MRI and MR angiography evaluation of pulsatile tinnitus: A focused, physiology‐based protocol

Abstract

Background and Purpose Pulsatile tinnitus (PT) is the subjective sensation of a pulse‐synchronous sound, most often due to a cerebrovascular etiology. PT can severely impact quality of life and may indicate a life‐threatening process, yet a timely and accurate diagnosis can often lead to effective treatment. Clinical assessment with a history and physical examination can often suggest a diagnosis for PT, but is rarely definitive. Therefore, PT should be evaluated with a comprehensive and targeted radiographic imaging protocol. MR imaging provides a safe and effective means to evaluate PT. Specific MR sequences may be used to highlight different elements of cerebrovascular anatomy and physiology. However, routine MR evaluation of PT must comply with economic and practical constraints, while effectively capturing both common and rarer, life‐threatening etiologies of PT. Methods In this state‐of‐the‐art review, we describe our institutional MR protocol for evaluating PT. Results This protocol includes the following dedicated sequences: time‐of‐flight magnetic resonance angiography; arterial spin labeling; spoiled gradient recalled acquisition in the steady state; time‐resolved imaging of contrast kinetics; diffusion weighted imaging, and 3‐dimensional fluid‐attenuated inversion recovery. Conclusions We describe the physiologic and clinical rationale for including each MR sequence in a comprehensive PT imaging protocol, and detail the role of MR within the broader evaluation of PT, from clinical presentation to treatment.

Management of vascular causes of pulsatile tinnitus

“…Hence some of the causes of PT warrant treatment to mitigate risk of stroke or blindness, while other causes may be treated to address the symptom itself and its psychiatric comorbidities. Advances in neuroimaging and endovascular treatment have resulted in increased detection of vascular causes6 7 and therapeutic options have burgeoned. Once a vascular etiology has been established, treatment recommendations should be based on the natural history of the disease, treatment risks, and the efficacy of treatment.…”

Cerebrovascular pulsatile tinnitus: causes, treatments, and outcomes in 164 patients with neuroangiographic correlation

“…In patients evaluated with DSA for PT, Lekovic et al found a rate of 40.0% (6/15) to be AVFs,12 and Deuschl et al found 44.4% (24/54) of PT cases to be from dAVFs 13. A dedicated MRI protocol for PT may have a high sensitivity and specificity (approaching 100%) for dAVFs,13 and is employed at our institution 9. However, suspicious findings for dAVFs may only be present on a single MR sequence and can be missed 13.…”

“…However, these causes may also be readily treatable, leading to resolution of debilitating symptoms 7 8. Newer imaging protocols, including MRI with arterial-spin labelling and dynamic contrast-enhanced angiography, are helpful first-line screening tools for patients with PT 9. However, endovascular evaluation of PT offers several distinct advantages over non-invasive modalities.…”

Retroauricular/Transcranial Color-Coded Doppler Ultrasound Approach in Junction With Ipsilateral Neck Compression on Real-Time Hydroacoustic Variation of Venous Pulsatile Tinnitus

“…Venous PT is characterized by the reduction or elimination of a vascular sound when the ipsilateral internal jugular vein (IJV) is compressed ( Mattox and Hudgins, 2008 ; Grewal et al, 2014 ). In addition, anatomical abnormalities related to the structural integrity of the sigmoid plate and the vascular shape are often revealed using imaging modalities ( Dong et al, 2015 ; Cummins et al, 2021 ; Ding et al, 2021 ).…”