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Vascular neurology
Clinical evaluation of pulsatile tinnitus: history and physical examination techniques to predict vascular etiology
  1. Daniel D Cummins1,
  2. M Travis Caton2,
  3. Kafi Hemphill3,
  4. Allison Lamboy1,
  5. Adelyn Tu-Chan3,
  6. Karl Meisel4,
  7. Kazim H Narsinh5,
  8. Matthew R Amans5
  1. 1 Departments of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
  2. 2 Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
  3. 3 Department of Neurology, University of California San Francisco, San Francisco, California, USA
  4. 4 McClaren Northern Michigan, Petoskey, Michigan, USA
  5. 5 Department of Radiology and Biomedical Imaging, Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to Dr Matthew R Amans, Department of Radiology and Biomedical Imaging and Department of Neurological Surgery, University of California San Francisco,505 Parnassus Ave, Room L308, San Francisco, California 94143, USA; matthew.amans{at}ucsf.edu

Abstract

Background Pulsatile tinnitus (PT) may be due to a spectrum of cerebrovascular etiologies, ranging from benign venous turbulence to life threatening dural arteriovenous fistulas. A focused clinical history and physical examination provide clues to the ultimate diagnosis; however, the predictive accuracy of these features in determining PT etiology remains uncertain.

Methods Patients with clinical PT evaluation and DSA were included. The final etiology of PT 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 164 patients were included. On multivariate analysis, patient reported high pitch PT (relative risk (RR) 33.81; 95% CI 3.81 to 882.80) compared with exclusively low pitch PT and presence of a bruit on physical examination (9.95; 2.04 to 62.08; P=0.007) were associated with shunting PT. Hearing loss was associated with a lower risk of shunting PT (0.16; 0.03 to 0.79; P=0.029). Alleviation of PT with ipsilateral lateral neck pressure was associated with a higher risk of venous PT (5.24; 1.62 to 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.

Conclusion In patients with PT, clinical history and physical examination can achieve high performance at detecting a shunting lesion. Potentially treatable venous etiologies may also be suggested by relief with neck compression.

  • Angiography
  • Vascular Malformation
  • Technique
  • Stroke

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request to the corresponding author.

https://doi.org/10.1136/jnis-2023-020440

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    Data availability statement

    Data are available upon reasonable request. Data are available upon reasonable request to the corresponding author.

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    Footnotes

    • X @traviscaton, @mattamansMD

    • Contributors DDC and MTC: conceptualization, data collection, analysis, and drafting original manuscript. KH and AL: data collection and revising original manuscript. AT-C, KM, KHN, and MRA: conceptualization, oversight, and revising original manuscript as well as gaurantor of overall content.

    • Funding This work was funded in part by the National Institute of Health (NIH) National Heart, Lung, and Blood Institute (NHLBI) of the NIH under the award No R56HL149124-01, and by the Office of the Assistant Secretary of Defense for Health Affairs through the Peer Reviewed Research Program under award No PR201091.

    • Competing interests MRA: board member: Mind Rhythm; consultancy: Stryker, Neurovascular, Covidien, and MicroVention; comments: pipeline proctor for Covidien and PHIL DSMB for MicroVention; patents (planned, pending, or issued): cerebral venous sinus stent; comments: provisional patent serial No 62/984,549. KHN: consultancy: Stryker Neurovascular and Imperative Care.

    • Provenance and peer review Not commissioned; externally peer reviewed.