鼻内镜下脑脊液鼻漏修补术前漏口定位方法

目的 探讨经鼻内镜行脑脊液鼻漏修补术前准确定位漏口的方法。方法 16例脑脊液鼻漏患者采用术前鼻内镜检查、多层螺旋CT(MSCT)及其三维重建、SPECT/CT脑脊液断层显像等方法判断漏口位置,并与手术结果对比。结果 14例脑脊液鼻漏患者可于MSCT及三维重建中显示颅底骨质异常,15例经SPECT/CT脑脊液断层显像可见颅底至鼻部有异常放射性浓聚影,4例于术前鼻内镜检查中见有脑脊液漏出。有15例患者术前漏点定位与术中所见一致,1例与术中所见不符,手术修补失败后详细检查为脑脊液耳漏经鼻孔流出。结论 经鼻内镜脑脊液鼻漏修补术前采用鼻内镜检查、MSCT及三维重建、SPECT/CT等多种方法对漏口进行综合定位分析,可为手术成功奠定基础。应警惕脑脊液耳漏漏液经鼻腔漏出的可能。     

The role of positron emission tomography/computed tomography in the management of recurrent papillary thyroid carcinoma

OBJECTIVES/HYPOTHESIS: The aim of the study was to evaluate the role of combined positron emission tomography/computed tomography (PET/CT) fusion imaging in the detection and management of recurrent papillary thyroid cancer. STUDY DESIGN: A retrospective analysis of 33 patients with suspected recurrent papillary thyroid carcinoma who had undergone PET/CT was performed. PET/CT was compared with standard imaging techniques in each patient to determine whether PET/CT contributed to the therapeutic management plan. Histopathological findings were correlated to PET/CT in patients who underwent surgery. METHODS: The senior author reviewed the charts of 33 patients with recurrent papillary thyroid carcinoma to determine the impact PET/CT had on management. PET/CT was compared with conventional imaging results. In surgical patients, PET/CT was compared with histopathological findings to determine its sensitivity, specificity, accuracy, positive predictive value, and negative predictive value. RESULTS: In 67% of the cases (22 of 33), PET/CT supplied additional information that altered or confirmed the management plan. Twenty of 33 patients underwent surgery with 36 sites assessed by histopathological analysis. PET/CT correlated with histopathological findings in 25 of 36 distinct anatomical sites, with an accuracy of 70%. The sensitivity of PET/CT in identifying recurrence was found to be 66%, with a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 27%. CONCLUSION: Combined PET/CT fusion scanning was most useful in the detection and management of recurrent papillary thyroid cancer in patients who had average thyroglobulin levels greater than 10 ng/mL and when the tumor no longer concentrated radioactive iodine. In 100% of the cases in which PET/CT localized a region suspicious for malignancy, histopathological analysis confirmed the results. When PET/CT is positive, it is a powerful tool for predicting exact locations of recurrent papillary thyroid cancer, thus making it a reliable guide for surgical planning. PET/CT is a supplement to conventional imaging and fine-needle aspiration in the workup of recurrent papillary thyroid cancer. A negative finding on PET/CT is not sufficiently reliable to preclude further investigation and treatment.     

Technetium 99m single positron emission computed tomography scanning for assessing mandible invasion in oral cavity cancer

OBJECTIVES: To study the accuracy of single positron emission computed tomography (SPECT) scanning and compare its results to clinical examination, Panorex, and computed tomography (CT) scanning with respect to determining mandibular invasion by oral cavity and oropharyngeal cancer, and to define the role of SPECT scanning in the preoperative assessment of oromandibular cancer. STUDY DESIGN: Prospective study of 38 patients who underwent technetium 99m SPECT scanning as part of their preoperative clinical assessment for cancer at risk of invading the mandible. All patients underwent partial or segmental mandibulectomy as part of their surgical management. METHODS: A data protocol was used to tabulate patient demographics, tumor characteristics and results of preoperative tests as patients were enrolled into the study. Following surgical treatment, these data were correlated with histopathological findings. Detailed analysis was performed to assess the tabulated data. RESULTS: The SPECT scanning demonstrated an 87% overall accuracy in predicting bone invasion compared with 71% for clinical examination, CT scanning, and Panorex x-rays. The SPECT scanning was significantly more sensitive (95%) than either CT scans (55%) or Panorex x-rays (50%). Notably SPECT scanning demonstrated a considerable improvement in specificity (72%) compared with conventional radionuclide scanning. Although not as specific as CT scanning or plain films, SPECT scanning was significantly more effective in ruling out disease than was clinical examination. CONCLUSIONS: Preoperative SPECT scanning used in combination with clinical examination, CT scanning, and Panorex x-rays to assess patients at risk for mandible involvement by oral cavity cancer can improve the accuracy of predicting bone invasion and help in appropriate treatment planning so as to safely reduce the proportion of disease-free jaws resected.     

Sentinel lymph node mapping using SPECT–CT fusion imaging in patients with oral cavity squamous cell carcinoma

Lymphoscintigraphic planar imaging is commonly performed to locate the sentinel lymph nodes (SLN) preoperatively. The images are, however, obscure lacking anatomical information and only rough topographical orientation of the SLNs is possible. Image fusion of Single Photon Emission Computed Tomography (SPECT) and Computed Tomography (CT) has been suggested to be an anatomically more precise method for preoperative SLN mapping. In the present study, preoperative lymphoscintigraphic SLN mapping was performed by using a hybrid gamma-camera with CT system (SPECT–CT) in addition to conventional planar lymphoscintigraphy in 15 consecutive patients with squamous cell carcinoma (SCC) of the oral cavity. The planar images were compared to fused SPECT and CT images. SPECT–CT fusion images showed only one SLN that was not detected in planar images. Two SLNs suspected in planar images could be excluded by SPECT–CT. The location of the SLNs could be determined more accurately by SPECT–CT. SPECT–CT fusion imaging was found feasible for preoperative SLN identification in patients with oral cavity SCC. It enables more accurate localisation of the SLNs, but it rarely reveals SLNs, that are not detected on planar images.     

Brain perfusion single photon emission computed tomography findings in patients with posttraumatic anosmia and comparison with radiological imaging

BACKGROUND: Different techniques in neuroimaging have been proposed for assessment of olfactory dysfunction but they are not without limitations. Recently, some studies showed the usefulness of single photon emission-computed tomography (SPECT) in evaluation of patients with posttraumatic anosmia. This study was designed to assess the possible diagnostic value of SPECT findings in patients with posttraumatic anosmia in comparison with magnetic resonance imaging (MRI)/CT imaging. METHODS: Sixteen patients who had head trauma and consequently anosmia, which was defined according to Cain's identification test, were included in this study. Two nonanosmic groups, traumatic patients and nontraumatic healthy individuals, were selected as control groups for this study. Qualitative and semiquantitative brain perfusion SPECT was performed by measuring the uptake ratio of the orbital frontal cortex to occipital pole in the sagittal projections (uptake index). All 16 target patients had a previous CT scan and/or MRI. Semiquantitative and qualitative brain perfusion SPECT were compared with radiological imaging. RESULTS: Semiquantitative assessment of brain perfusion SPECT revealed remarkable orbital frontal hypoperfusion as compared with two control groups. 87.5% of anosmic patients showed orbital frontal hypoperfusion (-2 SD below the lowest level in healthy controls). In addition, the semiquantitative SPECT method detected more orbitofrontal abnormality than the qualitative method or radiological imaging (MRI and/or CT). CONCLUSION: Findings suggest that by using SPECT, posttraumatic anosmia corresponds to the hypoperfusion in the orbital frontal cortex in a great number of patients. Because of its availability, rather low cost, technical ease, and possibility to obtain objective quantitative information, brain perfusion SPECT can be complementary to other diagnostic techniques in the evaluation of olfactory function, although additional neurophysiological and imaging studies are needed.     

Correlation between computed tomography and bone single photon emission-computed tomography scintigraphy in patients with chronic rhinosinusitis

BACKGROUND: Computed tomography (CT) has been the imaging study of choicefor evaluating chronic rhinosinusitis (CRS). 99mTc-MDP bone single photon emission-computed tomography (SPECT) has proven useful at identifying inflammation of bone and its use in CRS has been discussed recently. No studies, however, have documented the correlation between these two imaging modalities in CRS. METHODS: A retrospective analysis was performed of 30 patients with CRS who underwent CT and SPECT scan of the paranasal sinuses. Increased radiotracer uptake during SPECT scan was compared with CT findings graded on the Lund-Mackay score (LMS). The findings of the two imaging modalities were compared and evaluated for standard correlative statistics for diagnostic tests. RESULTS: SPECT imaging was abnormal in 25/30 patients, and CT was abnormal in 27/30 patients. Correlation between the two was highest for the ethmoid sinuses at 73.3%. SPECT had a high positive predictive value for mucosal inflammation on CT of 84.1%. Approximately 25% of individual sinuses with a positive SPECT in patients without prior surgery were not positive in corresponding sinuses onl CT. There was a positive correlation between the LMS and the number of SPECT positive sinuses within the same patient (r = 0.486; p = 0.006). CONCLUSION: 99mTc-MDP SPECT scan in patients with CRS is shown to be a useful indicator of bone involvement. The relatively high rate of bone involvement in the absence of mucosal inflammation as seen in this study warrants additional research and the potential need for different therapies than are currently available.     

Occult primary tumors of the head and neck: accuracy of thallium 201 single-photon emission computed tomography and computed tomography and/or magnetic resonance imaging

OBJECTIVE: To determine the accuracy of thallium 201 single-photon emission computed tomography (thallium SPECT) and computed tomography and/or magnetic resonance imaging (CT/MRI) in the detection of occult primary tumors of the head and neck. DESIGN: Study of diagnostic tests. SETTING: National Cancer Institute, Amsterdam, the Netherlands. PATIENTS AND METHODS: Thirty-two patients with a neck node metastasis of an epithelial tumor and negative findings by mirror examination at initial presentation were included in the study. Twenty-nine patients underwent thallium SPECT and CT/MRI before examination under general anesthesia (EUA). In 3 patients only thallium SPECT was performed before EUA. Histological confirmation of an occult primary tumor during EUA was used as the gold standard. Negative radiodiagnostic and nuclear findings in the upper aerodigestive tract in the presence of a primary carcinoma other than of the head and neck were interpreted as true-negative findings. RESULTS: For thallium SPECT the following results were recorded: sensitivity, 67%; specificity, 69%; accuracy, 69%; positive predictive value, 33%; and negative predictive value, 90%. In 1 patient, thallium whole body scan indicated a primary carcinoma beyond the mucosal lining of the upper aerodigestive tract. The CT/MRI results were as follows: sensitivity, 71%; specificity, 73%; accuracy, 72%; positive predictive value, 45%; and negative predictive value, 89%. CONCLUSIONS: Thallium SPECT and CT/MRI showed comparable results for detection of occult primary tumors of the head and neck. A potential advantage of thallium SPECT is that it allows total body screening.     

Usefulness of technetium-99m methoxyisobutylisonitrile single-photon emission computed tomography and computed tomography in the evaluation of cervical lymph node metastasis

The aim of this study was to compare the effectiveness of technetium-99m methoxyisobutylisonitrile ((99m)Tc-MIBI) single-photon emission computed tomography (SPECT) and computed tomography (CT) in evaluating cervical lymph node metastasis of head and neck cancer. Histopathologic results of 166 cervical lymph node levels in 31 neck-dissected patients were compared with pre-operative CT and (99m)Tc-MIBI SPECT findings about cervical lymph node metastasis, retrospectively. Sensitivity, specificity and predictability of CT and (99m)Tc-MIBI SPECT were 68.2, 93.1 and 89.8 per cent and 59.1, 87.5 and 83.7 per cent, respectively. When analysing CT and(99m)Tc-MIBI SPECT together, sensitivity and specificity were 86.4 and 99.3 per cent, respectively. The combined use of (99m)Tc-MIBI SPECT and CT could increase the accuracy of cervical lymph node metastases detection, compared with separate use of either (99m)Tc-MIBI SPECT or CT.     

The role of SPECT-CT in the lymphoscintigraphic identification of sentinel nodes in patients with oral cancer

CONCLUSION: SPECT-CT may improve the localization of sentinel nodes (SNs) in patients with oral squamous cell carcinoma (OSCC). Compared with planar lymphoscintigraphy SPECT-CT detected more SNs and provided additional anatomical and spatial information about their localization. New generation SPECT with higher resolution CT scanners are expected to provide more accurate information about the localization of SNs. OBJECTIVE: To assess the role of combined SPECT-CT in SN identification in the clinically negative neck of patients with OSCC. MATERIALS AND METHODS: Lymphoscintigraphy comprising planar and SPECT-CT acquisition was performed in 34 consecutive patients with OSCC stage I and II (T1-2N0M0) prior to sentinel node biopsy (SNB) and selective neck dissection. The number of SNs and anatomical location was recorded according to lymphoscintigraphy and operative findings. RESULTS: SNB was conducted in 33 patients. SNs were identified in 94% (32/34) of the patients using SPECT-CT. In 91% (29/32) of the patients SNs were harvested from all of the levels involved on SPECT-CT. SPECT-CT imaging demonstrated extra SNs compared with planar lymphoscintigraphic imaging in 47% (15/32) of patients. In seven cases the anatomical level of SN according to SPECT-CT was reclassified during surgery. The overall incidence of lymph node metastases was 19% (6/32). There were no false negative SNs.     

^131I-SPECT／CT对分化型甲状腺癌颈部及上纵隔转移灶的术前诊断价值

目的 探讨^131I-单光子发射型计算机断层显像-计算机断层摄影（single—photon emission computed tomography／computed tomography,SPECT／CT）同机融合显像对分化型甲状腺癌（differentiated thyroid carcinoma,DTC）患者头颈部及上纵隔转移灶的诊断价值。方法对30例术前行^131I-SPECT／CT同机融合显像的DTC头颈部或上纵隔转移的患者图像结果,与颈淋巴清扫术后病理结果进行比较并加以分析。结果^131I-SPECT／CT融合显像检查发现DTC转移灶110处,占95．65％（110／115）,有5处转移灶显示为阴性,占4．35％（5／115）,无假阳性病灶。结论 ^131I-SPECT／CT融合显像能准确检出、定位DTC转移灶和除外假阳性结果,有益于DTC患者术前头颈部及上纵隔转移灶的诊断和鉴别诊断。     

Assessment of cervical lymph node metastasis with different imaging methods in patients with head and neck squamous cell carcinoma

OBJECTIVE: To determine the predictive value of different imaging methods,-computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (US), and single-photon emission tomography (SPECT),-for cervical node metastasis. DESIGN: Prospective clinical trial. SETTING: An academic otolaryngology department. METHODS: Twenty-three consecutive patients with head and neck malignancy were prospectively evaluated for the presence of cervical lymphadenopathy. All patients underwent clinical, CT, MRI, US, and SPECT examinations. Neck dissection was performed for 31 neck sides, and the results of the preoperative evaluation were confirmed by the surgical and histopathologic findings. MAIN OUTCOME MEASURES: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for each method and a comparison of the methods was done. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CT, MRI, US, and SPECT were 77.7%, 85.7%, 91.3%, 66.6%, and 80.4%; 59.2%, 92.8%, 94.1%, 54.1%, and 70.7%; 81.4%, 64.2%, 81.4%, 64.2%, and 75.6%; 55.5%, 92.8%, 93.7%, 52.0%, and 68.2%, respectively. Both CT and US were found to be superior to clinical examination. There was no statistically significant difference between US and CT. US was found to be superior to MRI and SPECT in detecting cervical node metastasis. CT was also superior to SPECT. CONCLUSION: Our data show that, despite high specificity rates, especially with SPECT, none of the currently available imaging methods are reliable in evaluating the occult regional metastasis because the negative predictive values of all of these methods are rather low.     

The role of SPECT-CT in the lymphoscintigraphic identification of sentinel nodes in patients with oral cancer

Conclusion: SPECT-CT may improve the localization of sentinel nodes (SNs) in patients with oral squamous cell carcinoma (OSCC). Compared with planar lymphoscintigraphy SPECT-CT detected more SNs and provided additional anatomical and spatial information about their localization. New generation SPECT with higher resolution CT scanners are expected to provide more accurate information about the localization of SNs. Objective: To assess the role of combined SPECT-CT in SN identification in the clinically negative neck of patients with OSCC. Materials and methods: Lymphoscintigraphy comprising planar and SPECT-CT acquisition was performed in 34 consecutive patients with OSCC stage I and II (T1-2N0M0) prior to sentinel node biopsy (SNB) and selective neck dissection. The number of SNs and anatomical location was recorded according to lymphoscintigraphy and operative findings. Results: SNB was conducted in 33 patients. SNs were identified in 94% (32/34) of the patients using SPECT-CT. In 91% (29/32) of the patients SNs were harvested from all of the levels involved on SPECT-CT. SPECT-CT imaging demonstrated extra SNs compared with planar lymphoscintigraphic imaging in 47% (15/32) of patients. In seven cases the anatomical level of SN according to SPECT-CT was reclassified during surgery. The overall incidence of lymph node metastases was 19% (6/32). There were no false negative SNs.     

SPECT Gallium Scintigraphy in Malignant External Otitis: Initial Staging and Follow-up. Case Reports

Malignant external otitis (MEO) is a recognized entity characterized by a stubborn Pseudomonas external otitis; it has been most frequently observed in elderly diabetic patients. Early diagnosis is necessary for successful treatment but, despite a widespread inflammatory response, routine plain x-ray studies and computed tomography (CT) scanning show no abnormalities in its early stage. In this report, the clinical value of gallium 67 (Ga 67) single photon emission CT (SPECT) is studied in three patients suspected of having MEO, and the results are compared with findings on CT scan and laboratory tests. These results confirm that the high sensitivity of Ga 67 SPECT in the initial recognition of MEO provides a more adequate technique than CT scan. Furthermore, Ga 67 scintigraphy appears to be highly accurate for follow-up evaluation of these patients.     

Role of [18]-FDG PET/CT in the initial staging of head and neck cancers

OBJECTIVE: To evaluate the impact of fusion of positron emission tomography with computed tomography (FDG-PET/CT) in the initial staging of head and neck carcinomas. METHODS: This retrospective study included 44 patients with squamous cell carcinoma of the upper aerodigestive tract. Patients underwent a standard workup and a PET/CT image fusion during the initial staging. The standard workup included CT scan of the head, neck and chest, panendoscopy under general anaesthesia, oesophageal endoscopy and abdominal echography. Potential additional diagnostic value of PET/CT was evaluated. RESULTS: Findings between PET/CT and standard workup were concordant in 41/44 cases for primary tumour in 79/88 cases for lymph node staging, in 36/44 cases for distant metastases (or distant second primary) and in 41/44 cases for synchronous second primaries of the upper aero-digestive tract. PET/CT leads to a change of treatment for 6.8% of patients (1 for lymph node staging and 2 for distant metastases). 17.2% of pathological FDG uptake foci found by PET/CT were false-positives results. CONCLUSION: PET/CT enables to realise a whole body check-up in a single time. However, it cannot be used alone, due to its lack of spatial resolution: It must be used in complement of the standard workup. This high rate of false-positive findings, asking for further expensive diagnostic procedures, limits its usefulness.     

Utility of SPECT/CT for periparotid sentinel lymph node mapping in the surgical management of head and neck melanoma

Purpose

Sentinel lymph node (SLN) biopsy is instrumental in staging and treatment of cutaneous melanoma. SPECT/CT, single-photon emission computed tomography (SPECT) integrated with computed tomography (CT), increases the accuracy of SLN mapping to improve surgical planning. SPECT/CT can correct for signal scatter to prevent masking, which is especially common in the head and neck. For periparotid lymph nodes SPECT/CT may improve localization of SLNs compared to lymphoscintigraphy.

Materials/Methods

Hospital charts were reviewed for 14 patients with melanoma and suspected lymphatic drainage to the parotid region who received lymphoscintigraphy followed by SPECT/CT prior to surgical excision and SLN.

Results

Overall, SPECT/CT provided data, which changed management in 57% of patients.

Conclusions

Fifty-seven percent of our patients benefited from use of SPECT/CT. The distinction between level II and parotid sentinel lymph nodes was clearly identified through SPECT/CT images. We believe that patients with melanoma draining to the parotid region would benefit from SPECT/CT SLN mapping.     

多层螺旋CT增强扫描在喉癌诊断及临床分期中的应用价值

目的：探讨将多层螺旋CT增强扫描的横断面图像、多平面重建图像（MPR）和仿真喉镜（VE）图像结合起来（联合图像）在喉癌术前诊断及TNM分期中的应用价值。方法：①32例拟诊喉癌患者行术前前赡性多层螺旋CT增强扫描并行MPR和VE处理。②采用双盲法阅片，将单一横断面图像、MPR和VE联合图像分别作出CT诊断。③临床医师结合CT图像，分别进行国际抗癌协会（UICC）TNM临床分期。④完成喉癌手术，根据病理和电子喉镜确定病理学分期，将2种方法（横断面图像和MPR）的分期结果进行比较。结果：32例喉癌中，联合图像对评价室带、声带、前连合、声门下、声门旁间隙、会厌前间隙、甲状软骨、喉外结构受侵的准确率为98．3％，而横断面图像为91.3％，两者比较其准确率有统计学意义（X^2=20．624，P〈O．01）；横断面图像对喉癌分期的准确率为81．3％，联合图像为93．8％，两者比较差异无统计学意义（P〉O．05）。结论：多层螺旋CT增强扫描的MPR和VE是横断面图像很好的补充，能够帮助提高喉癌诊断水平，横断面图像和联合图像对于喉癌术前临床分期无明显差别。     

Craniofacial injuries and cerebral tomographic scintigraphy using N-isopropyl-iodo-amphetamine 123 I-AMP

An investigation was done with N.-isopropyl-iodoamphetamine (123I AMP) in 20 patients: 10 patients with craniofacial injury and 10 patients without brain dysfunction or injury. Brain X ray computerized Tomography was normal. SPECT 123 I AMP detected functional defects related with traumatic impacts. Sensitivity is higher with SPECT than with CT Scan. The indications for the initial evaluation of head injury, and the relations with later sequelae i.e. post traumatic epilepsia and subjective syndrome are discussed.     

The integrated PET/CT: technological advance in diagnostics of head and neck recurrencies and CUP?

BACKGROUND: In the last years (18)F-Fluoro-deoxy-glucose (FDG)-positron emission tomography (PET) worked satisfactorily as auxiliary method in order to show recurrency of head and neck tumors and to detect primary tumors in case of CUP especially when CT and MR imaging failed to identify the tumor accurately. The correlation of FDG hypermetabolism and anatomical structures is now provided by a new technology which is integrating PET and CT: Integrated PET/CT represents a new technical development, which combines the advantages of CT and PET. PATIENTS: In a retrospective investigation 84 non selected PET/CT studies of 83 patients with recurrent head and neck disease and CUP were critically analyzed. RESULTS: 33 cases had positive PET findings. 5 of these 33 cases showed false-positive findings. In 51 PET studies there was not found any sign of suspicious FDG hypermetabolism. CONCLUSION: Integrated PET/CT delivers substantial progress in detecting tumor localization. False positive findings have to be considered and therefore indications should be strictly limited to special cases of head and neck tumor recurrency, cases with complex anatomical sites and CUP.     

喉癌CT/MRI融合图像的建立及初步应用

目的 探索喉部CT/MRI融合图像的建立方法及意义。方法 改良头颈肩固定体膜体架并比较其与常规装置的重复摆位误差;31例喉癌患者应用同一装置固定体位,1 d内先后行CT和MRI扫描,层厚3 mm,将数据导入飞利浦公司Pinnacle³ V8.0放射治疗计划系统进行自动配准和融合。对融合图像、MRI、CT图像进行主观评价。结果 23例（23/31）CT/MRI融合图像清晰;融合后的数据可以透明混合、棋盘格式、靶区勾画多重显示三种方式观察;既能够清晰显示甲状软骨、环状软骨、杓状软骨,又可以显示会厌、 声带、室带、喉室、会厌前间隙、声门旁间隙、杓会厌皱襞、喉软骨破坏、喉外组织等喉部结构病变及喉癌的颈淋巴结转移。结论 喉部CT/MRI融合图像,可以弥补CT在喉部软组织病变的显示不清晰的缺点,对喉癌手术前肿瘤范围的评估具有重要意义。     

Role of angiography in the evaluation of patients with pulsatile tinnitus

OBJECTIVES/HYPOTHESIS: Pulsatile tinnitus in the face of normal findings on otoscopy is a common otological diagnostic dilemma and can be due to serious vascular malformations such as transverse or sigmoid sinus dural arteriovenous fistula (transverse or sigmoid sinus [TS] DAVF). Left untreated, TS DAVF may result in significant morbidity and mortality. TS DAVF can be suspected or diagnosed with computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA), with the gold standard being angiography. Our objective was to assess the utility of these various diagnostic modalities in the diagnosis of dural arteriovenous fistula. STUDY DESIGN: Retrospective clinical review. METHODS: Between 1986 and 1996, 54 patients were evaluated and treated for TS DAVF. Between 1996 and 1999, an additional 33 patients underwent MRI combined with MRA for the evaluation of pulsatile tinnitus. A retrospective review of the medical records for both groups, with special attention to clinical presentation, diagnostic evaluation, therapy, and outcome, was performed. RESULTS: All patients had pulsatile tinnitus with normal findings on otoscopy. CT scan was relatively insensitive in the detection of TS DAVF. MRI and MR/MRA were significantly more sensitive than CT. In the evaluation of patients with subjective pulsatile tinnitus, MRI/MRA defined anatomical abnormalities that may contribute to pulsatile tinnitus in 63% of patients. CONCLUSIONS: In the absence of objective pulsatile tinnitus, MRI/MRA is an appropriate initial diagnostic step. When a patient has an objective bruit, the clinician may choose to proceed directly to angiography to make certain that a TS DAVF is not missed.