DÄ internationalArchive43/2013No Indication for DSA Without Prior Ultrasound
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The recommended examination strategy to use imaging studies, including cranial imaging, only after taking a thorough history is certainly to be welcomed.

As the authors state, vascular ultrasonography is an essential part of the workup. One would have liked to read that the cause of the tinnitus can often already be revealed by means of ultrasonography – not only using digital subtraction angiography (DSA). Ultrasonography does not only detect vascular stenoses, arteriovenous fistulae can also be clearly identified using Doppler ultrasonography based on the abnormally increased perfusion of the fistula vessels, provided the shunt volume is sufficiently high. In addition to the routine examination procedure, a targeted investigation of the branches of the external carotid artery, in particular the occipital artery, is performed (1). In case the shunt volume of the fistula is low, ultrasonography will fail to diagnose the condition, but the pulsatile tinnitus will be absent too. Therefore, we can definitely not agree with the statement that a pulsatile tinnitus without detectable cause is an indication for DSA.

Our ultrasonography laboratory has diagnosed dural fistulas in seven patients with pulsatile tinnitus using ultrasound in the first half of this year alone, while MRI and MRA scans were unremarkable in most cases. In some cases, the diagnosis was established in advance by office-based colleagues using ultrasonography and confirmed by us. All imaging results of dural fistula were confirmed by angiography, because DSA is required for the evaluation of venous drainage and therefore for the assessment of the bleeding risk (2). Our concept “DSA only in case of abnormal ultrasound findings“ has proven its benefits over many years and is recognized beyond the service area of our hospital.

DOI: 10.3238/arztebl.2013.0734a

Prof. Dr. med. Christian Arning

Abteilung Neurologie,
Asklepios Klinik Wandsbek, Hamburg

c.arning@asklepios.com

1.
Arning C, Grzyska U, Lachenmayer L: Duplexsonographie von A. carotis externa-Ästen zum Nachweis duraler AV-Fisteln. Röfo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2005; 177: 236–41 CrossRef MEDLINE
2.
Cognard C, Gobin YP, Pierot L, et al.: Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology 1995; 194: 671–80 MEDLINE
3.
Hofmann E, Behr R, Neumann-Haefelin T, Schwager K: Pulsatile
tinnitus—imaging and differential diagnosis. Dtsch Arztebl Int 2013; 110(26): 451−8 VOLLTEXT
1.Arning C, Grzyska U, Lachenmayer L: Duplexsonographie von A. carotis externa-Ästen zum Nachweis duraler AV-Fisteln. Röfo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2005; 177: 236–41 CrossRef MEDLINE
2.Cognard C, Gobin YP, Pierot L, et al.: Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology 1995; 194: 671–80 MEDLINE
3.Hofmann E, Behr R, Neumann-Haefelin T, Schwager K: Pulsatile
tinnitus—imaging and differential diagnosis. Dtsch Arztebl Int 2013; 110(26): 451−8 VOLLTEXT

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