Awake embolization of sigmoid sinus diverticulum causing pulsatile tinnitus: simultaneous confirmative diagnosis and treatment

Causes of Pulsatile Tinnitus and Treatment Options

Pulsatile tinnitus (PT) requires detailed workup to evaluate for an underlying structural cause. With advances in neuroimaging, structural venous abnormalities that can cause PT have becoming increasingly recognized. A number of anomalies, including dural arteriovenous fistulas, idiopathic intracranial hypertension, transverse sinus stenosis, sigmoid sinus wall abnormalities, jugular venous anomalies, and hypertrophied emissary veins, have been implicated in flow disruption and turbulence in the vicinity of auditory structures, resulting in PT. Endovascular treatment options, including stenting, coiling, and embolization with liquid agents, have demonstrated high efficacy and safety. These treatments can lead to symptomatic relief in carefully selected cases.

Surgical Management of Pulsatile Tinnitus due to Sigmoid Sinus Diverticulum and Dehiscence - A Technical Note

Pulsatile tinnitus (PT) is the perception of an auditory sensation without an external source and in synchrony with the heartbeat. One of the most common cases of PT is bony anomalies of the sigmoid sinus, including dehiscence or diverticula. This case report describes a 26-year-old female patient who presented with pulsatile tinnitus caused by sigmoid sinus diverticula and dehiscence, which was successfully treated with cortical mastoidectomy with diverticula closure using pedicled temporalis fascia and resurfacing of the dehiscence with autogenous bone pate along with bone cement. We recommend thorough clinical and radiological workup to rule out other possible causes of PT before surgical intervention. In addition, we would like to highlight the surgical technique using pedicled temporalis fascia that we have used in our patient, which is easily reproducible and offers successful outcomes.

Endovascular vs surgical treatment of sigmoid sinus diverticulum causing pulsatile tinnitus: A systematic review

INTRODUCTION

Sigmoid sinus diverticulum (SSD) has been increasingly reported as a cause of pulsatile tinnitus (PT). While both endovascular and surgical treatments have been used, there is a lack of consensus on the treatment modality to treat SSD. We conducted a systematic review of the available literature to compare the clinical outcomes and safety of endovascular versus surgical approaches for treating SSD.

METHODS

A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify studies encompassing the management of SSD. Studies reporting the clinical outcomes and safety of endovascular or surgical treatments for SSD between January 2000 and January 2023 were included. Results were characterized using descriptive statistics.

RESULTS

Endovascular treatment (EVT) was reported by 17 articles, yielding 26 patients with 27 diverticula. Surgical treatment was reported by 20 articles, yielding 105 patients with 107 diverticula. EVT led to complete or near-complete resolution in all patients with SSD and PT. Complications occurred in 3.7% (1/27) with a return to baseline after 2 months. There were no permanent complications from EVT. Surgical treatment resulted in complete resolution in 77.6% (83/107) of cases, incomplete resolution in 11.2% (12/107), and no resolution in 11.2% (12/107). Significant complications occurred in 9.3% (10/107) of the surgical-treated patients.

CONCLUSION

EVT in patients with PT and venous diverticulum appears more effective and safer than surgical treatment, but large studies are lacking. Studies directly comparing endovascular and surgical treatment are needed.

Venous balloon test occlusion for pulsatile tinnitus assessment: A clinical feasibility study

BACKGROUND

Pulsatile tinnitus (PT) can have huge impact on the patients' quality of life and can be associated with curable vascular anomalies. In the present study, we aim firstly to describe our protocol for venous BTO and secondly to report possible predictors for a positive BTO test.

METHODS

All consecutive PT patients undergoing BTO for the purpose of determining eligibility for venous neuro-intervention were included. We recommend BTO for patients when there is uncertainty in the association of the venous pathology identified on non-invasive cross-sectional imaging (CTV or MRV) and the patient's symptoms.

RESULTS

Between May 2016 and October 2022, we recorded 29 venous balloon test occlusions fulfilling our inclusions criteria. Over the 29 procedures scheduled, 8 finally did not lead to a successful balloon test occlusion. The main reason was that the patient did not hear the PT on the day the angiogram was performed. Two patients could not have the BTO due to difficulties in venous navigation. After BTO, only four patients of our cohort were scheduled for an endovascular treatment.

CONCLUSION

We describe a technique and present a single cohort of venous BTO in severe PT patients with unclear anatomical cause. This angiographic test was useful to exclude patients from endovascular surgery and discuss the most probable cause of the PT. Complexity of vascular PT should support a patient-based approach when discussing interventional treatment.

Surgical treatment of pulsatile tinnitus related to the sigmoid sinus

Objective

Tinnitus-a common clinical symptom-can be categorized into pulsatile tinnitus (PT) and non-PT. Among these, PT is usually associated with sigmoid sinus symptoms, such as sigmoid sinus wall defect or diverticulum, for which various surgical treatments are available. We have discussed the clinical efficacy of surgery for sigmoid sinus-associated PT via the transmastoid approach in this study.

Methods

We conducted a retrospective review of 4 patients who underwent surgery for sigmoid sinus-associated PT via the transmastoid approach at Nanjing Drum Tower Hospital from January to December 2020. Of these, 2 patients had sigmoid sinus wall defect and 2 had sigmoid sinus diverticulum. Post-operative tinnitus grading and surgical efficacy were determined.

Results

After surgery, PT dissolved in 3 patients, while tinnitus significantly decreased in 1 patient. During the follow-up period of 12-18 months, none of the 4 patients showed complications related to increased intracranial pressure or venous sinus thrombosis, and tinnitus symptoms disappeared in 3 patients without recurrence, although 1 patient occasionally developed tinnitus. Postoperative thin-slice CTA of the temporal bone indicated that the sigmoid sinus bone wall defect or diverticulum was completely repaired with a thick soft tissue coverage.

Conclusion

Surgical repair of sigmoid sinus-associated PT via the transmastoid approach deserves clinical promotion as it exhibited better efficiency while being relatively less invasive.

Stent-assisted coiling of dural sinus diverticula: a case series

BACKGROUND

Dural sinus diverticula are a rare vascular etiology of pulsatile tinnitus. Patients typically present with disabling symptoms and undergo an extensive workup for common causes of pulsatile tinnitus. Endovascular treatment has been shown to be effective in several case reports. We present the largest case series of eight patients treated with endovascular therapy using stent-assisted coiling and describe the unique details of intervention.

METHODS

A retrospective chart review was performed on all patients who underwent endovascular dural sinus stenting.

RESULTS

One-hundred-twenty patients underwent dural sinus stetnting from August 2012 to February 2020. Eight of these had symptomatic pulsatile tinnitus secondary to a dural sinus diverticulum and were successfully treated with stent-assisted coil embolization. No complications occurred.

CONCLUSION

Our case series demonstrates that endovascular dural sinus stent-assisted coil embolization for symptomatic dural sinus diverticula is a safe and effective treatment.

Venous Causes of Pulsatile Tinnitus: Clinical Presentation, Clinical and Radiographic Evaluation, Pathogenesis, and Endovascular Treatments: A Literature Review

Tinnitus is an abnormal perception of a sound without external stimulation. Venous pulsatile tinnitus (VPT) is a specific form of tinnitus characterized by an objective and often subjective bruit that occurs as a result of localized venous abnormalities. Clinical evaluation relies on sound quality, duration, and precipitating factors. Idiopathic intracranial hypertension (IIH) and transverse sinus stenosis (TSS) are among the most common causes of VPT. Other causes include sigmoid sinus wall abnormalities (SSWAs), jugular vein anomalies (JVAs), and emissary veins anomalies. These anomalies can be detected on magnetic resonance imaging, magnetic resonance angiography/magnetic resonance venography, and high-resolution temporal bone computed tomography. The pathogenesis behind the VPT includes turbulent blood flow as a result of luminal stenosis or abnormal dilation, amplification of internal sound due to temporal bone defects, and abnormal position of the venous sinus system structures adjacent to the bony structures of the auditive apparatus. Based on these theories, different interventional treatment modalities can be applied to treat the underlying causes. Endovascular treatments have shown high efficacy and safety among those treatments which include stenting of the lateral sinus stenosis in IIH and TSS, coiling of the SSWA and JVA, and embolization of emissary veins anomalies. Further studies are needed to understand the natural history of these anomalies and the efficacy of treatments of VPT, which-unlike other types of tinnitus-can be cured with proper treatment.

State of the Art: Venous Causes of Pulsatile Tinnitus and Diagnostic Considerations Guiding Endovascular Therapy

Venous variants and pathologic abnormalities are the most common causes of pulsatile tinnitus. These conditions include causes of turbulence within normally located veins and sinuses, and abnormally enlarged or abnormally located veins in close transmissive proximity to the conductive auditory pathway. Such disorders include pathologic abnormalities of the lateral sinus (transverse sinus stenosis and sigmoid sinus wall anomalies), abnormalities and variants of the emissary veins, and anomalies of the jugular bulb and jugular vein. Despite being the most common causes for pulsatile tinnitus, venous variants and pathologic abnormalities are often overlooked in the workup of pulsatile tinnitus. Such oversights can result in delayed patient care and prolonged patient discomfort. Advances in both cerebrovascular imaging and endovascular techniques allow for improved diagnostic accuracy and an increasing range of endovascular therapeutic options to address pulsatile tinnitus. This review illustrates the venous causes of pulsatile tinnitus and demonstrates the associated endovascular treatment. © RSNA, 2021.

Hemodynamic Changes in the Sigmoid Sinus of Patients With Pulsatile Tinnitus Induced by Sigmoid Sinus Wall Anomalies

OBJECTIVE

This study is to investigate the hemodynamic changes of pulsatile tinnitus (PT) patients induced by sigmoid sinus wall anomalies (SSWA).

STUDY DESIGN

Prospective study.

SETTING

Tertiary referral university hospital.

PATIENTS

Fifteen unilateral PT patients with SSWA identified on computed tomography images and surgery and 15 age-, sex-, and body mass index-matched healthy volunteers underwent velocity-encoded, cine magnetic resonance imaging.

INTERVENTION

Hemodynamic data in sigmoid sinus were obtained from velocity-encoded, cine magnetic resonance imaging, and compared between PT patients and controls.

MAIN OUTCOME MEASURES

Heart rate was recorded. Cross-sectional area (CSA), peak positive velocity (PPV), average positive flow volume per beat (APFV/beat), average flow volume per beat (AFV/beat), peak negative velocity (PNV), and average negative flow volume per beat (ANFV/beat) were measured. Average flow volume per minute (AFV/min), average positive flow volume per minute (APFV/min), average negative flow volume per minute (ANFV/min), average positive velocity (APV), average negative velocity (ANV), and regurgitation fraction (RF) were calculated.

RESULTS

APV at PT side of patients was 13.4 ± 3.3 cm/s, which was significantly slower than that at corresponding side of controls (15.8 ± 2.6 cm/s). PNV and RF at PT side of patients were 21.0 ± 15.4 cm/s and 2.4% respectively, which were significantly higher than those values at corresponding side of controls (both of them were 0). HR, CSA, PPV, APFV/beat, APFV/min, AFV/beat, AFV/min, ANV, ANFV/beat, and ANFV/min were 69.8 ± 9.4 beat/min, 48.4 ± 17 mm, 31.4 ± 5.9 cm/s, 5.4 ± 1.8 ml/beat, 373.9 ± 117.7 ml/min, 5.1 ± 2.0 ml/beat, 352.0 ± 134.6 ml/min, 2 (0-4.9) cm/s, 1 (0-2.7) ml/beat, and 4.1 (0-141.3) ml/min at PT side of patients, and 67.4 ± 7.8 beat/min, 38.2 ± 18 mm, 29.9 ± 3.9 cm/s, 5.3 ± 2.0 ml/beat, 350.3 ± 125.3 ml/min, 5.1 ± 1.9 ml/beat, 340.5 ± 117.9 ml/min, 0 (0-2.1) cm/s, 0 (0-0.8) ml/beat, and 0 (0-55.4) ml/min at corresponding side of controls. These hemodynamics were not significantly different between groups.

CONCLUSION

APV, PNV, and RF changes take place in SSWA patients, which may be associated with the occurrence of PT and have the potential value to improve accurate etiological diagnosis and predict treatment success.

Venous sinus stenting for the treatment of isolated pulsatile tinnitus: Results of a prospective trial

OBJECTIVES

This prospective study evaluates the effectiveness and safety of venous sinus stenting for patients with isolated pulsatile tinnitus and lateral sinus stenosis.

METHODS

Patients with isolated pulsatile tinnitus and lateral sinus stenosis with a minimum trans stenotic gradient of 4 mm Hg were treated with stenting. Pulsatile tinnitus before and after treatment was assessed with the Tinnitus Handicap Inventory (THI). Periprocedural adverse events, neurological complications, clinical and radiographic follow-up were also recorded.

RESULTS

A total of 42 patients (41 females and 1 male) were included in the study (median age of 37.5 years). Thirty patients had post-stenotic fusiform and 12 had post-stenotic saccular venous sinus aneurysm. In addition to stenting, coils were used to treat the patients with saccular venous aneurysms. The median follow-up was 5 months (range 1 to 34 months). Most patients had complete (39/42) or near-complete (2/42) resolution of their pulsatile tinnitus post-procedure. There were no serious adverse events.

CONCLUSION

Stenting of the lateral venous sinus is a safe and effective treatment for patients with isolated pulsatile tinnitus due to venous sinus stenosis.

A rare case of jugular bulb diverticulum presenting as Meniere's disease, treated with embolization

BACKGROUND

  Jugular bulb diverticulum constitutes a rare clinical entity that may present with variable symptoms. When obstructing the endolymphatic duct, it may cause sensorineural hearing loss and vertigo, mimicking Meniere's disease. Diagnosis is based on computed tomography and magnetic resonance imaging scans, with magnetic resonance and digital subtraction angiography being more specific and detailed diagnostic methods. Treatment options include surgical decompression, endovascular embolization, or stenting. Description of the case: We report a jugular bulb diverticulum case manifesting as Meniere's disease and treated with endovascular embolization. The procedure was uneventful, and the patient's vertigo gradually disappeared over two months. No medical treatment was required for the next 2.5 years as the patient remained asymptomatic with no more vertigo attacks.

CONCLUSION

Endovascular embolization can be the method of choice in selected cases of jugular bulb diverticulum. HIPPOKRATIA 2019, 23(4): 172-174.

Endovascular treatment of debilitating tinnitus secondary to cerebral venous sinus abnormalities: a literature review and technical illustration

Background and objective

Pulsatile tinnitus (PT) can be debilitating and lead to significant morbidity. Cerebral venous sinus lesions, such as venous sinus stenosis, diverticula, and high-riding jugular bulb, are uncommon causes of PT, for which there is no standard treatment. Endovascular interventions have shown promising results for PT secondary to idiopathic intracranial hypertension, and may be a valid therapeutic option for isolated venous PT.

Methods

We conducted a systematic literature review on the outcome and safety of endovascular treatment for patients with isolated, debilitating venous PT. The venous lesion characteristics, endovascular techniques, complications, and clinical outcomes were assessed. In addition, an illustrative case of endovascular stenting for PT caused by venous sinus stenosis was included.

Results

A total of 41 patients (90.2% female) from 26 papers were included. The median age was 46 years (IQR 23; range 25–72 years). Focal venous sinus stenosis (20 patients) and sinus diverticula (14 patients) were the most common culprit lesions. Endovascular treatment included venous sinus stenting in 35 patients, 11 of whom had adjuvant coil embolization, and coil embolization alone in six patients. Complete resolution of the tinnitus was achieved in 95.1% of patients. There was one complication of cerebellar infarct, and no procedure-related mortality.

Conclusions

In patients with debilitating PT secondary to venous sinus lesions, endovascular treatment by stenting and/or coil embolization appears to be safe and effective. Prospective randomized studies with objective outcome assessments are needed to confirm the treatment benefits.

MR Venous Flow in Sigmoid Sinus Diverticulum

BACKGROUND AND PURPOSE

Case reports demonstrate that coiling of a sigmoid sinus diverticulum can treat pulsatile tinnitus. We hypothesized that MR imaging 4D flow and computational fluid dynamics would reveal distinct blood flow patterns in the venous outflow tract in these patients.

MATERIALS AND METHODS

Patients with pulsatile tinnitus of suspected venous etiology underwent MR imaging at 3T, using venous phase contrast-enhanced MR angiography, 4D flow, and 2D phase contrast. The contrast-enhanced MRA contours were evaluated to determine the presence and extent of a sigmoid sinus diverticulum. Computational fluid dynamics analysis was performed using the 4D flow inlet flow and the luminal contours from contrast-enhanced MRA as boundary conditions. In addition, computational fluid dynamics was performed for the expected post treatment conditions by smoothing the venous geometry to exclude the sigmoid sinus diverticulum from the anatomic boundary conditions. Streamlines were generated from the 4D flow and computational fluid dynamics velocity maps, and flow patterns were examined for the presence of rotational components.

RESULTS

Twenty-five patients with pulsatile tinnitus of suspected venous etiology and 10 control subjects were enrolled. Five (20%) of the symptomatic subjects had sigmoid sinus diverticula, all associated with an upstream stenosis. In each of these patients, but none of the controls, a stenosis-related flow jet was directed toward the opening of the sigmoid sinus diverticulum with rotational flow patterns in the sigmoid sinus diverticulum and parent sigmoid sinus on both 4D flow and computational fluid dynamics.

CONCLUSIONS

Consistent patterns of blood flow can be visualized in a sigmoid sinus diverticulum and the parent sinus using 4D flow and computational fluid dynamics. Strong components of rotational blood flow were seen in subjects with sigmoid sinus diverticula that were absent in controls.

Petrous Carotid Aneurysm Causing Pulsatile Tinnitus: Case Report and Review of the Literature

We present the case of a patient who developed pulsatile tinnitus that was found to be associated with a petrous carotid aneurysm. The aneurysm was successfully obliterated using stent-assisted coiling, after which the patient was symptom-free. Although aneurysms arising from the petrous segment of the internal carotid artery are rare, this pathology must be considered as a causative factor in patients with pulsatile tinnitus. Endovascular treatment appears to have been successful in resolving the symptoms associated with this pathology.

Surgical management of pulsatile tinnitus secondary to jugular bulb or sigmoid sinus diverticulum with review of literature

INTRODUCTION

Jugular bulb and sigmoid sinus anomalies are well-known causes of vascular pulsatile tinnitus. Common anomalies reported in the literature include high-riding and/or dehiscent jugular bulb, and sigmoid sinus dehiscence. However, cases of pulsatile tinnitus due to diverticulosis of the jugular bulb or sigmoid sinus are less commonly encountered, with the best management option yet to be established. In particular, reports on surgical management of pulsatile tinnitus caused by jugular bulb diverticulum have been lacking in the literature.

OBJECTIVES

To report two cases of pulsatile tinnitus with jugular bulb and/or sigmoid sinus diverticulum, and their management strategies and outcomes. In this series, we describe the first reported successful case of pulsatile tinnitus due to jugular bulb diverticulum that was surgically-treated.

SUBJECTS AND METHODS

Two patients diagnosed with either jugular bulb and/or sigmoid sinus diverticulum, who had presented to the Otolaryngology clinic with pulsatile tinnitus between 2016 and 2017, were studied. Demographic and clinical data were obtained, including their management details and clinical outcomes.

RESULTS

Two cases (one with jugular bulb diverticulum and one with both sigmoid sinus and jugular bulb diverticula) underwent surgical intervention, and both had immediate resolution of pulsatile tinnitus post-operatively. This was sustained at subsequent follow-up visits at the outpatient clinic, and there were no major complications encountered for both cases intra- and post-operatively.

CONCLUSION

Transmastoid reconstruction/resurfacing of jugular bulb and sigmoid sinus diverticulum with/without obliteration of the diverticulum is a safe and effective approach in the management of bothersome pulsatile tinnitus arising from these causes.

Sigmoid Sinus Wall Reconstruction for Pulsatile Tinnitus Caused by Sigmoid Sinus Wall Dehiscence: A Single-Center Experience

OBJECTIVE

To evaluate clinical characteristics and present surgical outcomes of PT caused by sigmoid sinus wall dehiscence (SSWD).

METHODS

This study retrospectively reviewed 34 patients with PT who were diagnosed with SSWD in our institution between December 2008 and July 2013. Among them, 27 patients underwent sigmoid sinus wall reconstruction (surgery group) and 7 patients refused surgery (non-surgery group). Preoperative data were obtained from the patients' medical records. All patients were followed up regularly for at least 25 months. Preoperative and postoperative computed tomography angiography (CTA) images were compared. Student's t-tests were used to compare age, body mass index (BMI) and preoperative Tinnitus Handicap Inventory (THI) scores between the surgery and the non-surgery groups and to compare pre- and follow-up THI scores.

RESULTS

There was no significant difference in age, body mass index, or preoperative THI scores between groups. Following surgery, 14 patients had complete resolution, 5 had partial resolution, 7 experienced no change and PT was aggravated in 1 patient. The difference between preoperative and postoperative THI scores was significant. No severe complications were found postoperatively. Comparison of the preoperative and postoperative CTA images revealed that remnant unrepaired dehiscences were the cause of unsatisfactory outcomes following surgery. In the non-surgery group, PT remained largely unchanged.

CONCLUSIONS

Sigmoid sinus wall reconstruction is an effective and safe treatment for PT caused by SSWD. It is imperative that all regions of the dehiscence are sufficiently exposed and resurfaced during surgery.

Transmastoid reshaping of the sigmoid sinus: preliminary study of a novel surgical method to quiet pulsatile tinnitus of an unrecognized vascular origin

OBJECTIVE

A dominant sigmoid sinus with focal dehiscence or thinning (DSSD/T) of the overlying bony wall is a commonly encountered, but frequently overlooked, cause of vascular pulsatile tinnitus (VPT). Also, the pathophysiological mechanism of sound perception in patients with VPT remains poorly understood. In the present study, a novel surgical method, termed transmastoid SS-reshaping surgery, was introduced to ameliorate VPT in patients with DSSD/T. The authors reviewed a case series, analyzed the surgical outcomes, and suggested the pathophysiological mechanism of sound perception. The theoretical background underlying VPT improvement after transmastoid SS-reshaping surgery was also explored.

METHODS

Eight patients with VPT that was considered attributable to DSSD/T underwent transmastoid SS-reshaping surgery between February 2010 and February 2015. The mean postoperative follow-up period was 9.5 months (range 4–13 months). Transmastoid SS-reshaping surgery featured simple mastoidectomy, partial compression of the SS using harvested cortical bone chips, and reinforcement of the bony SS wall with bone cement. Perioperative medical records, imaging results, and audiological findings were comprehensively reviewed.

RESULTS

In 7 of the 8 patients (87.5%), the VPT abated immediately after surgery. Statistically significant improvements in tinnitus loudness and distress were evident on numeric rating scales. Three patients with preoperative ipsilesional low-frequency hearing loss exhibited postoperative improvements in their low-frequency hearing thresholds. No major postoperative complications were encountered except in the first subject, who experienced increased intracranial pressure postoperatively. This subsided after a revision operation for partial decompression of the SS.

CONCLUSIONS

Transmastoid SS-reshaping surgery may be a good surgical option in patients with DSSD/T, a previously unrecognized cause of VPT. Redistribution of severely asymmetrical blood flow, reinforcement of the bony SS wall with bone cement to reconstruct a soundproof barrier, and disconnection of a problematic sound conduction route via simple mastoidectomy silence VPT.

Endovascular Management of Sigmoid Sinus Diverticulum

Sigmoid sinus diverticulum (SSD) is a rare vascular disorder due to dehiscence of the sigmoid plate. It may be associated with prediverticular venous sinus stenosis (SS) and usually presents as pulsatile tinnitus. The mechanism of development of the SSD and tinnitus from a sinus diverticulum and associated SS is unclear. Previous case reports have suggested that remodeling of the venous system targeting the stenosis, elimination of the diverticulum, or both, have resulted in symptom relief. We present a case of SSD with SS, treated by stenting of the stenosis along with coil embolization of the diverticulum, resulting in complete relief of symptoms. We have also reviewed the literature and discussed the evolution of management from open surgical treatment to endovascular treatment.

CT characteristics of dehiscent sigmoid plates presenting as pulsatile tinnitus: a study of 23 patients

BACKGROUND

Although some features of dehiscent sigmoid plates as a cause of pulsatile tinnitus (PT) have been reported, detailed imaging findings have not been evaluated.

PURPOSE

To retrospectively evaluate the computed tomography (CT) features of dehiscent sigmoid plates associated with PT.

MATERIAL AND METHODS

The CT images of 23 PT patients were assessed to evaluate the features of the dehiscent sigmoid plates, lateral sinuses, and temporal bone pneumatization.

RESULTS

A total of 31 defects were found on the PT side. Twenty-five defects involved the superior curve or the descending segment, four involved above both sites, and only two involved the inferior curve. Twenty-six defects involved the anterior border or the anterolateral border, and only five involved the lateral border of the sigmoid sinus. The dehiscent sigmoid plate was on the dominant side in all 18 patients with a unilateral dominant lateral sinus, and on the right side in two patients and on the left side in three patients with co-dominant lateral sinuses. Fourteen patients had hyperpneumatization and nine had good pneumatization of temporal bone. Fifteen of the 17 patients with resolution of PT after surgery had a single defect. Four of the six patients with persistence of PT after surgery had more than one defect.

CONCLUSION

Sigmoid plate dehiscence often involves the anterior or anterolateral border of the superior curve or the descending segment of the sigmoid sinus on the side of the dominant lateral sinus, which often coexists with extensive pneumatization of the temporal bone.

Sinus Wall Resurfacing for Patients With Temporal Bone Venous Sinus Diverticulum and Ipsilateral Pulsatile Tinnitus

BACKGROUND:

Pulsatile tinnitus (PT) caused by venous sinus diverticulum is a relatively common, potentially incapacitating condition. Although treatment via an external approach or endovascular coiling has been reported, much remains unknown about the possible pathophysiological mechanisms and appropriate management of PT.

OBJECTIVE:

To review our case series of PT resulting from either sigmoid sinus diverticulum (SSD) or middle cranial fossa venous sinus diverticulum (MFD-VS) and to discuss the possible pathophysiological mechanisms and desirable treatment options.

METHODS:

Four PT patients with either SSD or MFD-VS were treated with transmastoid resurfacing. In 1 case, a revision operation was performed as a result of recurrence of PT 4.5 years after the initial operation. The medical records and temporal bone imaging findings were retrospectively reviewed.

RESULTS:

PT was resolved in all cases immediately after transmastoid resurfacing, but 1 patient in whom bone wax was used for initial resurfacing experienced PT 4.5 years later. The PT was successfully managed with revision resurfacing with autologous bone chips/bone cement. In the other cases, the resolution of PT lasted throughout a median follow-up of 5.75 years. Notably, 2 of 4 cases had preoperative low-frequency hearing loss (LFHL) and experienced immediate postoperative improvement in LFHL.

CONCLUSION:

PT resulting from either SSD or MFD-VS can be treated successfully with transmastoid resurfacing of the venous wall. Preoperative ipsilesional LFHL and the improvement of hearing threshold after surgical intervention may be preoperative and postoperative surrogate objective signatures of PT. To ensure the resolution of symptoms, secure reconstruction with firm materials and long-term follow-up are mandatory.

Endovascular treatment of pulsatile tinnitus associated with transverse sigmoid sinus aneurysms and jugular bulb anomalies

Pulsatile tinnitus of vascular origin may arise in arterial or venous structures. Many authors have reported the association of pulsatile tinnitus with anomalies of dural venous sinuses and the jugular bulb. In such circumstances, mainly concomitantly with disabling tinnitus, endovascular treatment has been successfully employed. We describe here a new case of jugular bulb diverticulum associated with transverse sigmoid sinus stenosis, in a patient presenting with disabling pulsatile tinnitus. She was treated with dural sinus stenting and selective embolization of the diverticulum. In addition, we performed a literature review aiming to identify possible risk factors for developing the symptoms, as well as the safety and results of endovascular treatment.

Surgical treatment of pulsatile tinnitus caused by the sigmoid sinus diverticulum: a preliminary study

The sigmoid sinus diverticulum (SSD) is an increasingly recognized cause of pulsatile tinnitus (PT). Surgical reconstruction of the sigmoid sinus wall has been found to be highly effective for SSD; however, surgical techniques still need to be refined to reduce the incidence of serious postoperative complications. Moreover, scrutinizing more cases of SSD is desirable for establishing the diagnostic criteria and standardizing the surgical technique. This study was retrospectively undertaken in 28 patients who were diagnosed with SSD upon computed tomography angiography (CTA) and digital subtraction angiography findings at Beijing Tongren Hospital in China. A majority of patients (20/28) presented with SSD and accompanying sigmoid sinus wall dehiscence (SSWD). Twenty-five patients opted to undergo sigmoid sinus wall reconstruction, and 3 patients refused surgery. Following surgery, 17 patients experienced complete resolution of PT, 3 patients experienced partial resolution, and 5 patients experienced no change in PT. No serious complications were found postoperatively. A comparative analysis of the preoperative and postoperative CTA findings suggested that completely resolving SSD and the accompanying SSWD resulted in the elimination of PT. In conclusion, SSD is generally accompanied by SSWD. Sigmoid sinus wall reconstruction is a safe and effective approach for the treatment of SSD. During surgery, completely resolving both SSD and SSWD is advisable, and maintaining the normal diameter of the sigmoid sinus is imperative.

Changes in the jugular bulb associated with sacrifice of the internal jugular vein

OBJECTIVE

To determine whether sacrifice of the internal jugular vein (IJV) causes subsequent changes in the jugular bulb.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Patients were selected by CPT code for neck dissection and were included in the study if they had undergone unilateral neck dissection and had preoperative and postoperative computed tomographic scans through the temporal bone.

INTERVENTIONS

The jugular bulb was measured in the axial plane for anteroposterior and mediolateral diameters.

MAIN OUTCOME MEASURES

Cross-sectional area of the jugular bulb was calculated, and comparison was made between preoperative and postoperative studies in patients with or without ligation of the IJV.

RESULTS

After unilateral neck dissection, the mean change in the size of the jugular bulb ipsilateral to surgery with sacrifice of the IJV was found to be -10.4 mm (95% confidence interval [95% CI], ± 8.54 mm); ipsilateral to surgery without sacrifice of the internal jugular, -0.2 mm (95% CI, ± 3.24 mm); contralateral to surgery with sacrifice of the IJV, +1.9 mm (95% CI, ± 11.12 mm); and contralateral to surgery without sacrifice of the IJVa, +1.0 mm (95% CI, ± 2.66 mm). Analysis of variance demonstrated a significant difference for changes in the jugular bulb area ipsilateral to surgery with sacrifice of the IJV (p = 0.03) when compared with contralateral to surgery without sacrifice of the IJV.

CONCLUSION

Changes in size of the jugular bulb occur with surgical manipulation of the jugular vein. This study demonstrates a decrease in the size of the jugular bulb with ipsilateral IJV sacrifice.

Sigmoid sinus diverticulum and pulsatile tinnitus: analysis of CT scans from 15 cases

BACKGROUND

Although the imaging features of sigmoid sinus diverticulum induced pulsatile tinnitus (PT) have been presented in some extent, detailed imaging findings still have not been systematically evaluated and precise diagnostic radiographic criteria has not been established.

PURPOSE

To examine the computed tomography (CT) characteristics of sigmoid sinus diverticulum accompanied with PT.

MATERIAL AND METHODS

Fifteen PT patients with sigmoid sinus diverticula proven by surgery were recruited after consenting. CT images of 15 patients were obtained and analyzed, including features of diverticula, brain venous systems, integrity of the sigmoid plate, and the degree of temporal bone pneumatization.

RESULTS

Sigmoid sinus diverticulum was located on the same side of PT in 15 patients. Diverticula originated at the superior curve of the sigmoid sinus in 11 patients and the descending segment of the sigmoid sinus in four patients. Sigmoid sinus diverticula focally eroded into the adjacent mastoid air cells in 12 patients and mastoid cortex in three patients. Among eight patients with unilateral dominant brain venous systems, the diverticula were seen on the dominant side in seven patients and non-dominant side in one patient. In contrast, the other seven patients showed co-dominant brain venous systems, with three presenting diverticula on the right side and four on the left. More notably, dehiscent sigmoid plate on the PT side was demonstrated in all patients. In addition, temporal bone hyper-pneumatization was found in nine patients, good and moderate pneumatization in three patients, respectively.

CONCLUSION

Dehiscent sigmoid plate and extensive temporal bone pneumatization are two important imaging characteristics of the PT induced by sigmoid sinus diverticulum.