Why does unilateral pulsatile tinnitus occur in patients with idiopathic intracranial hypertension?

Outcomes of Pulsatile Tinnitus After Cerebral Venous Sinus Stenting: Systematic Review and Pooled Analysis of 616 Patients

BACKGROUND

Pulsatile tinnitus (PT) is a debilitating condition with substantial morbidity related to quality of life. Cerebral venous sinus stenosis has recently emerged as a noninfrequent cause of PT, either in the setting of concurrent idiopathic intracranial hypertension (IIH) or due to primary venous stenosis. Venous sinus stenting (VSS) is an endovascular technique that can be used to treat venous stenosis. However, it is unclear if outcomes are different between patients with primary venogenic PT and IIH associated PT.

METHODS

A systematic literature review and pooled analysis was completed to evaluate the clinical outcomes of PT in patients undergoing cerebral VSS. Outcome measures included: Improved PT, complete resolution of PT, and PT recurrence at follow-up. Subgroup analysis between patients with IIH and primary PT was completed.

RESULTS

In total, 28 studies were identified with 616 patients. The proportion of improved PT symptoms after VSS had an overall pooled rate of 91.7% (confidence interval [CI]:88.1%-95.2%; I2 = 65%) and no difference between subgroups (P = 0.12). Complete resolution after VSS had an overall pooled rate of 88.6% (CI: 84.0%-93.3%; I2 = 68%) and no significant difference between subgroups (P = 0.35). Recurrent PT after stenting occurred in 6.5% of cases (CI: 1.7%-11.3%; I2 = 62%). Furthermore, subgroup analysis demonstrated that IIH patients had a significantly higher recurrence rate (10.6%; CI: 5.2%-16.1%; I2 = 26%) compared to patients treated with venous stenting for PT as the primary indication (2.0%; CI: 0.8%-4.7%; I2 = 0%) (P < 0.0001).

CONCLUSIONS

Venous stenting in patients with PT results in a substantial decrease and often complete resolution of symptoms. PT is more likely to recur in patients with IIH-associated PT.

Sigmoid Sinus Wall Anomalies Can Progress and May Not Be Congenital

OBJECTIVE

Sigmoid sinus wall anomalies (SSWA) are closely linked to venous pulsatile tinnitus (PT). This study aims to demonstrate that SSWA develops progressively rather than being congenital.

METHODS

We retrospectively analyzed 42 PT patients with SSWA who had at least two non-operative CT scans at our clinic. CT images were longitudinally assessed to track SSWA progression, while MRI and Doppler ultrasound evaluated transverse sinus stenosis and venous hemodynamics. Changes in PT perception were tracked using the tinnitus handicap inventory (THI) questionnaire.

RESULTS

Among the 42 SSWA patients, 12 (28.6%) exhibited progression. Anastomosis between diploic vein and diverticulum was significantly higher compared to the dehiscence cohort (p < 0.01). Within the diverticulum group, seven individuals (30.4%) experienced enlargement, with a mean diverticular wall expansion of 5.9% ± 11.4%. Progressive erosion was observed in two cases (12.5%) in the dehiscence cohort, with a mean sigmoid plate erosion of 3.8% ± 10.1%. In cases progressing from dehiscence to diverticulum, three subjects transitioned, with a mean sigmoid sinus wall length expansion of 43.8% ± 31.9%. SSWA progression showed a significant negative correlation with QBILATERAL (r = -0.857, p = 0.014), and there was a significant difference between initial and revisit THI scores (p < 0.01).

CONCLUSION

SSWA can undergo morphological progression, indicating it is a progressive clinical condition rather than congenital.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Cerebral venous sinus stenting and jugular bulb embolization for pulsatile tinnitus: A case report

Background

Pulsatile tinnitus (PT) is a rare form of tinnitus that aligns with the heartbeat. It is typically brought on by lesions with significant vascularity, which produce aberrant sound conduction and increase the risk of mental health issues and hearing loss. Venous PT is more prevalent than arterial PT. Open procedures or interventional procedures can be used to treat PT. We present here a case of PT caused by venous luminal stenosis combined with jugular bulb (JB) malformation, which was improved by stenting and JB embolization.

Case presentation

A 59-year-old woman presented with long-term tinnitus consistent with heart rhythm and hearing loss, accompanied by anxiety, insomnia, and depression. The results of brain MRV, CT, and DSA showed stenosis of the right sigmoid sinus and high jugular bulb (JB) with dehiscence of the JB wall. The patient saw a significant improvement in PT symptoms following sigmoid sinus stenting and spring coil embolization of the high JB, following the diagnosis of PT. The patient had no PT recurrence for the course of the 31-month follow-up period.

Conclusion

In the present PT case, there was a simultaneous onset of the right sigmoid sinus stenosis and the high JB with the JB wall abnormalities. Sigmoid sinus stenting and spring coil embolization of high JB may be a treatment for the PT, but the prevention of post-stenting complications is still an issue that requires great attention and needs further study.

Clinical Predictors of Pulsatile Tinnitus in Patients With Idiopathic Intracranial Hypertension: An Age-Matched Cohort Study

INTRODUCTION

Pulsatile tinnitus (PT) occurs in many but not all patients with idiopathic intracranial hypertension (IIH). It is poorly understood why some patients with IIH develop PT, yet others do not. The purpose of this study was to determine if any clinical findings differ between those with and without PT in IIH, potentially shedding light on a pathophysiologic mechanism.

METHODS

Age-matched cohort analysis of patients with documented IIH and presence or absence of PT was performed, collecting data including body mass index (BMI), blood pressure, visual acuity, cerebrospinal fluid (CSF) opening pressure, sleep apnea, migraines, and transient visual obscurations, among others. Independent-sample t test and χ2 test were used to analyze continuous and binary variables, respectively, with multivariate analysis conducted including variables statistically significant on univariate analysis.

RESULTS

Eighty subjects with IIH met the inclusion criteria (40 PT+, 40 PT-). CSF opening pressure showed no significant difference between the two groups. The PT+ cohort was found to have an average BMI of 45.1 kg/m 2 , which was significantly higher than the PT- group (37.7 kg/m 2 ; p = 0.0023). PT+ pulse pressure (60.1 mm Hg) was also significantly higher than the PT- group (51.6 mm Hg; p = 0.019). PT+ patients were also significantly more likely to have sleep apnea ( p < 0.001) and migraines ( p = 0.0036). Multiple logistic regression revealed an adjusted odds ratio of 13.9 for sleep apnea, 4.1 for migraines, and 1.01 for every increase in unit of BMI.

CONCLUSION

Among patients with IIH, presence of PT is associated with higher BMI and pulse pressure, and increased incidence of sleep apnea and migraines. Given no significant difference in CSF pressures between the two groups, PT may not be a product of increased disease severity but may be related to sequelae of obesity, such as increased pulse pressure and sleep apnea.

Resurfacing Dehiscence(s) Without Reducing Diverticulum Effectively Silences Pulsatile Tinnitus: Novel Surgical Techniques for Diverticulum and Intraoperative Microphone Monitoring

OBJECTIVE

To emphasize the surgical importance of addressing dehiscence over diverticulum in resolving pulsatile tinnitus (PT) in patients with sigmoid sinus wall anomalies (SSWAs) and investigate anatomical differences.

STUDY DESIGN

Retrospective data analysis.

SETTING

Multi-institutional tertiary university medical centers.

PATIENTS

Fifty participants (dehiscence/diverticulum, 29:21 cases) with SSWA-associated PT were included in the study. All 21 diverticulum participants underwent surgical intervention.

INTERVENTIONS

1) Surgical intervention with novel techniques monitored by intraoperative microphone. 2) Radiologic and ophthalmologic imaging methods.

MAIN OUTCOME MEASURES

Quantitative and qualitative preoperative and postoperative alterations of PT and anatomical differences between dehiscence and diverticulum.

RESULTS

Addressing dehiscence overlying diverticulum and sigmoid sinus wall dehiscences significantly reduced visual analog score and Tinnitus Handicap Inventory ( p < 0.01). Sinus wall reconstruction led to substantial PT sound intensity reduction in the frequency range of 20 to 1000 Hz and 20 to 500 Hz (paired-sample t test, p < 0.01). Diploic vein analysis showed a significant positive correlation in 85.7% of the diverticulum cohort compared with the dehiscence cohort ( p < 0.01). Eight percent of the participants exhibited papilledema, which was limited to the dehiscence cohort.

CONCLUSION

1) Effective reduction of PT can be achieved by addressing all dehiscences, including those overlying the diverticulum, without the need to exclude the diverticulum. 2) Diploic vein may involve in the formation of diverticulum, and loss of dura mater and vascular wall thickness are observed at the SSWA locations.

A new method for assessing transverse sinus stenosis with CT venography based on the venous trans-stenotic pressure gradient

BACKGROUND

Evaluation of the transverse sinus stenosis (TSS) is essential for TSS-related diseases.

OBJECTIVE

To investigate a new method for the quantitative assessment of TSS based on the correlation between TSS and trans-stenotic pressure gradient (TPG).

METHODS

Patients with unilateral pulsatile tinnitus with or without idiopathic intracranial hypertension were retrospectively included. All patients underwent CT venography and venous manometry and were confirmed to have TSS. The cross-sectional diameter/area of TSS, the poststenotic and prestenotic segments, and the superior sagittal sinus (SSS) were measured. The degree of TSS was calculated by dividing the diameter/area of TSS by the diameter/area of the poststenotic segment (M1/M2), prestenotic segment (M3/M4), and SSS (M5/M6). Partial correlation analysis (controlling for the effect of age, sex, outflow laterality, and contralateral stenosis) was performed to evaluate the correlation between M1-M6 and the TPG. Receiver operating characteristic curve analysis of M1-M6 for diagnosing a significant TPG (≥8 mm Hg) was performed.

RESULTS

Ninety-nine patients met the inclusion criteria. The partial correlation coefficients between M1-M6 and the TPG were 0.60, 0.61, 0.43, 0.48, 0.39, and 0.54, respectively. The areas under the curve (AUCs) of M1-M6 for diagnosing a significant TPG were 0.81, 0.86, 0.68, 0.69, 0.64, and 0.72, respectively. The AUC of M2 was significantly larger than that of M3 (P=0.002), M4 (P<0.001), M5 (P=0.001), and M6 (P<0.001).

CONCLUSIONS

Quantitatively assessing TSS by taking the ratio of the cross-sectional area of TSS to that of the poststenotic segment might be a more efficient method for predicting the TPG.

Case report: Novel transtemporal transverse sinus decompression surgery to alleviate transverse sinus stenosis in a pulsatile tinnitus patient with restricted bilateral venous outflow

Transverse sinus (TS) stenosis is common in individuals with venous pulsatile tinnitus (PT). While PT can be addressed by endoluminal or extraluminal methods, the former has shown promise in alleviating symptoms associated with increased intracranial pressure. This study explores the potential of extraluminal methods to alleviate TS stenosis and eliminate PT caused by sigmoid sinus diverticulum. A 31-year-old male patient presenting with left-sided PT, attributed to a large, pedunculated sigmoid sinus diverticulum along with severe ipsilateral TS stenosis and contralateral TS hypoplasia, underwent ipsilateral extraluminal TS decompression surgery following sigmoid sinus wall reconstruction under local anesthesia. Postoperative CT and MR angiography revealed a significant increase in the TS lumen from 0.269 to 0.42 cm2 (56.02%) 2 years after surgery. Cervical Doppler ultrasound demonstrated a 36.07% increase in ipsilateral outflow volume to 16.6 g/s and a 77.63% increase in contralateral outflow volume to 1.35 g/s. In conclusion, this pioneering study showcases the potential of transtemporal TS decompression surgery in creating space for adaptive expansion of the TS lumen. However, the procedure should be reserved for individuals with severely compromised venous return.

Dynamics of cerebrospinal fluid pressure alterations and bilateral transverse-sigmoid sinus morphologies in Asian patients with venous pulsatile tinnitus

OBJECTIVE

This study was performed to investigate the dynamics of intracranial pressure (ICP) alterations and bilateral transverse-sigmoid sinus morphologies in patients with venous pulsatile tinnitus (PT).

METHODS

This retrospective study involved 27 patients with venous PT associated with sigmoid sinus wall anomalies. ICP and ICP metrics were measured by cerebrospinal fluid manometry and internal jugular vein compression tests. Correlation analysis was performed to determine the statistical correlation between ICP and the morphological metrics.

RESULTS

The mean ICP was 212.5 ± 47.3 mmH2O. The median Δ ICP total was 130 (range, 55-150) mmH2O. The Δ ICP total was linearly correlated with the open lumbar pressure, and a significant difference was found between patients with normal and elevated cerebrospinal fluid pressure. The Δ ICP difference was linearly correlated with the Len difference and Vol difference . Δ ICP was linearly correlated with Len difference .

CONCLUSIONS

Complete obstruction of flow patency should be avoided in patients with low ICP and large volumetric/patency differences in the bilateral transverse-sigmoid sinus systems.

Radiographic Sigmoid Sinus Wall Abnormalities and Pulsatile Tinnitus: A Case-Control Study

OBJECTIVE

Compare incidence of sigmoid sinus wall abnormalities (SSWAs) and other radiographic abnormalities in patients with pulsatile tinnitus (PT) versus controls.

STUDY DESIGN

Retrospective case-control.

SETTING

Tertiary referral center.

PATIENTS

Adults with PT and high-resolution computed tomography imaging were compared with adults undergoing cochlear implant workup including high-resolution computed tomography imaging.

MAIN OUTCOME MEASURES

Incidence of SSWA in PT cohort (n = 141) compared with control (n = 149, n = 298 ears). Secondary outcome measures included differences in demographics and in other radiographic abnormalities between cohorts.

RESULTS

Patients with PT had a higher incidence of SSWA (34% versus 9%, p < 0.001) and superior canal dehiscence (23% versus 12%, p = 0.017) than controls. Spearman product component correlations demonstrated that ipsilateral PT was weakly associated with SSWA ( r = 0.354, p < 0.001). When SSWA was present in the PT cohort (n = 48 patients, n = 59 ears), in 31 cases (64.6%), the SSWA correlated with PT laterality (e.g., left SSWA, left PT); in 12 (25.0%), SSWA partially correlated with PT laterality (e.g., bilateral SSWA, right PT); and in 5 (10.4%), the SSWA did not correlate with PT laterality (e.g., right SSWA, left PT).

CONCLUSIONS

For our patients with both PT and SSWA, the SSWA is likely a contributing factor in approximately 65% of cases. For a third of patients with PT and concomitant SSWA, the association between the two is either not causative or not solely causative. Surgeons counseling patients with PT and SSWA may be optimistic overall regarding sigmoid resurfacing procedures but must appreciate the possibility of treatment failure, likely because of untreated comorbid conditions.

Magnetic Resonance Imaging Findings in Idiopathic Intracranial Hypertension With and Without Pulsatile Tinnitus: An Age-Matched Cohort Study

OBJECTIVE

Many but not all patients with idiopathic intracranial hypertension (IIH) have pulsatile tinnitus (PT). However, little is known about why some patients with IIH develop PT and others do not. The purpose of this study was to determine if any of the classic magnetic resonance imaging (MRI)-detectable markers of IIH differ between patients with and without PT, thereby shedding light on potential pathophysiology.

METHODS

A retrospective age-matched cohort study of patients with documented IIH (diagnosed by neuro-ophthalmologist) was performed. All patients had MRI performed around the time of diagnosis. MRIs were assessed for 16 variables known to be associated with IIH (e.g., pituitary displacement/empty sella, optic nerve tortuosity, transverse sinus stenosis, inferior cerebellar tonsils, arachnoid granulations, slit-like ventricles) by two blinded neuroradiologists. All binary variables were analyzed via χ2 test with Yates correction, or Fisher exact when appropriate. Continuous variables were analyzed via Student t test. Inter-rater reliability for binary variables was assessed by Cohen κ. For continuous variables, intraclass correlation coefficient was calculated.

RESULTS

Forty age-matched patients with IIH met the inclusion criteria (20 with PT, 20 without PT). For all known binary MRI findings associated with IIH, there were no statistically significant differences between groups. Likewise, there were no statistically significant differences for continuous variables.

CONCLUSIONS

The classic MRI findings associated with IIH do not differ between patients with and without PT, suggesting that systemic (rather than localized intrinsic or extrinsic) factors may play a critical role in the pathophysiology.

Optic nerve sheath fenestration for treating papilloedema in the era of cerebral venous sinus stenting

BACKGROUND

Pseudotumour cerebri (PTC) is the syndrome of intracranial hypertension without intracranial mass or hydrocephalus and is the commonest cause of papilloedema seen in many eye clinics. In the last 10 years, we have increasingly used TSS in patients whose papilloedema was not well controlled with medical treatment and have done fewer ONSFs. Here, we review our experience at Royal Prince Alfred Hospital Sydney with ONSF in 35 patients over the period 2002-2021.

METHODS

Retrospective case series of 35 patients, 30 of whom had primary PTC [i.e., idiopathic intracranial hypertension (IIH)] and 5 with secondary PTC.

RESULTS

Eighteen patients had bilateral ONSF and 17 patients unilateral ONSF, in each case of the worse eye. Thirteen patients then underwent transverse sinus stenting (TSS), in each case following ONSF. The primary outcome measures were visual acuity (VA) and mean deviation (MD) on visual field (VF) testing. MD improved by 5 dB or more in 34 of 70 total eyes (48.6%); VA improved by 0.2 logMAR (two lines on Snellen chart) or more in 21 eyes (30%), and by both in 15 eyes (21.4%). Final MD was -10 dB or better in 38 eyes (54.3%); final VA was 0.3 (6/12) or better in 54 eyes (77.1%), and both in 39 eyes (55.7%).

CONCLUSIONS

The results confirm that ONSF can relieve papilloedoema in both eyes and improve both VF and VA, even in cases of fulminant PTC with severe acute visual impairment.

CT evaluation of unilateral pulsatile tinnitus with jugular bulb wall dehiscence

OBJECTIVES

To investigate the imaging features of unilateral pulsatile tinnitus (PT) with jugular bulb wall dehiscence (JBWD).

METHODS

Computerized tomography angiography images of unilateral PT patients were reviewed between 2019 and 2021. Thirty-one symptomatic JBWD patients without sigmoid sinus wall dehiscence (SSWD) were included. Thirty-eight patients with SSWD were used as the control group. The prevalence of JBWD was calculated. The area and height of the jugular bulb, the extent of dehiscence, the presence of jugular bulb diverticulum, posterior condylar emissary vein (PCEV), oblique occipital sinus (OOS), venous outflow laterality (VOL), the degree of transverse sinus stenosis (TSS), and the pituitary height to sella turcica ratio were compared between the two groups.

RESULTS

The prevalence of JBWD was 12.1%, and JBWD was established as a causative diagnosis in 5.0% of unilateral PT patients. There were no statistical differences in the gender, symptomatic side, or VOL between the two groups. The area of the jugular bulb was larger and the height was higher (p_area < 0.001, p_height = 0.005). The prevalence of jugular bulb diverticulum was higher in the JBWD group (p = 0.002). The degree of symptomatic TSS was less severe (p < 0.001), and the prevalence of bilateral TSS was lower in the JBWD group (p < 0.001). The pituitary height to sella turcica ratio was greater (p = 0.004), the prevalence of PCEV (p = 0.014) was lower, and OOS (p = 0.015) was greater in the JBWD group.

CONCLUSIONS

The correlating factors of PT with JBWD and PT with SSWD are significantly different. These findings can further facilitate early and efficient PT treatment.

KEY POINTS

• The incidence of jugular bulb dehiscence (JBWD) accounted for approximately 12.1% in pulsatile tinnitus (PT) patients, and JBWD was established as a causative diagnosis in 5.0% of PT patients. • PT required large blood flows and abnormal flow patterns, whether in JBWD or sigmoid sinus wall dehiscence groups. • JBWD causing PT has some unique characteristic findings on CT.

Flow patterns in the venous sinus of pulsatile tinnitus patients with transverse sinus stenosis and underlying vortical flow as a causative factor

BACKGROUND

Transverse sinus stenosis (TSS) is commonly found in Pulsatile Tinnitus (PT) patients. Vortex flow is prominent in venous sinus with stenosis, and so it is important to determine the distribution and strength of the vortical flow to understand its influence on the occurrence of PT.

METHODS

In this study, by using computational fluid dynamics for hemodynamic analysis in patient-specific geometries based on Magnetic Resonance Imaging (MRI), we have investigated the blood flow within the venous sinus of 16 subjects with PT. We have employed both laminar and turbulent flow models for simulations, to obtain (i) streamlines of velocity distribution in the venous sinus, and (ii) pressure distributions of flow patterns in the venous sinus. Then, hemodynamic analysis in the venous sinus recirculation zone was carried out, to determine the flow patterns at the junction of transverse sinuses and sigmoid sinuses. Finally, we have proposed a new model for turbulence evaluation based on the regression analysis of anatomic and hemodynamics parameters.

RESULTS

Correlation analysis between the anatomical parameters and the hemodynamic parameters has shown that stenosis at the transverse sinus was the main factor in the local hemodynamics variation in the venous sinus of patients; in this context, it is shown that vorticity can be used as a prime indicator of the severity of the stenosis function. Our results have shown a significant correlation between the vorticity and the stenotic maximum velocity (SMV) (r = 0.282, p = 0.004). Then, a parameterized prediction model is proposed to determine the vorticity in terms of flow and anatomic variables, termed as the turbulence eddy prediction model (TEP model). Our result have shown that the TEP model is sensitive to the dominant flow distribution, with a high correlation to the flow-based vorticity (r = 0.809, p = 0.009).

CONCLUSIONS

The quantification of the vorticity (as both vorticity and MVV) in the downstream of TSS could be a marker for indication of turbulent energy at the transverse-sigmoid sinus, which could potentially serve as a hemodynamic marker for the functional assessment of the PT-related TSS.

Influence of sigmoid plate and dura mater on vascular wall displacement, vibroacoustic/hydroacoustic sources characteristics, and frequency-loudness assessments of venous pulsatile tinnitus: A coupled-computational fluid dynamics study combining transcanal recording investigation

Investigations of pulsatile tinnitus (PT) caused by sigmoid sinus wall anomalies (SSWAs) using computational fluid dynamics (CFD) have recently increased in prevalence. However, accurate modeling of anatomical structures regarding sigmoid plate dehiscence and acoustic sources of PT remains lacking. This study incorporates coupled CFD techniques, micro-computed tomography, and scanning electron microscope to reveal the vibroacoustic and hydroacoustic sources and displacement characteristics of the transverse-sigmoid sinus system. Furthermore, the in vivo transcanal-recording technique combined with ipsilateral internal jugular vein compression was implemented to cross-reference the captured acoustic profile of PT with the calculated results. In this study, the transient state coupled CFD technique was used to calculate the vibroacoustic and hydroacoustic sources. The dehiscent sigmoid plate and periosteal dura mater were then reconstructed. The displacement characteristics and acoustic results were analyzed. The displacement of the vascular wall underneath the dehiscent area was 9.6 times larger than that of the sigmoid plate and 3,617 times smaller than that of the vascular wall without the overlying osseous structures. The peak amplitude of flow-induced vibroacoustic noise was 119.3 dB at 20.2 Hz measured at the transverse sinus. Within the observed 20–1,000 Hz frequency range, the largest peak amplitude of hydroacoustic noise was 80.0 dB at 20.2 Hz located at the jugular bulb region. The simulated results conformed with the in vivo acoustic profile which the major frequency of PT falls within 1,000 Hz. In conclusion, 1) the sigmoid plate and dura mater greatly impact vascular wall displacement, which should not be overlooked in CFD simulations. 2) By incorporating the transcanal recording technique with IJV compression test, the primary frequency of PT was found fluctuating below 1,000 Hz, which matches the frequency component simulated by the current CFD technique; amplitude-wise, however, the peak amplitude of in vivo pulse-synchronous somatosound measures approximately 10 dB, which is comparatively lesser than the CFD results and the subjectively perceived loudness of PT. Thus, the transmission pathway, intramastoid acoustic impedance/amplification effect, and the perceptive threshold of PT require further investigations to minimize the incidence of surgical failure.

Intracranial pressure, lateral sinus patency, and jugular ultrasound hemodynamics in patients with venous pulsatile tinnitus

The clinical and hemodynamic characteristics of venous pulsatile tinnitus (PT) patients with normal or elevated cerebrospinal fluid pressure (CSFP) have not been clearly differentiated. This study aimed to explore CSFP among patients with PT as the solitary symptom, as well as quantitatively and qualitatively assess the role of the degree of transverse sinus (TS) stenosis and jugular hemodynamics in venous PT patients. A total of 50 subjects with venous PT with or without sigmoid sinus wall anomalies (SSWAs) were enrolled in this study. In addition to radiologic assessments for TS stenosis and invagination of arachnoid granulation (AG) in TS, CSFP and jugular hemodynamics were measured via cerebrospinal fluid (CSF) manometry and Doppler ultrasound. Apart from group comparisons and correlation analyses, multivariate linear regression, and receiver operating characteristic (ROC) models were used to identify the sensitivity and specificity of the index of transverse sinus stenosis (ITSS) and hemodynamic variables with inferential significance. The mean CSFP of all cases was 199.5 ± 52.7 mmH2O, with no statistical difference in CSFP between the diverticulum and dehiscence groups. Multivariate linear regression analysis demonstrated that CSFP was linearly correlated with ITSS and pulsatility index (PI). ROC analysis showed that the area under the ROC curve of PI was 0.693 at 200 mmH2O threshold, and the best PI cut-off value was 0.467, with a sensitivity of 65.7% and specificity of 81.8%. For 250 mmH2O threshold, the area under the ROC curve of PI was 0.718, and the best PI cut-off value was 0.467 with a sensitivity of 68.4% and specificity of 75.0%. Additionally, the area under the ROC curve of ITSS was 0.757, and the best ITSS cutoff value was 8.5 (p = 0.002, 95% CI = 0.616–0.898) with a sensitivity of 72.4% and specificity of 75.0% at 200 mmH2O threshold. In conclusion, patients with venous PT as the only presenting symptom should be suspected of having borderline or increased CSFP when they present with high ITSS, BMI and low PI. Further, AG in TS without encephalocele and empty sellae are not limiting findings for differentiating the level of CSFP in patients with venous PT.

Systematic Evaluation of the Efficacy of Acupuncture Associated with Physical and Mental Intervention when Treating Idiopathic Tinnitus and the Improvement of Tinnitus Symptoms

Objective

To systematically evaluate the efficacy of acupuncture associated with physical and mental intervention when treating idiopathic tinnitus and the improvement of tinnitus symptoms, so as to supply evidence-based medicine for its popularization and adoption.

Methods

PubMed, EMBASE, ScienceDirect, Cochrane Library, China knowledge Network Database (CNKI), China VIP Database, Wanfang Database, and China Biomedical Literature Database (CBM) online database were searched for the controlled trial of acupuncture associated with physical and mental intervention when treating idiopathic tinnitus. The retrieval time limit is from January 2010 to March 2022. Separately, two researchers extracted the data, and according to the Cochrane Handbook 5.3, the bias risk of each piece of literature was assessed. The collected data were measured using RevMan5.3 statistical software.

Results

Finally, 5 CT articles were included in this study, with a total sample size of 282. Meta-analysis showed that the effective rate of the study group was significantly higher than that of the control group (P < 0.05). The scores of tinnitus disorder scale (THI) after treatment were analyzed by Meta. The THI scores of the study group after treatment were significantly lower than those before treatment. Meta-analysis of the severity of tinnitus after treatment showed that the severity of tinnitus in the observation group after treatment was significantly lower than that before treatment. There is a certain publication deviation in the literature, which may be related to the heterogeneity of the research and the small number of literatures.

Conclusion

On the basis of acupuncture treatment, associated with physical and mental intervention is helpful to the recovery of patients with idiopathic tinnitus, can effectively improve their clinical symptoms, and is suitable for clinical application. A popularization of this concept in clinical practice is worth considering, but further research and follow-up with a higher methodological quality and longer intervention time are needed to confirm its efficacy.

Retroauricular/Transcranial Color-Coded Doppler Ultrasound Approach in Junction With Ipsilateral Neck Compression on Real-Time Hydroacoustic Variation of Venous Pulsatile Tinnitus

Alterations in dural venous sinus hemodynamics have recently been suggested as the major contributing factors in venous pulsatile tinnitus (PT). Nevertheless, little is known about the association between real-time alterations in hemodynamics and the subjective perception of venous PT. This study aimed to investigate the hydroacoustic correlations among diverticular vortices, mainstream sinus flow, and PT using various Doppler ultrasound techniques. Nineteen venous PT patients with protrusive diverticulum were recruited. The mainstream sinus and diverticular hemodynamics before and after ipsilateral internal jugular vein (IJV) compression were investigated using an innovative retroauricular color-coded Doppler (RCCD) method to examine the correlation between the disappearance of PT and hemodynamic alterations. To reveal the hydroacoustic characteristics of disparate segments of venous return, a computational fluid dynamics (CFD) technique combined with the transcranial color-coded Doppler method was performed. When the ipsilateral IJV was compressed, PT disappeared, as the mean velocity of mainstream sinus flow and diverticular vortex decreased by 51.2 and 50.6%, respectively. The vortex inside the diverticulum persisted in 18 of 19 subjects. The CFD simulation showed that the flow amplitude generated inside the transverse–sigmoid sinus was segmental, and the largest flow amplitude difference was 20.5 dB. The difference in flow amplitude between the mainstream sinus flow and the diverticular flow was less than 1 dB. In conclusion, the sensation of PT is closely associated with the flow of kinetic energy rather than the formation of a vortex, whereby the amplitude of PT is correlated to the magnitude of the flow velocity and pressure gradient. Additionally, the range of velocity reduction revealed by the RCCD method may serve as a presurgical individual baseline curative marker that may potentially optimize the surgical outcomes.

Intervention of the Syndrome-Position Point Selection Method on Idiopathic Tinnitus of Phlegm-Fire Stagnation Pattern: A Randomized Controlled Study

Objective

To investigate the clinical effect of the syndrome-position point selection method on the intervention of idiopathic tinnitus of the phlegm-fire stagnation pattern.

Methods

One hundred patients with idiopathic tinnitus of phlegm-fire stagnation pattern who met the inclusion criteria were randomized into the treatment group and the control group by the random number table method, with 50 cases in each group. The treatment group (syndrome-position point selection method) was treated with acupuncture at the corresponding acupoints for tinnitus and associated symptoms and the corresponding acupoints located in Wernicke's area of scalp projection, while the control group (traditional acupuncture method) was treated with the combination of acupuncture points with the most frequent occurrence in the tinnitus research literature for acupuncture treatment. Both groups received acupuncture twice a week for 5 weeks. The efficacy was evaluated before and after treatment with the Tinnitus Severity Inventory (TSI), Sleep Spiegel Questionnaire, Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS).

Results

The 100 patients with idiopathic tinnitus of phlegm-fire stagnation pattern completed 5 weeks of clinical treatment and a month of follow-up with no loss of patients and no adverse event reports. Three patients recovered with the disappearance of the tinnitus symptoms in the treatment group after 5 weeks of treatment. After 5 weeks of treatment, obvious differences between the two groups were observed in the TSI scores (P < 0.05) and the Spiegel scores, with a better Spiegel score in the treatment group than in the control group (P < 0.05). Compared with the control group, the depression (SDS score) and anxiety (SAS score) of tinnitus patients in the treatment group were markedly improved (P < 0.05).

Conclusion

In line with the principle of symptomatic treatment and based on the modern imaging data, the syndrome-position point selection method is more accurate and effective compared with the traditional acupoint selection method, which significantly improves the symptoms, sleep quality, and psychological state of patients with idiopathic tinnitus of the phlegm-fire stagnation pattern.

Neurosurgical Causes of Pulsatile Tinnitus: Contemporary Update

Traditionally in the domain of the otolaryngologist, pulsatile tinnitus (PT) has become increasingly relevant to neurosurgeons. PT may prove to be a harbinger of life-threatening pathology; however, often, it is a marker of a more benign process. Irrespectively, the neurosurgeon should be familiar with the many potential etiologies of this unique and challenging patient population. In this review, we discuss the myriad causes of PT, categorized by pulse-phase rhythmicity.

Brain herniation (encephalocele) into arachnoid granulations: prevalence and association with pulsatile tinnitus and idiopathic intracranial hypertension

PURPOSE

Brain herniation into arachnoid granulations (BHAG) of the dural venous sinuses is a recently described finding of uncertain etiology. The purpose of this study was to investigate the prevalence of BHAG in a cohort of patients with pulsatile tinnitus (PT) and to clarify the physiologic and clinical implications of these lesions.

METHODS

The imaging and charts of consecutive PT patients were retrospectively reviewed. All patients were examined with MRI including pre- and post-contrast T1- and T2-weighted sequences. Images were reviewed separately by three blinded neuroradiologists to identify the presence of BHAG. Their location, signal intensity, size, presence of arachnoid granulation, and associated dural venous sinus stenosis were documented. Clinical records were further reviewed for idiopathic intracranial hypertension, history of prior lumbar puncture, and opening pressure.

RESULTS

Two hundred sixty-two consecutive PT patients over a 4-year period met inclusion criteria. PT patients with BHAG were significantly more likely to have idiopathic intracranial hypertension than PT patients without BHAG (OR 4.2, CI 1.5-12, p = 0.006). Sixteen out of 262 (6%) patients were found to have 18 BHAG. Eleven out of 16 (69%) patients had unilateral temporal or occipital lobe herniations located in the transverse sinus or the transverse-sigmoid junction. Three out of 16 (19%) patients had unilateral cerebellar herniations and 2/16 (13%) patients had bilateral BHAG.

CONCLUSION

In patients with PT, BHAG is a prevalent MRI finding that is strongly associated with the clinical diagnosis of IIH. The pathogenesis of BHAG remains uncertain, but recognition should prompt comprehensive evaluation for IIH.

Dual-phase contrast-enhanced CT evaluation of dural arteriovenous fistula in patients with pulsatile tinnitus as an initial symptom

PURPOSE

Intracranial dural arteriovenous fistula (DAVF) can cause pulsatile tinnitus (PT). The purpose of this study was to investigate the diagnostic performance of dual-phase contrast-enhanced CT (DP-CECT) for DAVF in PT patients compared with digital subtraction angiography (DSA).

METHOD

From February 2015 to April 2021, PT patients undergoing routine DSA examination were prospectively analyzed. Patients with and without DAVF diagnosed by DSA were included. In DP-CECT, the radiological signs related to DAVF were assessed as follows: asymmetric external carotid artery (ECA) branches, asymmetric enhancement of intracranial or extracranial veins, asymmetric venous collaterals in extracranial space, and shaggy tentorium or venous sinus on CTA; asymmetric enhancement of intracranial or extracranial veins on CTV; numerous transcalvarial channels and asymmetric size of foramen spinosum on high-resolution CT (HRCT).

RESULTS

253 PT patients receiving DSA were enrolled, and these patients had previously been screened by DP-CECT. Forty-six patients were diagnosed as DAVF by DSA. Therefore, the prevalence of DAVF was 18% (46/253) in patients with PT as the initial symptom. The sensitivity and specificity of DP-CECT for diagnosis of DAVF were 96% and 100%. The sensitivity of individual CTA signs ranged from 65% to 93%, and specificities ranged from 83% to 100%. The sensitivity of CTV sign was 80%, and specificity was 100%. The sensitivity of individual HRCT signs ranged from 48 to 52% and specificities from 61 to 100%.

CONCLUSIONS

DAVF is not rare in patients with PT as the initial symptom. DP-CECT can be used for screening DAVF in patients with PT.

Sensorineural Hearing Loss and Tinnitus Characteristics in Patients With Idiopathic Intracranial Hypertension

OBJECTIVES

To characterize patterns of sensorineural hearing loss (SNHL) and tinnitus in patients with idiopathic intracranial hypertension (IIH).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adult patients diagnosed with IIH via lumbar puncture (LP) between 2010 and 2020 who had available audiograms. The study included a total of 40 patients; 33 women, and 7 men with a median age of 43.

INTERVENTIONS

Diagnostic LP and audiogram.

MAIN OUTCOME MEASURES

Otologic symptoms, ophthalmologic signs, hearing thresholds, cerebrospinal fluid opening pressures.

RESULTS

The most commonly reported symptoms were tinnitus in 28 (70%, 23 pulsatile and 5 tonal), aural fullness in 11 (28%), and vertigo in 10 (25%). Twenty-nine patients had ophthalmologic examinations and 18 had evidence of papilledema. Twenty-five (63%) patients had hearing loss in at least one ear at one frequency range. Patients presented with both unilateral and bilateral hearing loss across low, middle, and high frequency ranges. No significant association was observed between hearing loss threshold and LP opening pressure except for 250 Hz in the left ear. After stratification by tinnitus group (pulsatile, tonal, and no tinnitus), no significant difference was found between mean hearing loss threshold at different frequencies. In addition, no significant mean age difference was identified in patients within each tinnitus group.

CONCLUSIONS

There was no classic pattern or presentation for hearing loss in our IIH patients. They developed sudden, unilateral, or bilateral SNHL in low, middle, or high frequency range. The degree of hearing loss did not correlate with CSF opening pressure.