893case report J Neurosurg 124: [893][894][895][896][897][898][899][900][901] 2016 N oNpulsatile tinnitus is the perception of a sound in the absence of an external source and is therefore often considered a phantom sound. 30 It is related to abnormal activity in the auditory and nonauditory brain areas, 48 which can be altered by neuromodulation techniques. 24 As tinnitus is most commonly related to auditory deafferentation 20 with 30,31 or without 59 audiometric hearing loss, it has been regarded as maladaptive auditory memory traces 5 attempting to reduce the inherent auditory uncertainty associated with auditory deafferentation.11 Apart from abnormal activity, pathological functional connectivity is also associated with the presence of tinnitus as demonstrated by electroencephalography (EEG), 57 magnetoencephalography (MEG), 38,39 and functional MRI (fMRI). 26,27 Thus, it has been proposed that the phenomenologically unified percept of tinnitus can be considered an emergent property of multiple, parallel, dynamically changing, and partially overlapping subnetworks, each with a specific spontaneous oscillatory pattern and functional connectivity signature. 17 Functional imaging studies using source-localized EEG and MEG have shown that tinnitus distress is related to a network involving the anterior cingulate cortex (ACC), anterior insula, and parahippocampal area, 6,22,56 whereas the auditory cortex is involved in the perceived tinnitus intensity. 44 The distress subnetwork is predominantly lateralized to the right, in contrast to a similar network encoding depression that is lateralized to the left. 21 The loudness and distress networks are clearly separable even though they interact. Communication between these different subnetworks is proposed to occur at hubs, brain areas that are involved in multiple subnetworks simultaneously. These hubs can take part in each separable subnetwork at different frequencies. ComabbreviatioNs ACC = anterior cingulate cortex; BA = Brodmann area; BOLD = blood oxygen level-dependent; d = dorsal; DLPFC = dorsolateral prefrontal cortex; EEG = electroencephalography; fMRI = functional MRI; HADS = Hospital Anxiety Depression Scale; MEG = magnetoencephalography; NRS = numeric rating scale; r = repetitive; sg = subgenual; sLORETA = standardized low-resolution electromagnetic tomography; tDCS = transcranial direct current stimulation; TENS = transcutaneous electrical nerve stimulation; TMS = transcranial magnetic stimulation; TQ = tinnitus questionnaire. Tinnitus can be distressful, and tinnitus distress has been linked to increased beta oscillatory activity in the dorsal anterior cingulate cortex (dACC). The amount of distress is linked to alpha activity in the medial temporal lobe (amygdala and parahippocampal area), as well as the subgenual (sg)ACC and insula, and the functional connectivity between the parahippocampal area and the sgACC at 10 and 11.5 Hz. The authors describe 2 patients with very severely distressing intractable tinnitus who underwent transcranial magnetic st...