Sudden Hearing Loss with Vertigo Portends Greater Stroke Risk Than Sudden Hearing Loss or Vertigo Alone

Abstract

Background Because it is unknown whether sudden hearing loss (SHL) in acute vertigo is a “benign” sign (reflecting ear disease) or a “dangerous” sign (reflecting stroke), we sought to compare long-term stroke risk among patients with (1) “SHL with vertigo,” (2) “SHL alone,” and (3) “vertigo alone” using a large national health-care database. Methods Patients with first-incident SHL (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] 388.2) or vertigo (ICD-9-CM 386.x, 780.4) were identified from the National Health Insurance Research Database of Taiwan (2002-2009). We defined SHL with vertigo as a vertigo-related diagnosis ±30 days from the index SHL event. SHL without a temporally proximate vertigo diagnosis was considered SHL alone. The vertigo-alone group had no SHL diagnosis. All the patients were followed up until stroke, death, withdrawal from the database, or current end of the database (December 31, 2012) for a minimum period of 3 years. The hazards of stroke were compared across groups. Results We studied 218,656 patients (678 SHL with vertigo, 1998 with SHL alone, and 215,980 with vertigo alone). Stroke rates at study end were 5.5% (SHL with vertigo), 3.0% (SHL alone), and 3.9% (vertigo alone). Stroke hazards were higher in SHL with vertigo than in SHL alone (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.28-2.91) and in vertigo alone (HR, 1.63; 95% CI, 1.18-2.25). Defining a narrower window between SHL and vertigo (±3 days) increased the hazards. Conclusions The combination of SHL plus vertigo in close temporal proximity is associated with increased subsequent stroke risk over SHL alone and vertigo alone. This suggests that SHL in patients with vertigo is not necessarily a benign peripheral vestibular sign.

Diagnosing Stroke in Acute Dizziness and Vertigo

“…23,47 If seen during an attack, a patient with AICA-territory TIA may demonstrate unilateral sensorineural hearing loss and peripheral-type nystagmus from labyrinthine ischemia, so diagnostic caution is advised when hearing loss is present. 48 Some s-EVS cases may show small strokes by MRI-DWI. 49 Dizziness is also the most common presenting symptom of vertebral artery dissection (58%), 50 which affects younger patients, mimics migraine, and is easily misdiagnosed.…”

“…Strong evidence indicates that a three-part bedside ocular motor examination battery (HINTS—Head Impulse, Nystagmus Type, Skew deviation) plus acute hearing loss by finger rub (HINTS “plus”) rules out stroke more accurately than early MRI (Table 2). 14,55-59 While it is possible for ED providers to learn these techniques, 48 only a minority use them and even fewer are confident in these bedside skills. 60 Skills also vary among neurologists.…”

Metabolic syndrome and idiopathic sudden sensori-neural hearing loss

“…MetS and ISSHL are both considered risk factors for cerebrovascular accidents especially if the hearing loss is associated with vertigo [7][8][9][10]. In the present study we have evaluated the association between the presence of MetS and ISSHL and we have showed that the average of MetS criteria met by ISSHL patients were significantly higher compared to controls.…”

“…Recently, in patients affected by ISSHL, endothelial dysfunction [4,5] and a high prevalence of cardiovascular risk factors [6] have been reported. Prospective studies have shown that patients affected by ISSHL have a higher risk of developing a cerebrovascular accident especially if ISSHL is associated with vertigo [7,8], suggesting that hearing loss may share similar etio-pathogenic mechanisms.…”

Acute Vestibular Syndrome

“…16 In another study that used Taiwan National Health Insurance claim data, patients with SSNHL and vertigo had a higher risk of stroke at 1 year (1.5%, 10/678) than did patients with SSNHL without vertigo (0.6%, 11/1,998; hazard ratio: 1.75, 95% CI: 1.15-2.66). 17 These studies emphasize that vascular causes should be a concern in acute presentations of unilateral cranial nerve 8 lesions. A genome-wide association study (GWAS) in 131 AUV patients and 2,609 controls was recently performed.…”