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Abstract
Introduction Pulsatile tinnitus (PT) may be the presenting symptom of a spectrum of cerebrovascular disorders, ranging from benign venous causes to life-threatening arteriovenous shunts (AVS). Early diagnosis is therefore essential in guiding neuroendovascular treatment. Clinical history and physical examination may aid in diagnosing PT etiology, but the performance and reliability of these tools in predicting the cause of PT remains undetermined.
Objective To investigate whether clinical factors (history and physical examination) can predict cerebrovascular etiology of PT as determined by digital subtraction angiography (DSA).
Methods Patients with clinical PT evaluation who underwent comprehensive DSA were included. PT etiology after DSA was categorized as ‘shunting,’ ‘venous,’ ‘arterial,’ or ‘non-vascular.’ Clinical variables were compared between etiologies using multivariate logistic regression and performance at predicting PT etiology was determined by area under the receiver operating curve (AUROC).
Results There were 164 patients included. On multivariate analysis, patient-reported high pitch PT (RR = 33.81; 95% CI = 3.81 - 882.80; p = 0.007) compared with exclusively low pitch PT and presence of a bruit on physical exam (RR = 9.95; 95% CI = 2.04 - 62.08; p = 0.007) were associated with shunting PT. Hearing loss was associated with lower risk of shunting PT (RR= 0.16; 95% CI = 0.03 - 0.79; p = 0.029). Alleviation of PT with ipsilateral jugular venous pressure was associated with higher risk of venous PT (RR = 5.24; 95% CI = 1.62 - 21.01; p = 0.010). An AUROC of 0.882 was achieved for predicting the presence or absence of a shunt and 0.751 for venous PT. A decision tree using PT pitch, presence of hearing loss, and bruit on physical exam indicated high positive and negative predictive value for arteriovenous shunting (figure 1). With high pitch PT, no hearing loss, and a bruit on physical exam, 92.9% (13/14) of patients had shunting PT. With exclusively low pitch PT and either hearing loss present OR no bruit on physical exam, 0% (0/36) had a shunt.
Conclusions Clinical history and physical examination achieve high performance for detecting a shunting cause of PT. Treatable venous etiologies can be predicted by relief with jugular compression. These findings support the value of a focused clinical assessment in the initial evaluation of patients with PT.
Disclosures D. Cummins: None. M. Caton: None. K. Hemphill: None. A. Lamboy: None. A. Tu-Chan: None. K. Meisel: None. K. Narsinh: None. M. Amans: None.