An evidence-based pulsatile tinnitus clinical workflow: A systematic review of literature

IntroductionEndovascular management options for pulsatile tinnitus (PT) patients have increased in recent years with promising results. However, standardized endovascular team referral criteria remain limited. We conducted a systematic review and suggested an evidence-based referral protocol for PT patients to the neuroendovascular team.MethodsA literature review was conducted in February 2025 using the PubMed/MEDLINE database. We included English-written studies published in the last 5 years, focusing on PT diagnosis and management. Exclusion criteria included: (1) in vitro or animal studies, (2) studies focused on open surgery approaches, (3) studies addressing only non-PT, and (4) case reports, case series (3-10 cases), commentaries, letters to the editor, editorials, and book chapters.ResultsOur initial search retrieved 257 papers. Of these, 219 were excluded after reading the title and abstract, and an additional 12 were excluded after full-text review. A total of 26 papers were eligible for inclusion in this review and in developing our protocol. After PT diagnosis and imaging, our protocol consists of the following three questions: (1) Is non-invasive imaging suspicious for a dural arteriovenous fistula, high-risk vascular lesions, or idiopathic intracranial hypertension? (2) Despite normal neuroimaging, is there clinical suspicion of a high-risk vascular lesion? (3) Although a low-risk lesion is diagnosed, is PT debilitating? If there is a "yes" to any of these questions, referral to the endovascular team is recommended.ConclusionWe suggested an evidence-based referral protocol for PT patients to the neuroendovascular team.