- Email: [email protected]
Endovascular Treatment of Pulsatile Tinnitus by Sigmoid Sinus Aneurysm: Technical Note and Review of the Literature
Accepted Manuscript Endovascular treatment of pulsatile tinnitus by sigmoid sinus aneurysm: technical note and review of literature Hugo Cuellar, Tanmoy Maiti, Devi Prasad Patra, Amey Savardekar, Hai Sun, Anil Nanda PII:
S1878-8750(18)30358-9
DOI:
10.1016/j.wneu.2018.02.087
Reference:
WNEU 7502
To appear in:
World Neurosurgery
Received Date: 29 June 2017 Revised Date:
12 February 2018
Accepted Date: 14 February 2018
Please cite this article as: Cuellar H, Maiti T, Patra DP, Savardekar A, Sun H, Nanda A, Endovascular treatment of pulsatile tinnitus by sigmoid sinus aneurysm: technical note and review of literature, World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.02.087. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Endovascular treatment of pulsatile tinnitus by sigmoid sinus aneurysm: technical note and review of literature Hugo Cuellar, Tanmoy Maiti, Devi Prasad Patra, Amey Savardekar, Hai Sun, Anil Nanda
RI PT
Department of Neurosurgery, Louisiana State University Health Sciences Center-Shreveport,
Corresponding Author Dr. Hugo Cuellar Associate Professor,
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M AN U
SC
LA, USA
EP
Director of Neurointerventional Surgery,
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LSUHSC-Shreveport
E mail: [email protected]
ACCEPTED MANUSCRIPT
Abstract Pulse-synchronous tinnitus is rare, and it almost always points towards a vascular pathology. We encountered a 56 year old patient presenting with 3 month history of right side tinnitus and was found to have a sigmoid sinus aneurysm after initial imaging. The patient was successfully managed
RI PT
using dual endovascular access and stent placement across the aneurysm, with a subsequent complete symptomatic relief.
Description on endovascular management of sigmoid sinus aneurysm is not infrequent in the
literature. This report provides a brief review of the available literature specifically addressing the
Key Words
M AN U
SC
management strategies.
Pulsatile tinnitus, sigmoid sinus aneurysm, sigmoid sinus diverticula, endovascular
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EP
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management, covered stent
ACCEPTED MANUSCRIPT
Introduction Pulsatile tinnitus is a rare disabling disease. Multifactorial associations, both vascular and nonvascular causes have been described. Sigmoid sinus aneurysm is one such cause of this rare manifestation. Difference of sigmoid sinus aneurysm from sigmoid sinus diverticulum (SSD) is not
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clear, and these terms have often been used interchangeably. The incidence seems to be much more frequent than originally thought, as several reports have been published in last two decades. We describe one such case, with brief discussion of available literature, reviewing the available treatment options and outcome.
SC
Case report
A 56-year old male presented with 3-month history of right side pulsatile tinnitus, headache and
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occasional right-sided bleeding from external auditory canal. The patient had a history of a right mastoid infection. He also had history of an episode of loss of consciousness 3 months prior to presentation. Significant past medical history included diabetes, hypertension, and obstructive sleep apnea. The imaging revealed a right sigmoid sinus aneurysm extending to the right EAC through the mastoid. Though uncertain, it was possibly attributed to the previous episode of infection.
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The patient was planned for embolization under general anesthesia. One percent lidocaine was used to anesthetize the skin over the right groin and a 19 gauge Seldinger needle was used to access the right femoral artery and a 5-French sheath was placed. A JB 1 catheter was advanced over a 0.035 glidewire and selective arterial catheterization were obtained. Using a 19 gauge Seldinger
EP
needle the right internal jugular vein was accessed and a short 7 French sheath was placed in the right jugular vein. Using a vertebral catheter, the venography of the right internal jugular vein, right
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sigmoid sinus, right transverse sinus, and superior sagittal sinus were obtained. Using the right internal carotid artery injections in the venous phase as road mapping, the vertebral catheter was advanced into the superior sagittal sinus distal to the aneurysm. A Bentson exchange wire was advanced, and 7 French short sheath was substituted for a 25 centimeter 7 French sheath. Several attempts to advance the 7 French sheath distal to the sigmoid sinus aneurysm were unsuccessful. The Bentson wire was removed, and an Amplatz wire was advanced at the distal superior sagittal sinus. The 7 French envoy was advanced over the Amplatz into the distal superior sagittal sinus, and the long 7 French sheath is advanced over the Envoy successfully into the right
ACCEPTED MANUSCRIPT
transverse sinus. With the distal end of the 7 French sheath at the right transverse sinus, the Envoy catheter was removed. Next, we advanced a 10 x 38 millimeter covered stent over the Amplatz wire and placed it across the neck of the aneurysm at the level of the sigmoid sinus. This sheath was withdrawn to uncover
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the stent and the stent was successfully deployed by inflating the balloon to 14 atmospheres, obtaining good apposition to the walls of the sigmoid sinus and complete exclusion of the
aneurysm. Follow-up venogram of the right sigmoid sinus shows no endoleak and complete
occlusion of the aneurysm. A follow-up angiogram of the right internal carotid artery with the
venous phase shows patency of all the cerebral veins as well as the right sigmoid sinus with no
SC
endoleak.
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The sheath in the right femoral artery was removed, and a 6 French Angio-Seal was used as closure device. The sheath in the right internal jugular vein was removed and a 7 French Minx was used as closure device.
Patient was started on Clopidogrel 75 mg once daily, 5 days prior to the procedure. After the procedure, Aspirin 325 mg once daily was added with Clopidogrel. After 6 months, both were
Discussion
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stopped, and Aspirin 81 mg was started for indefinite period.
EP
The pathophysiology of pulsatile tinnitus is controversial. Vascular pulsatile tinnitus, which is responsible for <5% of all cases of tinnitus, is one of the most common cause of treatable pulsatile tinnitus1. The vascular causes can be divided into arterial (e.g. carotid artery dissection,
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fibromuscular dysplasia, aberrant internal carotid artery, glomus tumor, contralateral carotid artery stenosis resulting in ipsilateral carotid high-flow state), and venous causes (e.g. stenosis, dural arteriovenous fistula, sinus diverticulum, high jugular bulb, intracranial hypertension). Position of the head may influence the venous tinnitus. There are certain clues helpful in differentiating arterial and venous causes of vascular tinnitus. For example, compression on jugulodigastric area accentuates venous tinnitus, whereas carotid compression test diminishes the arterial tinnitus. It is difficult to distinguish between diverticulum, and aneurysm based on angiogram. On most occasions, these terms have been used interchangeably. Otto et al suggested against a developmental cause because most patients present at middle age. However,
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histopathological examination of the wall of the sac have hardly ever been described to provide a conclusive evidence on its developmental pathogenesis (a diverticulum will contain all layers of wall, but a pseudoaneurysm won’t). A recent onset out-pouch indicates towards an aneurysm, especially after an infection (similar to formation of mycotic aneurysms), trauma, or procedure. In
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the present case, patient had a recent history of mastoid infection, which initiated the symptoms. Hence, an aneurysm was thought to be more likely than a diverticulum.
Schoeff et al reported that, unilateral SSD is present in 1.2% of asymptomatic subjects2. On the other hand, 20% of patients with PT of clinically suspected venous origin had unilateral SSD,
confirmed by temporal bone (TB) computed tomographic angiography (TB-CTA)1. An upstream
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stenosis of the venous sinuses is often noted in association with a sigmoid sinus diverticulum. The resultant PT may be a result of vibration of the venous sinus wall (caused by turbulence in the
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sigmoid sinus diverticulum) that is sensed by the cochlea. The upstream stenosis can be an additive factor for the development of an aneurysm as well, by facilitating the turbulence. Anatomically, the right sided venous system is dominant in most cases. This may explain why symptomatic SSD is on the right side on most cases. Notably, there are no reports suggesting any connection of the SSD
Management
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with the mastoid emissary vein.
It is difficult to formulate any management algorithm for any rare disease, and sigmoid sinus aneurysm/ SSD is no exception. In the reported cases available in literature, the approach was
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individualistic (Table 1).
Microsurgical treatment
The goal of surgical reconstruction is to excise or reduce the diverticulum and reconstruct the wall of the sigmoid sinus, to ensure a smooth internal lumen and a patent sinus3. A trans- mastoid approach is followed by reinforcement of bony wall of venous sinus. Appropriate precautions need to be taken to avoid possible complications, such as tear of the sinus during dissection, formation of dural sinus to mastoid air cell fistula (and consequent hemotympanum or hemorrhagic rhinorrhea)3.
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Otto et al3 used temporalis muscle, temporalis fascia, or bone wax to resurface the SSD. Eisenham et al4 cauterized the wall to reduce the size of SSD, before using bone substitute, and autologous bone for resurfacing the wall. Gologorsky et al5 used a series of U clips and gelfoam hemostatic sponge, to
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reconstruct the linear defect in the transverse sigmoid junction.
Endovascular Treatment
Endovascular intervention remained the mainstay for the sigmoid sinus diverticulum/ aneurysms. The details of endovascular treatment strategy in each case have been summarized in Table 26-16. There is no consensus for antiplatelet regimen in available literature. Simple coil embolization
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should be attempted whenever possible. Stents may be required to prevent coil prolapse. A pressure gradient of 10 mm of Hg may be used as an indication to treat the upstream stenosis. A
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balloon angioplasty/stent placement may be considered for upstream stenosis. The incidence of instent thrombosis inside venous system is rare. However, life-long antiplatelet treatment may be required. Patients usually report complete relief, whenever complete occlusion of aneurysms could be ensured. On rare occasions10 partial improvement was possible immediately, with further improvement on a subsequent follow-up. Notably, none of the reported patients, treated by either
Conclusion
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mode of intervention, had any recurrence.
SSD with or without SS is a rare cause of PT. Symptomatic SSD can be safely treated by endovascular coil embolization with or without stenting. Management of the associated stenosis may be performed during the same procedure. The microsurgical repair is invasive, and can
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probably be avoided as endovascular repair is safe and effective. Treatment must be individualized,
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and asymptomatic cases can be followed up safely.
Disclosure None
Conflict of interest None
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REFERENCES
5.
6. 7. 8. 9.
10.
11. 12.
13.
14. 15.
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4.
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3.
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2.
Song JJ, Kim YJ, Kim SY, et al. Sinus Wall Resurfacing for Patients With Temporal Bone Venous Sinus Diverticulum and Ipsilateral Pulsatile Tinnitus. Neurosurgery. 2015;77(5):709-717; discussion 717. Schoeff S, Nicholas B, Mukherjee S, Kesser BW. Imaging prevalence of sigmoid sinus dehiscence among patients with and without pulsatile tinnitus. Otolaryngol Head Neck Surg. 2014;150(5):841-846. Otto KJ, Hudgins PA, Abdelkafy W, Mattox DE. Sigmoid sinus diverticulum: a new surgical approach to the correction of pulsatile tinnitus. Otol Neurotol. 2007;28(1):48-53. Eisenman DJ. Sinus wall reconstruction for sigmoid sinus diverticulum and dehiscence: a standardized surgical procedure for a range of radiographic findings. Otol Neurotol. 2011;32(7):1116-1119. Gologorsky Y, Meyer SA, Post AF, Winn HR, Patel AB, Bederson JB. Novel surgical treatment of a transverse-sigmoid sinus aneurysm presenting as pulsatile tinnitus: technical case report. Neurosurgery. 2009;64(2):E393-394; discussion E394. Houdart E, Chapot R, Merland JJ. Aneurysm of a dural sigmoid sinus: a novel vascular cause of pulsatile tinnitus. Ann Neurol. 2000;48(4):669-671. Sanchez TG, Murao M, de Medeiros IR, et al. A new therapeutic procedure for treatment of objective venous pulsatile tinnitus. Int Tinnitus J. 2002;8(1):54-57. Zenteno M, Murillo-Bonilla L, Martinez S, et al. Endovascular treatment of a transverse-sigmoid sinus aneurysm presenting as pulsatile tinnitus. Case report. J Neurosurg. 2004;100(1):120-122. Lenck S, Mosimann PJ, Labeyrie MA, Houdart E. Pulsatile tinnitus caused by an aneurysm of the transverse-sigmoid sinus: a new case report and review of literature. J Neuroradiol. 2012;39(4):276-279. Mehanna R, Shaltoni H, Morsi H, Mawad M. Endovascular treatment of sigmoid sinus aneurysm presenting as devastating pulsatile tinnitus. A case report and review of literature. Interv Neuroradiol. 2010;16(4):451-454. Park YH, Kwon HJ. Awake embolization of sigmoid sinus diverticulum causing pulsatile tinnitus: simultaneous confirmative diagnosis and treatment. Interv Neuroradiol. 2011;17(3):376-379. Amans MR SC, Dowd CF, Higashida RT, Hetts SW, Cooke DL, Narvid J and Halbach VV. Resolution of Pulsatile Tinnitus after Coil Embolization of Sigmoid Sinus Diverticulum. Austin Journal of Cerebrovascular Disease & Stroke. 2014;1 (2):1-3. Gard AP, Klopper HB, Thorell WE. Successful endovascular treatment of pulsatile tinnitus caused by a sigmoid sinus aneurysm. A case report and review of the literature. Interv Neuroradiol. 2009;15(4):425-428. Li B, Lv X, Wu Z, et al. Stent-Assisted Coil Embolization of a Transverse-Sigmoid Sinus Diverticulum Presenting with Pulsatile Tinnitus. Turk Neurosurg. 2016;26(4):632-634. Paramasivam S, Furtado S, Shigamatsu T, Smouha E. Endovascular Management of Sigmoid Sinus Diverticulum. Interv Neurol. 2016;5(1-2):76-80.
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1.
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Santos-Franco JA, Lee A, Nava-Salgado G, Zenteno M, Vega-Montesinos S, Pane-Pianese C. Hybrid carotid stent for the management of a venous aneurysm of the sigmoid sinus treated by sole stenting. Vasc Endovascular Surg. 2012;46(4):342-346.
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Legends
Figure 1: Axial, Sagittal, and Coronal view of sigmoid sinus aneurysm in CT scan
Figure 2: A-B: DSA showing sigmoid sinus aneurysm: Antero-Posterior and lateral view C-D: Steps of embolization: selective catheterization: Antero-Posterior and lateral view
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E: Placement of stent
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F: Complete obliteration of aneurysm
ACCEPTED MANUSCRIPT Table 1: Sigmoid Sinus aneurysm/ diverticula
Presentation
Diameter
Axi s
Upstream stenosis
Treatment
Outcome
Antiplatelet
L
Dom inant sinus Y
1
Houdart et al. 2000
33/F
PT x 6 mon
6 mm
L
Y
Endovascular
54/M
L
Y
PT X 3 y
NM
L
N
ASA 160 OD: 5d before to 1 mon after; NM
Zenteno et al. 2004
38/F
L
Y
PT x 6 mon
AL
Otto et al. 2007
69/M
L
NM
PT X 10 y
wide-necked venous aneurysm of the left transverse—sigmoid sinus; 8 mm NM
No tinnitus till next 8 mon; no angio f/u Ataxia, improved in 2 mon; Post op angio: no diverticulum; No tinnitus till 1 yr F/U At 6 mon: symptom free
2
Sanchez et al. 2002
3
4
No tinnitus till next 6 mon CTA: patent sinus, no recurrence
NM
5
65/F
BL worse on R
NM
PT X 10 y
Immediate resolution
NM
6
49/M
L
NM
PT X 4 y
NM
PT X 5 y
Immediate resolution Immediate resolution
Asymptomatic 1 y after procedure 90% improvement at 1 y No recurrence in 7 yr No recurrence in 22 mon
ASA 325 X 6 wks
Endovascular
NM
6 x 6 mm, projecting lat
AL
N
Y
PT x 6 y
7.4 x 4 mm
L
NM
Endovascular
L
Y
PT
7 mm
AL
NM
Endovascular
R
Y
PT x 3 yr
7×6 mm; neck 4.5 mm, projected laterally
NM
N
Endovascular
Y
8
Gard et al. 2009
48/F
L
Y
9
Mehanna et al. 2010
46/F
L
10
Lenck et al. 2011 Park et al. 2011
28/F 31/F
NM
NM
NM
NM
NM
AL
NM
EP
R
NM
8 mm
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48/F
NM
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PT x several mon
Gologorsky et al. 2009
NM
Endovascular
exposing the normal sinus circumferentially around the diverticulum, reduction and oversewing the diverticulum with a small piece of temporalis muscle and fascia diverticulum excised, and the defect in the sigmoid wall repaired by suturing a plug of temporalis fascia over it reduced and secured with bone wax Surgical (neck coagulated and dome shrunk to a small remnant. the now-linear defect in the transverse sigmoid junction reconstructed with a series of no. 18 U-clips and covered with Gelfoam) Endovascular; coiling
7
11
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Side
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Age/ sex
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Author/ Year
Serial no No
ASA 325 OD+ CLO 75 OD X 6 mon
NM
ASA 325 X 2 wks ASA 160 OD X 2 mon No post op antiplatelet
ACCEPTED MANUSCRIPT Santos-Franco et al. 2012
59/F
R
NM
PT X 20 y
NM
NM
Y
Endovascular
No rec in 6 mon.
ASA 100 mg + CLO 75 mg
13
Amans et al. 2014
59/F
R
Y
PT X 18 mon
lobulated 6.8 x 8.0 x 4.2 mm right sigmoid sinus diverticulum with a 3.4 mm neck, a stenosis in the sigmoid sinus upstream from the diverticulum
NM
Y
Endovascular
Complete resolution at 6mon FU
ASA 81 X 2 WKS
14
Wang et al. 2015 (n=28)
R:18 L:10
NM
PT
Associated sigmoid sinus wall dehiscence in 20 cases
NM
NM
Paramasivam et al. 2016
R
Y
PT x 4 mon
SSD 7 X 5 mm, with T-S junction stenosis
NM
Complete resolution:17, partial:3, no change:5 No recurrence in 8 mon
NM
15
36.96 (mean) M:2, F:26 33/F
ASA 81 mg + CLO 75 mg
16
Li et al. 2016
39/ F
R
NA
PT x 4 yr
Diverticulum at T-S jn
No recurrence after 4 mon
ASA 100 X 6M CLO 75 X 1M
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Sigmoid sinus wall reconstruction=25; Non-operative 3
NM
N
Endovascular
Endovascular
ASA: Aspirin CLO: Clopidogrel
Table 2: Details of endovascular intervention Set Up
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Route, access vessel
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PT: Pulsatile tinnitus
Authors
Y
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NM: not mentioned
Serial No
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12
Sheath and catheter
Microguidecathe ter
Microguidewire
5 F catheter stationed in left sigmoid sinus
MicroFerret
NM
coil
stent
Treatment of Upstream stenosis
Occlusion rate
Angio FU
N
N
N
Y, selfexpanding
NA
Wallstent 10 x 28
NA
Complete immediat ely Complete immediat ely Reduction in size but
1
Houdart
Venous, Jugular
2
Sanchez
Venous, L IJV
NM
NM
NM
Three Detach 18 coil multiple
3
Zenteno
1st OP: Burr hole 3 cm lat to torcula to access
8F Arrow
NM
NM
N
N
Patency of sinus and
ACCEPTED MANUSCRIPT IJV
persistent filling
2nd OP: Femoral vein
6F Envoy in L IJV
Tracker Excel 14
NM
2 GDC coils
No
NA
complete
4 (1: Tetris 3D Tension Safe; 3: supersoft coils) Multiple
N
N
Complete occlusion
No
NA
Minimal
Y
N
N
Complete immediat ely Incomplet e
slight decrease in size of aneurysm 6 mon; complete occlusion of aneurysm N
Gard
Venous, femoral vein
5 F Envoy into L IJV;
90 deg Prowler14
Synchro-14
5
Mehanna
Venous, femoral
SL 10
NM
6
Lenck
Venous, R IJV
7F, Hyperform balloon at T-S junction, across neck of an 5 F sheath
NM
NM
7
Park
7F sheath and 7F Envoy; Prowler select plus
Excel 10
NM
2
N
NA
8
SantosFranco
Both, R femoral A for diagnostic; R femoral vein for treatment (at same sitting) Both, femoral a and v
5F (Artery) 6F (vein)
Excelsior SL10
Transend
N
Y (see previous column)
Complete occlusion
6 mon: no recurrence
9
Amans
Both, Common femoral vein and (7F) C/L common femoral artery (5F)
Synchro 2
7 detachable coils
Cristallo Ideale stent across stenosis an neck of aneurysm N
Not treated
Complete obliterati on with resolutio n of PT
6 mon: no recurrence
10
Paramasivam
Venous
11
Li
Venous, femoral
8 mon: remodeling of the R T-S; persistent obliteration of the diverticulum N
NM=Not mentioned
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4
Prowler select plus
NM
NM
3 Target 360 Ultra coils
Proteage 10 x 40 mm
N
Complete immediat ely
8 F Envoy MPD in R sigmoid sinus;
Renegade for coil, Vasco: 28 for stent;
0.014-inch XCelerator
3 Microplex coils
Leo stent
NP
Complete immediat ely
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coaxial 7F VBL guide catheter (right IJV) with 5F Vert (r IJSigmoid sinus junction); venous road map from C/L CCA injection NeuronMax advanced into IJV
6 mon: minimal filling N
N
ACCEPTED MANUSCRIPT N= No
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SC
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NA= Not applicable
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EP
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SC
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Highlights Sigmoid sinus diverticulum/ aneurysm is a rare cause of tinnitus. Endovascular management is generally associated with immediate complete relief.
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SC
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Recurrence is rare with successful endovascular management.
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ABBREVIATIONS
SSD: Sigmoid sinus diverticula
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CTA: Computed tomography angiogram
S1878-8750(18)30358-9
DOI:
10.1016/j.wneu.2018.02.087
Reference:
WNEU 7502
To appear in:
World Neurosurgery
Received Date: 29 June 2017 Revised Date:
12 February 2018
Accepted Date: 14 February 2018
Please cite this article as: Cuellar H, Maiti T, Patra DP, Savardekar A, Sun H, Nanda A, Endovascular treatment of pulsatile tinnitus by sigmoid sinus aneurysm: technical note and review of literature, World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.02.087. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Endovascular treatment of pulsatile tinnitus by sigmoid sinus aneurysm: technical note and review of literature Hugo Cuellar, Tanmoy Maiti, Devi Prasad Patra, Amey Savardekar, Hai Sun, Anil Nanda
RI PT
Department of Neurosurgery, Louisiana State University Health Sciences Center-Shreveport,
Corresponding Author Dr. Hugo Cuellar Associate Professor,
TE D
M AN U
SC
LA, USA
EP
Director of Neurointerventional Surgery,
AC C
LSUHSC-Shreveport
E mail: [email protected]
ACCEPTED MANUSCRIPT
Abstract Pulse-synchronous tinnitus is rare, and it almost always points towards a vascular pathology. We encountered a 56 year old patient presenting with 3 month history of right side tinnitus and was found to have a sigmoid sinus aneurysm after initial imaging. The patient was successfully managed
RI PT
using dual endovascular access and stent placement across the aneurysm, with a subsequent complete symptomatic relief.
Description on endovascular management of sigmoid sinus aneurysm is not infrequent in the
literature. This report provides a brief review of the available literature specifically addressing the
Key Words
M AN U
SC
management strategies.
Pulsatile tinnitus, sigmoid sinus aneurysm, sigmoid sinus diverticula, endovascular
AC C
EP
TE D
management, covered stent
ACCEPTED MANUSCRIPT
Introduction Pulsatile tinnitus is a rare disabling disease. Multifactorial associations, both vascular and nonvascular causes have been described. Sigmoid sinus aneurysm is one such cause of this rare manifestation. Difference of sigmoid sinus aneurysm from sigmoid sinus diverticulum (SSD) is not
RI PT
clear, and these terms have often been used interchangeably. The incidence seems to be much more frequent than originally thought, as several reports have been published in last two decades. We describe one such case, with brief discussion of available literature, reviewing the available treatment options and outcome.
SC
Case report
A 56-year old male presented with 3-month history of right side pulsatile tinnitus, headache and
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occasional right-sided bleeding from external auditory canal. The patient had a history of a right mastoid infection. He also had history of an episode of loss of consciousness 3 months prior to presentation. Significant past medical history included diabetes, hypertension, and obstructive sleep apnea. The imaging revealed a right sigmoid sinus aneurysm extending to the right EAC through the mastoid. Though uncertain, it was possibly attributed to the previous episode of infection.
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The patient was planned for embolization under general anesthesia. One percent lidocaine was used to anesthetize the skin over the right groin and a 19 gauge Seldinger needle was used to access the right femoral artery and a 5-French sheath was placed. A JB 1 catheter was advanced over a 0.035 glidewire and selective arterial catheterization were obtained. Using a 19 gauge Seldinger
EP
needle the right internal jugular vein was accessed and a short 7 French sheath was placed in the right jugular vein. Using a vertebral catheter, the venography of the right internal jugular vein, right
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sigmoid sinus, right transverse sinus, and superior sagittal sinus were obtained. Using the right internal carotid artery injections in the venous phase as road mapping, the vertebral catheter was advanced into the superior sagittal sinus distal to the aneurysm. A Bentson exchange wire was advanced, and 7 French short sheath was substituted for a 25 centimeter 7 French sheath. Several attempts to advance the 7 French sheath distal to the sigmoid sinus aneurysm were unsuccessful. The Bentson wire was removed, and an Amplatz wire was advanced at the distal superior sagittal sinus. The 7 French envoy was advanced over the Amplatz into the distal superior sagittal sinus, and the long 7 French sheath is advanced over the Envoy successfully into the right
ACCEPTED MANUSCRIPT
transverse sinus. With the distal end of the 7 French sheath at the right transverse sinus, the Envoy catheter was removed. Next, we advanced a 10 x 38 millimeter covered stent over the Amplatz wire and placed it across the neck of the aneurysm at the level of the sigmoid sinus. This sheath was withdrawn to uncover
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the stent and the stent was successfully deployed by inflating the balloon to 14 atmospheres, obtaining good apposition to the walls of the sigmoid sinus and complete exclusion of the
aneurysm. Follow-up venogram of the right sigmoid sinus shows no endoleak and complete
occlusion of the aneurysm. A follow-up angiogram of the right internal carotid artery with the
venous phase shows patency of all the cerebral veins as well as the right sigmoid sinus with no
SC
endoleak.
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The sheath in the right femoral artery was removed, and a 6 French Angio-Seal was used as closure device. The sheath in the right internal jugular vein was removed and a 7 French Minx was used as closure device.
Patient was started on Clopidogrel 75 mg once daily, 5 days prior to the procedure. After the procedure, Aspirin 325 mg once daily was added with Clopidogrel. After 6 months, both were
Discussion
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stopped, and Aspirin 81 mg was started for indefinite period.
EP
The pathophysiology of pulsatile tinnitus is controversial. Vascular pulsatile tinnitus, which is responsible for <5% of all cases of tinnitus, is one of the most common cause of treatable pulsatile tinnitus1. The vascular causes can be divided into arterial (e.g. carotid artery dissection,
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fibromuscular dysplasia, aberrant internal carotid artery, glomus tumor, contralateral carotid artery stenosis resulting in ipsilateral carotid high-flow state), and venous causes (e.g. stenosis, dural arteriovenous fistula, sinus diverticulum, high jugular bulb, intracranial hypertension). Position of the head may influence the venous tinnitus. There are certain clues helpful in differentiating arterial and venous causes of vascular tinnitus. For example, compression on jugulodigastric area accentuates venous tinnitus, whereas carotid compression test diminishes the arterial tinnitus. It is difficult to distinguish between diverticulum, and aneurysm based on angiogram. On most occasions, these terms have been used interchangeably. Otto et al suggested against a developmental cause because most patients present at middle age. However,
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histopathological examination of the wall of the sac have hardly ever been described to provide a conclusive evidence on its developmental pathogenesis (a diverticulum will contain all layers of wall, but a pseudoaneurysm won’t). A recent onset out-pouch indicates towards an aneurysm, especially after an infection (similar to formation of mycotic aneurysms), trauma, or procedure. In
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the present case, patient had a recent history of mastoid infection, which initiated the symptoms. Hence, an aneurysm was thought to be more likely than a diverticulum.
Schoeff et al reported that, unilateral SSD is present in 1.2% of asymptomatic subjects2. On the other hand, 20% of patients with PT of clinically suspected venous origin had unilateral SSD,
confirmed by temporal bone (TB) computed tomographic angiography (TB-CTA)1. An upstream
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stenosis of the venous sinuses is often noted in association with a sigmoid sinus diverticulum. The resultant PT may be a result of vibration of the venous sinus wall (caused by turbulence in the
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sigmoid sinus diverticulum) that is sensed by the cochlea. The upstream stenosis can be an additive factor for the development of an aneurysm as well, by facilitating the turbulence. Anatomically, the right sided venous system is dominant in most cases. This may explain why symptomatic SSD is on the right side on most cases. Notably, there are no reports suggesting any connection of the SSD
Management
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with the mastoid emissary vein.
It is difficult to formulate any management algorithm for any rare disease, and sigmoid sinus aneurysm/ SSD is no exception. In the reported cases available in literature, the approach was
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individualistic (Table 1).
Microsurgical treatment
The goal of surgical reconstruction is to excise or reduce the diverticulum and reconstruct the wall of the sigmoid sinus, to ensure a smooth internal lumen and a patent sinus3. A trans- mastoid approach is followed by reinforcement of bony wall of venous sinus. Appropriate precautions need to be taken to avoid possible complications, such as tear of the sinus during dissection, formation of dural sinus to mastoid air cell fistula (and consequent hemotympanum or hemorrhagic rhinorrhea)3.
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Otto et al3 used temporalis muscle, temporalis fascia, or bone wax to resurface the SSD. Eisenham et al4 cauterized the wall to reduce the size of SSD, before using bone substitute, and autologous bone for resurfacing the wall. Gologorsky et al5 used a series of U clips and gelfoam hemostatic sponge, to
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reconstruct the linear defect in the transverse sigmoid junction.
Endovascular Treatment
Endovascular intervention remained the mainstay for the sigmoid sinus diverticulum/ aneurysms. The details of endovascular treatment strategy in each case have been summarized in Table 26-16. There is no consensus for antiplatelet regimen in available literature. Simple coil embolization
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should be attempted whenever possible. Stents may be required to prevent coil prolapse. A pressure gradient of 10 mm of Hg may be used as an indication to treat the upstream stenosis. A
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balloon angioplasty/stent placement may be considered for upstream stenosis. The incidence of instent thrombosis inside venous system is rare. However, life-long antiplatelet treatment may be required. Patients usually report complete relief, whenever complete occlusion of aneurysms could be ensured. On rare occasions10 partial improvement was possible immediately, with further improvement on a subsequent follow-up. Notably, none of the reported patients, treated by either
Conclusion
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mode of intervention, had any recurrence.
SSD with or without SS is a rare cause of PT. Symptomatic SSD can be safely treated by endovascular coil embolization with or without stenting. Management of the associated stenosis may be performed during the same procedure. The microsurgical repair is invasive, and can
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probably be avoided as endovascular repair is safe and effective. Treatment must be individualized,
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and asymptomatic cases can be followed up safely.
Disclosure None
Conflict of interest None
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REFERENCES
5.
6. 7. 8. 9.
10.
11. 12.
13.
14. 15.
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4.
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3.
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2.
Song JJ, Kim YJ, Kim SY, et al. Sinus Wall Resurfacing for Patients With Temporal Bone Venous Sinus Diverticulum and Ipsilateral Pulsatile Tinnitus. Neurosurgery. 2015;77(5):709-717; discussion 717. Schoeff S, Nicholas B, Mukherjee S, Kesser BW. Imaging prevalence of sigmoid sinus dehiscence among patients with and without pulsatile tinnitus. Otolaryngol Head Neck Surg. 2014;150(5):841-846. Otto KJ, Hudgins PA, Abdelkafy W, Mattox DE. Sigmoid sinus diverticulum: a new surgical approach to the correction of pulsatile tinnitus. Otol Neurotol. 2007;28(1):48-53. Eisenman DJ. Sinus wall reconstruction for sigmoid sinus diverticulum and dehiscence: a standardized surgical procedure for a range of radiographic findings. Otol Neurotol. 2011;32(7):1116-1119. Gologorsky Y, Meyer SA, Post AF, Winn HR, Patel AB, Bederson JB. Novel surgical treatment of a transverse-sigmoid sinus aneurysm presenting as pulsatile tinnitus: technical case report. Neurosurgery. 2009;64(2):E393-394; discussion E394. Houdart E, Chapot R, Merland JJ. Aneurysm of a dural sigmoid sinus: a novel vascular cause of pulsatile tinnitus. Ann Neurol. 2000;48(4):669-671. Sanchez TG, Murao M, de Medeiros IR, et al. A new therapeutic procedure for treatment of objective venous pulsatile tinnitus. Int Tinnitus J. 2002;8(1):54-57. Zenteno M, Murillo-Bonilla L, Martinez S, et al. Endovascular treatment of a transverse-sigmoid sinus aneurysm presenting as pulsatile tinnitus. Case report. J Neurosurg. 2004;100(1):120-122. Lenck S, Mosimann PJ, Labeyrie MA, Houdart E. Pulsatile tinnitus caused by an aneurysm of the transverse-sigmoid sinus: a new case report and review of literature. J Neuroradiol. 2012;39(4):276-279. Mehanna R, Shaltoni H, Morsi H, Mawad M. Endovascular treatment of sigmoid sinus aneurysm presenting as devastating pulsatile tinnitus. A case report and review of literature. Interv Neuroradiol. 2010;16(4):451-454. Park YH, Kwon HJ. Awake embolization of sigmoid sinus diverticulum causing pulsatile tinnitus: simultaneous confirmative diagnosis and treatment. Interv Neuroradiol. 2011;17(3):376-379. Amans MR SC, Dowd CF, Higashida RT, Hetts SW, Cooke DL, Narvid J and Halbach VV. Resolution of Pulsatile Tinnitus after Coil Embolization of Sigmoid Sinus Diverticulum. Austin Journal of Cerebrovascular Disease & Stroke. 2014;1 (2):1-3. Gard AP, Klopper HB, Thorell WE. Successful endovascular treatment of pulsatile tinnitus caused by a sigmoid sinus aneurysm. A case report and review of the literature. Interv Neuroradiol. 2009;15(4):425-428. Li B, Lv X, Wu Z, et al. Stent-Assisted Coil Embolization of a Transverse-Sigmoid Sinus Diverticulum Presenting with Pulsatile Tinnitus. Turk Neurosurg. 2016;26(4):632-634. Paramasivam S, Furtado S, Shigamatsu T, Smouha E. Endovascular Management of Sigmoid Sinus Diverticulum. Interv Neurol. 2016;5(1-2):76-80.
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Santos-Franco JA, Lee A, Nava-Salgado G, Zenteno M, Vega-Montesinos S, Pane-Pianese C. Hybrid carotid stent for the management of a venous aneurysm of the sigmoid sinus treated by sole stenting. Vasc Endovascular Surg. 2012;46(4):342-346.
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Legends
Figure 1: Axial, Sagittal, and Coronal view of sigmoid sinus aneurysm in CT scan
Figure 2: A-B: DSA showing sigmoid sinus aneurysm: Antero-Posterior and lateral view C-D: Steps of embolization: selective catheterization: Antero-Posterior and lateral view
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E: Placement of stent
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F: Complete obliteration of aneurysm
ACCEPTED MANUSCRIPT Table 1: Sigmoid Sinus aneurysm/ diverticula
Presentation
Diameter
Axi s
Upstream stenosis
Treatment
Outcome
Antiplatelet
L
Dom inant sinus Y
1
Houdart et al. 2000
33/F
PT x 6 mon
6 mm
L
Y
Endovascular
54/M
L
Y
PT X 3 y
NM
L
N
ASA 160 OD: 5d before to 1 mon after; NM
Zenteno et al. 2004
38/F
L
Y
PT x 6 mon
AL
Otto et al. 2007
69/M
L
NM
PT X 10 y
wide-necked venous aneurysm of the left transverse—sigmoid sinus; 8 mm NM
No tinnitus till next 8 mon; no angio f/u Ataxia, improved in 2 mon; Post op angio: no diverticulum; No tinnitus till 1 yr F/U At 6 mon: symptom free
2
Sanchez et al. 2002
3
4
No tinnitus till next 6 mon CTA: patent sinus, no recurrence
NM
5
65/F
BL worse on R
NM
PT X 10 y
Immediate resolution
NM
6
49/M
L
NM
PT X 4 y
NM
PT X 5 y
Immediate resolution Immediate resolution
Asymptomatic 1 y after procedure 90% improvement at 1 y No recurrence in 7 yr No recurrence in 22 mon
ASA 325 X 6 wks
Endovascular
NM
6 x 6 mm, projecting lat
AL
N
Y
PT x 6 y
7.4 x 4 mm
L
NM
Endovascular
L
Y
PT
7 mm
AL
NM
Endovascular
R
Y
PT x 3 yr
7×6 mm; neck 4.5 mm, projected laterally
NM
N
Endovascular
Y
8
Gard et al. 2009
48/F
L
Y
9
Mehanna et al. 2010
46/F
L
10
Lenck et al. 2011 Park et al. 2011
28/F 31/F
NM
NM
NM
NM
NM
AL
NM
EP
R
NM
8 mm
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48/F
NM
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PT x several mon
Gologorsky et al. 2009
NM
Endovascular
exposing the normal sinus circumferentially around the diverticulum, reduction and oversewing the diverticulum with a small piece of temporalis muscle and fascia diverticulum excised, and the defect in the sigmoid wall repaired by suturing a plug of temporalis fascia over it reduced and secured with bone wax Surgical (neck coagulated and dome shrunk to a small remnant. the now-linear defect in the transverse sigmoid junction reconstructed with a series of no. 18 U-clips and covered with Gelfoam) Endovascular; coiling
7
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Side
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Age/ sex
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Author/ Year
Serial no No
ASA 325 OD+ CLO 75 OD X 6 mon
NM
ASA 325 X 2 wks ASA 160 OD X 2 mon No post op antiplatelet
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59/F
R
NM
PT X 20 y
NM
NM
Y
Endovascular
No rec in 6 mon.
ASA 100 mg + CLO 75 mg
13
Amans et al. 2014
59/F
R
Y
PT X 18 mon
lobulated 6.8 x 8.0 x 4.2 mm right sigmoid sinus diverticulum with a 3.4 mm neck, a stenosis in the sigmoid sinus upstream from the diverticulum
NM
Y
Endovascular
Complete resolution at 6mon FU
ASA 81 X 2 WKS
14
Wang et al. 2015 (n=28)
R:18 L:10
NM
PT
Associated sigmoid sinus wall dehiscence in 20 cases
NM
NM
Paramasivam et al. 2016
R
Y
PT x 4 mon
SSD 7 X 5 mm, with T-S junction stenosis
NM
Complete resolution:17, partial:3, no change:5 No recurrence in 8 mon
NM
15
36.96 (mean) M:2, F:26 33/F
ASA 81 mg + CLO 75 mg
16
Li et al. 2016
39/ F
R
NA
PT x 4 yr
Diverticulum at T-S jn
No recurrence after 4 mon
ASA 100 X 6M CLO 75 X 1M
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Sigmoid sinus wall reconstruction=25; Non-operative 3
NM
N
Endovascular
Endovascular
ASA: Aspirin CLO: Clopidogrel
Table 2: Details of endovascular intervention Set Up
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Route, access vessel
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PT: Pulsatile tinnitus
Authors
Y
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NM: not mentioned
Serial No
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12
Sheath and catheter
Microguidecathe ter
Microguidewire
5 F catheter stationed in left sigmoid sinus
MicroFerret
NM
coil
stent
Treatment of Upstream stenosis
Occlusion rate
Angio FU
N
N
N
Y, selfexpanding
NA
Wallstent 10 x 28
NA
Complete immediat ely Complete immediat ely Reduction in size but
1
Houdart
Venous, Jugular
2
Sanchez
Venous, L IJV
NM
NM
NM
Three Detach 18 coil multiple
3
Zenteno
1st OP: Burr hole 3 cm lat to torcula to access
8F Arrow
NM
NM
N
N
Patency of sinus and
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persistent filling
2nd OP: Femoral vein
6F Envoy in L IJV
Tracker Excel 14
NM
2 GDC coils
No
NA
complete
4 (1: Tetris 3D Tension Safe; 3: supersoft coils) Multiple
N
N
Complete occlusion
No
NA
Minimal
Y
N
N
Complete immediat ely Incomplet e
slight decrease in size of aneurysm 6 mon; complete occlusion of aneurysm N
Gard
Venous, femoral vein
5 F Envoy into L IJV;
90 deg Prowler14
Synchro-14
5
Mehanna
Venous, femoral
SL 10
NM
6
Lenck
Venous, R IJV
7F, Hyperform balloon at T-S junction, across neck of an 5 F sheath
NM
NM
7
Park
7F sheath and 7F Envoy; Prowler select plus
Excel 10
NM
2
N
NA
8
SantosFranco
Both, R femoral A for diagnostic; R femoral vein for treatment (at same sitting) Both, femoral a and v
5F (Artery) 6F (vein)
Excelsior SL10
Transend
N
Y (see previous column)
Complete occlusion
6 mon: no recurrence
9
Amans
Both, Common femoral vein and (7F) C/L common femoral artery (5F)
Synchro 2
7 detachable coils
Cristallo Ideale stent across stenosis an neck of aneurysm N
Not treated
Complete obliterati on with resolutio n of PT
6 mon: no recurrence
10
Paramasivam
Venous
11
Li
Venous, femoral
8 mon: remodeling of the R T-S; persistent obliteration of the diverticulum N
NM=Not mentioned
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4
Prowler select plus
NM
NM
3 Target 360 Ultra coils
Proteage 10 x 40 mm
N
Complete immediat ely
8 F Envoy MPD in R sigmoid sinus;
Renegade for coil, Vasco: 28 for stent;
0.014-inch XCelerator
3 Microplex coils
Leo stent
NP
Complete immediat ely
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coaxial 7F VBL guide catheter (right IJV) with 5F Vert (r IJSigmoid sinus junction); venous road map from C/L CCA injection NeuronMax advanced into IJV
6 mon: minimal filling N
N
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NA= Not applicable
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Highlights Sigmoid sinus diverticulum/ aneurysm is a rare cause of tinnitus. Endovascular management is generally associated with immediate complete relief.
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Recurrence is rare with successful endovascular management.
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ABBREVIATIONS
SSD: Sigmoid sinus diverticula
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CTA: Computed tomography angiogram