Abstract
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.
Keywords: Pulsatile tinnitus, venous sinus stenosis, venous aneurysm, noninvasive neuroimaging
Introduction
Pulsatile tinnitus is characterized by the acoustic perception of a sound that is synchronous to the heartbeat. 1 Apart from being a vexing symptom that markedly reduces quality of life,2–4 pulsatile tinnitus can indicate serious underlying neurological disorders such as idiopathic intracranial hypertension. Additionally, pulsatile tinnitus can be caused by several cerebrovascular conditions, some of which can lead to significant morbidity and mortality if left undiagnosed and untreated. Specifically, pulsatile tinnitus can occur in the setting of arterial anomalies, venous stenosis or thrombosis, carotid stenosis, and vascular malformations, including arteriovenous malformations (AVM) and dural arteriovenous fistulae (DAVF).1,5,6
Current diagnostic paradigms posit the need for digital subtraction angiography (DSA) if a clear diagnosis is not readily made based on clinical assessment and noninvasive imaging.7,8 DSA is the historic gold-standard diagnostic imaging method for occult cerebrovascular disease, but the procedure is invasive and carries a small but non-negligible risk.9,10 At the same time, noninvasive imaging modalities such as time-resolved magnetic resonance (MR) angiography (MRA) and contrast-enhanced MR venography (MRV) have evolved,7,11,12 raising the possibility that the current diagnostic paradigm can be updated to optimize the use of noninvasive testing. In this retrospective cohort study, we sought to evaluate the diagnostic yield and clinical impact of contrast-enhanced MR imaging (MRI), MRA, and MRV studies in patients presenting with pulsatile tinnitus without established etiologic diagnoses. Furthermore, we investigated clinical features that are associated with nondiagnostic noninvasive imaging.
Methods
Study design
This study was a single-center retrospective cohort study of adult patients presenting to Weill Cornell Medicine for outpatient evaluation of pulsatile tinnitus. The Weill Cornell Medicine Institutional Review Board approved this retrospective cohort study and granted a waiver of informed consent to Dr. Patsalides.
Patient population
We identified patients who presented to our institution for evaluation of pulsatile tinnitus from January 2018 to March 2020 by querying the electronic medical record system for all patients with an ICD-10 diagnosis code of H93.Ax (x: 1 (right ear), 2 (left ear), 3 (bilateral), or 9 (unspecified ear)). To do this, we first validated this ICD-10 diagnosis code at our institution. We obtained 25 randomly selected charts for patients with an ICD-10 diagnosis of pulsatile tinnitus and 25 randomly selected charts for patients with other cerebrovascular disease diagnosis codes. Two investigators (A.J.T. and N.S.P.) independently reviewed charts to adjudicate whether the patient had presented specifically with pulsatile tinnitus as opposed to non-pulsatile tinnitus. A third investigator (A.P.) served as tiebreaker for any disagreements. The ICD-10 code H93.Ax had a sensitivity of 100% (95% confidence interval (CI) 85–100%) and specificity of 86% (95% CI 69–95%) for pulsatile tinnitus. Charts for all patients with this diagnosis code were then manually reviewed and systematically abstracted. Patients were excluded if they did not actually have pulsatile tinnitus, whether this was because they had non-pulsatile tinnitus or because they did not have tinnitus at all. Last, because our objective was to evaluate the diagnostic yield of noninvasive imaging as part of the initial evaluation of pulsatile tinnitus, we excluded patients who already had an etiologic diagnosis such as idiopathic intracranial hypertension or another cerebrovascular condition. Patients presenting for treatment rather than diagnostic evaluation were also excluded.
Patient characteristics
Patient characteristics included age, sex, body mass index (BMI), comorbidities, clinical presentation, and prior imaging history and workup at time of first clinic visit at our institution. Hypertension was defined based on a diagnosis of hypertension, blood pressure > 130/80 mmHg, or use of anti-hypertensive medications. Hyperlipidemia was defined based on a diagnosis of hyperlipidemia, total cholesterol > 200 mg/dL, or use of statin therapy. Diabetes mellitus was defined based on a diagnosis of diabetes mellitus, use of diabetes medication, or a hemoglobin A1c ≥6.5%. Coronary artery disease was defined based on a history of myocardial infarction or other diagnosis of coronary artery disease. Atrial fibrillation was defined based on a diagnosis or presence of atrial fibrillation on electrocardiograms in the chart. Heart failure and migraine were defined on the basis of documented diagnoses. Smoking status was categorized as never, former, or current smoker, based on self-report.
Measurements
Age of onset of pulsatile tinnitus, laterality (left ear, right ear, or bilateral), history of head trauma, presence or absence of headaches, and whether pulsatile tinnitus was influenced by changing body positions or with neck compression or rotation were abstracted. Interference with sleep, relationship to environmental noise, and relationship to physical activity were extracted from the patient-reported Tinnitus Handicap Inventory. Hearing loss and visual symptoms were corroborated by review of notes from otolaryngological and ophthalmological evaluations when available. With respect to diagnostic evaluation, we abstracted the results of evaluations by neurology, otolaryngology, and ophthalmology in addition to diagnostic tests. Diagnosis imaging tests were categorized as noninvasive (MR or computed tomography based) and invasive (DSA).
We categorized patients into two groups: patients who received noninvasive imaging alone and patients who subsequently underwent DSA. We abstracted the final clinical diagnosis, which we classified according to the following categories: arterial (intracranial stenosis, extracranial stenosis, arterial anomaly), venous (jugular bulb diverticulum, large condylar veins, prominent emissary vein, venous sinus aneurysm, venous sinus stenosis, venous sinus stenosis, and post-stenotic venous aneurysm/diverticulum), and arteriovenous (DAVF, arteriovenous malformation, carotid cavernous fistula).
Statistical analysis
We summarized data using standard descriptive statistics, including standard deviations (SD) for means and exact 95% CIs for proportions. We compared patients who underwent exclusively noninvasive imaging to those who also underwent DSA using two-sample t-tests to compare parametric continuous variables, Wilcoxon signed-rank test to compare nonparametric continuous variables, and Fisher’s exact test to compare proportions. Then, in an exploratory analysis, we used univariate logistic regression to identify factors associated with nondiagnostic noninvasive imaging (i.e., diagnosis based on DSA) among patients who were given an etiologic diagnosis based on either noninvasive imaging or DSA. All statistical analyses were performed using R (RStudio, version 1.2.5033, R 3.6.3).
Results
Patient characteristics
A total of 236 patients were seen for outpatient diagnostic evaluation of pulsatile tinnitus during the study period. Patients found to have non-pulsatile tinnitus (N = 11) and patients presenting with established etiologic diagnoses (N = 38), such as idiopathic intracranial hypertension, were excluded. A total of 187 patients were included in the final analysis (Figure 1). They had a mean age of 48.6 years (SD = 15.5 years), and 74.3% were women. The mean BMI was 26.9 kg/m2 (SD = 6.1 kg/m2). The patients were categorized as those who had exclusively noninvasive imaging (n = 121; 64.7%) and those who also had DSA (n = 66; 35.3%). There were no patients who had only DSA. Patients were similar in these two groups across all clinical characteristics (p > 0.05; Table 1).
Figure 1.
Study cohort eligibility flow chart outlining patient selection for the study. DSA: digital subtraction angiography.
Table 1.
Clinical characteristics of patients undergoing diagnostic workup for pulsatile tinnitus, stratified by imaging type.
| Noninvasive imaging only (N = 121) | DSA (N = 66) | Overall (N = 187) | |
|---|---|---|---|
| Age (years), M (SD) | 48.2 (15.5) | 49.5 (15.6) | 48.6 (15.5) |
| Female | 93 (76.9%) | 46 (69.7%) | 139 (74.3%) |
| BMI (kg/m2), M (SD) | 27.1 (6.2) | 26.7 (5.9) | 26.9 (6.1) |
| Hypertension | 47 (38.8%) | 25 (37.9%) | 72 (38.5%) |
| Hyperlipidemia | 34 (28.1%) | 15 (22.7%) | 49 (26.2%) |
| Diabetes mellitus | 7 (5.8%) | 5 (7.6%) | 12 (6.4%) |
| Coronary artery disease | 2 (1.7%) | 0 (0%) | 2 (1.1%) |
| Atrial fibrillation | 0 (0%) | 1 (1.5%) | 1 (0.5%) |
| Smoker | |||
| Never | 89 (73.6%) | 49 (74.2%) | 138 (73.8%) |
| Past | 25 (20.7%) | 13 (19.7%) | 38 (20.3%) |
| Current | 5 (4.1%) | 3 (4.5%) | 8 (4.3%) |
| Migraine | 22 (18.2%) | 7 (10.6%) | 29 (15.5%) |
| History of head trauma | 9 (7.4%) | 2 (3.0%) | 11 (5.9%) |
| Laterality of pulsatile tinnitus | |||
| Bilateral | 20 (16.5%) | 13 (19.7%) | 33 (17.6%) |
| Left | 41 (33.9%) | 28 (42.4%) | 69 (36.9%) |
| Right | 60 (49.6%) | 25 (37.9%) | 85 (45.5%) |
| Visual symptoms | 36 (29.8%) | 18 (27.3%) | 54 (28.9%) |
| Headaches | 63 (52.1%) | 39 (59.1%) | 102 (54.5%) |
| Interference with sleep | 73 (60.3%) | 43 (65.2%) | 116 (62.0%) |
| Louder than environmental noise | 46 (38.0%) | 32 (48.5%) | 78 (41.7%) |
| Positional | 82 (67.8%) | 44 (66.7%) | 126 (67.4%) |
| Influenced by neck compression | 67 (55.4%) | 40 (60.6%) | 107 (57.2%) |
| Influenced by exercise or activity | 46 (38.0%) | 30 (45.5%) | 76 (40.6%) |
| Evaluated by ENT | 112 (92.6%) | 61 (92.4%) | 173 (92.5%) |
| Evaluated by ophthalmology | 58 (47.9%) | 24 (36.4%) | 82 (43.9%) |
| Evaluated by neurology | 37 (30.6%) | 24 (36.4%) | 61 (32.6%) |
| DSA | 0 (0%) | 66 (100%) | 66 (35.3%) |
| MRA | 111 (91.7%) | 58 (87.9%) | 169 (90.4%) |
| MRI | 97 (80.2%) | 56 (84.8%) | 153 (81.8%) |
| MRV | 110 (90.9%) | 60 (90.9%) | 170 (90.9%) |
Data are presented as n (%) unless otherwise specified.
M: mean; SD: standard deviation; BMI: body mass index; ENT: otolaryngology; DSA: digital subtraction angiography; MRA: magnetic resonance venography; MRI: magnetic resonance imaging; MRV: magnetic resonance venography.
Patients frequently reported additional associated symptoms such as migraines (15.5%), visual symptoms (28.9%), and headaches (54.5%). Pulsatile tinnitus was lateralized to the left in 36.9%, the right in 45.5%, and bilateral in 17.6%. Pulsatile tinnitus interfered with sleep in 62.0%, was louder than environmental noise in 41.7%, positional in 67.4%, modified by neck compression in 57.2%, and modified by exercise or activity in 40.6% (Table 1).
Diagnostic workup
During the diagnostic workup for pulsatile tinnitus, the most common imaging modalities that patients underwent included MRV (90.9%), MRA (90.4%), and MRI (81.8%), with some patients receiving CTA (22%), CTV (0.5%), and DSA (35.3%). Patients had received on average three (SD = 1) imaging studies prior to being seen at our institution, with 17 (9.1%) patients having received a prior DSA. Additionally, 92.5% patients were evaluated by ENT, 43.9% by ophthalmology, and 32.6% by neurology (Table 1).
Diagnoses based on imaging modalities
In patients who received exclusively noninvasive imaging (n = 121), 62 (51.2%) patients received an etiologic diagnosis (Figure 1). Among patients who underwent both noninvasive imaging and DSA (n = 66), 14 (21.2%) patients received a final diagnosis based on DSA, 29 (43.9%) patients received a diagnosis based on noninvasive imaging, and 23 (34.8%) patients did not receive a diagnosis. In addition, among 24 patients who had diagnostic noninvasive imaging and a subsequent DSA, one (4.2%) received a different diagnosis upon undergoing DSA. Among 21 patients who had nondiagnostic noninvasive imaging and then underwent DSA, five (23.8%) received a diagnosis based on DSA.
Vascular etiologies were identified in total of 105 (56.1%) patients, with 91 (86.7%) patients receiving a diagnosis based on noninvasive imaging and 14 (13.3%) patients receiving a diagnosis based on DSA (Table 2). Out of a total of 116 diagnoses, the most common identified cause was venous sinus stenosis and post-stenotic venous aneurysm/diverticulum (51.0% in exclusively noninvasive imaging group, 21.4% in DSA group). Other common causes included venous sinus stenosis (18.6% in exclusively noninvasive imaging group, 21.4% in DSA group) and jugular bulb diverticulum (10.8% in exclusively noninvasive imaging group, 7.1% in DSA group). While most diagnoses were venous in origin, arterial and arteriovenous causes were also identified, including dural arteriovenous fistula (7.8% in exclusively noninvasive imaging group, 7.1% in DSA group) and arteriovenous malformation (0% in exclusively noninvasive imaging group, 7.1% in DSA group). The more uncommon diagnoses included intracranial and extracranial stenoses, large condylar veins, prominent emissary vein, and carotid cavernous fistula.
Table 2.
Cerebrovascular diagnoses in patientsa presenting for evaluation of pulsatile tinnitus.
| Diagnoses by noninvasive imagingb (N=102) | Diagnoses by DSA (N=14) | |
|---|---|---|
| Arterial | ||
| Intracranial stenosis | 2 (2.0%) | 0 (0%) |
| Extracranial stenosis | 1 (1.0%) | 0 (0%) |
| Venous | ||
| Jugular bulb diverticulum | 11 (10.8%) | 1 (7.1%) |
| Large condylar veins | 0 (0%) | 1 (7.1%) |
| Prominent emissary vein | 2 (2.0%) | 3 (21.4%) |
| Venous sinus aneurysm | 6 (5.9%) | 1 (7.1%) |
| Venous sinus stenosis | 19 (18.6%) | 3 (21.4%) |
| Venous sinus stenosis and post-stenotic venous aneurysm/diverticulum | 52 (51.0%) | 3 (21.4%) |
| Arteriovenous | ||
| DAVF | 8 (7.8%) | 1 (7.1%) |
| AVM | 0 (0%) | 1 (7.1%) |
| Carotid cavernous fistula | 1 (1.0%) | 0 (0%) |
Data are presented as n (%).
aThe total denominator for this table is the 105 patients who received a cerebrovascular etiologic diagnosis for pulsatile tinnitus. Ninety-one patients received a diagnosis based on noninvasive imaging. Fourteen patients received a diagnosis based on DSA.
bPatients who had diagnostic noninvasive imaging but also underwent DSA were categorized as patients diagnosed on the basis of noninvasive imaging.
DAVF: dural arteriovenous fistula; AVM: arteriovenous malformation.
Factors associated with nondiagnostic noninvasive imaging
Among patients who received an etiologic diagnosis based on either noninvasive imaging or DSA, factors associated with nondiagnostic noninvasive imaging (i.e., diagnosis based solely on DSA) were age at presentation (odds ratio (OR) = 1.05 per year; 95% CI 1.01–1.09), age at onset of pulsatile tinnitus (OR = 1.05 per year; 95% CI 1.01–1.09), and BMI (OR = 0.88 per 1 kg/m2; 95% CI 0.77–0.98; Table 3).
Table 3.
Factorsa associated with nondiagnostic noninvasive imaging in patients who received an etiologic diagnosis.
| OR | 95% CI | p-Value | |
|---|---|---|---|
| Age at presentation | 1.05 | 1.01–1.09 | 0.02 |
| Age at symptom onset | 1.05 | 1.01–1.09 | 0.01 |
| BMI | 0.88 | 0.77–0.98 | 0.04 |
aOdds ratios represent association between factor (1 unit of age or BMI) and odds of having nondiagnostic noninvasive imaging.
OR: odds ratio; CI: confidence interval; BMI: body mass index.
Discussion
Pulsatile tinnitus can indicate a variety of underlying cerebrovascular causes, including high-risk pathologies such as dural arteriovenous fistula that may lead to significant morbidity and mortality if untreated. In this retrospective study of a large cohort of patients presenting with pulsatile tinnitus at a single institution, our findings highlight the role of noninvasive imaging modalities in the diagnosis of underlying etiologies for pulsatile tinnitus.
Our finding that etiologic diagnoses can often be identified through exclusive noninvasive imaging modalities of MRI, MRA, and MRV is consistent with a growing number of studies demonstrating noninvasive modalities can effectively screen for notable cerebrovascular abnormalities, including dural arteriovenous fistulas, on initial presentation.7,8,11,12 It also contributes to the mounting evidence that catheter cerebral angiogram should not be used as part of initial screening and should be reserved for further workup if high-risk cerebrovascular pathology is suspected after or despite noninvasive imaging.5,11,12 While there is a recent increasing appreciation for MRI/MRA,6–8 this study provides additional evidence regarding the utility of MRV in the workup of pulsatile tinnitus in a large contemporary patient cohort.
In this study, the most common identified cause of pulsatile tinnitus was venous stenosis with post-stenotic venous aneurysm. While our cases were mostly venous in origin, other studies have reported a larger fraction of arterial or arteriovenous causes. Previous reports in the literature include varying proportions of venous etiologies, ranging from 28% 1 to 43%. 8 Notably, these studies focused on the combination of MRI and MRA and did not include MRV. The higher percentage of venous etiologies identified in this cohort may reflect significantly increased use of MRV. In addition, this difference could be partially explained by the result of the referral pattern to our clinic. Increased utilization of MRV based on clinical suspicion of pulsatile tinnitus with venous etiology may lead to early detection of venous stenosis, which can be treated with venous sinus stenting that has been shown to lead to symptom resolution.13–15
Additionally, we found that age on presentation, age at pulsatile tinnitus onset, and BMI were associated with the use of DSA to achieve a final clinical diagnosis. Specifically, while higher age was associated with increased odds of diagnosis by DSA, higher BMI was associated with reduced odds. This finding may be because patients with higher BMI may have more readily identified venous sinus stenosis and because higher age is associated with venous sinus stenoses and arteriovenous malformations.16,17
Lastly, this patient cohort received an average of three separate imaging modalities during the diagnostic workup, with some patients having had received up to five imaging studies prior to presentation. A more thorough noninvasive evaluation in the initial workup would not only reduce exposing patients to invasive procedures but may also lead to more efficient utilization of limited imaging resources.
Limitations and future directions
Our study is limited to the patients in a single institution. Therefore, the generalizability to other settings and patient cohorts will need to be explored in future studies. Additionally, although our overall patient cohort is significantly larger compared to previous studies, the number of patients who received DSA is smaller compared to patients in the exclusive noninvasive imaging group. Finally, the type of noninvasive imaging was not consistent, as many patients had workup from outside institutions and presented to us for a second opinion.
Conclusions
In this retrospective cohort study, we systematically reviewed the diagnostic utility of noninvasive imaging methods in the workup of pulsatile tinnitus. Our findings indicate that many patients can be diagnosed with advanced noninvasive imaging, with DSA reserved for further workup of suspected high-risk cerebrovascular pathologies and patients with associated features such as higher age and lower BMI.
Footnotes
Conflict of interest: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Parikh reports unrelated funding from the NY State Empire Clinical Research Investigator Program, Florence Gould Foundation for Discovery in Stroke, and Leon Levy Foundation, in addition to personal fees for medicolegal consulting. The authors declare no other potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Alice J Tao https://orcid.org/0000-0003-3786-4243
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