Patients with Chiari I malformation had significantly greater frequency of unilateral or bilateral transverse sinus stenosis than did control subjects (p < 0.001). To investigate the relevant factors of unilateral pulsatile tinnitus (PT) in patients with idiopathic intracranial hypertension (IIH) using CT. CT angiography images of IIH patients with unilateral PT (n = 19), without PT (n = 13), and controls (n = 32) were reviewed. 4. In addition to the smooth tapering stenosis noted along the right transverse sinus, the characteristic, reproducible abnormality seen a large majority of IIH patients is unilateral or bilateral focal stenosis at the junction of the distal 1/3 portion of the transverse sinus and sigmoid sinus. BTSS was considered present when the signal flow was poor or lacking (flow gap) in the mid-lateral portion of both transverse sinuses, while unilateral TS stenosis was considered present when flow gaps were found in one TS. The upper limit of opening pressure in patients with both normal appearance of transverse sinuses and unilateral transverse sinus stenosis on MRV (n = 167) was 195 mmH 2 O with a range of 65–195 mmH 2 O. Venous sinus stenosis or collapse is emerging as a relatively common underlying cause of IIH, with significant success achieved with venous sinus stenting. During the deployment of the stent, significant pressure was required in order to overcome this focal venous sinus stenosis. 2. Catheter venography revealed codominant venous sinus anatomy with bilateral stenosis in 8 patients (62%) and unilateral stenosis of the dominant TSJ in 5 (38%), 3 on the left and 2 on the right. Pressure gradient across the stenosis > 8 mmHg; Signed informed consent obtained from the patient; Exclusion Criteria: Allergic reaction to iodine contrast despite premedication Was diagnosed with left-sided transverse sinus stenosis, but it was not possible to pull the catheter through the stenosed segment. We classified the transverse sinus (TS) stenosis as present or absent. The primary outcome measure was the radiographic presence of SSD. If medical therapy failed and TS stenosis was detected on contrast-enhanced magnetic resonance or computed tomographic venography, catheter cerebral angiography with venous manometry was performed. If a mean pressure gradient (MPG) of 4 mm Hg or greater was present, unilateral transverse sinus stenting was performed. The authors report the case of a 15-year-old boy who presented with headache, papilledema, decreased visual acuity, and diploplia who underwent successful unilateral transverse sinus stenosis stenting and experienced complete resolution of symptoms. A 19-year-old man with IIH, bilateral transverse sinus stenosis was apparent on the CT venography (figure 1), with reconstitution of the transverse sinus. It is still unknown whether this is the cause or consequence of raised ICP. Radiological examination (magnetic resonance venography (MRV) or computed tomographic venography (CTV)) shows bilateral transverse-sigmoid venous sinus stenosis (> 50%) or unilateral stenosis of the dominant sinus with contralateral hypoplastic sinus. On the contrary, our bilateral transverse sinus stenosis prevalence (17.5%) was significantly higher than the 5% found in healthy subjects . Eight of 13 stenoses (61.5%) were extrinsic and 5/13 (38.5%) were intrinsic. Usual right sinus dominance. Results: Patients with Chiari I malformation had significantly greater frequency of unilateral or bilateral transverse sinus stenosis than did control subjects (p < 0.001). 5. With the advent of modern CT and MR imaging, it has been shown that 30–93% of these patients have either unilateral or bilateral transverse sinus (TS) stenosis. There is a severe proximal sigmoid sinus stenosis present (red). Venous imaging showing bilateral transverse sinus stenosis or unilateral transverse sinus stenosis with contralateral transverse sinus atresia. A flow jet atrifact at location of stenosis (green) is an inconstant and unpredictable finding, varying widely based MR … The picture shows that the patient’s left transverse sinus and sigmoid sinus are a congenital developmental disadvantage. Inclusion Criteria: - Age > 18 year-old, living in Ontario, Canada - Patient with diagnostic of Idiopathic Intracranial Hypertension, who failed medical treatment. The transverse (blue) and sigmoid (white) sinuses are normal. Over the course of the postoperative months, 10 patients exhibited headaches differing from those experienced … CTA/V detection of bilateral sigmoid sinus dehiscence and suspected idiopathic intracranial hypertension in unilateral pulsatile tinnitus. 25 reported a high rate of empty sella and transverse sinus stenosis in a series of 40 patients presenting with PT who underwent transtemporal surgical reconstruction of sigmoid sinus wall anomalies. Ten patients had elevated intrasinus pressures (pressure gradient across stenosis, 11–50 mm Hg), which decreased following unilateral TS stent placement. MRI was then performed, and transverse sinus stenosis was confirmed (figure 2). Higgins et al. To confirm stenosis presence and severity, a microcatheter is inserted through the common femoral vein into the dural venous sinus with patients under local anesthesia. 5-7 TSS can not only increase the blood flow velocity but also lead to poststenotic turbulent flow. At least one of the stenoses must cause ≥ 50% reduction of the sinus lumen diameter. CSF opening pressure is > 25 cm H2O. Inclusion criteria included papilledema-related VF loss with mean deviation (MD) worse than or equal to 26.00 dB, elevated opening pressure (OP) on lumbar puncture (LP), VSS (either bilateral or unilateral in a dominant sinus), and an elevated ($8mm Magnetic Resonance Venography (MRV) or Computed Tomography Venography (CTV) demonstrating bilateral transverse sinus stenosis or unilateral transverse sinus stenosis with contralateral transverse sinus hypoplasia or atresia. An impressive network of dilated collateral veins became apparent on susceptibility-weighted sequences (figure 3). However, the relationship between venous stenosis and IIH is controversial. at the transverse-sinus sigmoid sinus junction, using a Pre-cise Pro carotid stent system (Cordis). 12 Our case shows that venous outflow can be altered by structures more distal than the dural venous sinuses: namely, the transverse processes of C1. CT venography revealed a stenosis of the transverse sinus upstream of the stent. Nineteen cases (47.5%) had evidence of transverse sinus stenosis: bilateral in seven patients (17.5%) and unilateral in 12 cases (30%). There was complete interreader agreement on presence or absence of transverse sinus stenosis by patient (κ = 1.0 [95% CI, 0.89-1.0]). Initial angiograms performed demonstrated bilateral or unilateral transverse sinus stenosis [18]. 8). Catheter venography and manometry showed a completely occluded left-distal TS with collateral filling, suggestive of thrombosis. There was complete interreader agreement on presence or absence of transverse sinus stenosis by patient (κ = 1.0 [95% CI, 0.89–1.0]). The sum of the right and left transverse sinus grade provides the combined conduit score). Each transverse sinus is graded from 0 to 4 [0: aplastic segment; 1: severe stenosis with less than 25% of residual lumen; 2: moderate stenosis with between 25 and 50% of residual lumen; 3: mild stenosis between 50 and 75% of residual lumen; 4: no stenosis]. Transverse sinus stenosis is a relatively rare cause of pulsatile tinnitus that evades most of the normal diagnostic tests, probably because we're talking about a tiny vein that is simply too small for a lot of tests to detect. Eisenman et al. ate sinus stenoses with normal intrasinus pressures were found in 3 patients and therefore stent placement was not performed. c The digital subtraction angiography (DSA) clearly shows the stenosis at the border of the transverse sinus and sigmoid sinus … In these 46 patients, stenting 1 transverse sinus and providing 1 functioning sinus lowered venous pressures and abolished papilledema and accompanying symptoms. Headaches improved or resolved in all stented patients. Transverse sinus stenosis (TSS), sigmoid sinus wall dehiscence (SSWD), and sigmoid sinus diverticulum (SSD) have proven to be the most common morphologic abnormalities in venous PT. was provided by Arjona et al. The paired left and right transverse sinuses are major dural venous sinuses and arise from the confluence of the superior sagittal, occipital and straight sinuses at the torcular herophili (confluence of sinuses).. On each side, the transverse sinus then runs in the lateral border of the tentorium cerebelli and grooves the occipital and squamous temporal bones. Less frequently seen abnormalities were focal transverse sinus stenotic area in a single patient, attenuated sigmoid in another, and genu stenosis with transverse and sigmoid sinus stenosis in a third patient (Table 4) (Fig. In the English-language literature only 18 cases, all from the UK and Australia, involving the use of transverse sinus stenosis stent treatment for BIH have been reported; the youngest patient to receive treatment was a 17-year-old girl. Bilateral venous sinus obstruction. A second stent procedure was therefore scheduled for this patient. Interestingly, unilateral transverse sinus stenosis prevalence in our sample is in line with the 33% reported in the general population . Interestingly, unilateral transverse sinus stenosis prevalence in our sample is in line with the 33% reported in the general population (11). No statistically significant differences in transverse sinus stenosis distribution were found between patients with opening pressure <200 mmH2O and those with opening pressure >200 mmH2O. Six patients had transverse sinus hypoplasia, 5 patients had bilateral genu stenosis and 3 patients had both findings. a, b Magnetic resonance venography suggests there is a stenosis at the border of the transverse sinus and sigmoid sinus on the right side. All these patients either had 1 hypoplastic transverse sinus and a stenosis of the other sinus or bilateral TSS. Diagnosis of IIH per Modified Dandy Criteria. None of the 50 headache sufferers with normal appearance of transverse sinuses or stenosis of one transverse sinus had abnormal pressure waves and elevated CSF pressures. Venous outlet obstruction has recently been reported to be a potentially treatable cause of benign intracranial hypertension (BIH). described the first venous sinus stenting (VSS) for refractory IIH and significant improvement of trans-sten osis pressure gradient and symptomatic im-provement. Stenosis may be unilateral or bilateral with involvement of the dominant lateral sinus or both lateral sinuses, respectively. The stenosis was localized to bilateral distal transvers sinus of the co-dominant system in 41% (n = 12), bilateral distal transverse sinuses of the dominant-hypoplastic system in 52% (n = 15) and to unilateral dominant system of the dominant-aplastic system in 7% (n = 2). 3. - Venous imaging showing bilateral transverse sinus stenosis or unilateral transverse sinus stenosis with contralateral transverse sinus atresia. 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