- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California, CA, United States.
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States.
- University of Texas Medical Branch, Galveston, Texas, United States.
- School of Medicine, University of New Mexico, Albuquerque, New Mexico, United States.
- University of Medicine and Health Sciences Medical School, New York, NY, United States.
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States.
College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States.
DOI:10.25259/SNI_1_2021Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Brian Fiani1, Athanasios Kondilis2, Thao Doan3, Juliana Runnels4, Nicholas J. Fiani5, Erika Sarno6. Venous sinus stenting for intractable pulsatile tinnitus: A review of indications and outcomes. 02-Mar-2021;12:81
How to cite this URL: Brian Fiani1, Athanasios Kondilis2, Thao Doan3, Juliana Runnels4, Nicholas J. Fiani5, Erika Sarno6. Venous sinus stenting for intractable pulsatile tinnitus: A review of indications and outcomes. 02-Mar-2021;12:81. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=10618
Background: Pulsatile tinnitus presents as a unique variation of tinnitus in which a conscious perception of the heartbeat is localized to the ears in either unilateral or bilateral fashion. The sensation is typically caused by an increase in turbulent blood flow in the affected ear, in most cases, due to a structural abnormality of the venous sinuses – the most common of which being stenosis. Herein, we discuss the etiology of pulsatile tinnitus followed by indications for treatment of various pathologies which have been successfully treated with venous sinus stenting and have led to resolution of auditory symptoms.
Methods: The authors queried PubMed database using combinations of the keywords “venous sinus stenting,” “endovascular treatment,” and “pulsatile tinnitus” to identify relevant studies published in English after 2001 and before December 1, 2020 and verified selected.
Results: Our results corroborate those published in prior reviews reporting a high rate of pulsatile tinnitus resolution with venous sinus stenting.
Conclusion: The success of venous sinus stenting is clinically relevant as an effective treatment option for patients suffering from pulsatile tinnitus. Future applications and studies are needed and are currently being developed to further demonstrate the effectiveness of stents in the treatment of pulsatile tinnitus.
Keywords: Angioplasty, Neuro-otology, Pulsatile tinnitus, Venous sinus stenosis, Venous sinus stenting
Tinnitus, often described as “ringing in the ears,” is the persistent, unwanted perception of sound, usually in the absence of a genuine physical source. There are two general subtypes of tinnitus: pulsatile and nonpulsatile. In nonpulsatile tinnitus, the sound is caused by a hearing malfunction. However, in pulsatile tinnitus, hearing is intact and the tinnitus is usually due to perception of turbulent, accelerated, or normal blood or cerebrospinal fluid (CSF) flow within vessels proximal to ear.[
Venous stenting procedures have been established as an effective in patients with pulsatile tinnitus resulting from vascular abnormalities.[
Patients with intractable pulsatile tinnitus present with an array of symptoms, the most common of which being a conscious perception of the heartbeat within the ears of the affected individual (typically unilateral, but in rare cases can present bilaterally).[
In the event of pulsatile tinnitus, patients will typically present with some form of cerebrovascular disease to warrant treatment through venous sinus stenting. This commonly includes idiopathic intracranial hypertension, of which pulsatile tinnitus tends to present secondarily to primary reports of headaches, papilledema, and visual disturbances.[
Although there is no current standard for stenting in VSS as a result of idiopathic intracranial hypertension, prior studies describe cases of significant intracranial hypertension (with a pressure gradient >10 mmHg across the area of stenosis and VSS >50%) as key indications for stenting following failed conservative treatment.[
VSS can also cause pulsatile tinnitus without a noticeable increase in ICP, which also poses one of the controversies of stenting as to whether or not the surgical intervention is warranted.[
Pulsatile tinnitus can also be caused by a sigmoid sinus diverticulum or dehiscence (SSDD) or venous sinus aneurysm when the lesion occurs proximal to mastoid air cells.[
First-line intervention for venous sinus thrombosis involves anti-coagulation therapy. However, in cases where patients are unresponsive to treatment or symptoms worsen over time, surgical intervention through stenting may be warranted, especially if pulsatile tinnitus is also present.[
Indications for stenting typically occur as a result of thrombus reformation following thrombectomy and unsuccessful balloon venoplasty (wherein a patient still exhibits stenosis) [
Pulsatile tinnitus is also found in cases of dural arteriovenous fistulas (AVF) or arteriovenous malformations (AVM), where stenting may present as an effective therapy, where concomitant VSS has manifested.[
Another known source of intractable pulsatile tinnitus is arterial supply aneurysms or atherosclerosis. Regarding aneurysms, the aneurysm can be intracranial or extracranial internal carotid artery, but most typically in the petrous portion of the internal carotid artery. Sound is transmitted to the inner ear creating the tinnitus sensation. Direct treatment with endovascular coiling or surgical clipping is the treatment of choice for resolution of symptoms.
Contraindications for the treatment of pulsatile tinnitus itself vary, however, in the case of venous sinus stenting; contraindications are more related to surgical intervention or the diagnostic modality rather than the specific procedure. Hypoplasia of the contralateral sigmoid sinus or small petrous hemangiomas has been reported by Couloigner et al. as a contraindication to surgical intervention due to risk of increased ICP following intervention.[
Before venous sinus stenting, patients are premedicated with antiplatelet therapy such as aspirin and clopidogrel, and the stenotic area is localized in the dural venous sinus using magnetic resonance venography. Stenosis may be unilateral or bilateral with involvement of the dominant lateral sinus or both lateral sinuses, respectively.[
It has been hypothesized in patients with pulsatile tinnitus with idiopathic intracranial hypertension and sinus stenosis, venous sinus stenting across the stenosis can alter venous flow dynamics and minimize turbulence to resolve pulsatile tinnitus.[
To identify studies reporting outcomes from venous sinus stenting in patients with intractable pulsatile tinnitus, the authors queried PubMed using combinations of the keywords: venous sinus stenting, endovascular treatment, and pulsatile tinnitus to identify relevant studies published in English after 2001 and before December 1, 2021. The authors verified selected publications by conducting a supplemental reverse bibliography search from previously published case reports, systematic reviews, and/or meta-analyses. Sixteen observational studies were identified and are listed in
Across studies, investigators assessed postoperative clinical outcomes by evaluating for persistence or resolution of pulsatile tinnitus in the immediate postoperative period or at the patient’s first postoperative clinic visit. Among included studies, follow-up time ranged from 3 months to 3 years. Following venous sinus stenting, pulsatile tinnitus resolved in 94% of all cases included in [
In a recent prospective study by Boddy et al., immediate and complete resolution of pulsatile tinnitus following venous sinus stenting in patients with idiopathic intracranial hypertension and distal transverse sinus stenosis was reported. This study was the only to use the tinnitus handicap inventory (THI), a common patient-reported outcome measure used in clinical trials to assess tinnitus.[
Our results corroborate those published in prior reviews reporting a high rate of pulsatile tinnitus resolution with venous sinus stenting [summarized in
Minor complications were uncommon, but those reported include transient focal headache, femoral pseudoaneurysm, and self-limited retroperitoneal hemorrhage.[
Although there is no randomized data supporting venous sinus stenting for treatment of pulsatile tinnitus at present, a prospective and randomized trial is ongoing at the Weill Medical College of Cornell University (NCT02734576).
Venous sinus stenting presents as an effective treatment option for patients suffering from pulsatile tinnitus and a concomitant cerebrovascular disease. As solo therapy, venous stenting has successfully reduced, if not outright eliminated pulsatile tinnitus in cases of IIH following conservative treatment failure, VSS where pulsatile tinnitus is present without additional symptoms and venous sinus thrombosis in cases where anticoagulant treatment is unsuccessful in reducing pulsatile tinnitus. Further, in combination therapy with coil embolization, venous stenting was shown to effectively reduce pulsatile tinnitus in patients presenting with venous sinus aneurysm. In cases of inoperable AVM or AVM with poor drainage or if failed embolization in AVF, stenting presents as a potential option to reduce severity of the physiologic issue at hand as well as the pulsatile tinnitus itself.
Although the data regarding resolution of pulsatile tinnitus through stenting is incredibly promising, there are limitations in the interpretation of said data due to smaller study cohorts. This is particularly true in studies describing AVM which are typically single case studies presenting with various complications making it difficult to ascertain the effectiveness of stenting when a patient is high-risk for rupture and restenosis. Although the Dandy criteria are currently utilized for diagnosis of IIH, criteria for determining whether venous stenting is warranted are not entirely clear and a consensus on such criteria has yet to be established. Additional studies are also needed to determine long-term resolution of pulsatile tinnitus in patients with venous sinus thrombosis as the current literature available did not present with sufficient data specifically investigating the connection between stenting in venous sinus thrombosis and pulsatile tinnitus severity (and ultimately resolution). The current data available describe venous sinus stenting as an effective tool for treatment of pulsatile tinnitus from a variety of etiologies, either as first-line therapy or as an adjunct. As such, further studies are indicated to assess the effectiveness in larger cohorts of patients of which pulsatile tinnitus presents as a chief complaint.
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