What is the management approach for tinnitus suspected to be caused by a stroke?

Management of Tinnitus Following Stroke

For tinnitus suspected to be caused by a stroke, the management approach should focus on comprehensive neurological evaluation, appropriate imaging, and targeted interventions based on the underlying vascular pathology.

Initial Assessment

• All patients with tinnitus following stroke should undergo a thorough clinical evaluation by a healthcare professional with expertise in stroke care to determine risk for recurrent stroke and initiate appropriate investigations 1
• Distinguish between pulsatile and non-pulsatile tinnitus, as this differentiation is crucial for determining the underlying cause and appropriate management approach 1, 2
• For patients with pulsatile tinnitus, temporal bone CT and CTA are appropriate to evaluate for vascular etiology 1
• For patients with non-pulsatile tinnitus, MRI of the internal auditory canals is the most appropriate imaging test to rule out retrocochlear pathology 1

Diagnostic Workup

For Pulsatile Tinnitus

• Urgent brain imaging (CT or MRI) and noninvasive vascular imaging (CTA or MRA from arch to vertex) should be completed without delay 1
• Evaluate for severe (≥70%) stenosis or occlusion of the internal carotid artery, which is significantly associated with pulsatile tinnitus 3
• Assess for vertebrobasilar disease, arterial tortuosity, or basilar artery dolichoectasia, which are also associated with pulsatile tinnitus 3
• Consider carotid artery stiffness evaluation, as increased stiffness has been associated with tinnitus severity 4

For Non-Pulsatile Tinnitus

• If there is concomitant asymmetric hearing loss, neurologic deficit, or head trauma, imaging should be guided by those respective conditions rather than the presence of tinnitus alone 1
• Obtain a comprehensive audiologic examination to assess hearing status and determine appropriate interventions 1

Management Strategies

For Vascular Causes

• For patients with tinnitus due to carotid or vertebral artery stenosis, management should focus on stroke prevention according to current guidelines 1
• Consider early surgical intervention (carotid endarterectomy) for patients with high-grade carotid stenosis, as the benefit is greatest within 2 weeks of symptom onset 1
• In selected cases of stenosis causing debilitating tinnitus, angioplasty and stenting may be considered if the patient is an appropriate candidate 5

For Hearing and Communication Issues

• If a hearing impairment is suspected, refer to an audiologist for audiometric testing 1
• Consider use of amplification devices (e.g., hearing aids) for patients with documented hearing loss 1
• Implement communication strategies such as looking at the patient when speaking and minimizing background noise 1
• For patients with persistent, bothersome tinnitus associated with documented hearing loss, recommend a hearing aid evaluation 6

For Cognitive and Perceptual Deficits

• For patients with visual-spatial/perceptual deficits following stroke that may contribute to tinnitus perception, multimodal audiovisual spatial exploration training is recommended to improve visual scanning 1
• Consider cognitive behavioral therapy for patients with persistent, bothersome tinnitus 6
• Sound therapy may be considered for patients with persistent, bothersome tinnitus 6

Follow-up and Monitoring

• Patients with tinnitus following stroke should be monitored for changes in symptoms that could indicate progression of vascular disease 1
• Regular follow-up should include assessment of stroke risk factors and adherence to secondary prevention measures 1
• For patients with persistent tinnitus, regular audiologic evaluation is recommended to monitor for changes in hearing status 1, 6

Important Considerations and Pitfalls

• Avoid unnecessary imaging studies in patients with non-pulsatile tinnitus that does not localize to one ear and is not associated with focal neurologic abnormalities or asymmetric hearing loss 1, 6
• Be aware that tinnitus may be a symptom of impending stroke, particularly when associated with other neurological symptoms 1, 2
• Consider that patients may have pre-existing hearing loss that was undiagnosed before the stroke, which can complicate assessment and management 1
• Recognize that stroke patients with communication or cognitive impairments may be unable to accurately describe their tinnitus symptoms, requiring careful assessment and family input 1