Dural Venous Sinus Research Articles

Dural Venous Sinus Variations Observed in Magnetic Resonance Venography at a Tertiary Care Hospital: An Observational Study

Introduction: The dural venous system, composed of various sinuses, plays a crucial role in draining deoxygenated blood from the central nervous system. Understanding its anatomical variations is essential to differentiate it from pathological conditions like cerebral venous sinus thrombosis. This study aims to evaluate the anatomical variations of the dural venous sinuses using Magnetic Resonance Venography.Methods: An observational, cross-section study was performed in the Department of Radiology from September 2023 to March 2024 after the approval by the Institutional Review Committee (Reference number: 149/080/081(6-11)E2). Magnetic Resonance Venography of 109 adult patients was performed using a 1.5 Tesla MRI scanner. Diameters of the superior sagittal sinus, straight sinus, and transverse sinuses were measured. Variations in transverse sinuses, straight sinus, and confluence were categorized and analyzed. Results: The study included 52 (47.70%) male and 57 (52.30%) female, with median age of 42 (IQR: 30.5 - 56) years. The superior sagittal sinus had the diameter of 6.4±1 mm. Symmetric transverse sinus variant seen was in 80 (73.39%) patients, and left transverse sinus hypoplasia was seen in 20 (18.35%) patients. Variations in the straight sinus and confluence were also documented with a true confluence (type III) was seen in 71 (65.10%) patients.Conclusions: Anatomical variations of the dural venous sinuses as observed in 1.5 Tesla MRI was quite common.

The Onerous task of managing paroxysmal nocturnal hemoglobinuria in a Low resource setting: a case report. A hematologist’s experience

Introduction: Paroxysmal nocturnal hemoglobinuria (PNH) is a form of red cell membrane defect characterized by increased sensitivity to complement-mediated cell lysis, resulting in intravascular hemolytic anemia, passage of hemoglobin-containing urine, a high risk of venous thrombosis and progression to pancytopenia.The diagnosis of PNH is based on the flow cytometric (FCM) detection of peripheral blood cell clones. Such clones lack expression of the surface molecules linked to the glycosylphosphatidylinositol (GPI) anchors. The underlying defect is a somatic mutation of the short arm of the phosphatidylinositol glycan class A gene (PIG-A). Case report: We report a case of a 34-year-old male, with recurrent hemolytic anemia and dural venous sinus thrombosis found to have PNH by flow cytometry. He is currently on anticoagulation, iron and folate supplements, intermittent steroids for hemolytic episodes as we await complement inhibitors. Conclusion: As part of the diagnostic workup for patients presenting with recurrent hemolytic anemia and thrombosis in unusual sites, clinicians should include PNH on the list of differential diagnoses. Effort should be taken to characterize the red urine reported on the urine dipstick as blood/hemoglobin by microscopy to differentiate hematuria and hemoglobinuria and order for flow cytometry as this has implications on patient management. Keywords: Thrombosis; hemolysis; complement; paroxysmal nocturia; hemoglobinuria.

Preoperative Radiographic Features Independently Predict High Blood Loss During Intracranial Meningioma Resection: A Case-Control Study

Surgical resection of intracranial meningioma carries the risk of several complications, including intraoperative blood loss. The objective of this study was to investigate preoperative clinical and radiographic factors predictive of intraoperative estimated blood loss (EBL). This case-control study evaluated EBL for all adults who underwent intracranial meningioma resection from January, 2010 to December, 2021 at our institution. Fifty cases of high EBL (i.e., ≥500mL) and 75 instances of low EBL (i.e., <500mL) were randomly selected. Patients were excluded if they had a recurrent meningioma, preoperative embolization, or lack of imaging data. A multivariable logistic regression model of high EBL likelihood was created. A total of 92 patients met eligibility criteria, with 48 (52%) cases of high EBL. Bivariable analyses identified maximal tumor diameter, intratumoral flow voids, skull base location, and dural venous sinus invasion as potential predictors of high EBL. Multivariable regression found intratumoral flow voids (adjusted odds ratio [aOR]= 5.68 [1.52-21.23], P= 0.009), maximal tumor diameter (aOR= 1.58 [1.11-2.25] per 1-cm increase, P= 0.01), and skull base location (aOR= 3.35 [1.19-9.41], P= 0.02) to be independent predictors of high EBL. Intratumoral flow voids, larger maximal tumor diameter, and skull base location were independently predictive of EBL ≥500mL. Intratumoral flow void presence was the strongest predictor, with 5.68 times the odds of high EBL. Each 1-cm increase in tumor diameter had 58% greater odds of high EBL. Skull base location was associated with 3.35 times the odds of high EBL. These results can inform preoperative patient counseling and blood management preparation.

Management of Compound Depressed Fractures over Venous Sinuses

Abstract Objective The aim of this study was to report our experience in the surgical treatment of compound depressed fractures over the venous sinuses with special highlights on the prediction and dealing with intraoperative sinus injury. Materials and Methods We conducted a retrospective review of all patients who underwent surgery for compound depressed fractures overlying the dural venous sinuses in our hospital between January 2019 and December 2021. Results A total of 34 patients were included in our study. The mean age of the patients was 19.85 years, most of our patients were males 27 (79.4%), and isolated head trauma was the most common mode of trauma (76.5%). The superior sagittal sinus (SSS) was distinguished as the most commonly involved venous sinus below the fractures in 28 patients (82.4%). An intraoperative tear in the sinus was found in 17 patients (50%), which was easily controlled with different methods. In two patients who had a severe head injury with a Glasgow Coma Scale (GCS) score of ≤8 associated with a fissure fracture crossing the sinus, there was a complete tear of the sinus followed by massive bleeding, which required sinus ligation. We lost both of them in following days. Conclusion In experienced tertiary neurotrauma centers, compound depressed fractures over the venous sinuses should be surgically elevated in most cases, taking into consideration that bleeding from the sinus can be controlled in most cases, and complete tear of the sinus with massive bleeding is the least scenario faced in reality and is usually associated with a severe head injury. If expert opinion favors the conservative approach, then close follow-up for months is recommended due to the high possibility of sinus thrombosis and intracranial hypertension, especially in children.

Analysis of cerebral venous sinus stenosis by flat panel angiographic CT (FP-CT) to guide treatment for idiopathic intracranial hypertension.

Cerebral venous sinus stenting (CVSS) is an effective treatment for idiopathic intracranial hypertension (IIH) secondary to dural venous sinus stenosis. Traditional selection of patients for CVSS has been made by microcatheter manometry, but pressure measurements are often equivocal. Here we present the results of a series of cases in which venous flat-panel CT (FP-CT) was used as an adjunct to microcatheter manometry to improve decision making and precise stent placement during CVSS. Ten consecutive patients with IIH underwent angiography with microcatheter manometry and venous FP-CT, with CVSS if indicated by the results. Cross-sectional measurements of the narrowed sinus were obtained on FP-CT before and after stenting. After the procedure, clinical outcomes were tracked. Follow-up with quantitative MRA with sinus flow measurements was also performed, when available. There was an exponential correlation between measured pressure gradient and degree of stenosis calculated using venous FP-CT. All patients with both a high degree of stenosis measured by FP-CT and a high pressure gradient across the stenosis showed a clinical benefit from stenting. True measurement of the cross-sectional area of the dural sinus, made by venous phase FP-CT, has a high degree of correlation with elevated venous pressure gradient across the point of stenosis. Even in a limited series of cases, we found an exponential decrease in flow with increasing severity of stenosis. Furthermore, patients with both an elevated venous pressure gradient and critical stenosis of the sinus on FP-CT showed symptomatic improvement after stenting.

A Rare Case of Tentorial Sinus Thrombosis in a Patient with Sickle Cell Disease

Background: The reported incidence of venous thromboembolism in sickle cell disease patients is approximately 12% before the age of 40, accompanied by an additional 5-10% incidence of cerebral venous sinus thrombosis. Tentorial sinuses are venous structures in the posterior cranial fossa, draining the occipital and temporal lobes and the superior part of the cerebellum. Here, we describe a rare case of lateral tentorial sinus thrombosis in a patient with sickle cell disease. Methods: Case report and review of the available literature Results: A 26-year-old woman with sickle cell disease presented with a 2-day history of headache, nausea, and vomiting. Neurological exam was normal. CT brain revealed hyperdensity in the right occipital region and subtle area of hypodensity in the right medial occipital lobe. MRI/MRV brain showed right lateral tentorial sinus and occipitobasal vein thrombosis in addition to right medial occipital lobe venous infarct. The patient was started on therapeutic heparin initially, then transitioned to apixaban. Hemoglobin electrophoresis revealed a HbS fraction of 80.6% and HbF 16.6%. The patient received an exchange transfusion and was discharged home in stable condition. Conclusions: In patients with symptoms concerning for cerebral venous thrombosis, attention is usually directed to the traditional dural venous sinuses and cortical veins, while other venous structures can be overlooked. Although, in this particular case, it was clear on imaging, tentorial sinus thrombosis can easily be missed if not associated with brain edema or venous infarct.

Central retinal artery and Common Carotid artery occlusions following COVID-19 infection: A case report.

To report a case of central retinal artery and common carotid artery occlusions following COVID-19 infection in a young female with no other risk factors. Retrospective analysis of the medical notes of a patient hospitalized with COVID 19 infection at University Hospital Southampton. The patient was found to have dural venous sinus thrombosis and an acute infarct within the right parietal lobe. There was an occlusive thrombus within the right common carotid artery. Subsequently she was found to have a right central artery occlusion secondary to the right common carotid artery occlusion. COVID-19 infection can cause retinal artery occlusion via systemic thrombosis in previously healthy patients.

The semispinalis capitis muscle skull attachment as a superficial external landmark for the location of the transverse dural venous sinuses

IntroductionIdentifiable superficial external landmarks can be used to determine the exact location of the internally located dural venous sinuses, for neurosurgical procedures. Several studies have been conducted to determine a standard method or a consistent reliable landmark, but all reported variations and inconsistencies with the examined landmarks. This study evaluated the relationship between the attachment site of the semispinalis capitis muscles on the external aspect of the skull and the internally located transverse dural venous sinuses. MethodsFifty-one South African skulls were used in this study. The Micro-focus X-ray Radiography and Tomography (MIXRAD) system at Necsa (Nuclear Energy Corporation South Africa) was used to scan and create three-dimensional images of each skull specimen. Pre-determined reference points were placed on the reconstructed images with the VGStudio Max volume rendering software. The relevant distances and locations of the reference points were measured and documented. ResultsThe muscle attachment site was located inferior to the transverse sinuses in all the skulls with a mean distance of 15.99 mm (left side) and 19.43 mm (right side). A statistically significant difference was found between all the measurements comparing the left- and right sides, however, no such difference was found between males and females. ConclusionThe apical attachment of the semispinalis capitis muscle is a good indicator for the internally located transverse dural venous sinus. This study indicates that a point of entry 8–10 mm inferior to this muscle attachment site be used, for safe access to the internal aspect of the posterior cranium.

What should otolaryngologists know about dural venous sinus stenting?

Dural venous sinus stenting is an emerging and exciting area in otolaryngology in collaboration with neurosurgeons and neuroradiologists. The first cases were reported 20 years ago. It is now considered part of the routine treatment of increased intracranial pressure due to transverse sinus stenosis. ENT doctors are the first to see these patients in their clinics, as sinus headaches, pulsating tinnitus, and dizziness are the most common symptoms. Previously, with limited success, high-dose diuretics and intracranial shunts had been the only options for treating these patients. Other methods, such as covering the sigmoid sinuses with graft material, appear to cause a sudden increase in intracranial pressure that can lead to blindness and even death. This overview summarizes the clinical and imaging characteristics of patients who will benefit from endovascular sinus stenting for elevated intracranial pressure.

Dural venous sinus angioplasty and stenting for treatment of idiopathic intracranial hypertension: a single-center experience with 20 consecutive cases

Background: Dural venous sinus stenosis has been shown to be a potential cause or aggravating factor of idiopathic intracranial hypertension (IIH). Endovascular therapy for angioplasty of venous sinus stenosis is emerging as a potential alternative to treat IIH. Objective: This article aims to present the results of a cases series representing the experience of a single center in treating this disease. Materials and Methods: We retrospectively reviewed the angiographic and manometric data of patients undergoing angioplasty and stenting for the treatment of IIH with venous sinus stenosis on magnetic resonance angiography. All patients had failed conventional medical treatment. Data on demographic features, clinical and radiologic presentation, and outcomes were collected retrospectively. Results: 20 female patients, with persistent headache and papilledema, underwent venous sinus angioplasty and stenting. Mean age was 35.9 (SD, 10) years. Eighteen patients (90%) had clinical improvement after the procedure. Of these, all showed resolution (17 patients, 94%) or partial improvement (1 patient, 6%) of papilledema within 6 months. Two patients had persistent moderate-to-severe headache (intensity &gt; 6 on a 10-point pain scale), with continued papilledema despite stable visual acuity on visual field testing. The mean pre-procedure lumbar puncture opening pressure was 30.1 (SD, 4) mm Hg, decreasing to 16.2 (SD, 4) mm Hg after the procedure. Only 4 patients experienced complications directly or indirectly related to the procedure, with no impact on outcome. Conclusion: Angioplasty and stenting of the stenotic segment may effectively and safely treat IIH associated with focal venous sinus stenosis, with a high technical success rate and an acceptable complication rate.

The effect of SARS-CoV-2 on the incidence of post-operative venous sinus thrombosis following skull base procedures.

Sinus thrombosis is a common post-operative finding after posterior fossa surgery performed in the vicinity of the dural venous sinuses. The SARS-CoV-2 virus has been shown to confer an increased risk of venous thromboembolic events owing to eliciting a hyper-inflammatory and pro-thrombotic state. In this study, we examine the incidence of post-operative venous sinus thrombosis in patients undergoing peri-sigmoid posterior fossa surgery in the pre- and post-COVID era and investigate whether COVID infection confers an increased risk of sinus thrombosis. A retrospective review of a single institution case series of patients underwent peri-sigmoid surgery (retrosigmoid, translabyrinthine, or far lateral) approach. Relevant clinical variables were investigated that may confer an increased risk of sinus thrombosis. A total of 311 patients (178 in the pre-COVID era, and 133 operated on after the pandemic began in March 2020) are included in the study. The composite incidence of sinus thrombosis seen on post-operative imaging was 7.8%. The incidence of sinus thrombosis in the pre-COVID cohort was N = 12 patients (6.7%) versus N = 12 (9%) in the post-COVID cohort (p = 0.46). A history of COVID infection was not shown to confer an increased risk of post-operative sinus thrombosis (OR: 0.61; 95% CI: 0.08-4.79, p = 0.64). Only a small number of patients (N = 7, 2.3%) required either medical or surgical intervention for post-operative sinus thrombosis. The overall incidence of post-operative sinus thrombosis is similar in the pre- and post-COVID era. The findings of this study suggest that COVID infection is not associated with a higher risk of venous sinus thrombosis.

Microsurgical Management of Complex Meningiomas Involving Dural Venous Sinuses: Operative Techniques, Case Illustrations and Long-Term Outcomes in a Series of 70 Cases

BackgroundMeningiomas involving the dural venous sinuses present unique therapeutic challenges. While gross total resection remains the mainstay of treatment for meningiomas, involvement of critical vascular structures may limit extent of resection and increase the risk of recurrence. Optimal management of meningiomas with venous sinus involvement has been discussed in the literature, with some advocating for subtotal resection with post-operative surveillance and radiation, if necessary, while others recommend total resection with reconstruction of resection of the involved sinus. MethodsWe performed a review of our series of 70 patients at a single institution who underwent resection of a meningioma involving the dural venous sinuses with reconstruction as needed, evaluating demographics, pre-operative assessment of venous anatomy, surgical technique, and outcomes. ResultsIn our series, we found successful maximal safe resection was achievable in patients with dural venous sinus involvement. We identified no venous infarctions and a low rate of recurrence. ConclusionsMaximal safe resection, including resection and reconstruction of involved sinuses, may be a safe and effective treatment for many patients. Careful pre-operative assessment of venous anatomy and planning extent of resection and reconstruction are essential for safe and successful surgery in these patients.

The postulated role of brain pulsations and arachnoid membranes in cerebrospinal fluid circulation, ventriculomegaly and related CSF disorders

Hydrocephalus can be obstructive or communicating. In cases of communicating hydrocephalus, patients will typically have enlarged brain ventricles. It has long been thought that the reason for this is obstruction to the outflow of cerebrospinal fluid from the subarachnoid space, which also results in raised intracranial pressure (ICP). However, there are several clinical and anatomic observations that are not well explained by this idea. These are for example, the conditions of Normal pressure hydrocephalus (NPH) which has normal ICP but ventriculomegaly, and idiopathic intracranial hypertension (IIH) which has raised ICP but normal sized ventricles. This hypothesis states that the mechanism for raised ICP and large ventricles seen in communicating hydrocephalus (ventriculomegaly) are different and seeks to explain the cause of ventriculomegaly using illustrative examples. It also suggests explanations for why ventriculomegaly occurs in NPH, infectious or carcinomatous meningitis, but is absent in IIH, or dural venous sinus thrombosis. Based on operative neurosurgical observations it states that the arachnoid membranes in the basal cisterns serve as part of a directional CSF flow mechanism consisting of fluid diodes, or “Tesla valves” of arachnoid membrane, containing CSF that is propelled by brain pulsations from the point of exit from the 4th ventricle to its points of absorption. This hypothesis suggests explanations for the physiologic appearance of a near uniform subarachnoid space, as well as the occurrence of the syndrome of the trephined and external hydrocephalus seen following a decompressive craniectomy. Also suggested are avenues of further research testing with MRI phase contrast CSF flow studies, classification of anatomic and peri-operative observations and rationale for creation of novel experiments to test the hypothesis, and aid diagnosis and treatment of a number of cranial CSF disorders.

Jugular foramen stenosis in external hydrocephalus in infants.

To measure the size of jugular foramina in infants affected by external hydrocephalus (EH) and in a control group, to support the hypothesis that a jugular foramen (JF) stenosis may determine dural venous sinus alterations and increased venous outflow resistance as main pathophysiological factor. Minimum, maximum, and mean values of JF areas were measured in a series of phase-contrast magnetic resonance venous angiography (angio MRV PCA3D) performed on 81 infants affected by EH. Results were compared with a group of 54 controls. Smaller JF area was significantly smaller in patients versus controls (43.1 ± 14.6 vs. 52.7 ± 17.8; p < 0.001) resulting in a significantly smaller mean JF areas in patients vs. controls (51.6 ± 15.8 vs. 57.0 ± 18.3; p = 0.043). In patients, smaller JF areas were significantly associated with higher venous obstruction grading score (VOGS) both on the right (p = 0.018) and on the left side (p = 0.005). Positional plagiocephaly (cranial vault asymmetry index > 3.5%) was more frequent among EH patients than controls (38/17) but the difference was not significant (p = 0.07). In the 38 plagiocephalic patients, JF area was smaller on the flattened side than the contralateral in a significant number of cases both in right (21/7) and left (9/1) plagiocephaly (p < 0.0005) as well as the mean area (48.2 + 16.4 mm2 vs. 57.5 + 20.7 mm2, p = 0.002) and VOGS was significantly higher on the plagiocephalic side than on the contralateral side (1.6 ± 1.1 vs. 1.1 ± 0.9, p = 0.019). In this series of infants affected by EH, the mean size of the ostium of both JF resulted significantly smaller than controls. JF stenosis was significantly associated with higher degrees of venous obstruction on both sides, suggesting a direct extrinsic effect of JF size on dural sinus lumen and possible consequent effect on venous outflow resistance. Positional plagiocephaly, when present, was associated with a decreased JF area and increased VOGS on the flattened side.

Arachnoid granulations in idiopathic intracranial hypertension: Do they have an influence?

The aim of this study was to investigate whether the relative narrowing of the dural venous sinuses by arachnoid granulations (AGs) is more pronounced in patients with idiopathic intracranial hypertension (IIH) compared to healthy controls. IIH is characterized by increased intracranial pressure, which is associated with symptoms such as headache and visual disturbances. The role of cerebral venous drainage obstruction in IIH is the subject of ongoing research. In this retrospective case-control study, 3D contrast-enhanced magnetic resonance images of a cohort of 43 patients with IIH were evaluated for (1) the number of AGs per venous sinus and (2) the diameters of the dural venous sinuses at the site of an AG and at standardized measurement points. In addition, the minimum width of the transverse/sigmoid sinus was measured. All data were compared to the same data from a cohort of 43 control participants. Patients with IIH showed less relative sinus narrowing by AG compared to controls (median: 7%, interquartile range [IQR] 10% vs. 11%, IQR 9% in controls; p = 0.009). In patients with IIH, sinus diameter was larger at the site of an AG (70 ± 25 mm2) compared to its diameter at the standardized measurement point (48 ± 23 mm2; p = 0.010). In the superior sagittal sinus (SSS), patients with IIH had smaller AGs (median: 3 mm2, IQR 2 mm2 vs. 5 mm2, IQR 3 mm2 in controls; p = 0.023) while the respective sinus segment was larger (median: 69 mm2; IQR 21 mm2 vs. 52 mm2, IQR 26 mm2 in controls; p = 0.002). The right transverse sinus was narrower in patients with IIH (41 ± 21 mm vs. 57 ± 20 mm in controls; p < 0.001). In contrast to our hypothesis, patients with IIH showed less pronounced relative sinus narrowing by AG compared to controls, especially within the SSS, where AGs were smaller and the corresponding sinus segment wider. Smaller AGs could result in lower cerebrospinal fluid resorption, favoring the development of IIH. Conversely, the smaller AGs could also be a consequence of IIH due to backpressure in the SSS because of the narrower transverse/sigmoid sinus, which widens the SSS and compresses the AG.

A high-precision view of intercompartmental drug transport via simultaneous, seconds-resolved, in situ measurements in the vein and brain.

The ability to measure specific molecules at multiple sites within the body simultaneously, and with a time resolution of seconds, could greatly advance our understanding of drug transport and elimination. As a proof-of-principle demonstration, here we describe the use of electrochemical aptamer-based (EAB) sensors to measure transport of the antibiotic vancomycin from the plasma (measured in the jugular vein) to the cerebrospinal fluid (measured in the lateral ventricle) of live rats with temporal resolution of a few seconds. In our first efforts, we made measurements solely in the ventricle. Doing so we find that, although the collection of hundreds of concentration values over a single drug lifetime enables high-precision estimates of the parameters describing intracranial transport, due to a mathematical equivalence, the data produce two divergent descriptions of the drug's plasma pharmacokinetics that fit the in-brain observations equally well. The simultaneous collection of intravenous measurements, however, resolves this ambiguity, enabling high-precision (typically of ±5 to ±20% at 95% confidence levels) estimates of the key pharmacokinetic parameters describing transport from the blood to the cerebrospinal fluid in individual animals. The availability of simultaneous, high-density 'in-vein' (plasma) and 'in-brain' (cerebrospinal fluid) measurements provides unique opportunities to explore the assumptions almost universally employed in earlier compartmental models of drug transport, allowing the quantitative assessment of, for example, the pharmacokinetic effects of physiological processes such as the bulk transport of the drug out of the CNS via the dural venous sinuses.

Comparative Evaluation of Lower Gadolinium Doses for MR Imaging of Meningiomas: How Low Can We Go?

Gadolinium-based contrast agents are widely used for meningioma imaging; however, concerns exist regarding their side effects, cost, and environmental impact. At the standard gadolinium dose, most meningiomas show avid contrast enhancement, suggesting that administering a smaller dose may be feasible. The purpose of this study was to evaluate the impact of a lower gadolinium dose on the differentiation between meningiomas and adjacent intracranial tissues. One hundred eight patients with presumed or confirmed meningiomas who underwent a brain MRI at multiple doses of gadolinium were included in the study. The patients' MRIs were categorized into 3 groups based on the gadolinium dose administered: micro (approximately 25% of the standard dose), low (approximately 62% of the standard dose), and standard dose. Multireader qualitative visual assessment and quantitative relative signal differences calculations were performed to evaluate tumor differentiation from the cortex and from the dural venous sinus. The relative signal differences for each dose were analyzed by using ANOVA for quantitative assessment and the McNemar test for qualitative assessment. Additionally, noninferiority testing was used to compare the low and micro doses to the standard dose. Decreasing the gadolinium dose to a low dose or micro dose resulted in a statistically significant decrease in signal difference between the tumor and the adjacent brain tissue (P < .02). However, on visual assessment, the low dose was noninferior to the standard dose. The proportion of cases with suboptimal differentiation was significantly higher for the micro dose than for the standard dose, both for the differentiation between the tumor and the cortex (P = .041) and the differentiation between the tumor and the sinus (P < .001). Reducing the gadolinium dose to 62% of the standard level still allows for sufficient visual delineation of meningiomas from surrounding tissues. However, further reduction to 25% substantially compromises the ability to distinguish the tumor from adjacent structures and is, therefore, not advisable.

Pulsatile Tinnitus: Differential Diagnosis and Approach to Management.

The purpose of this review is to provide an updated approach to the evaluation and management of pulsatile tinnitus (PT), an uncommon but often treatable subtype of tinnitus. Secondary PT can be due to either vascular or non-vascular etiologies, including, but not limited to: neoplasm, arteriovenous malformation or fistula, idiopathic intracranial hypertension, dural venous sinus stenosis, otoacoustic etiologies (e.g., otosclerosis, patulous eustachian tube) and bony defects (e.g., superior semicircular canal dehiscence). Computed tomography (CT) and magnetic resonance imaging (MRI) imaging have comparable diagnostic yield, though each may be more sensitive to specific etiologies. If initial vascular imaging is negative and a vascular etiology is strongly suspected, digital subtraction angiography (DSA) may further aid in the diagnosis. Many vascular etiologies of PT can be managed endovascularly, often leading to PT improvement or resolution. Notably, venous sinus stenting is an emerging therapy for PT secondary to idiopathic intracranial hypertension with venous sinus stenosis. Careful history and physical exam can help establish the differential diagnosis for PT and guide subsequent evaluation and management. Additional studies on the efficacy and long-term outcome of venous sinus stenting for venous stenosis are warranted.

Canadian Stroke Best Practice Recommendations, 7th Edition: Cerebral Venous Thrombosis, 2024.

The 7th edition of the Canadian Stroke Best Practice Recommendations (CSBPR) is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners, and intended to drive healthcare excellence, improved outcomes and more integrated health systems. This edition includes a new module on the management of cerebral venous thrombosis (CVT). Cerebral venous thrombosis is defined as thrombosis of the veins of the brain, including the dural venous sinuses and/or cortical or deep veins. Cerebral venous thrombosis is a rare but potentially life-threatening type of stroke, representing 0.5-1.0% of all stroke admissions. The reported rates of CVT are approximately 10-20 per million and appear to be increasing over time. The risk of CVT is higher in women and often associated with oral contraceptive use and with pregnancy and the puerperium. This guideline addresses care for adult individuals who present to the healthcare system with current or recent symptoms of CVT. The recommendations cover the continuum of care from diagnosis and initial clinical assessment of symptomatic CVT, to acute treatment of symptomatic CVT, post-acute management, person-centered care, special considerations in the long-term management of CVT, including pregnancy and considerations related to CVT in special circumstances such as trauma and vaccination. This module also includes supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

What Should Otolaryngologists Know About Dural Venous Sinus Stenting?

Dural venous sinus stenting is an emerging and exciting area in otolaryngology in collaboration with neurosurgeons and neuroradiologists. The first cases were reported 20 years ago. It is now considered part of the routine treatment of increased intracranial pressure due to transverse sinus stenosis.