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

Abstract

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.

Keywords: Pulsatile tinnitus; endovascular; sigmoid sinus diverticulum; surgical.

Figure 1.

PRISMA 2020 flow diagram for systematic reviews which included searches of Pubmed, Embase, Medline and Cochrane databases, registers and other sources. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2.

Axial MRI brain with contrast (a) and 3D reconstruction of rotational angiography showing bilateral transverse sinus stenoses (red arrows) and bilateral venous diverticula (right larger than the left). Antero-posterior and lateral cerebral angiogram (venous phase) showing the right-sided venous stenosis before (c, e) and after endovascular treatment (e, f). Treatment was performed with venous stenting (black arrowheads) and coiling (black arrows) (d, f).