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Point-of-care handheld ophthalmic ultrasound in the diagnosis and evaluation of raised intracranial pressure and Terson syndrome: a description of two cases

  • Jennifer Palermo
  • Michel Bojanowski
  • Stéphan Langevin
  • André Y. DenaultEmail author
Case Reports / Case Series
  • 56 Downloads

Abstract

Background

Ultrasound (US) examination of the eye can be used to detect and monitor elevated intracranial pressure (ICP) and its consequences. Elevated ICP is transmitted to the contiguous optic nerve and its sheath (dura mater), thus underlying the development of papilledema and a widened sheath diameter. The US measurement of the optic nerve sheath diameter (ONSD) has previously been validated to diagnose and monitor raised ICP. The occurrence of vitreous hemorrhage in association with subarachnoid hemorrhage (SAH)—i.e., Terson syndrome—can also be easily diagnosed using ophthalmic US. Because of its relevance in anesthesia and critical care, we describe how to perform the technique illustrated by two cases.

Case presentations

A 72-yr-old man with hydrocephalus secondary to a SAH developed raised ICP following the removal of an external ventricular drainage (EVD) system. Daily ONSD measurements using handheld US allowed us to diagnose and monitor the progression and resolution of the intracranial hypertension following the placement of a second EVD system. We also describe the steps used to obtain ONSD measurements during the ophthalmic US examination of a 53-yr-old woman who presented with a stage IV SAH with concomitant bilateral vitreous hemorrhages or Terson syndrome.

Conclusion

Ophthalmic US using a handheld device to measure and monitor ONSD at the bedside is useful in diagnosing and monitoring the progression of intracranial hypertension following EVD removal in a patient with hydrocephalus secondary to SAH. Ophthalmic US can also be used to identify concomitant vitreous hemorrhage that is associated with a worse prognosis.

L’échographie ophtalmologique portable au chevet pour le diagnostic et l’évaluation d’une élévation de la pression intracrânienne et du syndrome de Terson : une description de deux cas

Résumé

Contexte

L’examen échographique (EG) de l’œil peut être utilisé pour dépister et surveiller une pression intracrânienne (PIC) élevée et ses conséquences. Une PIC élevée est transmise au nerf optique et à sa gaine (dure-mère), et cause l’apparition d’un œdème papillaire et d’un diamètre agrandi de la gaine. La mesure par EG du diamètre de la gaine du nerf optique (DGNO) a précédemment été validée comme outil pour diagnostiquer et monitorer une PIC élevée. La survenue d’une hémorragie vitréenne en association à une hémorragie sous-arachnoïdienne (HSA) – c’est-à-dire, le syndrome de Terson – peut également être aisément diagnostiquée à l’aide de l’échographie ophtalmologique. En raison de sa pertinence pour les soins anesthésiques et critiques, nous décrivons la façon de réaliser cette technique telle qu’illustrée par deux cas.

Présentations des cas

Une PIC élevée est apparue chez un homme de 72 ans atteint d’hydrocéphalie secondaire à une HSA suite au retrait d’une dérivation ventriculaire externe (DVE). Des mesures quotidiennes du DGNO prises à l’aide d’un appareil portable d’échographie nous ont permis de diagnostiquer et monitorer la progression et la résolution de la pression intracrânienne suite à la mise en place d’une deuxième DVE. Nous décrivons également les étapes utilisées afin d’obtenir des mesures du DGNO pendant l’examen échographique ophtalmologique d’une femme de 53 ans avec une HSA de stade IV avec hémorragies vitréennes bilatérales concomitantes ou syndrome de Terson.

Conclusion

L’échographie ophtalmologique à l’aide d’un dispositif portable utilisé pour mesurer et surveiller le DGNO au chevet peut servir à diagnostiquer et surveiller la progression d’une hypertension intracrânienne suite au retrait d’un dispositif de DVE chez un patient souffrant d’hydrocéphalie secondaire à une HSA. L’échographie ophtalmologique peut également être utilisée pour identifier une hémorragie vitréenne concomitante, une condition associée à de moins bons devenirs.

Notes

Author contributions

Jennifer Palermo contributed to all aspects of this manuscript, including study conception and design; acquisition, analysis, and interpretation of data; and drafting the article. Michel Bojanowski contributed to study conception and design as well as the interpretation of the data. Stéphan Langevin contributed to study conception and design. André Y. Denault contributed to all aspects of this manuscript, including study conception and design; acquisition, analysis, and interpretation of data; and drafting the article.

Conflicts of interest

Dr. Denault is on the Speakers bureau for Masimo, Medtronic, and CAE Healthcare.

Funding statement

Supported by the Richard I. Kaufman Endowment Fund in Anesthesia and Critical Care and the Montreal Heart Institute Foundation. The funding body had no role in the study design, in the collection, analysis, and interpretation of data, and in the writing of the manuscript.

Editorial responsibility

This submission was handled by Dr. Philip M. Jones, Associate Editor, Canadian Journal of Anesthesia.

Supplementary material

12630_2019_1531_MOESM1_ESM.wmv (232 kb)
Video 1Case #2: Ultrasound view using handheld device of vitreous hemorrhage or Terson syndrome. (WMV 231 kb)
12630_2019_1531_MOESM2_ESM.wmv (1.1 mb)
Video 2Case #2: Ultrasound view of left eye vitreous hemorrhage or Terson syndrome. (WMV 1172 kb)
12630_2019_1531_MOESM3_ESM.wmv (960 kb)
Video 3Case #2: Ultrasound view of right eye vitreous hemorrhage or Terson syndrome. (WMV 959 kb)

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Copyright information

© Canadian Anesthesiologists' Society 2019

Authors and Affiliations

  1. 1.Department of AnesthesiologyUniversité de MontréalMontrealCanada
  2. 2.Department of NeurosurgeryCentre Hospitalier de l’Université de MontréalMontrealCanada
  3. 3.Department of Anesthesiology and Division of Critical CareInstitut Universitaire de Cardiologie et de PneumologieQuebecCanada
  4. 4.Division of Critical CareCentre Hospitalier de l’Université de MontréalMontrealCanada
  5. 5.Department of Anesthesiology and Critical Care Division, Montreal Heart InstituteUniversité de MontréalMontrealCanada

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