Venous Causes of Pulsatile Tinnitus and Corresponding Endovascular Therapy

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification:
[Note: Discipline-specific Targeted CE credits may be less than the total Category A credits approved for this course.]

Magnetic Resonance Imaging: 1.00
Procedures: 1.00
Neurological: 1.00

Registered Radiologist Assistant: 1.75
Procedures: 1.75
Neurological, Vascular, and Lymphatic Sections: 1.75

Vascular-Interventional Radiography: 1.75
Procedures: 1.75
Vascular Diagnostic Procedures: 1.75

Outline

1. Introduction
2. Classification and Etiologic Causes of Tinnitus
3. Imaging Approach to Patients with PT
4. CT and MRI Technical Considerations
5. Imaging Interpretation and Considerations for Endovascular Therapy
6. An Anatomic-Based Approach to Identify the Causes of Venous PT
   1. Pathologic Abnormalities of the Lateral Sinuses
      1. Transverse Sinus Stenosis
      2. Sigmoid Sinus Wall Abnormalities
   2. Emissary Vein Anomalies and Variants
      1. Mastoid Emissary Vein
      2. Petrosquamosal Emissary Vein
      3. Condylar Veins
   3. Jugular Bulb Abnormalities
      1. HRJB Abnormality
      2. Jugular Bulb Dehiscence
      3. Jugular Bulb Diverticulum
   4. Other Causes of Venous PT
7. Conclusion

Objectives

Upon completion of this course, students will:

1. recall the origin of the word “tinnitus”
2. choose the correct percentage of patients affected by subjective tinnitus
3. provide the characterizations of pulsative tinnitus
4. list the vascular causes of PT
5. state the most common cause of PT in older adults
6. list the venous causes of PT
7. describe how patients should be evaluated for PT at noninvasive imaging
8. choose the imaging study of choice to exclude cerebellopontine angle cistern or internal auditory canal lesions in patients with associated vertigo, dizziness, or hearing loss
9. choose the imaging modalities that can be used as first-line methods to identify dural arterio-venous fistulas
10. follow a diagnostic imaging algorithm to determine the proper imaging sequence
11. describe how computed tomography protocols may differ between institutions
12. state the sensitivity of the manual compression test for the prediction of venous lesions
13. review Table 2 within the article to determine definitions for specific venous anomalies
14. list the categories of venous pathologic abnormalities and variants that cause PT
15. list pathologic abnormalities of the lateral sinus that cause PT
16. state where enlarged arachnoid granulations may occur
17. review images to determine stent placement for enlarged arachnoid granulations
18. discuss interventions for arachnoid granulation
19. define extrinsic stenosis
20. define the 5 point scale used for grading the patency of the lateral sinus
21. confirm how idiopathic intracranial hypertension is diagnosed
22. state the most common symptom of idiopathic intracranial hypertension
23. give the percentage of idiopathic intracranial hypertension patients that experience pulsatile and unilateral tinnitus
24. state the most useful imaging finding of idiopathic intracranial hypertension
25. give the percent of patients that experience headache relief after stent placement for transverse sinus stenosis
26. give the failure rate of stents placed for transverse sinus stenosis
27. choose the imaging procedure recommended to assess for follow-up of stent placement for transverse sinus stenosis
28. list sigmoid sinus wall anomalies
29. state the types of interventions for treatment of sigmoid sinus diverticulum
30. choose the first line of treatment for narrow neck diverticulum
31. list the layers of which the venous system of the head develop from
32. list the anatomic categories of the main emissary veins
33. state what vein serves as the main collateral pathway for venous drainage
34. describe the location of the roof of a high-riding jugular bulb
35. recall the name of the boney layer covering the jugular bulb