Role of Angiography in the Evaluation of Patients With Pulsatile Tinnitus

Abstract

Objectives/Hypothesis: Pulsatile tinnitus in the face of normal findings on otoscopy is a common otological diagnostic dilemma and can be due to serious vascular malformations such as transverse or sigmoid sinus dural arteriovenous fistula (transverse or sigmoid sinus [TS] DAVF). Left untreated, TS DAVF may result in significant morbidity and mortality. TS DAVF can be suspected or diagnosed with computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA), with the gold standard being angiography. Our objective was to assess the utility of these various diagnostic modalities in the diagnosis of dural arteriovenous fistula. Study Design: Retrospective clinical review. Methods: Between 1986 and 1996, 54 patients were evaluated and treated for TS DAVF. Between 1996 and 1999, an additional 33 patients underwent MRI combined with MRA for the evaluation of pulsatile tinnitus. A retrospective review of the medical records for both groups, with special attention to clinical presentation, diagnostic evaluation, therapy, and outcome, was performed. Results: All patients had pulsatile tinnitus with normal findings on otoscopy. CT scan was relatively insensitive in the detection of TS DAVF. MRI and MRI/MRA were significantly more sensitive than CT. In the evaluation of patients with subjective pulsatile tinnitus, MRI/MRA defined anatomical abnormalities that may contribute to pulsatile tinnitus in 63% of patients. Conclusions: In the absence of objective pulsatile tinnitus, MRI/MRA is an appropriate initial diagnostic step. When a patient has an objective bruit, the clinician may choose to proceed directly to angiography to make certain that a TS DAVF is not missed.

CT Angiography as a Screening Tool for Dural Arteriovenous Fistula in Patients with Pulsatile Tinnitus: Feasibility and Test Characteristics

“…Moreover, the literature has many statements such as "if DAVF is likely, then catheter-angiography is warranted," 16 which presume some clinical symptom or sign unique to this diagnosis. The otology literature has described this dilemma, 18 with some advocating liberal use of angiography, while others advance MR imaging and CT-based approaches. 4,6 Clinical evaluation clarifies the presence of subjective "whooshing" 3. A, Coronal 3-mm-slab MIP from CTA in patient 3 with a right transverse sinus DAVF, predominantly supplied by right occipital, middle meningeal, and marginal tentorial branches; some supply from the left internal carotid is also seen, as described below.…”

“…18 The risk of neuroangiography is not negligible, however, and access to experienced neuroangiographers remains limited. 24 CT and CTA, on the other hand, are efficient, well-tolerated, widely available, and low risk if performed by using appropriate parameters.…”

The radiologic evaluation of tinnitus

“…Thus, contrast-enhanced magnetic resonance (MR) is the modality of choice [14]. This examination is often supplemented with MR arteriography (MRA) and MR venography (MRV) [15]. Although vascular abnormalities are more likely to cause pulsatile tinnitus, the addition of MR angiography provides a more thorough evaluation and decreases the likelihood of re-imaging.…”

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

“…The mean age at presentation reported in the literature is 52.8 years with a slight female preponderance. 2 Reported causes of PT are represented in Table 1. Evaluation of patients with PT begins with a detailed history.…”