Karen Alvarez, DO; Kimberly G. Yen, MD


November 24, 2010

Clinical Presentation

A previously healthy 10-month-old boy presented to the emergency department after his mother found him unresponsive at home. He had been under the care of his aunt's boyfriend, who admitted to police that he had shaken the patient and thrown him against the wall.

CT scan upon arrival revealed a very large mixed-density subdural hemorrhage wrapping around the right cerebral hemisphere, with extensive swelling and edema of the right hemisphere. Associated herniation of the right temporal horn was found, as well as uncal herniation. Ophthalmology was consulted for evaluation of the eyes due to a diagnosis of nonaccidental trauma.

On examination, the child did not blink to light with either eye. Pupils were mid-dilated and fixed in both eyes. Motility could not be assessed because the patient was unresponsive. The external and anterior segment examinations were normal. Fundus examination revealed extensive preretinal, intraretinal, and subretinal hemorrhages in the posterior pole and periphery of both eyes. Both optic nerves appeared to be avulsed (Figures 1-2).

Figure 1. Retinal photo of the right eye shows extensive retinal hemorrhages and possible avulsion of the optic nerve.

Figure 2. Retinal photo of the left eye shows extensive retinal hemorrhages and possible avulsion of the optic nerve.

Question 1. All of the following are true of Terson syndrome except:

A. It occurs after a subarachnoid hemorrhage
B. The classic presentation is hemorrhage in the subhyaloid phase
C. The primary increase in intracranial pressure is the main inciting event in Terson syndrome
D. All of the above are true

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Question 2. Which of the following is a finding of shaken baby syndrome?

A. Multilayered retinal hemorrhages extending to the ora serrata
B. Traumatic retinoschisis
C. Retinal hemorrhages too numerous to count
D. All of the above

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