|Year : 2016 | Volume
| Issue : 2 | Page : 134-135
Musical hallucination: Silent presentation of stroke
Prerna Kukreti1, Lomesh Bhirud2
1 Department of Psychiatry, Hamdard Institute of Medical Science and Research, Jamia Hamdard, New Delhi, India
2 Department of Neurology, Institute of Human Behaviour and Allied Sciences, New Delhi, India
|Date of Web Publication||4-Nov-2016|
Department of Psychiatry, Hamdard Institute of Medical Science and Research, Jamia Hamdard, New Delhi - 110 062
Source of Support: None, Conflict of Interest: None
Temporal lobe pathologies have often been associated with psychiatric symptoms. Left temporal lobe pathologies usually present with localizing neurological signs, however, right temporal lobe pathologies often go undetected. Here, we describe a case with unique psychopathology in form of musical hallucinations as the only silent manifestation of underlying right temporal lobe stroke. Case presentation, inherent diagnostic dilemma, and innovative treatment methodology have been described.
Keywords: Musical hallucination, reciprocal inhibition paradigm, right temporal lobe stroke
|How to cite this article:|
Kukreti P, Bhirud L. Musical hallucination: Silent presentation of stroke. J Mental Health Hum Behav 2016;21:134-5
| Introduction|| |
Musical hallucinations are a unique type of complex auditory hallucinations. They have been described in various neuropsychiatric conditions ranging from obsessive compulsive disorder, schizophrenia, depression,  complex partial seizures, tumors of the brain stem, , intoxication (alcohol), drugs (antidepressants, salicylate, quinine, and aspirin),  progressive deafness,  and rarely in stroke.  We, hereby report a unique case of stroke with musical hallucination as the only presenting feature.
| Case Report|| |
A 50 years right-handed male with no past or family history of psychiatric illness was referred by an otolaryngologist in view of abrupt onset musical hallucination of 1-week duration. The patient reported hearing a line of the national anthem, usually audible from a school on the way to his office. He would hear it for variable durations, without any lateralization and was aware of it being unreal. He used to hear the song's melody as of the original song, timbre as of his own voice, unaccompanied by the sound of any background musical instrument. He experienced reduction in songs while speaking. There was no prior history of fever, seizure disorder, drug intake; motor, sensory, or hearing deficit or disturbance in gait, memory, or visual discrimination.
Physical and mental status examination, Hindi mental state examination and neuropsychological assessment did not show any abnormality. His routine hematological, biochemical investigations, thyroid profile, and urine drug screen was unremarkable. Pure tone audiometry, brain stem evoked response audiometry, and electroencephalogram was normal. The noncontrast computed tomography of head at the time of presentation was suggestive of right temporal lobe hypodensity suggestive of infarct [Figure 1]. Visual field, cerebral angiography, echocardiography, electrocardiography, and ultrasound doppler of the neck were normal.
|Figure 1: Noncontrast computed tomography images shows hypodensity in the right temporal lobe suggestive of infarct|
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The patient was started on ecosprin and atorvastatin; carbamazepine was added as prophylactic antiepileptic agent along with low dose benzodiazepine to allay anxiety due to hallucinations for a short time. He was reassured that it is benign and was advised for protection from loud noises. Since patient reported decrease in hallucinations while speaking, audiologist helped him practice masking based on "response inhibition paradigm" and was advised to hear a recorded specific small set of melody during hallucinations at a higher frequency for few seconds followed by silence. Over next 6 months, the patient reported a decrease in frequency of hallucinations.
| Discussion|| |
Wieser  conceptualized perception of music at three levels: Acoustic, cognitive, and esthetic. At the acoustic level, the sound is perceived due to excitation of sensory cells of inner ear; acoustic pathway from here projects to Brodmann area, 39 in the temporal lobe giving rise to a pattern of sound. , Acoustic projections to superior temporal gyrus are responsible for analysis of sound, tones, pitch, timbre, and rhythm which is stored as acoustic memory; giving rise to centers of interest of auditory inputs at cognitive level. At the esthetic level, one takes into account the sociocultural aspect of music governed by auditory association cortex and limbic system. , Thus, temporal lobe plays an important role in the perception of music.
Right temporal lobe stroke is often a diagnostic challenge as there are no localizing signs in most patients. Covert quadrantanopia may be the only sign in a few patients as shown by Hoffmann.  Clinical presentation in the right temporal lobe stroke is characterized by neuropsychiatric syndromes, most commonly Geschwind-Gastaut syndrome and delusional misidentification syndrome followed by visuospatial dysfunction or amusia. However, left temporal lobe stroke has more neurological signs, for example, aphasia, alexia, acalculia, agnosia, or verbal amnesia.  Musical hallucination has been described in temporal lobe pathologies, but rarely with stroke. So far, only one case has been reported with musical hallucination as the presenting feature of the right temporal lobe infarct. 
In our case, the patient had no history of cardiovascular risk factors. Abrupt onset musical hallucination was the only presentation of an underlying nondominant lobe stroke with no associated localizing sign. Furthermore, in this case, melody of the song was as original, but there was loss of background orchestral component and timbre.
The speculated hypothesis based on clinical presentation and area of insult in imaging suggests that possibly ischemic insult to temporal lobe lead to abnormal perception of pattern-segmented sound in auditory cortex. Disturbance in auditory memory stored in temporal lobe could possibly have been the reason behind a well-known song being heard as the content of hallucinations and insult to superior temporal gyrus was possibly responsible for loss of timbre. However, further functional imaging studies can only discern the exact mechanism.
| Conclusion|| |
Thus, the presence of musical hallucination should alert clinicians, not only to work up for otological causes but also to rule out central causes. There is need of further systematic studies using functional imaging in association with magnetic encephalography to discern exact physiology of such experiences. Such cases provide a window of opportunity to understand exact etiology and formulate specific intervention.
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Conflicts of interest
There are no conflicts of interest.
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