Matthew Amans, MD, MSc, is an Associate Professor of Clinical Radiology of Neuro Interventional Radiology and Diagnostic Neuroradiology at UCSF. He completed Diagnostic Radiology residency at Weill Cornell Medical College in 2011. From 2011-2012, Dr. Amans was a Diagnostic Neuroradiology fellow at UCSF and then worked as an attending Neuroradiologist at UCSF San Francisco General Hospital. Subsequently, he completed a two-year Neurointerventional Radiology fellowship at UCSF.

Dr. Amans’ clinical focus is on the treatment of acute stroke, cerebral aneurysms and other vascular anomalies, and the use of directed chemotherapy for cerebral tumors, including pediatric retinoblastoma. His interest in pulsatile tinnitus led him to found and serve as co-director of the UCSF Pulsatile Tinnitus Clinic, a multidisciplinary group of physicians and researchers in the departments of Radiology, Neurology, and Psychiatry.

The multidisciplinary tinnitus clinic you created has created quite the buzz—pun intended! Please share how crafted this idea and describe the general workflow of the clinic.

That’s a good question! I am very interested in dural arterioveous fistulas, but I learned that patients were not always getting diagnosed. It turns out the most common symptom of a DAVF is pulsatile tinnitus. So I figured if I opened the UCSF Pulsatile Tinnitus Clinic, I could be the one to make the diagnosis. As it turns out, there are many diagnoses that cause pulsatile tinnitus. So I asked friends and colleagues if they would want to partner with me in a new clinic where we all saw patients that have the same exact symptom and we could work together to come up with the diagnosis. That we would take a collaborative approach to patient care and research, and bring the “experts” to the patient. My friends in Neurology, Head and Neck Surgery, Psychiatry, and Diagnostic Neuroradiology joined the crew!

When a patient gets referred to the UCSF Pulsatile Tinnitus Clinic, we do a brief film and chart review to try and screen patients at a high risk of stroke or intracranial hemorrhage, and see if their imaging is adequate. If not, we order the missing studies. All patients get an MRI of the brain with and without contrast including high resolution fat saturated post contrast sequences through the skull base, MRA TOF without contrast of the head (love to also get ASL), post contrast SPGR sequence or post contrast MRV to see the venous sinuses, and MRA or equivalent imaging of the cervical vasculature (preferably arteries and veins).

On the day of clinic, we have a multidisciplinary film review of all of the patients. Then the patients are put in an exam room and the physicians rotate around the patient. The patient stays in their room and the physicians take turns. Then we gather and discuss the patients to come up with a unified diagnosis. The person whose specialty usually manages the diagnosis takes the patient forward after clinic. ENT is typically consulted afterwards and doesn’t see every patient. We really only contact them with ENT-specific diseases. We have learned most are vascular issues.

Your clinic includes many disciplines under one roof, including neurointerventional radiology, ENT, and psychiatry. How did you engage clinicians from other disciplines to join you in this pursuit?

That’s a great question! I found other eager physicians that were junior in their career and needed some publications. So when we were together, we would generate hypotheses, and then we would work on these as individual projects. The team became pretty productive because we were all enthusiastic, had a lot of energy, had varying skill sets and backgrounds, and liked working together. It made it fun. There are always politics in institutions, but the right people can find creative ways to move things forward.

Within your own department, how did you engage your leadership to trust in your vision and fund your plans with both time and money?

I am very lucky to work at an institution that really elevates patient care and research above all else. Leaders like Ron Arenson, Bill Dillon, Chris Hess, Wade Smith, Andy Josephson, Randy Higashida really understood the vision and believed we could provide great patient care. To really move things with the institution and get resources allocated, I had to show the business plan. We were going to generate revenue from diagnostic imaging, procedures like lumbar punctures, ENT surgeries, and procedures in the Angiosuites.

It was very important to track the revenue streams to show how productive we were and lobby for additional resources. I was surprised by how many patients changed insurance companies to come to the UCSF Pulsatile Tinnitus Clinic. Then the patients would get all of their care at UCSF. The administration recognized that we were bringing a lot of new patients into the health network. So they setup a method to track our patients for a short period of time after our Pulsatile Tinnitus Clinic visit and would credit our group for other surgeries in that time period.

What metrics have you chosen to show your institution that the clinic is a success?

Clinical success is first. We are diagnosing between 85 and 95% of patients depending on the metric. Specific diagnosis (like it is venous sinus stenosis of the left lateral transverse sinus) is only 80-85%. We have higher rates if one were to include broad diagnosis like there is “neurogenic” pulsatile tinnitus where the nerve is firing and telling the brain there is sound when no sound is actually present, but we can’t find the exact inciting exposure.

Research success is second. The UCSF Cerebral Venous Disorders Lab is funded by government grants from the NIH and Department of Defense. We have been able to make some contributions to the literature and have had a lot of fun along the way!

Financial success is important, otherwise resources (including people’s time) will not be allocated. So we track the finances.

And most importantly we are having fun!

What pearls would you like to share with new radiologists to help make their dreams a reality?

Find something that no one else is really interested in and dig in. Follow your curiosity and don’t be afraid to pursue something new!