By Marcello Cherchi, MD PhD
For patients
Some problems with hearing and equilibrium can happen when certain blood vessels (arteries and veins) are abnormal. These situations are not common. If you have these kinds of symptoms, then depending on the circumstances, your doctor may want to do tests of hearing and/or balance, or may want to check imaging studies.
For clinicians
Overview
Broadly speaking, vascular problems can provoke auditory or vestibular symptoms by impinging on structures relevant to auditory and vestibular function. In addition, some vascular problems can provoke fluid dynamics whose turbulence generates sufficient vibrations to stimulate the cochlea.
Introduction
A several audiologic and vestibular problems have been reported in association with a variety of vascular abnormalities. Overall, vascular causes of such symptoms are rare. We discuss a selection of these here, including rotational vertebral artery syndrome, vascular impingement on the vestibulo-cochlear nerve, fibromuscular dysplasia, and glomus tympanicum.
Rotational vertebral artery syndrome (RVAS)
Cerebral hypoperfusion secondary to vascular compromise is often discussed as a mechanism of cervicogenic vertigo (CV). Rotational vertebral artery syndrome (RVAS), also called bowhunter syndrome, is a condition in which one of the vertebral arteries is transiently extrinsically compressed during neck rotation (Araz Server et al. 2018; Cornelius et al. 2012; Duan et al. 2016; Go et al. 2013; Helton and Bavry 2009; Kamouchi et al. 2003; Li et al. 2019; Lu et al. 2010; Mitchell 2009; Sakaguchi et al. 2003; Sarkar et al. 2014; Weintraub and Khoury 2004; Zaidi et al. 2014). This appears more likely to provoke symptoms if the contralateral vertebral artery is already narrowed, such as by atherosclerotic disease. In some cases, this compression, perhaps combined with torquing of the artery, results in damage to the artery itself, such as a dissection (Vibert et al. 1993). There are a few reports of RVAS manifesting with predominantly downbeat nystagmus (Choi et al. 2005; Ogawa et al. 2014), though such a pattern of nystagmus is not specific for the condition. If the vascular compromise is prolonged, it may culminate in infarction (Sorensen 1978). The discussions of RVAS are based primarily on case reports or small case series. Despite the apparent enthusiasm in the literature, this condition probably comprises only a small proportion of cases of cervicogenic vertigo. There is no consensus on the range of effects that neck turning can have on the vertebral arteries (Mitchell 2007), and while dynamic vascular imaging can provide corroborative evidence of RVAS, Hain (Hain 2015) pointed out that “Vertebral artery blood flow is compromised with full contralateral rotation in healthy individuals,” citing Mitchell (Mitchell 2009); thus, vascular imaging is not specific for this condition. Further, cadaveric animal model evidence suggests typical physiologic motions at the neck produce vertebral artery strains substantially lower than the failure point (dissection) (Symons et al. 2002).
Subclavian steal syndrome (SSS)
Subclavian steal syndrome (SSS) is a vascular phenomenon in which occlusion or stenosis (usually secondary to atherosclerotic disease) of either the subclavian or innominate artery (proximal to the origin of the vertebral artery) alters hemodynamics such that blood supply to the ipsilateral upper extremity is maintained at the expense of inducing retrograde flow in the ipsilateral vertebral artery, potentially compromising the function of brainstem structures supplied by the vertebral artery. In some cases the retrograde flow in the vertebral artery is insufficient to cause symptoms at rest, but exercising the ipsilateral arm (thereby increasing circulatory demands in that extremity) augments the retrograde vertebral artery flow and can bring on symptoms, including disequilibrium.
The prevalence of SSS has been estimated at 1.3%, has a 2:1 female:male ratio and is more common over the age of 55 years (Psillas et al. 2007). Suspicion for subclavian steal syndrome is raised when blood pressure in one arm is lower than the other by 20 mm Hg, but the diagnosis usually requires confirmation by Doppler ultrasound.
Although SSS can cause a presyncopal sensation (Porwal and Verma 2013; Psillas et al. 2007), curiously it has been reported as the cause of inversion illusions as well (Arntzen and Alstadhaug 2020).
Vascular impingement on the vestibulo-cochlear nerve: as a cause of vestibular paroxysmia
The original descriptions by Dr. Peter Jannetta (Jannetta 1975) attributed vestibular paroxysmia to “vascular cross compression” of the vestibular nerve by a loop of the anterior inferior cerebellar artery, though subsequent literature described vascular cross compression by other blood vessels as well, such as the posterior inferior cerebellar artery, a vertebral artery or a vein (Best et al. 2013), or the superior cerebellar artery (Ryu et al. 1998). This was thought to be analogous to some cases of trigeminal neuralgia, another condition in which a cranial nerve (the trigeminal nerve) is sometimes found to have vascular impingement (Gronseth et al. 2008).
Although some radiologic literature concluded that there was a correlation between vascular cross compression and audio-vestibular symptoms (De Ridder et al. 2005; Herzog et al. 1997; Jannetta et al. 1984; McCabe and Harker 1983; McDermott et al. 2003; Moosa et al. 2015; Nowe et al. 2004; Shinn et al. 2009; Wuertenberger and Rosahl 2009), other literature found no such correlation (Gorrie et al. 2010; Hoekstra et al. 2015; Makins et al. 1998; Parnes et al. 1990; Reisser and Schuknecht 1991; van der Steenstraten et al. 2007).
Since some patients whose clinical history is compatible with vestibular paroxysmia have no evidence of vascular impingement, and since some asymptomatic individuals have vascular impingement, this brought into question the hypothesis of a purely vascular etiology of this disease, and in fact, the Barany Society consensus document states, “The role of imaging in the diagnosis and identification of the affected side is not clear because of the high rate of blood vessels close to the 8th cranial nerve in healthy subjects” (Strupp et al. 2016).
Although there is some logic to the hypothesis of vascular cross compression, there are certainly other neural pathologies that can damage axons and/or Schwann cells (from demyelination, infection, ischemia, and others) that presumably could provoke episodic irritability of the nerve.
Vascular impingement on the vestibulo-cochlear nerve: as a cause of sensorineural hearing loss
Vascular cross-compression of the vestibulo-cochlear nerve has also been suggested as a cause of sensorineural hearing loss. There have been several attempts at developing radiographic/anatomical classifications of vascular impingement on the vestibulo-cochlear nerve (Di Stadio et al. 2020; Kazawa et al. 2013; Kim et al. 2019; Sirikci et al. 2005). A minority of literature concludes that there is some correlation between such vascular impingement on the vestibulo-cochlear nerve and sensorineural hearing loss (McDermott et al. 2003), but the majority of the literature and systematic reviews conclude that there is no such correlation (Gorrie et al. 2010; Leng et al. 2022; Makins et al. 1998; Papadopoulou et al. 2022; van der Steenstraten et al. 2007). Furthermore, literature regarding surgical intervention in cases of vascular impingement on the vestibulo-cochlear nerve report no improvement in sensorineural hearing loss (Esposito et al. 2016; Moosa et al. 2015).
Fibromuscular dysplasia (FMD)
Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic arteriopathy manifesting with morphological abnormalities such as tortuosity, dissection, aneurysm, stenosis and other occlusion. The etiology is unclear, but research increasingly suggests genetic predisposition (Ganesh et al. 2014; Gornik et al. 2019; Perdu et al. 2007; Persu et al. 2022). It has been reported in nearly all vasculature, but most commonly involves the renal, internal carotid and vertebral arteries. Olin and colleagues (Olin et al. 2012) studied 447 patients with FMD and reported that affected arteries included the renal (79.7%), extracranial carotid (74.3%) and vertebral (36.6%); presenting symptoms included pulsatile tinnitus (27.5%), dizziness (26.0%), “tinnitus” (presumably non-pulsatile) (18.8%) and stroke (6.9%). The literature reports various kinds of tinnitus (Arnold et al. 2009; Bagh et al. 2018; Dicks et al. 2021; Dufour et al. 1985; Foyt et al. 2006; Gruber and Hemmati 1991; Henrard et al. 2019; Hofmann et al. 2013; Kesav et al. 2023; Kim and Serhal 2016; Kythreotou et al. 2023; Narula et al. 2018; Olin et al. 2012; Raj et al. 2012; Topal et al. 2015; Vanzin et al. 2021; Waldvogel et al. 1998; Weissman and Hirsch 2000; Zhang et al. 2014) much more commonly than vestibular symptoms (De Groote et al. 2017; Krittanawong et al. 2019; Netsch et al. 2011; Tsien et al. 2014), with the mechanism for the latter usually being cited as stroke (Chen et al. 2004; Tsien et al. 2014).
Glomus tympanicum
A glomus tympanicum (GT) tumor is a paraganglioma arising at various locations in the middle ear. It is highly vascular, and the classic appearance under otomicroscopy/otoscopy is a red pulsatile mass behind the eardrum. It is usually a disease of adulthood, and is more common in women. A number of diseases can resemble GTs, and GTs can mimic other lesions. About 15% of GTs secrete catecholamines. The most common presenting symptoms are pulsatile tinnitus and hearing loss. Rarely GTs can cause disequilibrium and epistaxis. GTs are usually unilateral; they can occur with other paragangliomas anywhere along the sympathetic chain. Audiometry usually shows mixed conductive and sensorineural hearing loss. CT is usually the imaging modality of choice, but MRI and various forms of angiography may also play a role. Treatment is usually surgical, though radiation therapy has become more common. Recurrence is uncommon, and occurs more frequently in surgically-treated cases. If a clinician observes a red pulsatile mass behind the eardrum, referral to a neuro-otologic otolaryngologist is appropriate.
Vascular causes of pulsatile tinnitus
Pulsatile tinnitus has been reported in association with a number of arterial and venous abnormalities, including jugular bulb wall dehiscence, transverse sinus stenosis, sigmoid sinus diverticulum, sigmoid sinus wall dehiscence, enlarged oblique occipital sinus, stenoses of various dural venous sinuses from arachnoid granulations, superficial middle cerebral vein, dilated mastoid emissary vein, carotid artery stenosis, fibromuscular dysplasia, arteriovenous fistula and others.
References
Araz Server E, Edizer DT, Yigit O, Yasak AG, Erdim C (2018) Relationship between vertebral artery blood flow in different head positions and vertigo. Acta Otolaryngol 138: 1-5. doi: 10.1080/00016489.2017.1373849
Arnold M, De Marchis GM, Stapf C, Baumgartner RW, Nedeltchev K, Buffon F, Galimanis A, Sarikaya H, Mattle HP, Bousser MG (2009) Triple and quadruple spontaneous cervical artery dissection: presenting characteristics and long-term outcome. J Neurol Neurosurg Psychiatry 80: 171-4. doi: 10.1136/jnnp.2008.155226
Arntzen K, Alstadhaug KB (2020) Room tilt illusion and subclavian steal – a case report. BMC Neurol 20: 369. doi: 10.1186/s12883-020-01947-2
Bagh I, Olin JW, Froehlich JB, Kline-Rogers E, Gray B, Kim ESH, Sharma A, Weinberg I, Wells BJ, Gu X, Gornik HL (2018) Association of Multifocal Fibromuscular Dysplasia in Elderly Patients With a More Benign Clinical Phenotype: Data From the US Registry for Fibromuscular Dysplasia. JAMA Cardiol 3: 756-760. doi: 10.1001/jamacardio.2018.1638
Best C, Gawehn J, Kramer HH, Thomke F, Ibis T, Muller-Forell W, Dieterich M (2013) MRI and neurophysiology in vestibular paroxysmia: contradiction and correlation. J Neurol Neurosurg Psychiatry 84: 1349-56. doi: 10.1136/jnnp-2013-305513
Chen YL, Hsu YD, Lee JT (2004) Fibromuscular dysplasia of the vertebral artery presenting with lateral medullary syndrome: a case report. Acta Neurol Taiwan 13: 198-202.
Choi KD, Shin HY, Kim JS, Kim SH, Kwon OK, Koo JW, Park SH, Yoon BW, Roh JK (2005) Rotational vertebral artery syndrome: oculographic analysis of nystagmus. Neurology 65: 1287-1290. doi: PMID: 16247059
Cornelius JF, George B, N’Dri Oka D, Spiriev T, Steiger HJ, Hanggi D (2012) Bow-hunter’s syndrome caused by dynamic vertebral artery stenosis at the cranio-cervical junction–a management algorithm based on a systematic review and a clinical series. Neurosurg Rev 35: 127-35; discussion 135. doi: 10.1007/s10143-011-0343-4
De Groote M, Van der Niepen P, Hemelsoet D, Callewaert B, Vermassen F, Billiouw JM, De Vriese A, Donck J, De Backer T (2017) Fibromuscular dysplasia – results of a multicentre study in Flanders. Vasa 46: 211-218. doi: 10.1024/0301-1526/a000613
De Ridder D, De Ridder L, Nowe V, Thierens H, Van de Heyning P, Moller A (2005) Pulsatile tinnitus and the intrameatal vascular loop: why do we not hear our carotids? Neurosurgery 57: 1213-7; discussion 1213-7.
Di Stadio A, Dipietro L, Ralli M, Faralli M, Della Volpe A, Ricci G, Messineo D (2020) Loop characteristics and audio-vestibular symptoms or hemifacial spasm: is there a correlation? A multiplanar MRI study. Eur Radiol 30: 99-109. doi: 10.1007/s00330-019-06309-2
Dicks AB, Gornik HL, Gu X, Bacharach JM, Fendrikova Mahlay N, Froehlich JB, Gupta K, Gray BH, Kim ESH, Mahmood R, Sharma AM, Wells BJ, Olin JW, Weinberg I (2021) Association of Fibromuscular Dysplasia and Pulsatile Tinnitus: A Report of the US Registry for Fibromuscular Dysplasia. J Am Heart Assoc 10: e021962. doi: 10.1161/jaha.121.021962
Duan G, Xu J, Shi J, Cao Y (2016) Advances in the Pathogenesis, Diagnosis and Treatment of Bow Hunter’s Syndrome: A Comprehensive Review of the Literature. Interv Neurol 5: 29-38. doi: 10.1159/000444306
Dufour JJ, Lavigne F, Plante R, Caouette H (1985) Pulsatile tinnitus and fibromuscular dysplasia of the internal carotid. J Otolaryngol 14: 293-5.
Esposito G, Messina R, Carai A, Colafati GS, Savioli A, Randi F, De Benedictis A, Cossu S, Fontanella MM, Marras CE (2016) Cochleovestibular Nerve Compression Syndrome Caused by Intrameatal Anterior Inferior Cerebellar Artery Loop: Synthesis of Best Evidence for Clinical Decisions. World Neurosurg 96: 556-561. doi: 10.1016/j.wneu.2016.09.030
Foyt D, Carfrae MJ, Rapoport R (2006) Fibromuscular dysplasia of the internal carotid artery causing pulsatile tinnitus. Otolaryngol Head Neck Surg 134: 701-2. doi: 10.1016/j.otohns.2005.03.066
Ganesh SK, Morissette R, Xu Z, Schoenhoff F, Griswold BF, Yang J, Tong L, Yang ML, Hunker K, Sloper L, Kuo S, Raza R, Milewicz DM, Francomano CA, Dietz HC, Van Eyk J, McDonnell NB (2014) Clinical and biochemical profiles suggest fibromuscular dysplasia is a systemic disease with altered TGF-beta expression and connective tissue features. FASEB J 28: 3313-24. doi: 10.1096/fj.14-251207
Go G, Hwang SH, Park IS, Park H (2013) Rotational Vertebral Artery Compression : Bow Hunter’s Syndrome. J Korean Neurosurg Soc 54: 243-5. doi: 10.3340/jkns.2013.54.3.243
Gornik HL, Persu A, Adlam D, Aparicio LS, Azizi M, Boulanger M, Bruno RM, de Leeuw P, Fendrikova-Mahlay N, Froehlich J, Ganesh SK, Gray BH, Jamison C, Januszewicz A, Jeunemaitre X, Kadian-Dodov D, Kim ES, Kovacic JC, Mace P, Morganti A, Sharma A, Southerland AM, Touze E, van der Niepen P, Wang J, Weinberg I, Wilson S, Olin JW, Plouin PF (2019) First International Consensus on the diagnosis and management of fibromuscular dysplasia. Vasc Med 24: 164-189. doi: 10.1177/1358863X18821816
Gorrie A, Warren FM, 3rd, de la Garza AN, Shelton C, Wiggins RH, 3rd (2010) Is there a correlation between vascular loops in the cerebellopontine angle and unexplained unilateral hearing loss? Otol Neurotol 31: 48-52. doi: 10.1097/MAO.0b013e3181c0e63a
Gronseth G, Cruccu G, Alksne J, Argoff C, Brainin M, Burchiel K, Nurmikko T, Zakrzewska JM (2008) Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 71: 1183-90. doi: 10.1212/01.wnl.0000326598.83183.04
Gruber B, Hemmati M (1991) Fibromuscular dysplasia of the vertebral artery: an unusual cause of pulsatile tinnitus. Otolaryngol Head Neck Surg 105: 113-4. doi: 10.1177/019459989110500116
Hain TC (2015) Cervicogenic causes of vertigo. Curr Opin Neurol 28: 69-73. doi: 10.1097/WCO.0000000000000161
Helton T, Bavry A (2009) Images in Cardiovascular Medicine. Don’t turn your head! Circulation 120: e162. doi: 10.1161/CIRCULATIONAHA.109.896043
Henrard C, Belge H, Fastré S, Di Monaco S, Revencu N, Hammer F, Pasquet A, Persu A (2019) Cervical artery dissection: fibromuscular dysplasia versus vascular Ehlers-Danlos syndrome. Blood Press 28: 139-143. doi: 10.1080/08037051.2018.1557507
Herzog JA, Bailey S, Meyer J (1997) Vascular loops of the internal auditory canal: a diagnostic dilemma. Am J Otol 18: 26-31.
Hoekstra CE, Prijs VF, van Zanten GA (2015) Diagnostic yield of a routine magnetic resonance imaging in tinnitus and clinical relevance of the anterior inferior cerebellar artery loops. Otol Neurotol 36: 359-65. doi: 10.1097/MAO.0000000000000279
Hofmann E, Behr R, Neumann-Haefelin T, Schwager K (2013) Pulsatile tinnitus: imaging and differential diagnosis. Dtsch Arztebl Int 110: 451-8. doi: 10.3238/arztebl.2013.0451
Jannetta PJ (1975) Neurovascular cross-compression in patients with hyperactive dysfunction symptoms of the eighth cranial nerve. Surg Forum 26: 467-9.
Jannetta PJ, Moller MB, Moller AR (1984) Disabling positional vertigo. N Engl J Med 310: 1700-5. doi: 10.1056/NEJM198406283102604
Kamouchi M, Kishikawa K, Matsuo R, Yasumori K, Inoue T, Okada Y, Ibayashi S (2003) Ultrasonographic detection of extracranial vertebral artery compression in bow hunter’s brain ischemia caused by neck rotation. Cerebrovasc Dis 16: 303-5. doi: 10.1159/000071134
Kazawa N, Togashi K, Ito J (2013) The anatomical classification of AICA/PICA branching and configurations in the cerebellopontine angle area on 3D-drive thin slice T2WI MRI. Clin Imaging 37: 865-70. doi: 10.1016/j.clinimag.2011.11.021
Kesav P, Manesh Raj D, John S (2023) Cerebrovascular Fibromuscular Dysplasia – A Practical Review. Vasc Health Risk Manag 19: 543-556. doi: 10.2147/vhrm.S388257
Kim ES, Serhal M (2016) The Diagnosis and Treatment of Fibromuscular Dysplasia: An Update for Cardiologists. Curr Treat Options Cardiovasc Med 18: 37. doi: 10.1007/s11936-016-0460-z
Kim SH, Ju YR, Choi JE, Jung JY, Kim SY, Lee MY (2019) Anatomical location of AICA loop in CPA as a prognostic factor for ISSNHL. PeerJ 7: e6582. doi: 10.7717/peerj.6582
Krittanawong C, Kumar A, Johnson KW, Kaplin S, Virk HUH, Wang Z, Bhatt DL (2019) Prevalence, Presentation, and Associated Conditions of Patients With Fibromuscular Dysplasia. Am J Cardiol 123: 1169-1172. doi: 10.1016/j.amjcard.2018.12.045
Kythreotou A, Weerakkody RA, Koysombat K, Marzouqa N, Baker DM (2023) A Retrospective Cohort Study of Cerebrovascular Fibromuscular Dysplasia. Ann Vasc Surg 92: 104-110. doi: 10.1016/j.avsg.2022.12.092
Leng Y, Lei P, Liu Y, Chen C, Xia K, Liu B (2022) Vascular loops in cerebellopontine angle in patients with unilateral idiopathic sudden sensorineural hearing loss: Evaluations by three radiological grading systems. Laryngoscope Investig Otolaryngol 7: 1532-1540. doi: 10.1002/lio2.876
Li Q, Xie P, Yang WS, Yan B, Davis S, Caplan LR (2019) Vertebral Artery Compression Syndrome. Front Neurol 10: 1075. doi: 10.3389/fneur.2019.01075
Lu DC, Zador Z, Mummaneni PV, Lawton MT (2010) Rotational vertebral artery occlusion-series of 9 cases. Neurosurgery 67: 1066-72; discussion 1072. doi: 10.1227/NEU.0b013e3181ee36db
Makins AE, Nikolopoulos TP, Ludman C, O’Donoghue GM (1998) Is there a correlation between vascular loops and unilateral auditory symptoms? Laryngoscope 108: 1739-42. doi: 10.1097/00005537-199811000-00027
McCabe BF, Harker LA (1983) Vascular loop as a cause of vertigo. Ann Otol Rhinol Laryngol 92: 542-3. doi: 10.1177/000348948309200602
McDermott AL, Dutt SN, Irving RM, Pahor AL, Chavda SV (2003) Anterior inferior cerebellar artery syndrome: fact or fiction. Clin Otolaryngol Allied Sci 28: 75-80.
Mitchell J (2007) Doppler insonation of vertebral artery blood flow changes associated with cervical spine rotation: Implications for manual therapists. Physiother Theory Pract 23: 303-13. doi: 10.1080/09593980701593771
Mitchell J (2009) Vertebral Artery Blood flow Velocity Changes Associated with Cervical Spine rotation: A Meta-Analysis of the Evidence with implications for Professional Practice. J Man Manip Ther 17: 46-57. doi: 10.1179/106698109790818160
Moosa S, Fezeu F, Kesser BW, Ramesh A, Sheehan JP (2015) Sudden unilateral hearing loss and vascular loop in the internal auditory canal: case report and review of literature. J Radiosurg SBRT 3: 247-255.
Narula N, Kadian-Dodov D, Olin JW (2018) Fibromuscular Dysplasia: Contemporary Concepts and Future Directions. Prog Cardiovasc Dis 60: 580-585. doi: 10.1016/j.pcad.2018.03.001
Netsch C, Gross AJ, Brüning R (2011) Symptomatic hydronephrosis from renal artery aneurysm associated with fibromuscular dysplasia: management with transarterial embolization. J Endourol 25: 569-72. doi: 10.1089/end.2010.0127
Nowe V, De Ridder D, Van de Heyning PH, Wang XL, Gielen J, Van Goethem J, Ozsarlak O, De Schepper AM, Parizel PM (2004) Does the location of a vascular loop in the cerebellopontine angle explain pulsatile and non-pulsatile tinnitus? Eur Radiol 14: 2282-9. doi: 10.1007/s00330-004-2450-x
Ogawa Y, Itani S, Otsuka K, Inagaki T, Shimizu S, Kondo T, Nishiyama N, Nagai N, Suzuki M (2014) Intermittent positional downbeat nystagmus of cervical origin. Auris Nasus Larynx 41: 234-7. doi: 10.1016/j.anl.2013.07.012
Olin JW, Froehlich J, Gu X, Bacharach JM, Eagle K, Gray BH, Jaff MR, Kim ES, Mace P, Matsumoto AH, McBane RD, Kline-Rogers E, White CJ, Gornik HL (2012) The United States Registry for Fibromuscular Dysplasia: results in the first 447 patients. Circulation 125: 3182-90. doi: 10.1161/CIRCULATIONAHA.112.091223
Papadopoulou AM, Bakogiannis N, Sofokleous V, Skrapari I, Bakoyiannis C (2022) The Impact of Vascular Loops in the Cerebellopontine Angle on Audio-Vestibular Symptoms: A Systematic Review. Audiol Neurootol 27: 200-207. doi: 10.1159/000521792
Parnes LS, Shimotakahara SG, Pelz D, Lee D, Fox AJ (1990) Vascular relationships of the vestibulocochlear nerve on magnetic resonance imaging. Am J Otol 11: 278-81.
Perdu J, Boutouyrie P, Bourgain C, Stern N, Laloux B, Bozec E, Azizi M, Bonaiti-Pellie C, Plouin PF, Laurent S, Gimenez-Roqueplo AP, Jeunemaitre X (2007) Inheritance of arterial lesions in renal fibromuscular dysplasia. J Hum Hypertens 21: 393-400. doi: 10.1038/sj.jhh.1002156
Persu A, Dobrowolski P, Gornik HL, Olin JW, Adlam D, Azizi M, Boutouyrie P, Bruno RM, Boulanger M, Demoulin JB, Ganesh SK, T JG, Januszewicz M, Kovacic JC, Kruk M, de Leeuw P, Loeys BL, Pappaccogli M, Perik M, Touze E, Van der Niepen P, Van Twist DJL, Warchol-Celinska E, Prejbisz A, Januszewicz A (2022) Current progress in clinical, molecular, and genetic aspects of adult fibromuscular dysplasia. Cardiovasc Res 118: 65-83. doi: 10.1093/cvr/cvab086
Porwal V, Verma A (2013) Otoneurological manifestation in subclavian steal syndrome. Journal of Evolution of medical and Dental Sciences 2: 1634-1637. doi: 10.14260/jemds/436
Psillas G, Kekes G, Constantinidis J, Triaridis S, Vital V (2007) Subclavian steal syndrome: neurotological manifestations. Acta Otorhinolaryngol Ital 27: 33-7.
Raj RK, Gandhi RT, Katzen BT (2012) Fibromuscular dysplasia-related carotid pseudoaneurysm and pulsatile tinnitus. J Vasc Interv Radiol 23: 1657. doi: 10.1016/j.jvir.2012.08.014
Reisser C, Schuknecht HF (1991) The anterior inferior cerebellar artery in the internal auditory canal. Laryngoscope 101: 761-6. doi: 10.1288/00005537-199107000-00012
Ryu H, Yamamoto S, Sugiyama K, Nozue M (1998) Neurovascular compression syndrome of the eighth cranial nerve. What are the most reliable diagnostic signs? Acta Neurochir (Wien) 140: 1279-86.
Sakaguchi M, Kitagawa K, Hougaku H, Hashimoto H, Nagai Y, Yamagami H, Ohtsuki T, Oku N, Hashikawa K, Matsushita K, Matsumoto M, Hori M (2003) Mechanical compression of the extracranial vertebral artery during neck rotation. Neurology 61: 845-7. doi: 10.1212/01.wnl.0000078081.12097.ae
Sarkar J, Wolfe SQ, Ching BH, Kellicut DC (2014) Bow hunter’s syndrome causing vertebrobasilar insufficiency in a young man with neck muscle hypertrophy. Ann Vasc Surg 28: 1032 e1-1032 e10. doi: 10.1016/j.avsg.2013.06.038
Shinn JB, Bush ML, Jones RO (2009) Correlation of central auditory processing deficits and vascular loop syndrome. Ear Nose Throat J 88: E34-7.
Sirikci A, Bayazit Y, Ozer E, Ozkur A, Adaletli I, Cüce MA, Bayram M (2005) Magnetic resonance imaging based classification of anatomic relationship between the cochleovestibular nerve and anterior inferior cerebellar artery in patients with non-specific neuro-otologic symptoms. Surg Radiol Anat 27: 531-5. doi: 10.1007/s00276-005-0015-6
Sorensen BF (1978) Bow hunter’s stroke. Neurosurgery 2: 259-61.
Strupp M, Lopez-Escamez JA, Kim JS, Straumann D, Jen JC, Carey J, Bisdorff A, Brandt T (2016) Vestibular paroxysmia: Diagnostic criteria. J Vestib Res 26: 409-415. doi: 10.3233/VES-160589
Symons BP, Leonard T, Herzog W (2002) Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther 25: 504-10. doi: 10.1067/mmt.2002.127076
Topal H, Lemmens R, Fourneau I (2015) Possible Familial Presentation in Two Siblings with Carotid Fibromuscular Dysplasia. Acta Chir Belg 115: 83-6. doi: 10.1080/00015458.2015.11681073
Tsien MZ, Brorson JR, Lukas RV, Dawson EC (2014) A 16-year-old male with dizziness, parasthesias, and ataxia. Pediatr Ann 43: e116-9. doi: 10.3928/00904481-20140417-10
van der Steenstraten F, de Ru JA, Witkamp TD (2007) Is microvascular compression of the vestibulocochlear nerve a cause of unilateral hearing loss? Ann Otol Rhinol Laryngol 116: 248-52. doi: 10.1177/000348940711600404
Vanzin JR, Martio AE, Manzato LB, Abud DG (2021) Casper stent in the treatment of pulsatile tinnitus in fibromuscular dysplasia: Therapeutic review and case report. Brain Circ 7: 281-284. doi: 10.4103/bc.bc_35_20
Vibert D, Rohr-Le Floch J, Gauthier G (1993) Vertigo as manifestation of vertebral artery dissection after chiropractic neck manipulations. ORL J Otorhinolaryngol Relat Spec 55: 140-2. doi: 10.1159/000276405
Waldvogel D, Mattle HP, Sturzenegger M, Schroth G (1998) Pulsatile tinnitus–a review of 84 patients. J Neurol 245: 137-42. doi: 10.1007/s004150050193
Weintraub MI, Khoury A (2004) Mechanical compression of the extracranial vertebral artery during neck rotation. Neurology 62: 2143; author reply 2144. doi: 10.1212/wnl.62.11.2143-a
Weissman JL, Hirsch BE (2000) Imaging of tinnitus: a review. Radiology 216: 342-9. doi: 10.1148/radiology.216.2.r00au45342
Wuertenberger CJ, Rosahl SK (2009) Vertigo and tinnitus caused by vascular compression of the vestibulocochlear nerve, not intracanalicular vestibular schwannoma: review and case presentation. Skull Base 19: 417-24. doi: 10.1055/s-0029-1220209
Zaidi HA, Albuquerque FC, Chowdhry SA, Zabramski JM, Ducruet AF, Spetzler RF (2014) Diagnosis and management of bow hunter’s syndrome: 15-year experience at barrow neurological institute. World Neurosurg 82: 733-8. doi: 10.1016/j.wneu.2014.02.027
Zhang Y, Zheng H, Zhou M, He L (2014) Teaching neuroimages: carotid-cavernous fistula caused by fibromuscular dysplasia. Neurology 82: e134-5. doi: 10.1212/wnl.0000000000000319
