Role of angiography in the evaluation of patients with pulsatile tinnitus.

OBJECTIVES/HYPOTHESIS Pulsatile tinnitus in the face of normal findings on otoscopy is a common otological diagnostic dilemma and can be due to serious vascular malformations such as transverse or sigmoid sinus dural arteriovenous fistula (transverse or sigmoid sinus [TS] DAVF). Left untreated, TS DAVF may result in significant morbidity and mortality. TS DAVF can be suspected or diagnosed with computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA), with the gold standard being angiography. Our objective was to assess the utility of these various diagnostic modalities in the diagnosis of dural arteriovenous fistula. STUDY DESIGN Retrospective clinical review. METHODS Between 1986 and 1996, 54 patients were evaluated and treated for TS DAVF. Between 1996 and 1999, an additional 33 patients underwent MRI combined with MRA for the evaluation of pulsatile tinnitus. A retrospective review of the medical records for both groups, with special attention to clinical presentation, diagnostic evaluation, therapy, and outcome, was performed. RESULTS All patients had pulsatile tinnitus with normal findings on otoscopy. CT scan was relatively insensitive in the detection of TS DAVF. MRI and MR/MRA were significantly more sensitive than CT. In the evaluation of patients with subjective pulsatile tinnitus, MRI/MRA defined anatomical abnormalities that may contribute to pulsatile tinnitus in 63% of patients. CONCLUSIONS In the absence of objective pulsatile tinnitus, MRI/MRA is an appropriate initial diagnostic step. When a patient has an objective bruit, the clinician may choose to proceed directly to angiography to make certain that a TS DAVF is not missed.