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

Abstract

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.

Keywords: Pulsatile tinnitus; venous aneurysm; venous sinus stenosis; venous sinus stenting.

Figure 1.

30 year old woman with BMI of 29 and severe pulsatile tinnitus (THI score 62). History of headaches. No visual disturbances or papilledema. Lumbar puncture with opening pressure of 24 cm H₂O. Treated with Diamox for 2 months with no benefit. Catheter directed venography demonstrates the presence of short segment intrinsic stenosis (long-thin arrow), noting post-stenotic fusiform sinus enlargement (short-thick arrow) is present (a). Two overlapping stents were placed after successful crossing the stenosis, with the proximal end of the first stent (left-pointing curved arrow) deployed in the distal transverse sinus and the distal end of second stent (right-pointing curved arrow) deployed in the mid sigmoid sinus beyond the point of fusiform enlargement (b). Post-stenting venography demonstrates marked improvement in dural venous sinus caliber (star) and improved rate of flow through previously stenotic segment (c).

Figure 2.

27 year old woman with BMI 20 and severe pulsatile tinnitus (THI Score 66). No headaches or visual disturbances. No papilledema. Lumbar puncture was not performed. Axial contrast enhanced (a) and 2D Time-of-Flight 3D reconstruction (b) MRV demonstrate right lateral transverse-sigmoid sinus wall dehiscence with associated saccular venous aneurysm (short-thick arrow). Intraprocedural venography from the same patient reconfirms the presence of saccular venous aneurysm (short-thick arrow), noting intrinsic stenosis (long-thin arrow) proximal to the aneurysm is present (c and d). Following traversal of stenosis, overlapping stents were first placed with the proximal end of the first stent (down and left-pointing curved arrows) deployed in the distal transverse sinus and the distal end of second stent (up and right-pointing curved arrows) deployed in the mid sigmoid sinus beyond the point of fusiform enlargement (e and f). After stent placements, coil embolization of the venous aneurysm (arrow head) was performed (e and f). Post-stent-assisted coiling venography demonstrates marked improvement in dural venous sinus caliber (star), resolution of venous aneurysm (asterisk), and improved rate of flow through previously stenotic segment (g and h).

Figure 3.

Axial contrast enhanced (a), 3D contrast-enhanced reconstruction (b), and 2D Time-of-Flight reconstruction (c) images from MR Venography in a patient with right sided pulsatile tinnitus demonstrate classic image characteristics of a focal arachnoid granulation within the dural venous sinus. Note its rounded well-demarcated borders and resultant severe intrinsic stenosis, in this case short-segment (< 3 cm length). MRV findings correlate with those of catheter-directed venography, as seen by a focal filling defect in the right-sided transverse sigmoid sinus junction (d) with subsequent resolution of stenosis following dural venous sinus stent placement (e).