Should a brain MRI with and without gadolinium, including MR angiography (and MR venography if available), be ordered for a patient experiencing pulsatile tinnitus (whooshing in the ear), ear fullness, and migraines?

Imaging for Pulsatile Tinnitus with Ear Fullness and Migraines

Yes, obtain imaging for this patient—the combination of pulsatile tinnitus ("whooshing") with ear fullness warrants vascular imaging to exclude potentially life-threatening conditions like arteriovenous fistulae, vascular malformations, and intracranial hypertension. The presence of migraines further supports this recommendation, as they can be associated with vascular pathology.

Recommended Imaging Algorithm

First-Line Imaging Choice

For pulsatile tinnitus, you have two equally appropriate first-line options 1:

1. CT Angiography (CTA) of head and neck with mixed arterial-venous phase timing (20-25 seconds post-contrast)

   • Captures both arterial and venous anatomy in a single acquisition
   • Provides excellent bone detail for temporal bone evaluation
   • Can identify: paragangliomas, vascular anomalies, sigmoid sinus diverticula, jugular bulb dehiscence, dural AVFs, carotid dissection, atherosclerotic disease

2. MRI/MRA (with MRV if available) of brain with internal auditory canal protocol

   • Comparable accuracy to catheter angiography for vascular malformations 1
   • Better for intracranial masses, vestibular schwannomas, and intracranial hypertension
   • Can evaluate for vascular loops and nerve compression
   • Avoids radiation exposure

Which to Choose First?

Choose MRI/MRA with MRV in this case because:

• The combination of symptoms (pulsatile tinnitus + ear fullness + migraines) raises concern for intracranial hypertension (pseudotumor cerebri), which is best evaluated with MRI/MRV 1
• MRI better evaluates for other causes of these combined symptoms
• Research shows MRI/MRA detects underlying pathology in 40.7% of pulsatile tinnitus cases 2
• Recent data confirms 6.5% of pulsatile tinnitus patients have time-sensitive findings requiring intervention 3

Critical Pathologies to Exclude

The imaging must evaluate for these potentially treatable or dangerous conditions 1:

• Dural arteriovenous fistulae (most common serious finding—14.8% in one series) 2
• Intracranial hypertension/pseudotumor cerebri (associated with sigmoid sinus abnormalities)
• Vascular malformations
• Arterial dissection or aneurysm
• Paragangliomas (glomus tumors)
• Venous sinus stenosis or thrombosis
• Aberrant vascular anatomy

Important Clinical Caveats

Before Imaging

Perform otoscopic examination to look for:

• Vascular retrotympanic mass (changes imaging approach)
• Middle ear pathology
• If a retrotympanic mass is visible, this guides toward specific vascular tumor evaluation 1

When Noninvasive Imaging is Negative

If MRI/MRA or CTA is unrevealing but symptoms persist with objective findings (audible bruit on examination), proceed to catheter angiography 1, 4. Research shows that 21.2% of patients who undergo DSA after negative noninvasive imaging receive a diagnosis, particularly for subtle dural AVFs 5.

The Migraine Connection

While migraines can cause cochlear symptoms (tinnitus, ear fullness, hearing changes occur in 5.9-69% of vestibular migraine patients) 6, you cannot assume symptoms are benign migraine-related without excluding structural pathology first. The pulsatile nature of the tinnitus mandates vascular evaluation.

Common Pitfalls to Avoid

• Don't skip imaging because of the migraine history—migraines don't explain pulsatile tinnitus
• Don't order non-contrast studies—vascular evaluation requires contrast-enhanced imaging 1
• Don't accept "normal" imaging without venous phase evaluation—venous pathology (sigmoid sinus abnormalities, venous stenosis) is a major cause of pulsatile tinnitus with intracranial hypertension 1
• Don't forget that 59.5% of patients may have normal imaging 2, but the 40% diagnostic yield and potential for life-threatening pathology justifies the workup

Bottom Line

Order MRI brain with MRA and MRV (if available) using internal auditory canal protocol with gadolinium contrast. This single study addresses all three symptoms, has the highest yield for the combined presentation, and identifies the treatable vascular and structural causes that could lead to significant morbidity if missed 1, 7.