Case Report Amusia for Pitch Caused by Right Middle Cerebral Artery Infarct M. Seth Hochman, MD,* and Kevin J. Abrams, MD† A 61-year-old right-handed man with hypertension and dyslipidemia noted that he was singing along to classic rock songs on his car radio, but his voice was off pitch. Six days later, a magnetic resonance imaging scan of his brain revealed a cerebral infarct of the right temporal parietal cortex and insula. Case reports of the precise anatomic correlates of disordered pitch musical processing have been few and fragmentary. The anatomic involvement of our case coincides with the areas of involvement in 3 previously reported cases. Increased awareness of amusia as a rare clinical presentation of stroke should lead to earlier stroke intervention. Key Words: Amusia—pitch—cerebral infarct—right middle cerebral artery. Ó 2014 by National Stroke Association A 61-year-old right-handed optometrist with hypertension and dyslipidemia noted that he was singing along to classic rock songs on his car radio off pitch when he had lifelong always sung in tune. Three days later, his neurologic examination was normal without receptive or expressive aphasia, alexia, or agraphia. Six days after the onset of his inability to sing along in tune, a magnetic resonance imaging (MRI) scan of his brain (Fig 1) revealed confluent and gyriform areas of restricted diffusion, fluid-attenuated inversion recovery hyperintensity and gyriform enhancement of the right insula, perisylvian and right parietal cortex, and gyriform hyperintensity on T1-weighted images in some of these areas. One month later, a repeat MRI scan (Fig 2) revealed gyriform petechial hemorrhage and/or cortical laminar From the *Department of Neurology, University of Miami Miller School of Medicine and Baptist Hospital; and †Department of Radiology, Baptist Hospital, Miami, Florida. Received April 19, 2012; accepted June 27, 2012. Address correspondence to M. Seth Hochman, MD, Department of Neurology, University of Miami Miller School of Medicine, Baptist Hospital, 8600 SW 92nd Street, Miami, FL 33156. E-mail: mshochmanmd@ aol.com. 1052-3057/$ - see front matter Ó 2014 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2012.06.016 164 necrosis along the right temporoparietal cortex and right insula consistent with evolution of the previously noted early subacute right posterior middle cerebral artery (MCA) infarct. Intracranial and neck magnetic resonance angiography scans were normal. Impairment of processing of music has been termed amusia1,2 or musical agnosia,2,3 and has been associated with lesions of the right hemisphere.1-3 The precise anatomic correlates of amusia with impairment of pitch have varied among case reports, which are few and fragmentary.1-3 After the clipping of ruptured right MCA aneurysms, Ayotte et al3 reported 2 cases of disordered pitch perception—termed apperceptive music agnosia—that were associated with computed tomographic scans that revealed infarcts of the right posterior superior temporal lobe and/or insula. Terao et al1 described a professional tango singer with a deficit in pitch perception and a more severe inability to reproduce a presented pitch, which they termed vocal amusia, after a stroke of the right superior temporal cortex extending to the supramarginal gyrus posterior aspect of the postcentral gyrus and the posterior insula on MRI. Our patient’s MRI featured the same anatomic areas of involvement as these 3 previously reported cases—all of which point to the right posterior temporal lobe and/or insula as the anatomic correlate of disordered pitch. Journal of Stroke and Cerebrovascular Diseases, Vol. 23, No. 1 (January), 2014: pp 164-165 AMUSIA CAUSED BY RIGHT MCA INFARCT 165 Figure 1. Magnetic resonance imaging results at presentation. (A) Axial diffusion-weighted image. Note the hyperintense restricted diffusion of the right posterior insula and adjacent temporal lobe. (B) Axial fluid-attenuated inversion recovery image. Note the corresponding hyperintense signal of the right posterior insula and temporal lobe. Figure 2. Magnetic resonance imaging results at 1 month of follow-up. (A) Axial fluidattenuated inversion recovery imaging shows increased signal and reduced swelling of the infarcted tissue along the right insula and temporoparietal cortex. (B) Axial postcontrast T1weighted imaging reveals a hyperintensity corresponding to regions of enhancement and cortical laminar necrosis of the right insula and temporoparietal cortex. Increased awareness of amusia as a rare clinical presentation of stroke should lead to earlier stroke intervention. References 1. Terao Y, Mizuno T, Shindoh M, et al. Vocal amusia in a professional tango singer due to a right superior temporal cortex infarction. Neuropsychologia 2006;44: 479-488. 2. Alossa N, Castelli L. Amusia and musical functioning. Eur Neurol 2009;61:269-277. 3. Ayotte J, Peretz I, Rousseau I, et al. Patterns of music agnosia associated with middle cerebral artery infarcts. Brain 2000;123:1926-1938.