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Monoaural musical hallucinations caused by a thalamocortical auditory radiation infarct: a case report.

Woo PY, Leung LN, Cheng ST, Chan KY - J Med Case Rep (2014)

Bottom Line: Their causation can be classified as associated with either psychiatric disorders, such as schizophrenia, or organic disorders, such as epilepsy or sensorineural deafness.Our patient did not experience any psychiatric symptoms and there was no other neurological deficit.Our patient was managed expectantly and after three months her symptoms subsided spontaneously.

View Article: PubMed Central - PubMed

Affiliation: Room 318, Nursing Quarters, Department of Neurosurgery, Kwong Wah Hospital, 25 Waterloo Road, Yaumatei, Hong Kong, SAR, China. wym307@ha.org.hk.

ABSTRACT

Introduction: Musical hallucinations are complex auditory perceptions in the absence of an external acoustic stimulus and are often consistent with previous listening experience. Their causation can be classified as associated with either psychiatric disorders, such as schizophrenia, or organic disorders, such as epilepsy or sensorineural deafness. Non-epileptic musical hallucinosis due to lesions of the central auditory pathway, especially of the thalamocortical auditory radiation, is rare.

Case presentation: We describe the case of an 85-year old ethnic Chinese woman with a history of transient ischemic attacks and chronic bilateral hearing impairment, who experienced an acute onset of left unilateral musical hallucinations. Our patient did not experience any psychiatric symptoms and there was no other neurological deficit. Pure tone audiometry revealed bilateral hypacusis and magnetic resonance imaging revealed a right non-dominant hemisphere sublenticular lacunar infarct of the thalamocortical auditory radiation. Our patient was managed expectantly and after three months her symptoms subsided spontaneously.

Conclusion: We propose that all patients with monoaural musical hallucinations have brain imaging to rule out a central organic cause, especially within the non-dominant hemisphere, regardless of the presence of a hearing impairment.

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Related in: MedlinePlus

Central auditory pathway schematic and magnetic resonance imaging features of the patient’s brain. (a) Schematic of the central auditory pathway. The last subcortical station is the medial geniculate body (MGB), where there is ipsilateral projection of fibers to the primary and association auditory cortices. Extensive bilateral decussations exist from the cochlear nucleus (CN), superior olivary nucleus (SON) and inferior colliculus (IC). The majority of fibers reaching the MGB are derived from the contralateral cochlear nerve (black line with grey arrows; lateral lemniscus (LL)). An infarct of the auditory radiation and sensorineural hearing loss of the contralateral ear could cause contralateral monoaural musical hallucinosis. (b,c) T2-weighted magnetic resonance imaging (MRI) sequences showing sublenticular location of infarct (axial, white arrowhead in b; coronal, white arrow in c). (d) Restricted diffusion of the same lesion on diffusion-weighted MRI confirming infarction (black arrowhead).
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Fig1: Central auditory pathway schematic and magnetic resonance imaging features of the patient’s brain. (a) Schematic of the central auditory pathway. The last subcortical station is the medial geniculate body (MGB), where there is ipsilateral projection of fibers to the primary and association auditory cortices. Extensive bilateral decussations exist from the cochlear nucleus (CN), superior olivary nucleus (SON) and inferior colliculus (IC). The majority of fibers reaching the MGB are derived from the contralateral cochlear nerve (black line with grey arrows; lateral lemniscus (LL)). An infarct of the auditory radiation and sensorineural hearing loss of the contralateral ear could cause contralateral monoaural musical hallucinosis. (b,c) T2-weighted magnetic resonance imaging (MRI) sequences showing sublenticular location of infarct (axial, white arrowhead in b; coronal, white arrow in c). (d) Restricted diffusion of the same lesion on diffusion-weighted MRI confirming infarction (black arrowhead).

Mentions: An 85-year-old bilingual ethnic Chinese woman with chronic bilateral hearing impairment and a history of transient ischemic attacks, characterized by left hemiparesis, experienced sudden intermittent musical hallucinations for three months. The patient was prescribed aspirin due to her history of cerebral ischemia. The hallucinations were perceived exclusively by her left ear and were described as a radio broadcasting of recognizable tunes frequently played during childhood. Vocal and instrumental music were performed in both Chinese, namely in Cantonese and Putonghua dialects, and English. Our patient heard segments of three songs of distinctly different musical genres including the Cantonese opera “The Flower Princess,” a Putonghua folk song “Su Wu, the shepherd,” and an English minstrel song “My Old Kentucky Home.” Initially she was convinced that the music was playing in the room, but soon realized they did not originate from an external source. The hallucinations were intermittent, occurring when the environment was quiet, and discontinued or reduced in volume when she was engaged in conversation. Each episode lasted for five to ten minutes and was not distressing. There were no symptoms indicative of epilepsy or any psychopathology.Psychometric testing revealed our patient to have left hemispheric language dominance. She also had intact general cognition, with only subtle memory impairment as reflected by a Montreal cognitive assessment score of 23 out of 30. Pure tone audiometry confirmed bilateral hypacusis characterized by severe left sensorineural hearing loss, at a threshold of 80dB, and moderate right sensorineural deficit at 45dB. Brainstem auditory evoked potentials were undetectable on her left, but were normal on her right. Electroencephalography did not identify any epileptiform activity. Magnetic resonance imaging (MRI) showed evidence of a right sublenticular lacunar infarct and diffuse cortical atrophy (Figure 1). Our patient was ambivalent to the presence of these hallucinations and refused antipsychotic drug treatment. Aspirin was continued and bilateral hearing aids were prescribed. Three months later her hallucinosis subsided.Figure 1


Monoaural musical hallucinations caused by a thalamocortical auditory radiation infarct: a case report.

Woo PY, Leung LN, Cheng ST, Chan KY - J Med Case Rep (2014)

Central auditory pathway schematic and magnetic resonance imaging features of the patient’s brain. (a) Schematic of the central auditory pathway. The last subcortical station is the medial geniculate body (MGB), where there is ipsilateral projection of fibers to the primary and association auditory cortices. Extensive bilateral decussations exist from the cochlear nucleus (CN), superior olivary nucleus (SON) and inferior colliculus (IC). The majority of fibers reaching the MGB are derived from the contralateral cochlear nerve (black line with grey arrows; lateral lemniscus (LL)). An infarct of the auditory radiation and sensorineural hearing loss of the contralateral ear could cause contralateral monoaural musical hallucinosis. (b,c) T2-weighted magnetic resonance imaging (MRI) sequences showing sublenticular location of infarct (axial, white arrowhead in b; coronal, white arrow in c). (d) Restricted diffusion of the same lesion on diffusion-weighted MRI confirming infarction (black arrowhead).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4289290&req=5

Fig1: Central auditory pathway schematic and magnetic resonance imaging features of the patient’s brain. (a) Schematic of the central auditory pathway. The last subcortical station is the medial geniculate body (MGB), where there is ipsilateral projection of fibers to the primary and association auditory cortices. Extensive bilateral decussations exist from the cochlear nucleus (CN), superior olivary nucleus (SON) and inferior colliculus (IC). The majority of fibers reaching the MGB are derived from the contralateral cochlear nerve (black line with grey arrows; lateral lemniscus (LL)). An infarct of the auditory radiation and sensorineural hearing loss of the contralateral ear could cause contralateral monoaural musical hallucinosis. (b,c) T2-weighted magnetic resonance imaging (MRI) sequences showing sublenticular location of infarct (axial, white arrowhead in b; coronal, white arrow in c). (d) Restricted diffusion of the same lesion on diffusion-weighted MRI confirming infarction (black arrowhead).
Mentions: An 85-year-old bilingual ethnic Chinese woman with chronic bilateral hearing impairment and a history of transient ischemic attacks, characterized by left hemiparesis, experienced sudden intermittent musical hallucinations for three months. The patient was prescribed aspirin due to her history of cerebral ischemia. The hallucinations were perceived exclusively by her left ear and were described as a radio broadcasting of recognizable tunes frequently played during childhood. Vocal and instrumental music were performed in both Chinese, namely in Cantonese and Putonghua dialects, and English. Our patient heard segments of three songs of distinctly different musical genres including the Cantonese opera “The Flower Princess,” a Putonghua folk song “Su Wu, the shepherd,” and an English minstrel song “My Old Kentucky Home.” Initially she was convinced that the music was playing in the room, but soon realized they did not originate from an external source. The hallucinations were intermittent, occurring when the environment was quiet, and discontinued or reduced in volume when she was engaged in conversation. Each episode lasted for five to ten minutes and was not distressing. There were no symptoms indicative of epilepsy or any psychopathology.Psychometric testing revealed our patient to have left hemispheric language dominance. She also had intact general cognition, with only subtle memory impairment as reflected by a Montreal cognitive assessment score of 23 out of 30. Pure tone audiometry confirmed bilateral hypacusis characterized by severe left sensorineural hearing loss, at a threshold of 80dB, and moderate right sensorineural deficit at 45dB. Brainstem auditory evoked potentials were undetectable on her left, but were normal on her right. Electroencephalography did not identify any epileptiform activity. Magnetic resonance imaging (MRI) showed evidence of a right sublenticular lacunar infarct and diffuse cortical atrophy (Figure 1). Our patient was ambivalent to the presence of these hallucinations and refused antipsychotic drug treatment. Aspirin was continued and bilateral hearing aids were prescribed. Three months later her hallucinosis subsided.Figure 1

Bottom Line: Their causation can be classified as associated with either psychiatric disorders, such as schizophrenia, or organic disorders, such as epilepsy or sensorineural deafness.Our patient did not experience any psychiatric symptoms and there was no other neurological deficit.Our patient was managed expectantly and after three months her symptoms subsided spontaneously.

View Article: PubMed Central - PubMed

Affiliation: Room 318, Nursing Quarters, Department of Neurosurgery, Kwong Wah Hospital, 25 Waterloo Road, Yaumatei, Hong Kong, SAR, China. wym307@ha.org.hk.

ABSTRACT

Introduction: Musical hallucinations are complex auditory perceptions in the absence of an external acoustic stimulus and are often consistent with previous listening experience. Their causation can be classified as associated with either psychiatric disorders, such as schizophrenia, or organic disorders, such as epilepsy or sensorineural deafness. Non-epileptic musical hallucinosis due to lesions of the central auditory pathway, especially of the thalamocortical auditory radiation, is rare.

Case presentation: We describe the case of an 85-year old ethnic Chinese woman with a history of transient ischemic attacks and chronic bilateral hearing impairment, who experienced an acute onset of left unilateral musical hallucinations. Our patient did not experience any psychiatric symptoms and there was no other neurological deficit. Pure tone audiometry revealed bilateral hypacusis and magnetic resonance imaging revealed a right non-dominant hemisphere sublenticular lacunar infarct of the thalamocortical auditory radiation. Our patient was managed expectantly and after three months her symptoms subsided spontaneously.

Conclusion: We propose that all patients with monoaural musical hallucinations have brain imaging to rule out a central organic cause, especially within the non-dominant hemisphere, regardless of the presence of a hearing impairment.

Show MeSH
Related in: MedlinePlus