Surgical management of temporal lobe intracerebral hemorrhage presenting with bilateral deafness: a case report

Article information

J Korean Ster Func Neurosurg. 2021;17(1):30-33
Publication date (electronic) : 2021 June 18
doi : https://doi.org/10.52662/jksfn.2021.00010
Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chucheon, Korea
Address for correspondence: Hyukjai Choi, MD Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, 77 Sakju-ro, Chucheon 24253, Korea Tel: +82-33-240-5171, Fax: +82-070-5096-8691 E-mail: neurosurgeon@hallym.or.kr
Received 2020 December 22; Revised 2021 March 24; Accepted 2021 March 25.

Abstract

Temporal lobe intracerebral hemorrhage (ICH) causing bilateral sensorineural hearing loss (SNHL) is considered rare. However, there are a few reports regarding the treatment of this condition, most of which have described the use of conservative treatment. We herein report the surgical outcome of a 58-year-old patient diagnosed with temporal lobe ICH presenting with bilateral SNHL. A 58-year-old male presented to our hospital complaining of bilateral deafness. Pure tone audiometry (PTA) revealed bilateral SNHL. He had a history of spontaneous ICH in the left temporal lobe region 2 years previously. Following routine intravenous dexamethasone, the patient was screened with brain magnetic resonance imaging. Imaging showed subcortical ICH (3.4×2.5×4.0 cm3) in the right temporal lobe area. Further physical examination did not reveal any neurologic deficits other than deafness. He underwent surgery for ICH removal. Postoperative computed tomography confirmed that the ICH was removed. After surgery, his symptoms and follow-up PTA showed improvement on both sides within 2 days. Bilateral SNHL due to ICH is rare and has a poor prognosis. However, surgery may be an appropriate treatment for bilateral SNHL.

INTRODUCTION

Intracerebral hemorrhage (ICH) causes a neurologic syndrome associated with its location and volume [1]. However, neurological symptoms, such as altered consciousness and motor weakness, usually caused by cerebral hemorrhage, are one-sided [2].

Temporal lobe ICH comprises approximately 5% of cerebral hemorrhage cases [3]. Patients with temporal ICH usually present with headache, paraphasia, and speech or comprehension problems [4]. Both sensorineural hearing loss (SNHL) types due to ICH are considered rare. This case highlights a patient with hearing loss, after sequential history of cerebral hemorrhage. We report on a surgical treatment for ICH and SNHL without other neurologic symptoms as well as the clinical outcome after surgical removal.

CASE REPORT

A 58-year-old male patient came to the emergency center with sudden bilateral hearing loss. The patient had a history of spontaneous ICH in the left temporal lobe region extending to the putamen and corona radiata, 2 years ago. The tympanic membrane appeared intact. Pure tone audiometry (PTA) and otoacoustic emission test revealed bilateral SNHL (Fig. 1). While we administered routine intravenous dexamethasone treatment for sudden SNHL, computed tomography (CT) and magnetic resonance imaging (MRI) showed subcortical ICH (4.0 cm) in the right temporal lobe area (Fig. 2A, B). Further physical examination did not show any neurologic deficits other than deafness. The patient underwent navigation-guided-craniotomy for ICH removal. Postoperative CT confirmed ICH was removed (Fig. 2C). After surgery, his symptoms and PTA improved in 2 days. During the follow-up, the patient’s symptoms improved to serviceable hearing (Fig. 1).

Fig. 1.

The pure tone audiometry test results before and after surgery were compared to confirm that the patient’s symptoms improved to a serviceable hearing level. (A) Preoperative pure tone audiometry shows bilateral sensorineural hearing loss (HL). (B) Postoperative pure tone audiometry conducted 2 days after surgery shows bilateral sensorineural HL recovery to a serviceable hearing level. A/C: air conduction, B/C: bone conduction.

Fig. 2.

Preoperative examinations. (A) Computed tomography shows subcortical intracranial hemorrhage (3.4×2.5×4.0 cm3) in the right temporal lobe area. (B) Subcortical intracranial hemorrhage (3.4×2.5×4.0 cm3) shows low T2 signal intensity on magnetic resonance imaging. Perihematomal swelling shows high T2 signal intensity. (C) Postoperative computed tomography shows complete removal of the subcortical intracranial hemorrhage.

Ethical statements

This study was approved by the Institutional Review Board (IRB) of the Chuncheon Sacred Heart Hospital (IRB No: 2021-06-012). Written informed consent was obtained from the patient.

DISCUSSION

ICH causes various neurological symptoms, such as seizures, motor weakness, and aphasia. While symptoms of cerebral hemorrhage are often associated with neuroanatomical structures, it is rare to have only bilateral SNHL.

Hearing loss due to ICH could be explained by the auditory pathway. Sound stimulates hair cells in the organ of Corti. These nerves enter the brain stem and bifurcate, connecting the dorsal and ventral cochlear nuclei. The pathway enters the inferior colliculus, intersecting at the superior Olive complex. After the inferior colliculus, the signal is transmitted to the cortex located in the superior temporal lobe gyrus (auditory area) through the medial geniculate body [5]. Due to the intersections of the auditory system, symptoms appear to occur on both sides, even with one-sided lesions [6].

Sudden hearing loss may have various etiologies, such as viral infections, ototoxic drugs, and autoimmune diseases. Among them, central origins, such as hemorrhage or infarct, could be a cause of SNHL [7,8]. In most cases where patients received conservative treatment for ICH with SNHL, the prognosis was poor.

Kim et al. [6] reported a case of pontine hemorrhage with bilateral SNHL. In that case, after conservative treatment, PTA from 52 months of onset did not show definite improvement.

Surgical evacuation of hematoma is still controversial. However, in certain situations, hematoma removal through surgical treatment may be beneficial to the patient.

In this case, we performed surgery as opposed to other cases. The patient’s prognosis improved to the restoration of serviceable hearing. However, some symptoms may advance due to the improvement of edema and inflammation after surgery.

ICH causes edema and secondary neuronal damage [9]. Thus, direct nerve injury or compression by edema block signals from both auditory pathways and triggers bilateral SNHL. If complications are properly controlled, hematoma removal prevents secondary neurological damage by relieving local ischemia or removing of noxious chemicals. If the hematoma is localized to the subcortex, as in this case, complications are unlikely to occur. When, treating symptoms caused by compression rather than structural damage, surgery should be considered, as it has the highest chance of improving clinical outcomes.

Matsuda et al. [10] reported a case of cerebellar hemorrhage with right side SHNL. Wherein, craniotomy was performed, and an improvement in the SNHL was observed on the 6-month follow-up PTA. Our report highlights a rare case of ICH with bilateral SNHL and a basis for surgical treatment.

The main limitation of this case was that it was not clear whether the patient’s improvement was due to surgical treatment or steroid treatment. After steroid treatment, hearing improves in about 70% of patients between 4 and 7 days of age [11]. However, in this case, the patient’s SNHL immediately improved at 2 days after surgery; therefore, it is likely that decompression by surgery enhances clinical outcomes.

While further research is needed, we suggest that some of the temporal lobe ICH can cause bilateral SNHL, in which case surgery may be a suitable option to improve the prognosis if the patient’s general condition is good.

CONCLUSION

Temporal lobe ICH may be a rare cause of bilateral SNHL. Early surgical removal of hematoma could be an effective-treatment option to improve SNHL.

Notes

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

1. Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous intracerebral hemorrhage. N Engl J Med 2001;344:1450–60.
2. Tanaka A, Yoshinaga S, Nakayama Y, Kimura M, Tomonaga M. Cerebral blood flow and clinical outcome in patients with thalamic hemorrhages: a comparison with putaminal hemorrhages. J Neurol Sci 1996;144:191–7.
3. Mutlu N, Berry RG, Alpers BJ. Massive cerebral hemorrhage. Clinical and pathological correlations. Arch Neurol 1963;8:644–61.
4. Ropper AH, Davis KR. Lobar cerebral hemorrhages: acute clinical syndromes in 26 cases. Ann Neurol 1980;8:141–7.
5. Peterson DC, Reddy V, Hamel RN. Neuroanatomy, Auditory Pathway. In: StatPearls Treasure Island (FL): StatPearls Publishing; 2021.
6. Kim SK, Kim AR, Kim JY, Kim DY. A long-term follow-up of pontine hemorrhage with hearing loss. Ann Rehabil Med 2015;39:634–9.
7. Inoue Y, Kanzaki J, Ogawa K. Vestibular schwannoma presenting as sudden deafness. J Laryngol Otol 2000;114:589–92.
8. Martines F, Dispenza F, Gagliardo C, Martines E, Bentivegna D. Sudden sensorineural hearing loss as prodromal symptom of anterior inferior cerebellar artery infarction. ORL J Otorhinolaryngol Relat Spec 2011;73:137–40.
9. Veltkamp R, Purrucker J. Management of spontaneous intracerebral hemorrhage. Curr Neurol Neurosci Rep 2017;17:80.
10. Matsuda Y, Inagawa T, Amano T. A case of tinnitus and hearing loss after cerebellar hemorrhage. Stroke 1993;24:906–8.
11. Moon IS, Kim J, Lee SY, Choi HS, Lee WS. How long should the sudden hearing loss patients be followed after early steroid combination therapy? Eur Arch Otorhinolaryngol 2009;266:1391–5.

Article information Continued

Fig. 1.

The pure tone audiometry test results before and after surgery were compared to confirm that the patient’s symptoms improved to a serviceable hearing level. (A) Preoperative pure tone audiometry shows bilateral sensorineural hearing loss (HL). (B) Postoperative pure tone audiometry conducted 2 days after surgery shows bilateral sensorineural HL recovery to a serviceable hearing level. A/C: air conduction, B/C: bone conduction.

Fig. 2.

Preoperative examinations. (A) Computed tomography shows subcortical intracranial hemorrhage (3.4×2.5×4.0 cm3) in the right temporal lobe area. (B) Subcortical intracranial hemorrhage (3.4×2.5×4.0 cm3) shows low T2 signal intensity on magnetic resonance imaging. Perihematomal swelling shows high T2 signal intensity. (C) Postoperative computed tomography shows complete removal of the subcortical intracranial hemorrhage.