References 1. Malmberg K, for the DIGAMI (Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ 1997;314:1512–1515. 2. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359 –1367. 3. Kent TA, Soukup VM, Fabian RH. Heterogeneity affecting outcome from acute stroke therapy: making reperfusion worse. Stroke 2001;32:2318 –2327. 4. Williams LS, Rotich J, Qi R, et al. Effects of admission hyperglycemia on Sudden unilateral deafness due to a right vertebral artery dissection S.F.A. Raupp, MD; K. Jellema, MD; M. Sluzewski, MD, PhD; P.L.M. de Kort, MD, PhD; and L.H. Visser, MD, PhD Case report. We present a 42-year-old woman without a known connective tissue disorder, who sought treatment at the emergency department because of sudden right-sided deafness, vertigo, and tendency to fall to the right. She also reported right-sided neck pain for 3 days. Neurologic examination, performed 1 day after the onset of symptoms, revealed total deafness on the right side. There were no other abnormalities, including no nystagmus (also not present after use of Frenzel glasses) and no ataxia. An MRI scan showed a small cerebellar infarction in the territory of the right posterior inferior cerebellar artery (PICA) on the T2-weighted image (figure, A). On the sagittal T1-weighted images, the distal part of the right vertebral artery was hyperintense, and no flow void was seen (not shown). A contrast-enhanced MR angiography showed a normal proximal right vertebral artery that showed irregularities and tapering in the high cervical portion. The distal portion of the right vertebral artery was occluded (figure, B and C). The combination of image findings suggest vertebral dissection. In this patient, sudden deafness, vertigo, and neck pain were caused by a spontaneous right vertebral artery dissection. The patient was treated with low molecular weight heparin, especially to prevent new neurologic signs and symptoms. During follow-up evaluation, the unilateral deafness persisted without any other sequelae. The differential diagnosis of sudden deafness includes trauma, viral disease, syphilis, Lyme disease, vascular disease, HIV, ototoxic drugs, autoimmune inner ear disease, perilymph fistulae, Meniere disease, and acoustic neurinoma.1-3 The symptoms of sudden deafness combined with vertigo and neck pain suggested the diagnosis of a vertebral artery dissection. Discussion. Sudden deafness has been described in anterior inferior cerebellar artery (AICA) infarction. Lee et al. described the signs and symptoms of 12 patients with unilateral AICA in- mortality and costs in acute ischemic stroke. Neurology 2002;59:67–71. 5. Bruno A, Levine SR, Frankel MR, et al. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology 2002;59: 669 – 674. 6. Baird TA, Parsons MW, Phanh T, et al. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke 2003;34:2208 –2214. 7. Scott JF, Robinson GM, French JM, et al. Glucose potassium insulin infusions in the treatment of acute stroke patients with mild to moderate hyperglycemia: the Glucose Insulin in Stroke Trial (GIST). Stroke 1999;30:793–799. farction.1 Vertigo was the initial symptom in all patients, accompanied by a horizontal-rotatory nystagmus beating toward the healthy side. Sensorineural hearing loss was present in 11 patients. Unlike our patient, all 12 patients had gait and limb ataxia caused by involvement of the middle cerebellar peduncle or anterior inferior cerebellum.1 Another recent article described bilateral deafness in vertebral insufficiency caused by stenosis of the basilar artery. Vertigo was present, but no nystagmus was observed in this patient as well.4 Our patient had unilateral sudden deafness caused by a right vertebral dissection. In most patients, the internal auditory artery originates from the AICA, but in a few, it branches off the PICA. In our patient, most likely, small emboli originating from the dissection caused a small selective cerebellar and cochlear infarction, sparing the vestibular apparatus. This led to unilateral sensorineural hearing loss without nystagmus. In conclusion, for patients presenting with neck pain and sudden unilateral sensorineural deafness, with or without vertigo, a vertebral artery dissection should be considered and MR angiography performed. From the Department of Neurology and Radiology, St. Elisabeth Hospital, Tilburg, The Netherlands. Received September 15, 2003. Accepted in final form December 1, 2003. Address correspondence and reprint requests to Dr. Sigrid Raupp, Department of Neurology and Radiology, St. Elisabeth Hospital, Hilvarenbeekseweg 60, Tilburg, The Netherlands; e-mail: sigridraupp@hotmail.com Copyright © 2004 by AAN Enterprises, Inc. References 1. Lee H, Sohn SI, Jung DK, et al. Sudden deafness and anterior inferior cerebellar artery infarction. Stroke 2002;33:2807–2812. 2. Cadoni G, Fetoni AR, Agostino S, et al. Autoimmunity in sudden sensorineural hearing loss: possible role of anti-endothelial cell autoantibodies. Acta Otolaryngol Suppl 2002;548:30 –33. 3. Fitzgerald DC, Mark AS. Sudden hearing loss: frequency of abnormal findings on contrast-enhanced MR studies. AJNR Am J Neuroradiol 1998;19:1433–1436. 4. Lee H, Yi HA, Baloh HW. Sudden bilateral simultaneous deafness with vertigo as a sole manifestation of vertebrobasilar insufficiency. J Neurol Neurosurg Psychiatry 2003;74:539 –541. Figure. (A) MRI (T2-weighted) showing a small right-sided posterior inferior cerebellar artery (PICA) infarction. (B and C) Contrast-enhanced MR angiography showing a normal proximal right vertebral artery with irregularities and tapering in the high cervical portion. 1442 NEUROLOGY 62 April (2 of 2) 2004 Sudden unilateral deafness due to a right vertebral artery dissection S. F.A. Raupp, K. Jellema, M. Sluzewski, et al. Neurology 2004;62;1442 DOI 10.1212/01.WNL.0000120757.35082.35 This information is current as of April 26, 2004 Updated Information & Services including high resolution figures, can be found at: http://www.neurology.org/content/62/8/1442.full.html References This article cites 3 articles, 3 of which you can access for free at: http://www.neurology.org/content/62/8/1442.full.html##ref-list-1 Citations This article has been cited by 2 HighWire-hosted articles: http://www.neurology.org/content/62/8/1442.full.html##otherarticles Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): All Neurotology http://www.neurology.org//cgi/collection/all_neurotology Audition http://www.neurology.org//cgi/collection/audition Carotid artery dissection http://www.neurology.org//cgi/collection/carotid_artery_dissection Permissions & Licensing Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions Reprints Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus Neurology ® is the official journal of the American Academy of Neurology. 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