Can recurrent stroke cause hearing loss in an older adult with a history of vascular disease, hypertension, and diabetes?

Can Recurrent Stroke Cause Hearing Loss?

Yes, recurrent stroke can definitively cause hearing loss, particularly when involving the posterior circulation (vertebrobasilar territory), and patients with stroke history have significantly elevated risk of both acute hearing impairment and progressive auditory dysfunction.

Mechanisms of Stroke-Related Hearing Loss

Stroke causes hearing loss through multiple pathways depending on the vascular territory involved:

Posterior Circulation Strokes

• Labyrinthine infarction from AICA (anterior inferior cerebellar artery) occlusion causes acute unilateral hearing loss combined with vestibular symptoms in most cases 1
• Bilateral synchronous internal auditory artery occlusion associated with vertebrobasilar disease presents with hearing loss alongside vertigo, dysarthria, facial weakness, ataxia, and nystagmus 1
• Hearing loss occurred in 8% of acute posterior circulation strokes in a prospective series of 364 patients, sometimes preceding the stroke by several days 1

Anterior Circulation Strokes

• Unilateral strokes affecting the primary auditory cortex (Heschl gyrus) in the posteromedial temporal cortex typically do NOT cause symptomatic hearing loss 1
• Bilateral strokes affecting the primary auditory cortex are rare but can present with sudden hearing loss 1
• Recent research demonstrates that even anterior circulation strokes (particularly middle cerebral artery territory) show significantly elevated mean hearing thresholds (44.0 ± 12.1 dB) compared to matched controls (36.1 ± 11.4 dB, p = 0.001) 2

Prevalence and Risk in Your Patient Population

For older adults with vascular disease, hypertension, and diabetes—the exact profile you describe—hearing impairment after stroke is extremely common but frequently undetected:

• Sensorineural hearing loss is more common and severe in stroke patients compared to controls even after adjusting for diabetes and hypertension (p < 0.005) 2
• Studies show 67-90% of stroke patients have undiagnosed hearing loss 3
• The combination of peripheral hearing loss and central auditory processing disorder (CAPD) is the most common pattern in patients aged 61-80 years (55% prevalence) 4
• Stroke severity correlates with hearing threshold in both ears (mean B 0.775, R² 0.54, p = 0.020) 2

Bidirectional Relationship: Hearing Loss as Both Consequence and Predictor

Critically, the relationship between stroke and hearing loss is bidirectional:

• Patients admitted with sudden sensorineural hearing loss (SSNHL) have a 12.8% risk of stroke over the next 5 years versus 7.8% in controls 1
• After adjustment for hypertension, hypercholesterolemia, and diabetes, the hazard ratio remains 1.64 times higher for stroke in SSNHL patients 1
• Unilateral hearing loss can occasionally be a manifestation of transient ischemic attacks in the AICA distribution 1

Clinical Assessment Approach

Immediate Evaluation for Acute Hearing Loss

If your patient develops new hearing loss:

• Distinguish pulsatile versus non-pulsatile tinnitus, as this fundamentally determines diagnostic approach 5, 3
• For pulsatile tinnitus: obtain temporal bone CT and CTA to evaluate vascular etiology 5, 3
• For non-pulsatile unilateral tinnitus: MRI of internal auditory canals is most appropriate to rule out retrocochlear pathology 5, 3
• Urgent brain imaging (CT or MRI) and noninvasive vascular imaging (CTA or MRA from arch to vertex) should be completed without delay for pulsatile tinnitus 5

Chronic/Subacute Assessment

For established stroke patients:

• Obtain comprehensive audiologic examination including pure-tone audiometry 5, 2
• Consider central auditory processing assessment battery, as auditory processing deficits are present in 40% of stroke patients aged 18-60 years 4
• Patients with Heschl's gyrus involvement show worse early perceptual scores on auditory testing 6
• The central auditory nervous system stroke severity index (CANS SSI) correlates negatively with early perceptual test scores 6

Management Priorities for Recurrent Stroke Prevention

Given the 70% prevalence of premorbid hypertension in stroke/TIA patients and the 30% reduction in recurrent stroke risk with BP-lowering therapies, aggressive secondary prevention is paramount 1:

• For patients with established SBP ≥140 mm Hg or DBP ≥90 mm Hg: restart/initiate antihypertensive treatment (Class I recommendation) 1
• Target BP <130/80 mm Hg (Class IIb recommendation) 1
• Use diuretics, ACE inhibitors, or ARBs as first-line agents, as these have shown specific benefit in dedicated RCTs 1
• The annual risk of recurrent stroke is approximately 4%, with case mortality of 41% after recurrent stroke versus 22% after initial stroke 1

Critical Pitfalls to Avoid

• Do not assume hearing loss is simply age-related in stroke patients—sensorineural hearing loss is significantly more severe in stroke patients even after controlling for age and cardiovascular risk factors 2
• Do not overlook simple causes like cerumen impaction before pursuing extensive workup 3
• Recognize that 86% of stroke patients have undocumented hearing impairments that significantly impact rehabilitation and quality of life 3
• Only 21% of stroke patients with hearing loss use amplification devices 3
• Undetected hearing loss may impact post-stroke functional recovery and restrict participation in rehabilitation programs 2, 7, 4

Rehabilitation Considerations

• Refer to audiology for comprehensive audiometric testing 5, 3
• Consider amplification devices (hearing aids) for documented hearing loss 5
• Implement communication strategies: face the patient when speaking, minimize background noise 3
• Regular audiologic evaluation is recommended to monitor for changes in hearing status 5
• Auditory dysfunction may predict long-term patient outcome after stroke 7