Endovascular treatment of sigmoid Sinus diverticulum in patients with pulsatile tinnitus

Background Sigmoid sinus diverticula (SSD) are increasingly recognized among the most common causes of pulsatile tinnitus (PT). However, questions remain regarding their etiopathogenesis and optimal management. This study aims to review and compare management strategies and outcomes of SSD treated endovascularly in patients with PT. Methods We retrospectively reviewed all patients with refractory PT who were found to have SSD and were treated endovascularly between September 2020 and January 2024. Clinical features, radiological findings, and endovascular strategies were analyzed. Outcomes were evaluated at 24 hours, 3 months, and 1 year. Results A total of 26 SSDs were found in 23 patients. Diverticula were categorized as saccular in 76.9% (20/26) of cases and as fusiform in 23.1% (6/26) of cases. Their median dimensions were 5.1 mm [IQR 3.8–6.7 mm] in the transverse axis. Transverse sinus stenosis was present in all cases (26/26) with a median pre-procedural pressure gradient of 8 mmHg ([4–11 mmHg]; n = 23). Idiopathic intracranial hypertension was present in 65.4% (17/26) of cases. Ipsilateral sigmoid wall dehiscence was present in 84.6% (22/26) of cases. Stenting alone was performed in 14 cases (53.8%), stent-assisted coiling in 9 cases (34.6), and coiling alone was performed in 3 cases (11.5%). The primary outcome of treatment success, defined as complete resolution of PT at 3 months, occurred in 88.5% (23/26) of cases. Partial resolution of PT at 3 months occurred in an additional 11.5% (3/26) of cases. There was no difference in outcome between the different endovascular treatments at any time point (24 hours p = 0.58; 3 months p = 1.00; 1 year p = 1). Conclusion Endovascular treatment is safe and effective in resolving PT in patients with sigmoid sinus diverticulum. Stenting alone was as effective as stent-assisted coiling, indicating that direct treatment of the diverticulum may not be necessary as long as the associated stenosis is addressed. Further studies are needed to validate these findings and to refine the therapeutic options in PT patients with venous sinus anomalies.