Traumatic “Terson syndrome plus”: Pneumocephalocele with optic atrophy

Terson Syndrome is subarachnoid hemorrhage (SAH) with sub retinal hemorrhage flowing through channel. Reduced vision in such fresh case is due to hemorrhage itself, blocking macula / other photo receptors in the long run macular cellophane retinopathy which causes profound visual loss. SAH causes neurological problems which can become a risk factor for evacuating blood from vitreous. Hypertension is commonest cause to cause Terson Syndrome, but trauma is also devastating cause as it can lead to irreversible visual consequences like total loss of perception of light or blindness. Here we describe a case of Terson Syndrome plus disease features SAH in frontal lobe. When there is traumatic pneumocephalocele, it gives space to blood to imbibe towards bony optic canal and form hematoma around nerve sheath which causes compression around the same and leads to optic atrophy. Optic nerve can be injured by direct traumatic dissection during RTA, but even without that blood may accumulate around optic nerve and in turn leads to formation of hematoma and subsequently pressure induced optic atrophy. Moreover blood can slowly travel to subhyaloid space / sub retinal space with gliosis covering typical boat shaped blood. Gliosis may resolve through three injections of Tricort in the orbital floor near apex, but optic atrophy snatches vision. Thus diagnosis of Terson syndrome plus disease was established by addressing all features on CT scan and MRI. Plus features include pneumocephalous, optic nerve sheath hematoma, optic atrophy and gliosis over subhyaloid hemorrhage, typical boat shaped.