An explanation for Terson syndrome at last: the glymphatic reflux theory

Terson Syndrome (TS) describes the presence of intraocular hemorrhage in patients with intracranial hemorrhage, typically subarachnoid hemorrhage. Despite TS being a well-defined and frequently occurring phenomenon, its pathophysiology remains controversial. This review will present the current unde...

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Bibliographic Details
Published in:Journal of neurology 2022-03, Vol.269 (3), p.1264-1271
Main Authors: Kumaria, Ashwin, Gruener, Anna M., Dow, Graham R., Smith, Stuart J., Macarthur, Donald C., Ingale, Harshal A.
Format: Article
Language:English
Subjects:
Blood vessels
Hemorrhage
Humans
Intracranial Hypertension - etiology
Intracranial Pressure
Medicine
Medicine & Public Health
Nervous system
Neurology
Neuroradiology
Neurosciences
Optic nerve
Optic Nerve - diagnostic imaging
Pressure
Retina
Review
Subarachnoid hemorrhage
Subarachnoid Hemorrhage - complications
Subarachnoid space
Vitreous Hemorrhage - etiology
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Summary:Terson Syndrome (TS) describes the presence of intraocular hemorrhage in patients with intracranial hemorrhage, typically subarachnoid hemorrhage. Despite TS being a well-defined and frequently occurring phenomenon, its pathophysiology remains controversial. This review will present the current understanding of TS, with view to describing a contemporary and more plausible pathomechanism of TS, given recent advances in ophthalmic science and neurobiology. Previously proposed theories include a sudden rise in intracranial pressure (ICP) transmitted to the optic nerve sheath leading to rupture of retinal vessels; or intracranial blood extending to the orbit via the optic nerve sheath. The origin of blood in TS is uncertain, but retinal vessels appear to be an unlikely source. In addition, an anatomical pathway for blood to enter the eye from the intracranial space remains poorly defined. An ocular glymphatic system has recently been described, drainage of which from the globe into intracranial glymphatics is reliant on the pressure gradient between intraocular pressure and intracranial pressure. The glymphatic pathway is the only extravascular anatomical conduit between the subarachnoid space and the retina. We propose that subarachnoid blood in skull base cisterns near the optic nerve is the substrate of blood in TS. Raised ICP causes it to be refluxed through glymphatic channels into the globe, resulting in intraocular hemorrhage. We herewith present glymphatic reflux as an alternative theory to explain the phenomenon of Terson Syndrome.
ISSN:0340-5354
1432-1459
DOI:10.1007/s00415-021-10686-4