Endovascular Management of Sigmoid Sinus Diverticulum

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1 Published online: My 12, /16/ $39.50/0 Originl Pper Endovsculr Mngement of Sigmoid Sinus Diverticulum Srinivsn Prmsivm Sunil Furtdo Tomoyoshi Shigmtsu Eric Smouh b Center for Cerebrovsculr Surgery, Deprtment of Neurosurgery, nd b Deprtment of Otolryngology, Mount Sini Hospitl, New York, N.Y., USA Key Words Pulstile tinnitus Sigmoid sinus diverticulum Sinus stenosis Abstrct Sigmoid sinus diverticulum (SSD) is rre vsculr disorder due to dehiscence of the sigmoid plte. It my be ssocited with prediverticulr venous sinus stenosis (SS) nd usully presents s pulstile tinnitus. The mechnism of development of the SSD nd tinnitus from sinus diverticulum nd ssocited SS is uncler. Previous cse reports hve suggested tht remodeling of the venous system trgeting the stenosis, elimintion of the diverticulum, or both, hve resulted in symptom relief. We present cse of SSD with SS, treted by stenting of the stenosis long with coil emboliztion of the diverticulum, resulting in complete relief of symptoms. We hve lso reviewed the literture nd discussed the evolution of mngement from open surgicl tretment to endovsculr tretment. Introduction Pulstile tinnitus (PT) is symptom of vried etiology, mostly cused by vsculr pthology in nd round the er. In most cses, the etiology is identified using CT, CT ngiogrm, MRI nd digitl subtrction ngiogrphy (DSA). Sigmoid sinus diverticulum (SSD) is identified s one of the rre cuses of PT [1]. The mngement of SSD involves reconstruction of the sigmoid sinus wll nd hs chnged over the yers from open surgicl tretment to endovsculr tretment. Srinivsn Prmsivm Deprtment of Neurosurgery, Center for Cerbrovsculr Surgery Mount Sini Hospitl, 1450, Mdison Avenue, KCC 1 North New York, NY (USA) E-Mil hotmil.com

2 77 b Fig. 1., b CT scn ( ) nd bone window ( b ) revel the dehiscence of the bony wll leding to the SSD (rrows). c, d MR venogrms in nteroposterior nd lterl projection revel stenosis of the right trnsverse sigmoid sinus with the SSD (rrows). There is lso hypoplsi of the left trnsverse sigmoid sinus. c d Cse Report Our ptient is n obese femle in her lte thirties, who presented with persistent disturbing noise in her right er of 4 months durtion. The noise becme more obvious in quiet environment nd with physicl exertion. She hd no chnge in hering, blnce nd coordintion. She hd norml neurologic, otologic nd neuro-ophthlmologic evlutions. Subsequent noninvsive imging included crotid ultrsound, CT of the brin with bone window, nd MRI with MR venogrphy of the brin tht reveled dehiscence of the sigmoid plte with diverticulum of the venous sinus protruding into the mstoid ir cells on the right side with hypoplstic left trnsverse sigmoid sinus. An upstrem stenosis t the trnsverse sigmoid junction just proximl to the stenosis ws noted ( fig. 1 ). DSA identified the right SSD mesuring bout 7 5 mm, showing brod bse with prediverticulr stenosis t the trnsverse sigmoid sinus. Hypoplsi of the left trnsverse sigmoid sinus ws lso noted ( fig. 2 ). The ptient ws premedicted with spirin nd Plvix, nd pltelet function ws tested before the procedure. Under generl nesthesi, trnsvenous ccess ws obtined nd Neuron Mx ctheter ws dvnced into the right internl jugulr vein. A Protégé stent system of mm followed by Protégé stent of mm ws deployed in overlpping fshion. The diverticulum ws coiled using 3 Trget 360 Ultr coils resulting in totl oblitertion of the diverticul. Following the procedure, the ptient ws completely relieved of the symptoms. At 8 months follow-up, she ws symptom free, nd follow-up ngiogrm reveled remodeling of the right trnsverse sigmoid sinus nd persistent oblitertion of the diverticulum ( fig. 3 ).

3 78 b c d e f Fig. 2., b Angiogrms of the right internl crotid ( ) nd the left internl crotid rteries ( b ) in nteroposterior view revel the right SSD (rrows) nd proximl stenosis in the distl trnsverse sinus (rrowheds). c, d Posttretment ntive imges revel the stent in the trnsverse sigmoid sinus nd coils in the diverticulum (long rrow). e, f Right internl crotid rtery ngiogrms revel remodeling of the sinus with oblitertion of the diverticulum. b Fig. 3. Follow-up ngiogrm done t 8 months: ntive imges (, b ) revel stble stent nd coils (rrows), nd right internl crotid ngiogrms ( c, d ) revel stble nd complete oblitertion of the diverticulum with right trnsverse sigmoid sinus remodeling (rrowheds). c d

4 79 Tble 1. Summry of cse reports of SSD treted by endovsculr emboliztion First uthor [Ref.], yer Age, yers/sex Side/dominncy Tre tment Upstrem stenosis Antipltelet mediction Houdrt [1], /F Left/dominnt Simple coiling (+) ASA 160 mg Snchez [7], /M Left/unknown Stent-ssisted coiling (+) Not mentioned Zenteno [8], /F Left/dominnt Stent-ssisted coiling (+) ASA 325 mg + CLO 75 mg Grd [9], /F Left/dominnt Simple coiling ( ) ASA 325 mg Mehnn [10], /F Right/dominnt Blloon-ssisted coiling ( ) ASA 325 mg Prk [11], /F Right/dominnt Simple coiling ( ) None Sntos-Frnco [12], /F Right/dominnt Stenting lone (+) ASA 100 mg + CLO 75 mg Amns [13], /F Right/dominnt Simple coiling (+) ASA 81 mg Present cse, /F Right/dominnt Stent-ssisted coiling ( ) ASA 81 mg + CLO 75 mg ASA = Asprin; CLO = clopidogrel. Discussion A tinnitus my be subjective or objective nd my be pulstile or nonpulstile. In most cses, PT is cused by vsculr pthology tht my hve rteril or venous cuses, nd it is generted by turbulent flow of blood through stenotic or irregulr vsculr structures in nd round the petrous bone. Like ny solid structure, the petrous bone is good conductor of sound nd trnsmits to the middle er. The sound becomes more rpid nd is often louder with physicl exertion. Evlution for cuses of PT includes high-resolution crnil CT scn, CT ngiogrphy, MRI, MR ngiogrphy nd MR venogrphy exmintion of the hed, crotid Doppler scns nd DSA. Sonmez et l. [2] hve detected the etiology of PT using imging in 67.6% of cses nd 100% of the time when the tinnitus ws objective. SSD is rre venous nomly ssocited with PT; however, the exct incidence nd mechnisms of genertion re unknown. In bout hlf the cses, the SSD is present on the side of the dominnt trnsverse sigmoid sinus, being t lest 3 mm lrger thn the other [3]. This condition is reported more commonly in middle-ged women [3]. It is due to dehiscence of the wll of the sinus nd protrusion of prt of the sinus into the pneumtized bone, resulting in pulstile nd potentilly disbling tinnitus [4]. Upstrem sinus stenosis (SS) is often noticed with SSD nd hs been considered to hve custive role in sinus diverticulum genertion, s in our cse. Compression of the ipsilterl internl jugulr vein elimintes or ttenutes venous PT, with its loudness often influenced by hed position [3]. Durl SS per se cn cuse PT due to turbulent flow of blood through stenotic vsculr structures or secondry to intrcrnil hypertension cused by venous hypertension [4, 5]. Since not ll SSD cuses PT, in symptomtic ptients, tretment of either the stenosis or the diverticulum, or both, remins controversil. Successful surgicl tretment hs been described; it involves extended mstoidectomy, skeletoniztion of the ffected sinus wll, reduction of the diverticulum with bipolr cutery, reinforcement of the sinus wll using soft tissue grft of temporlis fsci nd reconstruction of the bony defect [5]. We cquired the knowledge of durl sinus stenting from benign intrcrnil hypertension [6]. Endovsculr tretment of SSD nd SS is fesible with coil emboliztion with or without stent ssistnce. We found seven cse reports describing endovsculr mngement of SSD s tretment of PT ( tble 1 ) [1, 7 13]. Three of these cses received stent with or without coiling [7, 8, 12]. All ptients needing sinus stenting will hve to be premedicted with dul

5 80 ntipltelet mediction. In order to minimize procedurl risks, risk of in-stent thrombosis nd hemorrhgic complictions, stents should be limited to cses requiring their use to dequtely position coils in the diverticulum, s in our cse nd previous one [8]. When the SSD with upstrem SS is identified, tretment of the stenotic lesion either by blloon ngioplsty lone or stenting remins unknown. Three cses of SSD with upstrem SS were reported with three different endovsculr tretments with symptom relief. One ws treted by stenting to resolve the SS without coiling the SSD [12], nother by coiling the SSD without tretment of stenois [13], nd the third ws treted by stenting the stenosis nd coiling of the SSD [7]. In generl, for ptients with SS cusing idiopthic intrcrnil hypertension, pressure grdient of more thn 10 mm Hg is used s n indictor for sinus stenting. The pressure grdient cross the stenotic segment my help in ssessing the severity of stenosis, determining the need for ngioplsty nd stenting the upstrem SS ssocited with SSD. Conclusion SSD with or without SS is rre cuse of PT. Symptomtic SSD cn be sfely treted by endovsculr coil emboliztion of the diverticul with or without stenting. Mngement of the ssocited stenosis my be performed during the sme procedure. Disclosure Sttement S.P. is consultnt to Microvention. There re no disclosures for the other uthors. References 1 Houdrt E, Chpot R, Merlnd JJ: Aneurysm of durl sigmoid sinus: novel vsculr cuse of pulstile tinnitus. Ann Neurol 2000; 48: Sonmez G, Bsekim CC, Ozturk E, Gungor A, Kizilky E: Imging of pulstile tinnitus: review of 74 ptients. Clin Imging 2007; 31: Wng GP, Zeng R, Liu ZH, Ling XH, Xin JF, Wng ZC, et l: Clinicl chrcteristics of pulstile tinnitus cused by sigmoid sinus diverticulum nd wll dehiscence: study of 54 ptients. Act Otolryngol 2014; 134: Krishnn A, Mttox DE, Fountin AJ, Hudgins PA: CT rteriogrphy nd venogrphy in pulstile tinnitus: preliminry results. AJNR Am J Neurordiol 2006; 27: Eisenmn DJ: Sinus wll reconstruction for sigmoid sinus diverticulum nd dehiscence: stndrdized surgicl procedure for rnge of rdiogrphic findings. Otol Neurotol 2011; 32: Albuquerque FC, Dshti SR, Hu YC, Newmn CB, Teleb M, McDougll CG, et l: Intrcrnil venous sinus stenting for benign intrcrnil hypertension: clinicl indictions, technique, nd preliminry results. World Neurosurg 2011; 75: ; discussion Snchez TG, Muro M, de Medeiros IR, Kii M, Bento RF, Clds JG, et l: A new therpeutic procedure for tretment of objective venous pulstile tinnitus. Int Tinnitus J 2002; 8: Zenteno M, Murillo-Bonill L, Mrtinez S, Aruz A, Pne C, Lee A, et l: Endovsculr tretment of trnsversesigmoid sinus neurysm presenting s pulstile tinnitus. Cse report. J Neurosurg 2004; 100: Grd AP, Klopper HB, Thorell WE: Successful endovsculr tretment of pulstile tinnitus cused by sigmoid sinus neurysm. A cse report nd review of the literture. Interv Neurordiol 2009; 15: Mehnn R, Shltoni H, Morsi H, Mwd M: Endovsculr tretment of sigmoid sinus neurysm presenting s devstting pulstile tinnitus. A cse report nd review of literture. Interv Neurordiol 2010; 16: Prk YH, Kwon HJ: Awke emboliztion of sigmoid sinus diverticulum cusing pulstile tinnitus: simultneous confirmtive dignosis nd tretment. Interv Neurordiol 2011; 17: Sntos-Frnco JA, Lee A, Nv-Slgdo G, Zenteno M, Veg-Montesinos S, Pne-Pinese C: Hybrid crotid stent for the mngement of venous neurysm of the sigmoid sinus treted by sole stenting. Vsc Endovsculr Surg 2012; 46: Amns MR, Stout C, Dowd CF: Resolution of pulstile tinnitus fter coil emboliztion of sigmoid sinus diverticulum. J Cerebrovsc Dis Stroke 2014; 1: 1010.