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04.02.2015
When a fistula forms, blood from an artery under high pressure and flow goes directly into a vein, which is a low pressure and low flow structure.  Even though the fistula is not directly on or within the brain, it can nevertheless lead to brain dysfunction by congesting the brain venous system, as will be explained below. Finally, many patients who have dural fistulas of all sizes and locations can have a myriad of symptoms such as different kinds of headache, tiredness, loss of concentration, memory problems, even hallucinations, psychosis or other psychiatric problems.  Unfortunately, in these patients the diagnosis of dural fistula can be significantly delayed because dural fistulas are relatively rare, while the above symptoms are very common and usually not due to a fistula. For an in-depth presentation on treatment of Brain Dural AV Fistulas, primarily geared towards neurointerventional professionals, you can visit Techniques: Brain Dural AV Fistula Embolization page.
Below are pictorial diagrams of what a fistula is like and how it can be treated.  The actual anatomy is much more complicated, but the pictures provide a frame of reference.
Finally, post-embolization views, showing the coils in the cavernous sinus (white arrows) and no evidence of fistula on injections of the external carotid artery (brown arrows).  This approach, though technically challenging, can be quite successful when other venues prove unfeasible. This patient developed a fistula on the dural covering that separates the back part of the brain, called cerebellum, from the overlying occipital lobe. MRA images (top) and stereo MRA composite (MIP) images on the bottom, demonstrating multiple intracranial and extracranial vessels (red arrows) feeding the fistula. The microcatheter has been positioned into another branch of the middle meningeal artery, showing residual fistula and aneurysm.  More glue is injected from this position. Post-embolization views of the left common carotid artery, showing that the fistula is gone. Inner ear disorders that increase hearing sensitivity (such as SCD) can cause pulsatile tinnitus.
There are some very large blood vessels -- the carotid artery and the jugular vein -- that are very close to the inner ear (see diagram above). This is a congenital anomaly in which the internal carotid can present as a middle ear mass. Dural Arteriovenous fistulae (DAVF) cause loud noises, synchronous with the pulse, that can often be heard by others with a stethescope, or sometimes by simply putting one's ear next to the person's head. To be certain there is no DAVF at all, 6 vessel DSA is suggested by the interventional radiologists. Radiosurgery is mainly reserved for cases that persist after embolization, but some authors use the opposite order -- radiosurgery first, followed by a clean up embolization (e.g.
Recurrence of fistulae may appear, possibly due to release of growth factors associated with local tissue hypoxia, following occlusion of the DAVF.
It may seem silly to say this, but in our opinion, it is generally not worth taking on a significant risk of having a stroke to attempt to get rid of a noise in one's head with embolization. Venous sinus diverticulum is a rare vascular cause for pulsatile tinnitus characterized by an out pouching of the venous sinus into the calvarium, usually involving the sigmoid venous sinus.
A 59-year-old postmenopausal woman presented with subjective right-sided pulse synchronous pulsatile tinnitus (PT) increasing in intensity over the previous 18 months. Noninvasive imaging, including contrast enhanced CT of the temporal bone, carotid ultrasound, and contrast enhanced MRI of the brain with MR venography and MR angiography were obtained. Figure 1 :Axial (A) and coronal (B) images from noncontrast CT of the temporal bone demonstrating smoothly marginated scalloping of the inner table of right sigmoid plate consistent with sigmoid sinus aneurysm (white arrow).
Figure 1 : Axial (A) and coronal (B) images from noncontrast CT of the temporal bone demonstrating smoothly marginated scalloping of the inner table of right sigmoid plate consistent with sigmoid sinus aneurysm (white arrow).
A conventional digital subtraction angiogram (DSA) excluded a dural arteriovenous fistula (DAVF) or other vascular pathology that might have been occult on noninvasive imaging.
Due to the debilitating nature of the right-sided PT, the patient elected to undergo coil embolization of the sigmoid sinus diverticulum.
Pulsatile tinnitus (PT) is the auditory perception of a rhythmic sound in the absence of external source.
Several authors have proposed the coincidence of venous sinus stenosis and sigmoid sinus diverticulum as a cause of PT [6,10,11]. The incidence of dural venous sinus stent thrombosis, which could result in complete dural venous sinus thrombosis, is unknown.
Endovascular treatment of sigmoid sinus diverticulum using detachable coils for treatment of PT was initially described by Houdart [5]. The potential risks of endovascular treatment of sigmoid sinus diverticulum include coil migration, thrombus formation on coils and, in cases requiring stent placement, stent migration, and in-stent thrombosis [1,2,12].
In summary, we present a case of PT in a 59-year-old woman with two potential venous etiologies, sigmoid sinus diverticulum and upstream sinus stenosis. Santos-Franco JA, Lee A, Nava-Salgado G, Zenteno M, Vega-Montesinos S, Pane-Pianese C, et al. SAS 70 is an acronym for Statement on Auditing Standard 70; it was developed and is maintained by the AICPA (American Institute of Certified Public Accountants). It should be noted that SAS 70 is not a barebones checklist audit; it is an extremely thorough audit that is used chiefly as an authoritative guidance.
Type II reports are similar to Type I, however an additional section is added, the additional section includes the service auditor's opinion on how effective controls operated under the defined period during the review (usually the defined period is six month, but can be longer). Ethernet over Copper is rapidly becoming the preferred choice for wide-area broadband connectivity for businesses of all sizes. With UIA Ethernet over Copper (EoC) service we can now offer an Ethernet solution with up to 20.0 Mbps of symmetrical speed, leveraging UIA experience and expertise with broadband technologies.
The brand new, state-of-the-art Ethernet network, introducing new broadband services using G.SHDSL technology is managed by UIA and proactively monitors end-to-end network performance from the customer premises to the Internet. Our group at the NYU Langone Medical Center is one of the premier neurointerventional centers in the world. When a fistula forms between an artery and a vein within the dura, it is called Brain Dural Fistula, or Brain Dural Arteriovenous Fistula, or BDAVF, etc.
The total amount of radiation delivered to the patient at conclusion of a dynamic CT scan, however, can be VERY high — in some cases resulting in (usually temporary) hair loss. The bottom picture is venogram obtained by directly injecting the cavernous sinus to demonstrate the basal vein (dark blue) and ophthalmic vein (light blue arrows).  Some coils have already been placed into the sinus.
If the carotid fails to develop correctly during fetal life, the inferior tympanic artery enlarges to take it's place. DAVF recieve blood through meningeal arteries or meningeal branches of cerebral arteries and drain directly through a dural sinus or venous channel tributary of a venous sinus through dilated deep veins (Signorelli et al, 2014).
The Cognard states that type I and II DAVFs drain directly into dural sinuses, the difference being antegrade flow in the type I, and retrograde flow in the type II.
Successful treatment requires occlusion of the venous recipient, as occlusion of the arteries alone can be associated with recruitment of more venous drainage (Adamczyk et al, 2012). Surgery is sometimes preferred for fistulae draining into the superior sagittal or dominant transverse sinus when embolization might result in an undesirable sacrifice of the dural venous sinus.


Her PT became increasingly bothersome resulting in both difficulties falling asleep and waking her from sleep as well as difficulty concentrating. A complete history and physical were performed (including otoscopy to evaluate for middle ear mass, auscultation for a bruit, and ophthalmoscopy to search for papilledema) and were normal. CT demonstrated a smoothly-marginated scalloping of the inner table of the sigmoid plate with narrow neck and extension of the sinus laterally into the sigmoid bone defect, characteristic of a sigmoid sinus diverticulum [5-9] (Figure 1).
3-D reconstruction (B) outlines the narrow neck, as well as the upstream stenosis (black arrow head) in the sigmoid sinus.
Under general anesthesia, a 7F vascular sheath was placed in the common femoral vein and 5F vascular sheath in the contralateral common femoral artery. She was admitted to the intensive care unit for observation overnight, and was discharged the following morning.
The differential diagnosis of PT can be classified into vascular and nonvascular etiologies. Since each lesion individually or the two together may be the causative factor in a patient with PT, a diagnostic and therapeutic dilemma is incurred.
A retrospective review of venous sinus stent placement for intracranial hypertension did not report a single case of in stent stenosis or thrombosis out of 52 stents placed [14].
Since that publication, 4 additional endovascular case reports have been published using a combination of detachable coils, detachable coils in conjunction with vascular stenting, as well as vascular stenting alone [2,12,13,16,17]. In addition to Eisenman, Gologorsky et al reported surgical treatment of venous sinus diverticula using self-tying U clips, as an alternative to stent-assisted coiling, in a case where primary coil embolization was technically unsuccessful; this approach resulted in resolution of symptoms (3 month follow up) [1].
In order to minimize procedural risk, stents should be limited to cases requiring their use to adequately position coils in the venous diverticulum. Novel surgical treatment of a transverse-sigmoid sinus aneurysm presenting as pulsatile tinnitus: technical case report. Endovascular treatment of a transverse-sigmoid sinus aneurysm presenting as pulsatile tinnitus.
Focal defect of mastoid bone shell in the region of the transverse-sigmoid junction: a new cause of pulsatile tinnitus.
Sinus wall reconstruction for sigmoid sinus diverticulum and dehiscence: a standardized surgical procedure for a range of radiographic findings.
Endovascular treatment of two concomitant causes of pulsatile tinnitus: sigmoid sinus stenosis and ipsilateral jugular bulb diverticulum.
Successful endovascular treatment of pulsatile tinnitus caused by a sigmoid sinus aneurysm.
Endovascular treatment of sigmoid sinus aneurysm presenting as devastating pulsatile tinnitus. Transverse sinus stenting for idiopathic intracranial hypertension: a review of 52 patients and of model predictions. Awake embolization of sigmoid sinus diverticulum causing pulsatile tinnitus: simultaneous confirmative diagnosis and treatment. Hybrid carotid stent for the management of a venous aneurysm of the sigmoid sinus treated by sole stenting. Sigmoid sinus diverticulum: a new surgical approach to the correction of pulsatile tinnitus. AES (Advanced Encryption Standard), is the latest and greatest encryption adopted by the U.S government.
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Specifically, SAS 70 is a "Report on the Processing of Transactions by Service Organizations" where professional standards are set up for a service auditor that audits and assesses internal controls of a service organization. In today's market, it is a very helpful and substantial audit that shows transparency to the businesses that a service organization works with. The first type commonly referred to as Type I includes an opinion written by the service auditor. Type II reports are more thorough, because the auditors gives an opinion on how effective the controls operated under the defined period of the review.
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Accordingly, other possibilities for vascular tinnitus include dehiscence (missing bone) of the jugular bulb -- an area in the skull which contains the jugular vein, and an aberrantly located carotid artery.
It enters the skull through it's own foramen, courses through the medial part of the middle ear, and then rejoins the petrous ICA (Branstetter and Weissman, 2006).
DAVF are thought to be acquired and are associated with intracranial surgery, ear infection, tumor, hypercoagulability, puerperium, and trauma. According to De Keukeleire et al (2011), Type I DAVs are low risk and need be treated only if symptoms are intolerable.
The reason for this order is that embolization might obscure the target for the radiosurgery if performed first.
While the exact mechanism of sound generation from a sinus diverticulum is unclear, several case reports have suggested that pulsatile tinnitus can resolve after remodeling of venous blood flow such that the diverticulum is excluded from the circulation.
Her PT abated with right neck compression and was exacerbated by strenuous activity, bending forward at the waist, and with Valsalva, suggestive of a venous etiology [1-4]. Audiologic assessment of auditory acuity and discrimination (understanding of words) was also unremarkable. In addition, a stenosis in the sigmoid sinus upstream from the diverticulum was lobular in appearance, suggestive of indentations in the sinus caused by arachnoid granulations. Mid coiling image (C) demonstrates the catheter in the diverticulum (black arrow), stenosis in the sigmoid sinus proximal to the diverticulum, and coils filling the diverticulum with partial filling of the neck of the diverticulum with contrast. A 5000 unit Heparin bolus was given intravenously (appropriately increasing the activated clotting time from 134 seconds to 314 seconds). She was placed on 81 mg ASA orally daily for two weeks to allow for endothelialization of the coil-sinus interface and minimize the risk of sinus thrombosis. Eisenman approached this dilemma by performing surgical reconstruction of the sinus to treat both lesions simultaneously [10].
A recently published multicenter analysis of cerebral arterial stent placement to assist aneurysm coil embolization found a 0.7% incidence of in-stent thrombosis (1 in 142), which resolved with intraprocedural administration of abciximab [15]. All cases involve female subjects (age range 31 to 59), involving the dominant sinus (either directly stated by the authors or ascertained from published images using previously proposed standards [6]), with resolution of symptoms following treatment, and no reported complications.


A series by Otto et al described transmastoid sigmoid sinus reconstruction to treat PT in 3 patients with sigmoid sinus diverticula.
Similar to treatment of arterial aneurysms, fastidious technique, appropriate coil selection, and mid embolization angiography to identify potential coil encroachment on the sinus or thrombus formation on the coils are required to minimize procedural risks. The patient’s PT immediately resolved without treatment of the ipsilateral sinus stenosis. At the end of the audit, the service auditor issues an important report called the "Service Auditor's Report". In addition, it shows the service organizations prospective clients that the service organization has been thoroughly checked and deemed to have satisfactory controls and safeguards either when hosting specific information or processing information such as data belonging to customers that they do business with. Type I reports describe the degree in which the service organization fairly represent its services in regards to controls that have been implemented in operations and its inherent design to achieve objectives set forth. Type I only lists the controls, but Type II tests the efficacy of these controls to reasonably assure that they are working correctly.
An enlarged jugular bulb on the involved side is common in persons with venous type pulsatile tinnitus.
Radiosurgery by itself has a low succes rate as the only treatment (Signorellli et al, 2014). To avoid conflicts of interest, ideally the expert should work for another medical insitution. Case reports have also suggested treatment of both the sigmoid sinus diverticulum and the often-associated upstream sinus stenosis may ameliorate pulsatile tinnitus. She denied changes in the pitch of the sound over time and also denied changes in hearing acuity, balance, swallowing, coordination, strength, or sensation. Lumbar puncture demonstrated bland cerebrospinal fluid (CSF) with a normal opening pressure.
Post coiling AP image (D) of the diverticulum demonstrates the diverticulum is no longer filling with contrast and the sigmoid sinus remains patent. A coaxial 7F VBL guide catheter (Cordis Neurovascular, Miami Lakes, FL, USA) with a 5F Vert (Cook Medical, Bloomington, IN, USA) inner catheter was guided over a Bentson guide wire (Boston Scientific, Natick, MA, USA) from the common femoral vein, through the right atrium, and into the right internal jugular vein (IJ). Signorelli’s decision to treat the venous stenosis was in a large part attributed to measuring 10 mmHg pressure gradient across the stenosis suggesting turbulent flow downstream from the stenosis [11].
Many of the authors utilized medications with platelet inhibitory properties to mitigate the risk of thrombus formation on the implanted coils and stents, presumably allowing for endothelialization as occurs in intra-arterial stent placement. In each of these cases, the wall of the sinus was reconstructed with extraluminal placement of bone wax or temporalis muscle and fascia resulting in complete resolution of PT (average 16.3 months follow up) [18]. Use of a stent will likely require extended (at least six months) use of dual platelet inhibitor therapy with aspirin and clopidogrel to minimize risks of stent thrombosis and subsequent sinus occlusion [2,11]. Perfectly suited for all government regulations on storing data of any kind, you can rest easy that your data is safe. Listed as BlackBerry KB24547, the have scored it using the Common Vulnerability Scoring System (CVSS) at 7.6.
Trans venous embolization is a good option when arterial feedrs are too numerous, and when the venous drainage of the DAVF can be sacrifised.
It is also a poor choice for those with hemmorage, because it is slow acting (1-3 years), and more hemmorage might occur while waiting for the blood vessels to close. We report a case of trans-venous coil embolization of a sigmoid sinus diverticulum without treatment of an additionally identified upstream sinus stenosis, resulting in cure of the patient’s pulsatile tinnitus. 3-D reconstructions in the venous phase post coiling (E and F) demonstrate the relationship of the coil mass to the sinus, as well as sinus patency.
With the 7 F guide catheter remaining in the high right IJ, and the 5 F catheter positioned at the right IJ sigmoid sinus junction, a 0.021 inches Prowler select plus (Cordis Neurovascular) microcatheter was guided over a Synchro 2 Standard (Stryker Neurovascular, Fremont, CA, USA) microwire into the sigmoid sinus diverticulum. Follow up angiogram demonstrated complete obliteration of the sigmoid sinus diverticulum and preserved patency of the dominant right sigmoid sinus. Signorelli and colleagues treated both conditions simultaneously by stent placement across both the stenosis and sigmoid sinus diverticulum with subsequent balloon dilatation of the stent in the area of stenosis. When approaching our case, we considered the large number of patients who have a stenosis in the dominant and non-dominant transverse or sigmoid sinus due to arachnoid granulations with very few of these patients presenting with PT.
Surgical remodeling of venous diverticula appears to carry a significant risk of morbidity including venous bleeding, hemotympanum, visual loss, embolization of bone wax, intracranial hypertension, and sinus thrombosis [1,18,19]; however, the incidence of complication remains unknown. As per Mehanna et al, we chose to place our patient on 325 mg aspirin orally for two weeks to minimize the risks of thrombus formation on the coils [13].
The risk of hemmorage increases with direct drainage into cortical veins (Signorelli et al, 2014). On the other hand, radiosurgery is likely a more durable long term treatment than embolization alone. A review of endovascular and open surgical treatment of sinus diverticula in the treatment of pulsatile tinnitus is also presented. Venous roadmap was obtained from venous phase of images of a DSA following injection of iodinated contrast into the contralateral left common carotid artery. As such, we hypothesized the stenosis may be an incidental finding, or possibly contributory in the pathogenesis of the sigmoid sinus diverticulum, and not the main factor in sound generation.
Injection of the arteries on the contralateral side of the venous lesion allowed for visualization of the venous sinuses without ipsilateral arteries toconfound the images.
In treating the diverticulum only, we cured the PT without having to remodel the venous sinus in the region of the stenosis, thereby decreasing the complexity of the procedure, reducing the amount of implanted hardware and decreasing the complication risk of the procedure.
The relative merits of open surgical sinus remodeling versus endovascular embolization require larger patient cohorts. Previous authors suggest that sinus diverticulum-induced PT may be a result of vibration of the venous sinus wall (caused by turbulence in the sigmoid sinus diverticulum) that is sensed by the cochlea [6,7].
We suggest the use of a stent be reserved for cases in which the sigmoid sinus diverticulum cannot otherwise be occluded endovascularly, and treatment of sinus stenosis only in cases of PT refractory to treatment of the sigmoid sinus diverticulum.
An upstream stenosis of the venous sinuses is often noted in association with a sigmoid sinus diverticulum, and it has been speculated to play an additive role in sound generation [6,10,11], or even a causative role in sinus diverticulum generation [6,7,10-13].
As such, several authors suggest the treatment of both lesions simultaneously to treat venous PT [10,11].
We report a case of coil embolization of a venous sinus diverticulum without treatment of an associated venous sinus stenosis resulting in cure of PT without complication.



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