器質化した硝子体出血に対する硝子体手術を行った重症くも膜下出血によるTerson症候群の1例 A Case of Terson's Syndrome Caused by Severe Aneurysmal Subarachnoidal Hemorrhage with Vitreous Surgery for Organized Vitreous Hemorrhage
A 40-year-old man in a deep coma following sudden severe headache was admitted to our hospital. Computed tomography (CT) of the head showed diffuse intracerebral subarachnoid hemorrhage (SAH) in the frontal lobe. Digital subtraction angiography revealed an aneurysm of the anterior communicating artery. The neck of the aneurysm was clipped with external decompressive craniectomy. Altered consciousness was, however, prolonged, and a tracheostomy was performed. On day 30 in the hospital, his pupils showed dilation. Ophthalmologic examination revealed bilateral massive vitreous hemorrhage or Terson's syndrome. Owing to an unstable general medical condition, especially due to severe diabetes insipidus following SAH, there was little hope of recovering consciousness. Therefore, vitreous surgery was not considered. After a long period of continued medical management, his level of consciousness improved, and gait training was started. On day 150 of hospitalization, his general medical condition and consciousness level considerably improved, and he was able to walk. He underwent surgery for bilateral vitreous hemorrhage. The hematoma was organized and hard, and proliferative vitreoretinopathy was present. Fifteen months after SAH onset, his right eye regained useful visual acuity, and he resumed an independent life at home. Retrospective assessment of his head CT revealed that preretinal hemorrhage had been present since as early as admission. On day 30, when his pupils were dilated, the preretinal hemorrhage had disappeared, and diffuse vitreous hemorrhage was present. We have, thus, elucidated the detailed time-course of vitreous hemorrhage development after SAH using serial CT scans; this finding has not been reported to date. Vitreous hemorrhage is often missed in head CT scans during the acute phase of SAH. It can also be missed in patients with altered consciousness over a prolonged clinical course. Serial ultrasonography for detecting vitreous hemorrhage may allow timely and appropriate vitreous surgery.
脳卒中の外科 46(5), 384-388, 2018