Abstract
BackgroundAmong the varied causes of pulsatile tinnitus, the condition that can cause severe mortality and morbidity is a cranial dural arteriovenous fistula (cDAVF). This study aimed to assess the diagnostic accuracy of the dilated middle meningeal artery on three-dimensional time-of-flight magnetic resonance angiography in cranial dural arteriovenous fistula and to identify other feeders that can aid in the detection of these lesions.MethodMagnetic resonance angiography and digital subtraction angiography data of all patients with cranial dural arteriovenous fistula treated in a single tertiary referral center between 2007–2020 were included. The middle meningeal artery and other feeders recorded from digital subtraction angiography were assessed on magnetic resonance angiography.ResultsThe overall agreement between readers in identifying the dilated middle meningeal artery was substantial (κ = 0.878, 95% confidence interval: 0.775–0.982). The dilated middle meningeal artery indicated the presence of a cranial dural arteriovenous fistula with a sensitivity of 79.49% (95% confidence interval: 66.81–92.16), specificity of 100% (95% confidence interval: 100.00–100.00), and negative predictive value of 94.56% (95% confidence interval: 90.89–98.02). An area under the curve of 0.8341 was observed for the ipsilateral middle meningeal artery, with a sensitivity of 92.2% and a specificity of 75.0% at a cut-off of 0.30 mm for identifying a cranial dural arteriovenous fistula. Of 73 other feeders, the occipital, meningohypophyseal trunk, ascending pharyngeal, and posterior meningeal arteries contributed to a large proportion visualized on magnetic resonance angiography (83.6% (41/49)).ConclusionThe dilated middle meningeal artery sign is useful for identifying a cranial dural arteriovenous fistula. Dilatation of the occipital and ascending pharyngeal arteries and meningohypophyseal trunk should be assessed to facilitate the detection of a cranial dural arteriovenous fistula, particularly in the transverse-sigmoid and petrous regions.
Highlights
Among the varied causes of pulsatile tinnitus, the condition that can cause severe mortality and morbidity is a cranial dural arteriovenous fistula
The etiologies of pulsatile tinnitus are divided into two main categories: (a) vascular pathologies, including cranial dural arteriovenous fistula, arteriovenous malformation, aberrant course of the internal carotid artery (ICA), atherosclerosis, high-riding jugular bulb, vertebro-vertebral fistula, vascular tumors, and (b) nonvascular pathologies, including idiopathic intracranial hypertension and Paget’s disease.[1,3]
A total of 1215 patients were referred to our institution for the investigation of a potential cranial dural arteriovenous fistula (cDAVF) between January 2007–July 2020
Summary
Among the varied causes of pulsatile tinnitus, the condition that can cause severe mortality and morbidity is a cranial dural arteriovenous fistula (cDAVF). This study aimed to assess the diagnostic accuracy of the dilated middle meningeal artery on three-dimensional time-of-flight magnetic resonance angiography in cranial dural arteriovenous fistula and to identify other feeders that can aid in the detection of these lesions. The middle meningeal artery and other feeders recorded from digital subtraction angiography were assessed on magnetic resonance angiography. Of 73 other feeders, the occipital, meningohypophyseal trunk, ascending pharyngeal, and posterior meningeal arteries contributed to a large proportion visualized on magnetic resonance angiography (83.6% (41/49)). Dilatation of the occipital and ascending pharyngeal arteries and meningohypophyseal trunk should be assessed to facilitate the detection of a cranial dural arteriovenous fistula, in the transverse-sigmoid and petrous regions. They are diagnosed on imaging examinations based on the presence of a hyperintense signal in dilated or non-dilated vessels on a non-enhanced time-of-flight (TOF) sequence, from retrograde leptomeningeal venous drainage and a pseudo-phlebitic pattern of the vessels.[7,8]
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