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

Abstract

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.

Resurfacing Dehiscence(s) Without Reducing Diverticulum Effectively Silences Pulsatile Tinnitus: Novel Surgical Techniques for Diverticulum and Intraoperative Microphone Monitoring

“…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.…”

Dynamics of cerebrospinal fluid pressure alterations and bilateral transverse–sigmoid sinus morphologies in Asian patients with venous pulsatile tinnitus

“…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.…”

“…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.…”