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Abstract
Introduction The mastoid emissary vein (MEV) is a connecting vein between the sigmoid sinus and the posterior auricular or occipital veins. The MEV carries clinical significance due to its potential involvement in various pathologies. When symptomatic, it typically presents as pulsatile tinnitus (PT), usually resulting from vein dilation. Treatment options for MEV-related disorders have historically included open surgical ligation or take-down. In recent years the efficacy of endovascular interventions for PT has become more popular. However, the literature on endovascular treatment of MEV is sparse. We present a case of endovascular embolization of a MEV presenting with PT. We also review the literature for cases of endovascular treatment of symptomatic MEV.
Results A 72-year-old male presented with bilateral PT, headache, and sleep disturbances. Symptoms persisted despite previous coil embolization of a high-riding right internal jugular bulb. A cerebral venogram under conscious sedation revealed dilated bilateral MEVs and balloon test occlusion (BTO) of each MEV at the time showed symptom improvement, more significant on the right, which measured 6.5 mm seen in figure 1. Given the BTO results, he underwent coil embolization of the right MEV under general anesthesia. The patient reported resolution in his right sided PT and felt more comfortable overall. Embolization of the left side MEV is planned for the future.
We searched for relevant articles on Embase, Pubmed, and Medline using search term ‘mastoid emissary.’ There were 119 duplicates removed. Of the remaining 125 articles, only three articles were found describing endovascular treatment of MEV. A total of four patients were described. All four cases presented with pulsatile tinnitus, and all were treated with MEV coil embolization. Symptoms resolved with successful embolization in all four patients.
Conclusion Endovascular coil embolization appears to be an effective treatment for pulsatile tinnitus associated with MEVs, as demonstrated by our case and a review of existing literature. Despite the limited number of reported cases, the consistent success in symptom resolution suggests the potential for this treatment option in similar patients. Additionally, the endovascular approach is advantageous due to the ability to utilize BTO to evaluate symptomatic response prior to embolization. Further research with larger cohorts is needed to establish the long-term efficacy and safety of this approach.
A: Sagittal view of dilated right MEV. B: Coronal View of dilated right MEV. C: Dilated right MEV prior to embolization. D: Right MEV after coil embolization
Disclosures V. Galate: None. A. Brake: None. M. Abraham: 2; C; Consultant for Stryker Neurovascular.