This study examines the use of transcranial Doppler (TCD) and duplex ultrasound to diagnose the cause of pulsatile tinnitus in two patients. TCD detected abnormalities in cerebral blood flow for both patients. Further imaging found an intracranial carotid artery dissection near the cochlea in one patient and a vertebrobasilar arteriovenous fistula in the other. Non-invasive tests like TCD and duplex ultrasound can help identify vascular causes of pulsatile tinnitus and guide further diagnostic imaging and treatment.

1. Perspectives in Medicine (2012) 1, 446—448
Bartels E, Bartels S, Poppert H (Editors):
New Trends in Neurosonology and Cerebral Hemodynamics — an Update.
Perspectives in Medicine (2012) 1, 446—448
journal homepage: www.elsevier.com/locate/permed
Transcranial and cervical duplex: A feasible approach
to the diagnosis of pulsatile tinnitus
Pedro Cardonaa,∗
, Helena Quesadaa
, Luis Canoa
, Jaume Campdelacreua
,
Anna Escrigb
, Paloma Morac
, Francisco Rubioa
a
Department of Neurology, Bellvitge University Hospital, Barcelona, Spain
b
Department of Neurology, Sant Boi Hospital, Spain
c
Department of Neuroradiology, Bellvitge University Hospital, Barcelona, Spain
KEYWORDS
Fistula;
Transcranial Doppler;
Duplex;
Tinnitus;
Pulsatile;
Dissection
Summary Pulsatile tinnitus is an uncommon form of tinnitus. Several vascular causes, such
as carotid dissection and arteriovenous fistulae, have been associated to pulsatile tinnitus.
Methods: We present two patients who complained of pulsatile tinnitus and headache in the
last 2 weeks.
Results: Transcranial Doppler demonstrated disturbances in systolic blood flow consisting of
turbulences in the middle cerebral artery in one patient and disturbances in a vertebral artery
in the other. MR and CT angiography confirmed the diagnosis of vertebrobasilar arteriovenous
fistula. Daily compression maneuvers reduced the flow and bruit of both fistulas.
Conclusions: Hemodynamic changes in cerebral flow through a non-invasive and feasible test
such as TCD or duplex can be very useful for the etiological diagnosis of pulsatile tinnitus.
© 2012 Elsevier GmbH. All rights reserved.
Introduction
Pulsatile tinnitus is an uncommon form of tinnitus. It has
some well-known causes including hypertension, heart mur-
mur or Eustachian tube dysfunction.
Pulsatile tinnitus could be a non-specific sign of cerebral
blood flow disturbances, or a disturbance of a cervical vein
or artery. Turbulent blood flow occurs when the wall of a
blood vessel becomes irregular or stenotic.
Several vascular causes, such as carotid dissection and
arteriovenous fistulae, have been associated to pulsatile tin-
nitus [1,2].
∗ Corresponding author. Tel.: +34 932607919; fax: +34 932607882.
E-mail address: pcardonap@bellvitgehospital.cat (P. Cardona).
Methods
We present two patients, a 27-year-old woman and a 43-
year-old man, who complained of pulsatile tinnitus and
headache in the last 2 weeks. Neurological examination was
normal in both cases. The tinnitus was not associated with
dizziness or vertigo and neither were there any related
drugs. CT scan and MR showed normal brain structures. In
the following weeks the patients explained that they were
obtaining a transient relief of tinnitus through compression
maneuvers on the neck.
Results
Transcranial Doppler demonstrated disturbances in systolic
blood flow consisting of turbulences in the middle cerebral
2211-968X/$ — see front matter © 2012 Elsevier GmbH. All rights reserved.
doi:10.1016/j.permed.2012.02.062

2. Transcranial and cervical duplex 447
Figure 1 CT angiography: intracranial carotid stenosis next to cochlea.
Figure 2 Turbulences in TCD test during left MCA and carotid
insonation (M1 segment left MCA).
artery in one patient and disturbances in a vertebral artery
in the other. Intracranial carotid dissection next to the tem-
poral bone and cochlea was diagnosed by CT angiography in
one patient. In the other patient, duplex of the extracra-
nial vertebral artery showed a dampened pulse wave and
turbulence with audible bruit. Duplex through the cervical-
occipital window showed an oscillating vascular flow related
to ipsilateral cervical compression maneuvers. MR and CT
angiography confirmed the diagnosis of vertebrobasilar arte-
riovenous fistula [3]. Daily compression maneuvers reduced
the flow and bruit of both the carotid artery and the
arteriovenous fistula as visualized by transcranial Doppler
(TCD) and duplex. Two months later the carotid artery
recovered its normal flow pattern in TCD and CT angiog-
raphy, allowing treatment with aspirin to be discontinued
(Figs. 1—3).
Discussion
Two types of blood flow disturbances are associated with
pulsatile tinnitus: a generalized increased flow, which can
occur in conditions like severe anemia, hyperthyroidism
or thyrotoxicosis and in the context of punishing exercise
or pregnancy; and a localized increased flow. Vascular
causes of tinnitus have been well described and include
arteriovenous malformations, arteriovenous fistula, carotid
artery-cavernous sinus fistula, vascular tumors in the middle
ear, intracranial vascular stenosis usually from atheroma
plaques and moya-moya syndrome. We present a patient
with an uncommon cause of stroke such as an isolated
intracranial carotid artery dissection. Vascular examination
through magnetic resonance or CT is mandatory for the
diagnosis of pulsatile tinnitus because it is sometimes
very difficult to determine the cause and location of
these bruits [4]. TCD or carotid-intracranial duplex can
help us determine whether there is a disturbance flow
with high sensitivity. However, a CT or MR angiography
is necessary to increase specificity for the diagnosis [5].
At first, patients with pulsatile tinnitus should be inves-
tigated with noninvasive techniques like ultrasounds. If
these tests fail to identify abnormal findings, selective
angiography can help us to the diagnosis and management
[6,7].
The most common ultrasound findings in carotid artery
dissection are an absence of flow signal in the internal
carotid artery, a biphasic (stump) flow in its bulb and a high-
resistance flow pattern of the ipsilateral common carotid
artery. Pulsatile tinnitus can occur in up to 25% of patients
with dissection of the internal carotid artery.
An arteriovenous fistula is an abnormal connection
or passageway between an artery and a vein, what
causes hemodynamic changes that can give rise to audi-
ble bruits. Trancranial color-coded sonography (TCCS) is a
good screening technique for the diagnosis of fistulae and
contrast-enhancement could be a good test to monitor com-
plete embolization of dural arteriovenous fistulae.
Treatment of vascular pulsatile tinnitus generally
involves a multi-disciplinary approach and includes a variety
of symptom management methods. A possible endovascular
or surgical treatment should be considered in selected cases
of vascular etiology [8,9].

3. 448 P. Cardona et al.
Figure 3 MR angiography shows several venous vessels next to left vertebral artery. Duplex through cervical/occipital window
shows a vascular flow that oscillates with ipsilateral cervical compression maneuvers.
Conclusion
The finding of direct or indirect hemodynamic changes in
cerebral flow through a non-invasive and feasible test such
as TCD or duplex can be very useful for the etiological
diagnosis of pulsatile tinnitus. MR and CT angiography are
needed to confirm the diagnosis and for treatment planning
[10].
References
[1] Mattox DE, Hudgins P. Algorithm for evaluation of pulsatile tin-
nitus. Acta Otolaryngol 2008;128(April (4)):427—31.
[2] Sonmez G, Basekim CC, Ozturk E, Gungor A, Kizilkaya E. Imag-
ing of pulsatile tinnitus: a review of 74 patients. Clin Imaging
2007;31(March—April (2)):102—8.
[3] Corr P, Tsheole-Marishane L. Pulsatile tinnitus. Br J Radiol
2001;74(July (883)):669—70.
[4] Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiol-
ogy 2000;216(August (2)):3429.
[5] Mehanna R, Shaltoni H, Morsi H, Mawad M. Endovascular treat-
ment of sigmoid sinus aneurysm presenting as devastating
pulsatile tinnitus. A case report and review of literature. Interv
Neuroradiol 2010;16(December (4)):451—4.
[6] De Candia A, Como G, Passon P, Pedace E, Bazzocchi M. Sono-
graphic findings in glomus tympanicum tumor. J Clin Ultrasound
2002;30(May (4)):236—40.
[7] Narvid J, Do HM, Blevins NH, Fischbein NJ. CT angiography as
a screening tool for dural arteriovenous fistula in patients with
pulsatile tinnitus: feasibility and test characteristics. AJNR Am
J Neuroradiol 2011;32(March (3)):446—53.
[8] Singh DP, Forte AJ, Brewer MB, Nowygrod R. Bilateral carotid
endarterectomy as treatment of vascular pulsatile tinnitus. J
Vasc Surg 2009;50(July (1)):183—5.
[9] Baumgartner RW, Arnold M, Baumgartner I, Mosso M, Gönner F,
Studer A, et al. Carotid dissection with and without ischemic
events: local symptoms and cerebral artery findings. Neurology
2001;57(September (5)):827—32.
[10] Harrer JU, Popescu O, Henkes HH, Klötzsch C. Assessment of
dural arteriovenous fistulae by transcranial color-coded duplex
sonography. Stroke 2005;36(May (5)):976—9.