Resolution of Pulsatile Tinnitus after Coil Embolization of Sigmoid Sinus Diverticulum

Case Report

Austin J Cerebrovasc Dis & Stroke. 2014;1(2): 1010.

Resolution of Pulsatile Tinnitus after Coil Embolization of Sigmoid Sinus Diverticulum

Amans MR1*, Stout C2, Dowd CF1, Higashida RT1, Hetts SW1, Cooke DL1, Narvid J1 and Halbach VV1

1Department of Radiology and Biomedical Imaging, University of California San Francisco, USA

2Department of Radiology, University of Massachusetts, USA

*Corresponding author: Amans MR, Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Room L352, San Francisco, CA, 94143-0628, USA

Received: July 10, 2014; Accepted: August 10, 2014; Published: August 11, 2014

Abstract

Venous sinus diverticulum is a rare vascular cause for pulsatile tinnitus characterized by an out pouching of the venous sinus into the calvarium, usually involving the sigmoid venous sinus. Sigmoid sinus diverticulum is often associated with upstream sinus stenosis. While the exact mechanism of sound generation from a sinus diverticulum is unclear, several case reports have suggested that pulsatile tinnitus can resolve after remodeling of venous blood flow such that the diverticulum is excluded from the circulation. Case reports have also suggested treatment of both the sigmoid sinus diverticulum and the often-associated upstream sinus stenosis may ameliorate pulsatile tinnitus. We report a case of trans-venous coil embolization of a sigmoid sinus diverticulum without treatment of an additionally identified upstream sinus stenosis, resulting in cure of the patient’s pulsatile tinnitus. A review of endovascular and open surgical treatment of sinus diverticula in the treatment of pulsatile tinnitus is also presented.

Keywords: Pulsatile tinnitus; Sigmoid sinus; Dural diverticulum; Venous sinus aneurysm

Abbreviations

PT: Pulsatile Tinnitus; CSF: Cerebrospinal Fluid; DSA: Digital Subtraction Angiography; DAVF: Dural Arteriovenous Fistula; IJ: Internal Jugular vein

Case Presentation

A 59-year-old postmenopausal woman presented with subjective right-sided pulse synchronous pulsatile tinnitus (PT) increasing in intensity over the previous 18 months. Her PT became increasingly bothersome resulting in both difficulties falling asleep and waking her from sleep as well as difficulty concentrating. Her PT abated with right neck compression and was exacerbated by strenuous activity, bending forward at the waist, and with Valsalva, suggestive of a venous etiology [1-4]. She denied changes in the pitch of the sound over time and also denied changes in hearing acuity, balance, swallowing, coordination, strength, or sensation.

A broad workup for causes of PT was performed. A complete history and physical were performed (including otoscopy to evaluate for middle ear mass, auscultation for a bruit, and ophthalmoscopy to search for papilledema) and were normal. Audiologic assessment of auditory acuity and discrimination (understanding of words) was also unremarkable. Lumbar puncture demonstrated bland cerebrospinal fluid (CSF) with a normal opening pressure.

Noninvasive imaging, including contrast enhanced CT of the temporal bone, carotid ultrasound, and contrast enhanced MRI of the brain with MR venography and MR angiography were obtained. CT demonstrated a smoothly-marginated scalloping of the inner table of the sigmoid plate with narrow neck and extension of the sinus laterally into the sigmoid bone defect, characteristic of a sigmoid sinus diverticulum [5-9] (Figure 1). No other vascular neoplasm, vascular malformation, or vascular anomaly was identified.

Citation: Amans MR, Stout C, Dowd CF, Higashida RT, Hetts SW, et al. Resolution of Pulsatile Tinnitus after Coil Embolization of Sigmoid Sinus Diverticulum. Austin J Cerebrovasc Dis & Stroke. 2014;1(2): 1010. ISSN: 2381-9103.