Tinnitus is an abnormal perception of a sound without external stimulation. Venous pulsatile tinnitus (VPT) is a specific form of tinnitus characterized by an objective and often subjective bruit that occurs as a result of localized venous abnormalities. Clinical evaluation relies on sound quality, duration, and precipitating factors. Idiopathic intracranial hypertension (IIH) and transverse sinus stenosis (TSS) are among the most common causes of VPT. Other causes include sigmoid sinus wall abnormalities (SSWAs), jugular vein anomalies (JVAs), and emissary veins anomalies. These anomalies can be detected on magnetic resonance imaging, magnetic resonance angiography/magnetic resonance venography, and high-resolution temporal bone computed tomography. The pathogenesis behind the VPT includes turbulent blood flow as a result of luminal stenosis or abnormal dilation, amplification of internal sound due to temporal bone defects, and abnormal position of the venous sinus system structures adjacent to the bony structures of the auditive apparatus. Based on these theories, different interventional treatment modalities can be applied to treat the underlying causes. Endovascular treatments have shown high efficacy and safety among those treatments which include stenting of the lateral sinus stenosis in IIH and TSS, coiling of the SSWA and JVA, and embolization of emissary veins anomalies. Further studies are needed to understand the natural history of these anomalies and the efficacy of treatments of VPT, which-unlike other types of tinnitus-can be cured with proper treatment.

Venous Causes of Pulsatile Tinnitus: Clinical Presentation, Clinical and Radiographic Evaluation, Pathogenesis, and Endovascular Treatments: A Literature Review

Background Previous studies have hypothesized that intracranial aneurysm (IA) morphology interacts with hemodynamic conditions. Magnetic resonance imaging (MRI) provides a single image modality solution for both morphological and hemodynamic measurements for IA. This study aimed to explore the interaction between the morphology and hemodynamics of IA using black-blood MRI (BB-MRI) and 4D flow MRI. Methods A total of 97 patients with unruptured IA were recruited for this study. The IA size, size ratio (SR), and minimum wall thickness (mWT) were measured using BB-MRI. Velocity, blood flow, pulsatility index (PI), and wall shear stress (WSS) were measured with 4D flow MRI. The relationship between hemodynamic parameters and morphological indices was investigated by linear regression analysis and unpaired two-sample t-test. To determine the independent interaction, multiple linear regression analysis was further performed. Results The findings showed that mWT was negatively correlated with IA size (r=-0.665, P<0.001). Maximum blood flow in IA (FlowIA) was positively correlated with IA size (r=0.458, P<0.001). The average WSS (WSSavg) was negatively correlated with IA size (r=-0.650, P<0.001). The relationships remained the same after the multivariate analysis was adjusted for hemodynamic, morphologic, and demographic confounding factors. The WSSavg was positively correlated with mWT (r=0.528, P<0.001). In the unpaired two-sample t-test, mWT, WSSavg, and FlowIA were statistically significantly associated with the size and SR of IAs. Conclusions There is potential for BB-MRI and 4D flow MRI to provide morphological and hemodynamic information regarding IA. Blood flow, WSS, and mWT may serve as non-invasive biomarkers for IA assessments, and may contribute to a more comprehensive understanding of the mechanism of IA.

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Associations between morphology and hemodynamics of intracranial aneurysms based on 4D flow and black-blood magnetic resonance imaging.

Multiphysics coupling study on the effect of blood flow pulsation in patients with pulsatile tinnitus

Bone remodeling in sigmoid sinus diverticulum after stenting for transverse sinus stenosis in pulsatile tinnitus: A case report

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 transverse sinus (TS) stenosis and jugular hemodynamics in venous PT patients. A total of 50 subjects with venous PT with or without sigmoid sinus wall anomalies (SSWAs) were enrolled in this study. In addition to radiologic assessments for TS stenosis and invagination of arachnoid granulation (AG) in TS, CSFP and jugular hemodynamics were measured via cerebrospinal fluid (CSF) manometry and Doppler ultrasound. Apart from group comparisons and correlation analyses, multivariate linear regression, and receiver operating characteristic (ROC) models were used to identify the sensitivity and specificity of the index of transverse sinus stenosis (ITSS) and hemodynamic variables with inferential significance. The mean CSFP of all cases was 199.5 ± 52.7 mmH2O, with no statistical difference in CSFP between the diverticulum and dehiscence groups. Multivariate linear regression analysis demonstrated that CSFP was linearly correlated with ITSS and pulsatility index (PI). ROC analysis showed that the area under the ROC curve of PI was 0.693 at 200 mmH2O threshold, and the best PI cut-off value was 0.467, with a sensitivity of 65.7% and specificity of 81.8%. For 250 mmH2O threshold, the area under the ROC curve of PI was 0.718, and the best PI cut-off value was 0.467 with a sensitivity of 68.4% and specificity of 75.0%. Additionally, the area under the ROC curve of ITSS was 0.757, and the best ITSS cutoff value was 8.5 (p = 0.002, 95% CI = 0.616–0.898) with a sensitivity of 72.4% and specificity of 75.0% at 200 mmH2O threshold. In conclusion, patients with venous PT as the only presenting symptom should be suspected of having borderline or increased CSFP when they present with high ITSS, BMI and low PI. Further, AG in TS without encephalocele and empty sellae are not limiting findings for differentiating the level of CSFP in patients with venous PT.

Intracranial pressure, lateral sinus patency, and jugular ultrasound hemodynamics in patients with venous pulsatile tinnitus

Objective To use 4D-flow MRI to characterize hemodynamics of transverse and sigmoid sinus in venous pulsatile tinnitus (PT) patients and to investigate their differences vs healthy controls. Methods A total of 21 patients with venous PT and 11 healthy controls were included in the retrospective study. All participants underwent 4D-flow and magnetic resonance venography scan in a 3.0T magnetic resonance scanner. All visualization, quantification, and analysis of 4D-flow data were performed using dedicated software. Two independent reviewers evaluated the existence of vortex or turbulence. Covariance analysis adjusted for age was used to compare average through-plane velocity (V tp_avg ), maximum through-plane velocity (V tp_max ), average velocity (V avg ), maximum velocity (V max ), average blood flow (Flow avg ), and pulsatility index (PI) between PT and control group. Results There were hemodynamic differences between PT patients and healthy controls. Compared with the control group, the PT group showed significantly higher V tp_avg , V tp_max , V avg , V max , and Flow avg , and slightly higher PI. For the assessment of flow pattern, inter-reader reproducibility was excellent (κ = 1.00). Vortex or turbulence was observed in PT patients with good sensitivity (86.4%) and specificity (90.9%). Drainage dominance was more frequently observed in patients (15/21, 71.4%) than healthy controls (4/11, 36.4%). Conclusions Significant hemodynamic differences were found between venous PT patients and healthy controls with 4D-flow MRI. Hemodynamic conditions could serve as noninvasive biomarkers for diagnosis and treatment evaluation of venous PT. Classification of evidence This study provides Class III evidence that 4D-flow MRI accurately identifies patients with venous PT.

Hemodynamic assessments of venous pulsatile tinnitus using 4D-flow MRI

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Hemodynamic assessments of venous pulsatile tinnitus using 4D-flow MRI