Emergence of Venous Stenosis as the Dominant Cause of Pulsatile Tinnitus

Abstract

BACKGROUND The role of arteriovenous shunts such as dural fistulas, arterial steno‐occlusive states, anatomic variants, and hypervascular tumors in the genesis of pulsatile tinnitus (PT) has long been recognized. On the venous side, diverticula, high‐riding jugular bulb, and sinus wall dehiscence have also been implicated. However, the overall most common cause—venous sinus stenosis (VSS)—continues to be underrecognized. Its clinical importance, separate from venous stenosis association with intracranial hypertension, also requires emphasis. METHODS A retrospective review of the last consecutive 208 cases of PT seen at our institution was performed and cause determined, when possible, based on clinical and radiographic data. RESULTS VSS was the common cause of PT (34% of overall cohort). Over 90% are women. Typical clinical presentation was a unilateral whoosh‐like sound in sync with heartbeat that could be completely or nearly completely abolished by ipsilateral jugular compression. This clinical scenario virtually guaranteed the presence of VSS, with very high sensitivity, specificity, positive, and negative predictive values. About two thirds of patients with VSS also harbored other venous anatomic variations such as a high‐riding jugular bulb or sinus diverticulum, that should not be misinterpreted as the primary cause of PT. Most did not have signs or symptoms of intracranial hypertension, even though cerebrospinal fluid and venous pressures are frequently elevated. CONCLUSIONS VSS appears to be the most common identifiable cause of PT. Judicious attention to this finding can be immensely helpful in prompt and accurate diagnosis.

Cerebrovascular pulsatile tinnitus: causes, treatments, and outcomes in 164 patients with neuroangiographic correlation

“…In addition, we routinely treat these patients with medical management for IIH (ie, Diamox and weight loss) for 6 months before considering venous sinus stenting, since many will have an adequate response. Our experience is comparable to a recent study by Raz et al which found venous sinus stenosis to be the most common cause of PT (34% of patients), typically diagnosed with non-invasive imaging or even solely with clinical history and physical examination 17. In these cases, endovascular evaluation may still play a vital role in planning and providing treatment for debilitating PT.…”

Cerebral venous anatomy: implications for the neurointerventionalist

“…Stenoses at transverse/sigmoid sinus junctions have been definitively linked to intracranial hypertension 32 and pulsatile tinnitus [33][34][35][36] (figure 10). The latter can be present as a sole symptom, without intracranial hypertension, or in a setting of mildly increased cerebrospinal fluid pressures, with no visual or other findings.…”