Two cases of left putaminal hemorrhage occurring immediately after singing Enka song at karaoke

We report two cases of hypertensivecerebral hemorrhage (CH) occurring immediatelyafter singing a song at karaoke. Patient 1 was a 71-year-old female, and Patient 2 was an 80-year-oldmale, both of whom had a long history ofhypertension but were free from antihypertensivemedication prior to the attacks. They developed righthemiparesis and dysarthria immediately aftersinging a song enthusiastically. CT demonstrated aleft putaminal hyperdense lesion, typical ofhypertensive CH, in both patients. Followingconservative treatment in the stroke unit, they weretransferred to our rehabilitation hospital under antihypertensive medication. At the time of theattack, Patient 1 sang one "Enka" song, a kind ofJapanese ballad, which needed a high tone and strongvocalization. Patient 2 also sang one Enka song,requiring a high tone and strenuous vocalization, atthe time of the attack. Although singing is consideredbeneficial for mental and physical health, hence itsuse in rehabilitation, singing songs requiring high-tone, strenuous vocalization may trigger CH inhypertensive patients, possibly due to effects similarto the Valsalva maneuver.