Balloon occlusion testing for non-sinus-stenosis venous pulsatile tinnitus: A technical case series

Abstract

IntroductionPulsatile tinnitus (PT) affects ∼ 10% of the population and can be debilitating. Venous etiologies of PT are increasingly recognized. Identifying the symptomatic vessel, particularly with multiple venous anomalies, remains challenging.MethodsIn this case series, we utilized venous balloon occlusion testing (vBOT) as a real-time diagnostic tool to identify symptomatic vessels in non-sinus stenosis venous PT. vBOT involved using a transform balloon (7 mm × 7 mm) under fluoroscopic guidance to occlude the venous anomaly, with immediate assessment of symptom resolution.ResultsWe report four cases involving high-riding jugular bulbs, jugular bulb diverticula, and enlarged emissary veins. vBOT successfully identified the culprit vessels, guiding targeted endovascular coil embolization. These procedures led to significant symptom resolution in all cases, though the varied patient responses underscored the importance of a tailored, iterative approach, particularly in those with bilateral symptoms or multiple venous variants.ConclusionThis series illustrates the utility of vBOT in accurately identifying symptomatic vessels in non-sinus stenosis venous PT, enabling effective, targeted interventions. While vBOT is a valuable diagnostic tool, its limitations, including potential false negatives due to PT variability or ambient noise, must be considered. Incorporating vBOT into the diagnostic framework for PT can enhance precision in vessel selection and improve patient outcomes, particularly in cases with uncommon venous etiologies.

Keywords: Case series; balloon occlusion; pulsatile tinnitus; venography; venous intervention.

Figure 1.

(a) DSA demonstrating a dilated MEV in Case 1a. (b) DSA demonstrating inflated balloon in BOT in Case 1a. (c) Post-coiled DSA of MEV in Case 1a. (d) DSA demonstrating coiled MEV in Case 1a.

Figure 2.

(a) DSA of dilated left PCV in Case 2b; (b) post-coiling DSA of right PCV in Case 2b; (c) DSA of left-sided HRJB in Case 2b; and (d) post-coiling DSA showing coiled HRJB in Case 2b.

Figure 3.

(a) DSA of HRJB in Case 3; (b) post-coiling DSA of HRJB in Case 3; and (c) DSA of dilated left PCV in Case 4 and post-coiling DSA of dilated left PCV in Case 4.