Bilateral sudden deafness as the main symptom in cerebral hemorrhage

1 Introduction

Supratentorial intracerebral hemorrhage presenting with bilateral sudden deafness as the initial or sole clinical manifestation is exceedingly rare (Bamiou, 2015). The rarity of this phenomenon is primarily attributable to the distinctive anatomical configuration and physiological mechanisms of the central auditory pathway (Gwak et al., 2021). Human auditory perception is mediated by a complex bilateral cortical network. Auditory signals originate in the cochlear nucleus, are relayed through the inferior colliculus and medial geniculate body, and are ultimately projected bilaterally to the transverse temporal gyri and associated cortical areas (Silva et al., 2021). Due to the extensive crossing and integration of fibers within this pathway, damage to the unilateral auditory cortex or subcortical white matter is typically insufficient to result in complete deafness (Silva et al., 2020). Clinically, such lesions are most commonly associated with contralateral deficits in sound source localization or auditory neglect. Central deafness resulting from simultaneous or successive bilateral damage to cortical or subcortical auditory pathways is exceedingly rare (Swartz, 1996; Musiek et al., 2004). Currently, research on bilateral sudden sensorineural hearing loss associated with cerebral hemorrhage, particularly involving deep brain nuclei such as the putamen, remains limited. The precise anatomical localization, potential neuroplastic compensatory mechanisms, and a systematic clinical classification framework require further elucidation. The existing literature predominantly focuses on unilateral lesions in regions such as the brainstem, temporal lobe, or corona radiata (Koyama and Domen, 2016). Consequently, a significant research gap remains regarding the mechanisms underlying hearing impairment associated with bilateral putaminal hemorrhage (Maffei et al., 2019). Therefore, in-depth research on such cases not only contributes to enhancing diagnostic accuracy during the acute phase but also provides critical evidence for understanding functional compensation and recovery potential within the central auditory pathway following sustained or bilateral injury (Arakaki et al., 2022; Agarwal, 2016).

This article presents a rare clinical case involving a 60-year-old male patient with a history of hemorrhage in the right putamen who developed nearly complete bilateral sudden sensorineural hearing loss following a new intraparenchymal bleed in the left putamen. The patient initially presented with bleeding 3 years ago, at which time no hearing impairment was observed. Following treatment for the condition, the patient's hearing function has largely recovered within 2 months. Rather than establishing a definitive classification system, this report aims to provide a concise, case-based conceptual framework that may assist clinical recognition and stimulate further research on this rare condition (Tabuchi, 2014).

2 Case presentation

A 60-year-old man presented with sudden bilateral hearing loss and numbness of the right extremity for 1 day. His blood pressure on admission was 190/100 mmHg. Neurological examination showed bilateral hearing loss, preserved written communication, normal articulation, and fluent spontaneous speech. Sensory function was decreased in the right extremity, whereas muscle strength in all limbs was normal.

Three years earlier, the patient had been admitted for a right putaminal hemorrhage, which had presented with numbness and weakness of the left extremity. No auditory symptoms were documented at that time, and no obvious neurological sequelae remained after treatment. He also had a 6-year history of hypertension.

During the current admission, non-contrast head CT revealed an acute hemorrhage in the left putamen and a focal slit-like lesion in the right putamen, consistent with remote hemorrhagic residue (Figure 1). The patient was diagnosed with hypertensive intracerebral hemorrhage. Auditory brainstem response testing showed normal interpeak latencies between waves I and V. Pure tone audiometry confirmed bilateral sensorineural hearing loss.

Subsequent MRI demonstrated a hematoma in the left putamen, while the lesion in the right putamen was consistent with prior hemorrhage extending toward the right temporal lobe. After more than 2 months of treatment and rehabilitation, the patient's hearing improved markedly and no longer significantly interfered with daily activities. Follow-up pure tone audiometry confirmed substantial improvement in bilateral hearing, particularly at low frequencies (Figure 2).

3 Discussion

Bilateral sudden central deafness caused by supratentorial intracerebral hemorrhage is rare (Bamiou et al., 2012; Musiek et al., 2007). In this case, the patient experienced bilateral sudden sensorineural hearing loss following sequential hemorrhages in the right and left putamen (Semenza et al., 2012; Magid-Bernstein et al., 2022). The central auditory pathway is responsible for auditory processing, involving both cortical and subcortical regions. However, damage to unilateral auditory radiation usually does not lead to cortical hearing loss, unless bilateral auditory radiations are involved (Akiyoshi et al., 2021; Deng et al., 2021; Musiek and Lee, 1998).

In this patient, the first hemorrhage, occurring 3 years prior in the right putamen, did not result in hearing loss due to the intact compensatory function of the left auditory radiation. The second hemorrhage in the left putamen led to bilateral sudden central deafness by affecting both auditory radiations. These findings are consistent with previous research, such as Koyama and Domen's study, which confirmed bilateral auditory radiation damage following putaminal hemorrhage (Tokida et al., 2017).

The observed bilateral hearing loss in this case is consistent with previous reports on cortical hearing loss resulting from bilateral auditory radiation damage, and further studies are needed to clarify the underlying mechanisms and establish a more refined diagnostic framework. The anatomical and clinical classification proposed in this study, based on the sequence of hemorrhages, provides an initial framework for understanding the pathophysiology of this rare condition (Taniwaki et al., 2000).

For bilateral sudden central deafness to occur, damage to both auditory radiations is necessary, as noted by studies of auditory dysfunction in patients with cerebrovascular disease. Furthermore, recovery is possible if edema-induced compression is the primary cause, which improves as edema resolves. The recovery observed in our patient after 2 months is consistent with this mechanism.

The proposed anatomical classification and clinical framework (Supplementary Tables S1, S2) aim to provide a basis for further research and clinical diagnosis, particularly for cases involving bilateral auditory radiation damage. However, these frameworks require validation in larger studies and clinical trials.

4 Conclusion

We report a rare case of bilateral sudden central deafness as the predominant manifestation of sequential bilateral putaminal hemorrhage. This case suggests that when unilateral intracerebral hemorrhage presents with bilateral sudden hearing loss, clinicians should consider the possibility of a pre-existing lesion in the contralateral auditory pathway and perform careful history-taking together with targeted neuroimaging evaluation.

Based on this case and the available literature, we tentatively propose preliminary anatomical and clinical frameworks for understanding this rare presentation. These frameworks are intended to be hypothesis-generating rather than definitive and should be validated in larger studies.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fauot.2026.1741822/full#supplementary-material

Supplementary material Supplementary material at the source

Footnotes

Edited by: Sofia Waissbluth, Pontificia Universidad Católica de Chile, Chile

Reviewed by: Cafer Ikbal Gulsever, Istanbul University, Türkiye

Nevin Pazarci, Ümraniye Egitim ve Araştirma Hastanesi, Türkiye