For a patient with unilateral pulsatile tinnitus whose computed tomography angiography shows abnormal blood vessels, should the referral be to cardiology or vascular surgery?

Referral to Vascular Surgery or Interventional Neuroradiology

For a patient with unilateral pulsatile tinnitus whose CTA shows abnormal blood vessels, refer to vascular surgery or interventional neuroradiology/neurosurgery (neuroendovascular team), NOT cardiology. 1

Rationale for Neuroendovascular/Vascular Surgery Referral

The abnormal blood vessels identified on CTA in pulsatile tinnitus represent structural vascular lesions in the head and neck region that require specialized neurovascular or vascular surgical expertise. These are not cardiac conditions requiring cardiology management.

When to Refer to the Neuroendovascular Team

Based on the most recent evidence-based protocol 1, refer to the neuroendovascular team if ANY of the following apply:

1. Non-invasive imaging (your CTA) is suspicious for:

   • Dural arteriovenous fistula
   • High-risk vascular lesions (aneurysms, arteriovenous malformations)
   • Idiopathic intracranial hypertension with venous abnormalities

2. Clinical suspicion of high-risk vascular lesion persists despite normal neuroimaging

3. Low-risk lesion is diagnosed BUT the pulsatile tinnitus is debilitating to the patient

Common Vascular Causes Requiring Specialized Referral

The vascular abnormalities causing pulsatile tinnitus include 2, 3:

• Dural arteriovenous fistulas
• Carotid stenosis or dissection
• Arteriovenous malformations
• Aneurysms
• Venous sinus stenosis
• Fibromuscular dysplasia
• Vascular tumors (paragangliomas, glomus tumors)

These lesions carry risk of hemorrhagic stroke, ischemic stroke, or blindness 2, making appropriate specialist referral critical for patient safety.

Why Not Cardiology?

Cardiology manages systemic cardiac conditions that might cause bilateral pulsatile tinnitus through increased cardiac output (e.g., severe anemia, hyperthyroidism, high-output heart failure). Your patient has:

• Unilateral pulsatile tinnitus
• Structural vascular abnormality on imaging

This indicates a localized neurovascular lesion, not a systemic cardiac problem 4.

Treatment Implications

Endovascular management options have significantly expanded with promising results 1. Treatment may include:

• Endovascular embolization 5
• Venous stenting
• Surgical intervention
• Observation for low-risk lesions

Time-sensitive findings occur in approximately 6.5% of pulsatile tinnitus cases 6, including pseudoaneurysms, arteriovenous fistulas, severe carotid stenosis, and fibromuscular dysplasia—all requiring neurovascular expertise.

Critical Pitfall to Avoid

Do not delay referral to the appropriate specialist. While only a small percentage have immediately life-threatening lesions, pulsatile tinnitus with identified vascular abnormalities requires neurovascular evaluation to assess stroke risk and treatment options. Referring to cardiology will result in inappropriate workup and delayed definitive care.