Role of angiography in the evaluation of patients with pulsatile tinnitus

Systematic Review of the Diagnostic Imaging Evaluation of Pulsatile Tinnitus

Objective

Aggregate published data on the imaging of pulsatile tinnitus as a step toward building a framework for an evidence-based approach to diagnostic imaging for this symptom.

Materials & Methods

A systematic review was performed. PUBMED and EMBASE were searched on December 1, 2021 for English-language articles on diagnostic imaging of pulsatile tinnitus. Articles that involved non-standard imaging techniques and those that focused on management of pulsatile tinnitus were excluded. Extracted data included: number of males and females; signs, symptoms, and physical examination findings with associated patient counts; imaging findings; count of patients with imaging-identified cause of pulsatile tinnitus; reported associated interventions and outcomes.

Results

41 articles were included with a total of 2,633 reported patients. 10 studies were prospective. MRA appears to be capable of identifying many of the same pathologies traditionally diagnosed with DSA. Few head-to-head comparisons were performed. In head-to-head comparisons of MRI and MRA, MRA was often able to identify more pathology. There was no clear relationship identified between specific symptoms and the imaging modality chosen, indicating that the imaging evaluation of pulsatile tinnitus is likely sensitive to the preferences of the evaluating provider.

Conclusion

There is limited evidence to inform best practices for the initial imaging evaluation of pulsatile tinnitus and preference-sensitive provider decisions will continue to guide the pulsatile tinnitus workup. We encourage prospective studies with multimodality imaging comparisons to build evidence that would support the development of more effective, efficient, and equitable protocols and pathways for the imaging evaluation of pulsatile tinnitus.

Imaging of Pulsatile Tinnitus

Tinnitus is a common complaint that approximately three-fourths of adults will experience at some point in their life. While for many it is a mild nuisance, for some it can be debilitating, affecting cognition and quality of life, increasing stress, and leading to anxiety, depression, and in severe circumstances even suicide. Pulsatile tinnitus refers to the perception of a heartbeat-like sound without external stimulus. Although less common than nonpulsatile tinnitus, pulsatile tinnitus raises concern for underlying disease that can have a high risk of causing the patient harm if undiagnosed, and most of these patients will have positive findings at imaging. While these findings are often subtle, identifying them can have a meaningful impact on the patient's quality of life. The literature on pulsatile tinnitus is changing rapidly with improved imaging techniques and novel minimally invasive treatment options. A careful history and physical examination together with appropriate imaging are therefore critical in identifying the underlying cause. With emerging surgical, endovascular, and supportive technologies, the vast majority of patients with bothersome pulsatile tinnitus can be cured or have their symptoms ameliorated. The objective of this narrative review is to present a comprehensive analysis of the currently available literature on pulsatile tinnitus, with a focus on understanding its pathophysiologic mechanisms, diagnostic pathways, imaging findings, and the spectrum of available management strategies and ultimately to propose a structured framework that aids radiologists as well as clinicians in identifying an underlying diagnosis and guiding management of these patients. ©RSNA, 2024 Supplemental material is available for this article.

Clinical evaluation of pulsatile tinnitus: history and physical examination techniques to predict vascular etiology

BACKGROUND

Pulsatile tinnitus (PT) may be due to a spectrum of cerebrovascular etiologies, ranging from benign venous turbulence to life threatening dural arteriovenous fistulas. A focused clinical history and physical examination provide clues to the ultimate diagnosis; however, the predictive accuracy of these features in determining PT etiology remains uncertain.

METHODS

Patients with clinical PT evaluation and DSA were included. The final etiology of PT after DSA was categorized as shunting, venous, arterial, or non-vascular. Clinical variables were compared between etiologies using multivariate logistic regression, and performance at predicting PT etiology was determined by area under the receiver operating curve (AUROC).

RESULTS

164 patients were included. On multivariate analysis, patient reported high pitch PT (relative risk (RR) 33.81; 95% CI 3.81 to 882.80) compared with exclusively low pitch PT and presence of a bruit on physical examination (9.95; 2.04 to 62.08; P=0.007) were associated with shunting PT. Hearing loss was associated with a lower risk of shunting PT (0.16; 0.03 to 0.79; P=0.029). Alleviation of PT with ipsilateral lateral neck pressure was associated with a higher risk of venous PT (5.24; 1.62 to 21.01; P=0.010). An AUROC of 0.882 was achieved for predicting the presence or absence of a shunt and 0.751 for venous PT.

CONCLUSION

In patients with PT, clinical history and physical examination can achieve high performance at detecting a shunting lesion. Potentially treatable venous etiologies may also be suggested by relief with neck compression.

Diagnostic Yield and Utility of Radiographic Imaging in the Evaluation of Pulsatile Tinnitus: A Systematic Review

Objective

The objective of this study is to assess diagnostic yield of imaging modalities used to evaluate patients presenting with pulsatile tinnitus (PT).

Databases Reviewed

PubMed, Embase, and Scopus were queried using the search terms "pulsatile tinnitus," "pulse-synchronous tinnitus," and "pulse synchronous tinnitus" with no date limitations.

Methods

Studies that reported diagnostic imaging for patients presenting with PT were included. Data were reviewed for sample size, gender, age, imaging study, indications, and diagnoses. The primary outcome measure from aggregated data was the yield of positive diagnoses made with each imaging modality. The quality of evidence was assessed for risk of bias.

Results

From an initial search of 1145 articles, 17 manuscripts met inclusion criteria, of which 12 studies evaluated individual imaging modalities. The number of unique patients included was 1232. The diagnostic yield varied between modalities: carotid ultrasound (21%, 95% confidence interval [CI]: 12%-35%), CT temporal bone (65%, CI: 20%-93%), computed tomographic angiography (86%, CI: 80%-90%), and MRI/magnetic resonance angiography (58%, CI: 43%-72%).

Conclusion

Studies on the diagnostic approach to PT are limited by heterogeneity in both inclusion criteria and reporting standards. A wide range of imaging modalities are used in practice during the initial evaluation of PT, and the diagnostic yield for imaging can be improved by utilizing more specific clinical indications.

Combined Arterial and Venous Phase Computed Tomographic Imaging of the Skull Base in Pulsatile Tinnitus

OBJECTIVE

To describe the demographic, clinical, and radiologic findings in a consecutive series of patients presenting with a chief complaint of pulsatile tinnitus (PT).

STUDY DESIGN

Retrospective review of 157 patients undergoing a combined arterial/venous phase computed tomographic (CT) imaging study.

SETTING

Tertiary referral center.

PATIENTS

Adult patients referred to neurotology faculty for evaluation of PT between 2016 and 2020.

INTERVENTIONS

Triple phase high-resolution arteriography/venography/temporal bone CT.

MAIN OUTCOME MEASURES

Prevalence of osseous, venous, and/or arterial pathology, clinicodemographic characteristics.

RESULTS

One hundred fifty-seven adults (mean age, 52 years; 79.6% female) were evaluated. A history of migraine headaches was common (19.7%). The average body mass index was 30.0 (standard deviation, 6.8), and 17.2% of subjects had a diagnosis of obstructive sleep apnea. Idiopathic intracranial hypertension was diagnosed by elevated opening pressure on lumbar puncture in 13.4%. Comorbid depression and anxiety were common (25.5% and 26.1%, respectively). Overall, abnormalities were found in 79.0% of scans, with bilateral transverse sinus stenosis (TSS) seen in 38.9% and unilateral TSS found in 20.4%. Fifteen subjects (9.6%) had evidence of osseous etiologies, including superior canal dehiscence or thinning in 8.9% and sigmoid sinus dehiscence in one subject. There were 3 dural arteriovenous fistulae identified. Unilateral PT was ipsilateral to the side of TSS in 84.4% of subjects with unilateral TSS.

CONCLUSION

In a large consecutive series of patients with PT referred for CT venography/arteriography, transverse sinus stenosis was the most common finding at 59%. Venous etiologies for PT should be suspected when patients are referred to neurotologists for evaluation.

Diagnosing Pulsatile Tinnitus: A Review of 251 Patients

OBJECTIVE

To analyze the underlying etiologies, presenting characteristics, and diagnostic workup of patients with pulsatile tinnitus (PT).

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral center.

PATIENTS

All patients who received a diagnostic workup for PT from January 01, 2015 and May 31, 2020.

MAIN OUTCOME MEASURE

Diagnostic rate of imaging studies.

RESULTS

Among 251 patients with PT, the most common etiologies included neoplasms (16%), arteriopathies (14%), venopathies (8.5%), middle/inner ear pathology (9.0%), or idiopathic (50%). Patients with identifiable etiologies of PT more often had hypertension, obesity, vision changes, ipsilateral asymmetric hearing loss, or an abnormal otologic examination. Only 18.5% of patients without those characteristics had an identifiable etiology of PT. The most commonly ordered diagnostic studies were magnetic resonance imaging with contrast (n = 146), MR angiography (MRA) (n = 105), CT angiography (CTA) (n = 84), computed tomography (CT) without contrast (n = 76), and MR Venogram (MRV) (n = 62). Magnetic resonance imaging with contrast and CT without contrast preferentially identified patients with nonvascular etiologies of PT, while MRA and CTA identified patients with vascular etiologies of PT. MRV did not demonstrate high diagnostic rate for either type of PT. No difference in diagnostic rate was found between MR-based or CT-based imaging.

CONCLUSIONS

Patients who lack a history of hypertension, obesity, vision changes, ipsilateral asymmetric hearing loss, or an abnormal otologic examination are less likely to have an identifiable cause for PT. In cases where a specific etiology was identified, MR-based imaging (MRI with contrast and MRA) or CT-based imaging (CT without contrast and CTA) were equally efficacious in identifying that etiology. MR-based imaging is preferred for neoplasms, while CT-based imaging is preferred for semicircular canal dehiscence.

Dual-phase contrast-enhanced CT evaluation of dural arteriovenous fistula in patients with pulsatile tinnitus as an initial symptom

PURPOSE

Intracranial dural arteriovenous fistula (DAVF) can cause pulsatile tinnitus (PT). The purpose of this study was to investigate the diagnostic performance of dual-phase contrast-enhanced CT (DP-CECT) for DAVF in PT patients compared with digital subtraction angiography (DSA).

METHOD

From February 2015 to April 2021, PT patients undergoing routine DSA examination were prospectively analyzed. Patients with and without DAVF diagnosed by DSA were included. In DP-CECT, the radiological signs related to DAVF were assessed as follows: asymmetric external carotid artery (ECA) branches, asymmetric enhancement of intracranial or extracranial veins, asymmetric venous collaterals in extracranial space, and shaggy tentorium or venous sinus on CTA; asymmetric enhancement of intracranial or extracranial veins on CTV; numerous transcalvarial channels and asymmetric size of foramen spinosum on high-resolution CT (HRCT).

RESULTS

253 PT patients receiving DSA were enrolled, and these patients had previously been screened by DP-CECT. Forty-six patients were diagnosed as DAVF by DSA. Therefore, the prevalence of DAVF was 18% (46/253) in patients with PT as the initial symptom. The sensitivity and specificity of DP-CECT for diagnosis of DAVF were 96% and 100%. The sensitivity of individual CTA signs ranged from 65% to 93%, and specificities ranged from 83% to 100%. The sensitivity of CTV sign was 80%, and specificity was 100%. The sensitivity of individual HRCT signs ranged from 48 to 52% and specificities from 61 to 100%.

CONCLUSIONS

DAVF is not rare in patients with PT as the initial symptom. DP-CECT can be used for screening DAVF in patients with PT.

Prevalence of Tinnitus in Patients Diagnosed with Cerebral Arteriovenous Fistula Treated with Endovascular Technique

Introduction  Tinnitus is characterized as the conscious and involuntary perception of sound, and it affects ∼ 30% of the population. Despite careful physical examination, the etiology of tinnitus can be established for only 30% of patients. Tinnitus is a common symptom of cerebral arteriovenous fistulas and results from increased blood flow through the dural venous sinuses, leading to turbulent arterial flow, mainly related to sigmoid and transverse sinus lesions.

Objectives  To analyze the frequency of tinnitus, patient profile, and endovascular treatment characteristics in individuals diagnosed with cerebral arteriovenous fistulas.

Methods  A retrospective and observational study based on reviewed data from medical records on the PHILIPS Tasy system (Philips Healthcare, Cambridge, MA, USA) at the neurosurgery and interventional neuroradiology service of Hospital Santa Isabel in Blumenau–state of Santa Catarina, Brazil.

Results  The profile of 68 individuals diagnosed with cerebral arteriovenous fistula who underwent endovascular treatment were analyzed. Most patients were female, aged 31 to 60. Tinnitus affected 18 individuals. Dural fistulas were the most prevalent in the sample, and computed tomography alone was the most used diagnostic method for initial investigation.

Conclusion  The prevalence of this symptom in patients diagnosed with cerebral arteriovenous fistula was found in 26.5% of this sample, mainly in women with associated comorbidities. Tinnitus remission was observed in all patients who underwent endovascular treatment to correct cerebral fistula.

The role of noninvasive imaging in the diagnostic workup for pulsatile tinnitus

OBJECTIVE

We sought to assess the diagnostic yield of advanced noninvasive imaging in the evaluation of patients with pulsatile tinnitus.

BACKGROUND

Pulsatile tinnitus can be caused by high-risk cerebrovascular pathologies such as arteriovenous fistulae. The role of advanced noninvasive imaging, including magnetic resonance angiography and magnetic resonance venography, in the diagnostic evaluation of pulsatile tinnitus is not well defined.

DESIGN AND METHODS

We performed a retrospective cohort study of patients presenting for outpatient diagnostic evaluation of pulsatile tinnitus from January 2018 to March 2020 at Weill Cornell Medicine. Patients with non-pulsatile tinnitus and established etiologic diagnoses were excluded. Systematic chart abstraction was summarized using standard descriptive statistics. Univariate logistic regression was used to identify factors associated with nondiagnostic noninvasive imaging.

RESULTS

A total of 187 patients (139 (74.3%) women) took part in this study, with a mean age of 48.6 years (standard deviation (SD) = 15.5 years) and a mean body mass index (BMI) of 26.9 kg/m² (SD = 6.1 kg/m²). Of the 187 patients, 121 (64.7%) underwent exclusively noninvasive imaging, and 66 (35.3%) patients also had digital subtraction angiography (DSA). In patients who had exclusively noninvasive imaging, 62 (51.2%) patients received a diagnosis. In patients who underwent noninvasive and DSA imaging, 14 (21.2%) patients received a diagnosis based on DSA. Patients who were older at symptom onset (odds ratio (OR) = 1.05; 95% confidence interval (CI) 1.01-1.09) and those with a lower BMI (OR = 0.88, 95% CI 0.77-0.98) were more likely to have nondiagnostic noninvasive imaging.

CONCLUSION

Noninvasive cerebrovascular imaging often uncovers the etiology of pulsatile tinnitus. DSA remains useful for additional evaluation for patients with specific associated features.

State of the Art: Venous Causes of Pulsatile Tinnitus and Diagnostic Considerations Guiding Endovascular Therapy

Venous variants and pathologic abnormalities are the most common causes of pulsatile tinnitus. These conditions include causes of turbulence within normally located veins and sinuses, and abnormally enlarged or abnormally located veins in close transmissive proximity to the conductive auditory pathway. Such disorders include pathologic abnormalities of the lateral sinus (transverse sinus stenosis and sigmoid sinus wall anomalies), abnormalities and variants of the emissary veins, and anomalies of the jugular bulb and jugular vein. Despite being the most common causes for pulsatile tinnitus, venous variants and pathologic abnormalities are often overlooked in the workup of pulsatile tinnitus. Such oversights can result in delayed patient care and prolonged patient discomfort. Advances in both cerebrovascular imaging and endovascular techniques allow for improved diagnostic accuracy and an increasing range of endovascular therapeutic options to address pulsatile tinnitus. This review illustrates the venous causes of pulsatile tinnitus and demonstrates the associated endovascular treatment. © RSNA, 2021.

Hemorrhagic Cerebrovascular Pathology in the Pediatric Population

Hemorrhagic cerebrovascular disease in the pediatric population can have devastating and long-term effects. Progress in the fields of genetics, neuroimaging, pharmacology, and surgical techniques has led to improved diagnosis and management of pediatric cerebrovascular diseases. In this review we discuss the current etiologies and medical and surgical treatments of hemorrhagic cerebrovascular pathology affecting infants and children. A special emphasis is placed on neuroendovascular treatment options. Increased knowledge about this unique pathology and the medical and therapeutic options will empower practitioners to more quickly and accurately identify and accurately treat hemorrhagic diseases in the pediatric population.

Vertebro-vertebral fistula presenting as a pulsatile tinnitus

Tinnitus is the perception of sound in the absence of a corresponding external acoustic stimulus, resulting in an estimated prevalence of 10% to 15% in adults. Tinnitus may be classified as pulsatile (PT) or continuous (non-PT), and may be subjective (heard only by the patient) or objective (also audible to the examiner). PT is usually related to vascular causes and is pulse synchronous (coinciding with the patient's heartbeat). PT is much less common affecting approximately 4% of patients with tinnitus, but unlike non-PT, usually has a specific identifiable cause. We present a case of a man without previous otological disease or head trauma, with a left-ear subjective PT. MR angiography detected a left vertebro-vertebral arteriovenous fistula, which was treated by endovascular embolisation with important symptomatic relief.

Radiologic features of vascular pulsatile tinnitus - suggestion of optimal diagnostic image workup modalities

OBJECTIVES

The aim of this study was to determine the optimal diagnostic workup modalities for vascular pulsatile tinnitus through analysis of clinical and radiologic findings.

MATERIALS AND METHODS

A total of 49 patients diagnosed with vascular pulsatile tinnitus along with their medical records and radiologic findings were thoroughly reviewed.

RESULTS

Of these patients, 84% had venous lesions. The jugular bulb variants (67%) were the most common venous lesions followed by sigmoid sinus variants (12%). About 88% (43/49) of these lesions were detected with computed tomography of the temporal bone (TBCT) alone and the lesions were either venous or intratemporal artery in origin. Simple manual neck compression test was 93% sensitive in predicting venous lesions. A high suspicion for venous lesion coupled with manual neck compression test and selection of the optimal imaging technique are useful for the proper evaluation of vascular pulsatile tinnitus at the initial visit.

CONCLUSION

Our stepwise strategy may increase the cost-effectiveness of the chosen imaging workup by reducing redundancy of multiple and simultaneous radiologic tests in patients with vascular pulsatile tinnitus.

Diagnostic performance of CT and MRI on the detection of symptomatic intracranial dural arteriovenous fistula: a meta-analysis with indirect comparison

INTRODUCTION

This study aims to review the diagnostic performance of computed tomography (CT) and magnetic resonance imaging (MRI) in symptomatic dural arteriovenous fistula (DAVF).

METHODS

EMBASE, PubMed, and Cochrane Library were searched until April 2015 for studies which compared CT, MRI, or both with angiography for the detection of DAVF. The diagnostic performances of MRI and CT were indirectly compared using modality as a covariate in the analysis.

RESULTS

Thirteen studies met our inclusion criteria. MRI had a sensitivity of 0.90 (95 % confidence interval (CI) = 0.83-0.94) and specificity of 0.94 (95 % CI = 0.90-0.96). CT had a sensitivity of 0.80 (95 % CI = 0.62-0.90) and specificity of 0.87 (95 % CI = 0.74-0.94). MRI showed better diagnostic performance than CT (p = 0.02). Contrast medium use and time-resolved MR angiography did not improve MRI diagnostic performance (p = 0.31 and 0.44, respectively).

CONCLUSION

Both CT and MRI had good diagnostic performance. MRI was better than CT on the detection of symptomatic intracranial dural arteriovenous fistula in the indirect comparison.

Degree of sigmoid sinus compression and the symptom relief using magnetic resonance angiography in venous pulsating tinnitus

OBJECTIVES

To show that mechanical compression of sigmoid sinus is effective for treatment of pulsatile tinnitus caused by sigmoid sinus enlargement, and to evaluate the relationship between the compression degree of sigmoid sinus and the tinnitus symptom relief using magnetic resonance angiography.

METHODS

Medical records of twenty-four patients who were diagnosed with venous tinnitus caused by sigmoid sinus enlargement and underwent mechanical compression of sigmoid sinus were reviewed between April 2009 and May 2013. All these patients received computed tomography and magnetic resonance venography study before undergoing surgery and were followed for at least 4 months.

RESULTS

Twenty-three patients felt relief from tinnitus three months after the surgery, and the cross-sectional area of the sigmoid sinus on the tinnitus side was compressed approximately by half (46%-69%) after the surgery. There were 4 patients whose tinnitus suddenly disappeared while lying on the operating table before operation, which may be a result of the patient's emotional tension or postural changes from standing. One of the four patients felt no relief from tinnitus after the surgery, with the cross-sectional area of the sigmoid sinus only compressed by 30%. And two patients of them had a recurrence of tinnitus about 6 months after the surgery. Seven patients had sigmoid sinus diverticula, and tinnitus would not disappear merely by eliminating the diverticulum until by compressing the sigmoid sinus to certain degree. There were 3 minor complications, including aural fullness, head fullness and hyperacusis. The preoperative low frequency conductive and sensorineural hearing loss of 7 subjects subsided.

CONCLUSION

Mechanical compression of sigmoid sinus is an effective treatment for pulsatile tinnitus caused by sigmoid sinus enlargement, even if it might be accompanied by sigmoid sinus diverticulum. A compression degree of sigmoid sinus about 54% is adequate for the relief of tinnitus symptom. Cases in which patients' tinnitus suddenly disappeared before the surgery might be excluded to improve the efficacy of surgery.

CT arteriography and venography in the evaluation of Pulsatile tinnitus with normal otoscopic examination

OBJECTIVES/HYPOTHESIS

Our retrospective study aims to assess the ability of computed tomography arteriography and venography (CT A/V) to detect various findings that suggest a potential cause of pulsatile tinnitus and to examine the association between these findings and the side of pulsatile tinnitus.

STUDY DESIGN

A retrospective review of CT arteriography and venography of 32 patients with established pulsatile tinnitus and normal otoscopic examination was performed. The scans were performed using a 64-slice multidetector scanner and were reviewed to look for findings that are known to cause pulsatile tinnitus.

RESULTS

One or more findings that are known to cause pulsatile tinnitus were detected on the symptomatic side in 30 patients; on the asymptomatic side in 3 patients, one patient with bilateral pulsatile tinnitus showed a potential cause of symptoms only on one side, and in one patient no potential cause could be identified. There is a significant association seen between the side of pulsatile tinnitus and various potential causes of pulsatile tinnitus detected (P < 0.001), between the side of pulsatile tinnitus and various potential venous cause detected (P < 0.001), and between the side of pulsatile tinnitus and the side of dominant venous system (P = 0.02).

CONCLUSION

CT arteriography and venography is a useful tool in detecting many described potential causes of pulsatile tinnitus. Significant association is demonstrated between the side of pulsatile tinnitus and the potential causes of pulsatile tinnitus detected by CT arteriography and venography when the otoscopic examination is normal.

Diagnostic utility of magnetic resonance imaging and magnetic resonance angiography in the radiological evaluation of pulsatile tinnitus

AIM

Our aim was to assess the diagnostic utility of magnetic resonance imaging with complimentary magnetic resonance angiography (MRI/MRA) in the radiological evaluation of patients with pulsatile tinnitus (PT).

MATERIALS AND METHODS

The present study was retrospectively conducted on 27 patients with pulsatile tinnitus. All patients showed normal otoscopic findings and were evaluated with magnetic resonance imaging (MRI) with complimentary magnetic resonance angiography (MRA), 9/27 (33.3%) patients were investigated by CT, and 12/27 (44.4%) were evaluated by angiography. All patients' clinical investigation was reviewed to discard systemic causes of PT.

RESULTS

All hard copies of MRI/MRA studies were evaluated. MRI/MRA detected the underlying etiology of subjective pulsatile tinnitus (PT) in 11/27 patients (40.7%), and 16/27 patients (59.5%) showed normal MRI/MRA examination. The most common cause was dural arteriovenous malformation (AFM) in 4/27 (14.8%) patients, high jugular bulbus in 2/27 (7.4%), aneurysm of internal carotid artery in 1/27 (3.7%), aberrant internal carotid artery in 1/27 (3.7%), vertebral artery hypoplasia in 2/27 (7.4%), and glomus tumor in 1/27 (3.7%). The statistical results of the present study showed that MRI/MRA had the following: 80% sensitivity, 88% specificity, 86% accuracy, 85% PPV, 83% NPV, and 15% error percentage for diagnosis of PT.

CONCLUSION

MRI/MRA was an effective radiological imaging method in detecting the underlying pathology of pulsatile tinnitus. Magnetic resonance may be considered a first line diagnostic imaging modality in the assessment of subjective pulsatile tinnitus.

Local anaesthetic surgical treatment of severe objective pulsatile tinnitus: a useful technique

Objective pulsatile tinnitus is a rare condition with an often dramatic presentation. We present the case of a 70-year-old woman who presented with over two years' history of unilateral distressing objective pulsatile tinnitus. Carotid arteriography revealed a highly tortuous internal carotid artery. Computed tomography of the ipsilateral temporal bones showed a large jugular bulb. Internal jugular vein ligation under local anaesthetic yielded immediate resolution of her symptoms.

CT angiography as a screening tool for dural arteriovenous fistula in patients with pulsatile tinnitus: feasibility and test characteristics

BACKGROUND AND PURPOSE

The diagnosis of intracranial DAVF with noninvasive cross-sectional imaging such as CTA is challenging. We sought to determine the sensitivity and specificity of CTA compared with cerebral angiography for DAVF in patients presenting with PT.

MATERIALS AND METHODS

Following approval of the institutional review board, we reviewed all patients who underwent CTA for PT from 2004 to 2009 and collected clinical and imaging data. Seven patients with PT and proved DAVF and 7 age- and sex-matched control patients with PT but no DAVF composed the study group. CTA images were blindly interpreted by 2 experienced neuroradiologists for the presence of 5 variables: asymmetric arterial feeding vessels, "shaggy" appearance of a dural venous sinus, transcalvarial venous channels, asymmetric venous collaterals, and abnormal size and number of cortical veins. Asymmetric attenuation of jugular veins was additionally assessed.

RESULTS

The presence of arterial feeders showed good test characteristics for screening, with a sensitivity of 86% (95% CI, 42-99) and a specificity of 100% (95% CI, 52-100). A shaggy sinus or tentorium was highly specific: sensitivity of 42% (95% CI, 11-79) and specificity of 100% (95% CI, 56-100). The presence of transcalvarial venous channels demonstrated a poor sensitivity of 29% (95% CI, 5-70) but a high specificity 86% (95% CI, 42-99). CT attenuation of the jugular veins showed statistically significant asymmetry in the DAVF group versus the control group (P < .05).

CONCLUSIONS

CTA can be used to screen for DAVF in patients with PT. The presence of asymmetrically visible and enlarged arterial feeding vessels has a high sensitivity and specificity for the diagnosis of DAVF.

Simple technique for intraoperative angiographic localization of small vascular lesions

BACKGROUND

Precise surgical localization of small arteriovenous malformations (AVMs), arteriovenous fistulae (AVFs), and aneurysms located in the distal portions of the intracranial arteries can be difficult.

OBJECTIVE

We describe a simple and accurate intraoperative angiographic localization technique for small AVMs, AVFs, and distal aneurysms.

METHODS

All patients had routine preoperative diagnostic imaging and evaluations, including catheter angiography. Once anesthetized, the patients were prepared for intraoperative angiography following cannulation of the femoral artery. Craniometric landmarks were utilized to approximately localize the lesion. A wire in the shape of a square was placed over the proposed craniotomy site and an angiogram was performed. With use of real-time angiography, the wire localizer was manipulated until the small vascular lesion was visualized entirely within the wire frame, thus defining the extent of the required craniotomy and the surgical trajectory.

RESULTS

The wire localizer was used to target small vascular lesions in 9 cases of AVMs, 4 cases of distal middle cerebral artery aneurysms, and 1 case of a diploic AVF. In all 14 cases, the lesion was accurately localized intraoperatively without further image-guided techniques, and there was no change in the craniotomy. There were no intraoperative complications, and all patients had uneventful recoveries.

CONCLUSION

Intraoperative angiography with a simple wire localizer can effectively and accurately aid in the planning of surgery for a range of small and distal vascular lesions with virtually no added cost, minimal setup time, and limited potential for technical errors.

A compartment-based approach for the imaging evaluation of tinnitus

Tinnitus affects 10% of the US general population and is a common indication for imaging studies. We describe a sequential compartment-based diagnostic approach, which simplifies the interpretation of imaging studies in patients with tinnitus. The choice of the initial imaging technique depends on the type of tinnitus, associated symptoms, and examination findings. Familiarity with the pathophysiologic mechanisms of tinnitus and the imaging findings is a prerequisite for a tailored diagnostic approach by the radiologist.

Pulsatile tinnitus: a harbinger of a greater ill?

BACKGROUND

Pulsatile tinnitus is an uncommon otologic symptom, which may be the presenting complaint of a potentially devastating pathology. Understanding this manifestation as a possible symptom of a significant vascular abnormality is crucial to guide management and treatment.

METHODS AND RESULTS

We describe a 38-year-old woman with sudden-onset right-sided pulsatile tinnitus. A right extracranial internal carotid artery (ICA) dissection was diagnosed with MRI/magnetic resonance angiography (MRA) and treated with anticoagulation. Follow-up MRI/MRA demonstrated complete resolution. Two months later, left-sided pulsatile tinnitus evolved. An MRI/MRA of the neck demonstrated left-sided extracranial ICA dissection. She was treated in a similar fashion and a repeat MRI/MRA demonstrated its resolution.

CONCLUSION

Spontaneous extracranial ICA dissection may present with pulsatile tinnitus as the only symptom in 4% to 50% of patients. Subsequent evolution of a contralateral dissection is even more uncommon. Generally, treatment of this phenomenon is conservative utilizing anticoagulation or aspirin; however, surgical intervention may be necessary.

Imaging in pulsatile tinnitus

Tinnitus may be continuous or pulsatile. Vascular lesions are the most frequent radiologically demonstrable cause of pulsatile tinnitus. These include congenital vascular anomalies (which may be arterial or venous), vascular tumours, and a variety of acquired vasculopathies. The choice of imaging depends on the clinical findings. If a mass is present at otoscopy, thin-section computed tomography (CT) is indicated. In the otoscopically normal patient, there is a range of possible imaging approaches. However, combined CT angiography and venography is particularly useful.

Quantitative analysis of white matter on DTI images of patients with tinnitus: preliminary report

Tinnitus is defined as an unwanted auditory perception of internal origin, usually localized, and rarely heard by others. Persisting appearances of tinnitus are most commonly combined with diseases or damage in the inner ear or neuro-auditory pathway. Diffusion tensor magnetic resonance imaging (DTI) is a new imaging method with the capability of providing non-invasive information on tissue microstructure not available in routine clinical MRI images. Since white matter regions of the brain are an ordered structure due to the myelination and directionality of axons and have a high degree of anisotropy, the ability to detect changes in anisotropy can be extremely useful in the study of diseases such as tinnitus and multiple sclerosis, which are assumed to involve the demyelination of axons. While several studies investigated tinnitus using MRI, few studies tried to analyze neurological disorders quantitatively using DTI. In this study, the cerebral volume of white matter on DTI images of patients with tinnitus was measured using the semi-automated and intuitive menu based image processing tool (Human Analyzer, ETRI, Korea). Total number of ten patients with tinnitus including three women was examined.

Post-traumatic pulsatile tinnitus: the hallmark of a direct carotico-cavernous fistula

Following trauma to her right frontal region, a 68-year-old woman suffered bilateral, benign, paroxysmal, positional vertigo and a left-sided, longitudinal petrosal bone fracture, with secondary facial palsy and ossicular luxation. From the onset, the patient complained of pulsatile, left-sided tinnitus. After eight weeks, she developed left-sided ocular symptoms, progressing from conjunctival hyperaemia and orbital oedema to an abducens nerve palsy, and ultimately to heart failure.

The case and the final diagnosis of carotico-cavernous fistula are discussed. Guidelines are proposed for a diagnostic approach to pulsatile tinnitus and for the optimal management of patients presenting with pulsatile tinnitus associated with ocular symptoms.

The radiologic evaluation of tinnitus

Tinnitus ("ringing in the ears") is a prevalent symptom in the general population, and often brings patients to medical attention. Many causes of tinnitus are evident radiographically. The most frequently-encountered causes of tinnitus are discussed, and imaging recommendations are provided.

Tinnitus

Tinnitus is a common otologic symptom secondary to numerous etiologies, such as noise exposure, otitis, Meniere's disease, otosclerosis, trauma, medications, and presbycusis. A thorough evaluation is necessary to rule out less common causes, which may include acoustic neuromas, glomus tumors, atherosclerosis of the carotid arteries, arteriovenous fistulae (AVFs), arteriovenous fistulae malformations (AVMs), and intracranial hypertension. Treating physicians need to have a very compassionate attitude towards these patients, and statements such as "there is nothing that can be done" are very inappropriate and should be strongly condemned. Reassurance, hearing aids, masking devices, retraining methods, antidepressants, intratympanic medications, and management of underlying pathologies such as carotid artery atherosclerosis, skull base tumors, intracranial hypertension, and AVMs/AVFs provide relief for the majority of these patients.

Pulsatile and nonpulsatile tinnitus: a systemic approach

Tinnitus is an annoying symptom that affects approximately 10% of the population. Unfortunately, in more than 60% of patients, even an extensive workup may not lead to diagnosis, partly because of the diverse causes of the symptom. The imaging protocol study should therefore be adapted to the history of the patient, and each imaging study should underline which etiologies it may exclude. Imaging studies should only be performed after a careful clinical examination and otoscopy. Some characteristic clinical findings are suggestive of such etiologies as pulsed synchronous tinnitus or positional tinnitus, varying with the venous pressure. History of associated neurological deficits, nerve palsies, trauma, ischemic attacks, and visual disturbance (in overweight women) may modify the imaging protocol. Study of the brain and the cervical vessels should always be included to rule out a benign intracranial hypertension. Path and size of the internal carotid artery should be systematically described with regard to the size of the jugular vein and presence of emissary veins. Objective pulsatile tinnitus and tinnitus in children always need a careful imaging study.