✓ The eyes of 23 patients with sudden intracranial hypertension were studied at post-mortem. Intraocular hemorrhage had occurred in 37% and optic nerve sheath hemorrhage in 87%. Expansion of the optic nerve sheath, particularly the fusiform retrobulbar portion, was a consistent finding. The subdural space of the optic nerve sheath bore the brunt of the hemorrhage which sometimes communicated with perivascular intradural hemorrhages. Optic nerve sheath hemorrhage is shown to result from rupture of dural and bridging vessels of the optic nerve sheath; this we conclude is subsequent to optic nerve sheath dilatation caused by the transmission of intracranial pressure through the subarachnoid communication between the optic nerve sheath and the intracranial cavity. Intraocular hemorrhage is the result of retinal venous hypertension and rupture brought on by obstruction of both the central retinal vein and the retinochoroidal anastomosis.

Intraocular and optic nerve sheath hemorrhage in cases of sudden intracranial hypertension.

Methods: Papers relating to vitreous haemorrhage in patients with subarachnoid haemorrhage were retrieved. The only studies considered were those with at least 10 consecutive cases of subarachnoid haemorrhage with or without vitreous haemorrhage. The frequency of vitreous haemorrhage in such cases was calculated in prospective and retrospective studies. Mortality was compared in patients with and without Terson's syndrome. 

Results: 154 papers were reviewed. Three prospective studies and six retrospective studies satisfied the inclusion criteria. Of 181 patients with subarachnoid haemorrhage assessed prospectively (mean age, 51.7 years), 24 (13%) had vitreous haemorrhage; among 1086 retrospective records, 37 (3%) had documented vitreous haemorrhage (p<0.001). Patients with Terson's syndrome had higher Hunt and Hess grades than those without (mean grade, 3.6 v 2.6). Patients with Terson's syndrome were also more likely to die (13 of 30 (43%) v 31 of 342 (9%); odds ratio 4.8; p<0.001). 

Conclusions: Prospective studies show a higher frequency of Terson's syndrome than retrospective studies, suggesting that vitreous haemorrhage is not well documented. Vitreous haemorrhage is an adverse prognostic finding in patients with subarachnoid haemorrhage.

https://jnnp.bmj.com/content/jnnp/75/3/491.full.pdf

A systematic review of Terson’s syndrome: frequency and prognosis after subarachnoid haemorrhage

Subarachnoid Hemorrhage: Intraocular symptoms and their pathogenesis

✓ Terson's syndrome refers to the occurrence of vitreous hemorrhage with subarachnoid hemorrhage (SAH), usually due to a ruptured cerebral aneurysm. Although it is a well-described entity in the ophthalmological literature, it has been only rarely commented upon in the neurosurgical discussion of SAH. Fundus findings are reported in a prospective study of 22 consecutive patients with a computerized tomography- or lumbar puncture-proven diagnosis of SAH. Six of these patients had intraocular hemorrhage on initial examination. In four patients vitreous hemorrhage was evident on presentation (six of eight eyes). In the subsequent 12 days, vitreous hemorrhage developed in the additional two patients (three of four eyes) due to breakthrough bleeding from the original subhyaloid hemorrhages. The initial amount of intraocular hemorrhage did not correlate with the severity of SAH. Two of the six patients with intraocular hemorrhage died, whereas five of the 16 remaining SAH patients without intraocular hemorrhage...

Terson's syndrome: a reversible cause of blindness following subarachnoid hemorrhage.

Long-term visual outcome in Terson syndrome.

Introduction THE not infrequent occurrence of haemorrhage into the subarachnoid space within the skull has long been known, but up to relatively recent times mainly as a cause of death in cases in whiclh an incorrect diagnosis had been made during life. It was not associated in the minds of clinicians with any distinctive symptomatology, and in consequence the belief was generally held that its recognition was almost impossi'ble at the bedside and its outcome usually fatal. But after the introduction of lumbar puncture by Quincke over twenty years ago it was fou;nd that the presence of blood in the spinal fluid under certain circumstances was a clear indication of bleeding into the subarachnoid space. Since then many important papers have been devoted to the subject, but our knowledge of it nevertheless is by no means complete. Aetiologically there are three main groups of cases: stibarachnoid haemorrhage from: (1) traumatic rupture of menipgeal vessels; (2) primary intracerebral haemorrhage, the blood usuavlly reaching the subarachnoid space by bursting through the brain substance; (3) non-traumatic rupture of a meningeal vessel or aneurysm.

https://bjo.bmj.com/content/bjophthalmol/9/5/209.full.pdf

On the relationship between subarachnoid and intraocular haemorrhage.

IT is well known that the visual perceptions of form and colour, are to be found dissociated as a result of injury to the occipital lobes. In the records in the literature of several cases of visual defects of cortical origin, it has been noted too, that coarse or even fine movements were detected before fingers presented to the so-called blind field could be recognized or counted. Wilfred Harris [2] has given very full accounts of cases of transient hemianopia, and, in a few, movement was perceived before form or colour. Indeed, he had noticed this dissociation in cases in which the lesions were more gross and the recovery only partial. But, hitherto, so far as I know, movement as a definite visual perception has not been recognized, nor have its fields been charted systematically. In the examination of war cases of injury to the occipital lobes, I was struck by the frequency with which movement could be detected in the affected field, before a stationary object was seen. Accordingly, I proceeded to chart both, to find out if any conclusions could be drawn from the records, and I hope to show from the cases to be quoted, which are in no way selected, (1) that movement should be recognized as a definite visual perception; (2) that it may be dissociated fromi JA-16

On the Relative Perceptions of Movement and a Stationary Object in Certain Visual Disturbances due to Occipital Injuries

On the Relationship between Sub-arachnoid and Intra-ocular Haemorrhage.

Case of Right Fronto-parietal Tumour; Cracked-pot Percussion Note over Right Frontal Bone; Left Palmar Reflex.

Three months ago: Feeling of pins and needles in both feet; this rapidly spread up both legs to the knees. Legs got tired easily, feet felt heavy, and knees occasionally gave way with him. Two months ago: weakness of lower limbs was at its height. Had difficulty in walking without support. Fingers began to feel numb and clumsy; grip rather weak. For two weeks his vision became misty for near objects and he could not see to read properly. His voice grew husky and at times he seemed to be talking through his nose. No difficulty in chewing or swallowing; no nasal regurgitation. One month ago: Began to improve; improvement was rapid and is now almost complete subjectively. Now complains simply of some tingling in his toes, soreness and tenderness in calves and soles, and a little weakness of both lower limbs. No history of sore throat or diphtheria-contact. On examination.-Well-nourished, healthy-looking youth. Nose and throat healthy. Nasal and throat swabs negative for Klebs-Loffler bacillus. Schick reaction negative. Functions of all cranial nerves now normal. Slight weakness of both grips, extensors and flexors of wrists and fingers. Lower limbs: Slight symmetrical weakness of both anterior tibial groups, not of a degree to produce any functional disability now, except early fatigue. Small muscles of feet tender to pressure. Gait and stance normal. Tendon reflexes all absent. Abdominals present, plantars flexor. Sensation: slight hypo-algesia over terminal phalanges of fingers, and over lower limbs up to level of knees. Posterior-column sensibility intact. Cerebrospinal fluid clear, three cells, total protein-0 150%. Wassermann reaction negative in blood and cerebrospinal fluid.

George Riddoch

Papers

On the relationship between subarachnoid and intraocular haemorrhage.

On the Relative Perceptions of Movement and a Stationary Object in Certain Visual Disturbances due to Occipital Injuries

On the Relationship between Sub-arachnoid and Intra-ocular Haemorrhage.

Case of Right Fronto-parietal Tumour; Cracked-pot Percussion Note over Right Frontal Bone; Left Palmar Reflex.

Hypertrophic Peripheral Neuritis.