaracnóide causada por um aneurisma rompido. Este estudo tem como objetivo avaliar a presença de hemorragia ocular nesses pacientes, buscando identificar aqueles que poderiam se beneficiar do tratamento específico para a recuperação do déficit visual. Métodos Estudo prospectivo de 53 pacientes com hemorragia subaracnóide espontânea (SSAH) por aneurisma rompido. Os pacientes foram avaliados quanto à hemorragia vítrea por fundoscopia indireta com 6 a 12 meses de seguimento. Resultados A idade dos pacientes variou de 17 a 79 anos (média de 45,9 ± 11,7); 39 pacientes eram do sexo feminino (73%) e 14 do sexo masculino (27%). Seis pacientes (11%) apresentaram ST e 83,3% apresentaram perda transitória de consciência durante a ictus. Conclusões Uma avaliação oftalmológica deve ser realizada rotineiramente em pacientes com hemorragia subaracnóide, especialmente naqueles com pior grau neurológico. Além disso, o prognóstico foi ruim em pacientes com ST.

Terson Syndrome: Assessment of 53 Patients with Subarachnoid Hemorrhage by a Ruptured Aneurysm

Objective Terson syndrome (TS), also known as vitreous hemorrhage, is reported in patients with subarachnoid hemorrhage caused by a ruptured aneurysm. This study aims to evaluate the presence of ocular hemorrhage in such patients, trying to identify those who could benefit from the specific treatment for visual deficit recovery. Methods Prospective study of 53 patients with spontaneous subarachnoid hemorrhage (SSAH) due to ruptured aneurysm. The patients were evaluated for vitreous hemorrhage through indirect fundoscopy with 6 to 12 months of follow-up. Results The ages of the patients ranged from 17 to 79 years-old (mean age, 45.9 11.7); 39 patients were female (73%) and 14 were male (27%). Six patients (11%) presented TS, and 83.3% had a transient loss of consciousness during ictus. Conclusions An ophthalmologic evaluation must be routinely performed in subarachnoid hemorrhage patients, especially in those with worse neurological grade. Moreover, prognosis was bad in TS patients.

Incidence of Terson Syndrome in Treated Subarachnoid Hemorrhage in South Korea: a National Health Insurance Database Study.

The aim of this study is to investigate the incidence and mortality of Terson syndrome in patients with treated subarachnoid hemorrhage (SAH) in South Korea. In this nationwide, population-based study, we used the National Health Insurance(NHI) database (2011-2015) to identify patients aged ≥18 years. Newly diagnosed non-traumatic SAH, treated using clipping or coil embolization, were identified, and Terson syndrome was defined as newly diagnosed retinal or vitreous hemorrhage within 3 months of SAH diagnosis. We identified 22,864 patients with treated SAH (tSAH), 196 of whom had Terson syndrome, with the cumulative incidence during 5 years of 0.86% (95% CI: 0.74-0.98): 1.10% (95% CI: 0.88-1.33) in men and 0.71% (95% CI, 0.58-0.85) in women. The cumulative incidence of Terson syndrome in patients aged under 40 was higher than in those aged 40 or over (1.41% vs. 0.81%; p = 0.007). The mortality rate of Terson syndrome in patients with tSAH was not different from that in those without Terson syndrome (4.08% vs. 7.30%; p = 0.089). This was the first nationwide epidemiological study of Terson syndrome using a population-based database. The incidence of Terson syndrome in patients with tSAH was higher in those age under 40 than in those aged 40 or over.

Long-term survival following diabetic vitrectomy.

AIM: To update long-term survival data on patients with proliferative diabetic retinopathy undergoing vitrectomy and to identify associated risk factors. METHODS: Retrospective clinical record review at a single New Zealand tertiary referral centre. A total of 182 eyes that underwent a vitrectomy for a diabetic vitreous haemorrhage and/or tractional retinal detachment between March 2000 and December 2010 were included. Kaplan-Meier survival curves and Cox-regression analyses were performed for survival rates and associated risk factors. RESULTS: The mean age of patients was 55 years (range 22 to 85) at time of surgery. The three-year survival rate following diabetic vitrectomy was 83.5%, and the five-year survival rate (N=154) was 70.1%. Increasing age, dialysis and high serum creatinine were associated with poorer survival on multivariate Cox regression analyses (hazard ratio of 1.035, 4.216 and 1.930 respectively with p-values of 0.018, <0.001 and 0.046). CONCLUSION: Survival rates after diabetic vitrectomy remain relatively poor but comparable to earlier New Zealand and international reports. However, there remain significant differences between ethnic groups within New Zealand that need to be addressed in addition to renal disease, which appears to be a major risk factor for poor survival. Overall, the contemporary survival outcomes observed in this study may influence decision making by patients and clinicians as well as encourage a review of current healthcare resource allocation in diabetes care.

Incidence, morbidity, and mortality of Terson syndrome in Hamilton, Ontario.

OBJECTIVE: Evaluate the incidence, neurologic morbidity, and mortality of patients with Terson syndrome. METHODS: Consecutive patients admitted to the Hamilton General Hospital from May 2012 to May 2013 with a diagnosis of spontaneous subarachnoid hemorrhage (SAH) were recruited. Funduscopic examinations were performed under pharmacological mydriasis. Outcome measures included: (1) the presence or absence of Terson syndrome; (2) The Glasgow Coma Scale (GCS), Hunt and Hess scale (H&H), and SAH Fisher score upon admission to the hospital; (3) the modified Rankin score upon discharge; and (4) and all-cause mortality. RESULTS: Forty-six patients were included and 10 had Terson syndrome (21%). The median H&H, GCS, and Fisher scores were 4, 6.5, and 4.0 for patients with Terson syndrome vs. 2, 14, and 3 for patients without Terson syndrome (p=0.0032, 0.0052, and 0.031), respectively. The median Rankin score was 6 for patients with Terson syndrome vs. 3.5 for patients without Terson syndrome (p=0.0019). The odds of all-cause mortality with Terson syndrome vs. no Terson syndrome was 12: 1 (95% confidence interval 2.33-61.7), p =0.003. Only four of the 10 patients with Terson syndrome survived. CONCLUSIONS: Based on this study, approximately one-fifth of patients admitted to the hospital with a spontaneous SAH could have Terson syndrome. Patients with Terson syndrome have significantly worse GCS and H&H scores upon admission to the hospital, lower modified Rankin scores upon discharge, and greater mortality. Thus, Terson syndrome is not rare among patients with SAH and carries a worse prognosis.

[Terson's syndrome--a neglected problem?]. / Terson-Syndrom--ein vernachlässigtes Problem?

BACKGROUND: The aim of our study was to analyze the incidence and prognostic value of intraocular hemorrhages caused by subarachnoid hemorrhages. PATIENTS AND METHODS: Retrospective data analysis of all patients with subarachnoid hemorrhage admitted to the University Hospital Zurich between 2005 and 2010. All patients have been classified according to Glasgow Coma, Hunt and Hess, WFNS and Fisher Scales. RESULTS: Out of 391 patients only 26 have been examined by an ophthalmologist. 11/26 (42%) showed Terson's syndrome, compared to 11/391 (2.8%) in the overall cohort. In patients with intraocular hemorrhages there was a trend for a lower GCS and higher Hunt and Hess, WFNS and Fisher scales. CONCLUSION: Intraocular hemorrhages are a relatively frequent, seemingly neglected complication of subarachnoid hemorrhages, and correlate with a higher mortality and morbidity in prospective studies. Routine fundoscopy of heavily impaired patients should be considered.

Terson's syndrome.

BACKGROUND: Terson's syndrome is intraocular hemorrhage (IOH) subsequent to subarachnoid hemorrhage (SAH). Its presence is associated with higher mortality in SAH. We report a case of Terson's syndrome and review the literature. CASE REPORT: A 71-year-old Caucasian gentleman collapsed and became comatose. Past medical history was notable for chronic anticoagulation for previous transient ischemia attacks. CT head scans showed severe SAH of Fisher grade 4 and a lesion suspicious for aneurysm. Formal angiography confirmed a supraclinoid right internal carotid artery aneurysm which was coiled. ICU admission was complicated by a stormy course. The patient eventually regained consciousness and was transferred to a regular ward. On hospital day 20, impaired vision was noted. Review of CT head scans revealed previously missed retinal hemorrhages and funduscopy confirmed vitreous hemorrhage. However, the patient remained in a poor neurologic state and expired several days later. DISCUSSION: Terson's syndrome occurs in up to 40% of acute aneurysmal bleeds. The sudden spike in intracranial pressure (ICP) with aneurysmal rupture is thought to underlie the cause of IOH as well as the high incidence of coma, higher Hunt and Hess grades, and mortality in these patients. Gold-standard diagnosis is funduscopy, and retinal hemorrhages may occasionally be seen on CT. CONCLUSIONS: Terson's syndrome occurs frequently following SAH, although it is under-reported. Suspected visual loss following SAH should prompt a search for Terson's syndrome by funduscopy, as its presence is an adverse prognostic factor.

Terson's syndrome as a prognostic factor for mortality of spontaneous subarachnoid haemorrhage.

PURPOSE: To evaluate the prognosis of mortality in patients with spontaneous subarachnoid haemorrhage associated with Terson's syndrome. METHODS: A prospective, consecutive case series study was conducted in patients admitted to the emergency room with a diagnosis of acute subarachnoid haemorrhage. After a complete neurological examination, funduscopic examination using binocular indirect ophthalmoscopy under mydriasis was performed upon admission and at days 3, 7, 30 and 60 after the onset. In all cases, the diagnosis of intracranial bleeding was made by computerized tomography, and the clinical condition was graded according to the Hunt & Hess and Glasgow coma scales. RESULTS: Forty-seven patients with the diagnosis of subarachnoid haemorrhage were enrolled. Forty-four cases were associated with a ruptured aneurysm and three cases with arterio-venous malformation. Fourteen patients (29%) were diagnosed with Terson's syndrome. Seven patients (50%) with Terson's syndrome died, whereas death occurred in three patients (9%) without Terson's syndrome (p = 0.002). Ocular findings in Terson's syndrome were preretinal, intraretinal, sub-retinal and vitreous haemorrhage. Associated ocular findings included third-nerve palsy, papilloedema and subconjunctival haemorrhage. CONCLUSION: The presence of Terson's syndrome was associated with an increased mortality rate (50% versus 9%; p < 0.01). Therefore, patients with the diagnosis of intracranial haemorrhage should be submitted to a funduscopic examination, because the presence of intraocular haemorrhage is an important life-threatening prognostic factor.

[Incidence of ophthalmologic complications in acute intracranial hypertension]. / Inzidenz ophthalmologischer Komplikationen bei akuter intrakranieller Drucksteigerung.

Although Terson's syndrome has been diagnosed more frequently since the early 1960s because of improved intensive-care facilities, these reports are single case reports or retrospective studies. Therefore, we examined prospectively 20 patients (11 male, 9 female), aged between 23 and 77 years, with subarachnoid hemorrhages or rapid increase in intracranial pressure (ICP) of other origin (tumor-associated, post-traumatic) to evaluate ocular changes. In all patients the increase in ICP was confirmed by computed tomography. Additionally, in 16 patients permanent monitoring of ICP was performed. Twelve patients presented with subarachnoid hemorrhage, 6 had a post-traumatic increase in ICP, and 2 more presented with a tumor-associated intracranial hemorrhage. A total of 8 patients (40%) presented with intraocular changes; 6 presented with uni- or bilateral intraretinal hemorrhage, 1 patient had a bilateral papilledema and 1 more patient had bilateral vitreal hemorrhage. When ocular hemorrhage occurred, the mortality was 2.5 times as high as in patients without ocular hemorrhage. For this prognostic feature of the ophthalmological status all patients with rapid increase in ICP should be monitored early for intraocular hemorrhage. The possibility of intraocular hemorrhage is elevated in high-degree subarachnoid hemorrhage, whereas a rapid increase in ICP also found when the pressure has other causes (tumor-associated, posttraumatic).