Pulsatile Tinnitus Neuroradiological Diagnosis and Treatment

Abstract

Pulsatile tinnitus can be annoying for a patient and also the only hint to a potentially devastating and life-threatening neurological disease. In order to better understand its clinical spectrum and management we analyzed the files of 84 patients seen at our hospital suffering from this entity. We reviewed the records of 84 consecutive patients with pulsatile tinnitus. The mean age was 51 years (range from 3 to 82 years, 58 women and 26 men). The evaluation of tinnitus was on average 13 months after onset. Noninvasive techniques (ultrasound, CT, MRI, MRA, First-pass-Gadolinium-MRA) and angiography were employed for work-up tailored to the individual patient. Endovascular treatment was performed using a biplane interventional angiography system (1024 × 1024 matrix) by arterial and transvenous approach. A vascular pathology was found in 36 (42%) patients (dural arteriovenous fistula: 17; carotid-cavernous-fistula: 6; arteriosclerotic carotid stenosis: 7; dissection of the ICA: 5; fibromuscular dysplasia with ICA stenosis: 5; cerebral venous sinus thrombosis: 2; cerebral venous sinus stenosis: 1; ICA aneurysm: 1; abnormal loop of the anterior inferior cerebellar artery: 1). In 12 patients (14%) nonvascular pathologies such as glomus tumor or intracranial hypertension due to different reasons caused the tinnitus (paraganglioma: 5, meningioma: 1, sarcoidosis: 1, intracranial hypertension due to intracranial tumors: 4, intracranial hypertension due to aqueduct stenosis: 1). We conclude that patients with pulsatile tinnitus should be worked-up primarily with non-invasive techniques, e.g. first-pass gadolinium MRA, MRI and doppler sonography. If these are negative or to clarify abnormal findings further selective angiography is needed for diagnosis and treatment.