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et al. Stroke‑like migraine attacks after radiation therapy (SMART) 41 and 42) on both transverse gyri (Heschl). The clinical syndrome is not always completely reversible: A case series. AJNR Am syndrome of cortical deafness with bitemporal infarction J Neuroradiol 2013;34:2298‑303. [1] 8. Di Stefano AL, Berzero G, Vitali P, Galimberti CA, Ducray F, Ceroni M, was described by Wernicke and Friedlander in 1883. et al. Acute late‑onset encephalopathy after radiotherapy: An unusual life‑threatening complication. Neurology 2013;81:1014‑7. Different causes of cortical deafness include congenital lesions, cerebral infarction or cerebral hemorrhage.[1] We Access this article online could find only four cases of cortical deafness caused by vasospasm in subarachnoid hemorrhage [Table 1]. Quick Response Code: Website: www.neurologyindia.com Peripheral hearing loss due to aneurysmal bleed is most commonly caused by antero‑inferior cerebellar PMID: *** artery (AICA) aneurysm [Table 2]. Rhoton divided AICA in to four segments ‑ anterior pontine, lateral pontine, DOI: floculonodular, and cortical. The lateral pontine segment 10.4103/0028-3886.141291 is divided into premeatal, meatal, and postmeatal parts. Mazzoni found the meatal segment was medial to porus Received: 10-07-2014 Review completed: 13-07-2014 Accepted: 19-08-2014 in 33%, reaching the porus in 27% and entered the canal in 40%. All the AICA aneurysm causing deafness belong to the latter group.[4] Vasospasm causing reversible cortical deafness in subarachnoid hemorrhage
Sir, b c A 32‑year‑old male presented with sudden onset of a holocranial severe headache of 2‑day duration. Magnetic resonance imaging (MRI) of brain showed subarachnoid hemorrhage (SAH) in the left sylvian fissure [Figure 1a‑d]. Cerebral computed tomographic angiography (CTA) revealed an aneurysm at bifurcation of the left‑middle cerebral artery [Figure 1e]. He was advised surgery but he did not turn up for five days due to some family issues. On the eighth day, he developed bilateral deafness of sudden d e onset. Pure tone audiometry (PTA) confirmed presence of Figure 1: T1 weighted axial image (a), FLAIR image (b), GRE sequence (c bilateral sensorineural hearing loss [Figure 2a]. Brainstem and d) of MRI showing blood in the left sylvain fissure. (e) CT angiography of brain showing aneurysm at bifurcation of left middle cerebral artery auditory evoked potentials demonstrated normal patterns bilaterally. Transcranial doppler (TSD) showed elevated blood flow velocities (~280 cm/s) involving both middle cerebral arteries. Patient refused surgery in that hospital due to economic constraints and got admitted to our facility. Neurologic examination revealed bilateral sensorineural hearing loss. Patient had left pterional craniotomy and clipping of the aneurysm. Patient improved in sensorium and deafness after five days of a surgery. Postoperative pure tone audiometry confirmed resolution of the sensorineural deafness [Figure 2b]. At follow‑up of 12 months the patient is doing well.
Severe auditory deficit due to bilateral cerebral lesions is called as “cortical deafness”. In cortical deafness, auditory signals cannot be perceived in the cortex and b audiometry reveals severe bilateral hearing loss. It results from damage to both temporal or temporoparietal lobes Figure 2: (a) Preoperative pure tone audiogram (PTA) of patient suggestive of bilateral sensorineural hearing loss. (b) Postoperative PTA including the primary auditory cortex (Broadmann areas of patient showing normal findings
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Table 1: Aneurysm causing central deafness Author/year Age/sex Lateralisation Site of aneurysm Mechanism Ogane et al.(1998)[1] 64/F Bilateral Right MCA Cortical due to MCA spasm Musiek et al.(2004)[2] 21/F Bilateral ND Subarachnoid bleed affecting both inferior colliculi Tabuchi et al.(2007)[1] 61/F Bilateral Right ICA Cotical due to MCA spasm Maslehaty et al.(2010)[2] 59/M Bilateral ACOM Cotical due to MCA spasm Ponzetti et al.(2013)[3] 55/F Bilateral ND Cotical due to MCA spasm Present case 32/M Bilateral Left MCA Cotical due to MCA spasm M - Male, F - Female, ND - Not described, ICA - Intenal carotid artery, ACOM - Anterior communicating artery, MCA - Middle cerebral artery
Table 2: Aneurysm causing peripheral deafness Author/year Age/sex Lateralisation Site of aneurysm Mechanism Castaigne et al. (1967)[4] 62/F Unilateral Intrameatal AICA Mass effect Glasscock et al. (1969)[4] 49/F Unilateral Intrameatal AICA Mass effect Hori et al. (1971)[4] 35/F Unilateral Intrameatal AICA Mass effect Arnold et al. (1977)[5] 68/F Unilateral Basilar artery Infiltration of internal auditory canal by erythrocytes Conclasure et al. (1981)[6] Bilateral PCOM artery ND Kamano et al. (1986)[4] 58/F Unilateral Intrameatal AICA Mass effect Inoue et al. (1987)[4] 43/F Intrameatal AICA Mass effect Nishizawa et al. (1989)[7] 49/F Unilateral Vertebral artery Spasm of internal auditory artery Gleeson et al. (1989)[4] 57/F Unilateral Intrameatal AICA Mass effect Kiya et al. (1989)[4] 64/F Unilateral Intrameatal AICA Mass effect Spallone et al. (1995)[4] 46/F Unilateral Intrameatal AICA Mass effect Banczerowski et al. (1996)[2] ‑ Unilateral AICA–IAA junction Mass effect Okumura et al.(1998)[2] 77/F Unilateral Intrameatal AICA Mass effect Zager et al. (2002)[2] 37/M Unilateral Intrameatal AICA Mass effect Tokumitsu et al. (2004)[2] 59/F Unilateral Intrameatal AICA Mass effect M - Male, F - Female, ND - Not described, PCOM - Posterior communicating artery, AICA - Anterio‑inferior cerebellar artery, IAA - Intenal auditory artery
The MRI including diffusion‑weighted imaging (DWI) References and perfusion‑weighted imaging (PWI) sequences are promising techniques to assess brain ischemia in SAH. 1. Tabuchi S, Kadowaki M, Watanabe T. Reversible cortical auditory Perfusion‑weighted MRI is a useful new tool in the dysfunction caused by cerebral vasospasm after ruptured aneurysmal subarachnoid hemorrhage and evaluated by perfusion magnetic treatment of patients with SAH, particularly those with resonance imaging. Case report. J Neurosurg 2007;107:161‑4. cerebral vasospasm, and the temporary neurological 2. Maslehaty H, Doerner L, Barth H, Rohr A, Mehdorn HM. Reversible deficits correlate well with the location of perfusion bilateral hypacusis after aneurysmal subarachnoid hemorrhage. changes.[1] We could not perform these investigations Neuroradiology 2010;52:1057‑9. 3. Ponzetto E, Vinetti M, Grandin C, Duprez T, Van Pesch V, Deggouj N, because of economic constraints on the part of the et al. Partly reversible central auditory dysfunction induced by cerebral patient. However, the findings of TCD study in bilateral vasospasm after subarachnoid hemorrhage. J Neurosurg 2013;119:1125‑8. MCA territories suggest cerebral vasospasm as the 4. Sun Y, Wrede KH, Chen Z, Bao Y, Ling F. Ruptured possible cause for bilateral deafness in outpatient. intrameatal AICA aneurysms‑‑a report of two cases and review of the literature. Acta Neurochir (Wien) 2009;151:1525‑30. 5. Arnold W, Vosteen KH. Sudden deafness as a consequence of rupture of All the cases of cortical deafness caused by vasospasm a basilar artery aneurysm (author’s transl). HNO 1977;25:127‑30. in SAH baring one report, which is reported by Ogane 6. Conclasure JB, Graham SS. Intracranial aneurysm occurring as et al. improved after treatment of aneurysm and sensorineural hearing loss. Otolaryngol Head Neck Surg 1981;89:283‑7. 7. Nishizawa S, Yokoyama T, Uemura K, Ryu H, Ninchoji T, Shimoyama I, vasospasm. The one reported by Ogane et al. had old et al. Unilateral nerve deafness due to rupture of a right vertebral artery [1‑3] temporal infarction. But peripheral deafness caused aneurysm. Case report. Neurol Med Chir (Tokyo) 1989;29:772‑6. by intrameatal aneurysm was irreversible except that reported by Okumura et al.[4] SAH should be considered Access this article online
in the differential diagnosis of acute hearing loss. Quick Response Code: Website: www.neurologyindia.com
PMID: Raghvendra Ramdasi, Aadil Chagla, *** Amit Mahore DOI: Department of Neurosurgery, King Edward Memorial 10.4103/0028-3886.141292 Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India E-mail: [email protected] Received: 15-07-2014 Review completed: 24-07-2014 Accepted: 19-08-2014
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