Detecting causes of pulsatile tinnitus on CT arteriography-venography: A pictorial review

Highlights: • Raises awareness of CT arteriography-venography as a 'one-catch' technique for detecting the causes of pulsatile tinnitus. • Reviews the multiple possible aetiologies that should be excluded on CT A–V. • Provides a pictorial review of the common findings in imaging assessment and the clinical utility and limitations of CT A–V. • Provides a reporting checklist to aid in radiological assessment. Pulsatile tinnitus (PT) can be a mild or debilitating symptom. Following clinical examination and otoscopy, when the underlying aetiology is not apparent, radiological imaging can be used to evaluate further. CT arteriography-venography (CT A–V) of the head and neck has recently been introduced as a single 'one catch' modality for identifying the many causes of PT including those which are treatable and potentially serious whilst also providing reassurance through negative studies or studies with benign findings. CT A–V is performed as a single phase study allowing both arterial and venous assessment, hence limiting radiation exposure. Additional multiplanar reformats and bone reconstructions are desirable. Understanding the limitations of CT A–V is also required, with an awareness of the scenarios where other imaging modalities should be considered. The causes of PT can be divided into systemic and non-systemic categories. Non-systemic aetiologies in the head and neck should be carefully reviewed on CT A–V and include a variety of vascular causes (arteriovenous malformations/fistulas, venous or arterial aetiologies) and non-vascular causes (tumours and bony dysplasias). Venous causes (dominant, aberrant, stenosed or thrombosed venous vessels) are more common than arterial aetiologies (aberrant or stenosed internal carotid artery, aneurysms or a persistent stapedial artery). Glomus tumours that are not visible on otoscopy and osseous pathologies such as bony dehiscence and otospongiosis should also be excluded. Careful assessment of all the potential vascular and non-vascular causes should be reviewed in a systematic approach, with correlation made with the clinical history. A structured reporting template for the reporting radiologist is provided in this review to ensure all the potential causes of PT are considered on a CT A–V study. This will help in providing a comprehensive radiological evaluation, hence justifying the radiation dose and for patient assessment and prognostication.