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Jugular Doppler ultrasound velocity spectra. (A) Ultrasound measurement of upper internal jugular vein (IJV). (B) Flow spectrum demonstrating an averaged pulsatility index (PI) of 1.54. (C) Flow spectrum demonstrating an averaged PI of 0.46. (D) Flow spectrum demonstrating an averaged PI of 0.21.
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The clinical and hemodynamic characteristics of venous pulsatile tinnitus (PT) patients with normal or elevated cerebrospinal fluid pressure (CSFP) have not been clearly differentiated. This study aimed to explore CSFP among patients with PT as the solitary symptom, as well as quantitatively and qualitatively assess the role of the degree of transv...
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Measurement of cerebrospinal fluid pressure through lumbar puncture (LP) manometry is an essential practical skill all paediatricians should possess competency in. The ability to perform manometry is crucial in the diagnosis of idiopathic intracranial hypertension and can provide critical information on raised (or lowered) intracranial pressure in...
Citations
... [12][13][14] However, it's worth noting that IIH-related symptoms are less prevalent among Asian patient populations. 15,16 Furthermore, studies suggest that while TSS, whether extrinsic or intrinsic, the presence of an empty sella, and arachnoid granulation in the transverse sinus may not directly cause PT, they do indicate a disruption in cerebrospinal fluid-sinus hemodynamics. 5,13,16 The transverse sinus impingement theory posits that high-velocity flow impact triggers SSWA, a notion supported by computational studies illustrating elevated regional wall pressure corresponding to the site of SSWA. ...
... 15,16 Furthermore, studies suggest that while TSS, whether extrinsic or intrinsic, the presence of an empty sella, and arachnoid granulation in the transverse sinus may not directly cause PT, they do indicate a disruption in cerebrospinal fluid-sinus hemodynamics. 5,13,16 The transverse sinus impingement theory posits that high-velocity flow impact triggers SSWA, a notion supported by computational studies illustrating elevated regional wall pressure corresponding to the site of SSWA. 17 In addition to aberrant regional sinus hemodynamics, SSWA shares similar radiological characteristics with superior semicircular canal dehiscence and spontaneous cerebrospinal fluid otorrhea/rhinorrhea, conditions associated with increased intracranial pressure, potentially leading to remodeling of the skull base bone. ...
... The measurement of TSS was consistent with our previous methods. 16 Two non-operative CT scans of each subject were performed using the same CT scan SOMATOM Definition Flash (Siemens AG, Munich, Germany) with identical parameters: 192 mA and 120 kV. All CT images underwent realignment, during which the intersection point of the sella turcica and clivus was aligned with the tip of the nose along the horizontal segments within the central part of the cranial bone. ...
Objective: Sigmoid sinus wall anomalies (SSWA) are closely linked to venous pulsatile tinnitus (PT). This study aims to demonstrate that SSWA develops progressively rather than being congenital. Methods: We retrospectively analyzed 42 PT patients with SSWA who had at least two non‐operative CT scans at our clinic. CT images were longitudinally assessed to track SSWA progression, while MRI and Doppler ultrasound evaluated transverse sinus stenosis and venous hemodynamics. Changes in PT perception were tracked using the tinnitus handicap inventory (THI) questionnaire. Results: Among the 42 SSWA patients, 12 (28.6%) exhibited progression. Anastomosis between diploic vein and diverticulum was significantly higher compared to the dehiscence cohort ( p < 0.01). Within the diverticulum group, seven individuals (30.4%) experienced enlargement, with a mean diverticular wall expansion of 5.9% ± 11.4%. Progressive erosion was observed in two cases (12.5%) in the dehiscence cohort, with a mean sigmoid plate erosion of 3.8% ± 10.1%. In cases progressing from dehiscence to diverticulum, three subjects transitioned, with a mean sigmoid sinus wall length expansion of 43.8% ± 31.9%. SSWA progression showed a significant negative correlation with Q BILATERAL ( r = −0.857, p = 0.014), and there was a significant difference between initial and revisit THI scores ( p < 0.01). Conclusion: SSWA can undergo morphological progression, indicating it is a progressive clinical condition rather than congenital.
... Despite the strong correlation between PT and idiopathic intracranial hypertension (IIH) postulated by other studies (35)(36)(37)(38), most Asian patients do not meet the diagnostic criteria for definitive IIH and rarely exhibit associated symptoms. These symptoms are more likely related to body mass index (35). ...
... Despite the strong correlation between PT and idiopathic intracranial hypertension (IIH) postulated by other studies (35)(36)(37)(38), most Asian patients do not meet the diagnostic criteria for definitive IIH and rarely exhibit associated symptoms. These symptoms are more likely related to body mass index (35). In this study, papilledema, with a prevalence of only 8%, is exclusively observed in the dehiscence group, all of whom experienced recent weight gain. ...
... In this study, papilledema, with a prevalence of only 8%, is exclusively observed in the dehiscence group, all of whom experienced recent weight gain. Other studies suggest that individuals with diverticulum have lower open pressure compared with those with dehiscence alone (35). These findings indicate that diverticulum formation may act as a compensatory mechanism to regulate central venous pressure by increasing venous volume. ...
Objective
To emphasize the surgical importance of addressing dehiscence over diverticulum in resolving pulsatile tinnitus (PT) in patients with sigmoid sinus wall anomalies (SSWAs) and investigate anatomical differences.
Study Design
Retrospective data analysis.
Setting
Multi-institutional tertiary university medical centers.
Patients
Fifty participants (dehiscence/diverticulum, 29:21 cases) with SSWA-associated PT were included in the study. All 21 diverticulum participants underwent surgical intervention.
Interventions
1) Surgical intervention with novel techniques monitored by intraoperative microphone. 2) Radiologic and ophthalmologic imaging methods.
Main Outcome Measure(s)
Quantitative and qualitative preoperative and postoperative alterations of PT and anatomical differences between dehiscence and diverticulum.
Results
Addressing dehiscence overlying diverticulum and sigmoid sinus wall dehiscences significantly reduced visual analog score and Tinnitus Handicap Inventory ( p < 0.01). Sinus wall reconstruction led to substantial PT sound intensity reduction in the frequency range of 20 to 1000 Hz and 20 to 500 Hz (paired-sample t test, p < 0.01). Diploic vein analysis showed a significant positive correlation in 85.7% of the diverticulum cohort compared with the dehiscence cohort ( p < 0.01). Eight percent of the participants exhibited papilledema, which was limited to the dehiscence cohort.
Conclusion
1) Effective reduction of PT can be achieved by addressing all dehiscences, including those overlying the diverticulum, without the need to exclude the diverticulum. 2) Diploic vein may involve in the formation of diverticulum, and loss of dura mater and vascular wall thickness are observed at the SSWA locations.
... 15 According to the Monro-Kellie doctrine, the combined volume of the brain, cerebrospinal fluid (CSF), and intracranial arterial/ venous compartments is kept constant. 16 Iatrogenically increased ICP is caused by severe blockage of the transverse-sigmoid sinus on the ipsilateral side and poor collateral sinus flow on the contralateral side, leading to a restriction in the volume of outflow from the venous compartment. 16,17 Operating on the venous sinus wall can be risky when surgeons disregard or are unaware of the pattern of the bilateral transverse-sigmoid sinuses, which are important conduits for the cerebral venous return of the posterior fossa. ...
... 16 Iatrogenically increased ICP is caused by severe blockage of the transverse-sigmoid sinus on the ipsilateral side and poor collateral sinus flow on the contralateral side, leading to a restriction in the volume of outflow from the venous compartment. 16,17 Operating on the venous sinus wall can be risky when surgeons disregard or are unaware of the pattern of the bilateral transverse-sigmoid sinuses, which are important conduits for the cerebral venous return of the posterior fossa. 15 Nonetheless, a standard approach for transtemporal sinus wall reconstruction surgery involves minimizing the diverticulum or significant transverse-sigmoid sinus junction, which necessarily reduces the volume of venous return. ...
... The bilateral sinus morphologic parameters measured in the 27 patients were the degree of TS stenosis, distance from the torcular herophili to the TS stenosis, and volume and length of the transverse-sigmoid sinus. TS stenosis was measured with Mimics software version 19.0 (Materialise, Leuven, Belgium) or the NUMARIS/4 workstation (SYNGO MR B17; Siemens AG, Munich, Germany) using patient-specific contrastenhanced two-dimensional time-of-flight MR slices (MR parameters are described in the reports by Guo and Wang 15 and Guo et al. 16 ). After the TS measurements, volumetric and length measurements were recorded using 3-matic 11.0 (Materialise) based on three-dimensional computational models reconstructed using MR venograms. ...
Objective:
This study was performed to investigate the dynamics of intracranial pressure (ICP) alterations and bilateral transverse-sigmoid sinus morphologies in patients with venous pulsatile tinnitus (PT).
Methods:
This retrospective study involved 27 patients with venous PT associated with sigmoid sinus wall anomalies. ICP and ICP metrics were measured by cerebrospinal fluid manometry and internal jugular vein compression tests. Correlation analysis was performed to determine the statistical correlation between ICP and the morphological metrics.
Results:
The mean ICP was 212.5 ± 47.3 mmH2O. The median ΔICPtotal was 130 (range, 55-150) mmH2O. The ΔICPtotal was linearly correlated with the open lumbar pressure, and a significant difference was found between patients with normal and elevated cerebrospinal fluid pressure. The ΔICPdifference was linearly correlated with the Lendifference and Voldifference. ΔICP was linearly correlated with Lendifference.
Conclusions:
Complete obstruction of flow patency should be avoided in patients with low ICP and large volumetric/patency differences in the bilateral transverse-sigmoid sinus systems.
BACKGROUND
To evaluate the clinical profile, risk factors, and ophthalmic diagnostic and monitoring tools in Omani patients with idiopathic intracranial hypertension (IIH) using optical coherence tomography (OCT).
METHODS
A retrospective single institutional cohort study on Omani patients with a fulfilled diagnosis of IIH from January 1, 2014, to January 1, 2020, was conducted. The data obtained from the neuro-ophthalmic clinic contained age of onset of the disease, gender of patients, body mass index (BMI), presence of other associated conditions, and medication use.
RESULTS
Our study group comprised 21 patients with IIH with an annual incidence rate of 2.8 per 100,000 population. Female-to-male ratio was 9.5:1 with a mean age of 27.24 ± 7.1. Headaches appeared to be the most prevalent symptom in 21 (100%) patients, followed by transient obscuration of vision in 9 (42.9%) patients and diplopia in 3 (14.3%) patients, and the least common symptom was pulsatile tinnitus in 2 (9.5%) patients. Increased BMI was seen in 19 (90.5%) patients and noted to be the most prevalent predisposing factor among our study group. The use of oral contraceptive pills was documented in 4 (19%) patients and 1 (4.8%) patient was noted to have polycystic ovary syndrome. All patients (100%) had a best-corrected visual acuity of 1.0 in both eyes pre- and postrecovery and 7 (33.3%) patients had an enlarged blind spot on visual field testing. All patients had papilledema on presentation and an average of 14.1 months to resolve to normal clinically and on OCT monitoring. All patients were treated with medications and only 1 (4.8%) continued to have intractable headaches that did not respond to maximum medical therapy and required surgery.
CONCLUSION
The incidence of IIH in the Omani population was found to be less than neighboring countries but comparable worldwide. OCT is considered a useful tool to confirm and document papilledema and more importantly monitor recovery.
Transverse sinus (TS) stenosis is common in individuals with venous pulsatile tinnitus (PT). While PT can be addressed by endoluminal or extraluminal methods, the former has shown promise in alleviating symptoms associated with increased intracranial pressure. This study explores the potential of extraluminal methods to alleviate TS stenosis and eliminate PT caused by sigmoid sinus diverticulum. A 31-year-old male patient presenting with left-sided PT, attributed to a large, pedunculated sigmoid sinus diverticulum along with severe ipsilateral TS stenosis and contralateral TS hypoplasia, underwent ipsilateral extraluminal TS decompression surgery following sigmoid sinus wall reconstruction under local anesthesia. Postoperative CT and MR angiography revealed a significant increase in the TS lumen from 0.269 to 0.42 cm ² (56.02%) 2 years after surgery. Cervical Doppler ultrasound demonstrated a 36.07% increase in ipsilateral outflow volume to 16.6 g/s and a 77.63% increase in contralateral outflow volume to 1.35 g/s. In conclusion, this pioneering study showcases the potential of transtemporal TS decompression surgery in creating space for adaptive expansion of the TS lumen. However, the procedure should be reserved for individuals with severely compromised venous return.
