Ears Ringing: Stroke Warning Sign?

Strokes are medical emergencies that occur when the brain's blood supply is interrupted. The two main types of strokes are ischemic strokes, which are caused by an obstruction in the brain's blood flow, and hemorrhagic strokes, which occur when blood leaks out of a ruptured artery and damages brain cells. While tinnitus itself is not life-threatening, recent research has suggested a potential link between strokes and tinnitus, a persistent ringing or buzzing in the ears. This article will explore the signs and symptoms of a stroke, the connection between tinnitus and strokes, and the importance of seeking immediate medical attention.

Tinnitus as a symptom of stroke

Tinnitus, a ringing, swishing, or whooshing sound in the ears, can be a symptom of a stroke. A stroke occurs when a blood vessel supplying blood to the brain is blocked or obstructed, usually by a blood clot or fatty deposit. When this happens, the brain's blood and oxygen supply is disrupted, potentially causing damage to the brain cells and nerves.

Tinnitus can occur when a stroke impacts areas of the brain responsible for auditory processing, such as the temporal lobe or brainstem. Post-stroke tinnitus may involve complex auditory sensations, including ringing, buzzing, whooshing, or even phantom sounds. It may be intermittent or constant.

Tinnitus is a potential indicator of neurological complications and should not be dismissed as a simple ear-related issue. If you experience tinnitus alongside other stroke symptoms, such as dizziness, vision problems, or difficulty speaking, it is crucial to seek immediate medical attention. Early detection and treatment are vital to prevent further damage caused by a stroke.

Tinnitus itself has no cure, but several treatments can help manage the symptoms, especially when linked to neurological conditions like stroke. These treatments include sound therapy, cognitive behavioural therapy, and hearing aids with tinnitus-masking features.

A study in Taiwan found that tinnitus was significantly associated with a higher risk of ischemic cerebrovascular disease (ICVD) in young and middle-aged adults, particularly those under 40. Tinnitus could be a novel risk factor or clinical indicator for young ischemic stroke, warranting further investigation.

The different types of strokes

Strokes are categorised into two main types: ischemic strokes and hemorrhagic strokes.

Ischemic Strokes

Ischemic strokes are the most common type of stroke, accounting for about 85-87% of all stroke cases in the US. They occur when a blood vessel supplying blood to the brain is blocked or obstructed by a blood clot, a fatty deposit, or a mix of the two. This blockage causes brain cells to stop working and can lead to serious damage, disability, or death. Symptoms of an ischemic stroke include:

• Weakness or numbness of the face, arms, or legs, especially on one side of the body.
• Confusion or difficulty speaking or understanding.
• Problems with vision, such as blurred or double vision.
• Dizziness or problems with balance or coordination, including difficulty walking.
• Loss of consciousness or seizures.
• Severe headaches with no other known cause, especially if of sudden onset.

Ischemic strokes are further divided into two groups:

• Thrombotic strokes: caused by a blood clot that develops in the blood vessels inside the brain, often in older persons with high cholesterol, atherosclerosis, or diabetes.
• Embolic strokes: caused by a blood clot or plaque debris that develops elsewhere in the body and then travels to one of the blood vessels in the brain through the bloodstream. Embolic strokes often result from heart disease or heart surgery and occur rapidly without warning signs.

Hemorrhagic Strokes

Hemorrhagic strokes account for about 13% of all strokes and occur when a weakened blood vessel supplying blood to the brain ruptures and bleeds. This can lead to brain cell damage and death due to the interruption of oxygen and nutrient supply, as well as increased pressure and irritation in surrounding tissues. The two types of weakened blood vessels that usually cause hemorrhagic strokes are aneurysms and arteriovenous malformations (AVMs). Hemorrhagic strokes are divided into two main categories:

• Intracerebral hemorrhage: Bleeding occurs from the blood vessels within the brain, usually caused by high blood pressure.
• Subarachnoid hemorrhage: Bleeding occurs in the subarachnoid space between the brain and the membranes that cover it. This type of hemorrhage is often due to an aneurysm or AVM and can also be caused by trauma.

Transient Ischemic Attack (TIA)

Transient ischemic attacks (TIAs) are often called "mini strokes" and can be warning signs of a future ischemic stroke. They resemble ischemic strokes but last only a short time, usually a few minutes, and may not cause permanent damage. However, it is crucial to seek immediate medical attention if you experience a TIA.

Vascular abnormalities and their link to tinnitus and stroke

Tinnitus, a persistent ringing or buzzing in the ears, can be linked to vascular abnormalities and, in some cases, may be a warning sign of an impending stroke. While the exact mechanisms underlying this association are not yet fully understood, several studies have established a connection between vascular abnormalities, tinnitus, and an increased risk of stroke.

Pulsatile Tinnitus and Vascular Abnormalities

Pulsatile tinnitus, characterised by whooshing or thumping sounds synchronised with an individual's heartbeat, has been linked to vascular abnormalities. This type of tinnitus is believed to be caused by turbulent blood flow in the veins or arteries, which can result in abnormal sound perception.

Vascular abnormalities associated with pulsatile tinnitus include:

• Venous stenosis: Narrowing of the transverse or sigmoid sinus veins, often due to chronic thrombosis or arachnoid granulations, can cause altered hemodynamics and turbulence, leading to pulsatile tinnitus.
• Sigmoid sinus wall abnormalities: Diverticula or thinning of the sigmoid sinus wall can lead to turbulent flow and pulsatile tinnitus.
• Emissary vein anomalies: Turbulent flow through emissary veins, such as the posterior condylar vein, mastoid emissary vein, or petrosquamosal vein, can cause pulsatile tinnitus, especially in the presence of intracranial venous obstruction or arteriovenous shunts.
• Jugular vein anomalies: A high-riding jugular bulb or jugular dehiscence/diverticulum can result in turbulent flow near the cochlea and mastoid air cells, leading to venous pulsatile tinnitus.

Vascular Abnormalities and Stroke Risk

Vascular abnormalities, particularly those affecting the cerebral vasculature, have been implicated in the development of strokes. While the specific pathophysiological mechanisms remain to be fully elucidated, several factors are believed to contribute to the association between vascular abnormalities and stroke risk:

• Arterial stiffness: Increased stiffness of arteries, such as the common carotid artery, can lead to impaired cochlear microcirculation and has been linked to both tinnitus and an increased incidence of stroke.
• Hypoxia: Conditions that affect oxygen supply to the cochlea, such as vascular abnormalities, can result in hypoxia and contribute to tinnitus and, potentially, stroke.
• Oxidative stress: Oxidative stress has been implicated in the development of both tinnitus and stroke.
• Neural inflammation: Inflammatory processes in the brain and cochlea have been associated with both tinnitus and stroke.
• Sleep disturbances: Poor sleep quality is a known risk factor for stroke and has also been linked to tinnitus.
• Sympathetic activity: Increased sympathetic nervous system activity has been implicated in both tinnitus and stroke.

Tinnitus as a Potential Warning Sign of Stroke

While the presence of tinnitus alone does not necessarily indicate an impending stroke, it can be one of the initial symptoms of a stroke. In some cases, tinnitus may be an early warning sign of a vascular abnormality that increases the risk of stroke. Therefore, it is crucial to recognise tinnitus as a potential indicator of an underlying vascular issue and to seek appropriate medical evaluation and treatment.

Vascular abnormalities, particularly those affecting cerebral blood flow, have been linked to both tinnitus and an increased risk of stroke. While the exact mechanisms underlying this association are still being elucidated, the available evidence suggests a complex interplay of physiological factors. Recognising the potential link between vascular abnormalities, tinnitus, and stroke can help individuals and healthcare professionals identify warning signs and initiate timely interventions to improve patient outcomes.

Risk factors for stroke

While anyone can have a stroke at any age, certain factors can increase the chances of having one. Some of these risk factors can be changed or managed, while others cannot.

Risk factors that can be changed, treated, or medically managed:

• High blood pressure
• Heart disease
• Diabetes
• Smoking
• High red blood cell count
• High blood cholesterol and lipids
• Excessive alcohol use
• Illegal drug use
• Abnormal heart rhythm
• Cardiac structural abnormalities

Risk factors that cannot be changed:

• Older age
• Race
• Gender
• History of prior stroke
• Heredity or genetics
• Where you live
• Temperature, season, and climate
• Social and economic factors

The importance of early treatment for strokes

Strokes, or "brain attacks", occur when something blocks blood supply to the brain or when a blood vessel in the brain bursts. The brain relies on a constant supply of blood to provide it with oxygen and nutrients and to carry away carbon dioxide. When this supply is interrupted or blocked, brain cells can quickly stop working and even die, leading to serious brain damage or even death.

In the case of an ischemic stroke, which is the most common type, occurring when blood vessels to the brain become blocked or obstructed, the aim of treatment is to restore blood flow as quickly as possible to the affected area of the brain. If the patient gets to the hospital within 3 hours of the first symptoms of an ischemic stroke, they may be given a thrombolytic (a "clot-busting" drug) to break up blood clots. Tissue plasminogen activator (tPA) is a thrombolytic that improves the chances of recovering from a stroke. Studies show that patients with ischemic strokes who receive tPA are more likely to recover fully or have less disability than patients who do not receive the drug. Patients treated with tPA are also less likely to need long-term care in a nursing home.

Recognising the signs and symptoms of a stroke and seeking immediate medical attention is essential to prevent stroke-related disability or death. The acronym FAST can be useful for remembering the signs and symptoms of an ischemic stroke:

• Face: Weakness or drooping of the face, usually limited to or more pronounced on one side.
• Arm: Numbness, weakness or strange sensations in one or both arms.
• Speech: Difficulty speaking or slurred speech, mumbling or not being able to speak at all.
• Time to call the emergency services: The sooner an ambulance is called, the better the chances of a successful recovery.

In addition to FAST, other less common symptoms of a stroke may include leg weakness, trouble seeing, weakness or numbness on one side of the body, difficulty walking or getting up, dropping to the floor, sudden tinnitus, soreness in the neck or face, confusion, sudden sleepiness, difficulty waking up, and sudden urinary incontinence.

If you or someone you know is showing signs of a stroke, call emergency services right away.

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