Abstract

Objective Aggregate published data on the imaging of pulsatile tinnitus as a step toward building a framework for an evidence-based approach to diagnostic imaging for this symptom.

Materials & Methods A systematic review was performed. PUBMED and EMBASE were searched on December 1, 2021 for English-language articles on diagnostic imaging of pulsatile tinnitus. Articles that involved non-standard imaging techniques and those that focused on management of pulsatile tinnitus were excluded. Extracted data included: number of males and females; signs, symptoms, and physical examination findings with associated patient counts; imaging findings; count of patients with imaging-identified cause of pulsatile tinnitus; reported associated interventions and outcomes.

Results 41 articles were included with a total of 2,633 reported patients. 10 studies were prospective. MRA appears to be capable of identifying many of the same pathologies traditionally diagnosed with DSA. Few head-to-head comparisons were performed. In head-to-head comparisons of MRI and MRA, MRA was often able to identify more pathology. There was no clear relationship identified between specific symptoms and the imaging modality chosen, indicating that the imaging evaluation of pulsatile tinnitus is likely sensitive to the preferences of the evaluating provider.

Conclusion There is limited evidence to inform best practices for the initial imaging evaluation of pulsatile tinnitus and preference-sensitive provider decisions will continue to guide the pulsatile tinnitus workup. We encourage prospective studies with multimodality imaging comparisons to build evidence that would support the development of more effective, efficient, and equitable protocols and pathways for the imaging evaluation of pulsatile tinnitus.

Clinical Relevance Statement Evidence is not available in support of any single optimal imaging evaluation of pulsatile tinnitus, but prudent imaging will include evaluation for life-threatening causes such as dural arteriovenous fistula and arteriovenous malformation.

Key Points

- Many imaging findings associated with pulsatile tinnitus may not be causal.

- Current evidence is insufficient to indicate the optimal imaging evaluation.

- Local preference-based imaging algorithms are reasonable in the absence of new high-level evidence.

Competing Interest Statement

Jeffrey P. Guenette is the recipient of research funding from the National Institute of Biomedical Imaging and Bioengineering (K08 EB034299) and the Agency for Healthcare Research and Quality (AHRQ R18 HS029348). C. Eduardo Corrales M.D. is an employee and shareholder of Regeneron Pharmaceuticals, Inc.

Funding Statement

Jeffrey P. Guenette is the recipient of research funding from the National Institute of Biomedical Imaging and Bioengineering (K08 EB034299) and the Agency for Healthcare Research and Quality (AHRQ R18 HS029348).

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

This systematic review used (or will use) ONLY available human data that were originally publicly published in journals. All data sources are cited in the manuscript.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

Footnotes

Jeffrey P. Guenette is the recipient of research funding from the National Institute of Biomedical Imaging and Bioengineering (K08 EB034299) and the Agency for Healthcare Research and Quality (AHRQ R18 HS029348). C. Eduardo Corrales M.D. is an employee and shareholder of Regeneron Pharmaceuticals, Inc.

Data Availability

All data produced in the present work are contained in the manuscript

AbbreviationsCTX-Ray Computed TomographyCTAX-Ray Computed Tomography AngiographyMRIMagnetic Resonance ImagingMRAMagnetic Resonance AngiographyMRVMagnetic Resonance VenographyUSUltrasoundDSADigital Subtraction Angiography