0:01

This is a patient who had pulsatile

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tinnitus bilaterally.

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And the initial head MRI scan

0:08

was relatively unremarkable.

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Here you can see the FLAIR scans where there was just a

0:12

minor amount of white matter disease, and the diffusion

0:16

weighted scans showed no evidence of strokes.

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And the MRA was also not revealing.

0:24

All of these studies were performed because of the

0:29

possibility of a vascular abnormality that was causing

0:33

pulsatile tinnitus on the MRA raw data.

0:37

However,

0:37

you may identify that there appear to be a large number of

0:43

flow signal vessels at the jugular

0:46

foramen on the left side.

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You can see we usually don't see that amount of small

0:52

vessels up in the jugular foramen on the MRA.

0:56

You can see on the contralateral side, the right side,

0:59

things look just fine. So of course,

1:03

this requires post-gadolinium enhanced

1:05

scanning with thin-section images.

1:08

Here is the post-gadolinium fat-sat of this patient

1:12

who had bilateral pulsatile tinnitus.

1:17

Let's start on the right side.

1:18

So we're going to focus on the right

1:20

side of the temporal bone.

1:22

And what we see almost immediately is contrast-enhancing

1:26

soft tissue overlying the cochlear promontory

1:28

and extending into the round window niche.

1:31

So this is the area of the cochlea.

1:33

You can make out the cochlear here,

1:36

and this is overlying the cochlea.

1:38

And at the cochlear promontory, we have a soft tissue

1:41

mass that is showing avid contrast enhancement,

1:44

which we didn't see on the non-contrast images.

1:47

There's nothing down here.

1:49

This is the sigmoid sinus going into the jugular bulb

1:53

and we don't see any abnormalities here in the jugular

1:56

on the right side. And those soft tissue masses.

1:59

Interestingly enough,

2:01

the patient also had contrast-enhancing tissue

2:05

along the petroclinoid ligament.

2:07

And this was a meningioma that was present with partial

2:12

calcification seen on the CT scan on the right side.

2:16

And we also note an arachnoid cyst.

2:19

What about the contralateral side?

2:21

We had left-sided pulsatile tinnitus as well.

2:24

So let's look on the left temporal bone.

2:27

In the left temporal bone, we see a soft tissue mass

2:31

which is present in the jugular foramen.

2:34

Here is our sigmoid sinus.

2:37

So just at the junction between the sigmoid

2:39

sinus and the jugular bulb,

2:41

we see soft tissue growing into that distalmost

2:43

portion of the sigmoid sinus.

2:45

And we have this irregular contrast-enhancing

2:49

tissue which has signal voids within it.

2:53

So here are those little dots of vascularity within

2:57

this mass that correspond to the MRA findings.

3:02

So here again,

3:04

vascular flow signal within the jugular bulb and jugular

3:09

proximal jugular vein representing a glomus jugular

3:15

tumor. And let's look on the coronal scan.

3:19

On the coronal scan here,

3:20

we have that flow void within the mass.

3:26

So we're below the skull base.

3:27

This is a tumor that grows into the jugular vein.

3:31

There's a manuscript I published with Emmanuel Oru from

3:35

Italy about the incidence of paragangliomas jugularis

3:41

growing into the jugular veins very high, over 85%,

3:45

and with a flow void within it.

3:47

And then here we are at the jugularamen.

3:50

And on the contralateral side,

3:51

you see the smaller area of contrast enhancement

3:55

in the middle ear cavity.

3:57

So bilateral paragangliomas with a meningioma on the

4:03

right side shown as thickening of the tentorium and

4:07

the petroclinoid ligament. And in point of fact,

4:11

I believe this patient had another small finding,

4:16

which was a small aneurysm,

4:21

also seen in the anterior communicating artery region.

4:26

So multiple paragangliomas. Again,

4:29

we consider that as potentially a hereditary congenital

4:34

syndrome of multiple paragangliomas.

4:38

We should definitely take a look at the carotid

4:42

bifurcations in a neck MRI scan to see whether there's

4:46

any lesion at the carotid bifurcation,

4:48

which could be a carotid body tumor,

4:50

and any lesions at the C1, C2 skull base,

4:53

which could represent a glomus vagale.