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Clinical neurology

CASE REPORT

Improvement of sudden bilateral hearing loss after
vertebral artery stenting
Ji Hwa Kim,1 Kyung Jin Roh,2 Sang Hyun Suh,3,4 Kyung-Yul Lee1,4
1

Department of Neurology,
Gangnam Severance Hospital,
Yonsei University College of
Medicine, Seoul, Republic of
Korea
2
Department of
Otorhinolaryngology, Gangnam
Severance Hospital, Yonsei
University College of Medicine,
Sooul, Republic of Korea
3
Department of Radiology,
Gangnam Severance Hospital,
Yonsei University College of
Medicine, Seoul, Republic of
Korea
4
Severance Institute for
Vascular and Metabolic
Research, Yonsei University,
Seoul, Republic of Korea
5
Department of Neurology,
Gangnam Severance Hospital
and Severance Institute for
Vascular and Metabolic
Research, Seoul, Republic of
Korea
Correspondence to
Dr Kyung-Yul Lee, Department
of Neurology, Gangnam
Severance Hospital, Yonsei
University College of Medicine,
211 Eonjuro, Gangnam-gu,
Seoul, 135-720, Korea;
kylee@yuhs.ac
Republished with permission
from BMJ Case Reports
Published 19 February 2015;
doi:10.1136/bcr-2014-011595
Received 4 January 2015
Revised 27 January 2015
Accepted 28 January 2015

ABSTRACT
Bilateral deafness is a rare but possible symptom of
vertebrobasilar ischemia. We report a case of sudden
bilateral sensorineural hearing loss caused by bilateral
vertebral artery (VA) occlusion which dramatically
improved after stenting. A 54-year-old man was
admitted with sudden onset of bilateral deafness,
vertigo, and drowsy mental status. Brain diffusionweighted MRI showed acute infarction involving both
the posterior inferior cerebellar artery and left posterior
cerebral artery territory. Cerebral angiography showed
bilateral distal VA occlusion, and emergency intracranial
stenting was performed in the left VA. After reperfusion
therapy his symptoms gradually improved, including
hearing impairment. Endovascular stenting may be
helpful in a patient with sudden deafness caused by
bilateral VA occlusion.

BACKGROUND
Bilateral deafness is a rare but possible symptom of
vertebrobasilar artery occlusion (VBO) due to
ischemia of the cochlear nerve and auditory tracts
in the brainstem.1 2 The hearing impairment tends
to precede other brainstem signs such as decreased
consciousness, dysarthria, ataxia, weakness, and
sensory deficits, or can be the only symptom of
VBO.3 4 Thus, hearing impairment caused by VBO
is difficult to detect early, despite its grave prognosis.2 3 In addition, few cases of hearing recovery
have been reported in these patients.1–3 We present
a case of sudden bilateral sensorineural hearing loss
(SSNHL) caused by bilateral VBO which improved
after endovascular stenting.

CASE PRESENTATION

To cite: Kim JH, Roh KJ,
Suh SH, et al. J
NeuroIntervent Surg
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A 54-year-old man was admitted to the emergency
room because of sudden bilateral deafness and
vertigo. He had no symptoms until the night
before admission and noticed the hearing impairment when he awoke. He arrived at the hospital
7 h after symptom onset because of symptom worsening and vertigo. The patient had a history of
hypertension and smoking, but no other known illnesses. Initial neurological examination revealed
bilateral deafness and right beating horizontal nystagmus without any motor weakness or sensory
impairment; drowsy mentality and dysarthria developed after admission.
Laboratory studies were normal, except an elevated fasting glucose (124 mg/dL), HbA1c (7.5%),
and low-density lipoprotein cholesterol (164 mg/
dL). ECG showed no abnormalities. Initial brain
CT angiography revealed bilateral distal vertebral

artery (VA) occlusion. Diffusion-weighted MRI
showed diffusion restriction in the bilateral posterior inferior cerebellar artery (PICA) and left posterior cerebral artery territories and perfusion MRI
showed decreased cerebral blood flow as well as
delayed mean transit time and time to peak in the
bilateral cerebellum, brainstem, and left occipital
lobe (figure 1). Cerebral angiography showed bilateral VA occlusion involving the origin of the PICA
(figures 2A–C). The basilar artery (BA) was barely
filled with collateral circulation from the anterior
spinal artery, and the right PICA was visualised by
BA collaterals but the right anterior inferior cerebellar artery (AICA) was not visualised (figures
2B, C). The left AICA–PICA common trunk was
also supplied by BA collaterals. Atherosclerotic
arterial occlusion was suspected due to vascular
risk factors and diffuse atherosclerotic changes in
other cerebral arteries. There was no evidence of
arterial dissection on cerebral angiography.

TREATMENT
Endovascular treatment was performed immediately due to worsening neurological signs. A 6 Fr
guiding catheter (Envoy; Codman Neurovascular,
Raynham, Massachusetts, USA) was introduced
into the left VA via the right femoral artery.
A microcatheter ( preshaped J Prowler select plus,
Codman Neurovascular) was guided carefully into
the occluded segment of the left VA using a
0.014 inch
microwire
(Synchro-2;
Stryker,
Fremont, California, USA) and was advanced
through the BA. Due to long segment occlusion of
the left VA (>30 mm), an Enterprise stent (38 mm,
Codman Neurovascular) was deployed in the
occluded segment of the left VA and 0.5 mg of
intra-arterial tirofiban was administered to prevent
reocclusion. Control angiography showed a patent
stent lumen without thrombosis, and the antegrade
flow was restored immediately in the right AICA,
PICA, and left AICA–PICA common trunk (figure
2D). Daily dual antiplatelet agents (aspirin 100 mg
and clopidogrel 75 mg) were started immediately
after the procedure.

OUTCOME AND FOLLOW-UP
Immediately after stent implantation the patient’s
neurologic symptoms improved, except bilateral
deafness. Pure tone audiography was performed
2 days after admission, which showed severe
sensory neural hearing loss at 72 dB in the right ear
and 75 dB in the left. However, his hearing
improved gradually and he could understand voice
when he was discharged 5 days after admission.

Kim JH, et al. J NeuroIntervent Surg 2015;00:1–3. doi:10.1136/neurintsurg-2014-011595.rep

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Clinical neurology

Figure 1 (A) Initial brain diffusion-weighted MRI shows diffusion restriction in both the posterior inferior cerebellar artery and left posterior
cerebral artery territory. (B) Perfusion MRI shows delay of mean transit time in the bilateral cerebellum, brainstem, and left occipital lobe.

The patient exhibited no hearing impairment or other neurologic deficits 1 month after discharge.

DISCUSSION
Although unilateral SSNHL is common with a relatively good
prognosis, bilateral SSNHL is rare, representing less than 5% of
cases, and typically has a poor prognosis with high morbidity
and mortality.5 It is associated with serious systemic conditions
such as toxins, neoplasms, vascular events, autoimmune diseases, infections, and iatrogenic causes.5 Some authors report
that SSNHL can be an early warning sign of impending vertebrobasilar ischemic stroke2 4 6 in which the incidence of hearing
impairment is 1.2–14.3%.1 4 Sauvaget et al1 described some features of hearing impairment associated with VBO, including
bilateral occurrence, associated occipital or posterior nuchal
pain, and delayed neurological deficits.

Regarding vascular causes, there were reports of ischemic
stroke in the AICA territory as well as the PICA and other brainstem territories, most of which are associated with VBO.4 The
internal auditory artery (IAA) is a main feeder to the inner ear
and it usually originates from the AICA or less frequently from
the PICA or BA. The IAA divides into two main branches, the
common cochlear artery and the anterior vestibular artery. Even
brief periods of ischemia can cause inner ear damage because
the IAA and its subdivisions are end arteries with minimal collaterals from other major arteries; this anatomical characteristic
explains the vulnerability of the cochlea to ischemia.7
There is no standard treatment for SSNHL with VBO. Some
case reports suggested that early recognition and immediate
anticoagulation therapy were associated with a relatively good
prognosis in hearing loss associated with vertebrobasilar ischemia.1 However, in the case of bilateral VA occlusion or BA

Figure 2 (A–C) Cerebral angiography before endovascular treatment. (A) Right vertebral angiogram in anteroposterior view and left vertebral
angiogram in (B) anteroposterior view and (C) lateral view show the occluded bilateral vertebral artery proximal to the posterior inferior cerebellar
artery (PICA). Retrograde upward flow through the anterior spinal artery (white arrow) supplies tenuous blood flow to the basilar artery. (D) Delayed
angiography after endovascular stenting in the anteroposterior view shows a patent stent lumen without thrombosis. The right anterior inferior
cerebellar artery (AICA) is visualized and the right PICA and left AICA–PICA common trunk flows are improved.
2

Kim JH, et al. J NeuroIntervent Surg 2015;00:1–3. doi:10.1136/neurintsurg-2014-011595.rep

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Clinical neurology
occlusion, it was associated with high morbidity and mortality,
even after treatment with anticoagulation or antiplatelet
agents1 2 or thrombolysis using intravenous tissue plasminogen
activator or intra-arterial urokinase.3 Endovascular treatment is
often the best treatment option in symptomatic VBO patients
and has been reported to be effective and safe.8 9 However,
there have been no reports of improvement in bilateral SSNHL
after VA stenting. This might be due to the rarity of bilateral
SSNHL and its late detection because of underestimated hearing
symptoms or delayed recognition of ischemia-associated hearing
impairment. Although we used antiplatelet agents in addition to
endovascular treatment, we speculated that recanalisation via
endovascular treatment was the main reason for the rapid and
dramatic improvement observed. Importantly, this report is
the first case that suggests reversibility of hearing loss after

recanalisation. Because endovascular treatment is available only
in acute stages of stroke, clinicians should be aware of the possibility of VBO in cases of sudden bilateral hearing impairment,
even when brainstem or cerebellar signs are not clear.
Contributors Study concept and design: JHK, KJR, SHS. Acquisition, analysis, or
interpretation of data: All authors. Drafting of the manuscript: JHK. Critical revision
of the manuscript for important intellectual content: SHS, K-YL. Study supervision:
K-YL. K-YL had full access to all of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data analysis.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
1
2
3

Key messages
▸ Sudden sensorineural hearing loss may be an early warning
sign of vertebrobasilar artery occlusion (VBO). However, in
cases where other neurologic symptoms are absent, it is
easy to overlook.
▸ Accurate neurologic examination and immediate brain
imaging may be helpful to distinguish VBO from other
causes of sudden hearing loss.
▸ This case shows that endovascular treatment is helpful in
patients with VBO who present with hearing loss as an early
symptom.

4

5
6
7
8

9

Kim JH, et al. J NeuroIntervent Surg 2015;00:1–3. doi:10.1136/neurintsurg-2014-011595.rep

Sauvaget E, Kici S, Petelle B, et al. Vertebrobasilar occlusive disorders presenting as
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Huang MH, Huang CC, Ryu SJ, et al. Sudden bilateral hearing impairment in
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Toyoda K, Hirano T, Kumai Y, et al. Bilateral deafness as a prodromal symptom of
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Lee H, Baloh RW. Sudden deafness in vertebrobasilar ischemia: clinical features,
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2005;228:99–104.
Sara SA, Teh BM, Friedland P. Bilateral sudden sensorineural hearing loss: review.
J Laryngol Otol 2014;128(Suppl 1):S8–15.
Lin HC, Chao PZ, Lee HC. Sudden sensorineural hearing loss increases the risk of
stroke: a 5-year follow-up study. Stroke 2008;39:2744–8.
Kim JS, Lopez I, DiPatre PL, et al. Internal auditory artery infarction: clinicopathologic
correlation. Neurology 1999;52:40–4.
Gawlitza M, Fritzsch D, Quaschling U, et al. Mechanical thrombectomy in patients
with acute vertebrobasilar occlusion using the Trevo device: a single-centre
experience. Neuroradiology 2014;56:977–83.
Brekenfeld C, Schroth G, Mattle HP, et al. Stent placement in acute cerebral artery
occlusion: use of a self-expandable intracranial stent for acute stroke treatment.
Stroke 2009;40:847–52.

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Downloaded from http://jnis.bmj.com/ on June 6, 2015 - Published by group.bmj.com

Improvement of sudden bilateral hearing loss
after vertebral artery stenting
Ji Hwa Kim, Kyung Jin Roh, Sang Hyun Suh and Kyung-Yul Lee
J NeuroIntervent Surg published online February 24, 2015

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