Patient-reported outcomes before treatment for localized prostate cancer: are there differences among countries? Data from the True North Global Registry.

INTRODUCTION: Similar Patient-Reported Outcomes (PROs) at diagnosis for localized prostate cancer among countries may indicate that different treatments are recommended to the same profile of patients, regardless the context characteristics (health systems, medical schools, culture, preferences…). The aim of this study was to assess such comparison. METHODS: We analyzed the EPIC-26 results before the primary treatment of men diagnosed of localized prostate cancer from January 2017 onwards (revised data available up to September 2019), from a multicenter prospective international cohort including seven regions: Australia/New Zealand, Canada, Central Europe (Austria / Czech Republic / Germany), United Kingdom, Italy, Spain, and the United States. The EPIC-26 domain scores and pattern of three selected items were compared across regions (with Central Europe as reference). All comparisons were made stratifying by treatment: radical prostatectomy, external radiotherapy, brachytherapy, and active surveillance. RESULTS: The sample included a total of 13,483 men with clinically localized or locally advanced prostate cancer. PROs showed different domain patterns before treatment across countries. The sexual domain was the most impaired, and the one with the highest dispersion within countries and with the greatest medians' differences across countries. The urinary incontinence domain, together with the bowel and hormonal domains, presented the highest scores (better outcomes) for all treatment groups, and homogeneity across regions. CONCLUSIONS: Patients with localized or locally advanced prostate cancer undergoing radical prostatectomy, EBRT, brachytherapy, or active surveillance presented mainly negligible or small differences in the EPIC-26 domains before treatment across countries. The results on urinary incontinence or bowel domains, in which almost all patients presented the best possible score, may downplay the baseline data role for evaluating treatments' effects. However, the heterogeneity within countries and the magnitude of the differences found across countries in other domains, especially sexual, support the need of implementing the PRO measurement from diagnosis.

MRI in head and neck cancer following chemoradiotherapy: what is the optimal delay to demonstrate maximal response?

OBJECTIVES: To investigate the optimal timing for post-chemoradiotherapy (CRT) reference magnetic resonance imaging (MRI) in head and neck cancer, so as to demonstrate a maximal treatment response. To assess whether this differs in human papillomavirus-related oropharyngeal cancer (HPV-OPC) and whether the MRI timing impacts on the ability to predict treatment success. METHODS: Following ethical approval and informed consent, 45 patients (40 male, mean age 59.7 ± 7.9 years, 33 HPV-OPC) with stage 3 and 4 HNSCC underwent pre-treatment, 6- and 12-week post-CRT MRIs in this prospective cohort study. Primary tumour (n = 39) size, T2w morphology and diffusion weight imaging (DWI) scores, together with nodal (n = 42) size and necrotic/cystic change, were recorded. Interval imaging changes were analysed for all patients and according to HPV-OPC status. MRI descriptors and their interval changes were also compared with 2-year progression-free survival (PFS). RESULTS: All MRI descriptors significantly changed between pre-treatment and 6-week post-treatment MRI studies (p < .001). Primary tumour and nodal volume decreased between 6- and 12-week studies; however, interval changes in linear dimensions were only evident for HPV-OPC lymph nodes. Nodal necrosis scores also evolved after 6 weeks but other descriptors were stable. The 6-week nodal necrosis score and the 6- and 12-week nodal volume were predictive of 2-year PFS. CONCLUSION: Apart from HPV-OPC patients with nodal disease, the 6-week post-CRT MRI demonstrates maximal reduction in the linear dimensions of head and neck cancer; however, a later reference study should be considered if volumetric analysis is applied. KEY POINTS: • This study provides guidance on when early post-treatment imaging should be performed in head and neck cancer following chemoradiotherapy, in order to aid subsequent detection of recurrent tumour. • Lymph nodes in HPV-related oropharyngeal cancer patients clearly reduced in size from 6 to 12 weeks post-treatment. However, other lymph node disease and all primary tumours showed only a minor reduction in size beyond 6 weeks, and this required a detailed volumetric analysis for demonstration. • Timing of the reference MRI following chemoradiotherapy for head and neck cancer depends on whether the patient has HPV-related oropharyngeal cancer and whether there is nodal disease. MRI as early as 6 weeks post-treatment may be performed unless volumetric analysis is routinely performed.

Endolymphatic hydrops magnetic resonance imaging in Ménière's disease.

This review is designed to help radiologists interested in developing a magnetic resonance imaging service for patients with symptoms of Ménière's disease. Examples are selected from our experience with delayed post-gadolinium three-dimensional (3D) fluid attenuated inversion recovery (FLAIR) inner ear imaging of endolymphatic hydrops. The imaging features of the normal and hydropic endolymphatic structures, semiquantitative grading systems, normal variations, and differential diagnoses will be illustrated, whilst appropriate clinical referrals, approaches to reporting and diagnostic pitfalls will be discussed.

Imaging of the temporal bone.

This review will focus on key recent advances in imaging of the temporal bone. The role of magnetic resonance imaging (MRI) in providing aetiological and prognostic information for patients with sudden sensorineural hearing loss will be discussed. Novel MRI sequences, such as delayed contrast-enhanced 3D fluid-attenuated inversion recovery (FLAIR) and their utility in the identification and grading of endolymphatic hydrops in Ménière's disease will be described. Furthermore, we will document the considerable advances in auditory implant technology (including active middle ear implants), and how multidetector computed tomography (CT) and cone-beam CT may be invaluable in their preoperative and postoperative assessment. Finally, advances in the imaging of cholesteatoma, third-window lesions, otospongiosis (including internal auditory canal diverticula), and vestibular schwannoma will be reviewed.

Is CT or MRI the optimal imaging investigation for the diagnosis of large vestibular aqueduct syndrome and large endolymphatic sac anomaly?

BACKGROUND AND PURPOSE: We explored whether there was a difference between measurements obtained with CT and MRI for the diagnosis of large vestibular aqueduct syndrome or large endolymphatic sac anomaly, and whether this influenced diagnosis on the basis of previously published threshold values (Valvassori and Cincinnati). We also investigated whether isolated dilated extra-osseous endolymphatic sac occurred on MRI. Secondary objectives were to compare inter-observer reproducibility for the measurements, and to investigate any mismatch between the diagnoses using the different criteria. MATERIALS/METHODS: Subjects diagnosed with large vestibular aqueduct syndrome or large endolymphatic sac anomalies were retrospectively analysed. For subjects with both CT and MRI available (n = 58), two independent observers measured the midpoint and operculum widths. For subjects with MRI (± CT) available (n = 84), extra-osseous sac widths were also measured. Results There was no significant difference between the width measurements obtained with CT versus MRI. CT alone diagnosed large vestibular aqueduct syndrome or large endolymphatic sac anomalies in 2/58 (Valvassori) and 4/58 (Cincinnati), whilst MRI alone diagnosed them in 2/58 (Valvassori). There was 93% CT/MRI diagnostic agreement using both criteria. Only 1/84 demonstrated isolated extra-osseous endolymphatic sac dilatation. The MRI-based LVAS/LESA diagnosis was less dependent on which criteria were used. Midpoint measurements are more reproducible between observers and between CT/MR imaging modalities. CONCLUSION: Supplementing MRI with CT results in additional diagnoses using either criterion, however, there is no net increased diagnostic sensitivity for CT versus MRI when applying the Valvassori criteria. Isolated enlargement of the extra-osseous endolymphatic sac is rare.

Contemporary imaging of auditory implants.

There have been significant advances in the diversity and effectiveness of hearing technologies in recent years. Implanted auditory devices may be divided into those that stimulate the cochlear hair cells (bone conduction devices and middle ear implants), and those that stimulate the neural structures (cochlear implants and central auditory implants). Contemporary preoperative and postoperative imaging may be used to help individualise implant selection, optimise surgical technique and predict auditory outcome. This review will introduce the concepts behind auditory implants, and explains how imaging is increasingly used to aid insertion and evaluation of these devices.

MRI in otology: applications in cholesteatoma and Ménière's disease.

Imaging of middle-ear cholesteatoma with diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI), and inner-ear endolymphatic hydrops (in Ménière's disease) with post-gadolinium high-resolution MRI, are reviewed. DWI MRI provides for a more specific diagnosis of tympano-mastoid cholesteatoma. There is an established and increasing role of DWI MRI in detecting both primary and postoperative cholesteatoma, localising disease, and planning surgery. The contemporary diagnostic accuracy of DWI is reviewed, pitfalls in interpretation are described, and potential future developments are highlighted. High-resolution post-gadolinium MRI of the inner ear is being explored for diagnosing endolymphatic hydrops. There is now increasing data to validate the application of three-dimensional (3D)-fluid attenuated inversion recovery (FLAIR) sequences, performed at 4 hours post-intravenous gadolinium, in the setting of potential Ménière's disease. The clinical context and the evolution of these MRI techniques are discussed. Current MRI-based grading schemes for endolymphatic hydrops are described, together with the available data on their clinical implications.

Diagnostic yield and impact of MRI for acute ischaemic stroke in patients presenting with dizziness and vertigo.

AIM: To identify predictors of acute ischaemic stroke (AIS) and evaluate the diagnostic yield and impact of magnetic resonance imaging (MRI) in patients imaged for dizziness and vertigo. MATERIALS AND METHODS: Patients imaged using MRI, including diffusion-weighted imaging (DWI) with or without computed tomography (CT), for dizziness and vertigo over a 2-year period were identified retrospectively. MRI findings were categorised as "acute ischaemic stroke", "significant", or "non-significant". We reviewed the medical records to identify presenting symptoms and signs, vascular risk factors, duration of symptoms, and pre- and post-MRI clinical management in patients with proven stroke. RESULTS: One hundred and eighty-eight patients were included: 39 with vertebrobasilar AIS (20.7%), 32 (17%) with a significant but non-ischaemic abnormality, and 117 (62.2%) with a normal or non-related abnormality. The sensitivity of CT in diagnosing AIS was 9.52% (95% CI: 1.67-31.8%). Posterior inferior cerebellar artery (PICA) territory infarcts were the most common (38.5%). Patients with AIS were significantly more likely to be older than 50 years (p = 0.04), have a greater number of cardiovascular risk factors (p < 0.01), shorter duration of symptoms (p = 0.03), and at least one neurological sign (p = 0.02). DWI MRI had a diagnostic impact on 21.6% patients with stroke. CONCLUSION: MRI plays an important role in differentiating peripheral and central aetiology when this proves challenging clinically. Predictors of AIS were identified that aid patient selection for MRI, to increase the yield and impact of neuroimaging.

Imaging of dizziness.

Dizziness is a frequent indication for neuroimaging within the outpatient and emergency setting with variable diagnostic yield. The majority of persistent, recurrent, and isolated dizziness can be managed clinically. However, it may be difficult to distinguish a benign peripheral aetiology from a central cause, particularly in the emergency setting. We review the relevant anatomy, differential diagnosis, and key imaging features of central and peripheral causes of dizziness, as well as the literature for the diagnostic yield in acute and outpatient settings.

MRI-based anatomical landmarks for the identification of thoracic vertebral levels.

AIM: To identify soft-tissue and bony anatomical landmarks on dedicated thoracic spine magnetic resonance imaging (MRI), and to assess their detectability, reproducibility, and accuracy in predicting specific thoracic vertebral levels. MATERIALS AND METHODS: One hundred dedicated thoracic MRI studies were retrospectively analysed by two radiologists independently. Ten bone and soft-tissue landmarks were localized to the adjacent vertebral level. The true numerical thoracic vertebral level was subsequently determined and recorded by cross referencing with a sagittal cervico-thoracic "counting scan". RESULTS: Six landmarks were defined in ≥98% cases; however, there was a low interobserver percentage agreement for the defined vertebral levels (>70% for only one landmark). The most useful landmark for defining a specific vertebral level was the most superior rib (98% detection, 95% interobserver agreement, 98% at a single vertebral level, 0.07 SD). Eight landmarks localized to a specific thoracic segment in only 16-44% of cases, with a standard deviation of >0.5 vertebral levels and with a range which was greater than four vertebral levels. CONCLUSION: The C2 vertebra must be identified and cross referenced to the dedicated thoracic spine MRI, as other MRI-based anatomical landmarks are unreliable in determining the correct thoracic vertebral level.

The Impact of Interactive MRI-Based Radiologist Review on Radiotherapy Target Volume Delineation in Head and Neck Cancer.

BACKGROUND AND PURPOSE: Peer review of head and neck cancer radiation therapy target volumes by radiologists was introduced in our center to optimize target volume delineation. Our aim was to assess the impact of MR imaging-based radiologist peer review of head and neck radiation therapy gross tumor and nodal volumes, through qualitative and quantitative analysis. MATERIALS AND METHODS: Cases undergoing radical radiation therapy with a coregistered MR imaging, between April 2019 and March 2020, were reviewed. The frequency and nature of volume changes were documented, with major changes classified as per the guidance of The Royal College of Radiologists. Volumetric alignment was assessed using the Dice similarity coefficient, Jaccard index, and Hausdorff distance. RESULTS: Fifty cases were reviewed between April 2019 and March 2020. The median age was 59 years (range, 29-83 years), and 72% were men. Seventy-six percent of gross tumor volumes and 41.5% of gross nodal volumes were altered, with 54.8% of gross tumor volume and 66.6% of gross nodal volume alterations classified as "major." Undercontouring of soft-tissue involvement and unidentified lymph nodes were predominant reasons for change. Radiologist review significantly altered the size of both the gross tumor volume (P = .034) and clinical target tumor volume (P = .003), but not gross nodal volume or clinical target nodal volume. The median conformity and surface distance metrics were the following: gross tumor volume Dice similarity coefficient = 0.93 (range, 0.82-0.96), Jaccard index = 0.87 (range, 0.7-0.94), Hausdorff distance = 7.45 mm (range, 5.6-11.7 mm); and gross nodular tumor volume Dice similarity coefficient = 0.95 (0.91-0.97), Jaccard index = 0.91 (0.83-0.95), and Hausdorff distance = 20.7 mm (range, 12.6-41.6). Conformity improved on gross tumor volume-to-clinical target tumor volume expansion (Dice similarity coefficient = 0.93 versus 0.95, P = .003). CONCLUSIONS: MR imaging-based radiologist review resulted in major changes to most radiotherapy target volumes and significant changes in volume size of both gross tumor volume and clinical target tumor volume, suggesting that this is a fundamental step in the radiotherapy workflow of patients with head and neck cancer.

Discontinuity of the incudo-stapedial joint within a fully aerated middle ear and mastoid on computed tomography: A clinico-radiological study of its aetiology and clinical consequence.

AIM: To investigate the aetiology and clinical consequences of incudo-stapedial (IS) discontinuity when it is demonstrated on computed tomography (CT) within a fully aerated middle ear and mastoid. METHODS AND MATERIALS: Patients with CT evidence of IS discontinuity within a fully aerated middle ear and mastoid were prospectively identified. Clinical history, otoscopic findings, audiometry, and CT data were evaluated. Predefined criteria were used to determine the likely aetiology of IS discontinuity, whether it was diagnosed prior to the CT study, and the clinical consequences in terms of degree of conductive hearing loss and requirement for surgical correction. The range of CT appearances was evaluated. RESULTS: The IS discontinuity in 34/36 ears was felt to be due to incus erosion secondary to chronic otitis, on the basis of clinical history and otoscopic findings. The IS discontinuity was rarely evident prior to CT with long-process deficiency being identified in only 5/36 cases. The mean air bone gap was only 22.5 dB. The ossicular defect was surgically addressed in only four cases. The incus deficiency was confined to the lower-third on CT in 19/36 cases. CONCLUSION: When IS discontinuity is demonstrated within a fully aerated middle ear and mastoid, the most likely aetiology is of acquired incus erosion due to chronic otitis media. The IS discontinuity on CT is usually not evident otoscopically. It usually results in only mild conductive hearing loss and the ossicular discontinuity was rarely surgically addressed in the present series.

The role of radiology in the diagnosis and management of vestibular schwannoma.

The most frequent lesion identified at the cerebellopontine angle cistern and internal auditory meatus (IAM) is the vestibular schwannoma. Radiological features, the role of imaging in screening and follow-up, therapeutic approaches and appearances following treatment will be discussed. Other cerebellopontine angle lesions will be illustrated and an algorithm presented to help in the imaging differential diagnosis. Whilst lesions other than vestibular schwannomas are rarely isolated to the IAM, the key clinical and radiological features that should raise the possibility of alternative neoplastic and inflammatory diseases will be highlighted.

'Black Bone' magnetic resonance imaging as a novel technique to aid the pre-operative planning of posterior tympanotomy for cochlear implantation.

Purpose: 'Black Bone' magnetic resonance imaging (BB MRI) is a novel sequence developed as an alternative to computed tomography (CT) for osseous imaging. We explored its potential utilisation in the pre-operative surgical planning of posterior tympanotomy for cochlear implantation through depiction of the mastoid facial nerve (mFN) canal and the posterior canaliculus of the chorda tympani (ChT), thus defining the facial recess. Methods: Twenty five adult patients were prospectively imaged with a dedicated BB MRI sequence. A consensus qualitative BB MRI 'visibility score' for the confidence of demonstration of the mFN canal and the posterior canaliculus of the ChT was recorded, as well as a 'corresponding score' to determine whether the neural structures on BB MRI corresponded to the paths of the nerves on a previous CT study. Results/discussion: The BB MRI sequence was able to clearly delineate the course of mFN in 100% of cases and that of ChT in 72%, with their courses corresponding to those depicted on CT in almost all cases. Maximum intensity projections with 7 mm slabs provided the optimal simultaneous demonstration of mFN, ChT and round window along the posterior tympanotomy surgical approach. Conclusion: The proposed BB MRI sequence reliably depicts mFN and ChT in the majority of cases, with a performance comparable to that of CT. It is proposed that it will be a useful adjunct to MRI protocols as part of cochlear implant assessment in those centres where CT is not routinely performed.

Persistent Trigeminal Artery: A Novel Imaging Finding in CHARGE Syndrome.

BACKGROUND AND PURPOSE: Coloboma of the eye, Heart defects, Atresia of the choanae, Retardation of growth and/or development, Genital and/or urinary abnormalities, Ear abnormalities and deafness (CHARGE) syndrome is an autosomal dominant genetic disorder with evolving clinical diagnostic criteria. Recently, a number of additional anomalies have been described in this syndrome, which may aid in early diagnosis, particularly in incomplete phenotypes or atypical cases. The persistent trigeminal artery is an embryonic carotid-vertebral anastomosis, rarely seen in the healthy population, with a reported prevalence of 0.4%. Because we had observed the persistent trigeminal artery in patients with CHARGE syndrome, this study aimed to explore the prevalence of the persistent trigeminal artery in this syndrome. MATERIALS AND METHODS: A retrospective study was performed at our tertiary center. MR imaging studies, clinical records, and genetic results were reviewed for patients diagnosed with CHARGE syndrome between 2006 and 2019. The prevalence of the persistent trigeminal artery in patients with CHARGE syndrome was recorded and compared with other established diagnostic criteria. RESULTS: Twenty-five patients with CHARGE syndrome were included. The persistent trigeminal artery was demonstrated on MR imaging in 14/25 (56%) patients and was seen more frequently than 4 of 9 other established diagnostic criteria in our cohort. When individual major or minor diagnostic criteria were absent, the persistent trigeminal artery was still demonstrated on MR imaging in 52%-67% of these patients with CHARGE syndrome. CONCLUSIONS: The prevalence of the persistent trigeminal artery in CHARGE syndrome of 56% is higher than that of some other established diagnostic criteria and much higher than that in the general population. The persistent trigeminal artery may be a useful addition to the expanding phenotype of CHARGE syndrome, supplementing other diagnostic criteria. Radiologists should be aware of this novel finding demonstrable on MR imaging.

Imaging of skull-base cephalocoeles and cerebrospinal fluid leaks.

Skull-base cephalocoeles and cerebrospinal fluid (CSF) leaks may be congenital, spontaneous, or secondary. A classification of congenital lesions is formulated and the imaging features are illustrated. The concept of spontaneous skull-base CSF leaks and the significance of aberrant arachnoid granulations in imaging these patients are explored. The majority of secondary lesions relate to trauma; however, other potential causes of secondary skull-base cephalocoeles and CSF leaks are discussed. Imaging evaluation in these clinical scenarios may be complex and the role of each imaging method is reviewed.

Diagnostic Yield and Therapeutic Impact of Face and Neck Imaging in Patients Referred with Otalgia without Clinically Overt Disease.

BACKGROUND AND PURPOSE: Otalgia may be secondary to serious pathology, such as upper aerodigestive tract malignancies, and CT or MR imaging of the skull base, face, and neck is often performed to detect clinically occult lesions. The diagnostic yield, management impact, and therapeutic impact of imaging in this clinical scenario, however, have yet to be elucidated. MATERIALS AND METHODS: CT and MR imaging in patients who presented with otalgia without clinically overt disease was retrospectively analyzed from a single center over a 9-year period. The cohort was subdivided into groups, depending on the presence of additional symptoms and a history of head and neck cancer. Relevant diagnostic outcome findings were categorized, and the diagnostic yield and impact of imaging on management and therapy were calculated for each group. RESULTS: In our study cohort of 235 patients, the diagnostic yield of imaging for otalgia, with or without other symptoms, in patients who lacked a history of head and neck cancer was negligible for upper aerodigestive tract malignancy (1%), abnormalities related to otalgia (2%), and other moderate or major findings (2%). Although equivocal or unimportant findings occasionally resulted in additional investigations, the therapeutic impact was also very low (2%). The diagnostic yield for upper aerodigestive tract malignancy (34%) and therapeutic impact increased (34%) when there was a history of head and neck cancer. CONCLUSIONS: The diagnostic yield and therapeutic impact of imaging for otalgia without clinically overt disease are very low, unless there is a history of head and neck cancer.

Metabolic cooperation between vascular endothelial cells and smooth muscle cells in co-culture: changes in low density lipoprotein metabolism.

A microcarrier co-culture system for aortic endothelial cells and smooth muscle cells (SMCs) was developed as a model for metabolic interactions between cells of the vessel wall. Low density lipoprotein (LDL) metabolism in SMCs was significantly influenced by co-culture with endothelium. The numbers of high affinity receptors for LDL was increased more than twofold (range, 2.1-5.6), with concomitant increases in LDL receptor-mediated endocytosis and degradation. These effects reached a plateau at an endothelial cell/SMC ratio of 1. Kinetic analysis of the endocytic pathway for LDL in SMCs indicated that, in co-culture with endothelium, there was no alteration in the binding affinity of LDL to its receptors but that the internalization rate constant declined and the rate constant for degradation increased. This analysis suggested that the formation and migration of endocytic vesicles was the rate-limiting step of enhanced LDL metabolism under co-culture conditions. Two mechanisms by which endothelial cells influenced smooth muscle LDL metabolism were identified. First, mitogen(s) derived from endothelial cells stimulated entry of SMCs into the growth cycle, and the changes in LDL metabolism occurred as a consequence of G1-S transition. Second, SMC lipoprotein metabolism was stimulated in the absence of mitogens by a low molecular weight (less than 3,500) factor or factors. Co-culture was a required condition for the latter effect, suggesting that the mediator(s) may be unstable or that cell-cell communication was necessary for expression. These results (a) demonstrate that vascular cell interactions can modify LDL metabolism in SMCs, (b) provide some insights into the mechanisms responsible, and (c) identify co-culture as an experimental approach appropriate to certain aspects of vascular cell biology.

Diagnostic yield of MRI for audiovestibular dysfunction using contemporary referral criteria: correlation with presenting symptoms and impact on clinical management.

AIM: To investigate the diagnostic yield of T2-weighted magnetic resonance imaging (MRI) screening for vestibular schwannoma and other relevant conditions in the setting of audiovestibular symptoms, given the more liberal contemporary referral criteria. To determine whether presenting clinical symptoms correlate with imaging outcome in order to guide future protocols for MRI referral. MATERIALS AND METHODS: Eight hundred and eighty-one consecutive MRI examinations performed in patients with audiovestibular dysfunction were reviewed. Clinical indications and findings were recorded. Case notes were reviewed in patients with positive imaging findings. Two-way, cross-tabulation, Chi-square analysis was performed to assess the relationship between presenting symptoms and imaging outcome. RESULTS: Twelve of the 881 (1.4%) were positive for vestibular schwannoma. A further four of 881 (0.4%) revealed other relevant conditions. Incidental conditions, felt to be irrelevant to the presenting symptoms, were noted in 12 of the 881 (1.4%). In all 12 cases that were positive for vestibular schwannoma, either tinnitus or hearing loss was present. CONCLUSION: The yield for T2-weighted MRI to diagnose vestibular schwannoma and other relevant retrocochlear conditions was lower than for previous studies, which is likely to reflect trends in referral criteria. No single audiovestibular symptom or combination of symptoms is a statistically significant predictor of imaging outcome.

Imaging in pulsatile tinnitus.

Tinnitus may be continuous or pulsatile. Vascular lesions are the most frequent radiologically demonstrable cause of pulsatile tinnitus. These include congenital vascular anomalies (which may be arterial or venous), vascular tumours, and a variety of acquired vasculopathies. The choice of imaging depends on the clinical findings. If a mass is present at otoscopy, thin-section computed tomography (CT) is indicated. In the otoscopically normal patient, there is a range of possible imaging approaches. However, combined CT angiography and venography is particularly useful.