Emergence of Venous Stenosis as the Dominant Cause of Pulsatile Tinnitus

BACKGROUND The role of arteriovenous shunts such as dural fistulas, arterial steno‐occlusive states, anatomic variants, and hypervascular tumors in the genesis of pulsatile tinnitus (PT) has long been recognized. On the venous side, diverticula, high‐riding jugular bulb, and sinus wall dehiscence have also been implicated. However, the overall most common cause—venous sinus stenosis (VSS)—continues to be underrecognized. Its clinical importance, separate from venous stenosis association with intracranial hypertension, also requires emphasis. METHODS A retrospective review of the last consecutive 208 cases of PT seen at our institution was performed and cause determined, when possible, based on clinical and radiographic data. RESULTS VSS was the common cause of PT (34% of overall cohort). Over 90% are women. Typical clinical presentation was a unilateral whoosh‐like sound in sync with heartbeat that could be completely or nearly completely abolished by ipsilateral jugular compression. This clinical scenario virtually guaranteed the presence of VSS, with very high sensitivity, specificity, positive, and negative predictive values. About two thirds of patients with VSS also harbored other venous anatomic variations such as a high‐riding jugular bulb or sinus diverticulum, that should not be misinterpreted as the primary cause of PT. Most did not have signs or symptoms of intracranial hypertension, even though cerebrospinal fluid and venous pressures are frequently elevated. CONCLUSIONS VSS appears to be the most common identifiable cause of PT. Judicious attention to this finding can be immensely helpful in prompt and accurate diagnosis.