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Abdelhaliem et al. Vessel Plus 2020;4:31 I http://dx.doi.org/10.20517/2574-1209.2020.13 Page 3 of 9

achieve in cases without symptoms or with the most minimal. On a parallel note, a reduction in cerebral
blood flow may be a contributory factor and can potentially be the culpable weakest link.

Hence, to date, the standard diagnostic tool for delineating this is the widely available duplex
ultrasonography. However, this tool is subjective and dependent on the operator. This raises the issue of
potential subjective biases in reporting and utilization of this resource. Consequently, in an attempt to
quantify the degree of stenosis present, other imaging modalities can also be implemented. These include
classical angiography, computed angiography, and magnetic resonance angiography. However, those
modalities raise a prudent question regarding timing and associated timely risk factors. The identification
of these risk factors and the unequivocal management of Tinnitus, shown to have a vascular origin, can
have an impact on central nervous system symptom manifestation and a natural effect on pulsatile tinnitus.
The carotid intima-media thickness as delineated on the aforementioned imaging modalities can be of
crucial help when identifiable in formulating the diagnosis and developing the axis of management but
cannot surely affect or quantify the pulsatility.

The microvascular remodelling implicated in increased pulsatile tinnitus through the increased resistance
in vascular beds and the emergence of microvascular ischemia has large implications on arterial stiffness
and crucially on the success of any intervention whether surgical or endovascular.

LITERATURE SEARCH STRATEGY
Electronic searches were performed on a number of databases including PubMed, Scopus, Embase and
Cochrane with no limits put in place on dates. Search terms included: natural history, carotid artery
disease, and stenosis, lesion size, location, prevalence, and natural history, risk factors, survival rates,
medical therapy, surgical intervention, and mortality. Search terms were charted to MeSH terms, combined
using Boolean operations and also used as keywords. Papers were selected on the basis of their title and
abstract. The reference lists of these selected papers were also reviewed to identify any relevant papers that
might be suitable for inclusion for this study. Forty-five publications were eventually identified with dates
ranging from 2002-2020. A full breakdown of number of studies identified is detailed in Figure 1.

SELECTION CRITERIA
Research papers were not excluded on the basis of their study design except for case reports. Any
comments, editorials or opinions were not included for selection to provide an unbiased view. Papers were
selected on the basis of providing primary endpoints of intervention used, the eventuality of the disease
intervention and/or information regarding medical therapeutics, endarterectomy and angioplasty. Papers
were not excluded on the basis of the age of the patient population.

WHAT IS THE PREVALENCE CHARACTERISTICS AND PATHOPHYSIOLOGY OF TINNITUS IN
VASCULAR SURGERY PRACTICE?
To date, there is no prevailing consensus or guidelines that are sufficient to best describe the natural history
of this disease and the current literature is lacking in detail regarding the prevalence and characteristics of
the condition. Therefore, robust research into the pathophysiological factors, etiological mechanisms and
pathogenesis of tinnitus in correlation with factors of carotid disease such as location, lesion size and extent
of stenosis of affected vessels among others is required.

Historically, atherosclerosis within the carotids was credited as the main arterial cause of tinnitus. However,
arterial stiffness has also become an important parameter that can predict the carotid event and can be
[13]
correlated with the incidence of stroke .